Relief Of Leg Pain Research Articles

Results From a Prospective, Clinical Study (US-nPower) Evaluating a Miniature Spinal Cord Stimulator for the Management of Chronic, Intractable Pain

BACKGROUND: Chronic, intractable, neuropathic pain is readily treatable with spinal cord stimulation (SCS). Technological advancements, including device miniaturization, are advancing the field of neuromodulation. OBJECTIVES: We report here the results of an SCS clinical trial to treat chronic, low back and leg pain, with a micro-implantable pulse generator (micro-IPG). STUDY DESIGN: This was a single-arm, prospective, multicenter, postmarket, observational study. SETTING: Patients were recruited from 15 US-based comprehensive pain centers. METHODS: This open-label clinical trial was designed to evaluate the performance of the Nalu™ Neurostimulation System (Nalu Medical, Inc., Carlsbad, CA) in the treatment of low back and leg pain. Patients, who provided informed consent and were successfully screened for study entry, were implanted with temporary trial leads. Patients went on to receive a permanent implant of the leads and micro-IPG if they demonstrated a >= 50% reduction in pain during the temporary trial period. Patient-reported outcomes (PROs), such as pain scores, functional disability, mood, patient impression of change, comfort, therapy use profile, and device ease of use, were captured. RESULTS: At baseline, the average pain Visual Analog Scale (VAS) score was 72.1 ± 17.9 in the leg and 78.0 ± 15.4 in the low back. At 90 days following permanent implant (end of study), pain scores improved by 76% (VAS 18.5 ± 18.8) in the leg and 75% (VAS 19.7 ± 20.8) in the low back. Eighty-six percent of both leg pain and low back pain patients demonstrated a >= 50% reduction in pain at 90 days following implant. The comfort of the external wearable (Therapy Disc and Adhesive Clip) was rated 1.16 ± 1.53, on average, at 90 days on an 11-point rating scale (0 = very comfortable, 10 = very uncomfortable). All PROs demonstrated statistically significant symptomatic improvement at 90 days following implant of the micro-IPG. LIMITATIONS: Limitations of this study include the lack of long-term results (beyond 90 days) and a relatively small sample size of 35 patients who were part of the analysis; additionally, there was no control arm or randomization as this was a single-arm study, without a comparator, designed to document the efficacy and safety of the device. Therefore, no direct comparisons to other SCS systems were possible. CONCLUSIONS: This clinical study demonstrated profound leg and low back pain relief in terms of overall pain reduction, as well as the proportion of therapy responders. The study patients reported the wearable aspects of the system to be very comfortable. KEY WORDS: Spinal cord stimulation, chronic pain, radiculopathy, micro-IPG, battery-free, persistent spinal pain syndrome, failed back surgery syndrome, low back pain, leg pain

Association of prolonged symptom duration with poor outcomes in lumbar spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

There is a scarcity of large multicenter data on how preoperative lumbar symptom duration relates to postoperative patient-reported outcomes (PROs). The objective of this study was to determine the effect of preoperative and baseline symptom duration on PROs at 90 days, 1 year, and 2 years after lumbar spine surgery. The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations between January 1, 2017, to December 31, 2021, with a follow-up of 2 years. Patients were stratified into three subgroups based on symptom duration: < 3 months, 3 months to < 1 year, and ≥ 1 year. The primary outcomes were reaching the minimal clinically important difference (MCID) for the PROs (i.e., leg pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), EQ-5D, North American Spine Society satisfaction, and return to work). The EQ-5D score was also analyzed as a continuous variable to calculate quality-adjusted life years. Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios, with the < 3-month cohort used as the reference. There were 37,223 patients (4670 with < 3-month duration, 9356 with 3-month to < 1-year duration, and 23,197 with ≥ 1-year duration) available for analysis. Compared with patients with a symptom duration of < 1 year, patients with a symptom duration of ≥ 1 year were significantly less likely to achieve an MCID in PROMIS PF, EQ-5D, back pain relief, and leg pain relief at 90 days, 1 year, and 2 years postoperatively. Similar trends were observed for patient satisfaction and return to work. With the EQ-5D score as a continuous variable, a symptom duration of ≥ 1 year was associated with 0.04, 0.05, and 0.03 (p < 0.001) decreases in EQ-5D score at 90 days, 1 year, and 2 years after surgery, respectively. A symptom duration of ≥ 1 year was associated with poorer outcomes on several outcome metrics. This suggests that timely referral and surgery for degenerative lumbar pathology may optimize patient outcome.

Response to Preoperative Steroid Injections Predicts Surgical Outcomes in Patients Undergoing Fusion for Isthmic Spondylolisthesis.

Retrospective cohort study. The decision to pursue operative intervention for patients with isthmic spondylolisthesis is complex. Although steroid injections are a well-accepted therapeutic modality that may delay or obviate surgery, little is known regarding their ability to predict surgical outcomes. Here, we examine whether improvement after preoperative steroid injections can accurately predict clinical outcomes after surgery. A retrospective cohort analysis was performed on adult patients undergoing primary posterolateral lumbar fusion for isthmic spondylolisthesis between 2013 and 2021. Data were stratified into a control (no preoperative injection) group and an injection group (received a preoperative diagnostic and therapeutic injection). We collected demographic data, peri-injection visual analog pain scores (VAS) pain scores, PROMIS pain interference and physical function scores, Oswestry Disability Index, and VAS pain (back and leg). Student t test was utilized to compare baseline group characteristics. Linear regression was performed comparing changes in peri-injection VAS pain scores and postoperative measures. Seventy-three patients did not receive a preoperative injection and were included in the control group. Fifty-nine patients were included in the injection group. Of patients who received an injection, 73% had >50% relief of their preinjection VAS pain score. Linear regression revealed a positive interaction between the injection efficacy and postoperative pain relief as measured by VAS leg scores ( P <0.05). There was also an association between injection efficacy and back pain relief, though this did not achieve statistical significance ( P =0.068). No association was found between injection efficacy and improvement in Oswestry Disability Index or PROMIS measures. Steroid injections are often utilized in the nonoperative therapeutic management of patients with lumbar spine disease. Here, we demonstrate the diagnostic value of steroid injections in predicting postoperative leg pain relief in patients undergoing posterolateral fusion for isthmic spondylolisthesis.

Risk factors for ninety-day readmissions following full-endoscopic transforaminal lumbar discectomy for 1542 patients in the biggest spine institutes in Korea.

Endoscopic techniques are becoming popular among spine surgeons because of their advantages. Though the advantages of endoscopic spine surgery are evident and patients can be discharged home within hours of surgery, readmissions can be sought for incomplete relief of leg pain, recurrent disc herniation, and recurrent leg pain. We aim to find out the factors related to the readmission of patients treated for lumbar pathologies. This is a retrospective analysis of the data between the time duration of 2012 and 2022. Patients in the age group of 18-85years, with lumbar disc herniation treated by transforaminal endoscopic lumbar procedures, were included. The patients who were readmitted within 90days were included in the R Group and those who were not were included in the NR group. Univariable and multivariable logistic regression analyses were used to find the risk factors for 90-day readmission. There were a total of 1542 patients enrolled in this study. Sex, number of episodes before admission, hypertension, smoking, BMI, migration, disc height, disc height index, spondylolisthesis, instability, pelvic tilt (PT), and disc cross-sectional area (CSA) were found significant on univariable analysis. Age, spondylolisthesis, instability and muscle CSA were the only variables that were found to be statistically significant on multivariable analysis. This study shows that the elderly age group, presence of spondylolisthesis, segmental instability and decreased muscle cross-sectional area are independent risk factors for 90-day hospital readmissions. Patients having the above risk factors should be carefully counseled regarding the possibility of readmission in the future.

Non-Invasive Treatments for Failed Back Surgery Syndrome: A Systematic Review.

Systematic Review. The aim of this systematic review is to evaluate the efficacy of non-invasive procedures in relieving chronic pain due to Failed Back Surgery Syndrome (FBSS). Since patients who suffered from FBBS are often non-responders to analgesics, we compared Visual Analogical Scale for low back and leg pain, Oswestry Disability Index, trial success rate, adverse events and complications between conservative treatment groups and control groups. The included studies were 15. Spinal Cord Stimulation (SCS) was performed in 11 trials; 4 studies assessed the efficacy of different epidural injections; one study evaluated repetitive Transcranial Magnetic Stimulation. All the studies reported back and leg pain relief after treatment with SCS, with a significant superiority in high frequences (HFS) group, compared to low frequences (LFS) group. Moreover, disability decreased with each non-invasive treatment evaluated. Epidural injections of steroids and hyaluronidase have shown controversial results. Adverse events were described in 7 studies: lead migration, hardware-related events, infection and incisional pain were the most reported. Finally, trial success rate showed better outcomes for HFS. Our systematic review highlights the efficacy of conservative treatments in FBSS patients, with an improvement in pain scores and a decrease in disability index, especially after SCS with HFS. However, due to the lack of homogeneity among trials and population characteristics, further studies are needed to confirm the effectiveness of non-invasive interventions in patients affected by FBSS.

Efficacy and safety of unilateral biportal endoscopy versus other spine surgery: A systematic review and meta-analysis.

BackgroundThis study aimed to evaluate the efficacy and safety of unilateral biportal endoscopy (UBE) versus other forms of spine surgery.MethodsElectronic databases were systematically searched up to February 2022. The authors used Review Manager 5.3 to manage the data and perform the review.ResultsAfter the preliminary selection of 239 studies from electronic databases, the full inclusion criteria were applied; 16 studies were found to be eligible for inclusion. These 16 studies enrolled 1,488 patients: 653 patients in the UBE group, 570 in the microendoscopic discectomy group, 153 in the percutaneous endoscopic lumbar discectomy group, and 70 in the posterior lumbar interbody fusion group. UBE was superior to microendoscopic discectomy regarding 1-day Visual Analog Scale(VAS) back pain scores (P < 0.00001). No difference was found between UBE and microendoscopic discectomy regarding 1-day Visual Analog Scale leg pain scores (P = 0.25), long-term VAS back pain scores (P = 0.06), long-term VAS leg pain scores (P = 0.05), Oswestry Disability Index scores (P = 0.09) or complications (P = 0.19). Pooled analysis indicated that UBE was similar to percutaneous endoscopic lumbar discectomy regarding 1-day VAS back pain scores (P = 0.71), 1-day VAS leg pain scores (P = 0.37), long-term VAS back pain scores (P = 0.75), long-term VAS leg pain scores (P = 0.41), Oswestry Disability Index scores (P = 0.07) and complications (P = 0.88). One study reported no difference between UBE and posterior lumbar interbody fusion regarding long-term VAS back pain, long-term VAS leg pain, or Oswestry Disability Index scores.ConclusionsUBE is superior to microendoscopic discectomy to relieve back pain 1 day postoperatively. However, these two procedures are similar regarding 1-day leg pain relief, long-term effects, and safety. UBE and percutaneous endoscopic lumbar discectomy are similar regarding 1-day pain relief, long-term effects and safety. More evidence is needed to evaluate the efficacy and safety of UBE versus posterior lumbar interbody fusion.

Risk Factors for Poor Outcomes Following Minimally Invasive Discectomy: A Post Hoc Subgroup Analysis of 2-Year Follow-up Prospective Data.

ObjectiveA post hoc subgroup analysis of prospectively collected data from a randomized controlled trial was conducted to identify risk factors related to poor outcomes in patients who underwent minimally invasive discectomy. MethodsPatients were divided into satisfied and dissatisfied subgroups based on Oswestry Disability Index (ODI), visual analogue scale (VAS) back pain score (VAS-back) and leg pain score (VAS-leg) at short-term and midterm follow-up according to the patient acceptable symptom state threshold. Demographic characteristics, radiographic parameters, and clinical outcomes between the satisfied and dissatisfied subgroups were compared using univariate and multivariate analysis. ResultsA total of 222 patients (92.1%) completed 2-year follow-up, and the postoperative ODI, VAS-back, and VAS-leg were significantly improved after surgery as compared to preoperatively. Multivariate analysis indicated older age (p=0.026), lateral recess stenosis (p=0.046), and lower baseline ODI (p=0.027) were related to poor short-term functional improvement. Higher baseline VAS-back (p=0.048) was associated with poor short-term relief of back pain, while absence of decreased sensation (p=0.019) and far-lateral disc herniation (p=0.004) were associated with poorer short-term relief of leg pain. Lumbar facet joint osteoarthritis was identified as a risk factor for poor functional improvement (p=0.003) and relief of back pain (p=0.031). Disc protrusion (p=0.036) predicted poorer relief of back pain at midterm follow-up. ConclusionIn this study, several factors were identified to be predictive of poor surgical outcomes following minimally invasive discectomy. (ClinicalTrials.gov number: NCT01997086).

Functional outcome of back pain after percutaneous endoscopic lumbar discectomy and annuloplasty for lumbar disc herniation: A prospective study

Objective: Percutaneous Transforaminal endoscopic lumbar discectomy and annuloplasty (PELDA) is a minimally invasive spinal technique for lumbar disc herniation. Following discectomy, the relief of leg pain is common; however, the relief of back pain is less predictable. The purpose of this study was to evaluate changes in back pain and to examine the predisposing factors for postoperative back pain following PELDA. Material and Method: In this prospective study, 104 patients with leg and back pain associated with disc herniation underwent PELDA. The patients were divided into two groups: unfavorable and favorable. Patients were defined as having unfavorable outcomes if the percentage improvement of back pain 20% at postoperative 12 months. The preoperative demo-graphic, clinical, and radiologic factors for each group were statistically analyzed. Results: 104 patients were enrolled in this study. The mean visual analog scale scores for back pain and the ODI scores significantly improved from 6.6 and 55.9% preoperatively to 2.5 and 12.7% at the 12 month follow-up. The surgical satisfaction rate was 78.4% at the final follow-up. Eighteen (34.6%) patients had unfavorable outcomes. Patients with advanced disc degeneration of operative levels had significantly worse outcomes than those with mild disc degeneration (odds ratio: 6.316, 95% confidence interval 1.25–31.86, P

Temporal Pattern of Pain and Disability Following the Administration of a Selective Nerve Root Block in Lumbar Disc Herniation With Radiculopathy

Lumbar disc herniation with radiculopathy has a favorable natural history, and a selective nerve root block (SNRB) is an accepted treatment modality. This study aims to ascertain the temporal pattern of pain and disability following the administration of an SNRB in the management of lumbar disc herniation with radiculopathy because there is limited evidence regarding this issue in the published literature. This prospective study included 50 patients who underwent an SNRB and were followed for 3 months. Numerical Rating Scale (NRS) for back and leg pain and Oswestry Disability Index (ODI) and Depression Anxiety Stress Scales-21 (DASS-21) scores were collected. At the final follow-up at 3 months, the number of patients who underwent surgery was ascertained. Forty-two of 50 (84%) patients avoided the surgery with a reduction in mean preinjection NRS for back and leg pain from 7.5 (SD 1.33) and 7.7 (SD 1.35) to 3.1 (SD 1.69) and 2.3 (SD 1.14) (P < 0.001), respectively, within the 30 minutes after injection. The pain relief was sustained until the last follow-up. The ODI score also decreased from a mean preinjection level of 59.4 (SD 14.69) to 26.3 (SD 9.43) (P < 0.001) at 3 months. The mean preinjection depression score was higher in patients who had recurrence of pain and eventually underwent surgery. Early administration of an SNRB in the course of lumbar radiculopathy is recommended as it provides instantaneous and sustained relief of back and leg pain and disability in a majority of patients. SNRB should be administered early in the course of management of lumbar radiculopathy and should not be delayed until after other non-surgical modalities have failed. 2.

Long-Term Outcome After Midline Lumbar Fusion for the Treatment of Lumbar Spine Instability Due to Degenerative Disease

Midline lumbar fusion (MIDLF) is one promising new surgical technique that has been developed to minimize perioperative damage to the paravertebral stabilizing musculotendinous system. The aim of this study was to assess long-term clinical and radiological effects of MIDLF. This prospective cohort study evaluated patients who underwent MIDLF for degenerative spinal instability. Clinical and radiological examinations were performed before and after surgery. Perioperative and postoperative complications were recorded. Follow-up was 2 years. P ≤ 0.05 was considered statistically significant. The study included 64 patients (mean age 58.9± 10.7 years; 41 women [64.1%]). The most frequent indication for MIDLF was degenerative spondylolisthesis grade I (28 cases [43.8%]); the prevalent spinal segment to be fused was L4-L5 (35 cases [54.7%]). Mean duration of surgery was 148.2 ± 28.9 minutes. Relief of low back pain and leg pain was significant and stable in the postoperative period as assessed by visual analog scale (P < 0.001). Of patients, 86.9% reported fair, good, or excellent outcomes in terms of pain relief based on MacNab score 2 years after surgery. Patients' level of function in activities of daily living improved significantly based on Oswestry Disability Index score: from 66.8 ± 9.8 before surgery to 33.9 ± 16.5 2 years after surgery (P < 0.001). X-rays and computed tomography at 12 months showed interbody fusion in 46 cases (73.4%), inconclusive results in 13 cases (20.3%), and no fusion in 4 cases (6.3%). No damage to neural or vascular structures and no failure of hardware or screw loosening were recorded. MIDLF is a safe, efficient method for surgical treatment of lumbar spine instability. Its limited invasiveness contributes to better preservation of paravertebral muscles and enhanced postoperative spinal stability.

Prevalence of Cannabidiol Use in Patients With Spine Complaints: Results of an Anonymous Survey.

Cannabidiol (CBD) is a cannabis derivative that has been popularized as a medicinal product with analgesic and anti-inflammatory effects. Given the anecdotal observations that several patients have reported use of CBD for spine-related pain, this study was designed to characterize CBD consumption patterns and perceived effects in patients with spine-related complaints. The study design was a cross-sectional survey. Over a 4-week period, an anonymous paper survey was administered to all patients presenting for evaluation by 1 of 9 spine surgeons at a single institution. Surveys were given upon registration for the office visit and collected by the office manager or nurse before evaluation by the surgeon. Patients were included regardless of surgical status (ie, preoperative, postoperative, or nonoperative) or region of pathology (lumbar, thoracic, or cervical). The survey consisted of multiple-choice questions on patient patterns of CBD use. Out of 300 surveys, 214 (71%) were completed. CBD use for spine-related pain was reported by 54 (25.2%) patients. CBD was initially used for potential relief of back pain (66.7%), neck pain (37.0%), leg pain (35.2%), and/or arm pain (9.3%). Users also sought improvements in insomnia (25.9%) and mood (18.5%). Oil was the most popular formulation (64.8%). CBD was most often consumed 2-5 times (40.7%) or 6-10 times (31.5%) per week. The most common source of initial recommendation for CBD was friends or family (75.9%). Reported benefits were pain relief (46.3%), improved sleep (33.3%), and reduced anxiety (20.4%); however, 24.1% of patients reported no benefit from CBD use. The most reported side effect was fatigue (7.4%). Most users (63.0%) would recommend CBD to a friend for pain relief. CBD is already used by many patients, and further high-quality research on this supplement is essential. 4. CBD is a commonly used by spine patients as an off label treatment.

The impact of pathoanatomical diagnosis on elective spine surgery patient expectations: a Canadian Spine Outcomes and Research Network study.

Patients undergoing spine surgery generally have high expectations for improvement postoperatively. Little is known about how these expectations are affected by the diagnosis. The purpose of this study was to examine whether preoperative expectations differ based on diagnostic pathoanatomical patterns in elective spine surgery patients. Patients with common degenerative cervical/lumbar pathology (lumbar/cervical stenosis, lumbar spondylolisthesis, and cervical/lumbar disc herniation) who had given their consent for surgery were analyzed using the Canadian Spine Outcomes and Research Network (CSORN). Patients reported the changes they expected to experience postoperatively in relation to 7 separate items using a modified version of the North American Spine Society spine questionnaire. Patients were also asked about the most important item that would make them consider the surgery a success. Sociodemographic, lifestyle, and clinical variables were also collected. There were 3868 eligible patients identified within the network for analysis. Patients with lumbar disc herniation had higher expectations for relief of leg pain compared with stenosis and lumbar degenerative spondylolisthesis cohorts within the univariate analysis. Cervical stenosis (myelopathy) patients were more likely to rank general physical capacity as their most important expectation from spine surgery. The multinomial regression analysis showed that cervical myelopathy patients have lower expectations for relief of arm or neck pain from surgery (OR 0.54, 0.34-0.88; p < 0.05). Patient factors, including age, symptoms (pain, disability, depression), work status, and lifestyle factors, were significantly associated with expectation, whereas the diagnoses were not. Patients with degenerative spinal conditions consenting for spine surgery have high expectations for improvement in all realms of their daily lives. With the exception of patients with cervical myelopathy, patient symptoms rather than diagnoses had a more substantial impact on the dimensions in which patients expected to improve or their most important expected change. Determination of patient expectation should be individualized and not biased by pathoanatomical diagnosis.

Diagnosis and surgical treatment of symptomatic lumbar spinal epidural liposis

To explore diagnosis and surgical treatment of symptomatic lumbar spinal epidural lipoplasia. A retrospective analysis of 19 patients with symptomatic lumbar spinal epidural hyperplasia treated with hemilaminectomy and interbody fusion and internal fixation from February 2012 to November 2018 were performed, including 7 males and 12 females, aged from 48 to 72 years old with an average of (57.6±1.2) years old;the course of disease ranged from 6 to 60 months with an average of (18.6±5.1) months;plane requiring decompression:L2, 3-L5S1 on 4 cases, L2, 3-L4, 5 on 5 cases, L3, 4-L4, 5 on 2 cases, L3, 4-L5S1 on 6 cases, L4, 5-L5S1 on 2 cases. Visual analogue scale (VAS) before operation and 6 months after opertaionwere used to evaluate relief of leg pain and back pain, Oswestry Disability Index (ODI) was used to evaluate recovery of functiona, and Fischgrund was used to assess overall efficacy. All patients were followed up from 12 to 37 months with an average of (16.3±3.8) months. Ninteen patients were successfully completed operation, and all adipose tissues in the compressed segment of the spinal canal were removed. Operation time was from 125 to 260 min with an average of (186± 15) min, and blood bleeding was from 150 to 500 ml with an average of (280±46) ml. Two patients occurred partial incision fat liquefaction and exudate did not heal, the incision was opened to remove effusion, the dressing was changed and anti-inflammatory treatments were performed. No complications such as cauda equina injury, cerebrospinal fluid leakage, and broken nails occurred. Preopertaive VAS of back pain and leg pain were 5.3±0.7 and 6.8±0.8, respectively, while 2.1±0.4 and 2.3±0.5 respectively at 6 months after opertaion, there were statisticalsignificant difference between 6 months after operation and before operation (P<0.05). Postoperative ODI score at 6 months was 12.1±2.3, and significantly improved than that of before operation 45.5±2.8 (P<0.05). According to Fischgrund criteria, 13 patients got excellent result, 4 good, and 2 fair. Patients with symptomatic lumbar spinal epidural lipoplasia undergo hemilaminectomy and internal fixation of compression segment could relieve compression of dura mater and cauda equina, and achieve good clinical results.

Full-Endoscopic Oblique Lateral Lumbar Interbody Fusion: A Technical Note With 1-Year Follow-Up.

Oblique lateral lumbar interbody fusion (OLLIF) is a minimally invasive lumbar interbody fusion procedure using a bullet-shaped polyetheretherketone (PEEK) nonexpandable fusion cage modified to diminish risk to the exiting nerve root during posterolateral implantation through the Kambin safe zone under fluoroscopic guidance. The objective of this study was to present feasibility of this procedure and 1-year clinical outcome data. The authors present a prospective cohort study of 20 patients who underwent fluoroscopy-guided and full-endoscopic OLLIF in 22 segments allowing protection of the exiting nerve root from January 2018 to March 2019. The foraminoplasty, discectomy, endplate preparation, placement of bone graft and insertion of the fusion cage was done under continuous full-endoscopic visualization. The OLLIF fusion was backed up with bilateral percutaneous posterior supplemental pedicle screw fixation. Primary clinical outcome measures were the visual analog scale (VAS) of low back and leg pain, and Oswestry disability index (ODI) at 1 week, 3 months, 6 months, and 1 year after the operation. At final follow-up, the Macnab score was also evaluated. Secondary outcome measures were computed tomography (CT) assessment fusion using the Mannion classification of spinal fusion and adverse events related to the device as well as magnetic resonance imaging (MRI) assessment of nerve root decompression. All patients had significant relief of low back pain and leg pain, by VAS and ODI scores that improved significantly (P < .01). There were no complications. Postoperative lumbar MRI of all patients showed sufficient direct nerve decompression. At 1-year follow-up, excellent Macnab outcomes were obtained 13 patients, good in six, and fair in one. Impaired sensation and muscle strength of the involved nerve root significantly recovered in all but 2 patients (P < .05). According to the Mannion CT-based classification of spinal fusion, CT showed complete interbody fusion achieved in all 22 segments. Full-endoscopic OLLIF is a safe, effective, minimally invasive, economical, practical, and widely applicable minimally invasive interbody fusion technique in the lumbar spine. 3.

Relief of Low Back Pain After Posterior Decompression for Lumbar Spinal Stenosis.

A retrospective study. The aim of this study was to confirm that decompression for lumbar spinal stenosis (LSS) relieves low back pain (LBP) as adequately as it relieves leg pain and to identify predictors for inadequate LBP relief. Although decompression for LSS is generally thought to yield worse results for LBP than for leg pain, some studies have reported similar improvements in pain scores between LBP and leg pain. To treat LBP or take measures to prevent inadequate LBP relief, reliable predictors for LBP relief should be identified. We retrospectively reviewed 175 patients who underwent posterior element-preserving decompression and evaluated the relief of LBP and leg pain using numeric rating scales (NRSs). Associations between demographic, clinical, or imaging parameters and LBP relief at 1 and 4 years were analyzed by stepwise linear regression analyses. The imaging parameters included Modic change type 1, disc degeneration, foraminal stenosis, vertebral slipping (within Grade 1), scoliosis (<15°) and lordosis. The mean improvements in LBP and leg pain NRS scores from baseline were 5.22 and 4.70 points (P = 0.064, paired t test) at 1 year and 5.12 and 4.62 points (P = 0.068) at 4 years, respectively. Poor LBP scores at 4 years were significantly associated with long-lasting LBP (beta = 0.31, P < 0.0001) and moderate or severe arm symptoms with cervical spinal cord compression or intramedullary hyperintense signal on T2-weighted MRI (beta = 0.22, P = 0.0014). The imaging parameters of the lumbar spine failed to show clear associations with poor LBP scores at 4 years, although Modic change type 1 showed a significant association with poor LBP scores at 1 year (beta = 0.28, P < 0.0001). Posterior decompression relieves LBP as well as leg pain. Long-lasting LBP and concurrent symptomatic cervical myelopathy are important predictors for inadequate LBP relief. There were no reliable imaging parameters predictive of inadequate LBP relief.Level of Evidence: 4.

A comparative study of Lumbar Decompression and Fusion with Internal Fixation versus Simple Decompression in elderly patients with two-segment Lumbar Spinal Stenosis.

Objective:To investigate and compare the effect of decompression and fusion with internal fixation vs. simple decompression in the treatment of elderly patients with two-segment lumbar spinal stenosis (LSS) in perioperative and postoperative follow-up periods.Methods:Twenty-eight elderly patients with two-segment LSS admitted in Baoding First Hospital between Mar. 2017 and Jan. 2018 were retrospectively analyzed. Fifteen patients who underwent simple decompression were included in the simple decompression group, and 13 who underwent decompression and fusion with internal fixation were included in the decompression-fixation group. The general data and perioperative conditions including wound complications, operation time, blood loss, and VAS (legs) and JOA score were analyzed and compared between the two groups.Results:There was no significant difference in postoperative leg pain (VAS) between the two groups, and a statistically significant difference in JOA score was found between the two groups one month after the operation. The operation time, length of stay, and blood loss in the decompression-fixation group were significantly different from those in the simple decompression group and no significant difference in wound complications was observed between the two groups.Conclusion:There is no significant difference in leg pain relief in elderly patients with two-segment LSS when treated with decompression and fusion with internal fixation or simple decompression. Simple decompression is associated with less intraoperative injuries, better postoperative functional recovery, and reduced hospital stay.

A Pilot Study of Full-Endoscopic Annulus Fibrosus Suture Following Lumbar Discectomy: Technique Notes and One-Year Follow-Up

Background: An annulus fissure or defect will inevitably be left on the posterior annulus fibrosus after almost all kinds of lumbar discectomy, which may lead to unsatisfying postoperative pain relief and recurrence of the disc herniation. Objective: The objective of this research is to introduce the technique of full-endoscopic annulus fibrosus suture following lumbar discectomy through the transforaminal or interlaminar approach, and to analyze the clinical outcome of full-endoscopic lumbar discectomy and annulus fibrosus suture. Study Design: This study used a prospective cohort design. Setting: The research was conducted in a hospital and outpatient surgery center. Methods: A total of 50 patients with noncontained lumbar disc herniation treated with full-endoscopic lumbar discectomy and annulus fibrosus suture were treated in our department between January 2018 and November 2018. Full-endoscopic single-stitch suture via the transforaminal approach (Group T) or double-stitch suture via the interlaminar approach (Group I) was selected according to the level of lesion. Lumbar magnetic resonance imaging (MRI) was reexamined on the second day and 3 months after operation to evaluate the completeness of the discectomy and the adequacy of nerve decompression. Patients were followed up on the second day, 3 months, 6 months, and one year after operation to evaluate the relief of low back pain and leg pain, using a visual analog scale (VAS, 100-point scale). At 3 months, 6 months, and one year after operation, the patients were followed up for recovery of lumbar spine function, using the Oswestry Disability Index (ODI). At the one-year follow-up, the MacNab score was used to evaluate the clinical outcome, and the recovery of nerve root function (sensation, muscle strength, and reflex) was recorded. Results: All operations were successfully completed, including 27 cases in Group T and 23 cases in Group I. There were no surgical complications and no recurrence of lumbar disc herniation. Lumbar MRI reexaminations of all patients showed that the herniated disc was completely removed and the nerves were fully decompressed. Postoperative low back pain and leg pain were significantly relieved, and the ODI score was significantly improved (P &lt; .01) in both groups. At the one-year follow-up, the excellent and good rates as measured by the MacNab score were 92.6% in Group T and 91.3% in Group I with no significant difference between the 2 groups (P &gt; .05). The impaired sensation and muscle strength in the low extremities of evolved nerve root of the 2 groups of patients recovered significantly at the oneyear follow-up (P &lt; .01), but the tendon reflex did not recover significantly (P &gt; .05). Limitations: This is an observational cohort study with relatively small sample sizes and short-term follow-up. Conclusions: Full-endoscopic lumbar discectomy and annulus fibrosus suture through either the transforaminal or interlaminar approach are safe and effective minimally invasive spinal surgery techniques that can reduce the recurrence rate of lumbar disc herniation after full-endoscopic lumbar discectomy. Keywords: Annulus fibrosus suture; full-endoscope; lumbar disc herniation; lumbar discectomy; minimally invasive spinal surgery

Effects of spinal cord stimulation on voxel-based brain morphometry in patients with failed back surgery syndrome

ObjectiveDespite the clinical effectiveness of Spinal Cord Stimulation (SCS), potential structural brain modifications have not been explored. Our aim was to identify structural volumetric changes during subsensory SCS, in patients with Failed Back Surgery Syndrome (FBSS). MethodsIn this cohort study, twenty-two FBSS patients underwent a magnetic resonance imaging protocol before SCS and 3 months after SCS. Clinical parameters were correlated with volumetric changes, calculated with voxel-based morphometry. ResultsAfter 3 months, a significant volume decrease was found in the inferior frontal gyrus, precuneus, cerebellar posterior lobe and middle temporal gyrus. Significant increases were found in the inferior temporal gyrus, precentral gyrus and the middle frontal gyrus after SCS. Additionally, significant increases in volume of superior frontal and parietal white matter and a significant decrease in volume of white matter underlying the premotor/middle frontal gyrus were revealed after SCS. A significant correlation was highlighted between white matter volume underlying premotor/middle frontal gyrus and leg pain relief. ConclusionsThis study revealed for the first time that SCS is able to induce volumetric changes in gray and white matter, suggesting the reversibility of brain alterations after chronic pain treatment. SignificanceVolumetric brain alterations are observable after 3 months of subsensory SCS in FBSS patients.

Open fenestration discectomy versus microscopic fenestration discectomy for lumbar disc herniation: a randomized controlled trial

BackgroundFenestration discectomy, for symptomatic lumbar disc herniation, is the most common surgical procedure in spine surgery. It can be done by open or microscopic procedures. This study compared the results of fenestration microdiscectomy with open fenestration discectomy in the treatment of symptomatic lumbar disc herniation as a relation to the functional outcome, leg pain, back pain, hospital stay, returns to daily activity, cost, recurrence, reoperation and type of surgery for recurrent disc herniation.Methods60 patients age (29 - 50 years), with L4-L5 disc herniation, are divided randomly into group A- 30 patients underwent an open fenestration discectomy- and group B- 30 patients underwent fenestration microdiscectomy. All patients are assessed at 1 week, 3 months, 6 months, 12 months after surgery for Oswestry disability index and Visual analogue scale for back pain and leg pain and followed up for 4 years.ResultsIn both groups, all patients have minimal disability by Oswestry Disability Index after surgery.There were significant differences between means of post-operative Visual Analogue Scale for back pain between these two groups after 1 week (3.7 in group A versus 2.2 in group B) (t = 13.28, P = < 0.001*) and after 3 months (1.73 in group A versus 0.43 in group B) (t = 10.54, P = < 0.001*).There were no significant differences between two groups regarding post-operative VAS for leg pain, recurrence (5 patients in group A versus 4 patients in group B) and reoperation rate (2 patients in each group).There were significant differences between means of length of hospital stay (2.10 in group A versus 1.06 in group B) (P < 0.001), time of returning to daily activities (7.33 in group A versus 4.03 in group B) (P < 0.001) and cost of surgery (1996.66 in group A versus 3003.3 in group B) (P < 0.001).ConclusionUse of microscope in fenestration discectomy for treatment of symptomatic lumbar disc herniation can achieve the same goals of open fenestration regarding nerve root decompression and relief of leg pain with advantage of less back pain, less hospital staying and early return to daily activities with disadvantage of more cost with the use of microscope. With 4 years follow up, there was no significant deference in rate of recurrence and reoperation with the use of microscope but we found that type of surgery for recurrent cases may be less invasive if microscope was used in primary surgery.Trial registrationNCT, NCT04112485. Registered 30 September 2019 - Retrospectively registered, https://clinicaltrials.gov/NCT04112485

10 kHz spinal cord stimulation for the treatment of non-surgical refractory back pain: subanalysis of pooled data from two prospective studies.

SummarySpinal cord stimulation at 10 kHz is a promising therapy for non‐surgical refractory back pain; however, published data are currently limited. We present a subanalysis of prospectively collected clinical outcome data for non‐surgical refractory back pain patients treated with 10 kHz spinal cord stimulation, from the independent cohorts of two previous studies (SENZA‐RCT and SENZA‐EU). Clinical outcomes were evaluated at pre‐implantation (baseline), 3 months, 6 months and 12 months following 10 kHz spinal cord stimulator implantation. These included: pain relief; responder rate (≥ 50% pain relief from baseline); remission rate (VAS ≤ 3.0 cm); disability (Oswestry Disability Index(ODI)); and opioid use. At 3 months, average back pain decreased by 70% in the combined cohort (60% in the SENZA‐RCT and 78% in the SENZA‐EU cohorts). This was sustained at 12 months, with a 73% back pain responder rate and 68% remission rate in the combined cohort. Leg pain relief results were generally comparable to those for back pain relief. At 12 months, the combined cohort had an average decrease in ODI scores of 15.7% points from baseline and opioid use more than halved. In conclusion, 10 kHz spinal cord stimulation reduced pain, disability and opioid consumption in non‐surgical refractory back pain subjects. Application of this therapy may improve the care of non‐surgical refractory back pain patients and reduce their opioid consumption.