PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (1344147)

Clipboard (0)
None

Related Articles

1.  Correlation between disability and MRI findings in lumbar spinal stenosis 
Acta Orthopaedica  2011;82(2):204-210.
Background and purpose
MRI is the modality of choice when diagnosing spinal stenosis but it also shows that stenosis is prevalent in asymptomatic subjects over 60. The relationship between preoperative health-related quality of life, functional status, leg and back pain, and the objectively measured dural sac area in single and multilevel stenosis is unknown. We assessed this relationship in a prospective study.
Patients and methods
The cohort included 109 consecutive patients with central spinal stenosis operated on with decompressive laminectomy or laminotomy. Preoperatively, all patients completed the questionnaires for EQ-5D, SF-36, Oswestry disability index (ODI), estimated walking distance and leg and back pain (VAS). The cross-sectional area of the dural sac was measured at relevant disc levels in mm2, and spondylolisthesis was measured in mm. For comparison, the area of the most narrow level, the number of levels with dural sac area < 70 mm2, and spondylolisthesis were studied.
Results
Before surgery, patients with central spinal stenosis had low HRLQoL and functional status, and high pain levels. Patients with multilevel stenosis had better general health (p = 0.04) and less leg and back pain despite having smaller dural sac area than patients with single-level stenosis. There was a poor correlation between walking distance, ODI, the SF-36, EQ-5D, and leg and back pain levels on the one hand and dural sac area on the other. Women more often had multilevel spinal stenosis (p = 0.05) and spondylolisthesis (p < 0.001). Spondylolisthetic patients more often had small dural sac area (p = 0.04) and multilevel stenosis (p = 0.06).
Interpretation
Our findings indicate that HRQoL, function, and pain measured preoperatively correlate with morphological changes on MRI to a limited extent.
doi:10.3109/17453674.2011.566150
PMCID: PMC3235292  PMID: 21434811
2.  Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability 
Background
Lumbar spinal stenosis (LSS) is the common term used to describe patients with symptoms related to the anatomical reduction of the lumbar spinal canal size. However, some subjects may have a markedly narrowed canal without any symptoms. This raises the question of what is the actual role of central canal stenosis in symptomatic patients. The purpose of this study was to compare radiological evaluations of LSS, both visually and quantitatively, with the clinical findings of patients with LSS.
Methods
Eighty patients [mean age 63 (11) years, 44% male], with symptoms severe enough to indicate LSS surgery, were included in this prospective single-center study. Lumbar magnetic resonance imaging was performed and one experienced neuroradiologist classified patients into three groups: 0 = normal or mild stenosis, 1 = moderate stenosis, and 2 = severe stenosis. In addition, the same observer measured the minimal dural sac area level by level from the inferior aspect of L1 to the inferior aspect of S1. The association between radiological and clinical findings were tested with Oswestry Disability Index, overall visual analog pain scale, specific low back pain, specific leg pain, Beck Depression Inventory, and walking distance on treadmill exercise test.
Results
In the visual classification of the central spinal canal, leg pain was significantly higher and walking distance achieved was shorter among patients with moderate central stenosis than in patients with severe central stenosis (7.33 (2.29) vs 5.80 (2.72); P = 0.008 and 421 (431) m vs 646 (436) m; P = 0.021, respectively). Patients with severe stenosis at only one level also achieved shorter walking distance than patients with severe stenosis of at least two levels. No correlation between visually or quantitatively assessed stenosis and other clinical findings was found.
Conclusions
There is no straightforward association between the stenosis of dural sac and patient symptoms or functional capacity. These findings indicated that dural sac stenosis is not the single key element in the pathophysiology of LSS.
doi:10.1186/1471-2474-15-348
PMCID: PMC4203914  PMID: 25319184
Spinal stenosis; Magnetic resonance imaging; MRI; Low back pain; Leg pain; Disability; Walking distance
3.  Preoperative MRI Findings Predict Two-Year Postoperative Clinical Outcome in Lumbar Spinal Stenosis 
PLoS ONE  2014;9(9):e106404.
Purpose
To study the predictive value of preoperative magnetic resonance imaging (MRI) findings for the two-year postoperative clinical outcome in lumbar spinal stenosis (LSS).
Methods
84 patients (mean age 63±11 years, male 43%) with symptoms severe enough to indicate LSS surgery were included in this prospective observational single-center study. Preoperative MRI of the lumbar spine was performed with a 1.5-T unit. The imaging protocol conformed to the requirements of the American College of Radiology for the performance of MRI of the adult spine. Visual and quantitative assessment of MRI was performed by one experienced neuroradiologist. At the two-year postoperative follow-up, functional ability was assessed with the Oswestry Disability Index (ODI 0–100%) and treadmill test (0–1000 m), pain symptoms with the overall Visual Analogue Scale (VAS 0–100 mm), and specific low back pain (LBP) and specific leg pain (LP) separately with a numeric rating scale from 0–10 (NRS-11). Satisfaction with the surgical outcome was also assessed.
Results
Preoperative severe central stenosis predicted postoperatively lower LP, LBP, and VAS when compared in patients with moderate central stenosis (p<0.05). Moreover, severe stenosis predicted higher postoperative satisfaction (p = 0.029). Preoperative scoliosis predicted an impaired outcome in the ODI (p = 0.031) and lowered the walking distance in the treadmill test (p = 0.001). The preoperative finding of only one stenotic level in visual assessment predicted less postoperative LBP when compared with patients having 2 or more stenotic levels (p = 0.026). No significant differences were detected between quantitative measurements and the patient outcome.
Conclusions
Routine preoperative lumbar spine MRI can predict the patient outcome in a two-year follow up in patients with LSS surgery. Severe central stenosis and one-level central stenosis are predictors of good outcome. Preoperative finding of scoliosis may indicate worse functional ability.
doi:10.1371/journal.pone.0106404
PMCID: PMC4167706  PMID: 25229343
4.  The relationship between the grading stenosis based on morphology of the dural sac on MRI and the preoperative symptoms in patients with lumbar spinal canal stenosis 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 52.
Abstract:
Background:
Grading stenosis based on morphology of the dural sac on MRI rather than surface measurements defines stenosis in various topics. To study the relations between the grading stenosis and the severity of clinical symptoms of spinal stenosis in patients diagnosed with lumbar spinal canal stenosis (LSCS).
Methods:
Patients diagnosed with lumbar spinal stenosis who were candidate for surgery entered into this cross sectional study. Grading stenosis based on morphology of the dural sac on magnetic resonance imaging (MRI) was determined. The severity of symptoms was evaluated based on the duration of symptoms, walking distance, visual analogue scale (VAS) of leg pain/numbness, the Neurogenic Claudication Outcome Score (NCOS) and the Japanese Orthopaedic Association (JOA) Score. We studied distribution of grades, relation between morphologic grading and severity of symptoms. The severity of symptoms and morphologic grading were compared between patients with different grades stenosis.
Results:
Eighty four patients were eligible to enter the study during the two years course of study. Patients were aged 61.2 ± 11.3 (18 to 82 years). All of patients were grades C and D stenosis 56 and 28 respectively. The symptoms were significantly worse in patients with a morphologic grade D stenosis (p less than 0.001). The walking distance in the patients with grade D stenosis was significantly shorter than those with grade C stenosis (P less than 0.001). In addition, the VAS of leg numbness in patients with grade D stenosis was significantly higher than those with a morphologic grade C stenosis (P less than 0.001). The JOA and the NCOS scores were significantly lower in patients with grade D stenosis (P less than 0.001). No significant difference was observed in the characteristics, duration of symptoms or VAS of leg pain between the groups.
Conclusions:
The findings suggest that the effect of grade D stenosis on patients’ symptoms, walking ability and functionality are more profound than grade C stenosis.
Keywords:
Lumbar spinal canal stenosis, Grading stenosis relationship, Severity of clinical symptoms
PMCID: PMC3571578
5.  Magnetic resonance imaging findings in low back pain and lower extremity radicular chronic pain 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 37.
Abstract:
Background:
Low back pain (LBP) is one of the most prevalent complaints among the people worldwide. According to the medical statistics, about 80 percent of people have at least one episode of LBP during their lifetime cause them to visit a physician for treatment. LBP is the most prevalent cause of work disability and its related leaves among people under 45 years old. Numerous studies have been conducted on the connection between clinical signs, patients’ complaints, the level of lumbar disc herniation, and abnormal findings of magnetic resonance imaging (MRI). In many cases, contradictory views have been reported and even in some cases canal stenosis and herniated disc have been reported in patient without clinical sings. The aim of this study was to analyze MRI findings in patients with LBP and radicular chronic pain (RCP) attending Imam Reza Hospital (Kermanshah, Iran).
Methods:
This cross-sectional study was conducted on 200 patients (100 with LBP and 100 with RCP). Following unsuccessful results of medical treatment for 1 to 48 months, the examination results, demographic information (age, sex, job, etc.) and their complaints along with MRI findings were documented and statistically analyzed. Patients with history of lumbar surgery, infective inflammatory diseases, fractures, tumors, etc were excluded from the study. To determine the significant correlation between qualitative and quantitative variables, the Chi-Square test and the independent t-test were respectively performed using the statistical package of SPSS (Version 12) The P-value of less than 0.05 was considered significant.
Results:
In the LBP group, patients complained only of posterior and inferior spinal column pain and did not have any pain distribution toward lower limbs or any other signs. However, in the RCP group, in addition to pain distribution towards the lower limbs, they were complaining about muscular myotonia and sensational disorder and 88% also had low back pain. 94 of them were men and 106 were women.106 subjects (80.5%) were urban residents and 39 (19.5%) rural residents. There were 42.5% housewife, 21.5% employee, 15% workers, 9.5% self-employed, and 8.5% were unemployed. In terms of education, 27% were uneducated, 40.5% with incomplete high school diploma, and 32.5% with high school diploma and higher levels of education. 33.5% of patients had the treatment period of one month, while for the rest this period was more than one month to 4 years. Twenty percent did not rest, 52.5% rested up to 3 weeks and 24% rested up to 3 months. In the RCP group, 41% complained of pain in the right leg, 36% in the left leg, and 23% in both legs. However, in the RCP group, 26% had limb paresis, 5% atrophy, 25% some levels of sensational disorders, and 2% had sphincter disorders.
MRI findings:
Herniated disc in the form of protrusion and extrusion at L4-L5 and L5-S1 spaces were mainly observed in patients with RCP rather than those with LBP. Twenty-six patients (13%) had spondylolisthesis of which 12 (46.2%) were in LBP group and the other 14 patients (53.8) in RCP group. Forty-eight patients (24%) had canal stenosis of which 11 patients were from LBP group and 37 from RCP group. Of these 48 patients, 11 had partial stenosis and 37 had absolute stenosis that were in the RCP group.
Conclusions:
The most prevalent herniated disc spaces were at the levels of L4-L5 (87%) and S1-S2 (65%). This is because that most of the movements occur in the mobile parts of disc surface and the stresses that are exerted on the mentioned part. Generally, a meaningful correlation between existence of canal stenosis at L4-L5 and L5-S1 levels and the existence of pressure effect on nerve in THECAL SAC and lat recess in patients with RCP was seen; and also a meaningful correlation among muscular myotonia, radicular distribution of limbs’ pain along with compressive effects on the nerve in the lat recess and the thecal sac and spinal canal stenosis were observed. A significant correlation between complaints of RCP in lower limbs and muscular myotonia with these findings was seen but in analyzing the distributing pain patterns or muscular myotonia on the base of RCP such a correlation was not seen.
Keywords:
Low back pain, Radicular back pain, Magnetic resonance imaging
PMCID: PMC3571563
6.  Do presence and location of annular tear influence clinical outcome after lumbar total disc arthroplasty? A prospective 1-year follow-up study 
Background
Lumbar total disc arthroplasty is often performed in patients with axial back pain. There are multiple etiologies for axial back pain, including disc degeneration and annular tears. The location of these annular tears can vary, producing differing preoperative symptomatology. Intraoperatively, disruptions in the annulus are identifiable, and it has been suggested that patients with discrete annular tears may have better clinical outcomes after surgery. The purpose of this study was to investigate whether the presence and location of annular tears have an effect on clinical outcomes after lumbar total disc arthroplasty.
Methods
Patients undergoing a single-level anterior disc replacement from L3-S1 at a single site by a single surgeon were evaluated preoperatively for the presence or absence of annular tears with magnetic resonance imaging. All patients were part of either the ProDisc (n = 41) (Synthes, Paoli, Pennsylvania) or Activ-L (n = 19) (Aesculap [B. Braun Melsungen AG], Tuttlingen, Germany) lumbar prospective clinical trials. In those patients with annular tears, the location of the tear (central, paracentral, or lateral) was documented. Patients were assessed at 6 and 12 months after lumbar total disc arthroplasty with the Oswestry Disability Index (ODI), visual analog scale (VAS) score for back pain, VAS score for leg pain, and radiographic imaging. All radiographic evaluations were conducted by an attending neuroradiologist and an attending spinal surgeon, and reliability testing was performed. An analysis of variance was performed among the 3 anatomic locations of annular tears.
Results
A total of 60 patients were included and had complete 12-month follow-up. The prevalence of annular tears among all patients was 42% (n = 25). Outcome data in patients without annular tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 8.0 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 2.9 preoperatively and 1.2 postoperatively. Among those patients with tears, the prevalence of central tears was 80%, the prevalence of paracentral tears was 12%, and the prevalence of lateral tears was 8%. Outcome data in patients with central tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 7.8 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 5.2 preoperatively and 0.5 postoperatively. Outcome data in patients with paracentral tears were as follows: ODI, 86% preoperatively and 59% postoperatively; VAS score for back pain, 8.8 preoperatively and 3.3 postoperatively; and VAS score for leg pain, 5.0 preoperatively and 5.4 postoperatively. Outcome data in patients with lateral tears were as follows: ODI, 6.5 preoperatively and 2.6 postoperatively; VAS score for back pain, 9.2 preoperatively and 0.2 postoperatively; and VAS score for leg pain, 1.4 preoperatively and 0.7 postoperatively. In those patients with paracentral tears, there was a significantly higher incidence of postoperative radicular symptoms both from an intensity standpoint and from a duration standpoint. Other complications did not vary among those patients with or without annular tears.
Conclusions
Although patients with annular tears and patients without annular tears improve after lumbar artificial disc replacement, those with central annular tears or without tears have significantly lower disability scores than those with paracentral tears or lateral tears, whose outcome scores showed significantly less improvement (P ≤ .03). In particular, patients with central tears have less postoperative leg pain than those with paracentral annular tears. In this study the presence or absence of an annular tear on magnetic resonance imaging was not a significant predictive factor for clinical outcome. Further investigation regarding the effects of paracentral annular tears and surgical techniques should be explored.
doi:10.1016/j.ijsp.2011.09.001
PMCID: PMC4300871
Lumbar disc arthroplasty; Annular tear; High intensity zone (HIZ)
7.  Endoscopic transforaminal decompression, interbody fusion, and percutaneous pedicle screw implantation of the lumbar spine: A case series report 
Background
On the basis of the experiences gained from conventional open spinal procedures, a long list of desirable objectives have emerged with the evolution of the lesser invasive spinal procedures. At the top of that list is the desire to minimize the trauma of surgery. The rest of the objectives, which include reductions of operating time, surgical blood loss, hospital stay, postoperative narcotic medication, convalescence, complication rates, and escalating health care costs, as well as the desire of elderly patients to continue rigorous physical activities, largely depend on the ability to minimize the trauma of surgery. The purpose of this study was to investigate the feasibility of the least invasive lumbar decompression, interbody fusion and percutaneous pedicle screw implantation, to minimize surgical trauma without compromising the quality of the treatment outcome, as well as to minimize risk of complications.
Methods
In this case series, 60 patients with diagnoses of degenerative disc disease, degenerative motion segments with stenosis, and spondylolisthesis, in whom nonoperative treatments failed, were treated with endoscopic transforaminal decompression and interbody fusion by 1 surgeon in 2 centers. The outcome measures were as follows: operating time, intraoperative blood loss, hospital stay, Visual Analogue Scale (VAS) scores for back and leg pain, scores on the Roland-Morris Disability Questionnaire, and postoperative imaging studies. A consecutive series of patients who met the treatment criteria completed VAS forms and Roland-Morris questionnaires preoperatively. Surgical procedures included arthroscopic decompression of the foramina and the discs; endplate preparation and implantation of allograft bone chips and bone morphogenetic protein 2 on absorbable collagen sponge into the disc space; and percutaneous implantation of pedicle screws. Postoperatively, the patients again completed the VAS forms and Roland-Morris questionnaires. Their charts were reviewed for office notes, operative notes, hospital stay, medications, and imaging studies. The latest X-ray and computed tomography scan films were reviewed and analyzed. Patients were followed up for a minimum of 6 months. The literature was reviewed for comparison of outcomes.
Results
Sixty patients met the inclusion criteria. The mean age was 52.8 years. The duration of illness averaged 5 years. Follow-up ranged from 6 to 25 months, with a mean of 12 months. Preoperative diagnoses included degenerative disc disease, degenerative motion segments with stenosis, and spondylolisthesis. The mean time in the operating room was 2 hours 54 minutes. Estimated blood loss averaged 57.6 mL. The duration of the hospital stay averaged 2.6 days. Preoperative back pain and leg pain were significantly reduced (P < .005). Forty-seven imaging studies obtained at the last visit, including X-ray and computed tomography scans, showed solid fusion in 28 patients (59.6%), stable fixation in 17 (36.2%), and osteolysis around the pedicle screws in 2 (4.2%). All patients had improvement of motor function, whereas 2 patients complained of residual numbness. In addition, 8 patients (13%) complained of residual discomfort on extension of the lumbar spine. Two patients had pedicle screw–related complications requiring surgery. A review of the literature showed that endoscopic transforaminal decompression and interbody fusion performed better than open transforaminal lumbar interbody fusion/posterior lumbar interbody fusion, minimally invasive transforaminal lumbar interbody fusion, and extreme lateral lumbar interbody fusion, with regard to most parameters studied.
Conclusions
The endoscopic transforaminal lumbar decompression, interbody fusion, and percutaneous pedicle screw instrumentation consistently produced satisfactory results in all demographics. It performed better than the alternative procedures for most parameters studied.
doi:10.1016/j.ijsp.2012.04.001
PMCID: PMC4300894
ETDIF; Arthroscopic; Posterolateral; Interbody; Percutaneous; BMP-2
8.  A Novel Tool for the Assessment of Pain: Validation in Low Back Pain 
PLoS Medicine  2009;6(4):e1000047.
Joachim Scholz and colleagues develop and validate an assessment tool that distinguishes between radicular and axial low back pain.
Background
Adequate pain assessment is critical for evaluating the efficacy of analgesic treatment in clinical practice and during the development of new therapies. Yet the currently used scores of global pain intensity fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms. We have developed a tool for a standardized assessment of pain-related symptoms and signs that differentiates pain phenotypes independent of etiology.
Methods and Findings
Using a structured interview (16 questions) and a standardized bedside examination (23 tests), we prospectively assessed symptoms and signs in 130 patients with peripheral neuropathic pain caused by diabetic polyneuropathy, postherpetic neuralgia, or radicular low back pain (LBP), and in 57 patients with non-neuropathic (axial) LBP. A hierarchical cluster analysis revealed distinct association patterns of symptoms and signs (pain subtypes) that characterized six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain. Using a classification tree analysis, we identified the most discriminatory assessment items for the identification of pain subtypes. We combined these six interview questions and ten physical tests in a pain assessment tool that we named Standardized Evaluation of Pain (StEP). We validated StEP for the distinction between radicular and axial LBP in an independent group of 137 patients. StEP identified patients with radicular pain with high sensitivity (92%; 95% confidence interval [CI] 83%–97%) and specificity (97%; 95% CI 89%–100%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. In addition, we were able to reproduce subtypes of radicular and axial LBP, underscoring the utility of StEP for discerning distinct constellations of symptoms and signs.
Conclusions
We present a novel method of identifying pain subtypes that we believe reflect underlying pain mechanisms. We demonstrate that this new approach to pain assessment helps separate radicular from axial back pain. Beyond diagnostic utility, a standardized differentiation of pain subtypes that is independent of disease etiology may offer a unique opportunity to improve targeted analgesic treatment.
Editors' Summary
Background
Pain, although unpleasant, is essential for survival. Whenever the body is damaged, nerve cells detecting the injury send an electrical message via the spinal cord to the brain and, as a result, action is taken to prevent further damage. Usually pain is short-lived, but sometimes it continues for weeks, months, or years. Long-lasting (chronic) pain can be caused by an ongoing, often inflammatory condition (for example, arthritis) or by damage to the nervous system itself—experts call this “neuropathic” pain. Damage to the brain or spinal cord causes central neuropathic pain; damage to the nerves that convey information from distant parts of the body to the spinal cord causes peripheral neuropathic pain. One example of peripheral neuropathic pain is “radicular” low back pain (also called sciatica). This is pain that radiates from the back into the legs. By contrast, axial back pain (the most common type of low back pain) is confined to the lower back and is non-neuropathic.
Why Was This Study Done?
Chronic pain is very common—nearly 10% of American adults have frequent back pain, for example—and there are many treatments for it, including rest, regulated exercise (physical therapy), pain-killing drugs (analgesics), and surgery. However, the best treatment for any individual depends on the exact nature of their pain, so it is important to assess their pain carefully before starting treatment. This is usually done by scoring overall pain intensity, but this assessment does not reflect the characteristics of the pain (for example, whether it occurs spontaneously or in response to external stimuli) or the complex biological processes involved in pain generation. An assessment designed to take such factors into account might improve treatment outcomes and could be useful in the development of new therapies. In this study, the researchers develop and test a new, standardized tool for the assessment of chronic pain that, by examining many symptoms and signs, aims to distinguish between pain subtypes.
What Did the Researchers Do and Find?
One hundred thirty patients with several types of peripheral neuropathic pain and 57 patients with non-neuropathic (axial) low back pain completed a structured interview of 16 questions and a standardized bedside examination of 23 tests. Patients were asked, for example, to choose words that described their pain from a list provided by the researchers and to grade the intensity of particular aspects of their pain from zero (no pain) to ten (the maximum imaginable pain). Bedside tests included measurements of responses to light touch, pinprick, and vibration—chronic pain often alters responses to harmless stimuli. Using “hierarchical cluster analysis,” the researchers identified six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain based on the patterns of symptoms and signs revealed by the interviews and physical tests. They then used “classification tree analysis” to identify the six questions and ten physical tests that discriminated best between pain subtypes and combined these items into a tool for a Standardized Evaluation of Pain (StEP). Finally, the researchers asked whether StEP, which took 10–15 minutes, could identify patients with radicular back pain and discriminate them from those with axial back pain in an independent group of 137 patients with chronic low back pain. StEP, they report, accurately diagnosed these two conditions and was well accepted by the patients.
What Do These Findings Mean?
These findings indicate that a standardized assessment of pain-related signs and symptoms can provide a simple, quick diagnostic procedure that distinguishes between radicular (neuropathic) and axial (non-neuropathic) low back pain. This distinction is crucial because these types of back pain are best treated in different ways. In addition, the findings suggest that it might be possible to identify additional pain subtypes using StEP. Because these subtypes may represent conditions in which different pain mechanisms are acting, classifying patients in this way might eventually enable physicians to tailor treatments for chronic pain to the specific needs of individual patients rather than, as at present, largely guessing which of the available treatments is likely to work best.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000047.
This study is further discussed in a PLoS Medicine Perspective by Giorgio Cruccu and and Andrea Truini
The US National Institute of Neurological Disorders and Stroke provides a primer on pain in English and Spanish
In its 2006 report on the health status of the US, the National Center for Health Statistics provides a special feature on the epidemiology of pain, including back pain
The Pain Treatment Topics Web site is a resource, sponsored partly by associations and manufacturers, that provides information on all aspects of pain and its treatment for health care professionals and their patients
Medline Plus provides a brief description of pain and of back pain and links to further information on both topics (in English and Spanish)
The MedlinePlus Medical Encyclopedia also has a page on low back pain (in English and Spanish)
doi:10.1371/journal.pmed.1000047
PMCID: PMC2661253  PMID: 19360087
9.  Clinical outcome of instrumented fusion for the treatment of failed back surgery syndrome: a case series of 100 patients 
Acta Neurochirurgica  2012;154(7):1213-1217.
Object
Failed back surgery syndrome is defined as persistent chronic low-back pain and/or leg pain lasting more than 1 year, despite of one or more surgical procedures. Instrumented spinal fusion has been offered by surgeons as a potential treatment to recover from pain and functional disability. Factors contributing to good outcome of instrumented spinal fusion have not been investigated extensively. This study evaluated the global perceived recovery and functional status of patients after instrumented fusion for the treatment of failed back surgery syndrome.
Methods
Between January 2004 and September 2007, 100 patients underwent instrumented spinal fusion because of persistent back and/or leg pain lasting more than 1 year despite of one or more previous spine surgeries. The global perceived recovery of the patients was documented on a seven-point Likert scale, in which good outcome was defined as “complete recovery” and “almost complete recovery”. Pain was evaluated by the 100-mm visual analogue scale (VAS) of back pain and leg pain, and functional disability measured by the Roland Disability Questionnaire for Sciatica (RDQ) and Oswestry Disability Index (ODI). The Hospital Anxiety and Depression Scale (HADS) evaluated psychological co-morbidity. All patients were sent questionnaires by mail. Pearson’s correlation coefficient was calculated between outcome measures and preoperative patient characteristics.
Results
Eighty-two patients (82% response rate) returned questionnaires that were useful for analysis. After a mean follow-up period of 15 months, 35% of the patients reported good outcome, whereas 65% had unsatisfactory outcome. The mean (± SD) score of VAS low-back pain and leg pain was 45.7 ± 29 and 37.9 ± 31.9, respectively. The mean (± SD) RDQ and ODI score was 11.8 ± 5.4 and 30.6 ± 20.3, respectively. HADS score indicated a possible anxiety disorder in 28% of the patients and in 30% a possible underlying depression. Of the patients’ baseline characteristics, there was only a significantly negative correlation between level of education and outcome.
Conclusions
The present study showed disappointing outcome of instrumented fusion for the treatment of failed back surgery syndrome in terms of perceived recovery, functional disability and pain. Conservative management is probably more beneficial and, therefore, more selective and careful assessment should be done in order to prevent unnecessary surgery.
doi:10.1007/s00701-012-1380-7
PMCID: PMC3382643  PMID: 22588339
Failed back surgery syndrome; Instrumented fusion; Pain; Postlaminectomy syndrome; Surgery
10.  Massive lumbar disc herniation with complete dural sac stenosis 
Indian Journal of Orthopaedics  2013;47(3):244-249.
Background:
Large lumbar disc herniation (LDH) has been reported to have a greater tendency to resolve in clinical and pathomorphological evolutions. However, various definitions of large LDH have been used without validation, and the clinical symptoms of large LDH have not been fully elucidated. We conducted a retrospective analysis to determine the clinical characteristics and treatment outcome of massive LDH with complete dural sac stenosis
Materials and Methods:
We retrospectively reviewed 33 cases of LDH with complete dural sac stenosis on magnetic resonance imaging. Complete dural sac stenosis was defined as no recognizable rootlet and cerebrospinal fluid signal on T2-weighed axial MR images. The clinical outcome parameters included back pain, leg pain, Oswestry disability index (ODI), and neurological dysfunction. The paired t-test and Wilcoxon's signed rank test were used to compare serial changes in back pain, leg pain and neurological dysfunction.
Results:
Mean duration of followup was 66 months (range 24 - 108 months). There were 24 male and 9 female. The mean age was 37 years (range 20 - 53 years). At presentation, mean visual analogue scales for back pain and leg pain were 75.3 ± 19.1 (range 12 - 100) and 80.2 ± 14.6 (range 0 -100), respectively. Mean ODI was 67.1 ± 18.8 (range 26 - 88). Neurological dysfunction was found in 9 patients (27.3%), and the bowel/bladder dysfunction was found in 2 patients (3.1%). Conservative treatment was performed in 21 patients (63.6%) with satisfactory results. Seven patients underwent decompressive surgery, and 5 underwent posterolateral fusion.
Conclusions:
A massive LDH with complete dural sac stenosis was found to be associated with severe back and leg pain at presentation, however surgical treatment can be deferred unless significant neurological symptoms occur.
doi:10.4103/0019-5413.111505
PMCID: PMC3687900  PMID: 23798754
Intervertebral disc; lumbar; massive disc herniation; MRI
11.  Clinical and psychofunctional measures of conservative decompression surgery for lumbar spinal stenosis: a prospective cohort study 
European Spine Journal  2002;12(2):197-204.
Abstract.
Less invasive decompressive surgery has emerged as a logical surgical treatment alternative to wide decompression of spinal stenosis. The clinical outcomes of such conservative surgical treatment, however, are not well known. The aim of the study was to evaluate short-term psychometric and functional outcomes after conservative decompressive surgery for lumbar canal stenosis. Forty patients had a lumbar laminectomy procedure, which preserved the integrity of the neural arches, facet joints and most muscle attachments. Pre-operative clinical evaluation of the patients included: Waddell's non-organic signs (NOS) performed by an independent surgeon observer; three self-report questionnaires – the Waddell Disability Index (WDI), the Oswestry Low Back Pain Disability Questionnaire (ODI), and the Low Back Outcome Score (LBOS); and a general questionnaire that included a visual analog pain intensity scale (VAS). Post-operative clinical evaluations and questionnaires were obtained in 36 subjects (mean age 59.8 years) after a 1.7-year follow-up (range 1–2.6 years). Pre-operative versus post-operative statistical comparisons of the data were performed using adjusted error rates within families of predictors. Successful surgical outcome was defined as an improvement in at least three of the following four criteria: self-reported pain on a VAS, self-reported functional status measured by LBOS, reduction of pain during walking and reduction of leg pain. At follow-up, there was a statistically significant improvement in VAS pain intensity, ODI, WDI, and LBOS. Patients classified as having mixed stenosis had a higher incidence of continuous pain symptoms in comparison with acquired stenosis, but there was no differential improvement with treatment depending upon stenosis classification and/or number of operative levels. Overall, 58% (21/36) of patients met the successful surgical outcome criteria, including 14 subjects who met all four success criteria. Based upon a stringent definition of successful surgical outcome, the results of a conservative laminectomy were as good as those of more aggressive decompressive procedures presented in the literature. Our findings indicate that, even in a highly organic disorder such as spinal stenosis, illness behavior plays an important role in predicting surgical outcome.
doi:10.1007/s00586-002-0479-6
PMCID: PMC3784854  PMID: 12709858
Lumbar vertebrae Conservative treatment Laminarthrectomy Stenosis Surgery
12.  Clinical outcomes following sublaminar-trimming laminoplasty for extensive lumbar canal stenosis 
European Spine Journal  2013;23(1):80-86.
Purpose
Current surgical approaches for treatment of lumbar canal stenosis are often associated with relatively high rates of reoperation and recurrent stenosis. We have developed a new approach for treatment of this condition: sublaminar-trimming laminoplasty. To describe the surgical approach of sublaminar-trimming laminoplasty and to assess associated outcomes.
Methods
Patients with extensive lumbar canal stenosis who received sublaminar-trimming laminoplasty from 2006 to 2008 were considered for inclusion in the study. The surgery comprised aspects of laminotomy and laminectomy. The following were assessed before surgery and 3 years after surgery: leg and back pain by visual analog scale (VAS), extent of disability by Oswestry Disability Index (ODI), severity of back pain by Japanese Orthopedic Association Score for Back Pain (JOA), walking tolerance, and leg numbness. Complications were noted.
Results
A total of 49 patients were included in the study (mean age 65.6 ± 10.6 years). VAS leg and back pain, ODI, and JOA scores significantly changed from before surgery to 3 years after surgery (P < 0.001). Mean changes (95 % confidence interval) were −6.2 (−6.7, −5.7), −4.3 (−4.8, −3.8), −21.4 (−23.4, −19.5), and 13.4 (12.1, 14.7) for leg pain, back pain, ODI, and JOA scores, respectively. Patients experienced significant improvements in walking tolerance and leg numbness (P < 0.001). There were no instances of recurrent stenosis or postoperative spinal instability. Complications included intraoperative dural tear (n = 2), postoperative urinary tract infection (n = 2), and inadequate decompression and junctional stenosis during follow-up (both n = 1).
Conclusion
Sublaminar-trimming laminoplasty shows promise as an effective treatment for extensive lumbar canal stenosis.
doi:10.1007/s00586-013-2888-0
PMCID: PMC3897809  PMID: 23852436
Laminoplasty; Lumbar canal; Stenosis; Sublaminar-trimming; Treatment
13.  Minimally invasive surgical treatment of lumbar spinal stenosis: Two-year follow-up in 54 patients 
Objective:
Minimally invasive surgery has seen increasing application in the treatment of spinal disorders. Treatment of degenerative spinal stenosis, with or without spondylolisthesis, with minimally invasive technique preserves stabilizing ligaments, bone, and muscle. Satisfactory results can be achieved without the need for fusion in most cases.
Methods:
Fifty-four consecutive patients underwent bilateral decompressions from a unilateral approach for spinal stenosis using METRx instrumentation. Visual Analog Scale (VAS) pain scores were recorded preoperatively and patients were interviewed, in person or by phone, by our office nurse practitioner (LD) to assess postoperative VAS scores, and patient satisfaction with the clinical results 21-39 months postoperatively (median 27 months).
Results:
Fifty-four patients underwent decompression at 77 levels (L4/5 = 43, L3/4 = 22, L5/S1 = 8, L1/2 = 4, L2/3 = 4), (single = 35, double = 16, triple = 2, quadruple = 1). There were 39 females and 15 males. The average age was 67 years. The average operative time was 78 minutes and the average blood loss was 37 ml per level. Twenty-seven patients had preoperative degenerative spondylolisthesis (Grade 1 = 26, Grade 2 = 1). Eight patients had discectomies and four had synovial cysts. Patient satisfaction was high. Use of pain medication for leg and back pain was low, and VAS scores improved by more than half. There were three dural tears. There were no deaths or infections. One patient with an unrecognized dural tear required re-exploration for repair of a pseudomeningocele and one patient required a lumbar fusion for pain associated with progression of her spondylolisthesis.
Conclusions:
Minimally invasive bilateral decompression of acquired spinal stenosis from a unilateral approach can be successfully accomplished with reasonable operative times, minimal blood loss, and acceptable morbidity. Two-year outcomes in this series revealed high patient satisfaction and only one patient progressed to lumbar fusion.
doi:10.4103/2152-7806.94294
PMCID: PMC3326943  PMID: 22530175
Lumbar spinal stenosis; minimally invasive surgery; spondylolisthesis
14.  Step activity monitoring in lumbar stenosis patients undergoing decompressive surgery 
European Spine Journal  2010;19(11):1855-1864.
Symptomatic degenerative central lumbar spinal stenosis (LSS) is a frequent indication for decompressive spinal surgery, to reduce spinal claudication. No data are as yet available on the effect of surgery on the level of activity measured with objective long-term monitoring. The aim of this prospective, controlled study was to objectively quantify the level of activity in central LSS patients before and after surgery, using a continuous measurement device. The objective data were correlated with subjective clinical results and the radiographic degree of stenosis. Forty-seven patients with central LSS and typical spinal claudication scheduled for surgery were included. The level of activity (number of gait cycles) was quantified for 7 consecutive days using the StepWatch Activity Monitor (SAM). Visual analogue scales (VAS) for back and leg pain, Oswestry disability index and Roland–Morris score were used to assess the patients’ clinical status. The patients were investigated before surgery and 3 and 12 months after surgery. In addition, the radiographic extent of central LSS was measured digitally on preoperative magnetic resonance imaging or computed tomography. The following results were found preoperatively: 3,578 gait cycles/day, VAS for back pain 5.7 and for leg pain 6.5. Three months after surgery, the patients showed improvement: 4,145 gait cycles/day, VAS for back pain 4.0 and for leg pain 3.0. Twelve months after surgery, the improvement continued: 4,335 gait cycles/day, VAS for back pain 4.1 and for leg pain 3.3. The clinical results and SAM results showed significant improvement when preoperative data were compared with data 3 and 12 months after surgery. The results 12 months after surgery did not differ significantly from those 3 months after surgery. The level of activity correlated significantly with the degree of leg pain. The mean cross-sectional area of the spinal canal at the central LSS was 94 mm2. The radiographic results did not correlate either with objective SAM results or with clinical outcome parameters. In conclusion, this study is the first to present objective data on continuous activity monitoring/measurements in patients with central LSS. The SAM could be an adequate tool for performing these measurements in spine patients. Except for leg pain, the objective SAM results did not correlate with the clinical results or with the radiographic extent of central LSS.
doi:10.1007/s00586-010-1324-y
PMCID: PMC2989265  PMID: 20186442
Step activity monitor (SAM); Lumbar spinal stenosis; Decompression; Level of activity; Mobility
15.  Clinical outcomes and safety assessment in elderly patients undergoing decompressive laminectomy for lumbar spinal stenosis: a prospective study 
BMC Surgery  2010;10:34.
Background
To assess safety, risk factors and clinical outcomes in elderly patients with spinal stenosis after decompressive laminectomy.
Methods
A prospective cohort of patients 70 years and older with spinal stenosis undergoing conventional laminectomy without fusion (n = 101) were consecutively enrolled from regular clinical practice and reassessed at 3 and 12 months. Primary outcome was change in health related quality of life measured (HRQL) with EuroQol-5 D (EQ-5D). Secondary outcomes were safety assessment, changes in Oswestry disability index (ODI), Visual Analogue Scale (EQ-VAS) score for self reported health, VAS score for leg and back pain and patient satisfaction. We used regression analyses to evaluate risk factors for less improvement.
Results
The mean EQ-5 D total score were 0.32, 0.63 and 0.60 at baseline, 3 months and 12 months respectively, and represents a statistically significant (P < 0.001) improvement. Effect size was > 0.8. Mean ODI score at baseline was 44.2, at 3 months 25.6 and at 27.9. This represents an improvement for all post-operative scores. A total of 18 (18.0%) complications were registered with 6 (6.0%) classified as major, including one perioperative death. Patients stating that the surgery had been beneficial at 3 months was 82 (89.1%) and at 12 months 73 (86.9%). The only predictor found was patients with longer duration of leg pain had less improvement in ODI (P < 0.001). Increased age or having complications did not predict a worse outcome in any of the outcome variables.
Conclusions
Properly selected patients of 70 years and older can expect a clinical meaningful improvement of HRQL, functional status and pain after open laminectomy without fusion. The treatment seems to be safe. However, patients with longstanding leg-pain prior to operation are less likely to improve one year after surgery.
doi:10.1186/1471-2482-10-34
PMCID: PMC2996343  PMID: 21092227
16.  A long-term (4- to 12-year) follow-up study of surgical treatment of lumbar spinal stenosis 
European Spine Journal  2000;9(6):563-570.
Limited data are available about the long-term outcome of surgical treatment for lumbar spinal stenosis, and there is a wide variation in reported success rates. There is also a controversy regarding differences in long-term outcome between patients undergoing decompressive surgery alone and those undergoing both decompression and fusion. The aim of this study was to evaluate the long-term clinical outcome and possible complications of decompressive surgery, with special reference to possible differences between patients undergoing fusion, with or without instrumentation, and those undergoing decompression alone. All 124 patients undergoing first-time surgery for lumbar spinal stenosis between 1982 and 1991 at our department were included, and their medical records were reviewed retrospectively. Ninety-six of the patients were available for follow-up and were re-examined by an independent investigator and assessed with a questionnaire after a mean follow-up period of 7.1 (range 4.0–12.2) years. Sixty-five percent of all the patients at the follow-up were subjectively satisfied. Eighty-eight percent of the patients reported constant or daily leg pain preoperatively compared to 43% at follow-up. Constant or daily low back pain was reported by 83% of the patients preoperatively compared to 45% at follow-up. Improvement in walking capacity was found in most patients, and only 4% of the patients who had a preoperatively documented maximum walking distance reported a decreased walking capacity. Twenty-four (25%) of all patients used analgesics daily at the time of follow-up, 34 patients (35%) occasionally and 38 patients (40%) never. The patients with fusions, instrumented or non-instrumented, did not differ significantly from the unfused patients regarding any of the above-mentioned parameters. The results of the study showed that most patients demonstrated a considerable improvement in walking capacity at follow-up. This improvement was significant (P < 0.001) and of clinical importance. A significant improvement regarding both low back pain and leg pain was found postoperatively compared to preoperatively (P < 0.001). There were no statistical differences, judged by all the evaluated parameters, regarding the clinical outcome between patients who were fused and those who were not. Neither were any significant differences found between instrumented fusions compared to uninstrumented fusions. In accordance with most other long-term follow-up studies, about two-thirds (65%) of the patients claimed a satisfactory result at follow-up.
doi:10.1007/s005860000161
PMCID: PMC3611425  PMID: 11189928
Key words Spinal disease; Spinal stenosis; Surgery; Follow-up; studies; Treatment outcome
17.  Descriptive Epidemiology and Prior Healthcare Utilization of Patients in the Spine Patient Outcomes Research Trial’s (SPORT) Three Observational Cohorts: Disc Herniation, Spinal Stenosis and Degenerative Spondylolisthesis 
Spine  2006;31(7):806-814.
Study Design
Prospective Observational Cohorts
Objective
To describe sociodemographic and clinical features, and non-operative (medical) resource utilization prior to enrollment, in patients who are candidates for surgical intervention for intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS) according to SPORT criteria.
Summary of Background Data
Intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis with stenosis are the three most common diagnoses of low back and leg symptoms for which surgery is performed. There is a paucity of descriptive literature examining large patient cohorts for the relationships among baseline characteristics and medical resource utilization with these three diagnoses.
Methods
The Spine Patient Outcomes Research Trial (SPORT) conducts three randomized and three observational cohort studies of surgical and non-surgical treatments for patients with IDH, SPS, and DS. Baseline data include demographic information, prior treatments received, and functional status measured by SF-36 and the Oswestry Disability Index (ODI-AAOS/Modems version). The data presented represents all 1,417 patients (745 IDH, 368 SpS, 304 DS) enrolled in the SPORT observational cohorts. Multiple logistic regression was used to generate independent predictors of utilization adjusted for sociodemographic variables, diagnosis, and duration of symptoms.
Results
The average age was 41 years for the IDH group, 64 years for the SPS group, and 66 years for the DS group.
At enrollment, IDH patients presented with the most pain as reported on the SF-36 (BP 26.2 vs 33 SPS and 33.7 DS) and were the most impaired (ODI 51 vs 42.3 SPS and 41.5 DS). IDH patients utilized more chiropractic treatment (42% vs 33% SPS and 26% DS); had more Emergency Department (ED) visits (21% vs 7 % SPS and 4% DS); and used more opiate analgesics (50% vs 29% SPS and 28% DS).
After adjusting for age, gender, diagnosis, education, race, duration of symptoms, and compensation, Medicaid patients used significantly more opiate analgesics (58% Medicaid vs 41% no insurance, 42% employer, 33% Medicare, and 32% private) and had more ED visits compared to other insurance types. (31% Medicaid vs 22% no insurance, 16% employer, 3% Medicare, and 11% private).
Conclusion
IDH patients appear to have differences in sociodemographics, resource utilization, and functional impairment when compared to the SpS/DS patients. In addition, the differences in resource utilization for Medicaid patients may reflect differences in access to care. The data provided from these observational cohorts will serve as an important comparison to the SPORT randomized cohorts in the future.
doi:10.1097/01.brs.0000207473.09030.0d
PMCID: PMC2775468  PMID: 16582855
SPORT; Disc herniation; spinal stenosis; degenerative spondylolisthesis; epidemiology; outcomes; utilization of healthcare resources
18.  Low back pain (acute) 
Clinical Evidence  2008;2008:1102.
Introduction
Low back pain (LBP) affects about 70% of people in resource-rich countries at some point. Acute low back pain is usually perceived as self-limiting; however, one year later, as many as 33% of people still have moderate-intensity pain and 15% have severe pain. It has a high recurrence rate; 75% of those with a first episode have a recurrence. Although acute episodes may resolve completely, they may also increase in severity and duration over time.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatments for low back pain? What are the effects of local injections for low back pain? What are the effects of non-drug treatments for low back pain? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 34 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics (paracetamol, opioids), back exercises, back schools, bed rest, behavioural therapy, electromyographic biofeedback, epidural corticosteroid injections, lumbar supports, massage, multidisciplinary treatment programmes, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), spinal manipulation (in the short term), temperature treatments (short wave diathermy, ultrasound, ice, heat), traction, and transcutaneous electrical nerve stimulation (TENS).
Key Points
Low back pain is pain, muscle tension, or stiffness, localised below the costal margin and above the inferior gluteal folds, with or without referred or radicular leg pain (sciatica), and is defined as acute when pain persists for less than 12 weeks. Low back pain affects about 70% of people in resource-rich countries at some point.Acute low back pain is usually self-limiting, although 2-7% develop chronic pain. Acute low back pain has a high recurrence rate with less-painful symptoms recurring in 50-80% of people within a year; one year later, as high as 33% still experience moderate-intensity pain and 15% experience severe pain.
NSAIDs have been shown to effectively improve symptoms compared with placebo. However, their use is associated with gastrointestinal adverse effects. Muscle relaxants may also reduce pain and improve overall clinical assessment, but are associated with some severe adverse effects including drowsiness, dizziness, and nausea.The studies examining the effects of analgesics such as paracetamol or opioids were generally too small to detect any clinically important differences.
We found no studies examining the effectiveness of epidural injections of corticosteroids in treating people with acute low back pain.
With regard to non-drug treatments, advice to stay active (be it as a single treatment or in combination with other interventions such as back schools, a graded activity programme, or behavioural counselling) seems the most effective. Spinal manipulation (in the short term) also seems to reduce pain, but not functional outcomes, compared with sham treatments.We found insufficient evidence to judge the effectiveness of acupuncture, back schools, behavioural therapy, massage, multidisciplinary treatment programmes (for either acute or subacute low back pain), ortemperature treatments in treating people with acute low back pain.We found no evidence examining the effectiveness of electromyographic biofeedback, lumbar supports, traction, or TENS in the treatment of acute low back pain. Back exercises do not seem to increase recovery time compared with no treatment, although there is considerable heterogeneity among studies with regard to the definition of back exercise. There is also disparity among studies in the definition of generic and specific back exercise. Bed rest does not improve symptoms any more effectively than other treatments, but does produce a number of adverse effects including joint stiffness, muscle wasting, loss of bone mineral density, pressure sores, and venous thromboembolism.
PMCID: PMC2907975  PMID: 19445792
19.  Predominant Leg Pain Is Associated With Better Surgical Outcomes in Degenerative Spondylolisthesis and Spinal Stenosis: Results from the Spine Patient Outcomes Research Trial (SPORT) 
Spine  2011;36(3):219-229.
Study Design
As-treated analysis of the Spine Patient Outcomes Research Trial (SPORT).
Objective
To compare baseline characteristics and surgical and nonoperative outcomes in degenerative spondylolisthesis (DS) and spinal stenosis (SpS) patients stratified by predominant pain location (i.e. leg vs. back).
Summary of Background Data
Evidence suggests that degenerative spondylolisthesis (DS) and spinal stenosis (SpS) patients with predominant leg pain may have better surgical outcomes than patients with predominant low back pain (LBP).
Methods
The DS cohort included 591 patients (62% underwent surgery), and the SpS cohort included 615 patients (62% underwent surgery). Patients were classified as leg pain predominant, LBP predominant or having equal pain according to baseline pain scores. Baseline characteristics were compared between the three predominant pain location groups within each diagnostic category, and changes in surgical and nonoperative outcome scores were compared through two years. Longitudinal regression models including baseline covariates were used to control for confounders.
Results
Among DS patients at baseline, 34% had predominant leg pain, 26% had predominant LBP, and 40% had equal pain. Similarly, 32% of SpS patients had predominant leg pain, 26% had predominant LBP, and 42% had equal pain. DS and SpS patients with predominant leg pain had baseline scores indicative of less severe symptoms. Leg pain predominant DS and SpS patients treated surgically improved significantly more than LBP predominant patients on all primary outcome measures at one and two years. Surgical outcomes for the equal pain groups were intermediate to those of the predominant leg pain and LBP groups. The differences in nonoperative outcomes were less consistent.
Conclusions
Predominant leg pain patients improved significantly more with surgery than predominant LBP patients. However, predominant LBP patients still improved significantly more with surgery than with nonoperative treatment.
doi:10.1097/BRS.0b013e3181d77c21
PMCID: PMC3057763  PMID: 21124260
Degenerative Spondylolisthesis; Spinal Stenosis; SPORT; Leg Pain; Back Pain
20.  Posterior lumbar interbody fusion using non resorbable poly-ether-ether-ketone versus resorbable poly-l-lactide-co-d,l-lactide fusion devices. Clinical outcome at a minimum of 2-year follow-up 
European Spine Journal  2010;20(4):618-622.
Previous papers on resorbable poly-l-lactide-co-d,l-lactide (PLDLLA) cages in spinal fusion have failed to report adequately on patient-centred clinical outcome measures. Also comparison of PLDLLA cage with a traditionally applicable counterpart has not been previously reported. This is the first randomized prospective study that assesses clinical outcome of PLDLLA cage compared with a poly-ether-ether-ketone (PEEK) implant. Twenty-six patients were randomly assigned to undergo instrumented posterior lumbar interbody fusion (PLIF) whereby either a PEEK cage or a PLDLLA cage was implanted. Clinical outcome based on visual analogue scale scores for leg pain and back pain, as well as Oswestry Disability Index (ODI) and SF-36 questionnaires were documented and analysed. When compared with preoperative values, all clinical parameters have significantly improved in the PEEK group at 2 years after surgery with the exception of SF-36 general health, SF-36 mental health and SF-36 role emotional scores. No clinical parameter showed significant improvement at 2 years after surgery compared with preoperative values in the PLDLLA patient group. Only six patients (50%) in the PLDLLA group showed improvement in the VAS scores for leg and back pain as well as the ODI, as opposed to 10 patients (71%) in the PEEK group. One-third of the patients in the PLDLLA group actually reported worsening of their pain scores and ODI. Three cases of mild to moderate osteolysis were seen in the PLDLLA group. Following up on our preliminary report, these 2-year results confirm the superiority of the PEEK implant to the resorbable PLDLLA implant in aiding spinal fusion and alleviating symptoms following PLIF in patients with degenerative spondylolisthesis associated with either canal stenosis or foramen stenosis or both and emanating from a single lumbar segment.
doi:10.1007/s00586-010-1568-6
PMCID: PMC3065608  PMID: 20842388
Lumbar interbody fusion; PEEK cage; PLDLLA; Resorbable cage
21.  Low back pain (acute) 
Clinical Evidence  2011;2011:1102.
Introduction
Low back pain affects about 70% of people in resource-rich countries at some point in their lives. Acute low back pain can be self-limiting; however, 1 year after an initial episode, as many as 33% of people still have moderate-intensity pain and 15% have severe pain. Acute low back pain has a high recurrence rate; 75% of those with a first episode have a recurrence. Although acute episodes may resolve completely, they may increase in severity and duration over time.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatments for acute low back pain? What are the effects of local injections for acute low back pain? What are the effects of non-drug treatments for acute low back pain? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 49 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics (paracetamol, opioids), back exercises, back schools, bed rest, behavioural therapy, electromyographic biofeedback, epidural corticosteroid injections, lumbar supports, massage, multidisciplinary treatment programmes, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), spinal manipulation, temperature treatments (short-wave diathermy, ultrasound, ice, heat), traction, and transcutaneous electrical nerve stimulation (TENS).
Key Points
Low back pain is pain, muscle tension, or stiffness, localised below the costal margin and above the inferior gluteal folds, with or without referred or radicular leg pain (sciatica), and is defined as acute when pain persists for <12 weeks. Low back pain affects about 70% of people in resource-rich countries at some point in their lives.Acute low back pain may be self-limiting, although there is a high recurrence rate with less-painful symptoms recurring in 50% to 80% of people within 1 year of the initial episode; 1 year later, as many as 33% of people still experience moderate-intensity pain and 15% experience severe pain.
NSAIDs have been shown to effectively improve symptoms compared with placebo. However, their use is associated with gastrointestinal adverse effects. Muscle relaxants may also reduce pain and improve overall clinical assessment, but are associated with some severe adverse effects including drowsiness, dizziness, and nausea.The studies examining the effects of analgesics such as paracetamol or opioids were generally too small to detect any clinically important differences.
We found no studies examining the effectiveness of epidural injections of corticosteroids in treating people with acute low back pain.
With regard to non-drug treatments, advice to stay active (be it as a single treatment or in combination with other interventions such as back schools, a graded activity programme, or behavioural counselling) may be effective. We don't know whether spinal manipulation improves pain or function compared with sham treatments.We found insufficient evidence to judge the effectiveness of acupuncture, back schools, behavioural therapy, massage, multidisciplinary treatment programmes (for either acute or subacute low back pain), lumbar supports, TENS, or temperature treatments in treating people with acute low back pain.We found no evidence examining the effectiveness of electromyographic biofeedback or traction in the treatment of acute low back pain. Back exercises may decrease recovery time compared with no treatment, but there is considerable heterogeneity among studies with regard to the definition of back exercise. There is a large disparity among studies in the definition of generic versus specific back exercise. Bed rest does not improve symptoms any more effectively than other treatments, but does produce a number of adverse effects including joint stiffness, muscle wasting, loss of bone mineral density, pressure sores, and venous thromboembolism.
PMCID: PMC3217769  PMID: 21549023
22.  Depressive symptoms during rehabilitation period predict poor outcome of lumbar spinal stenosis surgery: A two-year perspective 
Background
Previous research has shown an association between preoperative depressive symptoms and a poorer surgery outcome in lumbar spinal stenosis (LSS). It is not known whether depressive symptoms throughout the recovery period are relevant to the outcome of surgery in LSS. In this prospective clinical study the predictive value of preoperative and postoperative depressive symptoms with respect to the surgery outcome is reported.
Methods
96 patients (mean age 62 years) with symptomatic lumbar spinal stenosis underwent decompressive surgery. They completed the same set of questionnaires preoperatively and 3 months, 6 months, 1 year and 2 years postoperatively. Depressive symptoms were assessed with the 21-item Beck Depression Inventory. Physical functioning and pain were assessed with the Oswestry Disability Index, the Stucki Questionnaire, self-reported walking ability and VAS rating. Logistic regression analyses were used to examine the predictive value of preoperative and postoperative depressive symptoms regarding the surgery outcome. A "good" outcome was defined in two ways: first, by gaining a 30% improvement in relation to the preoperative disability and pain, and second, by having a score at or below the median value for disability and pain on 2-year follow-up.
Results
Having elevated depressive symptoms particularly on 3-month follow-up was predictive of a poorer surgery outcome regarding pain and disability: when the outcome was defined as less than 30% improvement from the baseline, the OR's (with 95% confidence intervals) were 2.94 (1.06-8.12), <0.05 for Oswestry and 3.33 (1.13-9.79), <0.05 for VAS. In median split approach the OR was 4.11 (1.27-13.32), <0.05 for Oswestry. Predictive associations also emerged between having depressive symptoms on 6-month and 1-year follow-ups and a poorer outcome regarding disability. The predictive value of elevated depressive symptoms particularly with respect to 2-yeard disability was evident whether the outcome was defined as a 30% improvement compared to the preoperative status or as belonging to the better scoring half of the study population on 2-year follow-up.
Conclusions
Preoperative and postoperative depressive symptoms may indicate those patients at greater risk of a poorer postoperative functional ability. For these patients, further clinical evaluation should be carried out, especially during postoperative stages.
doi:10.1186/1471-2474-11-152
PMCID: PMC2913992  PMID: 20604949
23.  A predictive model for outcome after conservative decompression surgery for lumbar spinal stenosis 
European Spine Journal  2003;13(1):14-21.
This study was designed to develop predictive models for surgical outcome based on information available prior to lumbar stenosis surgery. Forty patients underwent decompressive laminarthrectomy. Preop and 1-year postop evaluation included Waddell’s nonorganic signs, CT scan, Waddell disability index, Oswestry low back pain disability questionnaire, low back outcome score (LBOS), visual analog scale (VAS) for pain intensity, and trunk strength testing. Statistical comparisons of data used adjusted error rates within families of predictors. Mathematical models were developed to predict outcome success using stepwise logistic regression and decision-tree methodologies (chi-squared automatic interaction detection, or CHAID). Successful outcome was defined as improvement in at least three of four criteria: VAS, LBOS, and reductions in claudication and leg pain. Exact logistic regression analysis resulted in a three-predictor model. This model was more accurate in predicting unsuccessful outcome (negative predictive value 75.0%) than in successful outcome (positive predictive value 69.6%). A CHAID model correctly classified 90.1% of successful outcomes (positive predictive value 85.7%, negative predictive value 100%). The use of conservative surgical decompression for lumbar stenosis can be recommended, as it demonstrated a success rate similar to that of more invasive techniques. Given its physiologic and biomechanical advantages, it can be recommended as the surgical method of choice in this indication. Underlying subclinical vascular factors may be involved in the complaints of spinal stenosis patients. Those factors should be investigated more thoroughly, as they may account for some of the failures of surgical relief. The CHAID decision tree appears to be a novel and useful tool for predicting the results of spinal stenosis surgery
doi:10.1007/s00586-003-0583-2
PMCID: PMC3468041  PMID: 14658061
Biomechanics; Low back pain; Lumbar stenosis; Outcome scales; Predictive models
24.  Transforaminal Endoscopic Lumbar Decompression & Foraminoplasty: A 10 Year prospective survivability outcome study of the treatment of foraminal stenosis and failed back surgery 
Background
Conventional diagnosis between axial and foraminal stenosis is suboptimal and long-term outcomes limited to posterior decompression. Aware state Transforaminal Endoscopic Lumbar Decompression and Foraminoplasty (TELDF) offers a direct aware state means of localizing and treating neuro-claudicant back pain, referred pain and weakness associated with stenosis failing to respond to conventional rehabilitation, pain management or surgery. This prospective survivability study examines the outcomes 10 years after TELDF in patients with foraminal stenosis arising from degeneration or failed back surgery.
Methods
For 10 years prospective data were collected on 114 consecutive patients with multilevel spondylosis and neuro-claudicant back pain, referred pain and weakness with or without failed back surgery whose symptoms had failed to respond to conventional rehabilitation and pain management and who underwent TELDF. The level responsible for the predominant presenting symptoms of foraminal stenosis, determined on clinical grounds, MRI and or CT scans, was confirmed by transforaminal probing and discography. Patients underwent TELDF at the spinal segment at which the predominant presenting symptoms were reproduced. Those that required treatment at an additional segment were excluded. Outcomes were assessed by postal questionnaire with failures being examined by the independent authors using the Visual Analogue Pain Scale (VAPS), the Oswestry Disability Index (ODI) and the Prolo Activity Score.
Results
Cohort integrity was 69%. 79 patients were available for evaluation after removal of the deceased (12), untraceable (17) and decliners (6) from the cohort.
VAP scores improved from a pre-operative mean of 7.3 to 2.4 at year 10. The ODI improved from a mean of 58.5 at baseline to 17.5 at year 10. 72% of reviewed patients fulfilled the definition of an “Excellent” or “Good Clinical Impact” at review using the Spinal Foundation Outcome Score. Based on the Prolo scale, 61 patients (77%) were able to return and continue in full or part-time work or retirement activity post-TELDF. Complications of TELDF were limited to transient nerve irritation, which affected 19% of the cohort for 2 – 4 weeks. TELDF was equally beneficial in those with failed back surgery.
Conclusions
TELDF is a beneficial intervention for the long-term treatment of severely disabled patients with neuro-claudicant symptoms arising from spinal or foraminal stenosis with a dural diameter of more than 3mm, who have failed to respond to conventional rehabilitation or chronic pain management. It results in considerable improvements in symptoms and function sustained 10 years later despite co-morbidity, ageing or the presence of failed back surgery.
Clinical Relevance
The long term outcome of TELDF in severely disabled patients with neuro-claudicant symptoms arising from foraminal stenosis which had failed to respond to conventional rehabilitation, surgery or chronic pain management suggests that foraminal pathology is a major cause of lumbar axial and referred pain and that TELDF should be offered as primary treatment for these conditions even in the elderly and infirm. The application of TELDF at multiple levels may further widen the benefits of this technique.
doi:10.14444/1021
PMCID: PMC4325492
Lateral Recess Stenosis; Axial Stenosis; Foraminal stenosis; Spinal Decompression; Failed Back Surgery; Endoscopic Decompression; Foraminoplasty; Foraminotomy; Failed Fusion Surgery; Failed Chronic Pain Management; Differential Discography; Transforaminal Spinal Probing; disc degeneration; Disc Protrusion; Long-Term Outcome
25.  Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia 
Background
The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.1–6 The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.7
Methods
Thirty consecutive patients with FBSS presenting with back and leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections (Figure 1), were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open translaminar surgical treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla, also known as the “hidden zone” of Macnab (Figure 2).8, 9 The average follow up time was, average 40 months, minimum 12 months. Outcome data at each visit included Macnab, VAS and ODI.
A diagnostic and therapeutic epidural gram may help identify unrecognized lateral recess stenosis underestimated by MRI. An excellent result from a therapeutic block lends excellent prognosis for a more lasting and “permanent” result from transforaminal endoscopic lateral recess decompression.
Kambin's Triangle provides access to the “hidden zone” of Macnab by foraminoplasty. The foramen and lateral recess is decompressed by removing the ventral aspect and tip of the superior articular process to gain access to the axilla between the traversing and exiting nerve. FBSS contains patho-anatomy in the axilla between the traversing and exiting nerve that hides the pain generators of FBSS.
Results
The average pre-operative VAS improved from 7.2 to 4.0, and ODI 48% to 31%. While temporary dysesthesia occurred in 4 patients in the early post-operative period, all were happy, as all received additional relief of their pre-op symptoms. They were also relieved to be able to avoid “open” decompression or fusion surgery.
Conclusions / Level of Evidence 3
The transforaminal endoscopic approach is effective for FBSS due to residual/recurrent HNP and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve, including the DRG, which is located cephalad and near the tip of SAP.10 The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization.11 It also avoids going through the previous surgical site.
Clinical Relevance
Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.12 Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not “burn bridges” for a more conventional approach and it adds to the surgical armamentarium of FBSS.
Cadaver Illustration of Foraminal Stenosis (courtesy of Wolfgang Rauschning). As the disc narrows, the superior articular process impinges on the exiting nerve and DRG, creating lateral recess stenosis, lumbar spondylosis, and facet arthrosis.
doi:10.14444/1022
PMCID: PMC4325507
Failed Back Surgery Syndrome(FBSS); Hidden zone; Foraminal decompression; Recurrent herniation; Lateral stenosis; Foraminal osteophyte

Results 1-25 (1344147)