Residual Back Pain Research Articles

Orthobiologic Supplementation Improves Clinical Outcomes Following Lumbar Decompression Surgery.

BackgroundEndoscopic-assisted lumbar decompression is a minimally invasive spine surgery which has been touted to reduce collateral tissue damage, incisional pain, recovery time and complications. Residual back or leg pain and recurrent herniation are commonly reported post-operative outcomes. It has been suggested that injecting orthobiologics like cryopreserved amniotic-derived products (ADPs) and bone marrow aspiration (BMA) into the surgery site would have additional benefit on patient outcomes. This is a Western Institutional Review Board (WIRB)-approved level 1, randomized controlled trial of prospectively collected patient demographic and outcomes data for endoscopic-assisted lumbar decompression surgery. The primary goal of this study was to compare patient outcomes of orthobiologic supplementation during endoscopic-assisted lumbar decompression surgery.MethodsFollowing WIRB approval, 269 patients underwent lumbar endoscopic-assisted decompressive surgery between January 2011 and October 2017. Patients were randomized to receive ADP, BMA, both, or no supplementation (control group). Outcomes were measured by post-operative questionnaires (visual analog scale (VAS), Oswestry disability index (ODI), 36-item short-form health survey (SF-36)) over 12 months.ResultsMean VAS-leg for either BMA or ADP group displayed statistically significant improvements at 2 weeks (3.55 vs. 4.77, P = 0.002), 6 months (2.34 vs. 3.37, P = 0.026), and 9 months (2.18 vs. 3.57, P = 0.01) compared to no supplementation group (control group). Similarly, improvements in mean VAS-back were significant at 2 weeks (3.98 vs. 5.01, P = 0.011), 2 months (3.22 vs. 3.93, P = 0.04), 9 months (2.38 vs. 4.11, P = 0.004), and 12 months (2.23 vs. 3.58, P = 0.011) compared to no supplementation group (control group). There were statistically significant differences in the ODI (2 weeks, 42.19 vs. 31.11, P = 0.014) and SF-36 (4 months, 85 vs. 63, P = 0.043 for ADP only), but these differences did not subsist over time. Two patients (one control, one ADP) re-herniated at the same level.ConclusionsOrthobiologic BMA and ADP resulted in improved pain control during early post-operative periods.

Causes of Residual Back Pain at Early Stage After Percutaneous Vertebroplasty: A Retrospective Analysis of 1,316 Cases

Background: Percutaneous vertebroplasty (PVP) is now well accepted in the treatment of painful osteopathic vertebral compression fractures (OVCF), providing early pain relief and strengthening of the bone of the vertebrae. However, some patients still experienced severe back pain after PVP. Objectives: To analyze the possible reason for unsatisfactory back pain relief (UBPR) after PVP at early stage. Study Design: Retrospective analysis. Setting: Hong-Hui Hospital in Xi’an. Methods: Between March 2013 and January 2015, a total of 1,316 patients with OVCF were treated by PVP at our Hospital. Demographics, clinical data, and surgical data were collected to analyze the factors associated with UBPR after PVP. Results: Sixty cases complained of UBPR, and the prevalence was 4.6%. Univariate analyses showed that preoperative bone mineral density (BMD), number of fractures, cement distribution and volume injected per level, lumbodorsal fascia contusion, and depression were associated with UBPR after PVP (P < 0.001). Multivariate analysis revealed that preoperative BMD (odds ratio [OR], 3.577; P = 0.029), lumbodorsal fascia contusion (OR, 3.805; P = 0.002), number of fractures (OR, 3.440; P < 0.001), cement volume injected per level (OR, 0.079; P < 0.001), cement distribution (OR, 3.009; P = 0.013), and depression (OR, 3.426; P = 0.028) were independently associated with UBPR after PVP at the early postoperative stage. Limitations: A further prospective controlled study is needed to explore the association between the different degrees of the aforementioned factors and UBPR after PVP. Conclusions: Preoperative low BMD, lumbodorsal fascial injury, multiple segment PVP, insufficient cement injected volume, unsatisfactory cement distribution, and depression were strong risk factors associated with UBPR after PVP in patients with OVCF. Key words: Unsatisfactory back pain relief, residual back pain, percutaneous vertebroplasty

Relationship of endplate changes and low back pain after discectomy

ObjectivesDiscectomy is a conventional surgery for lumbar disc herniation. However, recurrence and residual back pain are the main postoperative complications. The contribution of endplate changes to the occurrence of these complications remains controversial. This study aimed to investigate the effect of endplate changes after discectomy. Patients and MethodsWe conducted a retrospective evaluation of 128 patients who had endplate changes after undergoing discectomy in our hospital. The patients were divided into three groups according to severity of abnormality according the Weishaupt classification (mild, moderate, and severe). The Oswestry Disability Index (ODI) and visual analog scale (VAS) were used to evaluate the efficacy of different surgical methods. ResultsSeventeen patients dropped out of the follow-up study. Satisfactory efficacy was observed in most patients, but 16 patients underwent reoperation. Significant differences were observed among the three groups in terms of low back pain severity and ODI (p < 0.05), but not radicular leg pain severity. The severe group had a higher recurrence rate of disc herniation (23.5%) than the mild and moderate groups (10.3% and 10.4%, respectively). ConclusionDiscectomy had a noticeable efficacy. However, severe endplate changes, which indicated fissures on the endplate, damaged the lumbar stability and resulted in a higher recurrence rate and residual back pain. For such cases, internal fixation surgery should be considered.

Therapeutic observation on point-toward-point needling at points on the low back regions for residual back pain after percutaneous kyphoplasty

Objective To observe the effect of point-toward-point needling at points on the low back regions on residual back pain after percutaneous kyphoplasty (PKP), thoracolumbar function and quality of life (QOL) in patients with osteoporotic vertebral compression fracture (OVCF).

Association between MRI findings and back pain after osteoporotic vertebral fractures: a multicenter prospective cohort study

BACKGROUND CONTEXTOsteoprotic vertebral fractures (OVFs) are common in elderly people. The association between back pain due to OVF with magnetic resonance imaging (MRI) signal change is unclear. In this study we hypothesized that MRI findings would be a predictive factor for back pain measured by visual analogue scale (VAS) at 6 months follow-up. PURPOSEThe aim was to study the MRI findings that predict back pain after OVF and the association between radiological findings and scores of back pain. STUDY DESIGNMulticenter prospective cohort study. PATIENT SAMPLEA total of 153 OVF patients. OUTCOME MEASUREThe outcome measures were VAS back pain and MRI signal change. METHODSThis study was performed from 2012 to 2015. Consecutive patients with less than 2-week-old OVFs at 11 institutions were enrolled prospectively. MRI was performed at enrollment and at 1, 3, and 6 months follow-up. T1- and T2-weighted images (T1WI and T2W1) were obtained at each time point and their association with VAS scores of back pain at 6 months were investigated. Anterior compression ratio, posterior compression ratio, and angular motion of vertebral bodies were also measured on X-rays at each follow-up. This research had no financial support. There are no conflicts of interest. RESULTThe 6 months follow-up was completed by 153 patients. At enrollment, the average VAS score of back pain was 75 mm, and it had improved at the 6-month follow-up to an average score of 20 mm. There was a significant correlation between T1 diffuse low signal change and VAS scores at the 6-month follow-up (p<.01). T2 high signal changes (odds ratio; 4.01, p<.01) and old vertebral fractures (odds ratio; 2.47, p=.04) were independent risk factors for back pain. The correlation between angular motion of vertebrae on X-rays and the VAS score of back pain was significant at all time points. CONCLUSIONThis study demonstrates the radiological factors associated with persistent back pain after an OVF and the association between the VAS score of back pain and radiological findings. In addition, T2 high signal changes in acute phase and old vertebral fractures were independent risk factors for residual back pain.

Long-term Radiological and Clinical Outcomes After Using Bone Marrow Mesenchymal Stem Cells Concentrate Obtained With Selective Retention Cell Technology in Posterolateral Spinal Fusion.

Retrospective study. The aim of this study was to evaluate the long-term clinical and radiological outcomes of the use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology using Cellect with a particular collagen scaffold, Healos for posterolateral spinal fusion. With the increasing rate of spinal fusion, the problem of pseudarthrosis, which contributes to recurrent pain with patient disability, is considered to be the most common cause of revision lumbar spine surgery. Intensive research is being carried out to develop an alternative source of bone grafting and improve the spinal fusion rate. A retrospective review of hospital records was performed. Identified patients were contacted to have a clinical and radiological evaluation follow-up. Clinical outcome was evaluated using visual analog scales for the back pain (VAS), Oswestry Disability Index (ODI) scores, and quality of life (EQ-5D) questionnaire. Radiological outcome was evaluated by performing dynamic flexion/extension lateral views and calculation of segmental Cobb angle. Any implant-associated complication was reported. Computed tomography (CT) scans were also performed. Twenty-one patients were included and all patients achieved successful fusion. The mean difference of the segmental Cobb angle was 0.48° (range 0.3°-0.7°). Computed tomography scans showed solid bilateral fusion with bridging bone (Grade I) in all patients, but solid unilateral fusion with bridging bone (Grade II) was detected for one patient at one level. Patients started to resume working activities within a mean period of 3.5 months. The VAS score for the residual back pain was 4.1 ± 2.1, whereas the ODI was 10.5 ± 5.6 points, and the mean disability index was 21.1%. The use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology could be considered as an effective means for augmenting spinal fusion. 3.

Spontaneous Spinal Arthrodesis in Stand-Alone Percutaneous Pedicle Screw Fixation Without in Situ Fusion in Patients With Lumbar Segmental Instability: Long-Term Clinical, Radiologic, and Functional Outcomes.

No study to date has established how commonly spontaneous fusion occurs after stand-alone percutaneous pedicle screw fixation in adult population. In this retrospective single-center study, we investigated the effectiveness, long-term solidity and safety of stand-alone percutaneous pedicle screw fixation without in situ fusion and the influence of presence or absence of fusion on the clinical outcome of patients with low-grade lumbar segmental instability. Eighty-eight patients with symptomatic low-grade spondylolisthesis were treated with posterior stand-alone percutaneous pedicle screw fixation without bone graft. Radiographic evaluation was used to determine if spontaneous fusion or absence of fusion was present. The solid fusion and absence of fusion groups were analyzed clinically (visual analog scale and Oswestry Disability Index) and with a validated self-administered questionnaire. The average duration of follow-up was 70.5 months (range, 48-120 months). Radiologic signs of spontaneous fusion were present in 45.5% of the cohort and absent in 54.5%. Clinical outcome was excellent to good in 73.8% of the cohort (in 70.9% of cases with spontaneous fusion and in 67.5% of cases with absence of fusion). No significant differences in visual analog scale scores for residual back and lower limb pain between the 2 groups were seen at the final follow-up. At the final follow-up, 5 of 88 patients (5.6%) underwent revision surgery. Percutaneous pedicle screw fixation offers several advantages that help minimize approach-related morbidity, while achieving similar clinical outcome as seen with more traditional invasive procedures. A solid fixation without bone graft provides long-term clinical benefits. In our patients, the appearance of a spontaneous solid fusion and the absence of fusion after stand-alone pedicle screw fixation were correlated with similar improved clinical outcomes at long-term follow-up.

Hybrid fascial closure with laparoscopic mesh placement for ventral hernias: a single surgeon experience

Background: Incisional hernia and primary ventral hernia are among the most common surgical problems that general surgeons face annually in the United States (U.S.). Over 2 million laparotomies are performed in the US and the subsequent incisional hernia rate is 3–20%. At our institution, over the last several years, one surgeon has been performing a unique repair of intermediate-sized hernias by combining open and laparoscopic approaches. We hypothesized that, through a minimal incision, lysis of adhesions and primary repair can be performed, which can then be buttressed with a laparoscopically placed mesh that provides a generous underlay reinforcement that cannot be achieved in open repair. Furthermore, this technique provides the additional benefit of apposition of the rectus muscles and decreased seroma formation compared to laparoscopic hernia repair. Methods: Patients that underwent ventral hernia repair with laparoscopic assistance at NYU Lutheran Medical Center between October of 2012 and January 2015 form this study population. Each patient’s demographic, intra-operative, and postoperative data were collected and analyzed. Patient demographics included gender, age, BMI, prior abdominal surgery, co morbidities, and anticoagulation use. Intra-operative data included defect size, mesh size, and operative time. Postoperative data included complications, length of hospitalization, re-currences, seroma formation, surgical site infections (SSI), and mesh explantation. The surgical technique was as follows: a minimal incision was used over the defect which was only big enough to allow dissection down to the hernia borders. The hernia was reduced and lysis of adhesions of surrounding tissue performed. The hernia was sized and a mesh chosen to provide at least 3 to 5 cm of underlay around the defect. A series of one to four stay sutures were placed in the midline of the mesh and the mesh was placed intra-corporeally. The defect was closed primarily using the Smead-Jones technique (in 17 of 19 patients) to provide a tension-free double layer closure. The abdomen was in-sufflated, the mesh visualized, fixed to the midline via the stay sutures, and tacked circumferentially. The subcutaneous tissue and the skin were closed with absorbable suture. Results: A total of 19 patients (12 females, 7 males) underwent the hybrid hernia repair from October 2012 through January 2015. Only 1 (5%) was admitted postoperatively due to severe underlying co morbidities. The average size of the hernia defect was 5.94 cm 2 (2.5–15 cm 2 ) with an average mesh size of 16×16 cm 2 (9×9–25×20 cm 2 ) being used. Average operative time was 153 minutes with a range of 69–281 minutes. One (5%) had an early (within the first three months post-surgery) recurrence of the hernia. One patient (5%) had an early superficial SSI noticed during the 1 week follow-up appointment and was treated with oral antibiotics. None of the patients required re-hospitalization. None of the patients developed any seroma or any deep tissue infections requiring mesh explantation. Fourteen (74%) of the 19 patients were reached via telephone for further follow-up. All 14 patients were satisfied with the results of their surgery with only 1 complaint of pre-existing gastritis unrelated to the surgery. All of the patients that were employed prior to the surgery were able to return to work post-operatively. None of the patients reported any residual incisional or back pain. Conclusions: Hybrid ventral hernia repair has the physiological benefit of fascial continuity by re-approximating the hernia edges. This technique also maximizes the benefit of laparoscopic repair while mini-mizing associated complications. Patients had no severe wound complications. This surgical technique resulted in a low recurrence rate, and minimal pain after the procedure, making the hybrid technique a safe alternative method when repairing intermediate sized ventral hernias.

Clinical and microbiological outcomes in haematogenous spondylodiscitis treated conservatively.

Spondylodiscitis refers to infections of the intervertebral disc and the adjacent vertebral body. Although it is still considered a rare condition, its rate is projected to increase. Mortality rate is considered to be low, but an estimated one third of the survivors experience residual disabilities. Literature shows that uncomplicated spondylodiscitis can be adequately treated by early antibiotic therapy and immobilization. The aim of the study is to evaluate the outcome of conservative treatment in patients with haematogenous spondylodiscitis. All patients with haematogenous spondylodiscitis observed in two orthopaedic centres were retrospectively considered. The medical records, radiologic imaging, bacteriology results, treatment, and complications of all patients were reviewed. Thirty patients (median age 64years, range 15-77, females 56.7%) were considered in the study, eight (26.7%) showed residual back pain at median follow-up of 117weeks (range 104-189). A significant difference in SF-36 physical (P<0.001), SF-36 mental function (P<0.002), and Oswestry Disability Index (ODI) (P<0.001) scores was observed among patients with residual local pain compared to the ones who had not. Methicillin-resistant Staphylococcus aureus (MRSA) infection and symptoms duration before the diagnosis were associated with an increased risk of persistent back pain and permanent disability. The most important negative determinants of SF-36 mental function were the age of patients (ρ=0.36, P<0.05), the duration of symptoms before the diagnosis (ρ=0.44, P<0.05) and MRSA infection (P=0.006). Spondylodiscitis sustained by MRSA and the duration of symptoms before the diagnosis influenced negatively the physical status (P=0.002) and ODI (ρ=0.36, P<0.05), respectively. Conservative approaches are safe and effective for patients without complications. A delayed diagnosis and MRSA infections are related to poor clinical outcome among patients treated by conservative treatment; this must be carried out scrupulously with close patient monitoring.

Analysis of clinical effects of three operative methods for osteoporotic vertebral compression fracture

To explore the clinical outcomes of percutaneous vertebroplasty(PVP), percutaneous kyphoplasty(PKP) and percutaneous hollow pedicle screw with lateral holes implanted bone cement reinforcement in treating osteoporotic vertebral compression fracture(OVCF). From May 2012 to November 2013, the clinical data of 90 patients with osteoporotic vertebral compression fracture were retrospectively analyzed. According to the different methods of operation, the patients were divided into three groups, including the percutaneous hollow pedicle screw with lateral holes implanted bone cement reinforcement group (group A), percutaneous vertebroplasty group (group B), percutaneous kyphoplasty group (group C), each group had 30 patients. Pre operative, postoperative at 1 day, 3 months, 1 year, the back pain was assessed by visual analogue scale(VAS), and vertebral height compression ratio, Cobb angle were measured by X-rays. All operations were successful and no complications such as postoperative infections and deep vein thrombosis were found. At the final follow up, there were 2 patients with mild postoperative back pain in group A;7 patients with moderate postoperative back pain, 4 patients with severe postoperative back pain, 2 patients with postoperative vertebral refracture in group B; 5 patients with moderate postoperative back pain, 3 patients with severe postoperative back pain, 4 patients with postoperative vertebral refracture in group C. Postoperative VAS, vertebral height compression ratio, Cobb angle of all patients have obviously improved than preoperative(P<0.05). On 1 day, 3 months, 1 year after operation, there was significant difference between group A and group B, C(P<0.05), there was no significant difference between group B and group C(P>0.05). There was no significant difference in group A above items and different times(P>0.05), and there was significant difference in group B, C above items and different times(P<0.05). The effect of PVP and PKP on the immediately postoperative pain relief was more than percutaneous hollow pedicle screw with lateral holes implanted bone cement reinforcement in treating osteoporotic vertebral compression fracture, but, residual back pain can happen in different extent in the patients underwent PVP and PKP. Percutaneous hollow pedicle screw with lateral holes implanted bone cement reinforcement technique has obvious advantage in recovery of the vertebral height, correction of vertebral deformity, reduction of postoperative back pain.

Role of Bone Marrow Mesenchymal Stem Cells Concentrate Using Selective Retention Cell Technology in Posterolateral Spinal Fusion

Introduction With increasing rate of spinal fusion, the problem of pseudarthrosis which contributes to recurrent pain with patient disability is considered to be the most common cause of revision lumbar spine surgery. Intensive research is being performed to develop an alternative source of bone grafting and improve the spinal fusion rate. Purpose Was to evaluate the long-term clinical and radiological outcome of the use bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology using Cellect (Depuy Spine, USA) with a particular collagen scaffold, Healos (Depuy Spine, USA) for posterolateral spinal fusion. Patient and Methods Retrospective review of the hospital records was performed. Then, the identified patients were contacted to have a clinical and radiological evaluation follow-up visit. Demographic data were reported. Preoperative diagnosis, surgical procedure report, previous spine surgery, postoperative complications and any re-operations were registered. Clinical outcome was evaluated using visual analog scales for the back pain (VAS), Oswestry Disability Index (ODI) scores, and quality of life (EQ-5D) questionnaire. Radiological outcome was evaluated by performing plain radiographs including anterior-posterior and dynamic flexion/extension lateral views. Segmental Cobb angle of the fused segment was calculated in the flexion/extension lateral views. Any implant associated complication, development of adjacent segment degeneration and any alteration of normal spinal curvature were reported. Computed tomography (CT) scans were also performed. Results All patients (100%) achieved successful fusion. The mean difference of the segmental Cobb angle was 0.5°, ranging from 0.3°-0.7°. CT scans showed solid bilateral fusion with bridging bone (Grade I) in all patients but solid unilateral fusion with bridging bone (Grade II) was detected at 1 patient at one level. Patients started to resume working activities within a mean period of 3.5 months. The VAS score for the residual back pain was 4.2 ±2 while the ODI was 10.7± 5.6 points with the mean disability index was 21.4%. Conclusion The use of bone marrow mesenchymal stem cells concentrate obtained with selective cell retention technology is shown be an effective mean for augmentation of spinal fusion.

Semi-Circumferential Decompression: Microsurgical Total en-bloc Ligamentum Flavectomy to Treat Lumbar Spinal Stenosis with Grade I Degenerative Spondylolisthesis.

BackgroundTo describe and assess clinical outcomes of the semi-circumferential decompression technique for microsurgical en-bloc total ligamentum flavectomy with preservation of the facet joint to treat the patients who have a lumbar spinal stenosis with degenerative spondylolisthesis.MethodsWe retrospectively analyzed the clinical and radiologic outcomes of 19 patients who have a spinal stenosis with Meyerding grade I degenerative spondylolisthesis. They were treated using the "semi-circumferential decompression" method. We evaluated improvements in back and radiating pain using a visual analogue scale (VAS) and the Oswestry Disability Index (ODI). We also evaluated occurrence of spinal instability on radiological exam using percentage slip and slip angle.ResultsThe mean VAS score for back pain decreased significantly from 6.3 to 4.3, although some patients had residual back pain. The mean VAS for radiating pain decreased significantly from 8.3 to 2.5. The ODI score improved significantly from 25.3 preoperatively to 10.8 postoperatively. No significant change in percentage slip was observed (10% preoperatively vs. 12.2% at the last follow-up). The dynamic percentage slip (gap in percentage slip between flexion and extension X-ray exams) did not change significantly (5.2% vs. 5.8%). Slip angle and dynamic slip angle did not change (3.2° and 8.2° vs. 3.6° and 9.2°, respectively).ConclusionsThe results suggested that semi-circumferential decompression is a clinically recommendable procedure that can improve pain. This procedure does not cause spinal instability when treating patients who have a spinal stenosis with degenerative spondylolisthesis.

Is thoracolumbar fascia injury the cause of residual back pain after percutaneous vertebroplasty? A prospective cohort study.

Some patients with osteoporotic vertebral compression fractures still suffer from back pain after percutaneous vertebroplasty. We have found that osteoporotic vertebral compression fractures with thoracolumbar fascia injury are common and that thoracolumbar fascia injury may account for the residual pain after percutaneous vertebroplasty. Osteoporotic vertebral compression fractures are successfully treated with percutaneous vertebroplasty (PVP). However, some patients still suffer from back pain after the procedure. We hypothesized that there is a relationship between thoracolumbar (TL) fascia injury and residual postoperative pain. This prospective study included 133 elderly patients (age range 55 - 92 years) with osteoporotic vertebral compression fractures treated with PVP from February 2010 to March 2012 in our hospital. The patients were divided into two groups based on the presence of TL fascia injury. A visual analog scale (VAS) and the Chinese modified Oswestry Disability Index were used to evaluate the pain before and after PVP. The mean VAS score and the Chinese modified Oswestry Disability Index in the patients with TL fascia injury were reduced from 9.11 ± 0.76 to 6.4 ± 1.1 and 73.93 ± 1.46% to 44.6 ± 3.1%, respectively, and in the patients without TL fascia injury from 9.26 ± 0.82 to 8.0 ± 1.3 and 73.96 ± 1.38% to 51.7 ± 1.8%, respectively. Pain and disability were reduced more in patients without TL fascia injury than in those with TL fascia injury (both p < 0.05). There may be a relationship between TL fascia injury and residual back pain after PVP.

Moral Distress for the Physician Assistant

Moral Distress for the Physician Assistant Sharyn L. Kurtz My morning rounds as an inpatient medical oncology physician assistant began as usual. I arrived at the hospital early to receive 7 a.m. sign out from the covering resident. The overnight report began favorably. All patients remained stable. Even my patient, whom I will call Mrs. Walker,* had a quiet night. However, given her tenuous admission presentation, including altered mental status, hypercalcemia (high levels of calcium in the blood), atrial fibrillation with rapid ventricular response (irregular, rapid heart function), widespread metastatic lung cancer, and recent neurosurgery to stabilize her spine, I decided to prioritize Mrs. Walker’s morning evaluation. Examining her medical chart proved reassuring. Her tachycardia (rapid heart rate) had been better controlled over the past two days. Her hypercalcemia had been treated, such that she was no longer somnolent. In fact, she was now arousable, conversant, and able to offer some input regarding her healthcare wishes. However, because she was experiencing intermittent delirium, her husband continued to act as her primary medical decision–maker. As her health care proxy, Mr. Walker had experienced conflict with the medical team during his wife’s prior hospital admission. However, even though Mr. Walker lived greater than 45 minutes from the hospital and was not able to visit regularly, he and I spoke daily by phone, which allowed me the opportunity to offer regular medical updates. Mr. Walker felt overwhelmed with his wife’s condition, but he was comfortable with the care the medical team had provided thus far. He was encouraged by the small improvements we had noted since her hospital admission five days prior. Mr. Walker stated on hospital admission that he wished for DNR/I orders to be placed, since this cohered with his wife’s previously stated wishes. However, he still wanted “everything else done” in terms of treating his wife’s medical conditions, including treatment of her atrial fibrillation, pain, and electrolyte anomalies. Most of all, he hoped Mrs. Walker would soon have increased mobility, which he felt would grant his wife the best quality of life possible. He was adamant that “being active” was what Mrs. Walker wished for, and that she had never wanted to be confined to bed. Mr. Walker’s requests seemed reasonable. Although Mrs. Walker’s lung cancer was widespread, and although many on the medical team felt she would not improve to the point where palliative chemotherapy could be considered, [End Page E13] she had stabilized. Her recent spine surgery had been successful, and she was healing adequately. The neurosurgeons had cleared Mrs. Walker for increased activity out of bed as soon as she could be fitted with a lumbar brace. The pain and palliative care specialists felt that Mrs. Walker’s residual back pain and delirium could be well managed with oral medications. Prior to my entering Mrs. Walker’s room to begin her physical evaluation, I was met by her seasoned nurse, whom I will call Amy. “Sharyn,” Amy warned, “Mrs. Walker’s heart rate is 150 and she is complaining of chest pain.” I entered Mrs. Walker’s room, and she was notably uncomfortable, grasping her chest. The monitor showed that Mrs. Walker’s heart rate was in fact in the 150’s. She was pale, short of breath, and wheezing. “Mrs. Walker,” I asked, “how severe is your chest pain on a scale from 1 to 10?” Mrs. Walker replied, “Nine.” I asked Amy to obtain an EKG, to provide oxygen, and to administer an IV medication that would slow Mrs. Walker’s heart rate. I stepped out of the room to place the computer orders, and I paged my attending physician to let him know about Mrs. Walker’s change in status. After hearing the update, my attending physician, whom I will call Dr. Clark, stated that he agreed with all of my treatment decisions thus far. He was on his way into the hospital. I planned out my next steps with him on the phone and returned to the patient’s room. The monitor gave evidence that Mrs. Walker’s heart rate was improving. Mrs. Walker reported that her pain was now “4 out of...

Phantom Limb Pain From Spinal Sarcoma: A Case Report

Phantom limb pain is a frequent sequela of amputation. A high prevalence of residual limb pain and back pain also exists among amputees. We present a case of a new-onset severe phantom limb pain resulting from a metastatic spinal mass in an 81-year-old patient with a history of malignant sarcoma and an old hip disarticulation amputation. The metastatic lesion, upon imaging, was found to involve the L3 vertebra and caused moderate compression of the thecal sac on the right and severe right lateral recess stenosis. After the mass was resected, the patient's phantom limb pain resolved. Our case report demonstrates that spinal metastatic pathologies may be a cause of phantom limb pain and should be included in the differential diagnosis of new-onset phantom limb pain or a change in phantom limb pain.

Vertebroplasty: benefits are more than risks in selected and evidence-based informed patients. A retrospective study of 59 cases

Vertebral compression fractures represent a frequent pathology among elderly population, with potentially devastating consequences. More than 20years have passed since percutaneous vertebroplasty was initially used in the treatment of angiomas, representing nowadays a widely used treatment for osteoporotic vertebral fractures. The authors present a retrospective review of 59 consecutive patients (in total 94 fractured levels) that underwent polymethylmethacrylate percutaneous vertebroplasty for vertebral compression fractures due to senile or secondary osteoporosis. All fractures were free from neurologic involvement and were classified as A1 type according to Magerl classification. All of patients were initially treated conservatively, by application of orthosis that allows immediate deambulation. At control, patients who complained of pain and limitation of daily activities underwent MRI. If presence of marrow signal changes, especially hypertense signal in T2-weighted images was confirmed, percutaneous vertebroplasty procedure was performed (we could call it "sub-acute" procedure). A limited group of patients that did not tolerate brace and had an insufficient pain control underwent vertebroplasty "in acute", few days after fracture. Immediate post-operative pain reduction and follow-up clinical outcome (estimating quality of life and residual back pain) were evaluated by means of Visual Analogue Scale, SF-36 and Oswestry Disability Index. In the immediate post-operative course a significant pain relief was found in 39 patients (66.1%), moderate pain relief in 17 (28.8%), while 3 (5.1%) did not achieve relevant pain improvement. Pain intensity and life quality was maintained within satisfactory limits after a mean follow-up of 16months. In conclusion, percutaneous vertebroplasty is an effective and safe procedure for treating vertebral compression fractures in the elderly. It provides immediate pain relief and allows early mobilization, thus avoiding potentially severe complications related to persistent back pain and prolonged bed rest. When performed by experienced surgeon complication rate is low, representing a safe procedure, able to provide a satisfactory outcome.

5:50 54. Short Segment Indirect Reduction and Fixation of Thoracolumbar Burst Fractures Without Decompression and Fusion

BACKGROUND CONTEXT: Thoracolumbar burst fractures with compression to less than 40% of the original anterior vertebral height and without neurological deficit are considered to be stable injuries. Most of these patients are treated conservatively while fewer are treated operatively with reduction and fixation and fusion either anteriorly, posteriorly, or through a combination of both approaches. However, there are still a significant number of patients with residual back pain. There is currently no data available for these patients treated with pedicle screw fixation without decompression and fusion.

Residual complaints following lumbar disc surgery: prognostic indicators of outcome

Physical as well as psychological features might be important prognostic factors for residual complaints following lumbar disc surgery in primary care. No studies have yet investigated both factors simultaneously. The aim of this prospective cohort study was to identify indicators of the short and long-term outcome of residual complaints following lumbar disc surgery. Patients ( n=105), aged between 18 and 65 years, were included if they still suffered residual complaints 6 weeks after first-time lumbar disc surgery and had therefore been referred to physiotherapy. All potential indicators were measured at baseline except treatment expectancy, which was measured after two treatment sessions enabling patients to rate treatment expectancy based on their actual perception of the treatment. Dimensions of recovery included perceived recovery, functional status, and pain intensity (back and leg) at the 3-month and 12-month follow-up. It was found that high treatment expectancy was associated with a favorable outcome on perceived recovery and functional status, both at the 3 and the 12-month follow-up. Taking pain medication and a poor functional status at baseline were associated with poor perceived recovery and functional status at both follow-up measurements. Leg pain and back pain at baseline were associated with residual leg and back pain at the 3 and the 12-month follow-up, respectively. The results for perceived recovery and functional status were rather robust. However, for leg pain and back pain, the results were less stable. Apparently, the clinical course to recovery of residual leg pain and residual back pain is not strongly influenced by these indicators.

Percutaneous Laser Disc Decompression for the Treatment of Discogenic Lumbar Pain and Sciatica: A Preliminary Report with 3-Month Follow-Up in a General Pain Clinic Population

Our aim was to evaluate the short-term efficacy of percutaneous laser disc decompression (PLDD) for the treatment of lumbar discogenic pain and sciatica. PLDD has been reported to be a safe, effective, minimally invasive treatment option for patients with lumbar spinal pain associated with herniated disc, as an alternative to open spinal surgery. The present study was designed to evaluate the effectiveness of the procedure in patients attending a comprehensive interventional pain management clinic. Thirty-two consecutive patients with discogenic lumbar spinal pain with or without sciatica were identified by MRI scanning and discography. Patients with symptoms attributable to a herniated or degenerated lumbar disc were treated with PLDD utilizing the neodymium-YAG laser. The primary endpoint of the study was the standardized symptom score on the American Academy of Orthopedic Surgery (AAOS) Outcomes Assessment Questionnaire for neurogenic and back pain symptoms at pre-treatment baseline, and at 3 months after laser treatment. Of the 30 patients with sciatica at baseline, 24 (80%) reported improvement in sciatica symptoms at three months, with a mean improvement of 68% (p = 0.001 from baseline values). Of the 32 patients with discogenic pain at baseline, 24 (75%) reported improvement at 3 months, with a mean improvement of 44% (p = 0.0005 from baseline values). No instances of infection, nerve injury, or clinically significant bleeding were identified during the 3-month follow-up period. Similar results were also seen in seven patients undergoing PLDD for residual back pain and sciatica following open spinal surgery. Sixty-three percent of patients complained of new-onset or worsening of mechanical low back pain following PLDD, thought to be related to the procedure. Back pain was considered mild to moderate and was self-limited, or responsive to analgesics and lumbar facet block with or without lumbar rhizotemy. PLDD with the neodymium-YAG laser is a safe and effective treatment for discogenic lumbar pain and sciatica during a preliminary 3-month follow-up period in a general pain management practice setting. Post-procedural mechanical low back pain is common and easily treated without sequellae. No instances of infection, neural injury, or other serious complications were observed.

Percutaneous Laser Disc Decompression for the Treatment of Discogenic Lumbar Pain and Sciatica: A Preliminary Report with 3-Month Follow-Up in a General Pain Clinic Population

Objective: Our aim was to evaluate the short-term efficacy of percutaneous laser disc decompression (PLDD) for the treatment of lumbar discogenic pain and sciatica. Background Data: PLDD has been reported to be a safe, effective, minimally invasive treatment option for patients with lumbar spinal pain associated with herniated disc, as an alternative to open spinal surgery. The present study was designed to evaluate the effectiveness of the procedure in patients attending a comprehensive interventional pain management clinic. Materials and Methods: Thirty-two consecutive patients with discogenic lumbar spinal pain with or without sciatica were identified by MRI scanning and discography. Patients with symptoms attributable to a herniated or degenerated lumbar disc were treated with PLDD utilizing the neodymium-YAG laser. The primary endpoint of the study was the standardized symptom score on the American Academy of Orthopedic Surgery (AAOS) Outcomes Assessment Questionnaire for neurogenic and back pain symptoms at pre-treatment baseline, and at 3 months after laser treatment. Results: Of the 30 patients with sciatica at baseline, 24 (80%) reported improvement in sciatica symptoms at three months, with a mean improvement of 68% (p = 0.001 from baseline values). Of the 32 patients with discogenic pain at baseline, 24 (75%) reported improvement at 3 months, with a mean improvement of 44% (p = 0.0005 from baseline values). No instances of infection, nerve injury, or clinically significant bleeding were identified during the 3-month follow-up period. Similar results were also seen in seven patients undergoing PLDD for residual back pain and sciatica following open spinal surgery. Sixty-three percent of patients complained of new-onset or worsening of mechanical low back pain following PLDD, thought to be related to the procedure. Back pain was considered mild to moderate and was self-limited, or responsive to analgesics and lumbar facet block with or without lumbar rhizotemy. Conclusion: PLDD with the neodymium-YAG laser is a safe and effective treatment for discogenic lumbar pain and sciatica during a preliminary 3-month follow-up period in a general pain management practice setting. Post-procedural mechanical low back pain is common and easily treated without sequellae. No instances of infection, neural injury, or other serious complications were observed.