Persistent Axial Pain Research Articles

Evaluation of Haplo-Paraspinal-Muscle-Preserving Technique to Prevent Postoperative Axial Pain in Cervical Laminoplasty.

The present study aimed to assess the efficacy of a new haplo-paraspinal-muscle-preserving (HMP) laminoplasty technique in the treatment of cervical myelopathy. The medical records of 68 patients diagnosed with multisegmental cervical myelopathy were retrospectively reviewed. Of these, 22 patients who underwent HMP laminoplasty were defined as the muscle-preserved group (MP), and 46 patients who underwent traditional open-door laminoplasty were enrolled and defined as the traditional open-door laminoplasty group (LP). Patient demographic data and surgical parameters like clinical and radiological parameters, operation duration, blood loss, and spinal canal expansion distance were compared. Average surgical time and blood loss were significantly reduced in the MP group when compared with the LP group (P < 0.05). Both groups demonstrated significant improvements in neurological function and spinal canal expansion (P > 0.05). However, the visual analog scale score in the MP group was significantly lower compared with the LP group at the 6-month follow-up (P < 0.05), but no differences were found at the 1-year follow-up. The loss of lordosis was more prominent in the LP group when compared with the MP group at 1-year follow-up (P < 0.05). Lower events of persistent axial pain were found in the MP group but with no statistical significance. More hinge side laminae fractures could be found in the MP group, but more hinge side displacements were found in the LP group. The HMP laminoplasty technique is relatively safe, effective, easier to perform, and better for lordosis maintenance and complication control compared with the traditional open-door technique. Although traditional open-door laminoplasty is an efficient approach in treating multisegmental cervical myelopathy, the complications could significantly affect the clinical outcome. Our new HMP laminoplasty technique has a lower complication rate and a better lordosis maintenance ability; therefore, it could be a better choice in treating multisegmental cervical myelopathy.

Rationale and Advantages of Endoscopic Spine Surgery.

The goal of a spine surgery is to achieve adequate neural tissue decompression, maintenance of spinal stability, and successful stabilization of an unstable spine. To achieve these surgical goals, damage to normal tissues, including the spinal column and surrounding soft tissues, is inevitable after the beginning of a spine surgery. Extensive damage to normal spinal column and paraspinal collateral tissues during operation can lead to unsuccessful outcomes due to persistent axial pain and additional surgeries due to occurrence of spinal instability. Numerous efforts, such as the usage of microscopy, tubular retractor systems, percutaneous instruments, and trials of new operative approaches have been attempted to reduce normal tissue damage and improve surgical outcomes. Endoscopic spine surgery (ESS) was introduced about 3 decades ago as a minimally invasive spine surgery and has been widely spread with the development of endoscopic surgical instruments and adoption of new endoscopic surgical approaches during the past 2 decades. Theoretically, ESS may be the gold standard method of spine surgery because of its minimal tissue damage and good visualization of the surgical field. However, surgeons hesitate to initiate an ESS due to its steep learning curve and the lack of high-level evidence of surgical outcomes. In this article, the rationale and advantages of performing ESS are discussed by reviewing published articles.

231 The Tolerability and Effectiveness of Duloxetine for the Prevention of Persistent Musculoskeletal Pain After Trauma and Injury: A Pilot Three-Group Randomized Controlled Trial

The primary aim was to examine the tolerability of duloxetine as a preventative treatment for emergency department (ED) patients who present with acute musculoskeletal pain after trauma or an injury. Tolerability was measured by drop-out rate and adverse effects. Secondary outcomes assessed drug effectiveness as measured by: (1) the proportion of participants with moderate to severe pain (numerical rating scale (NRS) > 4) at six weeks (pain persistence); (2) average pain by group over the six-week study period. Eligible participants were 18-69 years of age and had acute moderate to severe axial musculoskeletal pain. Exclusion criteria included: fracture, history of coronary artery disease, uncontrolled hypertension, antidepressant use, and chronic pain. Participants who consented were randomized to two weeks of a daily dose of one of the following: placebo (n=27), 30 mg duloxetine (n=24), and 60 mg duloxetine (n=27). Follow-up assessments were completed at days 3, 7, 10, 14, 17, and 21. An in-person assessment was completed at day 42. Descriptive data were examined. We conducted a mixed-effects model to examine pain over time by group and mechanism (traumatic vs. atraumatic). Participants (n=78 at baseline) were recruited from two EDs in the Northeastern USA. 29/78 (37%) presented after a traumatic stress exposure (motor vehicle collision, MVC), 49/78 (63%) were atraumatic (eg, lifting). Drop-out rates were 11.1%, 12.5%, and 25.9% in the placebo, 30mg, and 60mg groups, accordingly. There were no serious adverse events. Six weeks after enrollment, moderate to severe persistent pain was present in 52%, 50%, and 36% of participants in the placebo, 30mg, and 60mg groups, respectively. Among enrollees experiencing MVC, these proportions were 71%, 67%, and 25%, respectively. Mean MVC-related pain scores at six weeks were 5.3 (2.6), 4.2 (2.5), and 3.0 (2.5), respectively, and the proportion of those who remained very anxious getting in a car six weeks after MVC were 57%, 33%, and 13%, respectively. A piecewise trend with a break at 14 days provided the best fit for pain intensity scores amongst the entire sample. After controlling for age, sex, and race there was a significant difference in pain over time for 60mg vs placebo group (B=-.07, p=.03) across the whole sample, but not the 30mg vs placebo group (B=-.02, p=.51). Although patients receiving 60mg duloxetine had higher drop-out rates than placebo, these drop-out rates were similar to those reported for duloxetine in other pain trials, and no serious adverse events were observed. Among all participants, 60mg duloxetine was associated with a reduction in pain intensity at 6 weeks compared to placebo. Duloxetine may be a promising treatment option for reducing the transition from acute to persistent axial pain. Point estimates suggested that duloxetine may be particularly efficacious among individuals with acute pain after traumatic stress exposure/MVC and may also reduce psychological sequelae in such patients. These data are consistent with the role of stress systems in the development of chronic pain after traumatic stress.

Comparison of the anterior and posterior approach in treating four-level cervical spondylotic myelopathy.

The optimal surgical approach for four-level cervical spondylotic myelopathy remains controversial. The purpose of this study was to compare clinical and radiological outcomes and complications between the anterior and posterior approaches for four-level cervical spondylotic myelopathy. A total of 19 patients underwent anterior decompression and fusion and 25 patients underwent posterior laminoplasty and instrumentation in this study. Perioperative information, intraoperative blood loss, clinical and radiological outcomes, and complications were recorded. Japanese Orthopedic Association (JOA) score, 36-item short form survey (SF-36) score and cervical alignment were assessed. There were no significant differences in JOA scores between the anterior and posterior group preoperatively (11.6 ± 1.6 vs. 12.1 ± 1.5), immediately postoperatively (14.4 ± 1.1 vs. 13.8 ± 1.3), or at the last follow-up (14.6 ± 1.0 vs. 14.2 ± 1.1) (P > 0.05). The JOA scores significantly improved immediately postoperatively and at the last follow-up in both groups compared with their preoperative values. The recovery rate was significantly higher in the anterior group both immediately postoperatively and at the last follow-up. The SF-36 score was significantly higher in the anterior group at the last follow-up compared with the preoperative value (69.4 vs. 61.7). Imaging revealed that there was no significant difference in the Cobb angle at C2-C7 between the two groups preoperatively (-2.0° ± 7.3° vs. -1.4° ± 7.5°). The Cobb angle significantly improved immediately postoperatively (12.3° ± 4.2° vs. 9.2° ± 3.6°) and at the last follow-up (12.4° ± 3.5° vs. 9.0° ± 2.6°) in both groups compared with their preoperative values (P = 0.00). Three patients had temporary dysphagia in the anterior group and four patients had persistent axial symptoms in the posterior group. Both the anterior and posterior approaches were effective in treating four-level cervical spondylotic myelopathy in terms of neurological clinical outcomes and radiological features. However, the JOA score recovery rate and SF-36 score in the anterior group were significantly higher. Persistent axial pain could be a major concern when undertaking the posterior approach.

The Role of Minimal Invasive Split Laminotomy, the Alternative Parasplit Approach and the “Arch bone” Technique in Surgical Removal of Axial Longitudinal Pathologies in the Spinal Canal

Introduction Conventional approaches to open the spinal canal carries the risk of spinal deformities, instability, subluxation, and invariably separate the muscle attachments from the spinous processes and laminae. Damage to these muscles and bony connections can lead to persistent axial pain and cervical malalignment. With the aim of preserving and reconstructing the posterior structures, the authors developed a novel minimal invasive multilevel spinous process splitting and distraction laminotomy approach, the “arch bone” and the additional rescue parasplit technique. Patients and Methods These novel techniques were used in 70 adult patients with mainly midline located intramedullary pathologies of the cervical, thoracic, and thoracolumbar spine. All muscle attachments on the spinous processes and laminas, as well as the laminas themselves, were completely preserved. With the aim of moderate enlargement of the spinal canal, a spacer was placed between the bony parts facing each other in case of total resection of an intramedullary tumor was not possible. When midline splitting is not feasible or convenient because of anatomical differences of the spinous processes and laminas, we used the parasplit approach. The patients were followed with regular MRI, CT scans, fluoroscopy, and neurological examinations. Results The midline opening of the spinal canal gave a key-hole approach, achieving an adequate view of the intraspinal space for surgery in its entire longitudinal extension. The approach used did not affect the extent of resection proved by MRI evaluation or neurological outcome. The numbers of splitted laminae were 3 to 10. The incidence of postoperative local pain was lower, within acceptable limits (VAS: 2–4). The average length of hospital stay was 6.7 days. Average follow-up was 58 months. Instability and deformity was detected in none of the patients on the flexion–extension lateral radiographs during the follow-up period. Conclusion These surgical approaches suitable for exploring and removing different intramedullary pathologies, help in preventing damage to crucial posterior stabilizers of the spine. Its major advantage is that unnecessary exposure and tissue trauma is reduced, and structures not directly involved in the pathologic process are preserved. In contrast to conventional spinal canal approaches, leaves the muscle attachments intact, disintegration of vertebral arches and facet joints is reduced. Furthermore, these techniques are suitable methods for all spinal segments in all age group. Although the clinical and radiological results are very promising, the limited follow-up period precludes conclusions regarding the long-term results of the procedure, especially with respect to kyphotic deformity.

Efficacy of Super-Selective Laminoplasty Using Deep Extensor Muscle-Preserving Approach for Cervical Spondylotic Myelopathy

Cervical laminoplasty has become a standard treatment for cervical spondylotic myelopathy (CSM), providing a significant neurologic improvement. However, it has been well known that a persistent axial pain, restriction of neck motion, and loss of lordotic curvature are caused by a surgical damage to the paravertebral muscle and facet joints. To prevent these problems, several less invasive surgical procedures have been proposed. We have performed a super-selective laminoplasty (less than two laminae) or laminoplasty (more than three laminae) with deep extensor muscle-preserving approach for selective compressive lesions.

Is the self-reported history accurate in patients with persistent axial pain after a motor vehicle accident?

Background context A patient's self-reported history has, in general, assumed to be accurate. Clinical management of individuals with persistent axial pain after a motor vehicle accident (MVA) and measures to prevent future MVA, spinal cord injury, and traffic deaths often depend on a presumed accurate report of preexisting axial pain, drug, alcohol, and psychological problems to initiate intervention. In addition, research efforts to determine the effects of MVA on subsequent health are often predicated on a presumed accurate history from the patient of past medical and psychosocial problems. Despite so many clinical, public health, and research efforts being dependent on an accurate assessment of pre-injury health, the validity of the self-reported history after MVA has not been systematically investigated. Purpose To determine the validity of self-reported history in subjects with axial neck or back pain attributed to a recent MVA. Study design A prospective, multiclinic validation study examining the critical elements of a patient's self-reported history after an MVA judged against an audit of his or her medical records. Patient sample A cohort of consecutive patients with persistent axial pain after an MVA was prospectively identified from five spine-specialist's outpatient clinics. Of 702 patients, 335 subjects were randomly selected for auditing of their medical records. Outcome measures Self-reported demographic and clinical features were recorded by standardized questionnaires and clinical interviews. Audits compared these responses to an extensive medical record search. Methods The self-reported prevalence of preexisting axial pain, at-risk comorbidities (psychological distress, alcohol, and drug abuse), and control conditions (hypertension and diabetes) was recorded. The medical records of a random sample of 50% of the enrolled cohort underwent auditing of their medical records in a wide search of network paper and electronic and archived records, and compared with the self-reported history of pre-accident health. Results Overall, approximately 50% of the subjects were found to have previous axial pain problems at audit when none was reported to the spine-specialist after an MVA. Similarly, approximately 75% of the subjects were found to have one or more preexisting comorbid conditions at audit that were not reported during the evaluation after the MVA (alcohol abuse, illicit drug use, and psychological diagnosis). For those who perceived that the accident was the fault of another, as opposed to their own or no one's fault, the documented previous back and neck pain troubles in the medical records was more than twice the self-reported rate of these problems (p<.01). The rate of previously documented psychological problems was more than seven times that of the self-reported rate (p = 0.001). In those subjects who perceived that the accident was their own or no one's fault, a lesser degree of under-reporting of axial pain and comorbid conditions was found. Conclusion The validity of the patient's self-reported history when presenting with persistent axial pain after an MVA appears poor in this large multiclinic random sample.The self-reported rates of alcohol abuse, illicit drug use, and psychological diagnosis, as well as prior axial pain were significantly lower than that seen in the medical records, especially in thosewho perceive that the MVA was another's fault. The failure to recognize this under-reporting may seriously compromise clinical care, public health efforts at injury prevention, and research protocols dependent on accurate pre-accident morbidity assessments.

Outstanding Paper: Is the Self-reported History Accurate in Patients with Persistent Axial Pain Following a Motor Vehicle Accident?

BACKGROUND CONTEXT: A patient's self-reported history has, in general assumed to be accurate. Clinical management of individuals with persistent axial pain after MVA and well as measures to prevent future MVA, spinal cord injury and traffic deaths often depend on a presumed accurate report of pre-existing axial pain, drug, alcohol and psychological problems to initiate intervention. In addition, research efforts to determine the effects of MVA on subsequent health are often predicated on a presumed accurate history from the patient of past medical and psychosocial problems.

Validity of self-reported history in patients with acute back or neck pain after motor vehicle accidents

Background context Determining the presence of comorbid conditions in patients with persistent axial pain after motor vehicle accident (MVA) is important to direct appropriate care and as a public health measure against future traffic injuries. In the clinical care of patients after MVA, they are usually asked about previous axial pain problems and relevant comorbid conditions (psychological distress and drug and alcohol abuse). The accuracy of self-reported previous axial pain history and comorbid conditions after MVA has not been systematically evaluated but has been assumed to be high. Purpose To establish the validity of certain elements of the self-reported history in patients with back or neck pain attributed to an MVA. Study design A validation study of crucial elements of the patient history obtained after MVA using internal (chart audit) and external (age- and sex-matched population data) as gold standard references. Patient sample Medium-sized (n>400) clinical cohort of patients without fracture or dislocation seen within 3 months after an MVA in a university spine clinic. Outcome measures Responses to standardized questionnaires included previous back or neck pain, previous psychological distress, previous illicit drug usage, previous alcohol abuse, other chronic pain conditions, perceived fault of the MVA, and whether a compensation claim has been filed. Methods A consecutive cohort of patients seen from 1998 to 2004 for evaluation of back or neck/shoulder pain reportedly caused by an MVA was enrolled. All clinic patients completed standardized questionnaires. The prevalence of self-reported pre-MVA axial pain and at-risk conditions (drug, alcohol, and psychological problems) and control conditions (hypertension and diabetes) were compared against the age- and sex-matched prevalence determined by the 2005 US Department of Health and Human Services National Surveys on Drug Use and Health (external gold standard). Randomly selected previous medical records were also audited (internal gold standard) and compared with post-MVA description of preaccident health. Results Four hundred twenty-two subjects were enrolled, and random audits of 100 subjects were completed. In 68% of the random audits, comorbid conditions denied in the postaccident history (previous axial pain, drug or alcohol abuse, and psychological diagnoses) were documented. In subjects perceiving the MVA to be another's fault (but not their own), the reported prevalence of previous axial pain was markedly below matched data for population prevalence and audited data. Similar findings were observed for psychological problems, illicit drug use, and alcohol abuse. In subjects pursuing compensation claims and retaining an attorney, 80% had significant past axial pain history or serious comorbidities in their records not disclosed in the spine clinic evaluation. In subjects reporting that the MVA was either one's “own fault” or “no one's fault,” this effect was seen but was smaller in all dimensions. Conclusions In patients being seen for continued pain related to an MVA, the validity of self-reported previous axial pain and comorbid conditions appeared poor. The self-reported prevalence of previous axial pain and drug, alcohol, and psychological problems is much less than the documented prevalence in prior medical records. These rates were also markedly below the expected prevalence in age- and sex-matched populations. This effect was seen most prominently in patients perceiving the accident to be another party's fault and in those filing compensation claims. The failure to appreciate previous axial pain problems and drug, alcohol, and psychological problems may compromise patient care and public health opportunities.

4:40 149. Clinical impact of cervical laminoplasty with surgical approach preserving deep extensor muscles on cervical spine function and quality of life

BACKGROUND CONTEXT: To date, cervical laminoplasty has become a common surgical modality for cervical myelopathy, providing a sufficient neurologic improvement. However, the issues regarding persistent axial pain and the decrease in cervical mobility have been pointed out. We have utilized an open-door laminoplasty (Kirita-Miyazaki method) combined with a new surgical approach preserving deep extensor muscles. There have been few objective data reported on whether this approach improves the axial pain, cervical spine function, and QOL.