Treatment Options for Failed Back Surgery Syndrome: An Umbrella Systematic Review of Systematic Reviews on the Effectiveness of Therapeutic Interventions

Background

Failed back surgery syndrome (FBSS) is a common and incapacitating condition affecting patients with previous spine surgery in whom treatment approach can be challenging. This study aimed to summarize existing secondary studies and up-to-date randomized clinical trials (RCTs) that assess the effectiveness of available treatment options for FBSS.

Methods

Systematic searches were carried out in five databases (PubMed, Cochrane, Scielo, Epistemonikos, and Google scholar) for all systematic reviews on the effectiveness of treatment options for FBSS published after 2012. Outcomes of interest were pain levels measured through visual analog scale or numeric rating scale, Oswestry Disability Index, and quality of life. Methodological and risk of bias assessments were performed with the AMSTAR-2 tool for systematic reviews and the Joanna Briggs Institute checklist for RCT. Prospective PROSPERO registration: CRD42022307609.

Results

Fifteen studies, seven systematic reviews, and eight RCTs met the inclusion criteria and fulfilled the methodological quality assessment. Of the 15 included studies, 8 were on neurostimulation, 4 on adhesiolysis, 4 on epidural or intrathecal injections, and 3 on other treatment modalities. The risk of bias was low in seven studies, moderate in five, and high in three.

Conclusions

Based on this systematic overview and the considerable heterogeneity among studies, the FBSS therapeutic approach must be individualized. FBSS treatment should start with conservative management, considering the implementation of neurostimulation, a technique with the most robust evidence of effective results, in cases of refractory axial or neuropathic pain. As the last resource, in light of the evidence found, more invasive procedures or new surgical interventions are indicated.

Clinical and Radiological Outcome in a Series of Patients Treated by Anterior Cervical Discectomy and Fusion: Retrospective Controlled Study With 2 Different Stand-Alone Cages

BACKGROUND

Cervical spine balance and alignment targets after cervical spine surgery are poorly established in patients with cervical spine degenerative disease surgically treated by anterior cervical discectomy and fusion (ACDF). The objective of the study is to determine the correlation between radiological and clinical outcomes in patients surgically treated by ACDF with 2 different stand-alone cervical cages.

METHODS

Clinical outcomes were evaluated using visual analog scale (VAS), Neck Disability Index (NDI), Nurick Scale, and Japanese Orthopedic Association score for myelopathy. Radiological evaluation included cervical and segmental Cobb angles, cervical sagittal vertical axis (cSVA), T1 slope (T1s), C0-C2 angle, fusion rates, adjacent segment degeneration, and cage subsidence.

RESULTS

A total of 80 patients were included with an average age of 53 years. There was a statistically significant improvement in both clinical and radiological evaluations. There was a statistical significant correlation between cervical pain on cervical VAS and cSVA. There was a significant correlation between postoperative T1s and cSVA, related to the improvement in cervical angles. There was no significant difference in rates of fusion, adjacent segment changes, or reoperation between both cervical cages, and there was a higher rate of subsidence in the Aleutian group. There were significant differences between both groups on postoperative NDI and VAS, but this difference is not maintained during follow-up.

CONCLUSIONS

Cervical sagittal balance is directly related to clinical outcome in patients with cervical spine degenerative disease. Both cervical implants analyzed were comparable in clinical and radiological outcomes.

CLINICAL RELEVANCE

There are important clinical and radiological parameters that should be taken into account for the analysis of the surgical outcome of patients treated by ACDF; this is one of the few studies that report the results with 2 different cervical cage designs.

LEVEL OF EVIDENCE: 4

Minimally Invasive Surgical Technique for the Management of Giant Dumbbell Spinal Schwannoma

BACKGROUND

 Completely extradural spinal schwannomas have a unique morphology (dumbbell tumors) with an intra- and extraspinal component. When they compromise two contiguous vertebral bodies or have an extraspinal extension >2.5 cm, they are classified as giant spinal schwannomas. The aim of this study is to present our experience in the surgical management of completely extradural giant spinal schwannomas with a minimally invasive approach.

METHODS

 This study is a case series of patients treated at the Neurosurgery Department of the University Clinical and Provincial Hospital of Barcelona, Spain, between January 2016 and December 2019.

RESULTS

 Fifteen patients met the inclusion criteria, with thoracic and lumbar spines being the most frequent locations. All patients underwent surgical treatment, with a mini-open interlaminar and far-lateral technique. Total gross resection was accomplished in all patients and spine instrumentation was not necessary.

CONCLUSIONS

 Microsurgery is the treatment of choice for spinal schwannomas, and gross total resection with low morbidity must be the surgical goal. Mini-open interlaminar and far-lateral access is a valid surgical option, with low morbidity in experienced hands, and there is no need for spinal instrumentation.

Dynamic Fixation Techniques for the Prevention of Adjacent Segment Disease: A Retrospective Controlled Study

Study Design

Retrospective, controlled study.

Purpose

Dynamic fixation (topping-off technique) adjacent to a transforaminal lumbar interbody fusion (TLIF) level was developed to reduce the risk of adjacent segment disease (ASDi). This study was designed to compare the clinical and radiological outcomes between patients who underwent circumferential lumbar fusion (CLF) without the topping-off technique, CLF with dynamic rod constructs (DRC), and CLF with interspinous device (ISD).

Overview of Literature

Lumbar fusion can result in the re-distribution of stress, increased mobility, and increased intradiscal pressure at adjacent levels, ultimately leading to adjacent segment degeneration (ASDe) and ASDi. Dynamic fixation techniques (topping-off techniques) adjacent to vertebral fusion have been developed to reduce the risk of ASDe and ASDi because they provide a transitional zone between a caudal rigid fused segment and cephalad-mobile unfused levels.

Methods

A single-center, retrospective, controlled study was designed, including all patients who underwent CLF due to degenerative lumbar spinal disease in Hospital Clinic of Barcelona between 2012 and 2018. Three groups of patients were evaluated as per the type of topping-off technique used: CLF alone group, DRC group, and ISD group. Clinical and radiological outcomes were evaluated.

Results

A total of 117 patients were enrolled in the study. Sixty patients (51.3%) underwent CLF without dynamic stabilization, 24 (20.5%) were treated with DRC as topping-off technique, and 33 (28.5%) were treated with an ISD. A total of 12 patients (20.0%) in the CLF alone group showed ASDi at the final follow-up, compared to 1 (4.2%) in the DRC group (p=0.097) and 2 (6.1%) in the ISD group (p=0.127). The Cox regression model identified a significantly decreased risk of ASDi when a topping-off technique (DRC or ISD) was used (hazard ratio, 0.154; 95% confidence interval, 0.31–0.77).

Conclusions

Dynamic fixation adjacent to CLF was a safe and efficient procedure associated with improved clinical outcomes in patients with lumbar spine degenerative disease.

L4 erector spinal plane block after lumbar spine arthrodesi: A case-series

INTRODUCTION

Thoracic erector spinae plane block is now performed in many different surgical procedures, including lumbar spinal fusion. We evaluated the analgesic effect of lumbar ESP performed at L4 after lumbar spinal fusion surgery.

METHODS AND CASE SERIES

Eight patients scheduled for lumbar spinal fusion were included in the case series. Erector spinae plane block was performed at L4 preoperatively, administering 20ml of 0.2% ropivacaine on each side. We recorded patient-reported pain intensity during the first 48 postoperative hours using a visual analogue scale (VAS) and rescue analgesia requirements. Pain at rest was controlled in all patients (VAS 0 to 3), although pain on movement ranged from mild to severe (VAS 0 to 8). Rescue analgesia consumption ranged from 1 to 22mg morphine.

CONCLUSIONS

Lumbar ESP appears to contribute to pain control during the first 48hours after lumbar spinal fusion.

Unusual twin pregnancy: complete hydatidiform mole with coexistent normal fetus

The authors present a case of complete hydatidiform mole and coexisting fetus (CHMCF) in which mole gestation caused a placenta previa; with a posterior preterm premature rupture of membranes (PPROM) and ending in the 28h week of gestation due to acute chorioamnionitis, obtaining a live preterm newborn.

Spontaneous chronic epidural hematoma of the lumbar spine mimicking an extradural spine tumour

PURPOSE

Spontaneous chronic epidural hematomas are extremely rare and can be extremely challenging to diagnose and differentiate. The clinical findings, computed tomographic scan and magnetic resonance imaging does not always enough to complete differentiate this condition. Our purpose is to report a case of a spontaneous chronic epidural hematoma presenting as an extradural mass leading to compressive radicular symptoms with images of bony scalloping which are sparsely reported in the literature.

METHODS

We describe a 61-year-old woman who was evaluated after 18-month history of pain, disestesias and mild weakness in both lower extremities with significant radicular symptoms on the right side associated to neurogenic claudication.

RESULTS

CT scans revealed a nodular image of soft tissue density located in the right anterolateral epidural space at the L4-L5 level demonstrating resorption of the bony margins. MRI studies revealed a round mass in the vertebral canal displacing the dural sac and scalloping the posterior wall of the L4 vertebral body. Diagnosis was established between a degenerative cyst versus an atypical neurinoma. Surgical findings demonstrated an isolated well-formed chronic hematoma.

CONCLUSION

Spontaneous chronic epidural hematomas are rare, even more when they produce scalloping of bony structures becoming a diagnostic challenge. Therefore they should be always considered as a differential diagnosis in patients with extradural chronic compressions taking into account that also chronic epidural hematomas can cause bone involvement.

[Accuracy of pedicle screw insertion in the thoracolumbar spine using image-guided navigation]

INTRODUCTION

Computer image guidance is one of the most significant technologic advancements in the spine surgery, because preoperative or intraoperative images can be used for multiplanar, three-dimensional intraoperative navigation.

MATERIAL AND METHODS

We performed a prospective clinical study to assess the accuracy of pedicle screw insertion using an optoelectronic navigation system (SurgiGATE Spine 2.1 Medivision). The study population included 29 patients with diverse disorders of the thoraco- lumbar spine (degenerative 54%, spondylolisthesis 21%, fractures 14%, scoliosis 7% and spondylodiscitis 4%). One patient was excluded from the study because problems with the specific instruments or the computer system. Pre and post-operative axial computed tomography images were obtained for each patient and analyzed by two independent radiologists to placement accuracy. The correct location was defined accord to Heary scale in 5 grades.

RESULTS

163 image-guided thoraco-lumbar pedicle screws were placed 29 in the thoracolumbar spine and 134 in the lumbosacral spine. We achieved a completely intraosseous placement (Grade I) in 99.4% of lumbosacral spine screws and 100% of thoracolumbar spine screws. Only one misplaced screw (Grade III) in the pedicle of L III in the concavity of a scoliosis was reported. No implant related complications were noted.

CONCLUSIONS

The low rate of misplaced screws in this prospective study compares favorably with previously published results. Our initial results indicate that Image-guided spinal surgery is a safe technique which improves surgical performance during posterior transpedicle stabilization.

Psychometric characteristics of the Spanish version of instruments to measure neck pain disability

BACKGROUND

The NDI, COM and NPQ are evaluation instruments for disability due to NP. There was no Spanish version of NDI or COM for which psychometric characteristics were known. The objectives of this study were to translate and culturally adapt the Spanish version of the Neck Disability Index Questionnaire (NDI), and the Core Outcome Measure (COM), to validate its use in Spanish speaking patients with non-specific neck pain (NP), and to compare their psychometric characteristics with those of the Spanish version of the Northwick Pain Questionnaire (NPQ).

METHODS

Translation/re-translation of the English versions of the NDI and the COM was done blindly and independently by a multidisciplinary team. The study was done in 9 primary care Centers and 12 specialty services from 9 regions in Spain, with 221 acute, subacute and chronic patients who visited their physician for NP: 54 in the pilot phase and 167 in the validation phase. Neck pain (VAS), referred pain (VAS), disability (NDI, COM and NPQ), catastrophizing (CSQ) and quality of life (SF-12) were measured on their first visit and 14 days later. Patients' self-assessment was used as the external criterion for pain and disability. In the pilot phase, patients' understanding of each item in the NDI and COM was assessed, and on day 1 test-retest reliability was estimated by giving a second NDI and COM in which the name of the questionnaires and the order of the items had been changed.

RESULTS

Comprehensibility of NDI and COM were good. Minutes needed to fill out the questionnaires [median, (P25, P75)]: NDI. 4 (2.2, 10.0), COM: 2.1 (1.0, 4.9). Reliability: [ICC, (95%CI)]: NDI: 0.88 (0.80, 0.93). COM: 0.85 (0.75,0.91). Sensitivity to change: Effect size for patients having worsened, not changed and improved between days 1 and 15, according to the external criterion for disability: NDI: -0.24, 0.15, 0.66; NPQ: -0.14, 0.06, 0.67; COM: 0.05, 0.19, 0.92.

VALIDITY

Results of NDI, NPQ and COM were consistent with the external criterion for disability, whereas only those from NDI were consistent with the one for pain. Correlations with VAS, CSQ and SF-12 were similar for NDI and NPQ (absolute values between 0.36 and 0.50 on day 1, between 0.38 and 0.70 on day 15), and slightly lower for COM (between 0.36 and 0.48 on day 1, and between 0.33 and 0.61 on day 15). Correlation between NDI and NPQ: r = 0.84 on day 1, r = 0.91 on day 15. Correlation between COM and NPQ: r = 0.63 on day 1, r = 0.71 on day 15.

CONCLUSION

Although most psychometric characteristics of NDI, NPQ and COM are similar, those from the latter one are worse and its use may lead to patients' evolution seeming more positive than it actually is. NDI seems to be the best instrument for measuring NP-related disability, since its results are the most consistent with patient's assessment of their own clinical status and evolution. It takes two more minutes to answer the NDI than to answer the COM, but it can be reliably filled out by the patient without assistance.

TRIAL REGISTRATION

Clinical Trials Register NCT00349544.

[Spinal tuberculosis: early surgical treatment combined with medical treatment]

BACKGROUND

Spinal tuberculosis can produce kyphosis with neurologicaldeficit, despite antibiotic treatment. When there is no response to medical treatment, the recommended procedure is debridementand interbody fusion with bone autograft. The biological characteristicsof Mycobacterium tuberculosis do not prevent osteosynthesisof the infected bone from being performed.

PATIENTS AND METHOD

Five patients with spinal tuberculosis and neurological deficitunderwent debridement, interbody fusion and anterior osteosynthesisin addition to medical treatment. In order to ensure stability, posterior fusion was also performed in three patients. All 5 patientsdisplayed weakness and paralysis of their lower extremities, two patients suffered an L4 radiculopathy, one developed paraparesiaand one was excluded due to a short follow-up. Mean value of vertebralkyphosis was 22,8 degrees and mean follow-up was 3,1 years.

RESULTS

No patient had septic loosening or progression of the disease. Correction of kyphosis was 104,5% postoperatively and 80,5% atthe end of follow-up. All patients, apart from one with an L4radiculopathy, exhibited neurological recovery.

CONCLUSIONS

Anterior instrumentation allows spinal decompression, septic focusdebridement, deformity correction and autologous bone grafting. In severe kyphotic flattening, it is advisable to associate alimited posterior arthrodesis. When pathological fractures appearor there is no response to antibiotic treatment, the combinationof medical and surgical treatment improves patients' outcome.

Single-stage laparoscopic and endoscopic treatment for choledocholithiasis: a novel approach

The transcystic approach is ideal for the management of choledocholithiasis detected during the course of laparoscopic cholecystectomy. When this approach is not possible or fails, current alternatives include laparoscopic choledochotomy, conversion to open common bile duct exploration, or postoperative endoscopic sphincterotomy (ES). Intraoperative ES is not routinely advised, as it is thought to be difficult to carry out in the operating room with the patient in the supine position. We challenged this concept and have performed ES intraoperatively when the transcystic approach had failed. Five consecutive patients in whom transcystic extraction of choledocholiths had failed underwent intraoperative ES. The laparoscopic procedure was terminated, the trocars were removed, the wounds were closed, and the patients were placed in the left lateral decubitus position. In this position, the endoscope was inserted, ES was performed under fluoroscopic guidance, and choledocholithiasis was treated. There were no difficulties or complications, and the postoperative course was similar to that of a simple laparoscopic cholecystectomy in all five patients. Intraoperative ES is a viable and effective treatment for choledocholithiasis when the transcystic approach fails. This novel approach to choledocholithiasis is well tolerated and may save the extra time and effort associated with all other current alternatives.

Tuberculosis of the neural arch. A report of four cases

Four cases of spinal tuberculosis involving the posterior neural elements are reported; all the patients were from Africa. The condition is rare and its incidence may be different in different races. Neural arch involvement is likely to be associated with neurological complications.

Intrathoracic migration of a Kirschner wire

Migration of Kirschner wires, Rush pins, etc., is well known. Such migrations usually follow a retrograde path and the wires protrude near the entry point. Occasionally migration occurs in another direction. We describe a case in which the Kirschner wire migrated from the shoulder to the thorax. Several factors caused this migration. This complication must be avoided by bending the free end of the wire, removing the osteosynthesis material as soon as possible and following up the patient for a long period.

Direct repair of spondylolysis

Fifteen patients with spondylolysis have received compression screw and bone graft treatment for repair of this defect. In all but one case, solid fusion of the pars defect was achieved within six months after surgery. After one year, 13 of the 15 patients were able to participate fully in sports activities.