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Hirsch BP, Sossamon J, Khan MA, Reitman C, Lawrence JP, Glaser J, Chun R, Gerald B, Baron E, Goldstein T, Baaj AA, Patrick Johnson J, Elojeimy S, Ravinsky RA. Applications of SPECT/CT in the Evaluation of Spinal Pathology: A Review. Int J Spine Surg 2024; 18:9-23. [PMID: 38050030 DOI: 10.14444/8552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Accurate identification of pain generators in the context of low back and spine-related pain is crucial for effective treatment. This review aims to evaluate the potential usefulness of single photon emission computed tomography with computed tomography (SPECT/CT) as an imaging modality in guiding clinical decision-making. METHODS A broad scoping literature review was conducted to identify relevant studies evaluating the use of SPECT/CT in patients with spine-related pain. Studies were reviewed for their methodology and results. RESULTS SPECT/CT appears to have advantages over traditional modalities, such as magnetic resonance imaging and CT, in certain clinical scenarios. It may offer additional information to clinicians and improve the specificity of diagnosis. However, further studies are needed to fully assess its diagnostic accuracy and clinical utility. CONCLUSIONS SPECT/CT is a promising imaging modality in the evaluation of low back pain, particularly in cases where magnetic resonance imaging and CT are inconclusive or equivocal. However, the current level of evidence is limited, and additional research is needed to determine its overall clinical relevance. CLINICAL RELEVANCE SPECT/CT may have a significant impact on clinical decision-making, particularly in cases in which traditional imaging modalities fail to provide a clear diagnosis. Its ability to improve specificity could lead to more targeted and effective treatment for patients with spinal pathology. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Brandon P Hirsch
- Department of Orthopedic Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Jake Sossamon
- College of Medicine, Medical University of South Carolina College of Medicine, Charleston, SC, USA
| | - Monis A Khan
- Department of Neurologic and Orthopedic Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Charles Reitman
- Department of Orthopedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - James P Lawrence
- Department of Orthopedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - John Glaser
- Department of Orthopedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Rebecca Chun
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Brittany Gerald
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Eli Baron
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Theodore Goldstein
- Department of Orthopedics, Spine Center of Excellence, Los Angeles, CA, USA
| | - Ali A Baaj
- Department of Neurologic and Orthopedic Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Saeed Elojeimy
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Robert A Ravinsky
- Department of Orthopedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
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Abraham I, Lewandrowski KU, Elfar JC, Li ZM, Fiorelli RKA, Pereira MG, Lorio MP, Burkhardt BW, Oertel JM, Winkler PA, Yang H, León JFR, Telfeian AE, Dowling Á, Vargas RAA, Ramina R, Asefi M, de Carvalho PST, Defino H, Moyano J, Montemurro N, Yeung A, Novellino P, On Behalf Of Teams/Organizations/Institutions. Randomized Clinical Trials and Observational Tribulations: Providing Clinical Evidence for Personalized Surgical Pain Management Care Models. J Pers Med 2023; 13:1044. [PMID: 37511657 PMCID: PMC10381640 DOI: 10.3390/jpm13071044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023] Open
Abstract
Proving clinical superiority of personalized care models in interventional and surgical pain management is challenging. The apparent difficulties may arise from the inability to standardize complex surgical procedures that often involve multiple steps. Ensuring the surgery is performed the same way every time is nearly impossible. Confounding factors, such as the variability of the patient population and selection bias regarding comorbidities and anatomical variations are also difficult to control for. Small sample sizes in study groups comparing iterations of a surgical protocol may amplify bias. It is essentially impossible to conceal the surgical treatment from the surgeon and the operating team. Restrictive inclusion and exclusion criteria may distort the study population to no longer reflect patients seen in daily practice. Hindsight bias is introduced by the inability to effectively blind patient group allocation, which affects clinical result interpretation, particularly if the outcome is already known to the investigators when the outcome analysis is performed (often a long time after the intervention). Randomization is equally problematic, as many patients want to avoid being randomly assigned to a study group, particularly if they perceive their surgeon to be unsure of which treatment will likely render the best clinical outcome for them. Ethical concerns may also exist if the study involves additional and unnecessary risks. Lastly, surgical trials are costly, especially if the tested interventions are complex and require long-term follow-up to assess their benefit. Traditional clinical testing of personalized surgical pain management treatments may be more challenging because individualized solutions tailored to each patient's pain generator can vary extensively. However, high-grade evidence is needed to prompt a protocol change and break with traditional image-based criteria for treatment. In this article, the authors review issues in surgical trials and offer practical solutions.
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Affiliation(s)
- Ivo Abraham
- Pharmacy Medicine, and Clinical Translational Sciences, University of Arizona, Roy P. Drachman Hall, Rm. B306H, Tucson, AZ 85721, USA
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Tucson, AZ 85712, USA
- Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá 111321, Colombia
- Department of Orthopedics, Hospital Universitário Gaffre e Guinle, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20270-004, Brazil
| | - John C Elfar
- Department of Orthopaedic Surgery, College of Medicine-Tucson Campus, Health Sciences Innovation Building (HSIB), University of Arizona, 1501 N. Campbell Avenue, Tower 4, 8th Floor, Suite 8401, Tucson, AZ 85721, USA
| | - Zong-Ming Li
- Department of Orthopaedic Surgery, College of Medicine-Tucson Campus, Health Sciences Innovation Building (HSIB), University of Arizona, 1501 N. Campbell Avenue, Tower 4, 8th Floor, Suite 8401, Tucson, AZ 85721, USA
| | - Rossano Kepler Alvim Fiorelli
- Department of General and Specialized Surgery, Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro 20270-004, Brazil
| | - Mauricio G Pereira
- Faculty of Medicine, University of Brasilia, Federal District, Brasilia 70919-900, Brazil
| | - Morgan P Lorio
- Advanced Orthopaedics, 499 E. Central Pkwy, Ste. 130, Altamonte Springs, FL 32701, USA
| | - Benedikt W Burkhardt
- Wirbelsäulenzentrum/Spine Center-WSC, Hirslanden Klinik Zurich, Witellikerstrasse 40, 8032 Zurich, Switzerland
| | - Joachim M Oertel
- Klinik für Neurochirurgie, Universität des Saarlandes, Kirrberger Straße 100, 66421 Homburg, Germany
| | - Peter A Winkler
- Department of Neurosurgery, Charite Universitaetsmedizin Berlin, 13353 Berlin, Germany
| | - Huilin Yang
- Orthopaedic Department, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou 215031, China
| | - Jorge Felipe Ramírez León
- Minimally Invasive Spine Center Bogotá D.C. Colombia, Reina Sofía Clinic Bogotá D.C. Colombia, Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá 110141, Colombia
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Álvaro Dowling
- Department of Orthopaedic Surgery, University of São Paulo, Ribeirão Preto 14071-550, Brazil
| | - Roth A A Vargas
- Department of Neurosurgery, Foundation Hospital Centro Médico Campinas, Campinas 13083-210, Brazil
| | - Ricardo Ramina
- Neurological Institute of Curitiba, Curitiba 80230-030, Brazil
| | - Marjan Asefi
- Department of Biology, Nano-Biology, University of North Carolina, Greensboro, NC 27413, USA
| | | | - Helton Defino
- Department of Orthopaedic Surgery, University of São Paulo, Ribeirão Preto 14071-550, Brazil
| | - Jaime Moyano
- La Sociedad Iberolatinoamericana De Columna (SILACO), The Spine Committee of the Ecuadorian Society of Orthopaedics and Traumatology (Comité de Columna de la Sociedad Ecuatoriana de Ortopedia y Traumatología), Quito 170521, Ecuador
| | - Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
| | - Anthony Yeung
- Desert Institute for Spine Care, Phoenix, AZ 85020, USA
| | - Pietro Novellino
- Guinle and State Institute of Diabetes and Endocrinology, Rio de Janeiro 20270-004, Brazil
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3
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Lewandrowski KU, Yeung A, Lorio MP, Yang H, Ramírez León JF, Sánchez JAS, Fiorelli RKA, Lim KT, Moyano J, Dowling Á, Sea Aramayo JM, Park JY, Kim HS, Zeng J, Meng B, Gómez FA, Ramirez C, De Carvalho PST, Rodriguez Garcia M, Garcia A, Martínez EE, Gómez Silva IM, Valerio Pascua JE, Duchén Rodríguez LM, Meves R, Menezes CM, Carelli LE, Cristante AF, Amaral R, de Sa Carneiro G, Defino H, Yamamoto V, Kateb B. Personalized Interventional Surgery of the Lumbar Spine: A Perspective on Minimally Invasive and Neuroendoscopic Decompression for Spinal Stenosis. J Pers Med 2023; 13:jpm13050710. [PMID: 37240880 DOI: 10.3390/jpm13050710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 05/28/2023] Open
Abstract
Pain generator-based lumbar spinal decompression surgery is the backbone of modern spine care. In contrast to traditional image-based medical necessity criteria for spinal surgery, assessing the severity of neural element encroachment, instability, and deformity, staged management of common painful degenerative lumbar spine conditions is likely to be more durable and cost-effective. Targeting validated pain generators can be accomplished with simplified decompression procedures associated with lower perioperative complications and long-term revision rates. In this perspective article, the authors summarize the current concepts of successful management of spinal stenosis patients with modern transforaminal endoscopic and translaminar minimally invasive spinal surgery techniques. They represent the consensus statements of 14 international surgeon societies, who have worked in collaborative teams in an open peer-review model based on a systematic review of the existing literature and grading the strength of its clinical evidence. The authors found that personalized clinical care protocols for lumbar spinal stenosis rooted in validated pain generators can successfully treat most patients with sciatica-type back and leg pain including those who fail to meet traditional image-based medical necessity criteria for surgery since nearly half of the surgically treated pain generators are not shown on the preoperative MRI scan. Common pain generators in the lumbar spine include (a) an inflamed disc, (b) an inflamed nerve, (c) a hypervascular scar, (d) a hypertrophied superior articular process (SAP) and ligamentum flavum, (e) a tender capsule, (f) an impacting facet margin, (g) a superior foraminal facet osteophyte and cyst, (h) a superior foraminal ligament impingement, (i) a hidden shoulder osteophyte. The position of the key opinion authors of the perspective article is that further clinical research will continue to validate pain generator-based treatment protocols for lumbar spinal stenosis. The endoscopic technology platform enables spine surgeons to directly visualize pain generators, forming the basis for more simplified targeted surgical pain management therapies. Limitations of this care model are dictated by appropriate patient selection and mastering the learning curve of modern MIS procedures. Decompensated deformity and instability will likely continue to be treated with open corrective surgery. Vertically integrated outpatient spine care programs are the most suitable setting for executing such pain generator-focused programs.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Tucson, AZ 85712, USA
- Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá 111321, Colombia
- Department of Orthopedics at Hospital Universitário Gaffree Guinle Universidade Federal do Estado do Rio de Janeiro, R. Mariz e Barros, 775-Maracanã, Rio de Janeiro 20270-004, Brazil
- Brain Technology and Innovation Park, Pacific Palisades, CA 90272, USA
| | - Anthony Yeung
- Desert Institute for Spine Care, 1635 E Myrtle Ave Suite 400, Phoenix, AZ 85020, USA
- Department of Neurosurgery, University of New Mexico School of Medicine, 915 Camino de Salud NE Albuquerque, Albuquerque, NM 87106, USA
| | - Morgan P Lorio
- Advanced Orthopedics, 499 East Central Parkway, Altamonte Springs, FL 32701, USA
| | - Huilin Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou 215031, China
| | - Jorge Felipe Ramírez León
- Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá 111321, Colombia
- Minimally Invasive Spine Center Bogotá D.C. Colombia, Reina Sofía Clinic Bogotá D.C. Colombia, Bogotá 110141, Colombia
| | | | - Rossano Kepler Alvim Fiorelli
- Department of General and Specialized Surgery, Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro 20000-000, Brazil
| | - Kang Taek Lim
- Good Doctor Teun Teun Spine Hospital, Seoul 775 , Republic of Korea
| | - Jaime Moyano
- Torres Médicas Hospital Metropolitano, San Gabriel y Nicolás Arteta Torre Médica 3, Piso 5, Quito 170521, Ecuador
| | - Álvaro Dowling
- DWS Spine Clinic Center, CENTRO EL ALBA-Cam. El Alba 9500, Of. A402, Región Metropolitana, Las Condes 9550000, Chile
- Department of Orthopaedic Surgery, Faculdade de Medicina de Ribeirão Preto (FMRP) da Universidade de São Paulo (USP), Ribeirão Preto 14040-900, Brazil
| | | | - Jeong-Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 731, Republic of Korea
| | - Hyeun-Sung Kim
- Department of Neurosurgery, Nanoori Hospital Gangnam Hospital, Seoul 731, Republic of Korea
| | - Jiancheng Zeng
- Department of Orthopaedic Surgery, West China Hospital Sichuan University, Chengdu 610041, China
| | - Bin Meng
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215005, China
| | | | - Carolina Ramirez
- Centro de Cirugía Mínima Invasiva-CECIMIN, Avenida Carrera 45 # 104-76, Bogotá 0819, Colombia
| | - Paulo Sérgio Teixeira De Carvalho
- Department of Neurosurgery, Pain and Spine Minimally Invasive Surgery Service at Gaffree Guinle University Hospital, Rio de Janeiro 20270-004, Brazil
| | - Manuel Rodriguez Garcia
- Spine Clinic, The American-Bitish Cowdray Medical Center I.A.P, Campus Santa Fe, Mexico City 05370, Mexico
| | - Alfonso Garcia
- Department of Orthopaedic Surgery, Espalda Saludable, Hospital Angeles Tijuana, Tijuana 22010, Mexico
| | - Eulalio Elizalde Martínez
- Department of Spine Surgery, Hospital de Ortopedia, UMAE "Dr. Victorio de la Fuente Narvaez", Ciudad de México 07760, Mexico
| | - Iliana Margarita Gómez Silva
- Department of Spine Surgery, Hospital Ángeles Universidad, Av Universidad 1080, Col Xoco, Del Benito Juárez, Ciudad de México 03339, Mexico
| | | | - Luis Miguel Duchén Rodríguez
- Center for Neurological Diseases, Bolivian Spine Association, Spine Chapter of Latin American Federation of Neurosurgery Societies, Public University of El Alto, La Paz 0201-0220, Bolivia
| | - Robert Meves
- Santa Casa Spine Center, São Paulo 09015-000, Brazil
| | - Cristiano M Menezes
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte 31270-901, Brazil
| | | | | | - Rodrigo Amaral
- Instituto de Patologia da Coluna (IPC), Faculdade de Medicina de Ribeirão Preto (FMRP) da Universidade de São Paulo (USP), São Paulo 14040-900, Brazil
| | | | - Helton Defino
- Hospital das Clínicas of Ribeirao Preto Medical School, Sao Paulo University, Ribeirão Preto 14040-900, Brazil
| | - Vicky Yamamoto
- Brain Technology and Innovation Park, Pacific Palisades, CA 90272, USA
- The USC Caruso Department of Otolaryngology-Head and Neck Surgery, USC Keck School of Medicine, Los Angeles, CA 90033, USA
- USC-Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA
- World Brain Mapping Foundation (WBMF), Pacific Palisades, CA 90272, USA
| | - Babak Kateb
- Brain Technology and Innovation Park, Pacific Palisades, CA 90272, USA
- World Brain Mapping Foundation (WBMF), Pacific Palisades, CA 90272, USA
- Society for Brain Mapping and Therapeutics (SBMT), Pacific Palisades, CA 90272, USA
- National Center for Nano Bio Electronic (NCNBE), Los Angeles, CA 90272, USA
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Lewandrowski KU, Abraham I, Ramírez León JF, Telfeian AE, Lorio MP, Hellinger S, Knight M, De Carvalho PST, Ramos MRF, Dowling Á, Rodriguez Garcia M, Muhammad F, Hussain N, Yamamoto V, Kateb B, Yeung A. A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy. J Pers Med 2022; 12. [PMID: 35887562 DOI: 10.3390/jpm12071065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Endoscopically visualized spine surgery has become an essential tool that aids in identifying and treating anatomical spine pathologies that are not well demonstrated by traditional advanced imaging, including MRI. These pathologies may be visualized during endoscopic lumbar decompression (ELD) and categorized into primary pain generators (PPG). Identifying these PPGs provides crucial information for a successful outcome with ELD and forms the basis for our proposed personalized spine care protocol (SpineScreen). Methods: a prospective study of 412 patients from 7 endoscopic practices consisting of 207 (50.2%) males and 205 (49.8%) females with an average age of 63.67 years and an average follow-up of 69.27 months was performed to compare the durability of targeted ELD based on validated primary pain generators versus image-based open lumbar laminectomy, and minimally invasive lumbar transforaminal interbody fusion (TLIF) using Kaplan-Meier median survival calculations. The serial time was determined as the interval between index surgery and when patients were censored for additional interventional and surgical treatments for low back-related symptoms. A control group was recruited from patients referred for a surgical consultation but declined interventional and surgical treatment and continued on medical care. Control group patients were censored when they crossed over into any surgical or interventional treatment group. Results: of the 412 study patients, 206 underwent ELD (50.0%), 61 laminectomy (14.8%), and 78 (18.9%) TLIF. There were 67 patients in the control group (16.3% of 412 patients). The most common surgical levels were L4/5 (41.3%), L5/S1 (25.0%), and L4-S1 (16.3%). At two-year f/u, excellent and good Macnab outcomes were reported by 346 of the 412 study patients (84.0%). The VAS leg pain score reduction was 4.250 ± 1.691 (p < 0.001). No other treatment during the available follow-up was required in 60.7% (125/206) of the ELD, 39.9% (31/78) of the TLIF, and 19.7% (12/61 of the laminectomy patients. In control patients, only 15 of the 67 (22.4%) control patients continued with conservative care until final follow-up, all of which had fair and poor functional Macnab outcomes. In patients with Excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients (p < 0.001). The overall survival time in control patients was eight months with a standard error of 0.942, a lower boundary of 6.154, and an upper boundary of 9.846 months. In patients with excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients versus control patients at seven months (p < 0.001). The most common new-onset symptom for censoring was dysesthesia ELD (9.4%; 20/206), axial back pain in TLIF (25.6%;20/78), and recurrent pain in laminectomy (65.6%; 40/61) patients (p < 0.001). Transforaminal epidural steroid injections were tried in 11.7% (24/206) of ELD, 23.1% (18/78) of TLIF, and 36.1% (22/61) of the laminectomy patients. The secondary fusion rate among ELD patients was 8.8% (18/206). Among TLIF patients, the most common additional treatments were revision fusion (19.2%; 15/78) and multilevel rhizotomy (10.3%; 8/78). Common follow-up procedures in laminectomy patients included revision laminectomy (16.4%; 10/61), revision ELD (11.5%; 7/61), and multilevel rhizotomy (11.5%; 7/61). Control patients crossed over into ELD (13.4%), TLIF (13.4%), laminectomy (10.4%) and interventional treatment (40.3%) arms at high rates. Most control patients treated with spinal injections (55.5%) had excellent and good functional outcomes versus 40.7% with fair and poor (3.7%), respectively. The control patients (93.3%) who remained in medical management without surgery or interventional care (14/67) had the worst functional outcomes and were rated as fair and poor. Conclusions: clinical outcomes were more favorable with lumbar surgeries than with non-surgical control groups. Of the control patients, the crossover rate into interventional and surgical care was 40.3% and 37.2%, respectively. There are longer symptom-free intervals after targeted ELD than with TLIF or laminectomy. Additional intervention and surgical treatments are more often needed to manage new-onset postoperative symptoms in TLIF- and laminectomy compared to ELD patients. Few ELD patients will require fusion in the future. Considering the rising cost of surgical spine care, we offer SpineScreen as a simplified and less costly alternative to traditional image-based care models by focusing on primary pain generators rather than image-based criteria derived from the preoperative lumbar MRI scan.
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Demartini L, Bonezzi L, Bonezzi C. Pain diagnosis and treatment according to the pain generating factors. G Ital Med Lav Ergon 2020; 42:124-132. [PMID: 32614543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/30/2020] [Indexed: 06/11/2023]
Abstract
Chronic pain impacts on many aspects of patient life affecting autonomy, sleep, social activities and also employment. Adequate pain control is often challenging in patients with chronic pain, despite the availability of many medications and interventional techniques. Limitations to successful pain treatment are the poor understanding of contributing mechanisms and the lack of a mechanism based approach in clinical practice. The purpose of this article is to identify the factors contributing to pain generation in order to guide a personalized treatment. We analyze tissue specificity for chemical and physical stresses potentially causing pain, the changes that occur in the peripheral and central pain pathways during disease, the stimuli that, acting on a pathological pain pathway, can trigger pain. The pain generating factors should be recognized in each patient and addressed with pharmacological, rehabilitation and invasive interventions.
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Affiliation(s)
| | - Linda Bonezzi
- School of Medicine, Genova University, Genova, Italy
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