Failed Back Surgery Syndrome

Targeting IL-20 alleviates inflammatory mechanical allodynia and reduces epidural fibrosis in post-laminectomy syndrome rat model

BACKGROUND

Post-laminectomy syndrome (PLS) manifests as recurrent chronic back pain, with or without radiating leg pain, affecting 10-40% of patients following laminectomy. While surgical interventions can alleviate recurrent disc herniation or joint instability, medical management of PLS remains challenging due to unsatisfactory outcomes. Epidural fibrosis is a frequent cause of PLS, leading to nerve root tethering and dural sac compression. This study aimed to investigate the role of interleukin-20 (IL-20) in the development of epidural fibrosis and the pathogenesis of PLS.

METHODS

A rat model of PLS was used to investigate IL-20 production and its impact on downstream fibrotic biomarkers. Spinal tissues from L1-2 segments were analyzed for cytokine and fibrotic marker expression. Primary fibroblasts were isolated from PLS rats and cultured to assess IL-20 receptor expression. The functional effects of IL-20 on fibroblasts were evaluated, including its impact on cytokine production, fibrotic marker expression, and cell proliferation. Additionally, the efficacy of IL-20 inhibition using the anti-IL-20 monoclonal antibody (mAb) was investigated in relation to epidural fibrosis and the severity of PLS.

RESULTS

A significant increase in IL-20 production was observed along with increased expression of TGF-β, IL-1β, MCP-1, collagen-1, and fibronectin-1 in the L1-2 spinal segments of PLS rats. Treatment with the anti-IL-20 mAb significantly reduced epidural fibrosis and improved functional outcomes in the PLS rat model. Mechanistically, primary fibroblasts from PLS rats expressed IL-20 receptors, and IL-20 stimulation significantly increased IL-1β, TNF-α, and TGF-β levels, along with upregulated fibrotic markers, including fibronectin-1 and collagen-1. IL-20 also enhanced fibroblast proliferation and α-SMA production but did not alter MCP-1 levels.

CONCLUSION

IL-20 is implicated in promoting epidural fibrosis and may contribute to the pathogenesis of PLS through the modulation of fibroblast function. Targeting IL-20 could represent a potential therapeutic approach for managing PLS.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

This study demonstrates that blocking IL-20 with an anti-IL-20 mAb significantly reduces epidural fibrosis and improves pain-related outcomes in a rat model of PLS. These findings suggest that targeting IL-20 could represent a promising new therapeutic strategy for alleviating PLS symptoms and improving recovery.

Association between acute pain trajectory and patient-reported outcomes at 6-months following lumbar surgery for patients with lumbar degenerative disease

PURPOSE

To investigate the association between acute pain trajectory over one week and patient-reported outcomes (PRO) at 6-months following lumbar surgery in patients with lumbar degenerative disease (LDD).

METHODS

Two hundred and fifty-five subjects with LDD who received surgical treatment at our hospital between April 2019 and March 2022. Acute pain trajectory was measured using a pain trajectory calculator to determine an approximate line using the linear least squares method based on pain intensity on postoperative days 1, 3, 5, and 7. The pain trajectory-slope, which represents the change in postoperative pain intensity of the calculated approximation line, was evaluated as the main exposure for the present study. The PRO was assessed using the Oswestry Disability Index (ODI) measured at 6 ± 1 months postoperatively. Poor PRO scores in this study were defined using a threshold of an ODI of 22% or greater, which represents the patient acceptable symptomatic state after lumbar spine surgery. Multivariable logistic regression analysis including covariates was performed to investigate the association between pain trajectory-slope and PRO at 6-months following lumbar surgery.

RESULTS

In this study, 101 (39.6%) had poor PRO scores. Multivariable logistic regression analysis adjusted for covariates showed that pain trajectory-slope was associated with the poor PRO scores (odd ratios; 1.203, 95% confidence intervals; 1.130-1.288).

CONCLUSIONS

The results of this study show that acute pain trajectory is significantly associated with poor PRO scores 6-months after lumbar surgery. Patients with slower pain relief or worsening pain were associated with poor PRO scores.

[Persistent spinal pain syndrome : Consideration of psychosocial risk factors]

The introduction of the term persistent spinal pain syndrome (PSPS), replacing the term failed back surgery syndrome (FBSS) has significantly changed diagnostic and treatment approaches of PSPS. There are multiple risk factors that may contribute to the development of PSPS. Accurately identifying individual risk factors is, therefore, crucial for patient-centered treatment planning. This article mainly focuses on patient-related psychosocial risk factors. Possibilities of evaluating these risk factors prior to spinal surgery in order to prevent PSPS from developing, as well as treatment options for established PSPS will be discussed.

A "people-like-me" approach to predict individual recovery following lumbar microdiscectomy and physical therapy for lumbar radiculopathy

BACKGROUND CONTEXT

Lumbar microdiscectomy is an effective treatment for short-term pain relief and improvements in disability in patients with lumbar radiculopathy, however, many patients experience residual pain and long-term disability. The 'people like me' approach seeks to enhance personalized prognosis and treatment effectiveness, utilizing historical data from similar patients to forecast individual outcomes.

PURPOSE

The primary objective was to develop and test the 'people-like-me' approach for leg pain intensity and disability at 12-month follow-up after lumbar microdiscectomy and postoperative physical therapy. The secondary objective was to verify the clinical utility of the prediction tool via case vignettes.

STUDY DESIGN/SETTING

A 12-month prospective cohort study.

PATIENT SAMPLE

Patients (N=618, mean age: 44.7) with lumbar radiculopathy who undergo a lumbar microdiscectomy and postoperative physical therapy.

OUTCOME MEASURES

Leg pain intensity (Visual Analogue Scale) and disability (Roland-Morris Disability Questionnaire) were measured at 12-months following surgery.

METHODS

Predictors were selected from data collected in routine practice before and 3-months after lumbar microdiscectomy. Predictive mean matching was used to select matches. Predictions were developed using preoperative data alone or combined with 3-month postoperative data. The prediction performance was evaluated for bias (difference between predicted and actual outcomes), coverage (proportion of actual outcomes within prediction intervals), and precision (accuracy of predictions) using leave-one-out cross-validation.

RESULTS

Overall, the 'people-like-me' approach using preoperative data showed accurate coverage and minimal average bias. However, precision based on preoperative data alone was limited. Incorporating 3-month postoperative data alongside preoperative predictors significantly enhanced prognostic precision for both leg pain and disability. Including postoperative data, leg pain prediction accuracy improved by 43% and disability by 23% compared to the sample mean. Adjusted R2 values improved from 0.04 to 0.21 for leg pain, and from 0.07 to 0.34 for disability, enhancing model precision. The effectiveness of this method was highlighted in two case vignettes, illustrating its application in similar patient scenarios.

CONCLUSION

The 'people-like-me' approach generated an accurate prognosis of 12-months outcomes following lumbar discectomy and physical therapy. Scheduling a 3-month postoperative follow-up to evaluate the course, and refine therapy plans and expectations for patients undergoing lumbar microdiscectomy would be recommended to assist clinicians and patients in more personalized healthcare planning and expectation setting.

Postoperative early initiation of sequential exercise program in preventing persistent spinal pain syndrome type-2 after modified transforaminal lumbar interbody fusion: a prospective randomized controlled trial

PURPOSE

This prospective randomized controlled trial aimed to investigate the impact of early postoperative sequential motor control (starting first day post-operatively) and core stabilization training (starting fifth week post-operatively) compared to conventional exercise (starting fifth weeks post-operatively) on the risk of developing persistent spinal pain syndrome type-2 (PSPS-T2).

METHODS

395 patients with lumbar degenerative diseases (LDDs) undergoing modified transforaminal lumbar interbody fusion and a 12-week postoperative exercise program (sequential vs. conventional exercise: 214 vs. 181) were evaluated for low back pain (LBP) intensity, Oswestry Disability Index (ODI), pressure pain threshold (PPT), temporal summation (TS), fatty infiltration of paraspinal muscles, transversus abdominis (TrA) activation capacity and Fear-Avoidance Beliefs Questionnaire (FABQ) pre-operatively, 3 months post-operatively, and 1 year post-operatively.

RESULTS

At 3-month postoperative assessment, LBP in sequential exercise group were lower than those in conventional exercise group (P < 0.05), and sequential-exercise patients had greater local-area PPTs, lower TS, lower TrA activation capacities and less fatty infiltration of erector spinae than did the conventional-exercise patients (P < 0.05). At 1-year postoperative assessment, fewer sequential-exercise patients had PSPS-T2 compared with conventional-exercise patients (11/214 vs. 20/181; P < 0.05). LBP at rest and FABQ were lower in sequential-exercise patients than conventional-exercise patients (P < 0.05). Furthermore, both PPT and TS at 1-year postoperative assessment were associated with these measurements at 3-month postoperative assessment in patients with PSPS-T2 (P < 0.05).

CONCLUSIONS

Postoperative sequential exercise has more positive effects to avoid PSPS-T2 than conventional exercise in patients with LDDs possibly because of its advantages in improving central and peripheral sensitization.

Effect of Lumbar Spinal Stabilization Exercises Along With Neural Tissue Mobilization on Pain and Spinal Dysfunction in Failed Back Surgery Syndrome

Background Failed back surgery syndrome (FBSS) mainly involves back pain radiating to the lower limb after back-related surgeries. It can develop various complications around the operation site and its surrounding area. This study evaluates the effect of lumbar spinal stabilization exercises and neural tissue mobilization on pain and spinal dysfunction in FBSS. Objectives To study the impact of lumbar spinal stabilization exercises and neural tissue mobilization on pain and spinal dysfunction in FBSS. To compare the impact of lumbar spinal stabilization exercises and neural tissue mobilization with conventional therapy on pain and spinal dysfunction in FBSS. Methods The study included 76 participants aged 45-60 with back pain radiating to lower limbs after back-related surgeries within the past six months. Participants were randomly assigned to either a conventional treatment group (Group A) or an experimental exercise program group (Group B). The treatment duration was six weeks and data were analyzed by a paired t-test for within-group analysis and an unpaired t-test for between-group analysis. Results Both groups A and B showed significant differences in all three outcome measures. However, Group B showed extremely significant improvement (<0.0001) in outcome measures, including pain, lumbar muscle strength by manual muscle testing, and modified Oswestry index assessment compared to Group A. Conclusion Both conventional and experimental groups showed a significant impact on the pain and level of function in failed back surgery syndrome patients. However, lumbar stabilization exercises along with neural tissue mobilization (Group B) showed a more pronounced impact on all outcomes such as pain reduction and improvement in lumbar flexor, rotator, and extensor muscle strength and modified Oswestry index compared to the conventional treatment group (Group A).

Potential Cost Savings with 60-day Peripheral Nerve Stimulation Treatment in Chronic Axial Low Back Pain

INTRODUCTION

Chronic axial low back pain (CLBP) that is not responsive to medication management or physical therapy often requires significant clinical intervention. Several interventional pain management options exist, including a 60-day peripheral nerve stimulation (PNS) treatment. This economic evaluation investigated the potential for projected cost savings associated with prioritizing 60-day PNS treatment relative to a 'standard of care' (SOC) approach (where patients do not have access to 60-day PNS).

METHODS

A decision tree (supervised machine learning) model tracked treatment progression across two hypothetical cohorts of US patients with CLBP in whom non-interventional options were ineffective (Cohort A: treatment starting with 60-day PNS followed by any additional interventional and surgical treatments versus Cohort B: standard of care interventional and surgical treatments without access to 60-day PNS). Treatment efficacy estimates were based on published success rates. Conditional on treatment failure, up to two additional interventions were considered within the 12-month time frame in both cohorts. SOC treatment options included epidural injection, radiofrequency ablation (RFA), basivertebral nerve ablation (BVNA), PNS permanent implant (PNS-PI), spinal cord stimulator (SCS) trial/implant, and spinal fusion surgery. Treatment choice probabilities in both cohort algorithms were based on clinician interviews. Costs were based on national Medicare reimbursement levels in the ambulatory surgery center (ASC) setting. Savings reflected the difference in projected costs between cohorts. A Monte Carlo simulation and sensitivity analyses were conducted to generate confidence intervals and identify important inputs.

RESULTS

The treatment algorithm which prioritized initial 60-day PNS treatment was projected to save $8056 (95% CI $6112-$9981) per patient during the first year of interventional treatment relative to the SOC approach.

CONCLUSIONS

Use of the 60-day PNS treatment as an initial interventional treatment in patients with CLBP may result in significant savings for Medicare. Projected savings may be even larger for commercial payers covering non-Medicare patients.

Specific back pain - effective diagnosis and treatment from the radiologist's point of view

The diagnosis and treatment of specific back pain is important in radiology. Due to the high number of patients suffering from back pain, it is important to provide excellent diagnostic and therapeutic support.Based on a recent literature search and considering the relevant guidelines as well as expert opinions, the aspects of specific back pain important for radiologists in terms of pathogenesis, diagnosis, and treatment are presented.Clinical examination in combination with the medical history provides a valid suspected diagnosis. This should subsequently be verified radiologically. MRI is the most effective cross-sectional diagnostic method for investigating specific back pain. A conventional X-ray on two planes in a standing position can be a useful addition if postural causes are suspected. If the clinical symptoms match the morphological findings, radiological treatment can be carried out for nerve root involvement as well as for inflammatory changes of the facet joints. The improvement in symptoms after radiological therapy is considered good overall; at least a short-term improvement in symptoms can generally be achieved, but no reliable data is available regarding the long-term outcome. Using preparations containing triamcinolone, low dosages should be selected in accordance with the guidelines. Embedding in a multimodal pain therapy treatment concept should be considered.Radiology provides essential diagnostic findings regarding specific back pain. Interventional pain therapy is an effective and safe method of treating proven specific back pain. · First examine clinically, then confirm the suspected diagnosis radiologically.. · MRI is usually the method of choice.. · Interventional pain therapy should show success after a maximum of 2 interventions.. · The anti-inflammatory drug dose should be kept as low as possible.. · The individual course determines the number of interventions.. · Stueckle CA, Haage P. Specific back pain - effective diagnosis and treatment from the radiologist's point of view. Fortschr Röntgenstr 2024; DOI 10.1055/a-2371-1752.

Failed back surgery syndrome-terminology, etiology, prevention, evaluation, and management: a narrative review

Amid the worldwide increase in spinal surgery rates, a significant proportion of patients continue to experience refractory chronic pain, resulting in reduced quality of life and escalated healthcare demands. Failed back surgery syndrome (FBSS) is a clinical condition characterized by persistent or recurrent pain after one or more spinal surgeries. The diverse characteristics and stigmatizing descriptions of FBSS necessitate a reevaluation of its nomenclature to reflect its complexity more accurately. Accurate identification of the cause of FBSS is hampered by the complex nature of the syndrome and limitations of current diagnostic labels. Management requires a multidisciplinary approach that may include pharmacological treatment, physical therapy, psychological support, and interventional procedures, emphasizing realistic goal-setting and patient education. Further research is needed to increase our understanding, improve diagnostic accuracy, and develop more effective management strategies.

Effect of Residual Pain After Posterior Fusion Surgery for Lumbar Degenerative Disorders on Health-Related Quality of Life: A Two-Year Follow-Up Using Patient-Reported Outcome Measures

STUDY DESIGN

This is a prospective cohort study.

PURPOSE

The present study aimed to investigate the effects of residual pain after fusion surgery for lumbar degenerative diseases on quality of life (QOL).

OVERVIEW OF LITERATURE

Residual symptoms after spinal surgery often restrict patients' activities of daily living and reduce their QOL. However, few studies have comprehensively addressed physical, psychological, and social factors.

METHODS

The study population included a cohort of 208 patients (mean age: 67.9 years) who had undergone posterior interbody fusion for lumbar degenerative disease between 2012 and 2019. We asked the patients to complete the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and Short Form Health Survey (SF-36) preoperatively, as well as at six, 12, and 24 months postoperatively. The presence of residual postoperative pain (RPP) was determined using the low back pain score of the JOABPEQ at six months postoperatively, and patients with an improvement of < 20 points compared to preoperative assessment were classified as RPP+ based on a previous study.

RESULTS

In all patients, there was a notable postoperative improvement in all JOABPEQ and SF-36 domains compared to preoperative scores. The RPP+ group comprised 60 patients (69.6 years), while the RPP- group comprised 148 patients (67.2 years). In the RPP+ group, the lumbar function in the JOABPEQ and general health in the SF-36 showed limited postoperative enhancement. The pace of improvement in the role-emotional, role-physical, social functioning, vitality, and mental health scores was slower in the RPP+ group compared to the RPP- group.

CONCLUSIONS

In the current study, we found that the presence of residual pain at six months postoperatively affected QOL improvement up to 24 months after surgery. Lingering postoperative pain substantially impacted functional incapacity, social engagement, and psychological well-being. Notably, the lumbar function in the JOABPEQ and general health in the SF-36 showed distinct progression patterns in the RPP+ group.

Predictors of Persistent Postoperative Numbness Following Lumbar Fusion in Patients Older Than 75 Years: A Minimum 2-Year Follow-up

OBJECTIVE

To evaluate the preoperative and perioperative predictors of persistent leg numbness following lumbar fusion in patients aged ≥ 75 years.

METHODS

This single-center retrospective study examined 304 patients aged ≥ 75 years who underwent lumbar fusion for lumbar degenerative disease (102 men, 202 women; mean age, 79.2 [75-90] years). The visual analogue scale (VAS) score for leg numbness was examined preoperatively and at 2 years postoperatively. The persistent leg numbness group included patients with a 2-year postoperative VAS score for leg numbness ≥ 5 points. The demographic data were also reviewed. A multivariate stepwise logistic regression analysis was performed for variables with univariate analysis values of p < 0.2 on univariate analysis.

RESULTS

In total, 71 patients (23.4%) experienced persistent postoperative leg numbness. Multivariate logistic regression analysis revealed that a history of lumbar decompression, longer symptom duration, and a preoperative VAS score for leg numbness ≥ 5 points were associated with greater postoperative persistent leg numbness following lumbar fusion. In contrast, other factors, such as sex, body mass index, vertebral fracture, diabetes mellitus, depression, symptom duration, dural injury, operative time, and estimated blood loss, were not.

CONCLUSION

A history of preoperative lumbar decompression, longer symptom duration, and greater preoperative VAS scores for leg numbness were preoperative predictors of persistent postoperative leg numbness following lumbar fusion in older patients. Although lumbar fusion is expected to improve leg numbness, surgeons should consider the surgical history, duration, and preoperative numbness intensity and explain the potential postoperative persistent leg numbness in advance.

Retrospective review of the efficacy for sublingual ketamine in the treatment of chronic low back pain defined by a cause and central functional pain symptom focused clinical model

PURPOSE

Chronic low back pain is a leading cause of disability worldwide. A clinical model for its cause is lacking. Defining a cause based clinical model and a framework of understanding back pain in terms of peripheral structural and central functional pain is essential for optimal management.

MATERIALS AND METHODS

We describe the results of the largest published audit of 41 chronic low back pain patients, receiving outpatient sublingual ketamine therapy for defined central functional pain along with conventional peripheral structural pain management. Our clinical model assigns Movement Dysfunction as the primary cause for low back pain symptoms and restores it with Movement Therapy focused rehabilitation which is also defined. Patients were derived from a tertiary single neurosurgical specialist practice in Brisbane Australia over a three year period.

RESULTS

Severe pain and disability measurements more than halved and only 13% of patients ceased ketamine prematurely due to predominantly non-sinister side effects common to all pharmaceutical therapies. All other surveyed metrics of utility were highly favourable in this challenging cohort of chronic back pain patients biased to poor outcomes.

CONCLUSIONS

Outpatient ketamine maintains high efficacy and safety used in conjunction with a unique clinical model that describes chronic low back pain.

Graded exercise with motion style acupuncture therapy for a patient with failed back surgery syndrome and major depressive disorder: a case report and literature review

Effective treatment of failed back surgery syndrome (FBSS) remains challenging despite urgent medical attention requirements. Depression is a contributing factor to the development and poor prognosis of FBSS, and vice versa. We report the case of a patient with FBSS and major depressive disorder (MDD) treated with graded exercise combined with motion-style acupuncture therapy (MSAT). A 53-year-old male veteran who had undergone lumbar discectomy and laminectomy with instrumented fusion was admitted to the hospital with re-current back pain and radiative pain in the left leg. The effects of failed surgery triggered MDD as a comorbidity. After a six-week routine treatment without remarkable improvement, a three-week program of graded exercise with MSAT was applied. The numeric rating scale (NRS) and short form-36 (SF-36) were used to assess low back pain with radiating leg pain, and daily functioning levels, respectively. The voluntary walking distance of the patients was measured. To analyze the therapeutic effects and other applications of the intervention, we surveyed clinical trials using MSAT or graded exercise therapy (GET). Three weeks of graded exercise with MSAT reduced physical and mental functional disabilities (SF-36, physical component: 15.0 to 37.2, mental component: 21.9 to 30.1) as well as the intensity of low back pain and/or radiative leg pain (NRS: 50 to 30). Furthermore, as the therapeutic intensity gradually increased, there was a significant corresponding increase in daily walking distance (mean daily walking distance, the first week vs. baseline, second, and third week, 3.05 ± 0.56: 2.07 ± 0.79, 4.27 ± 0.96, and 4.72 ± 1.04 km, p = 0.04, p = 0.02, and p = 0.003, respectively). Three randomized controlled trials of GET were included, all showing statistically significant antidepressant effects in the diseased population. Graded exercise with MSAT may be an effective rehabilitative therapy for patients with FBSS and MDD who have impaired daily routines.

Mo-fi-disc scoring system: Towards understanding the radiological tools to better delineate the disease process and enhancing our solutions for low back pain in artificial intelligence era

BACKGROUND

'Mo-fi-disc' is a new scoring system that quantifies degeneration of the lumbar spine and predicts the intensity of low back pain (LBP). However, its association with LBP-related disability is unknown. In the present study, we aimed to analyze whether 'Mo-fi-disc' scoring system could predict LBP-related disability and distinguish patients with LBP from asymptomatic subjects, while the spine medicine marching towards the era of artificial intelligence (AI).

METHODS

This is a cross-sectional analysis of a prospectively collected database. We included age-, gender-, and BMI-matched 132 subjects (patients: 66, asymptomatic subjects: 66). Modic changes (Mo), fatty infiltration in the paraspinal muscles (fi), and intervertebral disc degeneration (disc) were evaluated using 'Mo-fi-disc' scoring system on lumbar spine magnetic resonance imaging. Pain and disability were evaluated with visual analogue scale (VAS) and Oswestry disability index (ODI), respectively.

RESULTS

A Mo-fi-disc score of 5.5 was the most appropriate cut-off value. Mo-fi-disc scoring system had an OR of 1.79 in distinguishing patients with LBP from asymptomatic subjects. One point increment in VAS and ODI had ORs of 1.82 and 1.13 for predicting higher Mo-fi-disc scores.

CONCLUSION

'Mo-fi-disc' scoring system is a useful tool depicting intensity of LBP and LBP-related disability. The cut off value of Mo-fi-disc score is 5.5 to distinguish patients with LBP from asymptomatic subjects. This scoring system, with progressive improvement of its faults, could help clinicians to select appropriate patients for conservative and surgical management in the very near future, in AI-based spine medicine.

IRB APPROVAL NO

ATADEK 2019-12/4.

Treatment Concept and Technical Considerations of Biportal Endoscopic Spine Surgery for Lumbar Spinal Stenosis

Decompression is a major component of surgical procedures for degenerative lumbar spinal stenosis (LSS). In addition to sufficient decompression to guarantee the relief of neurological pain, compensating surgical instability after wider laminectomy and foraminotomy and instrumentation with caging and fusion with grafting are performed to secure or restore the foraminal dimension and correct coronal/sagittal imbalance for longer survival of the adjacent segment. Endoscopic spinal surgery (ESS) has been developed under the flag of successful decompression while preserving structural integrity as much as possible with the help of magnification and illumination. ESS provides a technical possibility and feasibility for solving LSS by decompression alone. Recently, many endoscopic trials have been conducted to overcome conventional surgical treatment that requires wider dissection, escape inevitable complications from surgical damage, and compensate for the fusion technique. However, biportal ESS has some technical limitations, including clinical difficulties in accessibility for more moderate to severe stenosis and challenges for complicated conditions with segmental ventral slip, isthmic defect, stenosis combined with foraminal stenosis or foraminal disk rupture, or degenerative segmental scoliosis with disk height collapsing and endplate fatigue fracture. Because decompression alone is a skill for eliminating pathologies, there is no function of preserving degenerative structure or stopping the recurrence of disk degeneration or subsidence. This review of clinical reports investigated the possibility of biportal ESS for treating degenerative lumbar disorders by sufficient decompression and adequate elimination of various pathologies and decreasing technical complications. The results of this study may help develop better innovative spinal surgical techniques in the near future.

Clinical Patient-Relevant Outcome Domains for Persistent Spinal Pain Syndrome-A Scoping Review and Expert Panels

Large variation exists in the monitoring of clinical outcome domains in patients with persistent spinal pain syndrome (PSPS). Furthermore, it is unclear which outcome domains are important from the PSPS patient's perspective. The study objectives were to identify patient-relevant outcome domains for PSPS and to establish a PSPS outcomes framework. PubMed, CINAHL, Cochrane, and EMBASE were searched to identify studies reporting views or preferences of PSPS patients on outcome domains. The Arksey and O'Malley framework was followed to identify outcome domains. An expert panel rated the domains based on the importance for PSPS patients they have treated. A framework of relevant outcome domains was established using the selected outcome domains by the expert panel. No studies were found for PSPS type 1. Five studies with 77 PSPS type 2 patients were included for further analysis. Fourteen outcome domains were identified. An expert panel, including 27 clinical experts, reached consensus on the domains pain, daily activities, perspective of life, social participation, mobility, mood, self-reliance, and sleep. Eleven domains were included in the PSPS type 2 outcomes framework. This framework is illustrative of a more holistic perspective and should be used to improve the evaluation of care for PSPS type 2 patients. Further research is needed on the prioritization of relevant outcome domains.

Integrative approaches in spinal cord stimulation: Neuropathic pain management and motor recovery in spinal cord injury. A narrative review

Introduction

Spinal cord stimulation is a widespread treatment of chronic neuropathic pain from different conditions. Several novel and improving technologies have been recently developed to increase the effect of neuromodulation in patients refractory to pharmacological therapy.

Research question

To explore spinal cord stimulation's mechanisms of action, indications, and management.

Material and methods

The paper initially explores the mechanism of action of this procedure based on the generation of an electric field between electrodes placed on the posterior dural surface of the spinal cord probably interfering with the transmission of pain stimuli to the brain. Subsequently, the most consolidated criteria for selecting patients for surgery, which constitute a major issue of debate, were defined. Thereafter, the fundamental patterns of stimulation were summarized by exploring the advantages and side effects. Lastly, the most common side effects and the related management were discussed.

Results

Proper selection of the patient is of paramount importance to achieve the best results from this specific neuromodulation treatment. Regarding the different types of stimulation patterns, no definite evidence-based guidelines exist on the most appropriate approach in relation to the specific type of neuropathic pain. Both burst stimulation and high-frequency stimulation are innovative techniques that reduce the risk of paresthesias compared with conventional stimulation.

Discussion and conclusion

Novel protocols of stimulation (burst stimulation and high frequency stimulation) may improve the trade-off between therapeutic benefits and potential side effects. Likewise, decreasing the rates of hardware-related complications will be also useful to increase the application of neuromodulation in clinical settings.

Pregabalin versus Gabapentin Efficacy in the Management of Neuropathic Pain Associated with Failed Back Surgery Syndrome

OBJECTIVE

Failed back surgery syndrome (FBSS) is a common long-term complication following spine surgeries characterized by chronic persistent pain; different strategies of management were employed to deal with it. This clinical trial aims to compare the efficacy of Pregabalin and Gabapentin in the management of this condition.

METHODS

A double-blind, randomized, comparative study (clinical trial registry NCT05324761 on 11th April 2022) with two parallel arms with Pregabalin and Gabapentin were used in arms one and two, respectively. Visual analog scale was used for basal and endpoint assessment of pain. T-test and analysis of covariance were used to deal with different variables. A pairwise test was used to compare pairs of means.

RESULTS

Of 66 patients referred to the trial, 64 were eligible, with 60 patients completing the 30 days trial. Both pregabalin and gabapentin effectively reduce pain, with significant p-values of 0.001 for each group. However, the pregabalin group was superior to gabapentin in pain reduction (p=0.001). Gender was an insignificant factor (p=0.574 and p=0.445 for the pregabalin and gabapentin groups, respectively, with a non-significant reduction (p=0.393) for both groups in total. Location of stenosis before surgery and type of surgery performed show non-significant effect on pain reduction for both groups.

CONCLUSION

Both pregabalin and gabapentin effectively and safely relieve neuropathic pain associated with FBSS; pregabalin was significantly more effective irrespective of the patients' gender.

Evaluation of the Effect of Repetitive Transcranial Magnetic Stimulation of Motor Cortex on Failed Back Surgery Syndrome Pain Control in the Short Term

BACKGROUND

 This study aimed to evaluate the short-term efficacy of repetitive transcranial magnetic stimulation (rTMS) on the treatment of failed back surgery syndrome (FBSS).

METHODS

 In this prospective clinical trial study, 13 patients with FBSS were selected to undergo rTMS, including 5 sessions of stimulation of the primary motor cortex of 90 trains with a frequency of 10 Hz for 2 seconds and an intertrain interval of 20 seconds with a total pulse rate of 1800 per session. The time of each session was 30 minutes with an intensity of 80% of the motor threshold. The severity of pain before and after the intervention was measured by the short-form McGill Pain Questionnaire and visual analog scale (VAS).

RESULTS

 The mean of pain severity was 26.54 ± 6.78 and 14.92 ± 10.1 before and after rTMS, respectively. The severity of pain was significantly decreased after the intervention (p = 0.001). According to the McGill Pain Questionnaire, the severity of pain in the patients was decreased by 44.09 ± 27.32. The mean of the severity of pain according to VAS was 77.31 ± 16.66 before rTMS and 53.46 ± 22.49 after rTMS, which showed that pain intensity was significantly decreased after the intervention (p = 0.006).

CONCLUSIONS

 The use of rTMS of the primary motor cortex in patients who have undergone lumbosacral spine surgery and suffer from pain related to FBSS is associated with a significant reduction in the severity of pain. Because rTMS is a noninvasive treatment method, it can be used as a suitable treatment in these patients.

Importance of Sacrotuberous Ligament in Transgluteal Approach for Sciatic Nerve Entrapment in the Greater Sciatic Notch (Piriformis Syndrome)

OBJECTIVE

The efficacy of sciatic nerve decompression via transgluteal approach for entrapment of the sciatic nerve at the greater sciatic notch, called piriformis syndrome, and factors affecting the surgical outcome were analyzed.

METHODS

The outcome of pain reduction was analyzed in 81 patients with sciatic nerve entrapment who underwent decompression through a transgluteal approach. The patients were followed up for at least 6 months. The degree of pain reduction was analyzed using a numerical rating scale-11 (NRS-11) score and percent pain relief before and after last follow-up following surgery. Success was defined by at least 50% reduction in pain measured via NRS-11. To assess the degree of subjective satisfaction, a 10-point Likert scale was used. In addition, demographic characteristics, anatomical variations, and variations in surgical technique involving sacrotuberous ligamentectomy were analyzed as factors that affect the surgical outcome.

RESULTS

At a follow-up of 17.5±12.5 months, sciatic nerve decompression was successful in 50 of 81 patients (61.7%), and the pain relief rate was 43.9±34.17. Subjective improvement based on a 10-point Likert scale was 4.90±3.43. Among the factors that affect the surgical outcome, only additional division of the sacrotuberous ligament during piriformis muscle resection played a significant role. The success rate was higher in the scarotuberous ligementectomy group (79.4%) than in the non-resection group (42.6%), resulting in statistically significant difference based on average NRS-11 score, percent pain relief, and subjective improvement (p<0.05, independent t-test).

CONCLUSION

Sciatic nerve decompression is effective in pain relief in chronic sciatica due to sciatic nerve entrapment at the greater sciatic notch. Its effect was further enhanced by circumferential dissection of the sciatic nerve based on the compartment formed by the piriformis muscle and the sacrotuberous ligament in the greater sciatic notch.

Polycaprolactone/Polylactic Acid Membrane Fails to Prevent Laminectomy-induced Sprouting of CGRP- and SP-immunopositive Nerve Fibres in the Dura mater lumbalis of Rats

BACKGROUND CONTEXT

Mechanisms and prevention of failed back surgery syndromes are rarely known in the clinical context. It has been shown that laminectomy induces outgrowth of putative nociceptive peptidergic afferents in the dura mater lumbalis of rats.

PURPOSE

We aimed to investigate whether the application of a polycaprolactone/polylactic acid membrane (Mesofol) after surgery inhibits sensory hyperinnervation.

MATERIALS/METHODS

Adult Lewis rats were assigned to three groups: Control (no manipulation), Laminectomy and Laminectomy + Mesofol. Six weeks post-surgery, the durae were removed, immunohistochemically stained for CGRP- and SP-positive afferents and their density quantified.

RESULTS

In controls, CGRP- and SP-positive neurons were predominantly found in ventral but rarely observed in dorsal parts of the dura. Following laminectomy, the density of afferents significantly increased ventrally, resulting in a dense network of nerve fibers. In dorsal regions, neuronal sprouting of was observed. Covering the dura with Mesofol after laminectomy had no impact on nerve fibre outgrowth.

CONCLUSION

Application of Mesofol neither prevents nor significantly diminishes the laminectomy-induced increase in the density of peptidergic afferents.

Multimodal management strategies for chronic pain after spinal surgery: a comprehensive review

"Chronic pain after spinal surgery" (CPSS) is a nonspecific term for cases in which the end result of surgery generally does not meet the preoperative expectations of the patient and surgeon. This term has replaced the previous term i.e., failed back surgery syndrome. CPSS is challenging for both patients and doctors. Despite advancements in surgical techniques and technologies, a subset of patients continue to experience persistent or recurrent pain postoperatively. This review provides an overview of the multimodal management for CPSS, ranging from conservative management to revision surgery. Drawing on recent research and clinical experience, we aimed to offer insights into the diverse strategies available to improve the quality of life of CPSS patients.

Factors Predicting Clinically Relevant Pain Relief After Spinal Cord Stimulation for Patients With Chronic Low Back and/or Leg Pain: A Systematic Review With Meta-Analysis and Meta-Regression

RATIONALE

To optimize results with spinal cord stimulation (SCS) for chronic low back pain (CLBP) and/or leg pain, including persistent spinal pain syndrome (PSPS), careful patient selection based on proved predictive factors is essential. Unfortunately, the necessary selection process required to optimize outcomes of SCS remains challenging.

OBJECTIVE

This review aimed to evaluate predictive factors of clinically relevant pain relief after SCS for patients with CLBP and/or radicular leg pain, including PSPS.

MATERIALS AND METHODS

In August 2023, PubMed, Cinahl, Cochrane, and EMBASE were searched to identify studies published between January 2010 and August 2023. Studies reporting the percentage of patients with ≥50% pain relief after SCS in patients with CLBP and leg pain, including PSPS at 12 or 24 months, were included. Meta-analysis was conducted to pool results for back, leg, and general pain relief. Predictive factors for pain relief after 12 months were examined using univariable and multivariable meta-regression.

RESULTS

A total of 27 studies (2220 patients) were included for further analysis. The mean percentages of patients with substantial pain relief were 68% for leg pain, 63% for back pain, and 73% for general pain at 12 months follow-up, and 63% for leg pain, 59% for back pain, and 71% for general pain at 24 months follow-up assessment. The implantation method and baseline Oswestry Disability Index made the multivariable meta-regression model for ≥50% back pain relief. Sex and pain duration made the final model for ≥50% leg pain relief. Variable stimulation and implantation method made the final model for general pain relief.

CONCLUSIONS

This review supports SCS as an effective pain-relieving treatment for CLBP and/or leg pain, and models were developed to predict substantial back and leg pain relief. To provide high-grade evidence for predictive factors, SCS studies of high quality are needed in which standardized factors predictive of SCS success, based on in-patient improvements, are monitored and reported.

Patient profiling and outcome assessment in spinal cord stimulation for chronic back and/or leg pain (the PROSTIM study): a study protocol

Spinal cord stimulation (SCS) is a well-established treatment option in the multidisciplinary approach to chronic back and leg pain. Nevertheless, careful patient selection remains crucial to provide the most optimal treatment and prevent treatment failure. We report the protocol for the PROSTIM study, an ongoing prospective, multicentric and observational clinical study (NCT05349695) that aims to identify different patient clusters and their outcomes after SCS. Patients are recruited in different centers in Europe. Analysis focuses on identifying significant patient clusters based on different health domains and the changes in biopsychosocial variables 6 weeks, 3 and 12 months after implantation. This study is the first to include a biopsychosocial cluster analysis to identify significant patient groups and their response to treatment with SCS.

Should we Oppose or Combine Waveforms for Spinal Cord Stimulation in PSPS-T2 Patients? A Prospective Randomized Crossover Trial (MULTIWAVE Study)

Refractory persistent spinal pain syndrome after surgery (PSPS-T2) can be successfully addressed by spinal cord stimulation (SCS). While conventional stimulation generates paresthesia, recent systems enable the delivery of paresthesia-free stimulation. Studies have claimed non-inferiority/superiority of selected paresthesia-free stimulation compared with paresthesia-based stimulation, but the comparative efficacy between different waveforms still needs to be determined in a given patient. We designed a randomized controlled 3-month crossover trial to compare pain relief of paresthesia-based stimulation versus high frequency versus burst in 28 PSPS-T2 patients implanted with multiwave SCS systems. Our secondary objectives were to determine the efficacy of these 3 waveforms on pain surface, quality of life, functional capacity, psychological distress, and validated composite multidimensional clinical response index to provide holistic comparisons at 3-, 6-, 9-, and 15-month post-randomization. The preferred stimulation modality was documented during the follow-up periods. No difference between the waveforms was observed in this study (P = .08). SCS led to significant pain relief, quality of life improvement, improvement of multidimensional clinical response index, and of all other clinical outcomes at all follow-up visits. Forty-four percent of the patients chose to keep the paresthesia-based stimulation modality after the 15-month follow-up period. By giving the possibility to switch and/or to combine several waveforms, the overall rate of SCS responders further increased with 25%. In this study, high frequency or burst do not appear superior to paresthesia-based stimulation, wherefore paresthesia-based stimulation should still be considered as a valid option. However, combining paresthesia-based stimulation with paresthesia-free stimulation, through personalized multiwave therapy, might significantly improve SCS responses. PERSPECTIVE: This article assesses clinical SCS efficacy on pain relief, by comparing paresthesia-based stimulation and paresthesia-free stimulation (including high frequency and burst) modalities in patient presenting with PSPS-T2. Switching and/or combining waveforms contribute to increasing the global SCS responders rate.

Association of central sensitization, visceral fat, and surgical outcomes in lumbar spinal stenosis

BACKGROUND

Controversy remains regarding predictors of surgical outcomes for patients with lumbar spinal stenosis (LSS). Pain sensitization may be an underlying mechanism contributing to LSS surgical outcomes. Further, obesity is associated with dissatisfaction and poorer outcomes after surgery for LSS. Therefore, this study aimed to examine the relationship between central sensitization (CS), visceral fat, and surgical outcomes in LSS.

METHODS

Patients with LSS were categorized based on their central sensitization inventory (CSI) scores into low- (CSI < 40) and high- (CSI ≥ 40) CSI subgroups. The participants completed clinical outcome assessments preoperatively and 12 months postoperatively.

RESULTS

Overall, 60 patients were enrolled in the study (28 men, 32 women; mean age: 62.1 ± 2.8 years). The high-CSI group had significantly higher mean low back pain (LBP), leg pain, and leg numbness visual analogue scale (VAS) scores than the low-CSI group (p < 0.01). The high-CSI group had a significantly higher mean visceral fat area than the low-CSI group (p < 0.01). Postoperatively, LBP VAS score was significantly worse in the high-CSI group. Relative to preoperatively, postoperative leg pain and leg numbness improved significantly in both groups.

CONCLUSIONS

We believe that neuro decompression can be effective for LSS surgical outcomes in patients with CS; nonetheless, it should be approached with caution owing to the potential for worsening LBP. Additionally, visceral fat is an important indicator suggesting the involvement of CS.

Enhanced Intervertebral Disc Repair via Genetically Engineered Mesenchymal Stem Cells with Tetracycline Regulatory System

The therapeutic potential of Mesenchymal stem cells (MSCs) for the treatment of Intervertebral disc (IVD) degeneration can be enhanced by amplifying specific cytokines and proteins. This study aimed to investigate the therapeutic potential of tetracycline-off system-engineered tonsil-derived mesenchymal stem cells (ToMSC-Tetoff-TGFβ1-IGF1-BMP7) for treating intervertebral disc (IVD) degeneration. ToMSCs were isolated from a tonsillectomy patient and genetically modified with four distinct plasmids via CRISPR/Cas9-mediated knock-in gene editing. Transgene expression was confirmed through immunofluorescence, western blots, and an enzyme-linked immunosorbent assay for transforming growth factor beta 1 (TGFβ1) protein secretion, and the effect of MSC-TetOff-TGFβ1-IGF1-BMP7 on disc injury was assessed in a rat model. The ToMSC-Tetoff-TGFβ1-IGF1-BMP7 treatment exhibited superior therapeutic effects compared to ToMSC-TGFβ1, and ToMSC-SDF1α implantation groups, stimulating the regeneration of nucleus pulposus (NP) cells crucial for IVD. The treatment showed potential to restore the structural integrity of the extracellular matrix (ECM) by upregulating key molecules such as aggrecan and type II collagen. It also exhibited anti-inflammatory properties and reduced pain-inducing neuropeptides. ToMSC-Tetoff-TGFβ1-IGF1-BMP7 holds promise as a novel treatment for IVD degeneration. It appears to promote NP cell regeneration, restore ECM structure, suppress inflammation, and reduce pain. However, more research and clinical trials are required to confirm its therapeutic potential.

Percutaneous Computed Tomography-Guided Oxygen-Ozone (O2O3) Injection Therapy in Patients with Lower Back Pain-An Interventional Two-Year Follow-Up Study of 321 Patients

OBJECTIVES

To assess the effect of oxygen-ozone therapy guided by percutaneous Computed Tomography (CT) compared to corticosteroids in individuals experiencing lower back pain (LBP) not attributed to underlying bone-related issues.

METHODS

A total of 321 patients (192 males and 129 females, mean age: 51.5 ± 15.1 years) with LBP were assigned to three treatment groups: group A) oxygen-ozone only, group B) corticosteroids only, group C) oxygen-ozone and corticosteroids. Treatment was administered via CT-guided injections to the intervertebral disc (i.e., intradiscal location). Clinical improvement of pain and functionality was assessed via self-reported pain scales and magnetic resonance (MR) and CT imaging.

RESULTS

At all follow-up times, the mean score of the numeric rating scale and the total global pain scale (GPS) of study groups receiving oxygen-ozone (groups A and C) were statistically significantly lower than the study group receiving corticosteroids only (group B), with p < 0.001. There was a statistically significant difference between groups A and C at 30 days for the numeric rating scale.

CONCLUSIONS

The percutaneous application of oxygen-ozone in patients with LBP due to degeneration of the lumbosacral spine showed long-lasting significant pain reduction of up to two years post-treatment when compared to corticosteroids alone. Combination therapy of oxygen-ozone and corticosteroids can be useful as corticosteroids showed statistically significant improvement in LBP earlier than the oxygen-ozone-only treatment.

Does lumbar spinal decompression or fusion surgery influence outcome parameters in patients with intrathecal morphine treatment for persistent spinal pain syndrome type 2 (PSPS-T2)

OBJECTIVES

Intrathecal morphine pump (ITMP) infusion therapy is efficient in managing chronic pain refractory to standard treatment. This study evaluates pain relief and improvement of quality of life in chronic pain patients after intrathecal morphine pump implantation for treatment of persistent pain after lumbar spinal fusion surgery and lumbar spinal decompression alone.

METHODS

Forty three chronic pain patients that received an ITMP at our department between 2009 and 2019 were retrospectively analyzed divided into 2 cohorts (lumbar spinal fusion surgery and lumbar spinal decompression alone). Pain intensity was evaluated using the numeric rating scale (NRS), quality of life was assessed by EQ-5D-3L, mental health was assessed by Beck Depression Inventory (BDI-V), and Pain Catastrophizing Scale (PCS). Morphine dosage was assessed over time. Data was collected preoperatively, 6 and 24 months postoperatively. Statistical analysis was performed using Friedman's analysis of variance to evaluate the development of NRS, PCS, BDI and EQ-5D-3L over time and Mann-Whitney-U-test for the differences between these parameters in the different cohorts. A two-sided p-value <0.05 was considered statistically significant.

RESULTS

Median age was 64 years (IQR25-75 56-71 years). NRS, EQ-5D-3L, BDI-V, and PCS showed a significant overall improvement after 6 and 24 months compared to baseline data (p<0.001). No statistically significant differences between patients with lumbar spinal fusion surgery and lumbar spinal decompression alone were seen. Furthermore, no statistically significant differences for age and gender were seen. The initially administered median morphine dosage was significantly higher in the fusion group (3.0 mg/day; IQR25-75 1.5-4.2 mg/day) compared to the decompression-alone group (1.5 mg/day; IQR25-75 1.0-2.6 mg/day); (p=0.027).

CONCLUSIONS

This retrospective study showed that ITMP have a major long-term impact on pain relief, improve the quality of life, psychological distress, as well as pain catastrophizing in patients with chronic pain following lumbar spinal surgery independent of the previous surgical procedure. After ITMP implantation initial median morphine dosage seems to be significantly higher after spinal fusion compared to decompressive surgery alone.

Effect of Conventional Spinal Cord Stimulation on Serum Protein Profile in Patients With Persistent Spinal Pain Syndrome: A Case-Control Study

BACKGROUND

Spinal cord stimulation (SCS) provides pain relief for most patients with persistent spinal pain syndrome type 2 (PSPS 2). Evidence is mounting on molecular changes induced by SCS as one of the mechanisms to explain pain improvement. We report the SCS effect on serum protein expression in vivo in patients with PSPS 2.

MATERIALS AND METHODS

Serum proteins were identified and quantified using mass spectrometry. Proteins with significantly different expression among patients with PSPS 2 relative to controls, responders, and nonresponders to SCS, or significantly modulated by SCS relative to baseline, were identified. Those most correlated with the presence and time course of pain were selected using multivariate discriminant analysis. Bioinformatic tools were used to identify related biological processes.

RESULTS

Thirty patients with PSPS 2, of whom 23 responded to SCS, were evaluated, together with 14 controls with no pain who also had undergone lumbar spinal surgery. A significant improvement in pain intensity, disability, and quality of life was recorded among responders. Five proteins differed significantly at baseline between patients with PSPS 2 and controls, with three proteins, mostly involved in immune processes and inflammation, being downregulated and two, mostly involved in vitamin metabolism, synaptic transmission, and restorative processes, being upregulated. In addition, four proteins, mostly related to immune processes and inflammation, decreased significantly, and three, mostly related to iron metabolism and containment of synaptic sprouting, increased significantly during SCS.

CONCLUSION

This study identifies various biological processes that may underlie PSPS 2 pain and SCS therapeutic effects, including the modulation of neuroimmune response and inflammation, synaptic sprouting, vitamin and iron metabolism, and restorative processes.

Short-Term Health Care Costs of High-Frequency Spinal Cord Stimulation for the Treatment of Postsurgical Persistent Spinal Pain Syndrome

OBJECTIVE

High-frequency spinal cord stimulation (HF-SCS) is a treatment option for postsurgical persistent spinal pain syndrome (type 2 PSPS). We aimed to determine the health care costs associated with this therapy in a nationwide cohort.

MATERIALS AND METHODS

IBM Marketscan® Research Databases were used to identify patients who underwent HF-SCS implantation from 2016 to 2019. Inclusion criteria included prior spine surgery or diagnoses of PSPS or postlaminectomy pain syndrome any time within the two years before implantation. Inpatient and outpatient service costs, medication costs, and out-of-pocket costs were collected six months before implantation (baseline) and one, three, and six months after implantation. The six-month explant rate was calculated. Costs were compared between baseline and six months after implant via Wilcoxon sign rank test.

RESULTS

In total, 332 patients were included. At baseline, patients incurred median total costs of $15,393 (Q1: $9,266, Q3: $26,216), whereas the postimplant median total costs excluding device acquisition were $727 (Q1: $309, Q3: $1,765) at one month, $2,840 (Q1: $1,170, Q3: $6,026) at three months, and $6,380 (Q1: $2,805, Q3: $12,637) at six months. The average total cost was reduced from $21,410 (SD $21,230) from baseline to $14,312 (SD $25,687) at six months after implant for an average reduction of $7,237 (95% CI = $3212-$10,777, p < 0.001). The median device acquisition costs were $42,937 (Q1: $30,102, Q3: $65,880). The explant rate within six months was 3.4% (8/234).

CONCLUSIONS

HF-SCS for PSPS was associated with significant decreases in total health care costs and offsets acquisition costs within 2.4 years. With the rising incidence of PSPS, it will be critical to use clinically effective and cost-efficient therapies for treatment.

Pharmacotherapies to prevent epidural fibrosis after laminectomy: a systematic review of in vitro and in vivo animal models

BACKGROUND CONTEXT

Excessive production of epidural fibrosis in the nerve root can be a pain source after laminectomy. Pharmacotherapy is a minimally invasive treatment option to attenuate epidural fibrosis by suppressing proliferation and activation of fibroblasts, inflammation, and angiogenesis, and inducing apoptosis.

PURPOSE

We reviewed and tabulated pharmaceuticals with their respective signaling axes implicated in reducing epidural fibrosis. Additionally, we summarized current literature for the feasibility of novel biologics and microRNA to lessen epidural fibrosis.

STUDY DESIGN/SETTING

Systematic Review.

METHODS

According to the PRISMA guidelines, we systematically reviewed the literature in October 2022. The exclusion criteria included duplicates, nonrelevant articles, and insufficient detail of drug mechanism.

RESULTS

We obtained a total of 2,499 articles from PubMed and Embase databases. After screening the articles, 74 articles were finally selected for the systematic review and classified based on the functions of drugs and microRNAs which included inhibition of fibroblast proliferation and activation, pro-apoptosis, anti-inflammation, and antiangiogenesis. In addition, we summarized various pathways to prevent epidural fibrosis.

CONCLUSION

This study allows a comprehensive review of pharmacotherapies to prevent epidural fibrosis during laminectomy.

CLINICAL SIGNIFICANCE

We expect that our review would enable researchers and clinicians to better understand the mechanism of anti-fibrosis drugs for the clinical application of epidural fibrosis therapies.

Microstructural Changes in the Spinothalamic Tract of CPSS Patients: Preliminary Results from a Single-Center Diffusion-Weighted Magnetic Resonance Imaging Study

INTRODUCTION

Chronic pain after spinal surgery (CPSS), formerly known as failed back surgery syndrome, encompasses a variety of highly incapacitating chronic pain syndromes emerging after spinal surgery. The intractability of CPSS makes objective parameters that could aid classification and treatment essential. In this study, we investigated the use of cerebral diffusion-weighted magnetic resonance imaging.

METHODS

Cerebral 3T diffusion-weighted (DW-) MRI data from adult CPSS patients were assessed and compared with those of healthy controls matched by age and gender. Only imaging data without relevant artefacts or significant pathologies were included. Apparent diffusion coefficient (ADC) maps were calculated from the b0 and b1000 values using nonlinear regression. After skull stripping and affine registration of all imaging data, ADC values for fifteen anatomical regions were calculated and analyzed with independent samples T-tests.

RESULTS

A total of 32 subjects were included (sixteen CPSS patients and sixteen controls). The mean ADC value of the spinothalamic tract was found to be significantly higher in CPSS patients compared with in healthy controls (p = 0.013). The other anatomical regions did not show statistically different ADC values between the two groups.

CONCLUSION

Our results suggest that patients suffering from CPSS are subject to microstructural changes, predominantly within the cerebral spinothalamic tract. Additional research could possibly lead to imaging biomarkers derived from ADC values in CPSS patients.

Medical ozone treatment on prevention of epidural fibrosis in the rat model

Background/Aim

Epidural fibrosis is one of the problems that can be seen after spinal surgery. The aim of this study was to investigate the possible preventive role of medical ozone (O) treatment on epidural fibrosis.

Materials and Methods

Twenty-four Sprague Dawley rats were randomly split into four groups: control (C), O, laminectomy (L), and L+O groups. Animals in the C group were sacrificed at the beginning of the experiment. The L and L+O groups had L procedure, while O treatment was supplied for the O and O+L groups. After 42 days of follow-up, for histological evaluation and biochemical measurements, the ratio of epidural fibrosis and catalase (CAT) with malondialdehyde (MDA) levels in serum, respectively, were analyzed in terms of statistical differences.

Results

Histologically, a distinct difference was o bserved in the epidural space after O treatment. A significant difference in epidural fibrosis areas is found to be between the O, L, and O+L groups (P < 0,0001). There was no statistically significant difference between CAT and MDA levels that were obtained by spectrophotometric analysis.

Conclusion

Histological results suggest that medical O treatment after L can be used as an alternative method to prevent epidural fibrosis. Further studies with wide cohorts and interval measures are required to detail the effects of doses.

Failed Back Surgery Syndrome: No Longer a Surgeon's Defeat-A Narrative Review

The introduction of the term Persistent Spinal Pain Syndrome (PSPS-T1/2), replacing the older term Failed Back Surgery Syndrome (FBSS), has significantly influenced our approach to diagnosing and treating post-surgical spinal pain. This comprehensive review discusses this change and its effects on patient care. Various diagnostic methods are employed to elucidate the underlying causes of back pain, and this information is critical in guiding treatment decisions. The management of PSPS-T1/2 involves both causative treatments, which directly address the root cause of pain, and symptomatic treatments, which focus on managing the symptoms of pain and improving overall function. The importance of a multidisciplinary and holistic approach is emphasized in the treatment of PSPS-T1/2. This approach is patient-centered and treatment plans are customized to individual patient needs and circumstances. The review concludes with a reflection on the impact of the new PSPS nomenclature on the perception and management of post-surgical spinal pain.

Previous Lumbar Spine Surgery Decreases the Therapeutic Efficacy of Dorsal Root Ganglion Pulsed Radiofrequency in Patients with Chronic Lumbosacral Radicular Pain

Chronic lumbosacral radicular pain (CLRP) as a possible adverse consequence of lumbar spine surgery represents a serious medical challenge. Pulsed radiofrequency of dorsal root ganglion (PRF-DRG) treatment is known to be effective in alleviating CLRP. This retrospective study compares the efficacy of a single CT-guided PRF-DRG procedure in the treatment of unilateral CLRP between patients without (non-PSS) and with (PSS) previous lumbar spine surgery. Non-PSS and PSS groups included 30 and 20 patients, respectively. Outcomes (pain intensity and disability) were evaluated by means of the visual analog scale (VAS) and Oswestry disability index (ODI) immediately after the procedure (VAS), as well as three and six months after the procedure, respectively. Non-PSS group showed a significant (p ˂ 0.001) decrease of VAS (median) at all follow-up intervals (from 6 to 4; 4; 4.5 points, respectively). The PSS group showed a significant yet transient VAS (median) decrease (from 6 to 5 points) immediately after the procedure only (p < 0.001). The decrease of VAS was more pronounced in the non-PSS group after three and six months (p = 0.0054 and 0.011, respectively) in intergroup comparison. A relative decrease of VAS ≥ 50% during follow-up was achieved in 40%; 43.3%; 26.7% (non-PSS), and 25%; 5%; 0% (PSS) of patients. ODI (median) significantly decreased in the non-PSS group (from 21.5 to 18 points) at three and six months (p = 0.014 and 0.021, respectively). In conclusion, previous lumbar spine surgery decreases the therapeutic efficacy of PRF-DRG procedure in CLRP patients.

Pain and function in patients with chronic low back pain and leg pain after Zhineng Qigong - a quasi-experimental feasibility study

BACKGROUND

Qigong includes training for body and mind, one method is Zhineng Qigong. Scientific literature on qigong for chronic low back pain (LBP) is sparse. This study aimed to investigate feasibility including evaluation of a Zhineng Qigong intervention for pain and other lumbar spine-related symptoms, disability, and health-related quality of life in patients with chronic LBP and/or leg pain.

METHODS

Prospective interventional feasibility study without control group. Fifty-two chronic pain patients (18-75 years) with LBP and/or leg pain (Visual Analogue Scale ≥ 30) were recruited from orthopaedic clinics (spinal stenosis, spondylolisthesis, or segmental pain) and primary healthcare (chronic LBP). Patients from orthopaedic clinics were 1-6 years postoperative after lumbar spine surgery or on lumbar surgery waiting list. Patients received a 12-week training intervention with European Zhineng Qigong. The intervention consisted of face-to-face group activities in non-healthcare setting (4 weekends and 2 evenings per week), and individual Zhineng Qigong training. Main health outcomes were self-reported in a 14-day pain diary, Oswestry Disability Index (ODI), Short Form 36 version 2 (SF-36v2), and EuroQol 5 Dimensions 5 Levels (EQ-5D-5L), once directly before and once directly after the intervention.

RESULTS

Recruitment rate was 11% and retention rate was 58%. Dropouts did not report higher pain (baseline), only 3 dropped out because of lumbar spine-related pain. Adherence was median 78 h group attendance (maximum 94 h) and 14 min daily individual training. Ability to collect outcomes was 100%. Thirty patients completed (mean 15 years symptom duration). Twenty-five had degenerative lumbar disorder, and 17 history of lumbar surgery. Results showed statistically significant (within-group) improvements in pain, ODI, all SF-36v2 scales, and EQ-5D-5L.

CONCLUSIONS

Despite low recruitment rate, recruitment was sufficient. A multicentre randomized controlled trial is proposed, with efforts to increase recruitment and retention rate. After this Zhineng Qigong intervention patients with chronic LBP and/or leg pain, also patients with considerable remaining LBP/sciatica after lumbar surgery, had significantly improved in pain and function. Results support involvement of postoperative patients in a future study. The results are promising, and this intervention needs to be further evaluated to provide the most reliable evidence.

TRIAL REGISTRATION

NCT04520334. Retrospectively registered 20/08/2020.

Intraoperative Spinal Cord Stimulation Mitigates Central Sensitization After Spine Surgery in Mice

STUDY DESIGN

Double-blinded, prospective laboratory animal study.

OBJECTIVE

To examine whether intraoperative spinal cord stimulation (SCS) inhibits the development of spine surgery-induced hypersensitivity.

SUMMARY OF BACKGROUND DATA

Managing postoperative pain after spine surgery is challenging, and as many as 40% of patients may develop failed back surgery syndrome. Although SCS has been shown to effectively reduce chronic pain symptoms, it is unknown whether intraoperative SCS can mitigate the development of central sensitization that causes postoperative pain hypersensitivity and potentially leads to failed back surgery syndrome after spine surgery.

MATERIALS AND METHODS

Mice were randomly stratified into three experimental groups: (1) sham surgery, (2) laminectomy alone, and (3) laminectomy plus SCS. Secondary mechanical hypersensitivity was measured in hind paws using von Frey assay one day before and at predetermined times after surgery. In addition, we also performed a conflict avoidance test to capture the affective-motivational domain of pain at selected time points postlaminectomy.

RESULTS

Mice that underwent unilateral T13 laminectomy developed mechanical hypersensitivity in both hind paws. Intraoperative SCS applied to the exposed side of the dorsal spinal cord significantly inhibited the development of hind paw mechanical hypersensitivity on the SCS-applied side. Sham surgery did not produce any obvious secondary mechanical hypersensitivity in the hind paws.

CONCLUSIONS

These results demonstrate that spine surgery for unilateral laminectomy induces central sensitization that results in postoperative pain hypersensitivity. Intraoperative SCS after laminectomy may be able to mitigate the development of this hypersensitivity in appropriately selected cases.

Can Failed Back Surgery Syndrome Be Healed by Transverse Myelitis?

Failed back surgery syndrome (FBSS) is a condition characterized by persistent or recurring back pain following spinal surgery. Etiological factors for FBSS are being studied by investigators and clinicians in an attempt to organize them based on their temporal relation to the surgery event. However, many questions regarding the pathophysiology of FBSS remain, which has resulted in a lack of efficacy among its treatment options. In this report, we present a remarkable case of longitudinally extensive transverse myelitis (LETM) in a patient with a medical history of FBSS who was taking multiple pain medications but had persisting pain. The patient, a 56-year-old woman, presented with an incomplete motor injury (American Spinal Injury Association Impairment Scale D) and a neurological level of C4. Investigations revealed an idiopathic LETM that was unresponsive to high doses of corticosteroids. An inpatient rehabilitation program was initiated, resulting in favorable clinical progress. The patient no longer complained of back pain, and her pain medication was gradually discontinued. At the time of discharge, the patient was able to walk with a stick, dress and groom herself independently, and eat with an adapted fork without experiencing pain. As the pain mechanisms underlying FBSS are complex and not yet fully understood, this clinical case aims to contribute to the discussion of possible pathological mechanisms implicated in LETM that may have contributed to the shutdown of pain perception in a patient with a history of FBSS. By doing so, we hope to identify new and effective ways to treat FBSS.

sPinal coRd stimulatiOn coMpared with lumbar InStrumEntation for low back pain after previous lumbar decompression (PROMISE): a prospective multicentre RCT

INTRODUCTION

Persistent spine pain syndrome type 2 (PSPS2) represents a significant burden to the individual and society. Treatment options include revision surgery, stabilisation surgery of the spine, neuromodulation, analgesics and cognitive behavioural therapy. Nevertheless, structured treatment algorithms are missing as high-level evidence on the various treatments is sparse. The aim of this study is to compare higher frequency neuromodulation with instrumentation surgery in patients suffering from PSPS2.

METHODS AND ANALYSIS

The sPinal coRd stimulatiOn coMpared with lumbar InStrumEntation for low back pain after previous lumbar decompression (PROMISE) trial is a prospective randomised rater blinded multicentre study. Patients suffering from PSPS2 with a functional burden of Oswestry Disability Index (ODI) >20 points are randomised to treatment via spinal cord stimulation or spinal instrumentation. Primary outcome is back-related functional outcome according to the ODI 12 months after treatment. Secondary outcomes include pain perception (visual analogue scale), Short Form-36, EuroQOL5D, the amount of analgesics, the length of periprocedural hospitalisation and adverse events. Follow-up visits are planned at 3 and 12 months after treatment. Patients with previous lumbar instrumentation, symptomatic spinal stenosis, radiographical apparent spinal instability or severe psychiatric or systemic comorbidities are excluded from the study. In order to detect a significant difference of ≥10 points (ODI) with a power of 80%, n=72 patients need to be included. The recruitment period will be 24 months with a subsequent 12 months follow-up. The beginning of enrolment is planned for October 2022.

ETHICS AND DISSEMINATION

The PROMISE trial is the first randomised rater blinded multicentre study comparing the functional effectiveness of spinal instrumentation versus neuromodulation in patients with PSPS2 in order to achieve high-level evidence for these commonly used treatment options in this severely disabling condition. Patient recruitment will be performed at regular outpatient clinic visits. No further (print, social media) publicity is planned. The study is approved by the local ethics committee (LMU Munich, Germany) and will be conducted according to the Declaration of Helsinki.

TRIAL REGISTRATION NUMBER

NCT05466110.

Pirfenidone-loaded hyaluronic acid methacryloyl hydrogel for preventing epidural adhesions after laminectomy

It is inevitable that scar formation occurs between the spinal dura and surrounding tissues after laminectomy. While extensive epidural fibrosis, which results in limited nerve root activity and severe pain, is the main cause of postoperative failed-back surgery syndrome. Novel biomaterial loading effective drugs based on reasonable design are eagerly needed for the safe and effective prevention of epidural adhesions. We filtrated a suitable dose of pirfenidone (PFD) to load hyaluronic acid methacryloyl (HAMA) hydrogel in vitro. And then, we compare PFD-loaded HAMA hydrogel with only using PFD or HAMA hydrogels after laminectomy by in vivo studies in rats. We describe a safe and efficient anti-adhesive PFD-loaded HAMA hydrogel that prevents epidural fibrosis through the stable and sustained release of PFD. It was shown that the PFD-loaded HAMA hydrogel effectively inhibited cell penetration and suppressed collagen I/III expression. Thus, it effectively prevented the formation of adhesions through pharmacological and physical processes. The PFD-loaded HAMA hydrogel can effectively prevent adhesion formation in both pharmacological and physical barrier effects.

A Comparative Clinical Study of Lateral Lumbar Interbody Fusion between Patients with Multiply Operated Back and Patients with First-Time Surgery

Background and Objectives: Patients with multiply operated back (MOB) may suffer from persistent lower-back pain associated with back muscle damage and epidural fibrosis following repeated back surgery (Failed Back Spinal Syndrome). Lateral lumbar interbody fusion (LLIF) is considered to be favorable for MOB patients. However, little scientific research has been carried out for this issue due to variety of the pathogenesis. The purpose of this study was to compare the clinical results of MOB patients and first-time surgery patients who underwent LLIF for lumbar spinal stenosis with degenerative scoliosis and/or degenerative spondylolisthesis (spinal instability). Materials and Methods: LLIF was performed for lumbar spinal stenosis with spinal instability in 55 consecutive cases of single hospital (30 males, 25 females, average age: 69). Clinical outcomes were compared between the MOB patient group (MOB group) and the first surgical patient group (F group). We evaluated the Japanese Orthopaedic Association (JOA) scores and JOA Back Pain Evaluation Questionnaire (JOABPEQ) before and 2 years after surgery. MOB patients were defined as those who have had one or more lumbar surgery on the same intervertebral or adjacent vertebrae in the past. Results: There were 20 cases (12 males, 8 females, average age: 71) in MOB group, and 35 cases (19 males, 16 females, average age: 68) in the F group. There was no significant difference between the two groups in terms of age, sex, number of intervertebral fixations, modic change in fused intervertebral end plate, score of brief scale for evaluation of psychiatric problem, lumbar lordosis, and sagittal vertical axis before and after surgery. The preoperative JOA scores averaged 12.5 points in the MOB group and averaged 11.6 points in the F group. The postoperative JOA scores averaged 23.9 points in the MOB group and averaged 24.7 points in the F group. The preoperative JOABPEQ averaged 36.3 points in the MOB group and averaged 35.4 points in the F group. The postoperative average JOA score was 75.4 in the MOB group and 70.2 in the F group. Conclusions: Based on the results, there was no significant difference in clinical outcomes of the two groups, and there was no new residual lower-back pain. Thus, we considered that LLIF one option for patients with MOB.

Artificial lamina after laminectomy: Progress, applications, and future perspectives

In clinical practice, laminectomy is a commonly used procedure for spinal decompression in patients suffering from spinal disorders such as ossification of ligamentum flavum, lumbar stenosis, severe spinal fracture, and intraspinal tumors. However, the loss of posterior column bony support, the extensive proliferation of fibroblasts and scar formation after laminectomy, and other complications (such as postoperative epidural fibrosis and iatrogenic instability) may cause new symptoms requiring revision surgery. Implantation of an artificial lamina prosthesis is one of the most important methods to avoid post-laminectomy complications. Artificial lamina is a type of synthetic lamina tissue made of various materials and shapes designed to replace the resected autologous lamina. Artificial laminae can provide a barrier between the dural sac and posterior soft tissues to prevent postoperative epidural fibrosis and paravertebral muscle compression and provide mechanical support to maintain spinal alignment. In this paper, we briefly review the complications of laminectomy and the necessity of artificial lamina, then we review various artificial laminae from clinical practice and laboratory research perspectives. Based on a combination of additive manufacturing technology and finite element analysis for spine surgery, we propose a new designing perspective of artificial lamina for potential use in clinical practice.

Spinal cord stimulation and return to work of patients with failed back surgery syndrome

OBJECTIVES

Chronic pain has a substantial negative impact on work-related outcomes, which underlines the importance of interventions to reduce the burden. Spinal cord stimulation (SCS) efficiently relieves pain in specific chronic pain syndromes and is recommended for treating failed back surgery syndrome (FBSS) or post-surgical chronic back pain that is refractory to other treatments. To examine the impact of SCS in patients with FBSS on the return to work (RTW), we determined the RTW rate and the factors positively associated with the RTW.

MATERIALS AND METHODS

Among 106 patients with FBSS who benefitted from SCS at a single institution in France between September 1999 and March 2010, we retrospectively included 59 who had stopped work at the time of SCS because of disability or sick leave and evaluated the RTW (rate and predictors, estimating odds ratios [ORs] and 95% confidence intervals [CIs]).

RESULTS

The mean (SD) post-surgery follow-up for the 59 patients (34 men; mean [SD] age 46.9 [7.4] years) was 7.5 (3.6) years (range 5-15). The RTW rate was 30.5%, with a median [IQR] recovery time of 5.5 months [3-8.5]. RTW was improved with functional improvement evolution (OR 1.1, 95% CI [1.01-1.1], p = 0.02) and was reduced with unemployment > 3 years (OR 0.1, 95% CI [0.01-0.7], p = 0.02).

CONCLUSIONS

Our protocol for SCS for patients with FBSS, including a strict selection of patients and a multidisciplinary approach, led to good results, especially for the RTW. RTW should be a therapeutic goal, directly affecting indirect costs related to FBSS.

The analgesic effect of lumbar sympathetic ganglion block in patients with failed back surgery syndrome

Background

Persistent or recurrent lumbosacral pain is a common symptom after spinal surgery. Several interventions have been introduced for failed back surgery syndrome; however, their clinical efficacy, safety, and cost-effectiveness are insufficient. Sympathetic ganglion block has been selected for pain associated with the sympathetic nervous system. In this study, we compared pain and quality of life in patients with failed back surgery syndrome who responded and did not respond to lumbar sympathetic ganglion block.

Methods

We included 84 patients diagnosed with failed back surgery syndrome who had lumbosacral pain and underwent lumbar sympathetic ganglion block between January 2020 and April 2021. The patients' data were retrospectively analyzed; clinical outcomes were assessed before (T0), 1 week after (T1), and 4 weeks after (T4) lumbar sympathetic ganglion block. Based on the pain difference from T0 to T1, we categorized patients into two groups: patients with ≥ 50% pain reduction (responder group) and patients with < 50% pain reduction (non-responder group). Demographic, clinical, surgical, and fluoroscopic data were evaluated and compared. The primary outcome was pain scores and the EuroQol-5D score from T0 to T4.

Results

Among the 84 patients analyzed, 41 (48.8%) experienced ≥ 50% pain reduction at 1 week after lumbar sympathetic ganglion block. Lumbar sympathetic ganglion block significantly improved pain at T1 and T4 compared to T0 in both groups. Lumbar sympathetic ganglion block improved the EuroQol-5D score at T1 compared to T0 in the responder group. The responder group had a significant decrease in pain at T1 from T0 and T4 from T0 and a significant decrease in the EuroQol-5D score at T1 from T0 compared with the non-responder group. Coldness of the leg over time did not differ between the groups. No serious adverse events occurred in either of the groups.

Conclusion

Lumbar sympathetic ganglion block may improve pain at 1 and 4 weeks in patients with failed back surgery syndrome. Patients with ≥ 50% pain reduction at 1 week showed simultaneous improvement in quality of life and pain reduction at 4 weeks.

Clinical trial registration

https://cris.nih.go.kr/cris/index/index.do, identifier KCT0007236.

MR Neurography of Lumbosacral Plexus: Incremental Value Over XR, CT, and MRI of L Spine With Improved Outcomes in Patients With Radiculopathy and Failed Back Surgery Syndrome

BACKGROUND

Lower back pain is often evaluated using magnetic resonance imaging (MRI) and conventional imaging, which provide incomplete information about the etiology of pain and lead to less than optimal management.

HYPOTHESIS

MR neurography (MRN) of the lumbosacral (LS) plexus renders a more accurate diagnosis, alters the management strategy, and clinical outcomes of radiculopathy or failed back surgery Syndrome (FBSS) patients when compared to the conventional imaging modalities.

STUDY TYPE

Retrospective, cross-sectional.

POPULATION

A total of 356 patients (mean age 65.8 ± 12.3; 48.9% female) from single university hospital over 6 years with MRN of LS plexus were included from a cohort of 14,775 total patients with lumbar spine MR imaging.

ASSESSMENT

Conventional imaging obtained before and after MRN of LS plexus was reevaluated and categorized into three levels based on extent of imaging findings' correlation to presenting clinical symptoms (contributory levels). Clinical notes were reviewed for changes in ordering provider's recommended management and subsequent patients' symptom level pre-MRN to post-MRN.

FIELD STRENGTH/SEQUENCE

A 5 T and 3.0 T. T1-weighted (T1W), T2-weighted (T2W), short T1 inversion recovery (STIR), T1 turbo spin echo (T1 TSE), T2 spectral attenuated inversion recovery (T2 SPAIR).

STATISTICAL TESTS

Chi-squared test. Statistical significance was set at P < 0.05.

RESULTS

A total of 356 total patients (174 females) with mean age ± SD was 65.8 ± 12.3 years, 4.2% of patients imaged with lumbar spine MRI. Definitely contributory studies among X-rays, computed tomography, MRI, and MRN were 3 of the 129 (2.3%), 3 of the 48 (6.2%), 35 of the 184 (19.0%), and 283 of the 356 (79.8%), respectively. Pre-MRN vs. post-MRN led to change in recommendation in 219 of the 356 (61.5%) patients and 71 of the 99 (71.7%) patients had improved symptoms.

CONCLUSION

MRN of the LS plexus can provide more corroborative image findings for symptom correlation compared to other imaging modalities for accurate diagnosis, effects patient management and leads to positive clinical outcomes in a small subset of patients with radiculopathy or FBSS.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 5.

The post spinal surgery syndrome: A review

Post spinal surgery syndrome(PSSS) has always been considered only for the pain it causes. However, many other neurological deficits do happen after lower back surgery. The aim of this review is to look into the various other neurological deficits that could happen after a spinal surgery. Using the keywords, foot drop, cauda equina syndrome, epidural hematoma, nerve and dural injury in spine surgery, the literature was searched. Out of the 189 articles obtained, the most important were analyzed. The problems associated with spine surgery have been published in the literature but are much more than the failed back surgery syndrome and cause more discomfort to the patients. To bring about a more sustained and collective awareness and understanding of these complications following spinal surgery, we encompassed all these complications under the heading of PSSS.

Ozone disc nucleolysis in the management of herniated lumbar intervertebral disc: A retrospective analysis

Background

Various minimally invasive surgeries were proposed for the management of herniated lumbar intervertebral disc. However, to choose optimal treatment modality to maximize patient benefit is a clinical challenge for the treatment givers.

Objective

The objective was to study the role of ozone disc nucleolysis in the management of herniated lumbar intervertebral disc by retrospective analysis.

Methodology

We conducted a retrospective analysis of patients of lumbar disc herniation treated by ozone disc nucleolysis during May 2007-May 2021. There were total of 2089 patients with 58% of males and 42% of females. The age ranged from 18 to 88 years. Outcome was measured on the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) along with modified MacNab method.

Results

The mean baseline VAS score was 7.73, which became 3.07 at 1 month, 1.44 at 3 months, 1.42 at 6 months, and 1.36 at 1 year. Similarly, the mean ODI index was 35.92 at baseline, which improved to 9.17 at 1 month, 6.14 at 3 months, 6.10 at 6 months, and 6.09 at 1 year. VAS score and ODI analysis was found to be statistically significant with P < 0.05. Modified MacNab criterion showed successful treatment outcome in 85.6% with excellent recovery in 1161 (55.58%), good recovery in 423 (20.25%), and fair recovery in 204 (9.77%). Mediocre or no recovery was seen in the remaining 301 patients amounting to a 14.40% failure rate.

Conclusion

This retrospective analysis confirms that ozone disc nucleolysis is an optimally effective and least invasive treatment option for herniated lumbar intervertebral disc with a significant reduction in disability.

Risk factors for failed back surgery syndrome following open posterior lumbar surgery for degenerative lumbar disease

BACKGROUND

With the growing number of traditional posterior open surgery, the incidence of failed back surgery syndrome (FBSS) increases gradually. We aimed to investigate the incidence and risk factors for FBSS following open posterior lumbar surgery for degenerative lumbar disease (DLD).

METHOD

A multivariable regression analysis was performed for 333 consecutive patients to identify potential risk factors for FBSS. Clinical outcomes were evaluated by the validated North American Spine Society (NASS) Questionnaire and numerical rating scale (NRS) for pain. Demographics, diagnostic characteristics, surgical data, radiographic parameters for each patient were analyzed.

RESULT

16.8% of the included patients were classified as FBSS. Univariate analysis showed that age, hypertension, symptom location, intermittent claudication, preoperative pain NRS-leg, HIZ, Modic changes (MCs), surgical strategy and postoperative rehabilitation were related to FBSS. Multivariable logistic regression analysis demonstrated that preoperative NRS-leg (OR:0.80, 95%CI:0.71-0.91, P = 0.001), hypertension (OR: 2.22, 95%CI: 1.10-4.51, P = 0.027), intermittent claudication with waking distance > 100 m (OR: 4.07, 95%CI: 1.75-9.47, P = 0.001) and waking distance ≤ 100 m (OR: 12.43, 95%CI: 5.54-27.92, P < 0.001), HIZ (OR: 8.26, 95%CI: 4.00-17.04, P < 0.001), MCs (OR: 3.41, 95%CI: 1.73-6.71, P < 0.001), postoperative rehabilitation (OR: 2.63, 95%CI: 1.13-6.12, P = 0.024) were risk factors for FBSS.

CONCLUSION

Open posterior lumbar surgery is an effective treatment for DLD which provides pain reduction and lumbar curve improvement with a considerable satisfaction rate. Lower preoperative NRS-leg, hypertension, intermittent claudication, HIZ, MCs and postoperative rehabilitation are risk factors for FBSS, which can serve as a tool for clinicians to identify at-risk population and provide more effective management to mitigate the doctor-patient contradictions and further occupation of medical resources.