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

Aims

The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation.

Patients and Methods

A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12).

Results

A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days (sd 46.5) and 47 days (sd 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm (sd 10.3) and a mean VAS for arm pain of 6.3 mm (sd 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (sd 12.4; p < 0.001); mean NPAD, 19.3 (sd 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (sd 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (sd 6.8; p = 0.103).

Conclusion

Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71.

Correlation of pain, functional impairment, and health-related quality of life with radiological grading scales of lumbar degenerative disc disease

BACKGROUND

It is generally believed that radiological signs of lumbar degenerative disc disease (DDD) are associated with increased pain and functional impairment as well as lower health-related quality of life (HRQoL). Our aim was to assess the association of the Modic and Pfirrmann grading scales with established outcome questionnaires and the timed-up-and-go (TUG) test.

METHODS

In a prospective two-center study with patients scheduled for lumbar spine surgery, visual analogue scale (VAS) for back and leg pain, Roland-Morris Disability Index, Oswestry Disability Index and HRQoL, as determined by the Short-Form (SF)-12 and the Euro-Qol, were recorded. Functional mobility was measured with the TUG test. Modic type (MOD) and Pfirrmann grade (PFI) of the affected lumbar segment were assessed with preoperative imaging. Uni- and multivariate logistic regression analysis was performed to estimate the effect size of the relationship between clinical and radiological findings.

RESULTS

Two hundred eighty-four patients (mean age 58.5, 119 (42 %) females) were enrolled. None of the radiological grading scales were significantly associated with any of the subjective or objective clinical tests. There was a tendency for higher VAS back pain (3.48 vs. 4.14, p = 0.096) and lower SF-12 physical component scale (31.2 vs. 29.4, p = 0.065) in patients with high PFI (4-5) as compared to patients with low PFI (0-3). In the multivariate analysis, patients with MOD changes of the vertebral endplates were 100 % as likely as patients without changes to show an impaired TUG test performance (odds ratio (OR) 1.00, 95 % confidence interval (CI) 0.56-1.80, p = 0.982). Patients with high PFI were 145 % as likely as those with low PFI to show an impaired TUG test performance (OR 1.45, 95 % CI 0.79-2.66, p = 0.230).

CONCLUSIONS

There was no association between established outcome questionnaires of symptom severity and two widely used radiological classifications in patients undergoing surgery for lumbar DDD.

[Minimally invasive spine surgery: past and present]

In the early twentieth century, the understanding of spine biomechanics and the advent of surgical techniques of the lumbar spine, led to the currently emerging concept of minimal invasive spine surgery, By reducing surgical access, blood loss, infection rate and general morbidity, functional prognosis of patients is improved. This is a real challenge for the spine surgeon, who has to maintain a good operative result by significantly reducing surgical collateral damages due to the relatively traumatic conventional access.

Calcifying pseudoneoplasms of the neuraxis (CAPNON): clinical features and therapeutic options

INTRODUCTION

Calcifying pseudoneoplasms of the neuraxis (CAPNON) are rare, slow-growing lesions occurring anywhere in the central nervous system (CNS). Since their first description in 1978, only 39 cases have been reported in the literature.

METHODS

The cases of two patients with histopathologically verified diagnoses of CAPNON are presented. Thereafter, we review all reports published so far with respect to study type, number of patients, anatomical area (intracranial, spinal, or both), clinical presentation, radiological presentation, therapy, duration of follow-up, incidence and type of complication, and outcome. Furthermore, current recommendations for the management of spinal and cerebral CAPNON are discussed.

RESULTS

A total of 19 retrospective articles were identified and selected for review: 6 case series (31.6 %) and 13 reports of single cases (68.4 %). The 19 articles and our two additional cases added up to a total of 19 patients with spinal CAPNON and 22 patients with intracranial CAPNON. All patients were treated surgically. A follow-up was provided in 13 patients with spinal (68.4 %) and in 16 patients with intracranial CAPNON (72.7 %), respectively. The follow-up showed no signs of recurrence in 12 of 13 patients with spinal CAPNON (92.3 %) and in 15 of 16 patients with intracranial CAPNON (93.7 %). One-tailed Fisher's exact test revealed no significant difference between complete and incomplete resection in terms of disease recurrence (spinal: p = 0.6842; intracranial: p = 0.3749). Analysis of the literature did not reveal any deaths directly associated with CAPNON.

CONCLUSIONS

Calcifying pseudoneoplasms are rare benign lesions of the CNS of yet unknown origin. Because of the increasing number of reports, this clinical entity should be taken into consideration in the differential diagnosis of intracranial and intraspinal calcified lesions.

[Combination of two severe neurologic diseases--therapeutic dilemma with fatal outcome]

We present the case of a female patient with the combination of progressive cerebral sinus and venous thrombosis and unruptured intracranial aneurysm. Therapy of the symptomatic sinus thrombosis was initiated with heparin and endovascular occlusion of the aneurysm was planned within the next days. Before the coiling was performed fatal subarachnoid haemorrhage from the aneurysm occurred. The two dangerous neurologic diseases are presented and discussed with focus on symptomatology and therapeutic urgence.

[Cervicobrachialgia - an update under special consideration of the surgical management]

The classic cervicobrachialgia results acutely from cervical nerve root compression by disc herniation or subacutely by radicular compression after progressive spondylotic changes of the cervical spine. The clinical presentation includes local and radiating pain syndromes that can be accompanied by sensorimotor deficits. Besides the medical history and a targeted clinical examination, supplementary radiographic means should be undertaken to confirm diagnosis. If no urgent surgical indication exists, conservative therapy should be initiated. However, with varying results of conservative and surgical therapy, chronic impairment can occur.

Surgical treatment of unruptured intracranial aneurysms in a low-volume hospital--outcome and review of literature

BACKGROUND

The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature.

METHODS

A retrospective review of all consecutive craniotomies for UIA from July 1999 through June 2009 was performed. Morbidity was defined as modified Rankin Scale (mRS) ≥ 3 and evaluated six weeks after surgery. Cognitive function was evaluated at rehabilitation-to-home discharge. A PubMed database search (2001-2011) seeking retrospective, single-center studies reporting on surgical outcome of UIAs was performed.

RESULTS

There were 47 procedures performed in 42 patients to treat 50 UIAs (mean of 5 annual craniotomies). The mean age was 54.7 ± 12.1 years and mean aneurysm size was 7.6 ± 4.0mm. Favorable outcome (mRS 0-2) at six weeks after surgery was achieved in 45 of 47 procedures (95.7%). Aneurysm size ≥ 12 mm was statistically significant related to adverse outcome defined as mRS change ≥ 1 (71% vs. 29%; p = 0.018). Five patients (10.6%) with favorable neurological outcome (mRS 2) presented with cognitive impairment at rehabilitation-to-home discharge. There was no significant difference in overall morbidity and mortality comparing low- and high-volume hospitals (4.0% vs. 4.8%; p = 0.85).

CONCLUSIONS

Low-volume hospitals may achieve good results for surgical treatment of UIAs. The results indicate that defining numeric operative volume thresholds is not feasible to guide centralization of aneurysm treatment.

[The lumbar disc herniation - management, clinical aspects and current recommendations]

Lumbar disc herniation has a high prevalence and strong social-medical impact. Patients suffer from lower back pain that radiates from the spine. Loss of sensation or paresis adds to the clinical picture. The diagnosis should be confirmed by imaging in patients considered for surgery. High remission rates initially warrant conservative treatment (adequate analgesia and physiotherapy) in many patients. If this treatment does not lead to significant alleviation within 5-8 weeks, surgery should be performed to reduce the risk of chronic nerve affection. Posterior interlaminar fenestration is the intervention primarily conducted for this diagnosis. A relapse in the same region occurs in up to 10% of patients after months through years, which sometimes necessitates a reoperation if symptoms are pertinent.

[Cerebral arteriovenous malformations: clinical aspects and treatment possibilities]

Cerebral arteriovenous malformations (AVM) are vascular lesions that occur either congenitally or arise in early childhood. AVM are characterised by arteriovenous shunts through a nidus of coiled and tortuous vascular connections that connect feeding arteries to draining veins. Generally, AVM become evident through intracranial haemorrhage in patients aged 20-40 years. Especially, in the young adult presenting with epileptic seizures or focal neurological deficits AVM needs to be considered as an important differential diagnosis. Treatment modalities for the occlusion of symptomatic AVM include microneurosurgery, endovascular embolisation, or radiosurgery. These can be performed each on its own or in combination with the others. Incidentally diagnosed AVM require a thorough and individual consideration of treatment indications. This review deals with the current recommendations for the treatment of AVM in the adult patient.

[Intracerebral haemorrhage - when is a surgical treatment reasonable?]

Intracerebral haemorrhages (ICH) are responsible for 10-17% of all strokes and are associated with a high mortality and morbidity. More than 50% of the primary cases of ICH are associated with an underlying arterial hypertension and up to 30% with a cerebral amyloidosis. In supratentorial ICH, primary treatment generally should be conservative, as clinical studies could not show favourable outcomes after surgical haematoma evacuation. However, in patients with infratentorial haemorrhages and neurologic deterioration, early surgical evacuation should be considered. Modern therapeutic strategies and the focus of current and recent clinical research include early haemostasis, improvement of intensive care, and less invasive neurosurgical interventions, with the aim to reduce secondary brain damage. This review provides an overview of the clinical presentation of ICH and includes up-to-date recommendations concerning diagnostic and therapeutic options.

[Adult syringomyelia - a syndrome of different origins]

Syringomyelia describes an intra-medullary cyst in the spinal cord. In the adult patient, the pathology mostly results from Chiari-I-malformation or from severe spinal trauma. The clinical picture varies broadly, but symptoms often include pain and progressive neurologic deficits. During the clinical course, muscular atrophy and loss of pain and temperature sensation may develop in the affected region. Today, magnet resonance imaging helps to detect syringomyelia at an early stage. The interdisciplinary therapeutic approach includes an adequate pain treatment and physiotherapy, in selected cases a surgical intervention by an experienced surgeon. If not treated surgically, most symptomatic patients experience progressive neurologic deficits that may lead to severe paragplegia and chronic neuropathic pain.

[An uncommon reason for facial hypoesthesia]

A 58-year-old female admitted herself to the emergency department with progressive left-sided facial hypoesthesia. Magnetic resonance imaging revealed a 20 mm-sized aneurysm of the left vertebral artery leading to compression of the trigeminal nerve. An endovascular occlusion with a combined coiling and flow-diverter was performed. The left posterior inferior cerebellar artery (PICA) arised from the aneurysmal sac. Despite an extensive infarction of the left PICA-territory, the patient convalesced well and presented completely independent and without symptoms at the 4-week follow-up.

[The intracranial meningioma - therapeutic possibilities and limitations]

Meningiomas are common intracranial tumours that arise from arachnoidal cells. Clinically they often manifest by headache, focal or generalized seizures, or neurologic deficits as a result of brain compression. More than 90 percent of these mostly slow growing meningiomas are benign. In symptomatic patients a resection should be performed with the intention to cure or at least alleviate symptoms. In cases of subtotal resection an adjuvant radiotherapy should be deliberated. Stereotactic radiotherapy as initial treatment is an effective alternative for meningiomas, especially in patients not suitable for surgery due to various reasons. In patients that are refractory to treatment or with unresectable disease a hormonal- or chemotherapy can be considered.

[Craniopharyngioma--a "geographical malignant" tumour]

The craniopharyngioma is a rare dysontogenetic tumour that originates from either scattered cells of the craniopharyngeal duct or from metaplastically mutated anterior pituitary parenchyma cells. Despite being classified as a WHO-Class-I tumour, the histologically benign craniopharyngioma may display an aggressive behaviour. Like other congenital tumours, it usually becomes manifest within the first two decades of life. Patients typically complain of headache and a chiasma syndrome with bitemporal hemianopsy may develop depending on tumour localisation. In children, anterior pituitary insufficiency often manifests as growth restriction. Additionally, diabetes insipidus and other hormonal disturbances may develop. Therapeutically either radical total removal or subtotal resection in combination with postoperative radiation is recommended. In cystic tumors, stereotactic cyst drainage and adjuvant radiation may be a possible alternative. The prognosis is best in patients who are diagnosed early.

[Aneurysmal subarachonid haemorrhage]

The most characteristic symptom of an aneurysmal subarachnoid haemorrhage (aSAH) is a sudden onset of severe headache, which can be accompanied by meningism, impaired consciousness, and vegetative symptoms. A cerebral CT scan is the initial diagnostic tool of choice if aSAH is suspected. The localisation and morphology of the aneurysm is depicted in a CT-angiography and/or conventional panangiography. Until definitive exclusion of the aneurysm by either microsurgical clipping or endovascular coiling, rebleeding should be avoided implicitly. The postoperative phase, especially in patients with severe aSAH is embossed with the occurrence of disease-specific complications (cerebral vasospasm, intracranial hypertension, seizure disorder, hydrocephalus) and consecutively increased risk for secondary brain injury. Furthermore, many patients present systemic complications such as electrolyte disturbances and cardiac dysfunctions. Early identification and therapy of cerebral and systemic complications are very important in order improve functional outcome.

[Pott's puffy tumor - severe course of a sinusitis]

The disease pattern <<Pott's puffy tumour>> describes a local frontal-bone osteomyelitis that arises from an external infection with consecutive sub-periostal expansion. Symptoms may develop slowly or not at all with a mostly indolent protuberance on the patient's forehead. Symptomatic illness often indicates secondary morbidities. Here, we present a complicated case with intracranial dissemination.

[Trigeminal neuralgia - pathophysiology, clinical aspects and treatment]

The trigeminal neuralgia is characterised by paroxysmal appearing fulgurous stabbing pain. Its medical condition is caused through a local-circumscribed demyelinisation of the trigeminal nerve with consecutive conduction of salting impulses on afferent pain fibres. It is essential to differentiate the symptomatic from the idiopathic trigeminal neuralgia. As primary management, a pharmacological treatment with anticonvulsants is recommended in order to attenuate the ectopic-generated pain impulses. Different neurosurgical procedures are available in cases of resistance to therapy. Thereby, causal surgery in form of microvascular decompression is not only the operative treatment of choice, but because of the excellent results also a fundamental support of the theory of vascular compression. A comprehensive knowledge about diagnosis and management of trigeminal neuralgia is essential to treat patients efficiently and successfully. This synopsis summarises the current recommendations concerning diagnostics and therapeutic options.