Chronic Lumbar Pain Research Articles

Epidural steroid injections in treatment of chronic lower back pain caused by degenerative-dystrophic spine damage

Background. The high incidence of degenerative-dystrophic spine damage with the variability of research results on the effectiveness of epidural steroid injections for treatment of chronic lower back pain is an urgent issue regarding treatment of this pain with epidural steroid injections only. Objective. The aim of the study is to improve the effectiveness of treatment of chronic lower back pain caused by degenerative spine damage with monotherapy – epidural steroid injections only. Material and methods. The early and long-term treatment outcomes with epidural steroid injections only of 120 patients with chronic lower back pain were analysed. The control group consisted of 36 patients with lower back pain treated conservatively. The results of treatment were assessed by the dynamics of pain regression using the visual analog scale (VAS), as well as the functional status by the Oswestry index. The assessment was performed three times: before treatment, after treatment and six months after it. Results. In the early post-treatment period, reliable results of treatment of chronic lower lumbar pain was evidenced in both the main and control groups. There was no significant difference in treatment outcomes between these groups in the early period, although both the Oswestry index and the VAS by the Student’s T-test showed that the differences were in favour of the main group. There was a significant difference in long-term treatment outcomes between the main and control groups both by the Oswestry index and the VAS in favour of monotherapy with epidural steroid injections. Conclusions. The study proved a high effectiveness of monotherapy with epidural steroid injections for chronic lower back pain caused by degenerative-dystrophic spine damage.

Surgical Realignment After Anterior Multilevel Decompression Using Cages and Plate for 3-level to 5-level Degenerative Fusions: Lessons Learned From the Analysis of Geometric Changes, Reciprocal Coupling, and Prediction of Sagittal Cervical Balance.

Retrospective, single-center case study. Postoperative cervical imbalance with cervical sagittal vertical axis (cSVA) >4 cm can be predicted in 3-level to 5-level anterior-only cervical multilevel fusion surgery (ACMS). Previous studies established correlations between cervical kyphosis (CK) correction and postoperative balance (cSVA ≤4 cm) with improved clinical outcomes. Understanding of what influences restoration of cervical lordosis (CL) in patients with degenerative disease with mild to moderate CK subjected to ACMS is important. To achieve a better understanding of geometric changes after ACMS, this study examines factors predicting perioperative alignment changes and regional interdependencies. Analysis of patients with ACMS. Analysis included patient baseline characteristics, demographics and complications, and focused on radiographic measures including CL C2-7, fusion angle (FA), C7-Slope (C7S), T1-slope (T1S), T1-CL mismatch, and cSVA (cSVA ≤4 cm/>4 cm). We aimed to predict postoperative imbalance (cSVA >4 cm) and conducted a multivariable logistic regression analysis. Inclusion of 126 patients with 3-level to 5-level ACMS, mean age was 56 years and 4 fusion levels on average. Preoperative CK was present in 9%, mean FA-correction was 8 degrees, maximum 46 degrees. Postoperatively, 14 patients had cSVA >4 cm. A neural network model for prediction of cSVA >4 cm was established including preoperative cSVA, preoperative CL and correction of FA. The model achieved high performance (positive predictive value=100%, negative predictive value=94%, specificity=100%, sensitivity=20%). Also, variables such as nonunion, chronic lumbar pain or thoracolumbar multilevel fusion influenced the postoperative cSVA >4 cm rate. Alignment analysis highlighted strong correlations between C7S/T1S and cSVA/C2-tilt ( r =0.06/ r =0.7, P <0.0001). A formula was established to transfer cSVA data into C2-tilt data. This study identified independent variables predicting postoperative cSVA >4 cm including FA, which can be influenced by the surgeon. Our model supports the decision-making process targeting a postoperative cSVA ≤4 cm.

ID:16022 Neuromodulation for Neuropathic Pain Secondary to Cervical Ependymoma Resection

Chronic neuropathic pain is a widespread condition in which patients often fail pharmacological treatment. Advancements in invasive neuromodulation techniques are providing a wide range of applications that can significantly improve the quality of life for patients that suffer from progressive neuropathic pain unresponsive to conventional medical treatments. We present a case of a 62-year-old female with a history of cervical ependymoma status-post resection and three-year history of chronic cervical and lumbar pain as well as neuropathic symptoms including burning, numbness, and weakness in all four extremities. In addition, the patient had concerns for neurogenic bowel and bladder incontinence. These symptoms developed immediately status-post cervical laminectomy in 2017 which was performed for her C3-C4 ependymoma resection. Extensive work-up of her symptoms from multiple specialties and treatment regimens had been largely unsuccessful. Pain Management was consulted and a spinal cord stimulator trial using both a cervical lead and lumbar lead greatly reduced the patient’s pain in all extremities as well as her bowel and bladder symptoms. Four months after full implantation of a cervical and lumbar spinal cord stimulator, the patient rates a consistent 70% reduction in overall pain. She also reports significant reduction with neurogenic bowel or bladder incontinence. This case highlights spinal cord stimulation as a viable treatment option for refractory neuropathic pain of multiple origins and presentations, including multi-level spinal cord targeting such as presented in this case of post-laminectomy changes.

Effects of Self-Massage and Foot Exercises on Lumbar Spine Pain and Functional Condition in Sedentary Men

Background. Lumbar pain is one of the most common disorders of the musculoskeletal system in workers who sit for prolonged periods of time. Prolonged sitting hours change muscle activity and create tension, which negatively affects the structure of the fascia. Myofascial exercises for the posterior superficial chain have been shown to reduce lumbar pain, but the effect of self-massage and foot exercises on the functional condition of the lumbar in office workers is unclear.
 The aim. To assess the effect of self-massage and foot exercises on lumbar pain and functional condition in male office workers.
 Methods. The study included 20 men (25.8 ± 2,6 year) (10 in the experimental group, 10 in the control group) engaged in sedentary work and experiencing chronic non-specific lumbar pain. Before and after the study, a pain intensity assessment was performed using the numerical rating scale (NRS), a functional status assessment using the Oswestry questionnaire, and an assessment of the superficial length of the back superficial chain (lower part) using the toe reach test. For the experimental group, 5 times a week for 10 weeks for 10 minutes, self-massage was applied to each foot; and 3 times a week for 30 minutes, exercises for the feet.
 Results. After self-massage and foot exercises, the intensity of pain and functional disability decreased significantly (p <0.001), and the length of the back superficial chain (lower part) increased (p <0.001). Functional disability increased in the control group (p <0.001). After the study, functional disability differed significantly between groups (p = 0.02).
 Conclusion. Self-massage and foot exercises improved functional condition and reduced lumbar pain in male office workers.
 Keywords: low back pain, fascia, myofascial chain, massage, physiotherapy.

Core stabilisation exercises reduce chronic low back pain in Air Force fighter pilots: a randomised controlled trial

BackgroundThere is evidence that core stabilisation, strength and endurance training contribute to reduce low back pain in the general population. However, we are not aware of the effect of these...

Chronic Lumbar Pain and Insomnia in College-Aged Students.

Insomnia in college students has a significant impact on academic performance and mental health (e.g., depression). Although the mechanisms underlying insomnia and chronic pain are becoming clearer, only a few studies on college students have examined these factors by their location in the body. The purpose of the present study was to identify the location of chronic pain in the body most associated with insomnia in college students. A web-based survey was used to collect information pertaining to nine questions from 494 university students: sex, age, presence of chronic pain, intensity of chronic pain, location of chronic pain, and duration of chronic pain, as well as scores from the Athens Insomnia Scale (AIS), Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale. To examine the association between insomnia and the site of chronic pain, stepwise logistic regression analysis was conducted with AIS as the target variable. The results showed a significant positive correlation between chronic pain in the lumbar region and AIS scores. Future longitudinal studies including multiple factors are necessary to clarify the causal relationship between insomnia and chronic lower back pain.

EPIDURAL INJECTIONS IN THE TREATMENT OF RADICULAR SYNDROME AND CHRONIC LUMBAR PAIN IN DEGENERATIVE-DYSTROPHIC SPINE DAMAGE

Aim. To investigate the methodology and effectiveness of epidural steroid injection for radicular syndrome and lower back pain caused by degenerative-dystrophic process.
 Research methods: bibliosemantic, comparative, systemic.
 Results. A literature review and our study proved a high efficacy of both monotherapy and combined epidural steroid injections in treatment of chronic lumbar pain and radicular syndrome caused by degenerative-dystrophic spine damage. Epidural steroid injections are indicated for intervertebral disc herniation, spondyloarthritis, spinal canal stenosis, spondylolisthesis, which cause chronic lumbar pain, radicular syndrome. Epidural steroid blockades with stable remission were proved to have positive result in 20 to 100% of cases, averaging more than 80%. Anesthetics, corticosteroids, enzymes, and vitamins are administered to the epidural cavity to relieve pain and inflammation, but most authors still prefer steroids. Corticosteroids reduce the inflammatory response and oedema by inhibiting the synthesis and release of numerous anti-inflammatory mediators and cause the reverse local anaesthetic effect. Different approaches are used to introduce drugs into the epidural cavity: interlaminar, caudal and transforaminal; the method of long-term local pharmacotherapy is used. Interlaminar epidural steroid injection is as effective as transforaminal epidural injection. The middle interlaminar access is less traumatic. The choice of the administration technique depends on specialist experience and preferences. Epidural injections are performed both by a “blind method” (without imaging) and under control (fluoroscopy, ultrasound and CT) in order to improve the safety and carefulness of pharmacological drug administration. The equivalence of fluoroscopic, ultrasound and CT control of epidural injection in terms of treatment efficacy has been proved.
 Conclusions. Taking into account the high effectiveness of epidural steroid injections, the possibility of outpatient treatment in the absence of complications, makes it the method of choice in the treatment of radicular and lumbar pain caused by degenerative damage of the lumbar spine, after ineffective treatment.

Результати лікування хворих із нижньопоперековим больовим синдромом, де домінували прояви спондилоартрозу, із використанням радіочастотної денервації фасеточних суглобів у поєднанні з періартикулярним введенням місцевих анестетиків та стероїдних препараті

Актуальність. Висока поширеність дегенеративно-дистрофічного ураження хребта при малій ефективності терапії спондилоартрозу робить актуальним дослідження щодо лікування нижньопоперекового болю, зумовленого переважно спондилоартрозом, інноваційним міні-інвазивним методом високочастотної денервації фасеточних суглобів у поєднанні з періартикулярним введенням місцевих анестетиків і стероїдних препаратів. Мета дослідження: визначити ефективність впливу радіочастотної денервації фасеточних суглобів у поєднанні з періартикулярним введенням місцевих анестетиків і стероїдних препаратів з урахуванням ранніх та віддалених результатів лікування на ліквідацію больового синдрому у хворих із нижньопоперековим больовим синдромом, в яких переважали прояви спондилоартрозу. Матеріали та методи. Проведений аналіз ранніх та віддалених результатів лікування 78 пацієнтів (37 чоловіків та 41 жінка віком від 51 до 79 років) із нижньопоперековим больовим синдромом, в яких провідним клінічним проявом був артроз дуговідросткових суглобів, які становили основну групу, та проведена радіочастотна денервація фасеточних суглобів (за допомогою апарата RFG-1A/RFG-1B фірми Radionics) у поєднанні з періартикулярним введенням місцевого анестетика та стероїдного препарату. Оцінка больового синдрому проводилася чотири рази — у доопераційному, післяопераційному періодах (протягом тижня), через три місяці та через один рік після лікування. Використовувалася візуальна аналогова шкала болю та опитувальник індексу непрацездатності Освестрі. Контрольну групу становили 136 пацієнтів (73 чоловіки та 63 жінки віком від 44 до 81 року) із нижньопоперековим болем із домінуванням проявів спондилоартрозу, які лікувались виключно за допомогою методу радіочастотної денервації фасеточних суглобів. Результати. Як відразу ж після проведеного лікування, так і через три місяці після його здійснення отриманий вірогідний результат лікування хронічного нижньопоперекового больового синдрому, зумовленого переважно ураженням дуговідросткових суглобів, як в основній, так і контрольній групах, що свідчить про ефективність обох методів лікування. Разом із тим відмічається чітка вірогідна різниця між основною та контрольною групами як відразу після проведеного лікування, так і через три місяці після його здійснення, що свідчить про вірогідну вищу ефективність методу радіочастотної денервації фасеточних суглобів у поєднанні з періартикулярним введенням місцевого анестетика та стероїдного препарату в ранньому післяопераційному періоді. У віддаленому періоді (через 1 рік після лікування) отриманий вірогідний результат лікування як в основній так і в контрольній групах, але відмінність у результатах лікування між цими групами відсутня. Висновки. Отримані результати в ранньому та віддаленому періодах після лікування свідчать про ефективність та безпечність як радіочастотної денервації фасеточних суглобів, так і радіочастотної денервації фасеточних суглобів у поєднанні з періартикулярним введенням місцевого анестетика та стероїдного препарату у хворих із нижньопоперековим больовим синдромом, де домінують прояви спондилоартрозу. Вірогідно кращі результати в ранньому періоді отримані в групі пацієнтів, яким проводилось поєднання радіочастотної денервації фасеточних суглобів із періартикулярним введенням місцевого анестетика та стероїдного препарату. Тоді як у віддаленому періоді (через 1 рік після лікування) така відмінність між основною та контрольною групами відсутня. Періартикулярне введення місцевих анестетиків та стероїдів ефективне в короткотерміновій перспективі, а радіочастотна денервація фасеточних суглобів ефективна як у короткотерміновій, так і в довготерміновій перспективі. Обидві методики можуть бути рекомендовані до включення в алгоритм лікування фасеточного синдрому при неефективності консервативного лікування.

The effect of consecutive facet medial branch radiofrequency denervation and dorsal root ganglion pulse radiofrequency therapy on lumbar facet joint pain.

The aim of this study was to evaluate the efficacy of consecutive facet medial branch (FMB) radiofrequency denervation (RFD) and dorsal root ganglion pulse radiofrequency (DRG PRF) therapy in patients with chronic lumbar facet joint pain. The study included 27 patients with chronic lumbar pain who had ≥50% pain reduction after FMB block for suspected lumbar facet syndrome and subsequently underwent FMB RFD together with PRF to the adjacent DRG. The patients were retrospectively analyzed in terms of age, gender, pre-procedure symptom duration, history of previous back surgery, FMB RFD and DRG PRF level and side, and numerical rating scale scores immediately before and at 1, 3, and 6 months after the procedure, and subjective pain reduction at 6 months post-treatment. Treatment success was defined as ≥50% subjective pain reduction at 6 months. A total of 19 women and 8 men with a mean age of 57.7±12.4 years were analyzed. Twenty patients (74.1%) had no prior history of low back surgery. The success rate of the procedure in terms of subjective pain reduction at 6 months was 82.5% (n=25). The subjective percentage of pain reduction at post-procedure 6 months was significantly lower in patients with a pre-procedure symptom duration of 12 months or longer compared to those whose pre-procedure symptom duration was <12 months (p=0.04). Our study results show that the analgesic efficiency of DRG PRF added to FMD RFD treatment can be increased in patients with short symptom durations.

Evaluation of the effectiveness of treatment of patients with nonspecific pain syndrome in the lower back with celecoxib and a combined preparation of B vitamins

To evaluate the effectiveness of the effect of celecoxib and the combined vitamin complex of group B in comparison with meloxicam in patients with acute and chronic nonspecific lumbar pain (LP). The effectiveness of the effect on acute (44%; acute pain syndrome (APS)) and chronic (56%; chronic pain syndrome (CPS)) LP of moderate intensity (according to VAS/MPQ) (APS 5.7±2.3/2.13±0.67 points; CPS 5.2±2.8/1.47±0.61 points), the leading component of which is sensory sensations (when APS is lower than in CBS; Kr-W=6.15, p=0.04) and affective disorders in CPS (U=117.5, p=0.04) celecoxib without (APS 25%; CPS 75%) and with the addition of Neuromultivit (APS 36%; CPS 64%) and in comparison with meloxicam (APS 100%) against the background of basic therapy in 93 patients (61.3% women and 38.7% men; average age 49.9±9. years) with nonspecific LP pain syndrome in the lower back, with a low degree of severity of motor function (MF) disorders according to the ICF (2±1 points), due to spondyloarthrosis of the lumbosacral spine. It was found that celecoxib and meloxicam cause the same significant remitting decrease in the severity of APS and restoration of MF disorders in patients with APS, equally cause rare adverse events (gastropathy, increased blood pressure) in comorbid pathology. Celecoxib proved to be more effective in relieving CPS and improving MF (p<0.05), and the combination of celecoxib with Neuromultivit caused more pronounced relief of APS and CPS, restoration of MF (p<0.01). A steady decrease in the intensity of PS (1-2 points according to VAS), recovery of MF occurs only on the 10th-11th day of therapy (p<0.01), with complete relief of LP by day 21 only in 60.22% of cases. The results of the study confirm the benefits of celecoxib in combination with a vitamin complex for the relief of CPS.

Physical activity in patients with nonspecific low back painin therapy

Introduction. Kinesitherapy (KT) – one of the leading areas of patient care with chronic nonspecific (musculoskeletal pain) low back pain. For chronic lumbar pain, a standard KT is commonly used, that includes group sessions with a medical specialist. Often not taking into account the individual characteristics of patients, their attitude to KT, does not use a backpain education program in combination with KT (extended KT). Physical activity and hypodynamia are compared in patients with chronic nonspecificlow back pain in standard KT and extended KT.Aim of study is to assess the effectiveness of the standard and extended KT in the enhancement of physical activity.Materials and methods. 71 patients were observed (17 men and 54 women, average age 55.09 ± 13 years) with chronic nonspecific low back pain. Patients received non-steroidal anti-inflammatory drugs (NSAIDs) as painkillers. 34 patients received a standard KT, 37 patients – an extended KT. Patients were asked to complete the Numeric Pain Rating Scale (NPRS), the Oswestry Low Back Pain Disability Questionnaire, and the International Physical Activity Questionnaire (IPAQ) at baseline, after 7 days and 90 days.Results and discussion. In the extended KT group, physical activity increased from 11 (7–16) points to 16 (13–19) points after 7 days (p = 0.001) and up to 23 (15–26) points after 3 months (p = 0.0002). There has been a statistically significant decrease in the proportion of patients with hypodynamy (p = 0.0015). There is no statistically significant increase in physical activity in the standard therapy group. The use of NSAIDs in non-specific low back pain is discussed, the effectiveness of the use of dexketoprofen (Dexalgin) during lumbar pain is noted.Conclusion. In the case of nonspecific low back pain, the extended KTimprovesphysical activity and reduce hypodynamy.

MRI FINDINGS OF SACROILIAC JOINT IN ADULTS WITH CHRONIC LOW BACK PAIN

Background: Low back pain is a common disease that has shown unspecified etiology in significant percentage of patients. In this study, the main purpose is determination of the frequency of Sacroiliac MRI findings in 18–45-year-old patients with chronic low back pain. Methods: This descriptive study was performed on 224 patients aged 18–45 years with chronic lumbar pain who referred to Imam Ali Hospital Imaging Center, Zahedan, Iran in 2018–2019. These patients were subjected to sacroiliac imaging. Data were analyzed by SPSS software and Chi-square test. Results: In this study, the frequencies of different findings related to sacroiliac joint were recorded: Bone marrow edema: 55(24%), transitional vertebra: 41(18%) fatty marrow deposition: 32 (14%), erosion:20(89%), sclerosis: 15(6%), osteitis condense ilii: 5(2%), accessory sacroiliac joint: 3(1%), abnormal segmentation: 2, spina bifida:2, malignant involvement:1. Out of 224 patients, 127 (56%) had undergone sacroiliac MRI which could be related to their low back pain, while these findings were ignored in the usual Lumbosacral imaging. Conclusions: The importance of sacroiliac MRI was ignored in the usual imaging of low back pain. It might be better to perform MRI as a routine in these patients.

Relationship between structural changes in paravertebral muscles and the development of spine degenerative diseases

Based on the systematic approach to the diagnosis of spinal patho­logy, there are no fundamental differences in the etiology of spine degenerative disease, facet joints arthritis, and other diseases. These diseases are considered multifactorial: age (aging), systemic regulatory factors (hormones, peptides, cytokines), genetic predisposition, inadequate physical activity, unfavorable environmental factors, and others lead to pathological changes in the structure of the spinal motor segment components. Recently, much attention has been paid to the paravertebral muscles changes, in which over time, as a result of injuries or degenerative processes, inevitably lead to dysfunction, which can lead to the occurrence of chronic lumbar pain. Objective. To assess the relationship between structural changes in paravertebral muscles and the development of degenerative diseases of the spine on the basis of scientific literature review. It was found that degenerative changes in paravertebral muscles, as components of spinal motor segments, develop with aging. In particular, muscle fibers are replaced by fat tissue, which is more pronounced in women compared to men. A direct correlation between chronic lumbar pain and paravertebral muscle atrophy has been reported. Systemic factors, in particular low levels of vitamin D, also can cause the development of degenerative changes in paravertebral muscles, especially in women. Obesity provokes systemic inflammation, increases fatty infiltration of skeletal muscles and increases sensitivity to pain. Reduced levels of physical activity lead to weakness and atrophy of the paravertebral muscles, which can cause degeneration of the intervertebral disc. At the same time, exercise prior to spinal surgery for degenerative disea­ses improves functional outcomes and reduces pain. Conversely, damage to the paravertebral muscles increase the load on the adjacent to spinal fusion segments. In general, the role of paravertebral muscles in the development of degenerative spinal diseases has not been definitively studied.

Conceptual model of patho- and sanogenesis of the sacroiliac joint osteoarthritis

Objective. To develop a conceptual model of patho- and sanogene­sis of the sacroiliac joint (SIJ) osteoarthritis on base of the known data about the SIJ, the results of our own biomechanical studies of this joint, its ligaments and stabilizing muscles by finite element modelling, data of clinical verification of these results. Methods. The object of the model is the SIJ as a link, which connects the spine and pelvis. The proposed conceptual model is based on the M. Panjabi hypothesis of chronic lumbar pain in the case of partial dama­ge to ligaments, which leads to muscle dysfunction. Results. A new conceptual model of SIJ osteoarthritis was developed. In this model we tried to take into account the limitations of the existing SIJ stability hypotheses and models of the appearance of the pelvic girdle pain, SIJ dysfunction and SIJ arthrosis. The model is based on the results of our own research. It was proved, that patients with SIJ osteoarthritis have an asymmetry of the width of the joint slits, the inclination of the sacrum and pelvis, sacral rotation, hyperlordosis in the LV–SI segment. These factors lead to a shift of the horizontal axis of sacral rotational mobility relative to the pelvic bones. This horizontal axis shift leads to the instabili­ty of the SIJ on one side of the joint, and to the functional block on another side. The results of these functional changes were damage of the SIJ ligaments-stabilizers, dysfunction of the SIJ muscles-stabilizers, degenerative changes of SIJ elements and pain. The deve­loped model allows to explain the distortion of muscular response pattern in patients with improper SIJ biomechanics in conditions of SIJ osteoarthritis. The increase of the SIJ biomechanics changes enlarges the the muscle response pattern distortion. Conclusions. The developed conceptual model explains many clinical manifestations of the SIJ osteoarthritis and will help to understand better the mechanics of the pelvic girdle pain in such conditions, will improve the results of diagnosis and treatment.

Single Centre Experience in Open and Endovascular Treatment of Renal Artery Aneurysms

Background: The true incidence and natural history of renal artery aneurysm (RAA) remain unclear and still exists controversy over indication for treatment. Several techniques of conventional surgical reconstructions are described in literature, and more recently endovascular therapies have been reported with satisfying results and lower complication rate. This paper aims to investigate the outcomes of both endovascular and open repair of RAA achieved in a single institution involving 3 medical teams (urology, vascular surgery and neuroradiology). Material and Methods: We conducted a single-centre retrospective observational study about all patients surgically or endovascularly treated for RAA over a 15-year period. Pre-operative, procedural and post-operative data at the early, mid- and long-term follow-up were collected and analysed, focusing on operative technique used for repair and related outcomes. Results: A total of 27 patients (n = 17 (63%) women, mean age 58 ± 13.2, n = 26 saccular RAA) were included. Mean aneurysm was size was 18.8 ± 6.3 mm. Most diagnosis were accidental. Symptomatic RAA showed with macroscopic haematuria (n = 3, 25.9%), unstable hypertension (n = 2; 7%), chronic lumbar pain (n = 1, 3.7%) and renal infarct (n = 1, 3.7%).Conventional surgery (ex-vivo repair, aneurysmorraphy, aneurysm resection and end-to-end anastomosis) was performed in 14 (51.8%) cases and endovascular coiling embolization in 13 (48.2%). Mean hospital length of stay was 5.4 ± 3.6 days. Intensive Care Unit stay was needed only in the surgically treated patients (mean 1.1 ± 1.2 days). During the early follow-up, morbidity rate was 7/14 in surgically treated patients vs. 1/13 in endovascular group; it included bleeding, retroperitoneal hematoma, arterial thrombosis and bowel obstruction. The discharge imaging showed complete aneurysm exclusion and renal artery patency in all cases.At a mean follow-up of 39 ± 42 months, 3 patients (11%) were lost to follow up and 2 (7.4 %) died from unrelated cause. None of these patients required dialysis but a statistically significant (P = 0.09) decrease in GFR was noted between the preoperative period and last follow-up control. RAA repair neither showed blood pressure control improvement nor reduced the need for anti-hypertensive drug use. Conclusion: Open or endovascular techniques are both safe and efficient to treat RAA. Even though, surgical management is burdened with higher morbidity rate, the operative technique should be selected according to anatomical features, diameters and location of RRA; and the number of renal branches involved. Further larger studies are needed to define the feasibility and safety for a wider application of the endovascular approach.

Giant Pyelic Stone: Clinical Image

The management of giant stones of the upper urinary tract remains a challenge for the urologist because of the potential risk of treatment-related complications [1]. We report as a clinical picture the case of a 42-year-old patient received for chronic right lumbar pain in whom the CT scan performed revealed the presence of a giant pyelic stone (Figure 1a and 1b) whose dimensions on the sagittal plane are 43.1mmx41.5mm. The patient underwent an open pyelolithotomy in our department, which allowed the extraction of a giant pyelic calculus of 12cm (Figure 1c). The postoperative course was simple.

Preoperative Elevated Levels for Depression, Anxiety, and Subjective Mental Stress Have No Influence on Outcome Measures of Peripheral Nerve Field Stimulation for Chronic Low Back Pain—A Prospective Study

Peripheral nerve field stimulation (PNFS) is an effective alternative treatment for patients with chronic low back pain. The treatment of low back pain strongly depends on psychological factors like anxiety, depression, and mental stress. The aim of this study was to evaluate the impact of such factors on outcome measures after lead- and implantable pulse generator-implantation. Between 2014 and 2019, a prospective cohort study of 39 patients with chronic lumbar pain was conducted. Hospital Anxiety and Depression Scale (HADS) score was assessed at baseline to measure symptoms of anxiety and depression. Symptom checklist-90 (SCL-90) was used to measure subjective psychopathology. Pain intensity (numeric pain rating scale [NRS]), SF12v2 with Physical Component Summary and Mental Component Summary (MCS) scores, and Oswestry Disability Index (ODI) were assessed pre- and postoperatively as well as three and six months after PNFS implantation. Outcome values were compared to baseline data. Statistical analysis was performed using depending t-test and analysis of variance (ANOVA). A pvalue <0.05 was considered significant. The cohort consisted of 39 patients (18 females, 21 males) with a median age of 61 years (IQR25-75 =52-67 years). NRS, ODI, and SF12v2 showed significant improvement in the whole follow-up period compared to baseline values (p < 0.05). Elevated HADS scores for anxiety were seen in 64.1%, for depression in 76.9% of the patients at baseline. SCL-90 was pathologic in 71.8% of the cases. A one-way ANOVA revealed no differences between elevated HADS- and SCL-90 values and all outcome measures after PNFS implantation in the whole follow-up period (p > 0.05). Chronic low back pain is often associated with psychological distress. Our study showed highly elevated levels for anxiety and depression as well as subjective mental stress in patients with chronic low back pain without negative impact on NRS, ODI, and SF12v2 in the whole follow-up after PNFS implantation.

The Predictive Value of Transcutaneous Electrical Nerve Stimulation for Patient Selection in Peripheral Nerve Field Stimulation for Chronic Low Back Pain: A Prospective Study

Peripheral nerve field stimulation (PNFS) is an effective alternative treatment for patients with chronic low back pain. Transcutaneous electrical nerve stimulation (TENS) is frequently used in pain therapy. Aim of this prospective study was to examine the predictive value of TENS for later PNFS treatment. Between 2014 and 2019, a prospective cohort study of 41 patients with chronic lumbar pain was conducted. Pain intensity (NRS) was assessed before and after TENS use, preoperatively/postoperatively and in the follow-up after three and sixmonths, SF12v2 questionnaires with physical (PCS) and mental component summary (MCS) scores, and Oswestry disability index (ODI) questionnaire at baseline as well as three and six months after PNFS implantation. Implantation of the PNFS-system with two percutaneous leads was performed after four to seven days of positive testing. Statistical analysis was performed using depending t-test, ANOVA, and Spearman correlation. The cohort consisted of 41 patients (19 females, 22 males) with a median age of 60.5 years (IQR25-75 52-67). Two patients were lost to follow-up. After positive PNFS testing a pulse generator (IPG) was implanted in 15 patients with positive TENS effect and 15 patients without TENS effect. Leads were explanted in nine patients after negative PNFS trial phase. TENS positive patients showed significant correlation to a positive effect in the PNFS trial phase in NRS reduction (p=0.042) indicating that TENS responders will also respond to PNFS (94% patients). After three and six months follow-up median NRS and SF12v2 (PCS) improved significantly in both cohorts, SF12v2 (MCS) and ODI only in the TENS positive cohort, respectively. TENS can be predictive for patient selection in PNFS, as TENS positive patients showed significant correlation with a positive PNFS trial period. Therefore, TENS positive patients might be justifiable to be directly implanted with leads and IPG. TENS positive patients further tend to show a better improvement in the follow-up.

Trans-limb embolization for treatment of Type 2 endoleak post EVAR: Case report.

IntroductionType 2 endoleaks (T2EL) occur after 10%–25% of endovascular abdominal aortic aneurysm repairs and increase the risk factor of endograft repair failure and rupture. Herein we report a case of endovascular treatment of T2EL where we performed a trans-limb embolization.Presentation of caseA 63-years-old male previously treated for AAA with endovascular aortic aneurysms repair (EVAR), showed an angio-CT scan followup with a type 2 endoleak fed from inferior mesenteric artery (AMI) with growth of AAA greater of 1 cm than preoperative CT-scan and increase of chronic lumbar pain. Due to high risk of rupture was performed a trans-limb embolization with complete sealing. The 6 months CT-angiography showed complete type 2 endoleak exclusion without changes of AAA.DiscussionThe risk of aneurysm rupture in the presence of an isolated T2EL is exceptionally low. However, when a persistent T2EL is associated with a significant sac size increase, commonly considered as at least 5 mm over 6 months, should be treated. Detachable coils are repositionable, allowing an extremely precise deployment and subsequent embolization of different targets.ConclusionIn this experience trans-limb embolization was feasible and this tool should be taken in account especially when no other surgical options exists.

Association between Physical Activity and Comorbidities in Spanish People with Asthma-COPD Overlap

Asthma and chronic obstructive pulmonary disease (COPD) are important conditions which often coexist. Higher rates of comorbidities among people with asthma-COPD overlap (ACO) may complicate clinical management. The aim of this study was to determine the prevalence of 30 different comorbidities and to analyze associations between these comorbidities and physical activity (PA) in Spanish people with ACO. Cross-sectional data from the Spanish National Health Survey 2017 were analyzed. A total of 198 Spanish people with ACO aged 15–69 years (60.6% women) were included in this study. PA was measured with the International Physical Activity Questionnaire (IPAQ) short form. Diagnosis of chronic conditions were self-reported. Associations between PA and comorbidities were analyzed using multivariable logistic regression models. The most prevalent comorbidities were chronic allergy (58.1%), chronic lumbar pain (42.4%), chronic cervical pain (38.4%), hypertension (33.3%) and arthrosis (31.8%). A PA level lower than 600 MET·min/week was significantly associated with urinary incontinence (OR = 3.499, 95% CI = 1.369–8.944) and osteoporosis (OR = 3.056, 95% CI = 1.094–8.538) in the final adjusted model. Therefore, the potential influence of PA on reducing the risk of these conditions among people with ACO should be considered, not only because of the health benefits, but also because PA can contribute to a more sustainable world.