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Minimally Invasive Percutaneous Treatment of Lumbar Disk Degeneration and Stenosis
Abstract
This chapter presents a comprehensive review of disk degeneration and lumbar stenosis disease, diagnosis, and percutaneous image-guided decompressive spinal techniques.
... This process creates energy quanta that break the molecular bonds without increasing the kinetic energy of the molecules and, therefore, not raising the temperature. Electrosurgical devices that use QMR allow surgeons to maintain the biological structure of the tissue as the functionality is provided at a temperature below 50 • C. QMR can be used for percutaneous disc decompression as it causes the hernia or protrusion to retract to its natural position, reducing compression and inflammation of the adjacent nerve roots [13][14][15]. However, contrary to other techniques used for percutaneous disc decompression, such as laser or radiofrequency, evidence on the effectiveness of QMR is scarce and requires further research. ...
Within the practice of pain management, one of the most commonly encountered events is low back pain. Lumbar radiculopathy (LR) is a pain syndrome caused by the compression or irritation of the nerve roots in the lower back due to lumbar disc herniation, vertebra degeneration, or foramen narrowing. Symptoms of LR include low back pain that propagates toward the legs, numbness, weakness, and loss of reflexes. The aim of this study is to assess the long-term effectiveness of quantum molecular resonance disc decompression and its combination with a percutaneous microdiscectomy using Grasper© forceps (QMRG) in patients with persistent lumbar radiculopathy (LR) in relation to patient physical stress status. The main outcome measures of this prospective observational study were DN4, NRS, ODI, SF12, PGI, CGI, and MOS Sleep Scale. An improvement 12 months post-intervention was observed in patients without physical stress, presenting better overall results. The mean change was over the minimal clinically important difference in 64.3% of outcome measures studied for the whole sample. QMRG appears to be an effective treatment option for LR, but a reduction in physical stress is needed to ensure long-term effectiveness.
Degeneration of the intervertebral disc (IVD) is a normal part of aging. Due to the spine's declining function and the development of pain, it may affect one's physical health, mental health, and socioeconomic status. Most of the intervertebral disc degeneration (IVDD) therapies today focus on the symptoms of low back pain rather than the underlying etiology or mechanical function of the disc. The deteriorated disc is typically not restored by conservative or surgical therapies that largely focus on correcting symptoms and structural abnormalities. To enhance the clinical outcome and the quality of life of a patient, several therapeutic modalities have been created. In this review, we discuss genetic and environmental causes of IVDD and describe promising modern endogenous and exogenous therapeutic approaches including their applicability and relevance to the degeneration process.
A comprehensive description of the literature regarding interspinous process devices (IPD) mainly focused on comparison with conservative treatment and surgical decompression for the treatment of degenerative lumbar spinal stenosis. Recent meta-analysis and articles are listed in the present article in order to establish IPD pros and cons.
Corticosteroids have played a standard role in the multimodal pain management in the treatment of chronic spinal pain (cervical and lumbar) and osteoarthritis pain over the past three decades. In this review we discuss different types of injectable steroids that are mainly used for injection into the epidural space (for the treatment of radicular back and neck pain), and as intra-articular injections for different types of osteoarthritis related pain conditions. Furthermore, we discuss different approaches taken for epidural corticosteroid injections and spinal surgical rates when injections fail to resolve painful conditions, as well as the possibility of using local anesthetics alone for neuraxial injections, instead of in combination with corticosteroids. While we present some beneficial effects of newly available treatment options for low back pain and osteoarthritis pain, such as use of PRP and hyaluronic acid, corticosteroids remain important considerations in the management of these chronic pain conditions.
Study Design
Meta-analysis-based calculation.
Objectives
Lumbar degenerative spine disease (DSD) is a common cause of disability, yet a reliable measure of its global burden does not exist. We sought to quantify the incidence of lumbar DSD to determine the overall worldwide burden of symptomatic lumbar DSD across World Health Organization regions and World Bank income groups.
Methods
We used a meta-analysis to create a single proportion of cases of DSD in patients with low back pain (LBP). Using this information in conjunction with LBP incidence rates, we calculated the global incidence of individuals who have DSD and LBP (ie, their DSD has neurosurgical relevance) based on the Global Burden of Disease 2015 database.
Results
We found that 266 million individuals (3.63%) worldwide have DSD and LBP each year; the highest and lowest estimated incidences were found in Europe (5.7%) and Africa (2.4%), respectively. Based on population sizes, low- and middle-income countries have 4 times as many cases as high-income countries. Thirty-nine million individuals (0.53%) worldwide were found to have spondylolisthesis, 403 million (5.5%) individuals worldwide with symptomatic disc degeneration, and 103 million (1.41%) individuals worldwide with spinal stenosis annually.
Conclusions
A total of 266 million individuals (3.63%) worldwide were found to have DSD and LBP annually. Significantly, data quality is higher in high-income countries, making overall quantification in low- and middle-income countries less complete. A global effort to address degenerative conditions of the lumbar spine in regions with high demand is important to reduce disability.
Background
Lumbar spinal stenosis is the most common indication for spine surgery in older adults. Interspinous process decompression (IPD) using a stand-alone spacer that functions as an extension blocker offers a minimally invasive treatment option for intermittent neurogenic claudication associated with spinal stenosis.
Methods
This study evaluated the 5-year clinical outcomes for IPD (Superion®) from a randomized controlled US Food and Drug Administration (FDA) noninferiority trial. Outcomes included Zurich Claudication Questionnaire (ZCQ) symptom severity (ss), physical function (pf), and patient satisfaction (ps) subdomains, leg and back pain visual analog scale (VAS), and Oswestry Disability Index (ODI).
Results
At 5 years, 84% of patients (74 of 88) demonstrated clinical success on at least two of three ZCQ domains. Individual ZCQ domain success rates were 75% (66 of 88), 81% (71 of 88), and 90% (79 of 88) for ZCQss, ZCQpf, and ZCQps, respectively. Leg and back pain success rates were 80% (68 of 85) and 65% (55 of 85), respectively, and the success rate for ODI was 65% (57 of 88). Percentage improvements over baseline were 42%, 39%, 75%, 66%, and 58% for ZCQss, ZCQpf, leg and back pain VAS, and ODI, respectively (all P<0.001). Within-group effect sizes were classified as very large for four of five clinical outcomes (ie, >1.0; all P<0.0001). Seventy-five percent of IPD patients were free from reoperation, revision, or supplemental fixation at their index level at 5 years.
Conclusion
After 5 years of follow-up, IPD with a stand-alone spacer provides sustained clinical benefit.
Study Design
Preliminary clinical trial.
Purpose
To determine the safety and initial efficacy of intradiscal injection of autologous platelet-rich plasma (PRP) releasate in patients with discogenic low back pain.
Overview of Literature
PRP, which is comprised of autologous growth factors and cytokines, has been widely used in the clinical setting for tissue regeneration and repair. PRP has been shown in vitro and in vivo to potentially stimulate intervertebral disc matrix metabolism.
Methods
Inclusion criteria for this study included chronic low back pain without leg pain for more than 3 months; one or more lumbar discs (L3/L4 to L5/S1) with evidence of degeneration, as indicated via magnetic resonance imaging (MRI); and at least one symptomatic disc, confirmed using standardized provocative discography. PRP releasate, isolated from clotted PRP, was injected into the center of the nucleus pulposus. Outcome measures included the use of a visual analog scale (VAS) and the Roland-Morris Disability Questionnaire (RDQ), as well as X-ray and MRI (T2-quantification).
Results
Data were analyzed from 14 patients (8 men and 6 women; mean age, 33.8 years). The average follow-up period was 10 months. Following treatment, no patient experienced adverse events or significant narrowing of disc height. The mean pain scores before treatment (VAS, 7.5±1.3; RDQ, 12.6±4.1) were significantly decreased at one month, and this was generally sustained throughout the observation period (6 months after treatment: VAS, 3.2±2.4, RDQ; 3.6±4.5 and 12 months: VAS, 2.9±2.8; RDQ, 2.8±3.9; p<0.01, respectively). The mean T2 values did not significantly change after treatment.
Conclusions
We demonstrated that intradiscal injection of autologous PRP releasate in patients with low back pain was safe, with no adverse events observed during follow-up. Future randomized controlled clinical studies should be performed to systematically evaluate the effects of this therapy.
Purpose of review:
Interspinous process devices (IPDs) are used in the surgical treatment of lumbar spinal stenosis. The purpose of this review is to compare the first generation with the next-generation devices in terms of complications, device failure, reoperation rates, symptom relief, and outcome.
Recent findings:
Thirty-seven studies were included from 2011 to 2016. Device failure occurred at a mean of 3.7%, with a lower tendency to happen with next-generation IPDs. Reoperations occurred at a lower rate with the next-generation devices, with a mean follow up of 24 months (3.7% vs. 11.1%). The clinical outcome is not influenced by the type of IPD. The long-term functionality of these devices is questionable, with radiologic changes and recurrence of symptoms often seen by 2 years following implantation. Next-generation devices do not appear to be subject to the same "bounce back" effect of symptom re-emergence after several years.
Purpose of review:
Lumbar spinal stenosis has historically been treated with open decompressive surgery which is associated with significant morbidity and may give rise to various complications. Interspinous spacers (ISS) have been developed as a less invasive strategy which may serve to avoid many of these risks. The two current spacers that are FDA approved and commercially available are the Coflex and Superion devices. The goal is to review these two implants, their indications, and patient selection.
Recent findings:
The Coflex device has been shown to be analogous to decompression and fusion when treating moderate spinal stenosis. It provides dynamic stability after a decompression is performed, without the rigidity of pedicle-screw instrumentation. Recent results show improved outcomes in Coflex patients at 3 years of follow-up, as compared to decompression and fusion. The Superion implant is placed percutaneously in the interspinous space with minimal disruption of spinal anatomy. When compared to the X-Stop device (which is no longer available), the Superion implant shows improved outcomes at 3 years of follow-up. ISS are lesser invasive options as compared to formal decompression and fusion for the treatment of lumbar spinal stenosis.
Low back pain is the main cause of disability and is associated with intervertebral disc degeneration. Contemporary treatments are limited to palliative therapeutics or aggressive surgical interventions; however, current advancements in cell therapy offer to fill this breach. Clinical data suggest that cell transplantation can accomplish pain relief without any observed adverse effects. Despite a large variety of preclinical studies and preliminary clinical investigations, controversy remains on the optimal cell type and transplantation strategies. The translational potential of this article lies in the aim to update on the current state of intervertebral disc cell therapy and to identify current obstacles.
Biologic-based treatment strategies for musculoskeletal diseases have gained traction over the past 20 years as alternatives to invasive, costly, and complicated surgical interventions. Spinal degenerative disc disease (DDD) is among the anatomic areas being investigated among this group, notably due to its high incidence and functional debilitation. In this review, we report the literature encompassing the use of biologic-based therapies for DDD. Articles published between January 1995 and November 2015 were reviewed, with a subset meeting the primary and secondary inclusion criteria of clinical trial results that could be sub-classified into bimolecular, cell-based, or gene therapies, as well as studies investigating the utility of allogeneic and tissue-engineered intervertebral discs. Ongoing clinical trials that have not yet published results are also mentioned to present the current state of the field. This exciting area has demonstrated positive and encouraging results across multiple strategies; thus, future bimolecular and regenerative techniques and understanding will likely lead to an increase in the number of human clinical trials assessing these therapies.
Background:
Lumbar spinal stenosis (LSS) is a common degenerative condition of the spine, which is a major cause of pain and functional disability for the elderly. Neurogenic claudication symptoms are a hallmark of LSS, where patients develop low back or leg pain when walking or standing that is relieved by sitting or lumbar flexion. The treatment of LSS generally begins with conservative management such as physical therapy, home exercise programs, and oral analgesics. Once these therapies fail, patients commonly move forward with interventional pain treatment options such as epidural steroid injections (ESIs) or MILD® as the next step.
Objective:
To assess improvement of function and reduction in pain for Medicare beneficiaries following treatment with MILD (treatment group) in LSS patients with neurogenic claudication and verified ligamentum flavum hypertrophy and to compare to a control group receiving ESIs.
Study design:
Prospective, multi-center, randomized controlled clinical trial.
Setting:
Twenty-six US interventional pain management centers.
Methods:
Patients in this trial were randomized one to one into 2 study arms. A total of 302 patients were enrolled, with 149 randomized to MILD and 153 to the active control. Outcomes are assessed using the Oswestry Disability Index (ODI), Numeric Pain Rating Scale (NPRS) and Zurich Claudication Questionnaire (ZCQ). Primary efficacy is the proportion of ODI responders, tested for statistical superiority of the MILD group versus the ESI group. ODI responders are defined as patients achieving the validated Minimal Important Change (MIC) of = 10 point improvement in ODI from baseline to follow-up. Similarly, secondary efficacy is the proportion of NPRS and ZCQ responders using validated MIC thresholds. Primary safety is the incidence of device- or procedure-related adverse events in each group. This report presents safety and efficacy results at 1-year follow-up. Outcomes at 2 years will be collected and reported for patients in the MILD group only.
Results:
At 1-year follow-up, ODI, NPRS, and all 3 ZCQ domains (Symptom Severity, Physical Function and Patient Satisfaction) demonstrated statistically significant superiority of MILD versus the active control. For primary efficacy, the 58.0% ODI responder rate in the MILD group was higher than the 27.1% responder rate in the epidural steroid group (P < 0.001). The primary safety endpoint was achieved, demonstrating that there is no difference in safety between MILD and ESIs (P = 1.00).
Limitations:
There was a lack of patient blinding due to considerable differences in treatment protocols, and a potentially higher non-responder rate for both groups versus standard-of-care due to adjunctive pain therapy study restrictions. Study enrollment was not limited to patients that had never received ESI therapy.
Conclusions:
One-year results of this randomized controlled clinical trial demonstrate that MILD is statistically superior to ESIs in the treatment of LSS patients with neurogenic claudication and verified central stenosis due to ligamentum flavum hypertrophy. Primary and secondary efficacy outcome measures achieved statistical superiority in the MILD group compared to the control group. With 95% of patients in this study presenting with 5 or more LSS co-factors, it is important to note that patients with spinal co-morbidities also experienced statistically significant improved function that was durable through 1 year.
Key words:
MILD, minimally invasive lumbar decompression, interlaminar epidural steroid injections, ESI neurogenic claudication, ligamentum flavum, ENCORE, PILD, CED Study, LSS.
Background:
In a previous prospective study on pulsed radiofrequency (PRF) treatment adjacent to the lumbar dorsal root ganglion (DRG) for patients with chronic lumbosacral radicular pain, we reported success in 55.4% of the patients at 6 months. Identification of predictors for success after PRF may improve outcome. We assessed the predictors of PRF in patients with chronic intractable lumbosacral radicular pain.
Methods:
Patients with monosegmental chronic lumbosacral radicular pain of L5 or S1 first received a selective nerve root block at the corresponding level. Independent of the result of this block a PRF treatment at the same level was performed. At 6 weeks, 3 months, and 6 months after the procedure the outcome was evaluated.
Results:
A positive diagnostic nerve root block and age ≥ 55 were predictive factors for successful outcome at 6 months, while disability was a negative predictor.The use of failed back surgery syndrome, gender, duration of pain, Numerical Rating Scale, level and side of treatment, DN4, and RAND-36 as predictors for success was not supported.
Conclusions:
Successful outcome after PRF adjacent to the DRG, in patients with intractable chronic lumbosacral radicular pain, is more likely in patients ≥ 55 years, with limited disability and after a positive diagnostic nerve root block. A combination of all these factors creates a fair predictive value (AUC: 0.73).
Degeneration of the intervertebral disc results in initial relative instability, hypermobility, and hypertrophy of the facet joints, particularly at the superior articular process. This finally leads to a reduction of the spinal canal dimensions and compression of the neural elements, which can result in neurogenic intermittent claudication caused by venous congestion and arterial hypertension around nerve roots. Most patients with symptomatic lumbar stenosis had neurogenic intermittent claudication with the risk of a fall. However, although the physical findings and clinical symptoms in lumbar stenosis are not acute, the radiographic findings are comparatively severe. Magnetic resonance imaging is a noninvasive and good method for evaluation of lumbar stenosis. Though there are very few studies pertaining to the natural progression of lumbar spinal stenosis, symptoms of spinal stenosis usually respond favorably to non-operative management. In patients who fail to respond to non-operative management, surgical treatments such as decompression or decompression with spinal fusion are required. Restoration of a normal pelvic tilt after lumbar fusion correlates to a good clinical outcome.
Background:
This study evaluated the efficacy of percutaneous nucleoplasty using coblation technique for the treatment of chronic nonspecific low back pain (LBP), after 5 years of follow-up.
Methods:
From September 2004 to November 2006, 172 patients underwent percutaneous nucleoplasty for chronic LBP in our department. Forty-one of these patients were followed up for a mean period of 67 months. Nucleoplasty was performed at L3/4 in 1 patient; L4/5 in 25 patients; L5/S1 in 2 patients; L3/4 and L4/5 in 2 patients; L4/5 and L5/S1 in 7 patients; and L3/4, L4/5, and L5/S1 in 4 patients. Patients were assessed preoperatively and at 1 week, 1 year, 3 years, and 5 years postoperatively. Pain was graded using a 10-cm Visual Analogue Scale (VAS) and the percentage reduction in pain score was calculated at each postoperative time point. The Oswestry Disability Index (ODI) was used to assess disability-related to lumbar spine degeneration, and patient satisfaction was assessed using the modified MacNab criteria.
Results:
There were significant differences among the preoperative, 1-week postoperative, and 3-year postoperative VAS and ODI scores, but not between the 3- and 5-year postoperative scores. There were no significant differences in age, sex, or preoperative symptoms between patients with effective and ineffective treatment, but there were significant differences in the number of levels treated, Pfirrmann grade of intervertebral disc degeneration, and provocative discography findings between these two groups. Excellent or good patient satisfaction was achieved in 87.9% of patients after 1 week, 72.4% after 1 year, 67.7% after 3 years, and 63.4% at the last follow-up.
Conclusions:
Although previously published short- and medium-term outcomes after percutaneous nucleoplasty appeared to be satisfactory, our long-term follow-up results show a significant decline in patient satisfaction over time. Percutaneous nucleoplasty is a safe and simple technique, with therapeutic effectiveness for the treatment of chronic LBP in selected patients. The technique is minimally invasive and can be used as part of a stepwise treatment plan for chronic LBP.
To determine if single injections of autologous PRP into symptomatic degenerative intervertebral discs (IVDs) will improve participant-reported pain and function.
Prospective, double-blind, randomized controlled study.
Outpatient Physiatric spine practice.
Adults with chronic (≥ 6 months) moderate to severe lumbar discogenic pain, unresponsive to conservative treatment.
Participants were randomized to receive intradiscal PRP or contrast agent following provocative discography. Data on pain, physical function, and participant satisfaction were collected at 1 week, 4 weeks, 8 weeks, 6 months, and 1 year. Participants in the control group who did not improve at eight weeks were offered the option to receive PRP and subsequently followed.
Functional Rating Index (FRI), Numeric Rating Scale (NRS) for pain, the pain and physical function domains of the 36-item Short Form Health Survey (SF-36), and the modified North American Spine Society (NASS) Outcome Questionnaire were used.
Forty-seven participants (29 in the treatment group, 18 in the control group) were analyzed by an independent observer with a 92% follow up rate. Over eight weeks of follow-up, there were statistically significant improvements in participants who received intradiscal PRP with regards to pain (NRS Best Pain) (p=.02), function (FRI) (p=.03), and patient satisfaction (NASS Outcome Questionnaire) (p=.01) when compared to controls. No adverse events of disc space infection, neurologic injury, or progressive herniation were reported following the injection of PRP.
Participants who received intradiscal PRP showed significant improvements in FRI, NRS Best Pain, and NASS patient satisfaction scores over eight weeks when compared to controls. Those who received PRP maintained significant improvements in FRI scores through at least one year of follow-up. While these results are promising, further studies are needed to define the subset of participants most likely to respond to biologic intradiscal treatment and the ideal cellular characteristics of the intradiscal PRP injectate.
Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
To evaluate the pathological changes of the lumbar spine and the instability of the lumbar intervertebral joints observed in patients with low back pain, with the study of the transition from supine to orthostatic position through the use of dedicated MRI-G-scan machine.
Within 10 years, 4305 patients, aged between 21 and 80 years old, with history of low back pain with or without sciatica, underwent MRI examinations in upright and in supine position. The open MRI-scanner used is Esaote G-scan, which enables the acquisition of images in supine and standing positions. The used sequences were sagittal T2-weighted FSE, T1-weighted SE and axial 3D HYCE. Patients were divided into two groups: "negatives", with no changes in the two positions (supine and upright), and "positives", with MRI modifications of imaging in upright position.
Orthostatic examination showed MRI changes in 2870 out of 4305 (66.6 %) patients, including 1252 males and 1618 females.
The G-scan is useful to assess instability of the lumbar spine detecting hidden modifications of protrusions and/or herniated discs already present in the supine position. It is also helpful in assessing the presence or modification of spondylolisthesis and lumbar canal stenosis.
Purpose
Interspinous process devices (IPDs) are implanted to treat patients with intermittent neurogenic claudication (INC) based on lumbar spinal stenosis. It is hypothesized that patients with lumbar spinal stenosis treated with IPD have a faster short-term recovery, an equal outcome after 2 years and less back pain compared with bony decompression.
Methods
A randomized design with variable block sizes was used, with allocations stratified according to center. Allocations were stored in prepared opaque, coded and sealed envelopes, and patients and research nurses were blind throughout the follow-up. Five neurosurgical centers (including one academic and four secondary level care centers) included participants. 211 participants were referred to the Leiden–The Hague Spine Prognostic Study Group. 159 participants with INC based on lumbar spinal stenosis at one or two levels with an indication for surgery were randomized into two groups. Patients and research nurses were blinded for the allocated treatment throughout the study period. 80 participants received an IPD and 79 participants underwent spinal bony decompression. The primary outcome at long-term (2-year) follow-up was the score for the Zurich Claudication Questionnaire. Repeated measurement analyses were applied to compare outcomes over time.
Results
At two years, the success rate according to the Zurich Claudication Questionnaire for the IPD group [69 % (95 % CI 57–78 %)] did not show a significant difference compared with standard bony decompression [60 % (95 % CI 48–71 %) p value 0.2]. Reoperations, because of absence of recovery, were indicated and performed in 23 cases (33 %) of the IPD group versus 6 (8 %) patients of the bony decompression group (p
Lumbar central spinal stenosis is common and often results in chronic persistent pain and disability, which can lead to multiple interventions. After the failure of conservative treatment, either surgical or nonsurgical modalities such as epidural injections are contemplated in the management of lumbar spinal stenosis.
Recent randomized trials, systematic reviews and guidelines have reached varying conclusions about the efficacy of epidural injections in the management of central lumbar spinal stenosis. The aim of this systematic review was to determine the efficacy of all three anatomical epidural injection approaches (caudal, interlaminar, and transforaminal) in the treatment of lumbar central spinal stenosis. A systematic review was performed on randomized trials published from 1966 to July 2014 of all types of epidural injections used in the management of lumbar central spinal stenosis. Methodological quality assessment and grading of the evidence was performed.
The evidence in managing lumbar spinal stenosis is Level II for long-term improvement for caudal and lumbar interlaminar epidural injections. For transforaminal epidural injections, the evidence is Level III for short-term improvement only. The interlaminar approach appears to be superior to the caudal approach and the caudal approach appears to be superior to the transforaminal one.
The available evidence suggests that epidural injections with local anesthetic alone or with local anesthetic with steroids offer short- and long-term relief of low back and lower extremity pain for patients with lumbar central spinal stenosis. However, the evidence is Level II for the long-term efficacy of caudal and interlaminar epidural injections, whereas it is Level III for short-term improvement only with transforaminal epidural injections.
Upon activation, platelets secrete more than 300 active substances from their intracellular granules. Platelet dense granule components, such as ADP and polyphosphates, contribute to haemostasis and coagulation, but also play a role in cancer metastasis. α-Granules contain multiple cytokines, mitogens, pro- and anti-inflammatory factors and other bioactive molecules that are essential regulators in the complex microenvironment of the growing thrombus but also contribute to a number of disease processes. Our understanding of the molecular mechanisms of secretion and the genetic regulation of granule biogenesis still remains incomplete. In this review we summarise our current understanding of the roles of platelet secretion in health and disease, and discuss some of the hypotheses that may explain how platelets may control the release of its many secreted components in a context-specific manner, to allow platelets to play multiple roles in health and disease.
Copyright © 2014. Published by Elsevier Ltd.
To estimate the global burden of low back pain (LBP).
LBP was defined as pain in the area on the posterior aspect of the body from the lower margin of the twelfth ribs to the lower glutaeal folds with or without pain referred into one or both lower limbs that lasts for at least one day. Systematic reviews were performed of the prevalence, incidence, remission, duration, and mortality risk of LBP. Four levels of severity were identified for LBP with and without leg pain, each with their own disability weights. The disability weights were applied to prevalence values to derive the overall disability of LBP expressed as years lived with disability (YLDs). As there is no mortality from LBP, YLDs are the same as disability-adjusted life years (DALYs).
Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden (DALYs). The global point prevalence of LBP was 9.4% (95% CI 9.0 to 9.8). DALYs increased from 58.2 million (M) (95% CI 39.9M to 78.1M) in 1990 to 83.0M (95% CI 56.6M to 111.9M) in 2010. Prevalence and burden increased with age.
LBP causes more global disability than any other condition. With the ageing population, there is an urgent need for further research to better understand LBP across different settings.
Lumbar spinal stenosis (LSS) is common in the elderly. However, there have been few reports on its impact on quality of life (QoL) in community-dwelling individuals. The purpose of this study was to clarify how symptomatic LSS affects QoL at the community level. A total of 1862 people (697 males and 1165 females, most subjects were between 40 and 85 y.o.) agreed to participate and were interviewed. The presence of symptomatic LSS was assessed by a specially designed questionnaire. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) was also administered. In addition, the presence of comorbid conditions that affect QoL, such as osteoarthritis of the knee and hip, cardiovascular disease, cerebrovascular disease, or respiratory disease, was also analyzed. The prevalence of symptomatic LSS gradually increased with age. Furthermore, the presence of symptomatic LSS had a strong negative effect on all 8 physical and mental domains and the physical component summary (PCS) (OR: 1.547-2.544) but not the mental component summary (MCS). In comparison with comorbid conditions, LSS had a much stronger negative impact on health-related QoL (HR-QoL). The current study confirmed that the presence of symptomatic LSS might have a strong negative influence on HR-QoL in the community setting.
Intervertebral disc degeneration (IDD) is a common orthopedic disease associated with mechanical changes that may result in significant pain. Current treatments for IDD mainly depend on conservative therapies and spinal surgeries that are only able to relieve the symptoms but do not address the cause of the degeneration and even accelerate the degeneration of adjacent segments. This has prompted research to improve our understanding of the biology of intervertebral disc healing and into methods to enhance the regenerative process. Recently, biological therapies, including active substances, gene therapy and tissue engineering based on certain cells, have been attracting more attention in the field of intervertebral disc repair and regeneration. Early selection of suitable biological treatment is an ideal way to prevent or even reverse the progressive trend of IDD. Growth factors have been enjoying more popularity in the field of regeneration of IDD and many have been proved to be effective in reversing the degenerative trend of the intervertebral disc. Identification of these growth factors has led to strategies to deliver platelet-derived factors to the intervertebral disc for regeneration. Platelet-rich plasma (PRP) is the latest technique to be evaluated for promoting intervertebral disc healing. Activation of the PRP leads to the release of growth factors from the α-granules in the platelet cytoplasm. These growth factors have been associated with the initiation of a healing cascade that leads to cellular chemotaxis, angiogenesis, synthesis of collagen matrix, and cell proliferation. This review describes the current understanding of IDD and related biological therapeutic strategies, especially the promising prospects of PRP treatment. Future limitations and perspectives of PRP therapy for IDD are also discussed.
Study design. Review of the literature.Objective. The focus of this work is to provide a resource which promotes a clear understanding of lumbar disc terminology amongst clinicians, radiologists, and researchers.Summary of background data. The paper "Nomenclature and Classification of Lumbar Disc Pathology, Recommendations of the Combined Task Forces of the American Society of Spine Radiology, the American Society of Neuroradiology and the North American Spine Society," was published in 2001 after being formally endorsed by the Boards of the three societies. It has served its purpose well for over a decade.Since 2001 there has been sufficient evolution in our understanding of the lumbar disc to merit revision and updating of the original paper. The revised document represents the consensus recommendations of the contemporary combined task forces and governing boards of the American Society of Spine Radiology, the American Society of Neuroradiology, and the North American Spine Society, reflecting changes consistent with present-day concepts in radiologic and clinical care.Methods. A PubMed search was performed for literature pertaining to the lumbar disc. The task force members individually and collectively reviewed the literature and revised the 2001 document. It was then reviewed by the governing boards of the ASSR, ASNR, and NASS. After further revision based on their feedback, the paper was approved for publication.Results. The paper provides a detailed glossary of terms and a discussion of recommended diagnostic categories pertaining to the lumbar disc, as well as updated illustrations and literature references.Conclusions. We have revised and updated a document that, since 2001, has provided a widely acceptable nomenclature that helps maintain consistency and accuracy in the description of the anatomic and physiologic properties of the normal and abnormal lumbar disc; and that serves as a system for classification and reporting built upon that nomenclature.
Degenerative lumbar spinal stenosis is caused by mechanical factors and/or biochemical alterations within the intervertebral disk that lead to disk space collapse, facet joint hypertrophy, soft-tissue infolding, and osteophyte formation, which narrows the space available for the thecal sac and exiting nerve roots. The clinical consequence of this compression is neurogenic claudication and varying degrees of leg and back pain. Degenerative lumbar spinal stenosis is a major cause of pain and impaired quality of life in the elderly. The natural history of this condition varies; however, it has not been shown to worsen progressively. Nonsurgical management consists of nonsteroidal anti-inflammatory drugs, physical therapy, and epidural steroid injections. If nonsurgical management is unsuccessful and neurologic decline persists or progresses, surgical treatment, most commonly laminectomy, is indicated. Recent prospective randomized studies have demonstrated that surgery is superior to nonsurgical management in terms of controlling pain and improving function in patients with lumbar spinal stenosis.
Intervertebral disc herniation, spinal stenosis, intervertebral disc degeneration without disc herniation, and post lumbar surgery syndrome are the most common diagnoses of chronic persistent low back and lower extremity symptoms, resulting in significant economic, societal, and health care impact. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back pain. However the evidence is highly variable among different techniques utilized - namely interlaminar, caudal, and transforaminal - and for various conditions, namely - intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. Multiple systematic reviews conducted in the evaluation of the effectiveness of interlaminar epidural injections have been marred with controversy. Consequently, the debate continues with regards to the effectiveness, indications, and medical necessity of interlaminar epidural injections.
A systematic review of lumbar interlaminar epidural injections with or without steroids.
To evaluate the effect of lumbar interlaminar epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain emanating as a result of disc herniation or radiculitis, spinal stenosis, and chronic discogenic pain.
The available literature on lumbar interlaminar epidural injections with or without steroids in managing various types of chronic low back pain with or without lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, or limited based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles.
The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake.
Overall, 82 lumbar interlaminar trials were identified. All non-randomized studies without fluoroscopy and randomized trials not meeting the inclusion criteria were excluded. Overall, 15 randomized trials and 11 non-randomized studies were included in the analysis. Analysis was derived mainly from fluoroscopically-guided randomized trials and non-randomized studies. The evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids, fair with local anesthetic only; whereas it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with local anesthetic with or without steroids, with fluoroscopically-guided epidural injections.
The limitations of this study include that we were unable to perform meta-analysis for disc herniation, and the paucity of evidence for discogenic pain and spinal stenosis. Further, methodological criteria have been highly variable along with sample sizes. The studies were heterogenous.
The evidence based on this systematic review is good for lumbar epidural injections under fluoroscopy for radiculitis secondary to disc herniation with local anesthetic and steroids, fair with local anesthetic only; whereas it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with local anesthetic with or without steroids.
Lumbosacral radicular pain is characterized by a radiating pain in one or more lumbar or sacral dermatomes; it may or may not be accompanied by other radicular irritation symptoms and/or symptoms of decreased function. The annual prevalence in the general population, described as low back pain with leg pain traveling below the knee, varied from 9.9% to 25%, which means that it is presumably the most commonly occurring form of neuropathic pain.
The patient's history may give a suggestion of lumbosacral radicular pain. The best known clinical investigation is the straight-leg raising test. Final diagnosis is made based on a combination of clinical examination and potentially additional tests. Medical imaging studies are indicated to exclude possible serious pathologies and to confirm the affected level in patients suffering lumbosacral radicular pain for longer than 3 months. Magnetic resonance imaging is preferred. Selective diagnostic blocks help confirming the affected level.
There is controversy concerning the effectiveness of conservative management (physical therapy, exercise) and pharmacological treatment.
When conservative treatment fails, in subacute lumbosacral radicular pain under the level L3 as the result of a contained herniation, transforaminal corticosteroid administration is recommended (2 B+). In chronic lumbosacral radicular pain, (pulsed) radiofrequency treatment adjacent to the spinal ganglion (DRG) can be considered (2 C+). For refractory lumbosacral radicular pain, adhesiolysis and epiduroscopy can be considered (2 B±), preferentially study-related.
In patients with a therapy-resistant radicular pain in the context of a Failed Back Surgery Syndrome, spinal cord stimulation is recommended (2 A+). This treatment should be performed in specialized centers.
Background: While low back pain is the number one cause of disability in the United States, lumbar spinal stenosis along with intervertebral disc herniation and degenerative spondylolisthesis is one of the 3 most common diagnosis of low back and leg pain for which surgery is performed. Numerous modalities of treatments including drug therapy and complex surgical fusions have been recommended for treatment of central spinal stenosis. Epidural injections are one of the commonly performed nonsurgical interventions in managing central spinal stenosis; however, there has been paucity of literature in reference to efficacy of epidural injections in managing central spinal stenosis with lumbar interlaminar epidural injections. Study Design: A randomized, double-blind, active controlled trial. Setting: Private interventional pain management practice and specialty referral center in the United States. Objective: To assess the effectiveness of lumbar interlaminar epidural injections with or without steroids in providing effective and long-lasting pain relief with improvement in functional status for the management of chronic low back and lower extremity pain related to lumbar central spinal stenosis. Methods: A randomized, double-blind, active-control trial was designed with the inclusion of 120 patients assigned to 2 groups. Group I patients received lumbar interlaminar epidural injections of local anesthetic (lidocaine 0.5%) 6 mL, whereas Group II received lumbar interlaminar epidural injections with local anesthetic (lidocaine 0.5%) 5 mL mixed with 1 mL of steroids and 6 mg of betamethasone. Outcomes Assessment: Outcomes were assessed utilizing the numeric pain rating scale (NRS) and Oswestry Disability Index (ODI) at 3, 6, 12, 18, and 24 months post treatment. The primary outcome measure was significant improvement, defined as 50% improvement in pain and disability scores. Results: Significant relief and functional status improvement was seen in 72% and 73% of patients in Groups I and II at the end of 2 years considering all participants; however, this was 84% and 85% in the successful group. Overall significant improvement was achieved for 65.7 ± 37.3 weeks in Group 1 and 68.9 ± 37.7 weeks in Group II at the end of 2 years when all participants were considered; whereas, this was 77 ± 27.8 weeks and 77.9 ± 30.2 weeks when they were separated into successful categories. The average number of procedures per patient was 5 to 6 in both groups. Limitations: Limitations of this trial include lack of placebo control group and treatment of patients with multiple procedures over a period of 2 years. Conclusion: Lumbar interlaminar epidural injections of local anesthetic with or without steroids provide relief in a significant proportion of patients with lumbar central spinal stenosis. Key words: Chronic low back pain, lower extremity pain, central spinal stenosis, interlaminar epidural injections, caudal epidural injections, steroids, local anesthetics, placebo, active control
This International Society for the Advancement of Spine Surgery guideline is generated to respond to growing requests for background, supporting literature and evidence, and proper coding for intraosseous ablation of the basivertebral nerve for chronic low back pain.
Purpose
Lumbar spinal canal stenosis and lumbar spinal foraminal stenosis are common, degenerative pathologies which can result in neurogenic claudication and have a negative impact on function and quality of life. Percutaneous interspinous devices (PIDs) are a recently-developed, minimally-invasive, alternative treatment option. This study details a 9 year single-centre experience with PIDs and examines the complementary use of spinous process augmentation (spinoplasty) to reduce failure rates.
Methods
A retrospective cohort assessment of 800 consecutive patients who presented to a specialized spine hospital was performed with 688 receiving treatment. Inclusion was based on high-grade stenosis, failure of conservative management and electromyography. 256 had a PID alone while 432 had concurrent polymethyl methacrylate (PMMA) augmentation of the adjacent spinous processes. The patients were followed up at 3 and 12 months using the Zurich Claudication Questionnaire (ZCQ) and Oswestry Disability Index (ODI).
Results
Both groups showed marked improvement in the patients’ ZCQ scores (3.2 to 1.3) and ODI scores (32 to 21), with strong satisfaction results (1.7). The symptom recurrence rate from complications for the group which received concurrent spinous process augmentation was reduced when compared with the PID alone cohort (<1% vs 11.3%).
Conclusion
This study demonstrates the efficacy of percutaneous interspinous devices in treating lumbar spinal stenosis. It also provides evidence that concurrent spinous process augmentation reduces the rate of symptom recurrence.
Purpose
To retrospectively assess safety and potential effectiveness of percutaneous intervertebral disc coagulation therapy (PDCT) using plasma thermal reaction for the treatment of lumbar and cervical disc hernias resistant to medical therapy.
Materials and Methods
Forty-four patients (age range 18–87 years, mean 52.7) with contained and extruded symptomatic lumbar (N = 48) and cervical (N = 6) disc hernias in the absence of free fragments causing radiculopathy without improvement after 6-week conservative therapy were enrolled. Pretreatment discography has been performed in every patient. Spine MRI was performed before the procedure and 4 months later, in order to check post-PDCT changes. Technical success was defined as correct placement of PDCT fiber; clinical outcomes were evaluated using visual analog scale (VAS) and the Oswestry Disability Index (ODI) before the procedure and after 4 months.
Results
A total of 54 levels have been treated with 98% technical success; in 12 patients (27%), the treatment was performed in two levels at the same time. All patients well tolerated the procedure; most patients (N = 39; 89%) had significant improvement in symptoms, with ODI score reduction from 47.61 ± 8.7 to 13.38 ± 9.4 (p < 0.001). The mean pre-PDCT VAS score was 7.47 ± 0.8. VAS score was decreased down to 1.36 ± 1.6 at final follow-up (p < 0.001). There were no cases of infection, nerve damage, or bleeding.
Conclusions
PDCT can be an effective and safe for minimally invasive indirect decompression for cervical and lumbar hernia resistant to conservative treatment, particularly when patients are correctly selected.
Spinal pain is a common condition leading to significant disability and high cost. Spinal injections have been demonstrated to be effective short-term treatments with cost–utility superior to numerous other treatments, including surgical procedures. Appropriate patient selection—based on clinical and imaging finding—and the use of image guidance associated with technical precautions improve the safety and effectiveness of spinal injection and overall patient outcomes.
Background
Lumbar spinal stenosis (LSS) can lead to compression of neural elements and manifest as low back and leg pain. LSS has traditionally been treated with a variety of conservative (pain medications, physical therapy, epidural spinal injections) and invasive (surgical decompression) options. Recently, several minimally invasive procedures have expanded the treatment options.
Methods
The Lumbar Spinal Stenosis Consensus Group convened to evaluate the peer‐reviewed literature as the basis for making Minimally Invasive Spine Treatment (MIST) recommendations. Eleven consensus points were clearly defined with evidence strength, recommendation grade, and consensus level using United States Preventive Services Task Force (USPSTF) criteria. The Consensus Group also created a treatment algorithm. Literature searches found 9 studies (2 randomized controlled trials or RCTs; 7 observational studies, 4 prospective and 3 retrospective) of minimally invasive spine treatments, and 1 RCT for spacers.
Results
The LSS treatment choice is dependent on the degree, spinal or anatomic level, and architecture of the stenosis, the severity of the symptoms, failed, past, less‐invasive treatments, previous fusions or other open surgical approaches, and patient comorbidities. There is Level I evidence for percutaneous image‐guided lumbar decompression (PILD) as superior to lumbar epidural steroid injection, and 1 RCT supporting spacer use in a non‐inferiority study comparing 2 spacer products currently available.
Conclusions
Minimally invasive spine treatments should be used in a judicious and algorithmic fashion to treat LSS, based on the evidence of efficacy and safety in the peer‐reviewed literature. The MIST Consensus Group recommend that these procedures be used in a multimodal fashion as part of an evidence‐based decision algorithm.
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Advances in imaging and the development of injection techniques have enabled spinal intervention to become an important tool in managing chronic spinal pain. Epidural steroid injection (ESI) is one of the most widely used spinal interventions; it directly delivers drugs into the epidural space to relieve pain originating from degenerative spine disorders-central canal stenoses and neural foraminal stenoses-or disk herniations. Knowledge of the normal anatomy of the epidural space is essential to perform an effective and safe ESI and to recognize possible complications. Although computed tomographic (CT) or combined CT-fluoroscopic guidance has been increasingly used in ESI, conventional fluoroscopic guidance is generally performed. In ESI, drugs are delivered into the epidural space by interlaminar or transforaminal routes in the cervical spine or by interlaminar, transforaminal, or caudal routes in the lumbar spine. Epidurography is usually performed before drug delivery to verify the proper position of the needle in the epidural space. A small amount of contrast agent is injected with fluoroscopic guidance. Familiarity with the findings on a typical "true" epidurogram (demonstrating correct needle placement in the epidural space) permits proper performance of ESI. Findings on "false" epidurograms (demonstrating incorrect needle placement) include muscular staining and evidence of intravascular injection, inadvertent facet joint injection, dural puncture, subdural injection, and intraneural or intradiscal injection. (©)RSNA, 2016.
Image-guided spinal injection is commonly performed in symptomatic patients to decrease pain severity, confirm the pain generator, and delay or avoid surgery. This article focuses on the radiologist as spine interventionist and addresses the following four topics relevant to the radiologist who performs corticosteroid injections for pain management: (a) the rationale behind corticosteroid injection, (b) the interaction with patients, (c) the role of imaging in procedural selection and planning, and (d) the pearls and pitfalls of fluoroscopically guided injections. Factors that contribute to the success of a pain management service include communication skills and risk mitigation. A critical factor is the correlation of clinical symptoms with magnetic resonance (MR) imaging findings. Radiologists can leverage their training in MR image interpretation to distinguish active pain generators in the spine from incidental abnormalities. Knowledge of fluoroscopic anatomy and patterns of contrast material flow guide the planning and execution of safe and effective needle placement.
The prevalence of lumbar spinal stenosis is approximately 9.3%, with people most commonly affected in the sixth or seventh decade of life. Patients often have pain, cramping, and weakness in their legs that is worsened with standing and walking. Although the Spine Patient Outcomes Research Trial clearly demonstrated that surgery improves health-related quality of life, treatment for lumbar spinal stenosis varies widely from the type of decompression performed to the need for fusion. This variability can be attributed largely to the lack of an accepted classification system. A good classification system serves as a common language to define the severity of a condition, guide treatment, and facilitate clinical research.
Background
The comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive laminectomy in patients with symptomatic lumbar grade I degenerative spondylolisthesis with spinal stenosis is unknown.
Methods
In this randomized, controlled trial, we assigned patients, 50 to 80 years of age, who had stable degenerative spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) and symptomatic lumbar spinal stenosis to undergo either decompressive laminectomy alone (decompression-alone group) or laminectomy with posterolateral instrumented fusion (fusion group). The primary outcome measure was the change in the physical-component summary score of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; range, 0 to 100, with higher scores indicating better quality of life) 2 years after surgery. The secondary outcome measure was the score on the Oswestry Disability Index (range, 0 to 100, with higher scores indicating more disability related to back pain). Patients were followed for 4 years.
Results
A total of 66 patients (mean age, 67 years; 80% women) underwent randomization. The rate of follow-up was 89% at 1 year, 86% at 2 years, and 68% at 4 years. The fusion group had a greater increase in SF-36 physical-component summary scores at 2 years after surgery than did the decompression-alone group (15.2 vs. 9.5, for a difference of 5.7; 95% confidence interval, 0.1 to 11.3; P=0.046). The increases in the SF-36 physical-component summary scores in the fusion group remained greater than those in the decompression-alone group at 3 years and at 4 years (P=0.02 for both years). With respect to reductions in disability related to back pain, the changes in the Oswestry Disability Index scores at 2 years after surgery did not differ significantly between the study groups (−17.9 in the decompression-alone group and −26.3 in the fusion group, P=0.06). More blood loss and longer hospital stays occurred in the fusion group than in the decompression-alone group (P<0.001 for both comparisons). The cumulative rate of reoperation was 14% in the fusion group and 34% in the decompression-alone group (P=0.05).
Conclusions
Among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health–related quality of life than laminectomy alone. (Funded by the Jean and David Wallace Foundation and others; SLIP ClinicalTrials.gov number, NCT00109213.)
Whole blood is composed of both cellular and plasma components, providing a rich source of therapeutic products. Of late, platelet derived biomaterial (platelet rich plasma) consisting of plasma proteins and platelets are increasingly being used for various indications. Protocols for preparation and nomenclature of this biomaterial vary widely amongst authors and are often not well defined. Additionally, they are not uniformly documented in the literature, making results difficult to compare or replicate. In this paper we review the evolution and type of these products available for clinical use. Further we will discuss the scientific rational and technical aspects in preparation of these platelet biomaterials in order to administer them in
various fields of medicine.
Background. Platelet-rich plasma (PRP) has been found to be effective for a variety of musculoskeletal conditions. The treatment of discogenic pain with PRP is under investigation.
Objective. To assess changes in pain and function in patients with discogenic low back pain after an intradiscal injection of PRP.
Study Design. Prospective trial.
Methods. Patients were diagnosed with discogenic low back pain by clinical means, imaging, and exclusion of other structures. Provocation discography was used in a minority of the patients. Patients underwent a single treatment of intradiscal injection of PRP at one or multiple levels.
Main Outcome Measures. Patients were considered a categorical success if they achieved at least 50% improvement in the visual analog score and 30% decrease in the Oswestry Disability Index at 1, 2, and 6 months post-treatment.
Results. 22 patients underwent intradiscal PRP. Nine patients underwent a single level injection, ten at 2 levels, two at 3 levels, and one at 5 levels. Categorical success rates were as follows: 1 month: 3/22 = 14% (95% CI 0% to 28%), 2 months: 7/22 = 32% (95% CI 12% to 51%), 6 months: 9/19 = 47% (95% CI 25% to 70%).
Conclusion. This trial demonstrates encouraging preliminary 6 month findings, using strict categorical success criteria, for intradiscal PRP as a treatment for presumed discogenic low back pain. Randomized placebo controlled trials are needed to further evaluate the efficacy of this treatment.
Background context:
The paper ''Nomenclature and classification of lumbar disc pathology, recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology,'' was published in 2001 in Spine (© Lippincott, Williams & Wilkins). It was authored by David Fardon, MD, and Pierre Milette, MD, and formally endorsed by the American Society of Spine Radiology (ASSR), American Society of Neuroradiology (ASNR), and North American Spine Society (NASS). Its purpose was to promote greater clarity and consistency of usage of spinal terminology, and it has served this purpose well for over a decade. Since 2001, there has been sufficient evolution in our understanding of the lumbar disc to suggest the need for revision and updating of the original document. The revised document is presented here, and it represents the consensus recommendations of contemporary combined task forces of the ASSR, ASNR, and NASS. This article reflects changes consistent with current concepts in radiologic and clinical care.
Purpose:
To provide a resource that promotes a clear understanding of lumbar disc terminology amongst clinicians, radiologists, and researchers. All the concerned need standard terms for the normal and pathologic conditions of lumbar discs that can be used accurately and consistently and thus best serve patients with disc disorders.
Study design:
This article comprises a review of the literature.
Methods:
A PubMed search was performed for literature pertaining to the lumbar disc. The task force members individually and collectively reviewed the literature and revised the 2001 document. The revised document was then submitted for review to the governing boards of the ASSR, ASNR, and NASS. After further revision based on the feedback from the governing boards, the article was approved for publication by the governing boards of the three societies, as representative of the consensus recommendations of the societies.
Results:
The article provides a discussion of the recommended diagnostic categories pertaining to the lumbar disc: normal; congenital/developmental variation; degeneration; trauma; infection/inflammation; neoplasia; and/or morphologic variant of uncertain significance. The article provides a glossary of terms pertaining to the lumbar disc, a detailed discussion of these terms, and their recommended usage. Terms are described as preferred, nonpreferred, nonstandard, and colloquial. Updated illustrations pictorially portray certain key terms. Literature references that provided the basis for the task force recommendations are included.
Conclusions:
We have revised and updated a document that, since 2001, has provided a widely acceptable nomenclature that helps maintain consistency and accuracy in the description of the anatomic and physiologic properties of the normal and abnormal lumbar disc and that serves as a system for classification and reporting built upon that nomenclature.
Background
Lumbar spinal stenosis is a major public health issue. Interspinous devices implanted using minimally invasive techniques may constitute an alternative to the reference standard of bony decompression with or without intervertebral fusion. However, their indications remain unclear, due to a paucity of clinical and biomechanical data. Our objective was to evaluate the effects of four interspinous process devices implanted at L4–L5 on the intervertebral foramen surface areas at the treated and adjacent levels, in flexion and in extension.
Materials and method
Six fresh frozen human cadaver lumbar spines (L2–sacrum) were tested on a dedicated spinal loading frame, in flexion and extension, from 0 to 10 N·m, after preparation and marking of the L3–L4, L4–L5, and L5–S1 foramina. Stereoscopic 3D images were acquired at baseline then after implantation at L4–L5 of each of the four devices (Inspace®, Synthes; X-Stop®, Medtronic; Wallis®, Zimmer; and Diam®, Medtronic). The surface areas of the three foramina of interest were computed.
Results
All four devices significantly opened the L4–L5 foramen in extension. The effects in flexion separated the devices into two categories. With the two devices characterized by fixation in the spinous processes (Wallis® and Diam®), the L4–L5 foramen opened only in extension; whereas with the other two devices (X-Stop® and Inspace®), the L4–L5 foramen opened not only in extension, but also in flexion and in the neutral position. None of the devices implanted at L4–L5 modified the size of the L3–L4 foramen. X-Stop® and Diam® closed the L5–S1 foramen in extension, whereas the other two devices had no effect at this level.
Conclusion
Our results demonstrate that interspinous process devices modify the surface area of the interspinous foramina in vitro. Clinical studies are needed to clarify patient selection criteria for interspinous process device implantation.
Level of evidence
Level IV. Investigating an orthopaedic device.
Prospective randomized controlled multicenter study.
To compare the effect of X-Stop with minimally invasive decompression (MID) in patients with neurogenic intermittent claudication due to lumbar spinal stenosis.
Lumbar spinal stenosis is the most common indication for operative treatment in elderly. Laminectomy has been the "gold standard," but MID is now widely used. Another minimally invasive surgery option is X-Stop showing good result compared with nonoperative treatment, but showing higher reoperation rate than laminectomy.
We enrolled 96 patients aged 50 to 85 years, with symptoms of neurogenic intermittent claudication within 250-m walking distance and 1- or 2-level lumbar spinal stenosis, randomized to either MID or X-Stop. Primary outcome was Zurich Claudication Questionnaire in this intention-to-treat analysis. Secondary outcome was Oswestry Disability Index, EuroQol 5-dimensional questionnaire, numerical rating scale 11 for lower back pain and leg pain, and risk for secondary surgery and complications.
No significant differences were found in Zurich Claudication Questionnaire between the groups at any follow-ups. Both groups had a statistical and clinical significant improvement at 6 weeks and throughout the 2-year observation period. The number of patients having secondary surgery due to persistent or recurrent symptoms was significantly higher in the X-Stop group, odds ratio (95% confidence interval) = 6.5 (1.3-31.9). Complication rate was similar and low, but more severe for MID.
Both MID and X-Stop led to significant symptom improvements. There were no significant clinical differences in effect between the methods at any of the follow-up time points. X-Stop had significant higher risk of secondary surgery. Complication was more severe for MID.Level of Evidence: 2.
Background
Open discectomy remains the standard of treatment for patients with lumbar radicular pain secondary to a prolapsed intervertebral disc. Open discectomy performed in patients with small, contained herniations may result in poor outcomes. The various techniques of percutaneous disc decompression (PDD) have been developed to address this population.MethodsA literature search was conducted on articles, which address PDD for lumbar radicular pain. Published techniques include chymopapain chemonucleolysis, percutaneous laser disc decompression (PLDD), automated percutaneous lumbar discectomy (APLD), Dekompressor, nucleoplasty, and targeted disc decompression (TDD). In addition, the rationale of provocative discography, selective nerve root injections, and intra-op discograms before performing PDD is discussed in detail.ResultsDekompressor and nucleoplasty have the best level of evidence with a score of 2B+. The chymopapain chemonucleolysis has the most publications, but it is also accompanied by the most significant adverse complications and so it is scored as a 2B+/−. The other techniques are supported mainly by observational studies and thus their scores range between 0 and 2B+/−. There is no supporting evidence for provocative discography in patients with lumbar radicular pain. The evidence for a positive selective nerve root injection as an inclusion criteria or the need for an intra-op discogram shows mixed results.Conclusions
Nucleoplasty and Dekompressor have a weak positive recommendation for the treatment of patients with lumbar radicular pain. There is no role for provocative discography in this group of patients, although the evidence for a selective nerve root injection or an intra-op discogram is inconclusive.
Degenerative disc disease (DDD) induces chronic back pain with limited non-surgical options. In this open label pilot study, twenty-six patients (median age 40 years; range 18-61) received autologous bone marrow concentrate (BMC) disc injections (13 one level, 13 two levels). Pre-treatment Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) were performed to establish baseline pain scores (average 56.5 and 79.3 respectively), while MRI were independently scored according to the modified Pfirrmann scale. Approximately 1 mL of BMC was analyzed for total nucleated cell (TNC) content, colony forming unit-fibroblast (CFU-F) frequency, differentiation potential, and phenotype characterization. The average ODI and VAS scores were reduced to 22.8 and 29.2 at 3 months, 24.4 and 26.3 at 6 months, and 25.0 and 33.2 at 12 months, respectively (p≤0.0001). Eight of 20 patients improved by one modified Pfirrmann grade at one year. The average BMC contained 121x106 TNC/mL with 2,713 CFU-F/mL (synonymous with mesenchymal stem cells). Although all subjects presented a substantial reduction in pain, patients receiving greater than 2,000 CFU-F/mL experienced a significantly faster and greater reduction in ODI and VAS. Subjects older than 40 years who received fewer than 2,000 CFU-F/mL experienced an average pain reduction of 33.7% (ODI) and 29.1% (VAS) at 12 months, while all other patients’ average reduction was 69.5% (ODI, p=0.03) and 70.6% (VAS, p=0.01). This study provides evidence of safety and feasibility in the non-surgical treatment of DDD with autologous BMC and indicates an effect of mesenchymal cell concentration on discogenic pain reduction. Stem Cells 2014
Background:
Reports of prevalence of spinal pain indicate the prevalence of thoracic pain in approximately 13% of the general population compared to 32% of the population with neck pain and 43% of the population with low back pain during the past year. Even though, thoracic pain is less common than neck or low back pain, the degree of disability resulting from thoracic pain disorders seems to be similar to other painful conditions. Interventions in managing chronic thoracic pain are also less frequent, leading to the paucity of literature about various interventions in managing chronic thoracic pain. Thoracic intervertebral discs and thoracic facet joints have been shown to be pain generators, even though thoracic radicular pain is very infrequent. Thoracic epidural injections are one of the commonly performed procedures in managing thoracic pain. The efficacy of thoracic epidural injections has not been well studied.
Study design:
A randomized, double-blind, active controlled trial.
Setting:
Private interventional pain management practice and specialty referral center in the United States.
Objective:
The primary objective was to assess the effectiveness of thoracic interlaminar epidural injections in providing effective pain relief and improving function in patients with chronic mid and/or upper back pain.
Methods:
One hundred and ten patients were randomly assigned into 2 groups with 55 patients in each group receiving either local anesthetic alone (Group I) or local anesthetic with steroids (Group II). Randomization was performed by computer-generated random allocation sequence by simple randomization.
Outcomes assessment:
Outcomes were assessed utilizing Numeric Rating Scale (NRS), the Oswestry Disability Index (ODI) 2.0, employment status, and opioid intake. The patients experiencing greater than 3 weeks of significant improvement with the first 2 procedures were considered as successful. Others were considered as failed participants. Significant improvement was defined as a decrease of greater than 50% NRS scores and ODI scores with measurements performed at baseline, 3, 6, 12, 18, and 24 months post treatment.
Results:
Significant improvement was seen in 71% in Group I and 80% in Group II at the end of 2 years with all participants; however, improvement was seen in 80% and 86% when only successful patients were considered. Therapeutic procedural characteristics showed 5 to 6 procedures per 2 years with total average relief of 80 weeks in Group I and 78 weeks in Group II in the successful patient category; whereas, it was 71 and 72 weeks when all patients were considered.
Limitations:
Limitations of this assessment include lack of a placebo group.
Conclusions:
Based on the results of this trial, it is concluded that chronic thoracic pain of non-facet joint origin may be managed conservatively with thoracic interlaminar epidural injections with or without steroids.
Objective:
The objective of our study was to perform a systematic review of the semiquantitative and qualitative radiologic criteria that are used for the diagnosis of lumbar spinal stenosis (LSS).
Materials and methods:
A four-step systematic literature search including the MEDLINE database was performed by an experienced librarian to reveal all semiquantitative or qualitative radiologic criteria used for the diagnosis of LSS. The precise definitions of all criteria, normal or abnormal values (if applicable), and intra- and interrater reliability were noted by two independent readers. Descriptive statistics were used.
Results:
A total of 14 semiquantitative or qualitative radiologic parameters were identified and distinguished according to relevant anatomic spaces into criteria for central canal stenosis, lateral (recess) stenosis, and foraminal stenosis. Great variability in terms of the exact definitions of the criteria was found. For 10 of the 14 criteria, the intra- and interrater reliability data were found with kappa values ranging from 0.01 to 1.0.
Conclusion:
Our systematic literature review identified 14 different semiquantitative or qualitative radiologic criteria that are used for the diagnosis of LSS; however, these criteria show remarkable variability in terms of their exact individual definitions and intra- and interrater reliability.
Pain innate to intervertebral disc, often referred to as discogenic pain, is suspected by some authors to be the major source of chronic low back and neck pain. Current management of suspected discogenic pain lacks standardized diagnosis, treatment, and terminology.
In an attempt to determine whether patterns existed that may facilitate standardization of care, we sought to analyze the terminologies used and the various modes of diagnosis and treatment of suspected discogenic pain.
A systematic review of the recent literature.
A Medline search was performed using the terms degenerative disc disease, discogenic pain, internal disc disruption while using the limits of human studies, English language, and clinical trials, for the last 10 years. The search led to a total of 149 distinct citations, of which 53 articles, where the intervertebral disc itself was considered the principal source of patient's pain and was the main target of the treatment, were retained for further analysis.
The results of this review confirm and help quantify the significant differences that existed in the terminology and all the areas of diagnosis and treatment of presumed discogenic pain.
Our findings show that suspected discogenic pain, despite its extensive affirmation in the literature and enormous resources regularly devoted to it, currently lacks clear diagnostic criteria and uniform treatment or terminology.
The Sound Judgment Series consists of invited articles highlighting the clinical value of using ultrasound first in specific clinical diagnoses where ultrasound has shown comparative or superior value. The series is meant to serve as an educational tool for medical and sonography students and clinical practitioners and may help integrate ultrasound into clinical practice.
Study design:
Prospective, randomized, multicenter, Food and Drug Administration Investigational Device Exemption trial.
Objective:
To evaluate the safety and efficacy of Coflex interlaminar stabilization compared with posterior spinal fusion in the treatment of 1- and 2-level spinal stenosis and degenerative spondylolisthesis.
Summary of background data:
Long-term untoward sequelae of lumbar fusion for stenosis and degenerative spondylolisthesis have led to the search for motion-preserving, less-invasive alternatives.
Methods:
Three hundred twenty-two patients (215 Coflex and 107 fusions) from 21 sites in the United States were enrolled between 2006 and 2010. Subjects were randomized to receive laminectomy and Coflex interlaminar stabilization or laminectomy and posterolateral spinal fusion with spinal instrumentation in a 2:1 ratio. Overall device success required a 15-point reduction in Oswestry Disability Index, no reoperations, no major device-related complications, and no postoperative epidural injections.
Results:
Patient follow-up at minimum 2 years was 95.3% and 97.2% in the Coflex and fusion control groups, respectively. Patients taking Coflex experienced significantly shorter operative times (P < 0.0001), blood loss (P < 0.0001), and length of stay (P < 0.0001). There was a trend toward greater improvement in mean Oswestry Disability Index scores in the Coflex cohort (P = 0.075). Both groups demonstrated significant improvement from baseline in all visual analogue scale back and leg parameters. Patients taking Coflex experienced greater improvement in Short-Form 12 physical health outcomes (P = 0.050) and equivalent mental health outcomes. Coflex subjects experienced significant improvement in all Zurich Claudication Questionnaire outcomes measures compared with fusion (symptom severity [P = 0.023]; physical function [P = 0.008]; satisfaction [P = 0.006]). Based on the Food and Drug Administration composite for overall success, 66.2% of Coflex and 57.7% of fusions succeeded (P = 0.999), thus demonstrating noninferiority. The overall adverse event rate was similar between the groups, but Coflex had a higher reoperation rate (10.7% vs. 7.5%, P = 0.426). At 2 years, fusions exhibited increased angulation (P = 0.002) and a trend toward increased translation (P = 0.083) at the superior adjacent level, whereas Coflex maintained normal operative and adjacent level motion.
Conclusion:
Coflex interlaminar stabilization is a safe and efficacious alternative, with certain advantages compared with lumbar spinal fusion in the treatment of spinal stenosis and low-grade spondylolisthesis.
Level of evidence:
1.
Study design:
Prospective randomized controlled study.
Objective:
To compare the outcome of indirect decompression by means of the X-Stop (Medtronics Inc., Minneapolis, MN) implant with conventional decompression in patients with neurogenic intermittent claudication due to lumbar spinal stenosis.
Summary of background data:
Decompression is currently the "gold standard" for lumbar spinal stenosis but is afflicted with complications and a certain number of dissatisfied patients. Interspinous implants have been on the market for more than 10 years, but no prospective study comparing its outcome with decompression has been performed.
Methods:
After power calculation, 100 patients were included: 50 in the X-Stop group and 50 in the decompression group. Patients with symptomatic 1- or 2-level lumbar spinal stenosis and neurogenic claudication relieved on flexion were included. X-Stop operations were performed under local anesthesia.The mean patient age was 69 (49-89) years, and the male/female distribution was 56/44. Minimal dural sac area was in all cases except two 80 mm or less.The noninferiority hypothesis included 6, 12, and 24 months of follow-up, and included. intention-to-treat as well as as-treated analyses.The primary outcome meansure was the Zürich Claudication Questionnaire, and the secondary outcome measures was the visual analogue scale pain, Short-Form 36 (SF-36), complications, and reoperations.
Results:
The primary and secondary outcome measures of patients in both groups improved significantly. The results were similar at 6, 12, and 24 months and at no time point could any statistical difference between the 2 types of surgery be identified. Three patients (6%) in the decompression group underwent further surgery, compared with 13 patients (26%) in the X-Stop group (P = 0.04). Results were identical in intention-to-treat and as-treated analyses.
Conclusion:
For spinal stenosis with neurogenic claudication, decompressive surgery as well as X-Stop are appropriate procedures. Similar results were achieved in both groups, however, with a higher number of reoperations in the X-Stop group. Patients having X-Stop removal and decompression experienced results similar to those randomized to primary decompression.
Level of evidence:
1.
Objective: A comparative randomized prospective clinical study to compare the clinical outcome of transpedicular screw fixation and dynamic stabilization using X-stop.
Background: Spinal fusion has been offered to patients who suffer from lumbar spinal stenosis or spondylolisthesis. Despite improvement in fusion it significantly alters spinal biomechanics, which causes premature disc degeneration at levels neighboring fusion. Dynamic stabilization maintains or restores intervertebral motion in a controlled fashion, whether by restricting the extremes of spinal movement or by dampening the kinetic energy involved in motion.
Methods: This study included 60 patients who were divided into 2 equal groups (A and B) randomly assigned to undergo either transpedicular screw fixation (group A) or dynamic stabilization using X-stop (group B). Patients had degenerative spondylolisthesis or retrolisthesis (Grade I), lateral or central spinal stenosis. Participants were evaluated preoperatively, postoperatively at 3 weeks, and then at 6-month, 12-month, and 24-month intervals. Visual Analog Scale (VAS) was used to score both lower-limb and back pain. Patient functioning was evaluated using the Oswestry Disability Index (ODI).
Results: In group A, the mean pain and function scores improved as follows: leg pain from 80.5 to 35.5, back pain from 54 to 37.5, and ODI score from 55 to 34.5%. In group B, the mean pain and function scores improved as follows: leg pain from 82.5 to 25.5, back pain from 52 to 29.5, and ODI score from 53 to 26.5%.
Conclusions: The long-term outcome of dynamic stabilization is promising. The procedure is preferable to fusion because it avoids the greater tissue destruction and the morbidity of donor site problems. Adjacent-level disc degeneration after lumbar fusion has been well documented and little controversy exists as to the additional disability resulting from this proximate degenerative process.
Lumbar spinal stenosis is one of the most common causes of low back pain among older adults and can cause significant disability. Despite its prevalence, there is a paucity of literature concerning the treatment of spinal stenosis symptoms. Multiple interventions, including surgery and interventional techniques such as epidural injections and adhesiolysis, are commonly utilized in managing pain related to central spinal stenosis. However, there is a paucity of literature from randomized, controlled trials about the effectiveness of epidural injections for lumbar central spinal stenosis.
This study sought to assess the effectiveness of caudal epidural injections with or without steroids in providing effective and long-lasting pain relief for the management of chronic low back pain related to lumbar central stenosis.
A randomized, double-blind, active-controlled trial.
One hundred patients were randomly assigned to one of 2 groups, with Group I patients receiving caudal epidural injections of local anesthetic (lidocaine 0.5%), whereas Group II patients received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of steroid, 6 mg (non-particulate betamethasone).
Multiple outcome measures, including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake were utilized. Assessments were carried out at 3, 6, 12, 18, and 24 months posttreatment. The primary outcome was defined as pain relief and improvement in disability scores of 50% or more. Successful treatment was considered as at least 3 weeks of relief following the first 2 injections, categorizing these patients into a successful group, and others into a failed group.
Significant pain relief and functional status improvement were seen in 51% in Group I and 57% in Group II at the end of 2 years in the successful group when the participants were separated into successful and failed groups. However, overall, significant pain relief and functional status improvement (≥ 50%) was demonstrated in 38% in Group I and 44% in Group II at the end of 2 years. The overall number of procedures for 2 years were 4 in both groups, with 5 procedures on average in the successful groups, and approximately 60 weeks of relief in Group I and 54 weeks of relief in Group II at 2 years in the successful group.
Caudal epidural injections of local anesthetic with or without steroids provide relief in a modest proportion of patients undergoing the treatment and may be considered as an effective treatment for a select group of patients who have chronic function-limiting low back and lower extremity pain secondary to central spinal stenosis.