Relief Of Leg Pain Research Articles

Cocktail Treatment with a Gelatin Sponge Impregnated with Ropivacaine, Dexamethasone, and Vitamin B12 Promotes Early Postoperative Recovery after Percutaneous Endoscopic Lumbar Discectomy: A Retrospective, Case-Controlled Study

Percutaneous endoscopic lumbar discectomy (PELD) can only relieve mechanical compression but cannot directly reduce the inflammatory reaction of the adjacent nerve root, which contributes to persistent pain and physical disabilities postoperatively. Numerous studies have explored the application of epidural steroids after an open lumbar discectomy in relieving pain by reducing local inflammatory reactions and further peridural scar formation. To explore that whether "cocktail treatment" in which a gelatin sponge was impregnated with ropivacaine, dexamethasone, and vitamin B12 promoted early postoperative recovery after PELD. Retrospective, case-controlled study. All data were from Hong-Hui Hospital in Xi'an. Between January 2016 and January 2017, 100 patients of single-level lumbar disc herniation were treated with PELD in our hospitals. The cocktail treatment was applied in the first 50 patients (group cocktail), and an equal size gelatin sponge without drugs was used in the other 50 patients as control (group noncocktail). The clinical outcome evaluation included the Visual Analog Scale (VAS) score for back and leg pain and Oswestry Disability Index (ODI) score. There was a significant difference in the mean periods of return to work (4.25 ± 1.88 weeks in the cocktail group and 5.18 ± 2.19 weeks in the noncocktail group) (P < 0.01). Compared with the preoperative data, a significant improvement in VAS scores of back pain and sciatica and ODI were observed in each follow-up interval (P < 0.05, respectively). In the noncocktail group, there were visible fluctuations in the 3 indicators within the first week after surgery. This phenomenon was not observed in the cocktail group, a difference that was statistically significant (P < 0.05, respectively). In further follow-up, no significant differences were observed between the 2 groups (P > 0.05, respectively). The nonrandomized, single-center, retrospective design is a major limitation of this study. The "cocktail treatment" with a gelatin sponge impregnated with ropivacaine, dexamethasone, and vitamin B12 promotes early and satisfactory back and leg pain relief and fast functional recovery after PELD. Endoscopic lumbar discectomy, lumbar disc herniation, steroids, nerve root block, gelatin sponge.

A retrospective comparison on surgical management of varicose veins with and without venous stripping

Varicose veins, one of the oldest known diseases of mankind were treated by various modalities starting from simple phlebotomy to minimally invasive approaches. Aim and Objectives: In this study the outcome of two surgical treatment modalities of varicose surgery with and without venous stripping was compared based upon a follow up period of two months. Materials and Methods: Among the 92 patients operated for varicose veins between September 2018 to November 2019 in all surgical units of Trichy SRM Medical College Hospital, S50 patients of age group 16 – 70 yrs were taken up for the study after matching. Results: In this study males contribute the maximum bulk of about 82%. As for as the age is considered, patients aged between 40 – 70 yrs was more, which was about 58%. The hematoma formation after venous stripping was 28% whereas it was only 4% in the other group. There was no significant difference in healing of leg wounds in both the studies The first postoperative comfortable ambulation with minimal pain was possible in more patients who did not undergo venous stripping (92%) than who underwent stripping (68%).Long postoperative stay of more than 6 days was found in 8% of those who underwent stripping and 4% of the other group. The long stay was mostly due to pain and delayed wound healing. Pain relief was seen in 96% of those who had venous stripping and 88 % of those who did not undergo venous stripping at the end of second month.Conclusion: This study on observation concludes there was no significant difference in healing of leg wounds, hospital stay and pain relief in both the studies, but the Trendelenburg procedure with incompetent perforators ligation without venous stripping appears to be better than Trendelenburg procedure with incompetent perforators ligation with venous stripping.

Long-Term Effect of Peripheral Nerve Field Stimulation as Add-On Therapy to Spinal Cord Stimulation to Treat Low Back Pain in Failed Back Surgery Syndrome Patients: A 12-Month Follow-Up of a Randomized Controlled Study

Different approaches in neuromodulation have been used to treat chronic low back pain in failed back surgery syndrome (FBSS) patients. We previously randomized 52 FBSS patients to be treated with spinal cord stimulation (SCS) and additional peripheral nerve field stimulation (PNFS) or SCS alone. At three months, we found a significant reduction of back pain in the PNFS-SCS group compared to the SCS group. In the subsequent open phase part of the study, all patients received optimal SCS and PNFS simultaneously. Here, we present the 12-month follow-up data on back and leg pain. Data regarding back and leg pain, function, quality of life, patient satisfaction, anxiety and depression, and use of medication were collected by analyzing patients' questionnaires at 12 months and compared with data collected at baseline. Data were analyzed using multilevel regression models. A combined group of 50 subjects completed the 12-month follow-up. Back pain, measured on a 100-mm visual analog scale (VAS), significantly decreased over this period by 30.0 mm (95% CI: [-37.7/-22.4]; p < 0.001), while leg pain decreased by 43.7 mm (95% CI: [-51.5/-36.2]; p < 0.001). We observed statistically significant improvement in almost all secondary outcome measurements. At 12-month follow-up, PNFS in addition to SCS continues to provide a statistically significant and clinically relevant relief of low back pain in FBSS patients in whom SCS alone is effective for relief of leg pain only.

Effectiveness of two bundles in venous leg ulcer healing: A randomized controlled trial

The objective of this study was to compare the effectiveness of 2 bundles in venous leg ulcer healing. This study is a open, randomized, controlled clinical trial with parallel treatment, 1:1 allocation rate, and 24-week follow-up. Twenty-eight patients with venous leg ulcers of the lower limbs were allocated to 2 groups: group A (n=14) and group B (n=14). The mean age of the participants was 59.67±11.95years, and the mean ulcer surface area was 29.32 (±98.43) cm2. The primary outcome was ulcer healing. Secondary outcomes were wound area reduction rate, Pressure Ulcer Scale of Healing (PUSH) scores, and the presence and intensity of pain before, during and after dressing change. Two different bundles were applied in 2 phases to the randomized groups. All participants engaged in an educational activity, performed exercises, rested with legs elevated, received oral nutrition supplementation (Cubitan; Danone Nutricia), and had their ulcers cleaned with warm saline solution and biguanide polyhexanide solution (Prontosan; B. Braun). Topical therapy in the first phase was papain 2% or 4% for group A and 2% hydrogel for group B. Both groups received single-layer elastic compression therapy (SurePress; ConvaTec). In the second phase, group A received compression therapy with Unna boot (Viscopaste; Smith-Nephew) as the primary dressing, while group B received a cellulose membrane (Membracel; Vuelo Pharma) followed by the Unna boot (Viscopaste; Smith-Nephew).In group A, 71.42% of the ulcers healed; in group B, the figure was 64.28%. Wound area, PUSH scores, and the occurrence and intensity of pain decreased significantly and equivalently in groups A and B.Both bundles are effective in the treatment of venous leg ulcers and pain relief.

Percutaneously full endoscopic decompressive laminectomy with precise localization for the treatment of lumbar spinal stenosis

To explore the feasibility of full endoscopic fenestration (FE-FE) via interlaminar approach for the treatment of lumbar spinal stenosis (LSS), and meanwhile, to analyze the related practicability and clinical outcome. Referring to the traditional laminectomy and decompression, the lumbar spinal canal decompression was performed by using the water-medium spinal endoscopy (named FE-FE technique). Thirty-seven patients with LSS treated by FE-FE technique were retrospectively analyzed. There were 19 males and 18 females, aged from 55 to 83 years old with an average of (67.1±18.9) years. Visual analogue scale(VAS), Japanese Orthopaedic Association Scores(JOA), Oswestry Disability Index (ODI) and 36-Item Short-Form Health Survey (SF-36) were recorded. The patient's conscious pain and recovery of neurological function were observed, and the clinical efficacy was evaluated according to the improvement rate of JOA score. All 37 patients were followed up for 8 to 24 months with an average of (13.7±6.1) months. The postoperative follow-up and clinical evaluation for conscious pain and neurological function recovery showed that VAS, JOA, ODI and SF-36 scores were significantly improved compared with those before surgery(P<0.05). According to the improvement rate of JOA score to evaluate the clinical effects, at 6 months after opertion, the results were excellent in 17 cases, good in 13 cases, fair in 5 cases, and poor in 2 cases;and the last follow-up, the results were excellent in 19 cases, good in 13 cases, fair in 4 cases, and poor in 1 case. Postoperative imaging showed significant expansion of spine canal volume, and the followed-up clinical symptoms were improved satisfactorily, with the relief of lumbago and leg pain, improvement of daily life quality, and increased adaptability to social activities and no serious complications. Precise localization is the key to complete the canal decompression under full endoscopic surgery. FE-FE technique can effectively enlarge the narrow lumbar canal with less trauma, positive efficacy, safety and reliability. FE-FE has a broad application prospect though large cases and multi-center studies need to be further carried out.

Spinal Cord Stimulation for Failed Back Surgery Syndrome -- Patient Selection Considerations

Failed back surgery syndrome (FBSS) refers to the condition where persistent pain is experienced by patients following back surgery. This condition is historically difficult to treat. Spinal cord stimulation (SCS) and its recent technical advances have opened the door to a promising treatment option for FBSS. However, critical appraisal of supporting and refuting data is necessary to identify the best patient population for this treatment modality. In this systematic review, we review randomized controlled studies and cohort studies with matched controls to synthesize the data on the overall efficacy of spinal cord stimulation for FBSS. We further identify available data on outcome measurements based on working status, psychological status, smoking, sex, and race to provide insight on patient selection and identify needs for further research. The literature search identified 34 publications, of which 23 were excluded due to duplication and inclusion/ exclusion criteria, yielding a total of 11 publications for review. Seven out of eleven studies reviewed had sources of potential funding or affiliation bias. Three out of 4 studies with radiating leg pain relief as their primary outcome showed statistically significant improvement with SCS treatment, while 2 out of 5 studies with mixed radiating leg pain and axial back pain as the primary outcome showed statistically significant improvement with SCS. All randomized controlled trials that included functional status and quality of life outcome measures showed improvement after SCS, though scales utilized in each study varied. Six studies included work status as a patient descriptor with only three reporting inclusion of workers' compensation patients. There was limited data on the effect of psychological status, smoking, sex or race on SCS outcomes based on the studies reviewed. Evidence for the efficacy of SCS in FBSS is accumulating, with most studies demonstrating its efficacy especially for those patients with leg pain as the predominant symptom. However, a significant weakness in the current data includes potential bias based on the funding source for most studies. Additionally, it is clear that SCS provides short-term benefit, yet there is no solid evidence that SCS provides any benefit beyond two years of implantation. Another major concern is the significant placebo effect, which makes the true therapeutic response difficult to judge. Further, it is increasingly important to focus future studies on refining patient populations to those that may best respond to both SCS therapy in general, as well as specific stimulation techniques.

Spinal fluid taps provide temporary relief in patients with unexplained widespread pain and fibromyalgia

Chronic unexplained widespread pain (WSP) and fibromyalgia (FM) are generally assumed centralized pain disorders. However, FM shows characteristics of neurological disorder. Moreover, there are similarities between FM, WSP and cerebrospinal pressure dysregulation syndromes such as idiopathic intracranial hypertension and idiopathic normal pressure hydrocephalus. When intracranial pressure increases, drainage of excess CSF through the cranial and the spinal nerves increases. Increased CSF pressure inside the nerves irritates the nerve fibers and consequently causes widespread radicular pain. We hypothesized that the neurological symptoms may be caused by CSP dysregulation and that withdrawal of spinal fluid might relieve the pain in patients suffering from FM and unexplained WSP. Retrospectively, CSP measurements followed by spinal fluid taps in an attempt to relieve the pain were reviewed in 30 patients (12 males and 18 females, mean age 42.0 y + 11.2 y) suffering from debilitating WSP and FM. Within the first week postpuncture, patients were asked to observe to list the most striking changes of their symptoms. The opening pressure ranged from 12 to 32 cm H20 (mean 19.7 + 4.8 cm H20, median 20.0 cm H20). In 21 patients (70%), spinal fluid withdrawal had a favorable effect on the pain from a few hours to 8 weeks. Other improvements were: relief of low back pain, leg pain and/or coccygodynia; disappearance of headache; improved concentration; improved mood; improved sleep; more clear in the head; being able to sit longer without pain; being able to walk better; no more urinary frequency; more easy to empty the bowel and/or the bladder; less pain in the jaw. Exploring the issues on raised CSP may open perspectives for the diagnosis and treatment of unexplained WSP and fibromyalgia. In patients with chronic pain, when performing a lumbar puncture for diagnostic reasons, opening pressure should be measured.

Anterior Lumbar Interbody Fusion With Cement Augmentation Without Posterior Fixation to Treat Isthmic Spondylolisthesis in an Osteopenic Patient-A Surgical Technique.

Anterior lumbar interbody fusion (ALIF) has been well established as an effective surgical intervention for chronic back pain due to osteoporotic vertebral collapse. Historically, ALIF has consisted of an anterior approach to disc height restoration with a subsequent posterior pedicle screw fixation. Although the applications of cement augmentation with posterior fixation have been previously reported, treatment of patients with both isthmic spondylolisthesis and decreased bone mineral density using a stand-alone ALIF is controversial because of concerns for decreased fusion rates and increased subsidence risk, respectively. We report a case of stand-alone ALIF used to treat a low-grade isthmic spondylolisthesis in the setting of idiopathic thoraco-lumbar scoliosis in a patient with secondary degenerative changes and discuss the benefits of this surgical technique in a patient with several comorbidities. An osteopenic 66-year-old woman with multiple medical comorbidities and 2 years of left radicular leg pain was found to have a Myerding grade I isthmic spondylolisthesis in the setting of idiopathic thoraco-lumbar scoliosis with secondary changes. The patient underwent an L5-S1 stand-alone ALIF with anterior cement augmentation without posterior pedicle screw fixation. The patient experienced immediate relief of radicular leg pain postoperatively and had an uneventful course. At 2 years follow-up, she remained symptom free, and radiographs showed excellent fusion and maintenance of intervertebral disc height. The use of stand-alone ALIF with anterior cement augmentation of the vertebral bodies is a surgical technique that could produce excellent improvement in patients with low-grade isthmic spondylolisthesis in the setting of osteopenia. The use of the all-anterior approach in similar patients with multiple medical comorbidities can also be a useful technique, as it decreases associated morbidity of surgery and complication risks associated with prolonged operative times.

The Value of Short-Term Pain Relief in Predicting the Long-Term Outcome of Lumbar Transforaminal Epidural Steroid Injections.

A previous report demonstrated predictive power of short-term leg pain relief after lumbar transforaminal epidural steroid injections for 1-month treatment response. The question whether the long-term response could be similarly predicted remained unanswered. A prospective cohort of 57 patients who underwent a transforaminal epidural steroid injection for sciatica secondary to a lumbar disc herniation was followed for 24 months. Leg and back pain on the visual analog scale, health-related quality of life using the 12-Item Short Form Survey, and functional outcome using the Oswestry Disability Index were assessed. Responders were defined as not receiving any additional invasive treatment after a single injection. Patients who underwent a second injection or surgery were defined as treatment failures (nonresponders). At 24 months, 31 (54.4%) patients were responders, and 26 (45.6%) were nonresponders. Nonresponders left follow-up at 1 month (n= 9), 3 months (n= 9), 6 months (n= 6) and 12 months (n= 2). No patients were injected again or operated on between the 12- and 24-month follow-up. Responders at 24 months had significantly lower visual analog scale leg pain (P < 0.05) than nonresponders starting from the second week after TFESI and better 12-Item Short Form Survey scores and less disability on the Oswestry Disability Index. Most patients with a symptomatic lumbar disc herniation who opt for a second injection or surgery do so within the first 6 months. Reliable prediction of the long-term treatment response based on short-term pain relief is not possible.

Endovascular treatment of iliofemoral deep vein thrombosis in pregnancy using US-guided percutaneous aspiration thrombectomy.

We aimed to describe ultrasonography (US)-guided percutaneous aspiration thrombectomy in pregnant women with iliofemoral deep vein thrombosis. This study included nine pregnant women with acute and subacute iliofemoral deep vein thrombosis, who were severe symptomatic cases with massive swelling and pain of the leg. Patients were excluded from the study if they had only femoropopliteal deep vein thrombosis or mild symptoms of deep vein thrombosis. US-guided percutaneous aspiration thrombectomy was applied to achieve thrombus removal and uninterrupted venous flow. The treatment was considered successful if there was adequate venous patency and symptomatic relief. Complete or significant thrombus removal and uninterrupted venous flow from the puncture site up to the iliac veins were achieved in all patients at first intervention. Complete relief of leg pain was achieved immediately in seven patients (77.8%). Two patients (22.2%) had a recurrence of thrombosis in the first week postintervention. One of them underwent a second intervention, where percutaneous aspiration thrombectomy was performed again with successful removal of thrombus and establishment of in line flow. Two patients were lost to follow-up after birth. None of the remaining seven patients had rethrombosis throughout the postpartum period. Symptomatic relief was detected clinically in these patients. Endovascular treatment with US-guided percutaneous aspiration thrombectomy can be considered as a safe and effective way to remove thrombus from the deep veins in pregnant women with acute and subacute iliofemoral deep vein thrombosis.

Is the duration of pre-operative conservative treatment associated with the clinical outcome following surgical decompression for lumbar spinal stenosis? A study based on the Spine Tango Registry.

The incidence of lumbar spinal stenosis (LSS) continues to rise, with both conservative and surgical management representing options for its treatment. The timing of surgery for LSS varies from shortly after the onset of symptoms to several months or years after conservative treatment. The aim of this study was to investigate the association between the duration of pre-operative conservative treatment and the ultimate outcome following surgical interventions for LSS. The study was based on prospective multicentre registry data (Spine Tango). Cases of LSS with a documented duration of conservative treatment, undergoing spinal decompression with at least one post-operative patient assessment between 3 and 30months, were included in the study. Cases of LSS with spondylolisthesis, additional spinal pathology or previous spinal surgery were excluded. Interrogation of the Spine Tango Registry listed 3478 patients meeting the prescribed inclusion criteria. This cohort was stratified into four groups: (1) no previous treatment (n=497; 14.3%), (2) conservative treatment <6months (n=965; 27.8%), (3) conservative treatment between 6 and 12months (n=758; 21.8%), and (4) conservative treatment >12months (n=1258; 36.1%). Group 4 reference group in regression analysis. The inverse probability of treatment weighting (IPTW) was applied using the propensity score to balance the groups for their characteristics. Outcome measures included achievement of the minimum clinically important change (MCIC) score of 2 points for (a) back pain, (b) leg pain and (c) Core Outcome Measures Index (COMI), and (d) surgical complications, (e) general complications and (f) operation time >2h. Patient group ("duration of conservative therapy") was not associated with achievement of the MCIC for post-operative relief of leg pain (p=0.22), achievement of MCIC for the COMI score (p=0.054), surgical complications (p=0.11) or general complications (p=0.14). Only MCIC for post-operative relief of back pain (p=0.021) and operation time were significantly associated with patient group (p=0.038). However, compared with the reference group of >12months of conservative treatment there was no significant difference in the likelihood of achieving the MCIC for those with none, <6 or 6-12months of conservative treatment. The duration of pre-operative conservative treatment was not associated with the ultimate outcome of decompression surgery. Further research is required to investigate optimal thresholds/indications for surgery and its appropriate timing in individual patients.

Surgery versus prolonged conservative treatment for sciatica associated with lumbar disc herniation

Background and objective: There is little information available on comparing conservative versus immediate surgery results in the long run for patients with lumbar disc herniation in the modern clinical practice. The aim of this study was to assess one-year outcomes of patients with sciatica resulting from a lumbar disc herniation treated surgically versus non-surgically in two hospitals in Erbil Methods: A prospective comparative cohort study was conducted over two years (January 2010 to February 2012). A sample 100 patients, 50 treated surgically and 50 conservatively, were followed up for one year. All participants had baseline interviews with follow-up questionnaires filled in the next specially designed follow up visits along the study time at regular intervals of 2, 8, 28 and 52 weeks. The outcome included patient-reported symptoms of leg and back pain, functional status, satisfaction versus expectation and working capacity after treatment or overall disability degree. Results: Change in the modified Roland back-specific functional status scale favored surgical treatment initially, and the relative benefit decreased but persisted over the follow-up period. Despite these differences, work and disability status at one year were comparable among those treated surgically or non-surgically. Conclusion: Surgically treated patients with a herniated lumbar disc had more complete relief of leg pain and improved function and satisfaction compared with non-surgically treated patients over one year. Nevertheless, improvement in the patient's predominant symptom and work and disability outcomes were closely similar regardless of treatment received

Relief of Lower Back and Leg Pain after Myelography.

Introduction:It is well-known that many patients will have adverse reactions such as headache and nausea after undergoing myelography, but we have often seen cases where symptoms such as lower back pain and leg pain were alleviated following myelography. To the best of our knowledge, such clinical cases of post-myelographic alleviation have not been reported.Materials and Methods:A total of 325 patients with a degenerative lumbar spinal disorder who underwent myelography were prospectively investigated at four hospitals from April 2012 to March 2014 to survey the post-myelographic alleviation of lower back and leg pain prospectively. The severities of lower back pain, leg pain and numbness of the lower extremities were evaluated and intermittent claudication distance was measured before myelography. The magnetic resonance imaging (MRI) findings and myelographic findings were also evaluated for the patients that their symptoms were improved.Results:Thirty-five of 325 cases (10.8%) of these patients had their symptoms alleviated after undergoing myelography; 26 cases of lower back pain, two cases of leg pain, two cases of numbness of the lower extremity, and five cases of intermittent claudication.Conclusion: In the patients of a degenerative lumbar spinal disorder, about 10% cases with lower back pain or intermittent claudication had post-myelographic alleviation. Intradural injection therapy might be a therapeutic method to alleviate these symptoms.

The Value of Short-Term Pain Relief in Predicting the One-Month Outcome of Lumbar Transforaminal Epidural Steroid Injections

Clinical management after epidural steroid injections of patients with radiculopathy secondary to a lumbar disc herniation is uncertain. It is the aim of this study to determine whether short-term alleviation of leg pain after computed tomography-guided transforaminal epidural steroid injections can predict the 1-month outcome. Prospective observational study of 57 patients at a tertiary radiological department. Study components were visual analog scale leg and back pain at baseline, 15, 30, 45 minutes, 1, 2, and 4 hours, on days 1-14, as well as at 1 month. Health-related Quality of Life and functional impairment were assessed with the Short Form-12 and Oswestry Disability Index. Patients who reported >80% persisting leg pain, as well as patients who underwent a second injection or an operation within 1 month, were defined as nonresponders. Logistic regression was used to analyze the effect size of the relationship between >50% pain relief at any given study visit and responder status. Patients experiencing a >50% pain reduction 4 hours after the injection were 3.38 times as likely to beresponders as those experiencing ≤50% pain reduction (odds ratio 3.38, 95% confidence interval 1.07-10.65). The effect decreased between days 1 and 2, reappeared on day3, was strongest on day 6 (odds ratio 6.87, 95% confidence interval 1.99-23.72), and remained significant until day14. The results of this study can guide physicians in managing patients with lumbar disc herniation: a ≤50% leg pain relief within 1 week after a transforaminal epidural steroid injection predicts an unfavorable 1-month outcome and suggests that other treatment options may be considered.

Microscopic tubular discectomy for far lateral lumbar disc herniation

Microscopic tubular discectomy (MTD) reduces muscle trauma associated with treatment of far lateral lumbar disc herniation (FLDH), but data from randomised controlled studies concerning its efficacy on posterolateral disc herniation, has failed to demonstrate its superiority over standard open techniques. Importantly concerns have been raised that it may be inferior in terms of relief of leg and back pain. Although several FLDH series show that MTD can deliver excellent outcomes, the volume of literature in this field has remained small and evidence based on health-related quality of life (HRQOL) measures, scarce. In this study we therefore evaluated the role of MTD for FLDH through analysing multiple HRQOL scores collected in a prospective database. We identified 24 patients who underwent MTD through a caudal approach, targeting directly the disc space to minimise traction on the dorsal root ganglion implicated in causing iatrogenic neuralgia. With a mean follow-up of 9.2months, the improvement in Oswestry Disability Index and Short Form 36 physical functioning and bodily pain scores was 32, (95% confidence interval [CI]: 21–43), 40 (95% CI: 30–51) and 35 (95% CI: 26–43) respectively. The improvement on the Visual Analogue Scale was 38mm (95% CI: 23–54) and 35mm (95% CI: 21–48) for leg pain and back pain respectively. There was no postoperative neuralgia noted and no reoperation required. Our data demonstrated clinically meaningful treatment effects and compare favourably with HRQOL surgical outcomes established for posterolateral disc herniation, supporting MTD as a valid treatment option for FLDH.

Evaluation of the Effectiveness of Percutaneous Octapolar Leads in Pain Treatment with Spinal Cord Stimulation of Patients with Failed Back Surgery Syndrome During a 1-Year Follow-Up: A Prospective Multicenter International Study.

To evaluate the effectiveness and safety of percutaneous octapolar (8-contact) leads in spinal cord stimulation (SCS) treatment of failed back surgery syndrome (FBSS) patients who have not reached their therapy goals with other treatment interventions. Our prospective, multicenter, open-label, nonrandomized study included 93 patients ≥18years of age suffering from chronic (≥6months), intractable pain predominantly in the legs. Patients implanted with octapolar lead(s) and a neurostimulator after a successful test trial were followed for 12months. Patients provided self-reported data on change in visual analog scale (VAS) score for leg pain (primary outcome) and low back pain, quality of life (EuroQol 5 dimensions [EQ-5D] index), sleep, medication use, and paresthesia coverage (secondary outcomes). Adverse events and preferred stimulation settings were documented. Eighty-one (87%) patients had a successful SCS trial. Patients reported significantly improved leg pain relief; average VAS score was 72±17 prior to SCS treatment and 32±24 at 12 months (P<0.001). Significant decrease in back pain (P<0.001), improvement in quality of life (P<0.001), and improvement in sleep (P<0.05) was observed. Sixty-three percent and 40% of patients were responders (≥50% pain reduction) on leg and back pain, respectively, after 12months. A decrease in medication use was seen for antidepressants and anticonvulsants. Eighty-eight percent of the patients managed with 1 or 2 programs for optimal effect and paresthesia coverage. Twenty-five SCS-related adverse events were registered in 22 patients (24%). Surgical revision due to lead displacement or dysfunction was needed in 6 (6%) of the patients. Use of percutaneous octapolar SCS leads gives significant long-term pain relief and improvement in quality of life and sleep in FBSS patients. The outcomes are better than reported on 4-contact leads and indicate that the progress in SCS technology that has taken place during the past decade correlates with therapy improvements.

High Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Chronic Pain: 6-Month Australian Clinical Experience

Background: High frequency spinal cord stimulation at 10 kHz (HF10 therapy) represents a prominent advance in spinal cord stimulation (SCS) therapy, having demonstrated enhanced efficacy in patients with back and leg pain and pain relief without paresthesia that is sustained at 24 months post implant. Objective: To report on the effectiveness HF10 SCS therapy for a wide range of intractable pain conditions in clinical practice. Study Design: Retrospective investigation of 256 patients who trialed HF10 SCS for chronic intractable pain of various etiologies. Setting: Three Australian pain clinics. Methods: Two hundred fifty-six patients trialed HF10 SCS with view of a permanent implant if successful. Pain distributions included back + leg, back only, head ± neck, and neck ± arm/ shoulder. About 30% of patients had previously failed traditional low-frequency paresthesiabased stimulation, while the remaining cohort were either highly refractory to treatment or not recommended by the pain physician for traditional SCS. Pain scores (numerical pain rating scale – NPRS) and functional outcome measures (Oswestry Disability Index – ODI; and activity tolerance times) were assessed at baseline, post-trial, and at 3 and 6 months post-implant as available in the medical records. Results: Of the 256 patients, 189 (73%) reported a positive trial and were implanted. Patients with back + leg pain demonstrated the highest trial success rate (81%). A mean reduction in pain, among those for whom data were available, of 50% was sustained up to 6 months postimplant across the entire patient population. Sixty-eight percent of patients who failed traditional SCS reported a positive trial and mean pain relief at 6 months was 49% (P &lt; 0.001). An 8.6 point reduction in ODI (21%) at 6 months and improved sitting, standing, and walking tolerances were also reported. Limitations: As data was collected retrospectively, missing data points were unavoidable; this was primarily due to inconsistent data collection and patients being lost to follow-up. Patient populations were diverse and a control group was not appropriate in this setting. Conclusions: These retrospective results demonstrate a significant advancement for patients suffering with chronic intractable pain and are consistent with recently published clinical results for HF10 SCS. HF10 SCS appears to be a viable, paresthesia-free alternative to traditional SCS, with high trial success rates, demonstrated effectiveness in a range of pain distributions including those typically difficult to treat with traditional SCS, and the possibility to restore pain control in patients who have previously failed traditional SCS. Key words: Spinal cord stimulation, high frequency stimulation, HF10, paresthesia-free stimulation, back pain, leg pain, cervical pain, neuromodulation

Use of Neuropathic Pain Questionnaires in Predicting the Development of Failed Back Surgery Syndrome following Lumbar Discectomy for Radiculopathy

Objective Failed back surgery syndrome has been historically used to describe extremity neuropathic pain in lumbar disease despite structurally corrective spinal surgery. It is unclear whether specific preoperative pain characteristics predict patients prone to such postoperative disabling symptoms. Clinical predictors of patients unlikely to improve following surgical intervention has significant implications on patient selection to undergo spinal surgery. Methods This prospective study analyzed consecutive surgical microdiscectomy patients treated for lumbar degenerative painful radiculopathy. Clinical parameters included general demographics, preoperative and postoperative clinical examination, self-reported pain and disability scores, and neuropathic pain scoring. The neuropathic pain screening tests used in this study were the Douleur Neuropathique 4 (DN4) and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), with correlation tested using Spearman's correlation coefficient for ordinal score and screen positivity. Multiple logistic regression analysis was used to define predictors of postoperative symptomatology. Results Twelve percent of the 250 surgical radiculopathy patients underoing microdiscectomy experienced persistent postoperative neuropathic pain (PPNP) with only modest if any relief of leg pain. The condition was highly associated with abnormal preoperative screens for neuropathic pain, but not gender, smoking status, or preoperative pain severity (α=0.05). Good correlation was seen between the two screening tests used in this study for both absolute ordinal score (Spearman's ρ=0.84, p &lt; 0.001) and thresholding for terming the patient as having neuropathic pain features (Spearman's ρ=0.48, p &lt; 0.001). Younger age at treatment also correlated with a higher likelihood of developing PPNP ( p = 0.03). With regards to predictive value, the positive and negative predictive values for FBSS are 40% and 97% for the DN4 and 70% and 96% for the LANSS respectively. Conclusion This cohort of surgical patients was evaluated using validated neuropathic pain screening tools to understand the presence of these features among lumbar radiculopathy patients. Good correlation was seen between both DN4 and LANSS screening tools, suggesting that neuropathic pain diagnosis does exist among a surgical cohort of lumbar radiculopathy patients, with further findings that exceeding established threshold values portends worse prognosis for postoperative recovery. These findings will better inform both patient and surgeon with regards to surgical expectations and decision-making for cases where neuropathic pain features exist, and screening for such diagnosis is recommended in a complete evaluation of the spine surgical patient. References Asch HL, Lewis PJ, Moreland DB, et al. Prospective multiple outcomes study of outpatient lumbar microdiscectomy: should 75 to 80% success rates be the norm? J Neurosurg 2002;96(1, Suppl)34–44 Unal-Cevik I, Sarioglu-Ay S, Evcik D. A comparison of the DN4 and LANSS questionnaires in the assessment of neuropathic pain: validity and reliability of the Turkish version of DN4. J Pain 2010;11(11):1129–1135 Voorhies RM, Jiang X, Thomas N. Predicting outcome in the surgical treatment of lumbar radiculopathy using the Pain Drawing Score, McGill Short Form Pain Questionnaire, and risk factors including psychosocial issues and axial joint pain. Spine J 2007;7(5):516–524

Functional Outcome of Lumbar Discectomy by Fenestration Technique in Lumbar Disc Prolapse - Return to Work and Relief of Pain.

Low back pain affects every population and is one of world's foremost debilitating conditions. Clinically significant sciatica due to lumbar disc prolapse occurs in 4-6% of population. Fenestration discectomy as a surgical procedure is less time consuming, with lesser blood loss, lesser post-operative complications and does not compromise with stability of spine when compared to laminectomy. Present study was conducted to determine extent of functional recovery i.e. pain relief and return to work in patients with lumbar disc prolapse treated by fenestration technique. From October 2010 to March 2012, 50 patients with signs and symptoms of prolapsed lumbar intervertebral disc who failed to respond to conservative treatment were operated for discectomy by fenestration technique and studied prospectively. Functional outcome was evaluated by 'Back Pain Functional Score (BPFS)' of Strafford et al., PROLO rating scale to determine preoperative functional and economical status and outcome at final follow up after 6 months. In order to identify physical signs from non organic signs Wadell's score system was used. Result of surgery was evaluated with help of McNab's criteria. In our study, according to Back Pain Functional Scale by Strafford et al., and PROLO scale, good results were found in 42 (84%) cases, fair result in 8 cases (16%) and none with poor results at follow up of six months. According to PROLO economical and functional scale, 84% cases were able to join their previous occupation at end of six months and 76% cases had complete pain relief. In our study, correlation of age and duration of symptoms to functional outcome was statistically significant (p=0.089 & p = 0.098+ respectively) showing more good results among patients with age less than 30 years and patients having duration of symptoms less than 6 months. Functional outcome of fenestration technique in terms of return to work and complete back and leg pain relief at end of six months had been satisfactory in our study. Moreover, old age, long duration of symptoms and presence multiple psychological issues are negative predictors of functional outcome.

Short-Term Clinical Result of Cortical Bone Trajectory Technique for the Treatment of Degenerative Lumbar Spondylolisthesis with More than 1-Year Follow-Up.

Study DesignRetrospective follow-up study on the result of surgical treatment for patients with degenerative lumbar spondylolisthesis (DLS) using cortical bone trajectory (CBT) technique.PurposeTo evaluate the capability of CBT to manage patients with DLS.Overview of LiteratureCBT is a recently advocated, novel, less-invasive technique of lumbar pedicle screw, which provides enhanced screw purchase by maximizing the thread contact with higher density bone surface. Despite the frequent use of CBT technique in the lumbar spine surgery, little is known of the capability of this technique to manage patients with DLS.MethodsThirty two consecutive patients (5 males, 27 females) surgically treated with single-level DLS in our institute using CBT were included. All patients were followed up at least 12 months (mean 24 months). Their clinical and radiological features were measured.ResultsGood leg pain relief was achieved in all patients. The mean postoperative percentage slip demonstrated significant reduction with significant neurological recovery when compared with preoperative percentage slip, and it was maintained until the latest follow-up. Loss of correction of more than 3 mm during the follow-up period was observed in 3 cases. Surgical site infection was observed in one case; however, pull-out of PSs or neurological deterioration was not found. No patient needed additional surgery during the follow-up period.ConclusionsThese preliminary results confirmed that CBT is useful for the treatment for patients with DLS. This technique allows good reduction of spondylolisthesis and neurological improvement.