A Proposed Treatment Algorithm for Low Back Pain Secondary to Bertolotti's Syndrome

BACKGROUND

Chronic low back pain is widely prevalent, and there are a range of conditions that may result in the low back pain. In general, treatment of low back pain starts with conservative management such as medications, physical therapy, and home exercise regimens. If conservative measures fail, a range of interventional techniques can be employed to manage back pain. An uncommonly recognized cause of back pain is Bertolotti's syndrome which is a result of back pain due to lumbosacral transitional vertebrae (LSTV). LSTV is a congenital abnormality either characterized by the lumbarization of the sacrum where the first sacral bone fails to fuse with the rest of the sacrum or the sacralization of the lumbar spine where the L5 vertebra fuses with the sacrum creating a longer sacrum. In many cases, the condition can be recognized by imaging techniques such as an x-ray, computed tomography, or magnetic resonance imaging.

OBJECTIVES

To propose a treatment algorithm for patients with low back pain secondary to Bertolotti's syndrome.

STUDY DESIGN

Case study and treatment algorithm proposal.

METHODS

A treatment algorithm for patients with low back pain secondary to Bertolotti's Syndrome which involves starting with local anesthetic and steroid injection of the pseudo-articulation, followed by radiofrequency ablation of the pseudo-articulation, and then complete endoscopic resection of the pseudo joint.

RESULTS

The proposed stepwise treatment guideline has the ability to diagnose Bertolotti's syndrome as the cause of low back pain and provide symptomatic relief.

LIMITATIONS

Several limitations exist for the study including the fact that the algorithmic approach may not fit every patient. Additionally, there would be benefit in future research studies comparing each step of the algorithm with conservative measures to compare efficacy and long-term outcomes of the procedures.

CONCLUSIONS

Our stepwise approach to diagnosing and managing the pain resulting from Bertolotti's syndrome is an effective method of treatment for the condition.

Discogenic Low Back Pain: Anatomy, Pathophysiology and Treatments of Intervertebral Disc Degeneration

Intervertebral disc (IVD) degeneration is a major contributing factor for discogenic low back pain (LBP), causing a significant global disability. The IVD consists of an inner core proteoglycan-rich nucleus pulposus (NP) and outer lamellae collagen-rich annulus fibrosus (AF) and is confined by a cartilage end plate (CEP), providing structural support and shock absorption against mechanical loads. Changes to degenerative cascades in the IVD cause dysfunction and instability in the lumbar spine. Various treatments include pharmacological, rehabilitation or surgical interventions that aim to relieve pain; however, these modalities do not halt the pathologic events of disc degeneration or promote tissue regeneration. Loss of stem and progenitor markers, imbalance of the extracellular matrix (ECM), increase of inflammation, sensory hyperinnervation and vascularization, and associated signaling pathways have been identified as the onset and progression of disc degeneration. To better understand the pain originating from IVD, our review focuses on the anatomy of IVD and the pathophysiology of disc degeneration that contribute to the development of discogenic pain. We highlight the key mechanisms and associated signaling pathways underlying disc degeneration causing discogenic back pain, current clinical treatments, clinical perspective and directions of future therapies. Our review comprehensively provides a better understanding of healthy IVD and degenerative events of the IVD associated with discogenic pain, which helps to model painful disc degeneration as a therapeutic platform and to identify signaling pathways as therapeutic targets for the future treatment of discogenic pain.

Intervertebral disc degeneration and regeneration: a motion segment perspective

Back and neck pain have become primary reasons for disability and healthcare spending globally. While the causes of back pain are multifactorial, intervertebral disc degeneration is frequently cited as a primary source of pain. The annulus fibrosus (AF) and nucleus pulposus (NP) subcomponents of the disc are common targets for regenerative therapeutics. However, disc degeneration is also associated with degenerative changes to adjacent spinal tissues, and successful regenerative therapies will likely need to consider and address the pathology of adjacent spinal structures beyond solely the disc subcomponents. This review summarises the current state of knowledge in the field regarding associations between back pain, disc degeneration, and degeneration of the cartilaginous and bony endplates, the AF-vertebral body interface, the facet joints and spinal muscles, in addition to a discussion of regenerative strategies for treating pain and degeneration from a whole motion segment perspective.

Surgical Impacts of Metastatic Non-small Cell Lung Cancer to the Thoracic and Lumbar Spine

BACKGROUND

Surgery for spinal metastasis is rapidly increasing in frequency with procedures ranging from laminectomy to spondylectomy combined with stabilization. This study investigated the effect of various surgical procedures for spinal metastasis of non-small cell lung cancer (NSCLC).

METHODS

A single-center consecutive series of patients who underwent surgery for spinal metastasis of NSCLC were retrospectively reviewed. Patients' characteristics, radiographic parameters, operative data, clinical outcomes, and complications were analyzed. Surgical outcomes were assessed according to pain and performance status before and after surgery. Overall survival (OS) rate was estimated using the Kaplan-Meier method. Multivariate analysis was performed to detect factors independently associated with OS using a Cox proportional hazards model.

RESULTS

Twenty-one patients were treated with laminectomy, 24 with corpectomy, 13 with spondylectomy (piecemeal or total en bloc fashion), and all procedures were combined with stabilization. Back pain and performance status improved significantly after surgical treatment among the three groups. Revision surgery due to tumor progression at the index level or spinal metastasis at another level were four patients (19.0%) in the laminectomy group, six patients (25.0%) in the corpectomy group, and one patient (7.7%) in the spondylectomy group. A Charlson comorbidity index and the number of spinal metastasis negatively affected OS (hazard ratio [HR], 19.613 and 2.244). Postoperative chemotherapy, time to metastasis, spondylectomy, and corpectomy had favorable associations with OS (HR, 0.455, 0.487, 0.619, and 0.715, respectively).

CONCLUSION

Postoperative chemotherapy was the most critical factor in OS of patients with metastatic NSCLC to the spine. An extensive surgical procedure (corpectomy/spondylectomy) with stabilization also could be beneficial for limited patients with spinal metastasis of NSCLC.

Predictive values of inflammatory back pain, positive HLA B27 antigen and acute and chronic magnetic resonance changes in early diagnosis of Spondyloarthritis. A study of 133 patients

OBJECTIVES

To analyse the predictive values of inflammatory back pain (IBP), positive HLA B27 antigen, increased C-reactive protein (CRP), Spondyloarthritis (SpA) features, familial history (FH), magnetic resonance sacroiliac joints (MRI-SIJ) imaging and its weight in early SpA diagnosis.

METHODS

133 patients with back pain, aged <50, duration of the pain <2 years were included. Data such as IBP, HLA B27, increased CRP, SpA features, FH, SIJ´s radiography and MRI were collected for each patient. STIR sequences were classified as strongly positive bone morrow oedema (SPBME ≥2), clearly present and easily recognisable as positive according to the ASAS criterion, weakly positive (WPBME ≥2), suggestive, but not easily recognisable and, clearly negative none of those features. T1-weighted sequences were assessed as positive/negative for erosion, fat metaplasia, backfill and sclerosis, if ≥1, for each lesion was present. MRI images were read by three blinded readers.

RESULTS

The average age was 38.9 years. 47 (35.3%) patients received SpA diagnosis according to the clinical opinion. IBP was highly specific, 0.81 and sensitive, 0.83. HLA B27 was positive in a half of the SpA patients. SPBME ≥2 provided a great specificity, 0.94 and an acceptable sensitivity, 0.79. Erosion was significantly more frequent in SpA patients (72% vs 7%), specificity 0.93. The addition of erosion ≥1 to the WPBME ≥2 noticeably improved specificity, 0.98, although slightly decreased sensitivity, 0.64. Fat metaplasia and backfill were highly specific, but poorly sensitive. Factors forecasting positive diagnosis were IBP, followed by SpA features and increased CRP.

CONCLUSIONS

At the onset, IBP might be a good marker for selecting patients with suspicion of SpA. The addition of erosion to the ASAS criterion might be helpful for early diagnosis, especially in patients with doubtful STIR imaging where BME is present but it is hard to determinate whether the ASAS "highly suggestive" criterion is met.

Prevalence of benign osseous lesions of the spine and association with spinal pain in the general population in whole body MRI

Background

Benign osseous lesions of the spine are common but precise population prevalence estimates are lacking. Our study aimed to provide the first population-based prevalence estimates and examine association with back and neck pain.

Materials and methods

We used data from the population-based Study of Health in Pomerania (SHIP). Whole-body MRI examinations (1.5 Tesla: T1, T2, and TIRM weightings) were available from 3,259 participants. Readings of the spinal MRI images were conducted according to a standardized protocol by a single reader (JS). The intra-rater reliability was greater than Kappa values of 0.98. Pain measures included the seven-day prevalence of spine pain and neck pain, and average spine pain intensity due to spine pain during the past three months.

Results

We found 1,200 (36.8%) participants with at least one osseous lesion (2,080 lesions in total). Osseous lesions were less common in men than in women (35.5% vs 38.9%; P = .06). The prevalence of osseous lesions was highest at L2 in both sexes. The prevalence of osseous lesions increased with age. Up to eight osseous lesions were observed in a single subject. Hemangioma (28%), and lipoma (13%) occurred most often. Sclerosis (1.7%), aneurysmal bone cysts (0.7%), and blastoma (0.3%) were rare. Different osseous lesions occurred more often in combination with each other. The association with back or neck pain was mostly negligible.

Conclusion

Osseous lesions are common in the general population but of no clinical relevance for spinal pain. The prevalence of osseous lesions varied strongly across different regions of the spine and was also associated with age and gender. Our population-based data offer new insights and assist in judging the relevance of osseous lesions observed on MRIs of patients.

[Spinal metastases: early recognition and a multidisciplinary approach]

Early diagnosis of spinal metastases is essential. The neurological condition at the time of diagnosis determines functional outcome. Optimal treatment planning requires a multidisciplinary approach by the general practitioner, internist/oncologist/haematologist, radiotherapist, radiologist, neurologist and the spinal surgeon. Radiation therapy is the most common treatment for patients with spinal metastases. However, in specific cases, surgery or chemotherapy should be the primary treatment. We present three patients with spinal metastases: a 55-year-old woman with back pain and a history of breast cancer, a 71-year-old woman with instability of the spine requiring surgical stabilisation and a 68-year-old man with spinal localisation of multiple myeloma treated with systemic therapy. Their cases illustrate the early symptoms of spinal metastases, the role of spinal stability in treatment decisions and the role of systemic therapy in patients with spinal metastases or haematological tumours located in the spine. Recognising early symptoms and appropriate multidisciplinary treatment planning are essential in improving the functional outcome in patients with spinal metastases.

Characteristics of late-onset spondyloarthritis in Japan: A retrospective cohort study

Spondyloarthritis may be increasingly present in older patients as life expectancy increases. We investigated clinical differences between early-onset and late-onset spondyloarthritis in Japan.We retrospectively reviewed 114 patients consecutively diagnosed with spondyloarthritis. The clinical course of each patient was observed for ≥1 year. We defined early-onset and late-onset spondyloarthritis as <57 or ≥57 years at a median age of this study group, respectively. We compared clinical characteristics between these 2 groups.Disease duration was significantly shorter before diagnosis in the late-onset group (P < .01). Inflammatory back pain (IBP) was significantly more common in the early-onset group (P < .01), whereas dactylitis frequency was significantly higher in the late-onset group. Significantly more patients with early-onset spondyloarthritis were human leukocyte antigen (HLA) B27-positive (P < .01). Articular synovitis, particularly of the wrist, was significantly more common on power Doppler ultrasound (PDUS) in the late-onset group (P < .01). Tenosynovitis or peritendinitis, particularly in the finger and wrist flexors were also more frequent in the late-onset group (P < .001 and P < .05, respectively). Enthesitis of the finger collateral ligament and lateral collateral ligament were significantly more common in the late-onset group (both P < .05). Multiple logistic regression analysis revealed that, comparatively, IBP was significantly and independently much more likely to occur in the early-onset group.The patients with late-onset spondyloarthritis had a lower frequency of IBP and HLA B27 and a higher frequency of dactylitis and PDUS findings in peripheral involvement.

Natural Course of Myxopapillary Ependymoma: Unusual Case Report and Review of Literature

BACKGROUND

Spinal cord ependymomas are the most frequent primary intramedullary tumors of the cord in middle age (40-60 years of age). Myxopapillary ependymomas are low-incidence tumors and occur in the cauda equina and conus medullaris. They are typically described as fleshy, sausage-shaped, vascular lesions.

CASE DESCRIPTION

In this report, we present a 36-year-old woman who was seen in another hospital with complaints of back pain radiating into both legs 5 years ago. Magnetic resonance imaging (MRI) examinations revealed a lesion releated to the spinal cord. At that point, the patient refused the proposed surgical treatment. Five years later, the patient was referred to our clinic with advancement of the complaint to paraparesis. The new MRI showed an intradural mass at the level of T11 and S1. We performed a total intradural tumor resection. Histopathologic examination revealed a myxopapillary ependymoma.

CONCLUSIONS

Myxopapillary ependymomas grow slowly and are well defined by MRI. Advancements in radiologic technology and surgical equipment have allowed this tumor type to be treated successfully. Unfortunately, if untreated, these lesions have poor prognosis and result in clinical symptoms such as paraparesis. Surgical treatment of these lesions using total resection was performed total resection and was associated with an excellent postoperative outcome. We highlight the natural course of myxopapillary ependymomas.

BILATERAL ADRENOCORTICAL CARCINOMA: CASE REPORT AND REVIEW OF LITERATURE

Adrenocortical carcinoma is a very rare and aggressive endocrinological malignancy arising from the adrenal cortex. The estimated incidence is 1 per million people, with an estimated 5-year survival rate of 16-47%. It can be bilateral in roughly 2-10% of cases, but the data is scarce and there is no conclusive evidence whether the contralateral mass is an independent tumor or a metastasis from the other adrenal gland cancer. Radical surgical excision is the only curative treatment. Therefore, careful pre- and intraoperative surgical planning is critically important. Open adrenalectomy has historically been the gold standard approach for surgical treatment of adrenocortical carcinoma. Laparoscopic adrenalectomy has emerged as a minimally invasive alternative, but its oncological safety and effectiveness has long been under debate. Current evidence suggests that in experienced hands laparoscopic adrenalectomy is as safe and effective as its open counterpart in the treatment of localized adrenocortical carcinoma and the adrenal masses ≤10 cm. Urologists have been tempted to apply laparoscopy also to bilateral disease, although the need to reposition the patient and a longer operative time can be limitations. Given the rarity of adrenocortical carcinoma and the lack of quality evidence for the bilateral disease, we used the conventional narrative strategy to review the available literature. We also report a case of nonfunctioning bilateral adrenocortical carcinoma in a 65-year old man, who was operated on with simultaneous bilateral laparoscopic adrenalectomy for suspected localized (stage 2) disease, which proved to be bilateral locally advanced carcinoma (stage 3). Postoperatively, the disease rapidly progressed to the fatal outcome. The case once again highlights the importance of detailed operative planning and the need of imaging studies as close as possible to the date of planned surgery.

Intradural-Extramedullary Capillary Hemangioma with Acute Bleeding: Case Report and Literature Review

OBJECTIVES

Capillary hemangiomas are benign vascular tumors. They are commonly founded in the vertebral bodies but very seldom in the spinal cord. The most common symptom at onset is long-lasting axial pain without neurologic deficit. In rare cases, the onset may be acute with neurological deficit due to an intratumoral hemorrhage.

PATIENT AND METHODS

We report a case of a 58-year-old male with a history of 15 days upper back pain triggered by a mild traumatism that evolves acutely to paraplegia and urinary and fecal retention. An urgent MR showed an intradural lesion with signs of intratumoral haemorrhage.

RESULTS

Urgent surgical intervention was performed and the anatomopathological results were capillary hemangioma. The symptoms of the patient improved after the surgery.

CONCLUSIONS

Intradural capillary hemangioma with acute intratumoral hemorrhage is a rare pathology, but it must be kept in mind because early diagnosis and treatment are key to achieve a good outcome. As far as we know, this is the first case reported of an intradural-extramedular capillary hemangioma that presents sudden neurologic deficit due to intratumoral bleeding.

Carbonic anhydrase XII functions in health and disease

Human CAXII was initially identified as a cancer marker in different cancers and tumors. Expression of CAXII is regulated by hypoxia and estrogen receptors. CAXII expression has been also detected in several tissues, whereas in cancer and tumor tissues its expression is several fold higher. In brain tumors, an alternatively spliced form of CAXII is expressed. Higher expression of CAXII in breast cancer is indicative of lower grade disease. CAXII plays a key role in several physiological functions. Mutation in the CAXII gene causes cystic fibrosis-like syndrome and salt wasting disease. CAXII is also seen in nuclear pulposus cells of the vertebrae. Aging dependent stiffness or degeneration of backbone correlates with CAXII expression level. This finding suggests a possible implication of CAXII as a biomarker for chronic back pain and a pharmacological target for possible treatment of chronic back pain.

3D Morphometric Analysis of Normal Sacroiliac Joints: A New Classification of Surface Shape Variation and the Potential Implications in Pain Syndromes

BACKGROUND

Normal sacroiliac (SI) joints vary widely in shape, and it is unclear whether SI joint morphology plays a role in the development of pain. To answer this question, we used 3D-CT surface rendering to image healthy study participants and used the resulting images to develop a classification system for SI joint morphology. In a case-control study comparing health research participants to patients with SI pain, we assessed whether the classification of SI joint morphology was associated with pain.

OBJECTIVES

We aimed to define normal variation in area and shape of the synovialized SI joint. We also aimed to determine interactions between joint area and shape and SI pain in men and women.

STUDY DESIGN

A retrospective cohort study.

SETTING

University hospital tertiary care center.

METHODS

We conducted a retrospective case-control study. We acquired 3D-CT surface rendered images of the SI joint in 223 normal controls and 34 patients with SI pain syndrome. We measured the sacral and iliac surface areas and performed morphologic 3D assessment of both articular surfaces. We classified SI joints into 3 types based on morphology (types one, 2, and 3). We used descriptive statistics to provide a reference standard for normal SI joints. We used multivariate models to assess whether articular surface area differed between study participants with and without SI pain. We also assessed the association between morphology type and the presence of pain.

RESULTS

Sacral and iliac surface areas differ by participant gender. Sacral and iliac surface area was associated with SI joint pain in both men (P = 0.0007) and in women (P = 0.02). In women (P = 0.04), but not in men (P = 0.11), joint shape was associated with pain.

LIMITATIONS

A retrospective study may create potential for misclassification bias if SI joint symptoms/histories were present but not well-documented in the electronic medical record. A lack of clinical standardization in the pre-procedural assessment of SI joint pain via provocative maneuvers (FABER, etc.) is also a limitation.

CONCLUSIONS

Our study provides insight into the association between shape and joint surface area and SI joint pain. Further, prospective studies will allow us to determine the role of joint shape and surface area in the patho-etiology of SI joint pain, and thus provide information for patients and physicians about prevention or treatment.

KEY WORDS

Sacroiliac joint, spine pain, 3D reformation, SI joint area, SI joint shape, SI joint pain syndrome.

Surgical intervention for vertebral metastases may benefit lung cancer patients no less than other patients: a retrospective study

BACKGROUND

Spinal metastasis is considered to have a worse prognosis in lung cancer than in other cancers, but recent clinical studies report improved overall survival of lung cancer. We compared the postoperative prognoses of vertebral metastatic tumors from lung with other types of cancer.

METHODS

From 2011 to 2015, 31 Japanese patients (mean age 73 years, range 55-88 years; 19 males, 12 females) underwent surgery for spinal metastasis at our center. We observed patients retrospectively in March 2016, dividing them into groups by cancer type: lung (LK group, n = 10); prostate, breast, or thyroid (PB group, n = 12); and other (OT group, n = 9). We compared survival and revised Tokuhashi score, which provides a basis for choosing a treatment course. Neurologic status was graded before and after surgery using the Frankel system.

RESULTS

Mean follow-up was 16.5 months (range 1-62 months). Only seven of 31 patients (22.6%) were alive at final follow-up. Frankel grade significantly improved postoperatively only in the LK (P = 0.01) and PB (P = 0.048) groups. Revised Tokuhashi score differed across groups (P < 0.0001), and was significantly lower in the LK group than in the PB group (P = 0.00) and OT group (P = 0.02). Postoperative survival was significantly shorter in the LK group than in the PB group (P = 0.01) but did not differ between the LK and OT groups.

CONCLUSIONS

The revised Tokuhashi score may underestimate the survival of lung cancer patients, who may derive the same benefit from surgical intervention as those with vertebral metastasis from other cancer types.

[Not Available]

Dynamics of the posttraumatic spasticity syndrome, a key component of spinal trauma, was investigated on simulation model of the open penetrating spinal cord (SC) trauma on adult male rats of aWistarline after half transection of the SC cross'section with its durable compression by biocompatible foreign body. Squeezing of the injured SC by foreign body potentiates formation of spasticity syndrome, and do not influence or restricts a severe pain syndrome occurrence. Reduction of the SC squeezing due to the foreign body elongation and reduction of its volume was accompanied by trustwor' thy rising of functional activity and the spasticity reduction in paretic extremity. Changes in activity of efferent chain of the movement system while formation of spasticity syn' drome in simulated trauma have occurred in both parts of SC ' in the injured one and in intact one as well, its severity did not correlate with presence of foreign body in zone of trauma.

Occurrence of Donor Cell-derived Lymphoid Blast Crisis 24 Years Following Related Bone Marrow Transplantation for Chronic Myeloid Leukemia

We herein report a unique case of donor cell leukemia (DCL), as donor cell-derived lymphoid blast crisis of chronic myeloid leukemia (CML) was observed 24 years after related bone marrow transplantation for CML in the chronic phase. Short tandem repeat testing of the leukemic blast sample revealed full donor chimerism, strongly indicative of DCL. The original donor is healthy with a normal complete blood cell count for the past 24 years. This rare case may provide a precious opportunity to consider not only the underlying mechanism of DCL, but also the pathogenesis of CML.

CAPACITIVE COUPLING ELECTRIC FIELDS IN THE TREATMENT OF VERTEBRAL COMPRESSION FRACTURES

Positive effects of Capacitive Coupling Electric Field (CCEF) stimulation are described for several orthopedic indications such as the healing of recent fractures, non-unions and spinal fusion, due to the capacity to involve the up-regulation of osteopromotive factors. In vitro studies on MC3T3-E1 bone cells showed that CCEF acts opening the plasma membrane voltage gated calcium channels, thus increasing the cytosolic calcium concentration and the phospholipase A2 (PLA2) activity. Cytosolic calcium activates the calmodulin pathway, thus resulting in an up-regulated expression of osteogenic genes, such as transforming growth factor-β superfamily genes (TGF-β1, -β2 -β3, bone morphogenetic protein-2 and -4), fibroblast growth factor (FGF)-2, osteocalcin (BGP) and alkaline phosphatase (ALP). PLA2 acts increasing the synthesis of Prostaglandin E2 (PGE2), which promotes osteogenesis by raising the cellular L-ascorbic acid uptake through the membrane carrier sodium vitamin C transporter-2 (SVCT-2). In vivo, Brighton et al. in a castration-induced osteoporosis animal model, demonstrated that CCEF was able to restore bone mass/unit volume in the rat vertebral body. To investigate the role of CCEF stimulation in vertebral bone marrow edema (VBME) its percentage was assessed in 24 patients with 25 acute vertebral compression fractures (VCFs) conservatively treated with CCEF (group A) or without CCEF (group B) using serial MR imaging follow-up at 0, 30, 60, 90 days. Pain and quality of life were assessed by visual analog scale (VAS) and Oswestry Low Back Disability Index (ODI) in the same periods. At 90 day follow-up the complete resolution of VBME was found only in group A (p=0.0001). A significant improvement of VAS (p=0.007) and ODI (p=0.002) was also observed in group A. This preliminary observational study shows that patients treated with CCEF stimulation present an improvement of clinical symptoms with faster fracture healing and a complete VBME resolution.

Impact of osteopathic treatment on pain in adult patients with cystic fibrosis--a pilot randomized controlled study

Background

Pain is a common complication in patients with cystic fibrosis (CF) and is associated with shorter survival. We evaluated the impact of osteopathic manipulative treatment (OMT) on pain in adults with CF.

Methods

A pilot multicenter randomized controlled trial was conducted with three parallel arms: OMT (group A, 16 patients), sham OMT (sham treatment, group B, 8 patients) and no treatment (group C, 8 patients). Medical investigators and patients were double-blind to treatment for groups A and B, who received OMT or sham OMT monthly for 6 months. Pain was rated as a composite of its intensity and duration over the previous month. The evolution of chest/back pain after 6 months was compared between group A and groups B+C combined (control group). The evolution of cervical pain, headache and quality of life (QOL) were similarly evaluated.

Results

There was no statistically significant difference between the treatment and control groups in the decrease of chest/back pain (difference = −2.20 IC95% [−4.81; 0.42], p = 0.098); also, group A did not differ from group B. However, chest/back pain decreased more in groups A (p = 0.002) and B (p = 0.006) than in group C. Cervical pain, headache and QOL scores did not differ between the treatment and control groups.

Conclusion

This pilot study demonstrated the feasibility of evaluating the efficacy of OMT to treat the pain of patients with CF. The lack of difference between the group treated with OMT and the control group may be due to the small number of patients included in this trial, which also precludes any definitive conclusion about the greater decrease of pain in patients receiving OMT or sham OMT than in those with no intervention.

Trial Registration

ClinicalTrials.gov NCT01293019

A tool for classifying individuals with chronic back pain: using multivariate pattern analysis with functional magnetic resonance imaging data

Chronic pain is one of the most prevalent health problems in the world today, yet neurological markers, critical to diagnosis of chronic pain, are still largely unknown. The ability to objectively identify individuals with chronic pain using functional magnetic resonance imaging (fMRI) data is important for the advancement of diagnosis, treatment, and theoretical knowledge of brain processes associated with chronic pain. The purpose of our research is to investigate specific neurological markers that could be used to diagnose individuals experiencing chronic pain by using multivariate pattern analysis with fMRI data. We hypothesize that individuals with chronic pain have different patterns of brain activity in response to induced pain. This pattern can be used to classify the presence or absence of chronic pain. The fMRI experiment consisted of alternating 14 seconds of painful electric stimulation (applied to the lower back) with 14 seconds of rest. We analyzed contrast fMRI images in stimulation versus rest in pain-related brain regions to distinguish between the groups of participants: 1) chronic pain and 2) normal controls. We employed supervised machine learning techniques, specifically sparse logistic regression, to train a classifier based on these contrast images using a leave-one-out cross-validation procedure. We correctly classified 92.3% of the chronic pain group (N = 13) and 92.3% of the normal control group (N = 13) by recognizing multivariate patterns of activity in the somatosensory and inferior parietal cortex. This technique demonstrates that differences in the pattern of brain activity to induced pain can be used as a neurological marker to distinguish between individuals with and without chronic pain. Medical, legal and business professionals have recognized the importance of this research topic and of developing objective measures of chronic pain. This method of data analysis was very successful in correctly classifying each of the two groups.

Intervertebral discs from spinal nondeformity and deformity patients have different mechanical and matrix properties

BACKGROUND CONTEXT

It is well-established that disc mechanical properties degrade with degeneration. However, prior studies utilized cadaveric tissues from donors with undefined back pain history. Disc degeneration may present with pain at the affected motion segment, or it may be present in the absence of back pain. The mechanical properties and matrix quantity of discs removed and diagnosed for degeneration with patient chronic pain may be distinct from those with other diagnoses, such as spinal deformity.

PURPOSE

To test the hypothesis that discs from nondeformity segments have inferior mechanical properties than deformity discs owing to differences in matrix quality.

STUDY DESIGN/SETTING

In vitro study comparing the mechanical and matrix properties of discs from surgery patients with spinal nondeformity and deformity.

METHODS

We analyzed nucleus and annulus samples (8-11 specimens per group) from surgical discectomy patients as part of a fusion or disc replacement procedure. Tissues were divided into two cohorts: nondeformity and deformity. Dynamic indentation tests were used to determine energy dissipation, indentation modulus, and viscoelasticity. Tissue hydration at a physiologic pressure was assessed by equilibrium dialysis. Proteoglycan, collagen, and collagen cross-link content were quantified. Matrix structure was assessed by histology.

RESULTS

We observed that energy dissipation was significantly higher in the nondeformity nucleus than in the deformity nucleus. Equilibrium dialysis experiments showed that annulus swelling was significantly lower in the nondeformity group. Consistent with this, we observed that the nondeformity annulus had lower proteoglycan and higher collagen contents.

CONCLUSIONS

Our data suggest that discs from nondeformity discs have subtle differences in mechanical properties compared with deformity discs. These differences were partially explained by matrix biochemical composition for the annulus, but not for the nucleus. The results of this study suggest that compromised matrix quality and diminished mechanical properties are features that potentially accompany discs of patients undergoing segmental fusion or disc replacement for disc degeneration and chronic back pain. These features have previously been implicated in pain via instability or reduced motion segment stiffness.

The use of minimally invasive approaches to resect intradural extramedullary spinal cord tumors

AIM

To conduct a comparative analysis of outcomes in patients with extramedullary tumors operated on using a minimally invasive approach and traditional laminectomy.

MATERIAL AND METHODS

The study included 40 patients (13 males and 27 females) who underwent surgical treatment at the Department of Spinal Neurosurgery of the Burdenko Neurosurgical Institute. The mean age of patients was 47 years (range: 41-60 years). Tumors were located in the cervical, thoracic and lumbar spine. All patients were divided into two groups. In the control group, 20 patients underwent traditional laminectomy using a yard retractor or an Egorov-Freidin retractor. In the study group, 20 patients underwent hemilaminectomy using a retractor for minimally invasive surgery (Caspar and MAST Qudrant). The outcomes were evaluated 3, 6, and 12 months after surgery. The McCormik and VAS scales were used for the evaluation. MRI data were also evaluated.

RESULTS

Total tumor resection was reached in all cases. The mean surgery duration was 247 min (range: 180-320 min) for the first group and 105.25 min (range: 60-190 min) for the second one. The volume of blood loss was 297 mL (range: 100-600 mL) for the first group and 210 mL (50 to 400 mL) for the second group. The histological nature of the tumors was as follows: neurinoma, meningioma, and ependymomas of the cauda equina. The evaluation of the pain syndrome in the early postoperative period revealed that the pain syndrome intensity according to VAS was reduced in patients of the second group compared to that in patients of the first group. The evaluation using the McCormik scale revealed no obvious difference in the results between the study and control groups. MRI studies performed in the postoperative period showed no tumor recurrence.

CONCLUSION

Surgical treatment of patients with intradural extramedullary tumors can be safely and effectively performed using minimally invasive approaches. A potential reduction in surgery duration, intraoperative blood loss, the amount of anesthetic drugs and reduction in the pain syndrome in the early postoperative period allow us to conclude that, when performed by an experienced surgeon, the method of minimally invasive surgery may be an alternative to the traditional removal of an extramedullary tumor.

[Clinical significance of specific lumbocrural pain for the diagnosis of lumbar intervertebral disc herniation]

Lumbar intervertebral disc herniation clinical symptoms and signs are very complicated, lumbocrural pain is the most characteristic clinical symptoms,and show the site (range or area), intensity, nature, evolution, influence factors and adjoint symptoms and so on has certain characteristics and rules. Among them, the dermatomal pain, kinesthetic dysesthesia, dynamic changing pain and lesions segment vertebral side deep tenderness are the most impotent characteristics and rules of pain, therefore, can be regarded as the main basis of clinical diagnosis of the disease, and also the core content of this article.

Percutaneous vertebroplasty: Technique and results in 192 procedures

Percutaneous vertebroplasty with acrylic cement (usually polymethylmethacrylate) consists of injecting cement into vertebral bodies weakened by osseous lesions. The objective of this procedure is to obtain an analgesic effect by mechanical stabilization in destructive lesions of the spine. The three major indications are aggressive vertebral hemangiomas, severe or refractory pain related to osteoporotic vertebral fractures, and malignant vertebral tumors. Complications are infrequent, but occur essentially in patients with vertebral malignant tumors. We present our experience with 148 patients that underwent 192 percutaneous PMMA vertebroplasties for the treatment of painful osteoporotic compression fractures (76 patients, 105 vertebral levels), hemangiomas (31 patients, 43 vertebral levels) and neoplasms (31 patients, 43 vertebral levels). In a vast majority of appropriately selected cases and especially in osteoporotic cases, vertebroplasty constitutes a relatively simple procedure with a very high rate of success.

A universal pedicle screw and V-rod system for lumbar isthmic spondylolysis: a retrospective analysis of 21 cases

Objective

To investigate the surgical outcome of a universal pedicle screw-V rod system and isthmic bone grafting for isthmic spondylolysis.

Methods

Twenty-four patients with isthmic spondylolysis at L5 and grade 0–I spondylolisthesis (Meyerding classification) received isthmic bone graft and stabilization using the universal pedicle screw-V rod system. Back pain was evaluated using the visual analog scale (VAS) and time to bone healing, improvement in spondylolisthesis and intervertebral space height at L5/S1 and L4/L5 were assessed.

Results

Twenty-one patients were followed up for 24 months and included in the analysis. Back pain was markedly improved at 3 months postoperatively with a statistical difference in VAS scores compared with preoperative VAS scores (P<0.001). The VAS scores were 0 to 3 at 6 months postoperatively in all patients and no back pain was reported in all patients except 2 patients who complained of back pain after prolonged sitting. X-ray examination showed a bone graft healing time of 3 to 12 months. Grade I spondylolisthesis improved to grade 0 in 4 patients and no noticeable change was observed in the remaining 17 cases. The intervertebral space height at L5/S1 was statistically increased (P<0.05) while no statistically significant change was seen at L4/L5. There was no statistically significant difference in the ROM of the intervertebral disks of L5/S1 and L4/5 before and after surgery.

Conclusions

The universal pedicle screw-V rod system and isthmic bone grafting directly repairs isthmic spondylolysis and reduces back pain, prevents anterior displacement of the diseased segment and maintains intervertebral space height, thus offering a promising alternative to current approaches for isthmic spondylolysis.

[Imaging of inflammatory back pain]

We recommend magnetic resonance imaging of the sacroiliac joints as the first line imaging method in suspected inflammatory back disorder. Plain X-ray can be taken from those over 35 years of age. A nonconclusive finding in plain X-ray should be verified by MR imaging. For the present, diagnostic criteria for spondylarthritis do not take into account spinal changes. Typical spinal findings can, however, be helpful in making treatment decisions. In case the spinal region MR imaging should be utilized if possible, because radiography is particularly insensitive for thoracic spine. After a confirmed diagnosis, the inflammatory nature of the condition can usually be assessed clinically.

Infectious, inflammatory, and metabolic diseases affecting the athlete's spine

Sports and weight-bearing activities can have a positive effect on bone health in the growing, mature, or aging athlete. However, certain athletic activities and training regimens may place the athlete at increased risk for stress fractures in the spine. In addition, some athletes have an underlying susceptibility to fracture due to either systemic or focal abnormalities. It is important to identify and treat these athletes in order to prevent stress fractures and reduce the risk of osteoporosis in late adulthood. Therefore, the pre-participation physical examination offers a unique opportunity to screen athletes for metabolic bone disease through the history and physical examination. Positive findings warrant a thorough workup including a metabolic bone laboratory panel, and possibly a DEXA scan, which includes a lateral spine view.

The influence of preoperative MRI findings on lumbar fusion clinical outcomes

INTRODUCTION

Spinal fusion as a treatment for degenerative disc disease is controversial. Prior authors have identified various MRI findings as being pain generators, which might help guide patient selection for lumbar fusion procedures. These findings have included disc desiccation, disc contour, high-intensity zone annular disruption, the presence of Modic endplate changes, and disc space collapse. The purpose of this study is to investigate which MRI findings in patients with degenerative disc disease predict clinical improvement with lumbar fusion.

METHODS

A single-center surgical database of patients undergoing lumbar fusion was reviewed for patients whose indication for fusion surgery was primary disc pathology. We identified 51 patients (71 disc levels) who had completed 2-year prospectively collected outcomes questionnaires and had preoperative MRIs available for review. NRS (0-10) back and leg pain, Oswestry Disability Index (ODI) and SF-36 Physical Composite Summary scores were obtained preoperatively and at 1- and 2-year follow-up. MRIs were reviewed by three fellowship-trained spine surgeons who were asked to grade them for the following five characteristics: (a) disc desiccation, (b) disc contour, (c) presence of a high-intensity zone (HIZ) annular tear, (d) presence of Modic endplate changes and (e) disc height. Two-year outcome measures were compared to MRI findings to identify which findings correlated with improvement in outcome scores.

RESULTS

Statistically significant improvements were noted in back pain, leg pain, SF-36 PCS and ODI in the group overall. Disc desiccation, disc contour, presence of an HIZ lesion, and the presence of Modic endplate changes did not correlate with 2-year outcomes. Disc height was correlated with 2-year change in outcome measures. Discs with preoperative height less than 5 mm demonstrated a 23.4 point ODI improvement compared to 9.2 points for discs >7 mm. Similarly, SF-36 PCS improved 9.5 points in discs <5 mm compared to 0.7 in discs greater than 7 mm. Discs between 5 and 7 mm demonstrated intermediate levels of improvement.

CONCLUSIONS

Several commonly utilized MRI criteria proposed as indications for lumbar fusion do not seem to correlate with 2-year improvement in clinical outcomes. Discs which are narrowed and collapsed, preoperatively, demonstrate better improvement at 2 years postoperatively as compared to discs which have maintained disc height. Significant disc space collapse may represent a subset of "degenerative disc disease" which responds more favorably to treatment with fusion.

Low frequency of axial involvement in southern Italian Caucasian children with HLA-B27 positive juvenile onset undifferentiated spondyloarthritis

OBJECTIVES

To establish how many children with HLA B27-positive juvenile undifferentiated spondyloarthritis (JuSpA) living in southern Italy develop axial disease after 5 years of disease.

METHODS

All children with B27-positive enthesitis-related arthritis (ERA) consecutively seen in a 7-year period were entered in a special register and were followed prospectively. Each patient was examined at 6-month intervals, even if asymptomatic. In patients with inflammatory spinal pain and/or buttock pain, MRI of the sacroiliac joints and spine was performed. Five years after inclusion, sacroiliac joint plain radiographs were obtained and read blindly after being mixed with those of control subjects.

RESULTS

Thirteen children, 9 boys and 4 girls, with B27-positive ERA and one girl with B27-positive isolated SpA dactylitis were seen in the study period. Their median age at disease onset and at our first examination were 10 (range 2-16) and 12 years (range 3-16), respectively. During follow-up, only one patient had axial symptoms, i.e. alternate buttock pain. MRI revealed moderate bone oedema at both sacroiliac joints. After five years of disease, no patient showed reduced spinal movement. No sign of sacroiliitis was seen in any patient and control on plain films. A new MRI of the sacroiliac joints of the patient who showed bone oedema in the first years of disease was normal.

CONCLUSIONS

This study confirms that the onset of axial involvement in Italian Caucasian HLA-B27 positive children with ERA is rare in the first five years of disease.

[Dorsopathy in the elderly: pathobiology and multimodality therapy in clinical practice]

The lecture considers the most common causes of dorsopathy in elderly patients, by taking into account pathobiology, age markers, and aging processes. It discusses the general issues in the management of elderly patients, including advice on exercise and treatment; particular emphasis is placed on vitamin B group-containing xefocam and neurobion.

Brain morphological signatures for chronic pain

Chronic pain can be understood not only as an altered functional state, but also as a consequence of neuronal plasticity. Here we use in vivo structural MRI to compare global, local, and architectural changes in gray matter properties in patients suffering from chronic back pain (CBP), complex regional pain syndrome (CRPS) and knee osteoarthritis (OA), relative to healthy controls. We find that different chronic pain types exhibit unique anatomical ‘brain signatures’. Only the CBP group showed altered whole-brain gray matter volume, while regional gray matter density was distinct for each group. Voxel-wise comparison of gray matter density showed that the impact on the extent of chronicity of pain was localized to a common set of regions across all conditions. When gray matter density was examined for large regions approximating Brodmann areas, it exhibited unique large-scale distributed networks for each group. We derived a barcode, summarized by a single index of within-subject co-variation of gray matter density, which enabled classification of individual brains to their conditions with high accuracy. This index also enabled calculating time constants and asymptotic amplitudes for an exponential increase in brain re-organization with pain chronicity, and showed that brain reorganization with pain chronicity was 6 times slower and twice as large in CBP in comparison to CRPS. The results show an exuberance of brain anatomical reorganization peculiar to each condition and as such reflecting the unique maladaptive physiology of different types of chronic pain.

[Analgesic effects of cannabinoids on central pain syndrome]

It was shown that cannabinoids anandamide, HU210 and WIN 55,212-2 inhibit both spontaneous episodes of pain and mechanical allodynia in rats with central pain syndrome caused by disturbance of inhibitory processes in the dorsal horns of lumbar spinal cord. The analgesic effect is most pronounced in the intrathecal route of administration. The intensity of analgesic actions of cannabinoids on the central pain syndrome in rats, depending on the drug is as follows: HU210 > WIN 55,212-2 > anandamide.

Guidance of magnetic resonance imaging and placement of skin-marker localization devices

AIM

A variety of magnetic resonance imaging (MRI)-compatible skin-marker localization devices are available on the market. MRI protocols call for the liberal use of the skin markers over the specific site of symptoms or over any palpable mass. This study investigates the usefulness of patient-assisted placement of 1 000-mg fish oil capsules as skin markers over the area of maximum localized pain, signs, or symptoms and correlates this placement with any potential underlying neuropathology or potential pain generator.

METHODS

One-hundred symptomatic patients undergoing MRI were assessed for focal or localized signs or symptoms. Under the direction of a physician and with guidance from the patient, the MRI technician placed a 1 000-mg fish-oil capsule over the area of maximum pain or signs and symptoms. Patients with poorly localized, diffuse symptoms or an area of maximal signs and symptoms outside the field of view of the MRI were not included in this study. All MRI exams were reviewed by clinical physicians and radiologists or neuroimaging physicians.

RESULTS

In all 100 cases, the images show clearly visible MRI-compatible skin-surface markers that correlate with potential underlying neuropathology.

CONCLUSION

Our results show that 1 000-mg fish-oil capsules can be used as MRI localization devices as a cost-effective alternative to more expensive commercially available devices.

Prevalence and profile of back pain in Nigerian adolescents

OBJECTIVE

This study aimed to investigate prevalence, characteristics, perceived predisposing factors and mode of treatment sought for back pain among school-aged adolescents in Nigeria.

SUBJECTS AND METHODS

A self-administered questionnaire employed in this cross-sectional study was distributed to 4,400 students [mean age 15.0 ± 1.7 years (range 10-19)] from 44 randomly selected schools.

RESULTS

Of the 4,400 questionnaires, 3,185 were completed (1,455 boys and 1,730 girls), thereby yielding a response rate of 72.4%. The lifetime and point prevalence of back pain were 59 and 17%, respectively. Low back pain was the most prevalent type, reported by 25%. The prevalence of back pain was 59.7% among boys and 57.5% among girls. Back pain was significantly associated with age, religion and involvement in commercial activity (p < 0.05). Among those with back pain, most cases were mild (56%), but chronic in 21%, and 27% used self-medication. Prolonged sitting posture (17%) was the most implicated predisposing factor to back pain.

CONCLUSION

Back pain is common among Nigerian adolescent students, but it is mostly mild. The prevalence of back pain increased with advancing age in both genders. More research is needed to find necessary risk factors and interventions including appropriate back education to reduce back pain.

A planning study for palliative spine treatment using StatRT and megavoltage CT simulation

Megavoltage CT (MVCT) simulation on the TomoTherapy Hi·Art system is an alternative to conventional CT for treatment planning in the presence of severe metal artifact. StatRT is a new feature that was implemented on the TomoTherapy operator station for performing online MVCT scanning, treatment planning and treatment delivery in one session. The clinical feasibility of using the StatRT technique and MVCT simulation to palliative treatment for a patient with substantial spinal metallic hardware is described. A patient with metastatic non-small-cell lung cancer involving the thoracic spine underwent conventional kilovoltage CT simulation. The metal artifact due to stainless steel spine-stabilizing rods was too severe for treatment planning, despite attempts to correct using density override. The patient was then re-scanned using MVCT on a tomotherapy unit. Plans were generated using both StatRT and conventional tomotherapy planning (Tomo plan) with different settings for comparison. StatRT planning ran a total of five iterations in a short planning window (10-15 min). Two Tomo plans were generated using: (1) five iterations in the "full scatter" mode, and (2) 300 iterations in the "beamlet" mode. It was noted that the DVH of the StatRT plan was almost identical to the Tomo plan optimized by the "full scatter" mode and the same number of iterations. Dose distribution analysis reveals that these three planning methods yielded comparable doses to heart, lungs and targets. This work also demonstrated that undermodulation can result in a high degree of thread effects. The overall time for the treatment process (including 7 minutes for simulation, 15 minutes for contouring, 10 minutes for planning and 5 minutes for delivery) decreases from hours to around 40 minutes using the StatRT procedure. StatRT is a feasible treatment-planning tool for physicians to scan, contour and treat patients within one hour. This can be particularly beneficial in urgent palliative treatments.

Percutaneous therapy for symptomatic synovial cysts

Synovial cysts have long been known to create radicular pain in the spine, with the clinical effect mimicking a disk herniation. These cysts have traditionally been treated with open surgical therapy. Now a minimally invasive, image-guided approach to treatment is available to relieve this problem, using a simple percutaneous needle stick and injection. This article describes the technical aspects and precautions needed for this intervention.

Spinal cord compression complicating aseptic spondylodiscitis in ankylosing spondylitis

Aseptic spondylodiscitis is a well recognized complication of ankylosing spondylitis. Neurological complications of such discovertebral lesions are uncommon. We report a new case with a diagnosis of T12-L1 spondylodiscitis which developed ten years after a spinal cord compression. Such neurological complications of aseptic spondylodiscitis may be explained by proliferative epidural tissue without predominant inflammatory infiltrates and also the development of new bone reaction, suggesting the contribution of mechanical factors.

Primary spinal hydatid disease

Primary spinal hydatid disease is rare. Spinal hydatid disease should be considered in the differential diagnosis of spinal cord compression syndrome in endemic countries and evaluated with imaging and serology. Our case was a 34- year-old man. The patient presented with progressive back pain for 8 months and lower extremity weakness for 3 months. Neurological examination was suggestive of upper motor neuron type of paraperesis. Magnetic resonance images of the thoracal region showed an intradural multicystic lesion. The mass was explored with T 10-11 laminectomy. It had displaced the cord to the right side. The fluid was clear and did not contain pus. The lesion was easily dissected from the cord and was resected totally. The pathological diagnosis was hydatid disease.

Acute pyogenic diskitis (spondylodiskitis) in adults

Most cases of back pain are the result of degenerative changes in the spine or are related to musculoskeletal elements. Pyogenic infections of the back can be subcategorized into cases involving the paraspinal epidural space, vertebral bodies, or the intervertebral disk spaces. Any region of the spine may be the site of diskitis, although the process most commonly involves the lumbar spine. Most cases of diskitis are managed with conservative therapy, including antibiotics and spinal immobilization using braces or corsets. Surgical therapy is generally reserved for patients with neurological complications, spinal instability, or progressive spinal deformity or those who fail to respond clinically to antibiotic therapy alone.

Appropriate selection of patients with lumbar spinal stenosis for interspinous process decompression with the X STOP device

With the aging of the population, the number of patients suffering from progressive lumbar spinal stenosis with symptomatic neurogenic intermittent claudication is projected to increase. Unfortunately, these patients are limited to a choice between nonsurgical conservative care and more invasive decompressive surgical procedures such as laminectomy with or without fusion. The X STOP interspinous process decompression system is a commercially available device that provides a minimally invasive alternative treatment, an intermediate option within the continuum of care for these patients. The X STOP is appropriate for patients with moderately severe functional impairment whose symptoms are exacerbated in extension and relieved in flexion. Implanted between the spinous processes without disrupting the normal anatomical structures, the X STOP limits narrowing of the spinal canal and neural foramina by reducing extension at the symptomatic level(s). In this report the author details the approved indications for use of the X STOP and discusses several illustrative cases.

Traumatic L4-L5 spondylolisthesis: case report

We report a case of L4-L5 traumatic anterolisthesis. The patient was treated surgically 4 months after the injury. His radiological and operative findings showed L4 inferior facet tip fracture, L4-L5 anterior displacement and left L4-L5 foraminal disc protrusion. Decompression, reduction with L3, L4, L5 pedicular screw fixation, L4-L5 disc excision and interbody cage insertion with autologous bone grafts were done. Flexion type injury was thought to be the probable mechanism.