Radicular Symptoms Research Articles

Spinal epidural lipomatosis presenting to a U.S. Veterans Affairs pain and rehabilitation department: a report of two cases

BackgroundSpinal epidural lipomatosis is an uncommon source of neurogenic claudication. We present two cases of spinal epidural lipomatosis as it relates to diagnosis, management, and a possible association with common medical intervention.Case presentationCase 1: 63-year old male patient presented with neurogenic claudication symptoms, but without evidence of bony central canal stenosis on lumbar computed tomography. He entered a trial of spinal manipulation with transient beneficial gains after seven appointments, but no durable change in neurogenic claudication. An MRI was recommended at this point which revealed grade III spinal epidural lipomatosis at the L5/S1 level.Case 2: 51-year old male patient presented to a pain management physician with radicular symptoms for a series of lumbar epidural steroid injections. He completed a series of three lumbar epidural steroid injections with only short-term benefit. A repeat MRI demonstrated the presence of grade I (borderline grade II) spinal epidural lipomatosis.ConclusionsThe first case illustrates a limitation of ruling out central canal stenosis with computed tomography for patients unable to undergo an MRI. The second case demonstrates a possible association between steroid injections and spinal epidural lipomatosis. An association of this kind has not been established; further research is needed to determine the significance.

Novel technique of diagnosing and reducing pain in cervical radiculopathy

Background: Neck pain with upper limb pain is a common complaint of patients seen in Out Patient Department (OPD). Such pain may be because of a pinched nerve. There is inflammation in the nerve which causes radicular symptoms. The available clinical tests for cervical radiculopathy are provocative tests, difficult to perform and techniques vary from author to author. The reliability of these tests is only when done in clusters. We devised a novel non-provocative clinical sign to diagnose cervical radiculopathy and a method to reduce upper limb radicular pain and thereby improving the function of the upper limb. Method: Patient’s bilateral pronated wrists were palpated dorsomedially on the ulnar styloid. This elicited tenderness over the Dorsal Cutaneous branch of Ulnar Nerve (DCU). The painless active degree of movement at shoulder and elbow joints was noted. Nerve block at the palpated tender point was given using 2% lignocaine in 95 patients. We used Visual Analogue Scale score to measure radicular pain intensity before and 5 minutes after injection Results: All patients had tenderness at the DCU on the symptomatic upper limb. All patients had reduction in VAS of radicular pain from 7.36±0.89 before injection to 1.89±0.98 after injection with improvement of shoulder and elbow active movement.Conclusion: We recommend palpation of DCU in both upper limbs in all cases of suspected cervical radiculopathy. Palpation to elicit tenderness over DCU in cervical radiculopathy, was documented as Pote’s sign positive. Injection of local anesthetic agent over DCU reduces pain and improves upper limb function and it was documented as Pote’s test positive. This test is of diagnostic and therapeutic significance. This test is minimally invasive and can be done in an OPD set-up.

Repeat epidural steroid injections for radicular pain due to lumbar or cervical disc herniation

The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12). A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days (sd 46.5) and 47 days (sd 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm (sd 10.3) and a mean VAS for arm pain of 6.3 mm (sd 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (sd 12.4; p < 0.001); mean NPAD, 19.3 (sd 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (sd 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (sd 6.8; p = 0.103). Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364-71.

Combination of degenerative lumbar spinal stenosis and spinal deformity. Literature review

The study objective is to analyze currently available publications on spinal deformity in patients with degenerative lumbar spinal stenosis.Materials and methods. We analyzed 90 manuscripts published between 1980 and 2017.Results. We describe the parameters used to assess spinal deformity and evaluate their role for predicting the course of degenerative spinal disease. We provide the results of latest studies assessing the impact of spinal deformity on the outcome of surgical treatment in patients with degenerative lumbar spinal stenosis. We identified the following risk factors for scoliosis progression: wedge-shaped intervertebral disc in the frontal projection, low middle sacral axis, lateral spondylolisthesis, small L vertebral body, vertebral rotation, Cobb angle &gt;20°, and sagittal imbalance.Conclusion. We recommend decompressive interventions with facet joint preservation in patients with spinal deformity and degenerative lumbar spinal stenosis with no risk factors for scoliosis progression and radicular symptoms only (without pronounced low back pain). In patients with no risk factors for scoliosis progression, radicular symptoms, and low back pain, it is advisable to combine decompression with short fixation. For individuals at risk of scoliosis progression, we recommend supplementing decompression with long fixation exceeding scoliosis curve.

Prospective randomized controlled trial in the treatment of lateral epicondylitis with a new dynamic wrist orthosis

BackgroundIn the treatment of lateral epicondylitis (LE), the role of a new dynamic wrist orthosis is unclear.Patients and methodsPatients suffering from a LE longer than 3 months were multicentrically and prospectively randomized into a physiotherapeutic group (PT group) and in a physiotherapy group plus wrist orthosis (PT + O group). Physiotherapy consisted of daily eccentric strengthening exercises under initial professional supervision. Inclusion criteria were a Placzek score greater than 4. Exclusion criteria were previous surgery, rheumatic arthritis, elbow instability, radicular symptoms, higher-grade extensor tendon rupture, or cervical osteoarthritis. The clinical evaluation was performed after 12 weeks and 12 months. The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale, Placzek Score, the pain rating (VAS), range of motion and the Subjective Elbow Score were evaluated.ResultsOf the initially 61 patients, 31 were followed up after 12 weeks and 22 after 12 months. Twenty-nine patients (43%) were male, the mean age was 46, and 44 patients (66%) had the right elbow involved. At 12 weeks, there was a pain reduction on the VAS in both groups (PT + O: 6.5–3.7 [p = .001]; PT: 4.7–4.1 [p = .468]), albeit it was only significant for the PT + O group. At 12 months, reduction was significant in both groups (PT + O: 1.1 [p = .000]; PT: 1.3 [p = .000]). The painless maximum hand strength in kg improved in both groups significant after 3 and 12 months. The Placzek score was reduced from 8.25 to 3.5 [p = .001] after 12 weeks for the PT + O group and from 8.1 to 3.8 [p = .000] in the PT group, as well as after 12 months in the PT + O group to 0 [p = .000] and in the PT group to 2.0 [p = .000]. The PRTEE improved in both groups after 12 weeks (PT + O: 52.8––31.3 [p = .002]; PT: 48.6–37.6 [p = .185]) and 12 months (PT + O: 16.15 [p = .000]; PT: 16.6 [p = .000]), although the reduction at 12 weeks was not significant for the PT group.ConclusionThe elbow orthosis appears to accelerate the healing process with respect to the PRTEE and pain on the VAS (12 weeks follow-up), although there is an adjustment after 12 months in both groups and a significant improvement of symptoms is achieved in all endpoints.

Predicting Likelihood of Surgery Before First Visit in Patients With Back and Lower Extremity Symptoms: A Simple Mathematical Model Based on More Than 8,000 Patients.

Retrospective analysis of prospectively collected data. To create a data-driven triage system stratifying patients by likelihood of undergoing spinal surgery within 1 year of presentation. Low back pain (LBP) and radicular lower extremity (LE) symptoms are common musculoskeletal problems. There is currently no standard data-derived triage process based on information that can be obtained before the initial physician-patient encounter to direct patients to the optimal physician type. We analyzed patient-reported data from 8006 patients with a chief complaint of low back pain and/or LE radicular symptoms who presented to surgeons at a large multidisciplinary spine center between September 1, 2005 and June 30, 2016. Univariate and multivariate analysis identified independent risk factors for undergoing spinal surgery within 1 year of initial visit. A model incorporating these risk factors was created using a random sample of 80% of the total patients in our cohort, and validated on the remaining 20%. The baseline 1-year surgery rate within our cohort was 39% for all patients and 42% for patients with LE symptoms. Those identified as high likelihood by the center's existing triage process had a surgery rate of 45%. The new triage scoring system proposed in this study was able to identify a high likelihood group in which 58% underwent surgery, which is a 46% higher surgery rate than in nontriaged patients and a 29% improvement from our institution's existing triage system. The data-driven triage model and scoring system derived and validated in this study (Spine Surgery Likelihood-11), significantly improved existing processes in predicting the likelihood of undergoing spinal surgery within 1 year of initial presentation. This triage system will allow centers to more selectively screen for surgical candidates and more effectively direct patients to surgeons or nonoperative spine specialists. 4.

Management of symptomatic sacral perineural cysts with microsurgery and a vascularized fasciocutaneous flap.

The optimal treatment of symptomatic perineural (Tarlov) cysts is controversial. Numerous surgical techniques have been proposed with conflicting results. A series of Tarlov cysts treated with a novel surgical approach is presented. Patients with surgically treated symptomatic perineural cysts during 2013-2016 were included. The main indications for surgery were persistent radicular symptoms, pelvic pain, urinary and/ or bowel disturbances. At surgery, the cyst was opened and fenestrated. The cyst wall was then closed with packing, fibrin glue and a pedicled vascularized fasciocutaneous flap rotated into the area for obliteration of the dead space. Patients were followed-up with clinical visits and repeat magnetic resonance imaging (MRI) scans. Seven consecutive patients were included. The mean age was 50.3 years (range, 25-80 years) and the mean duration of symptoms was 49.3 months (range, 3-130 months). With one exception, all patients had urine and/or bowel problems (incontinence) preoperatively. A lumbar drain was inserted in five patients. The mean follow-up period was 15.4 months. Symptoms improved in 4/7 patients, in two cases no clinical difference was noted while one patient deteriorated. In two cases, a spinal cord stimulator was eventually implanted. In all seven cases, a significantly decreased cyst size was noted on MRI. Cyst fenestration and the use of a vascularized fasciocutaneous flap successfully obliterated all cysts, with satisfactory clinical efficacy. Larger and comparative studies are warranted to clarify the long-term effects of this surgical technique in patients with symptomatic Tarlov cysts.

The strategy and results of percutaneous endoscopic surgery for cervical disc herniation

Objective To evaluate the strategy and clinical effects of percutaneous endoscopic surgery for cervical disc herniation. Methods Fifty-one patients with cervical disc herniation were treated with percutaneous endoscopic surgery from June 2015 to March 2017, including 32 men and 19 women, with an average age of 52.2 years (range, 28-66 years). Radicular symptoms were present in all patients, while 23 patients had mild myelopathy (Nurick Grade: 0-3) and 3 patients of multilevel stenosis had severe myelopathy (Nurick Grade: 4-5). According to axial image of preoperative magnetic resonance imaging (MRI), 31 patients had lateral herniation that was located lateral to the edge of spinal cord, 20 patients had central herniation that was located within the lateral edge of spinal cord. Among them, 48 patients had soft herniation and 3 patients had ossified lateral herniation combined with foraminal stenosis. All surgery was carried out under general anesthesia, while posterior and anterior percutaneous endoscopic surgeries were performed for lateral herniation and central herniation respectively. Posterior endoscopic surgery was performed with keyhole fenestration at V point (the junction of lateral edge of lamina space and inner edge of facet). Lateral edge of thecal sac and nerve root were exposed and decompressed, soft herniation was explored and removed. Anterior endoscopic surgery was performed through puncture and 4mm tube between the visceral sheath and vascular sheath. The tube was inserted through disc to the base of herniation under fluoroscopy. The herniation was removed until the dura sac was exposed and relaxed. One stage open-door laminoplasty was performed for 3 patients with severe multiple segmental stenosis and huge central herniation. The operative time and blood loss were recorded, and patients were followed-up (range, 6-18 months, average 12.1 months) to evaluate the clinical efficacy. Results The mean operative time of posterior endoscopic surgery was 90 min (range, 45-150 min). The nerve root was not well exposed, and the fenestration was too lateral in 1 patient, with partial relieve of symptoms; and simple nerve root decompression was performed for 3 patients of ossified herniation combined with foraminal stenosis. Herniated or sequestered nucleus pulposus was removed for 27 patients, one of them had transient paralysis ipsilateral limb and 2 of them had linkage of cerebrospinal fluid. The Visual Analogue Score (VAS) score improved form preoperative 8.9±1.6 to 0.5±0.4, and the Oswestry Disability Index (ODI) score improved form 32.8±4.2 to 2.3±1.9 at final follow-up. For anterior percutaneous endoscopic surgery, the mean operative time was 80 min (range, 45–120 min). Herniated or free nucleus was successfully removed for all patients. The thecal sac was lacerated due to unclear exposure in 1 case. The VAS score improved form preoperative 6.9±2.3 to 0.9±0.8, and the ODI score improved form 40.1±8.6 to 5.6±3.0 at final follow-up, with improvement of myelopathy at least one Nurick Grade. During follow-up, the alignment of cervical spine was well preserved without kyphosis for two groups, while the height of intervertebral space decreased with 0.4±0.3 mm and 0.9±0.6 mm in posterior and anterior surgery respectively. Conclusion Percutaneous endoscopic surgery provides minimally invasive alternatives for some cervical disc herniation with predominant radicular pain. Posterior endoscopic surgery is suitable for lateral herniation, and anterior endoscopic discectomy is suitable for some central soft herniation without obvious collapse and instability. However, the long-term results of disc space collapsed after anterior approach remains unclear. Key words: Cervical vertebrae; Intervertebral disc displacement; Endoscopy; Surgical procedures, minimally invasive

Fungal spinal epidural abscess: a case series of nine patients

BACKGROUND CONTEXTFungal spinal epidural abscess (FSEA) is a rare entity with high morbidity and mortality. Reports describing the clinical features, diagnosis, treatment, and outcomes of FSEA are scarce in the literature. PURPOSEThis study aimed to describe the clinical features, diagnosis, treatment, and outcomes of FSEA. STUDY DESIGNThis study is designed as a retrospective clinical case series. PATIENT SAMPLEA continuous series of patients with the diagnosis of FSEA who presented at our institution from 1993 to 2016. METHODSWe reviewed the electronic medical records of patients with SEA who were treated within our hospital system from 1993 to 2016. We only included SEA cases that were due to fungi. We also reviewed FSEA cases in the English language literature from 1952 to 2017 to analyze the features of FSEA. RESULTSFrom a database of 1,053 SEA patients, we identified 9 patients with FSEA. Aspergillus fumigatus was isolated from 2 (22%) patients, and Candida species were isolated from 7 (78%). Focal spine pain, neurologic deficit, and fever were demonstrated in 89%, 50%, and 44% of FSEA cases, respectively. Five of nine cases involved the thoracic spine, and eight were located anterior to the thecal sac. Three cases had fungemia, six had long symptom duration (>2 weeks) prior to presentation, seven had concurrent immunosuppression, and eight had vertebral osteomyelitis. Additionally, one case had residual motor deficit at last follow-up, one had S1 sensory radicular symptoms, two suffered recurrent FSEA, two died within hospitalization, and two died within 90 days after discharge. CONCLUSIONSIn summary, the classic diagnostic triad (focal spine pain, neurologic deficit, and fever) is not of great clinical utility for FSEA. Biopsy, intraoperative tissue culture, and blood culture can be used to diagnose FSEA. The most common pathogens of FSEA are Aspergillus and Candida species. Therefore, empiric treatment for FSEA should cover these species while definitive identification is pending. FSEA is found in patients with poor baseline health status, which is the essential reason for its high mortality.

Acupuncture for treatment of depressive disorders in pain diseases

Therapy with acupuncture as apart of Traditional Chinese Medicine (TCM) is increasingly being used as an alternative or complementary method. The regular diagnostic processes and conventional therapies must primarily be applied as the basic principle of a treatment concept. In addition to aqualified education and training with recognition of the further qualification in acupuncture acontinued medical education is required to treat patients. In the field of regular medical care diseases with the symptoms chronic low back pain, chronic low back pain with radicular symptoms radiating to the knee and chronic osteoarthrosis of the knee can be treated: by implementation of a differentiated documentation of the treatment and the results of treatment using Likert scales for the severity of depressive symptoms. Under the aspects of a health services research approach, the results of treatment with acupuncture in practice under the prerequisite of 15 sessions for chronic low back pain including radicular symptoms reaching the knee were analyzed based on syndromes of TCM. Due to the importance of depressive symptoms in pain disorders in asecond group additional special acupuncture points (Ren12, Bl20, Bl21, Ma36, Mi6, Pe6) in the area of the conversion phase "earth" were additionally used to influence a depressive disorder under standardized aspects. The results showed the positive influence of atherapy with acupuncture on depressive symptoms in both groups M = 7.67, M = 7.95, M = 3.29 and M = 2.29 (p < 0.001) with significant differences (p < 0.01) and an increase in the effect when using additional specific points for treatment of depression (p < 0.01). Further investigations are necessary in the future for treatment with acupuncture using standardized and reproducible selection of acupuncture point.

Friday, September 28, 2018 1:00 PM–2:30 PM abstracts: a new look at imaging: 208. Normalization of spinal cord displacement with the straight leg raise with resolution of sciatica in patients with lumbar intervertebral disc herniation: a 1.5-year follow-up study

BACKGROUND CONTEXT Lumbar intervertebral disc herniation (LIDH) is known to be a key cause of sciatica. Previously we found a significant limitation of neural displacement (66.6%) with the straight leg raise test (SLR) on the symptomatic side of patients with sub-acute single level posterolateral LIDH. PURPOSE To ascertain if changes incord excursion with SLR at 1.5-year follow-up time accompany changes in clinicalsymptoms. STUDY DESIGN/SETTING Controlled radiological study. PATIENT SAMPLE Follow-up study on 15 patients with significant sciatic symptoms due to a single level posterolateral LIDH. OUTCOME MEASURES Conus medullaris displacement was quantified reliably with a randomized procedure during the unilateral and bilateral SLR and results compared both between maneuvers and with baseline data. LIDH was examined with 1.5T Magnetic Resonance Imaging (MRI) scannerusing different scanning sequences for planning and for measurement purposes, while low back pain (LBP) and radicular symptoms were assessed during clinical examination with visual analogic scales. METHODS The patients were re-assessed clinically and radiologically with a 1.5T MRI scanner at 1.5-year follow-up. Displacement of the conus medullaris with the unilateral and bilateral SLR was quantified with a randomized procedure and compared between SLRs and to data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables associated with the patients’ symptoms. RESULTS Conus medullaris caudal displacement in response to SLRs increased significantly in all the tested subjects. Compared to baseline values, the data showed a large increase in neural sliding with the symptomatic SLR (323.4%, 2.52mm, p≤.001), 37.1% with asymptomatic SLR (0.82mm, p=.0058) and 48.2% with bilateral SLR (1.64mm, p≤.001). Increase in neural sliding correlated significantly with the resolution of radicular symptoms in the ipsilateral limb (Pearson=−0.719, p≤.001) and low back pain (LBP) (Pearson=−0.693, p≤.001). Backward variable selection method indicated improvement of neural sliding (p=.004) and degrees of hip flexion with symptomatic SLR (p=.025) as the main variables being associated with improvement of radicular pain. Reduction of LBP showed to be associated with improvement of neural sliding (p=.006). Overall, there was an average increase in neural sliding of 230.7% (symptomatic, asymptomatic and bilateral SLRs) in association with decrease of symptoms during the follow-up period. This improvement of neural sliding was found to be associated with 74.7% decrease in self-reported LBP symptoms on visual analog scale (VAS), as well as 76.0% decrease in self-reported radicular symptoms on VAS. CONCLUSIONS This study shows a significant association between the improvement of neural adaptive movement with the SLR and resolution of both radicular and LBP symptoms in patients with posterolateral LIDH during 1.5-year follow-up time. To our knowledge, these are the first noninvasive data to objectively support the association between magnitude of neural adaptive movement and improvement of clinical symptoms in in-vivo and structurally intact human subjects. The data also gives new and valuable insights into our understanding of the mechanisms of the SLR test.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P131. The duration of lumbar radicular symptoms does not impact clinical outcomes following lumbar decompression surgery

BACKGROUND CONTEXT The success of surgical interventions for lumbar spinal stenosis can vary significantly depending on various factors, one of which is the duration of symptoms. Literature does not provide a clear indication of when lumbar decompression surgery become less effective in the setting of acute versus chronic symptoms from nerve root compression. PURPOSE The main objective of this study was to assess whether the duration of symptoms has an effect on clinical outcomes, especially resolution of radicular symptoms due to pathology compressing the lumbar nerve roots in patients undergoing lumbar decompression-only procedures. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar laminectomy, discectomy or a combination of the two between 2009 and 2015 by one of two senior orthopedic spine surgeons. Patients were excluded from analysis if they had any previous lumbar surgery were under 18years of age at the time of surgery or had postoperative follow-up less than 3 months. Patients were divided into two groups: those with lumbar radicular symptoms for less than one year prior to surgery, and those who experienced symptoms for one year or greater before undergoing surgery. OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. Patients were also surveyed about their expectations and satisfactions following surgery. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 210 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 24.14 months (range 3–78 months). There were 108 patients that experienced radicular symptoms for less than one year, while 102 patients experienced radicular symptoms for one year or more. Patients who experienced radicular symptoms for less than one year had a significantly higher rate of a herniated nucleus pulposus present (75.9% vs. 49.0%; p 1 year 7.9%; p=.904). Patients presented with high levels of satisfaction (pain 1 year 82.4%; OR1.06, p=.904) and expressed that the surgery met or exceeded their expectations (pain 1 year 96.1%; OR1.06, p=.904). CONCLUSIONS Overall, patients present with similar clinical outcome scores, despite the differences in the duration of their lumbar radicular symptoms prior to surgery. At approximately 2years following lumbar decompression-only surgery, all patients, despite their symptom chronicity, appear to show similar improvement in their clinical outcome scores. Re-operation rates were low and similar between the two groups of patients. Most patients report being satisfied with their outcome and with their expectations being met or exceeded to similar degrees. Given the various options available for nonoperative management of lumbar spinal stenosis and/or a lumbar herniated nucleus pulposus, the extended effort of these conservative treatments or delay of operative intervention do not appear to negatively impact the eventual outcome of surgery. Patients report significant improvement in their symptoms, based on clinical outcome surveys, regardless of their symptom chronicity.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P71. The effects of insurance and employment on the presence of Waddell signs

BACKGROUND CONTEXT Waddell signs were originally introduced as manifestations of “nonorganic” low back pain. Once thought to indicate malingering, positive Waddell signs are now understood to represent real pain, potentiated through mechanisms of central sensitization. This study examines the relationship between the presence of Waddell signs and patient social environments, specifically insurance and employment status. PURPOSE To examine the relationship between the presence of Waddell signs, insurance status, and employment status. STUDY DESIGN/SETTING Prospective cross-sectional study at a single academic institution. PATIENT SAMPLE Three orthopedic spinal surgeons, two spinal neurosurgeons, and two physiatrists participated in the study over a one-year period. All patients over age 16 with thoracic or lumbar back pain due to a degenerative condition, with or without radicular symptoms, were included in the analysis. Full-time students were excluded, identifying 462 eligible patients for detailed analysis. OUTCOME MEASURES The primary outcome measures were 1+ or 3+ Waddell signs. METHODS Patient medical records were extracted for age, sex, employment, and insurance status. Subjects over age 65 and not working were considered retired. At their initial appointment, all patients were given a standard spinal examination where Waddell signs were noted if present. Age, sex, insurance status, and employment status were compared between those with and without any (1+) Waddell signs or clinically significant (3+) Waddell signs. Frequency data comparisons were performed using contingency table analysis; comparisons of means were analyzed for continuous variables. A frequency co-analysis of employment and insurance status was performed. Statistical analysis was performed using SAS (SAS Institute Inc., Cary, NC). RESULTS Nonworking subjects under age 65 had a significantly higher prevalence of 1+ Waddell signs than employed subjects (43% vs. 24%; p CONCLUSIONS Working age patients that do not work have a significantly higher prevalence of Waddell signs than those working or retired. Medicaid patients also have higher prevalence, but this effect appears to be a function of employment status rather than public medical assistance.

Friday, September 28, 2018 1:00 PM–2:30 PM abstracts: achieving lumbar interbody fusion: 196. Preoperative disc height predicts TLIF cage subsidence

BACKGROUND CONTEXT Postoperative subsidence of the transforaminal lumbar interbody fusion (TLIF) cages can result in loss of lordosis and foraminal height, and in some cases recurrence of nerve root impingement and radicular symptoms. PURPOSE The purpose of this study is to determine factors associated with TLIF cage subsidence. Specifically, we sought to determine if preoperative disc height compared to cage height could be used to predict TLIF interbody cage subsidence. STUDY DESIGN/SETTING Retrospective case-control study. PATIENT SAMPLE We identified 127 patients with complete imaging who met our inclusion criteria, with a mean clinical follow up of 27 months. OUTCOME MEASURES The primary outcome of this study was presence of cage subsidence identified with radiograph or CT. METHODS We retrospectively reviewed all patients undergoing instrumented TLIF from two institutions between July 2004 and June 2014. Postoperative imaging studies (radiographs and CT) were evaluated for evidence of implant subsidence. Preoperative disc height was measured for the operative and adjacent level disc heights. The delta between cage height and disc heights were measured and compared between groups. RESULTS Fifty four patients (44.3%) had evidence of interbody cage subsidence. Average cage subsidence was 5.5mm, with a range of 2.2–10.8mm. We found implant height was significantly higher in the subsidence group (12.6mm) when compared to the nonsubsidence group (11.2mm). Additionally, the delta between cage height and preoperative disc height was significantly larger in the subsidence group delta (5.5mm vs. 3.9mm). Similarly, the delta between cage height and preoperative adjacent level disc height was also significantly larger (1.2mm vs. 3.8mm). CONCLUSIONS This study demonstrates that preoperative disc height and preoperative adjacent level disc height can be used to template TLIF cage height to potentially decrease rates of subsidence. Larger cages subsided more frequently than smaller cages. Patients with evidence of subsidence had larger deltas between cage height and preoperative disc height. Similarly, a significant difference existed if preoperative adjacent level disc height was compared to cage height. This demonstrates that preoperative imaging should be used for TLIF cage height templating to avoid subsidence.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Interventional Pain Management: 35. Rate of conversion to surgery and risk factors analysis following fluoroscopically guided facet cyst rupture

BACKGROUND CONTEXT Facet cysts are a common finding on magnetic resonance imaging (MRI) when evaluating a patient with back pain and radicular symptoms. Several different clinical and radiographic findings have been associated with this diagnosis. It is thought that these differences may relate to the difference in efficacy of fluoroscopically guided cyst rupture. PURPOSE The purpose of this study was to evaluate the rate of conversion to surgery following cyst rupture, and to assess for clinical, radiographic and procedural variables that were associated with that conversion. If specific clinical and radiographic risk factors can be elucidated which are associated with conversion to surgery, it may be possible to more effectively and efficiently counsel and treat patients. STUDY DESIGN/SETTING A retrospective review at an academic medical center. PATIENT SAMPLE All patients who underwent fluoroscopically guided facet cyst rupture from 2010 to 2016. OUTCOME MEASURES The primary outcome was conversion to surgery. For those who converted to surgery, the rate of decompression and fusion compared to fusion alone was recorded. Secondary outcomes included clinical, radiographic and procedural variable analysis to determine if there were risk factors associated with conversion to surgery. The clinical variables included sex, age, number of comorbidities, location (unilateral or bilateral), type of symptoms (pain, motor deficit, sensory deficit), and whether the pain was predominantly leg, back or combined. The radiographic variables included cyst size, shape, cyst signal, rim signal, level involved, laterality, presence of spondylolisthesis, whether there was canal or lateral recess stenosis, presence of facet joint fluid, bilateral fluid, facet bone edema and bone erosion. The procedural variables included cyst opacification, successful rupture and difference in pre and post procedure pain. METHODS Basic statistics, as well as single and multivariate analysis was performed. RESULTS Forty-nine patients met the inclusion criteria. Four were excluded because they had either no clinical notes or no MRI available for review. Twenty-nine percent of patients eventually underwent a surgical procedure to address their facet cyst. The average interval to surgery was 95 days after cyst rupture. Of those who had a surgical intervention, 38% had a decompression and fusion. Of the clinical, radiographic and procedural variables evaluated, only the number of comorbidities and the MRI signal of the facet rim were associated with conversion to surgery, p=.03 and p=.05, respectively. CONCLUSIONS Facet cysts have been recognized as a cause of spinal stenosis, but their optimal treatment is unknown. Typically, all nonoperative interventions are attempted prior to conversion to surgery, which often includes fluoroscopically guided facet cyst rupture. However, there is a significant percentage of patients in whom this treatment fails to provide durable relief, and eventually, patients undergo a surgical intervention. Despite the two associated risk factors, at this time, we would recommend continuing to attempt fluoroscopic guided facet cyst rupture with postprocedural clinical monitoring for all patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P61. Clinical outcomes of microendoscopic decompression for lumbar canal stenosis: a comparison between patients with and without degenerative lumbar scoliosis

BACKGROUND CONTEXT The operative management of degenerative lumbar scoliosis includes decompression or decompression with fusion. However, there is currently no consensus on the criteria for the role of adjunctive fusion. We have performed microendoscopic decompression in patients with the chief complaint of radicular and/or cauda equina symptoms due to degenerative lumbar scoliosis. Although the surgical procedure almost improved leg symptoms, it seemed that the patients had severe low back pain postoperatively as compared with patients without degenerative lumbar scoliosis. PURPOSE To compare the clinical outcomes of microendoscopic decompression for lumbar canal stenosis between patients with and without degenerative lumbar scoliosis. METHODS A total of 75 patients with lumbar canal stenosis between March 2006 and December 2014 were included in this study. The patients who had disc herniation and foraminal stenosis were excluded. The patients were treated with microendoscopic decompression and followed more than two years after the surgery. Of those, 34 were males and 41 were females. The mean age at the time of the surgery was 73.1years (range, 61–86 year). The mean follow-up period was 48.1 months (range, 24–102 months). Twenty-seven patients had degenerative lumbar scoliosis with coronal curvature of more than 10° measured by Cobb's method (DLS group). The other 48 patients had neither degenerative lumbar scoliosis nor degenerative lumbar spondylolisthesis (nonDLS group). Clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) score and Short-Form 36 (SF-36) preoperatively and at the final follow-up. Recovery rate of the JOA score was calculated as (postoperative score − preoperative score)/(29 − preoperative score)×100%. The visual analogue scale (VAS) for low back pain was also measured at the final follow-up. RESULTS In the DLS group, the JOA score significantly improved from 13.7 preoperatively to 23.4 postoperatively. Also in the nonDLS group, the preoperative JOA score of 15.7 significantly improved to 25.0 postoperatively. Recovery rate in the DLS and nonDLS group were 62.5% and 69.0%, respectively. There were no significant differences in preoperative and postoperative JOA scores between the two groups. At the final follow-up, VAS for low back pain in the DLS group (45.4 mm) was significantly higher than that in the nonDLS group (25.4 mm). As for the preoperative SF-36 score, there were no significant differences in all 8 subscales between the two groups. In the DLS group, a significant improvement was observed only in bodily pain scores after surgery. In the nonDLS group, all subscales except general health perception significantly improved after surgery. All postoperative subscales except social role function and mental health in the DLS group were significantly lower than in the nonDLS group. CONCLUSIONS This study showed that the patients with lumbar degenerative scoliosis had higher VAS for low back pain and lower QOL scores after microendoscopic decompression as compared with the patients without lumbar degenerative scoliosis. We might consider other surgical options in patients with lumbar canal stenosis due to degenerative lumbar scoliosis.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P97. The risk of recurrent laryngeal nerve injury with laterality of approach in anterior cervical discectomy and fusion procedures: a randomized, prospective study over 10 years

BACKGROUND CONTEXT Recurrent laryngeal nerve (RLN) injury is a well known, but potentially devastating injury after anterior cervical discectomy and fusion (ACDF) procedures. Although RLN injury is most often transient in nature, there are the associated clinical consequences of dysphonia, impaired phonation or cough reflex, airway obstruction, hoarseness, vocal fatigue, and in some cases, tracheotomy. The incidence of RLN injury in the literature ranges from 0.07% to 5.1%. There has been debate regarding the risk of RLN injury in relation to laterality of approach, with proponents of each left and right sided approaches. There are numerous papers reviewing the complication, but there is no large-scale, randomized prospective single surgeon, single study investigating the correlation of laterality of approach to the risk of recurrent laryngeal nerve injury. PURPOSE To determine if the side of approach in anterior cervical discectomy and fusion is associated with increased risk of recurrent laryngeal nerve injury. STUDY DESIGN/SETTING A fellowship trained spine surgeon prospectively performed ACDFs between the years of 2003-2012. Side of approach was chosen based on contralateral to side of symptoms (ie right sided radicular symptoms, patient received a left-sided approach). Patients were monitored postoperatively for development of recurrent laryngeal nerve palsy symptoms. Patients found to have signs of recurrent laryngeal nerve injury were sent to ENT for confirmation and monitored for recovery. PATIENT SAMPLE A total of 411 patients undergoing anterior cervical decompression procedures over 10years in central Pennsylvania. OUTCOME MEASURES Symptoms of recurrent laryngeal nerve injury (dysphonia, dysphagia). METHODS Retrospecive analysis of prospectively collected data over 10years. RESULTS A total of 411 ACDFs were performed during the 10-year period. 190 right sided and 221 left sided procedures were done. The incidence of recurrent laryngeal nerve injury was 14 (13 primary procedures and 1 revision). Seven nerve injuries were in a right sided approach and 7 were in a left sided approach. The risk of injury was 3.18% in a left sided approach and 3.70% in a right sided approach with a p-value of 0.7723 indicating that there is no significant difference between the sides of the approach. CONCLUSIONS Our study's analysis showed that there was a 3.18% chance of RLN with a left-sided approach compared to a 3.70% chance of RLN injury with a right-sided approach (p-value: .7723), indicating that there is no significant difference in RLN injury between the sides of approach. Although there is usually spontaneous resolution of hoarseness, it is important to remember that patients with a vocal cord paresis may be asymptomatic, and patients with symptomatic dysphonia may have no vocal cord paresis. Our data represents the first randomized prospective single surgeon study of risk of symptomatic RLN injury from side of approach. There was no significant difference noted between the side of approach and the risk of recurrent laryngeal nerve palsy, and it is recommended that the surgeon choose an approach based on his or or her comfort and clinical judgement.

Operation of Soft or Calcified Thoracic Disc Herniations in the Full-Endoscopic Uniportal Extraforaminal Technique

Surgery for thoracic disc herniation and stenosis is comparatively rare and often demanding. The goal is to achieve sufficient decompression without manipulating the spinal cord and to minimize surgical trauma and its consequences. Individual planning and various surgical techniques and approaches are required. The key factors for selecting the technique are anatomical location, consistency of the pathology, general condition of the patient, and the surgeon's experience. The objective of the study was the evaluation of the technical implementation and outcomes of a full-endoscopic uniportal technique via the extraforaminal approach in patients with symptomatic soft or calcified disc herniation of the thoracic spine, taking specific advantages and disadvantages and literature into consideration. Retrospective study. A center for spine surgery and pain medicine. Between 2009 and 2015, decompression was performed on 26 patients with thoracic disc herniation or stenosis with radicular or myelopathic symptoms in a full-endoscopic uniportal technique with an extraforaminal approach. No patients underwent additional posterior stabilization. Imaging and clinical data were collected in follow-up examinations for 18 months. Sufficient decompression was achieved in the full-endoscopic uniportal technique in all cases. The individual selection of the respective approach made it possible to reach the target area without manipulating the spinal cord. One patient experienced deterioration of a myelopathy. No other serious complications were observed. All patients, except one, experienced regression or improvement of symptoms. No evidence of increasing instability was found in imaging. This is a retrospective study. The limited number of cases must be considered. The full-endoscopic uniportal technique with an extraforaminal approach was found to be a sufficient and minimally invasive method with the known advantages of an endoscopic procedure under continuous irrigation for monosegmental disc herniations. The inclusion criteria must be taken into consideration. If they are not met, an alternative full-endoscopic approach (interlaminar, transthoracic retropleural) or decompression in a conventional method must be selected. Additional stabilization does not appear to be necessary due to the low level of trauma. Extraforaminal approach, thoracic disc herniation, giant disc herniation, Full-endoscopic, minimally invasive, thoracic spine.

Predictive value of Modic type II changes in the choice of surgical treatment of lumbar disc herniation

ObjectiveTo evaluate the predictive value of Modic typeII changes on nuclear magnetic resonance (NMR) prior to intervention by discectomy for lumbar disc herniation in patients with radicular symptoms. Material and methodRetrospective descriptive study of 190 patients (58.2% men and 41.8% women) with a mean age of 43.5 years, treated between December 2005 and January 2013.They were divided into group 1, single disc herniation (n=85), and group 2, with disc herniation and changes Modic typeII (n=80).Variables studied: weight, height, handedness, level of injury, previous neurological deficit, postoperative complications, persistent pain and need for posterior lumbar fusion, with a mean of 67 months (group 1: 68.1; group 2: 66.8). ResultsIn group 1 there were four hernia recurrences requiring revision surgery and six patients needed lumbar fusion. In group 2, four recurrences were also revised and eight cases requiring arthrodesis were observed.No statistically significant differences were found when comparing the occurrence of relapse (p=.903), the need for subsequent fusion (p=.572) or in the remaining variables. DiscussionThe data obtained and the characteristics of our study, we cannot say that Modic typeII changes were a predictive sign of the result of lumbar discectomy in our study population.

The effect of needle tip position on lumbar transforaminal epidural steroid injection using nerve stimulator

To determine the effect of needle tip positions on short-term effect of transforaminal epidural steroid injection (TFESI) using nerve stimulator (NS) for lumbar radiculopathy. Forty-five patients who received TFESI using NS were retrospectively reviewed. The TFESI was conducted under fluoroscopic guide. The goal of positioning was to allow a needle tract toward injection site such as “safe triangle”. We used the NS to optimize the position of needle tip. The needle tip was repositioned to achieve minimal current output (0.2 mV) when the patients had paresthesias within dermatomal areas. The needle tip positions were assessed by dividing the intervertebral foramen into 4 quadrants in the anterior-posterior view. The grade of nerve root compression on MRI in 45 patients was evaluated. The outcome measurement (OM) was evaluated before pre-injection and after 2 weeks. Ninety-one TFESIs were conducted in the 45 patients. The position of needle tip was 68, 19 and 4 cases in the quadrant 1, 2 and 3, respectively. The mean score of OM reduced significantly in the quadrant 1 and 2, but not in the quadrant 3 after 2 weeks. There were no significant differences in the mean score of OM according to the grade of nerve root compression. As the neural structures lie medially in the foramen, it is believed that a medially placed needle such as quadrant 2 has a higher likelihood of causing neurological complication. Bogduk proposed the ideal needle tip position by defining a “safe triangle” like quadrant 1. Our study showed that there was a similar effect in the quadrant 2 just the same in the quadrant 1. We conclude that the NS to guide TFESI in addition to fluoroscopy can be a useful therapeutic tool in the patient with radicular symptoms.