Percutaneous radiofrequency denervation of spinal facets. Treatment for chronic back pain and sciatica.

A technique for radiofrequency localization and coagulation of articular nerves supplying the spinal facets is described and results are reported from a series of 207 patients followed 6 to 21 months (mean 31 months). Relief of pain was achieved in 79% of previously unoperated patients, in 41% of those with laminectomy but no fusion, and in 27% of those with an earlier fusion. No neurological complications were encountered.     

MULTIPLE OPERATIONS FOR A LUMBAR DISC LESION1

Lumbar spinal disability ranks amongst the most important causes of permanent disability in the community. Patients with a history of multiple lumbar spinal operations form an important group amongst the permanently disabled. Two thousand, six hundred and forty-two spinal operations were carried out in New South Wales in 1977; an estimated 75% by orthopaedic surgeons and 25% by neurosurgeons. One in three patients operated upon underwent spinal fusion. Ninety percent of all the procedures were carried out In the Metropolitcan and Hunter Regions. An estimated 22% of patients operated on for a lumbar disc lesion underwent more than one surgical procedure. The common pattern of multiple operations comprises first laminectomy or interlaminar discectomy, second, either spinal fusion and/or dissection of adhesions or removal of disc sequesters, and third, various combinations of previous procedures. The patients' long term prognosis deteriorates with every subsequent procedure. After two to three unsuccessful attempts, the patient becomes permanently disabled by intractable pain and not uncommonly addicted to hard drugs. The underlying pathology at that late stage is most often intrinsic root damage (root fibrosis) and arachnoiditis. Neurosurgical procedures for intractable pain such as rhizotomy, neurotomy and spino-thalamlc tractotomy carry a varying degree of success in providing last relief from pain, but do not relieve permanent spinal disability in the patient who has had multiple operations. The preventable causes for multiple surgery may originate in poor judgement in diagnosis, ill defined indications for surgery and may be compounded by poor surgical technique. These are discussed in some detail. Not all multiple surgery can be eliminated, but a significant part of it can be prevented through better standards of diagnostic assessment, clearer and more stringent definition of Indications and improved surgical technique. This can only be achieved through closer neurosurgical and orthopaedic collaboration in the training of young surgeons and systematic exchange of clinical experience in diagnosis, indications for surgery and surgical techniques between the two specialties.     

High frequency of cough after intravenous bolus injection of Ketogan® (ketobemidone + N, N-dimethyl-3,3-diphenyl-1-methylallylamine chloride) for postoperative pain relief

The frequency of cough 15-45 s after intravenous administration of a low dose of the opioid receptor agonist ketobemidone given for postoperative pain relief was assessed in 121 patients undergoing gynaecological or obstetrical operations. In patients subjected to caesarean section under spinal anaesthesia using bupivacaine, the frequency of an early cough reaction was 50.7%, whereas in patients previously exposed to opioids during the surgical procedure the frequency was 11.1%. This side-effect of ketobemidone has not been reported before.     

Subtotal vertebrectomy and spinal fusion for cervical spondylotic myelopathy

To perform decompression of the spinal cord and stabilization of the cervical spine in the patients with cervical spondylotic myelopathy, subtotal vertebrectomy and spinal fusion of the cervical spine were carried out in 30 patients. In 18 patients, three vertebrectomies and a spinal fusion were carried out, and in 12 patients, four vertebrectomies and a spinal fusion were carried out. Neurologic symptoms that were present before the operations ranged from transverse lesion type myelopathy to motor system syndrome. The patients' symptoms improved significantly after the operations. By the final consultation, the cervical spine motion reduced by about half in the four level vertebrectomy patients and about one third in the three level vertebrectomy patients. No patients reported cervical pain or pain in the arms.     

Facetal distraction as treatment for single- and multilevel cervical spondylotic radiculopathy and myelopathy: a preliminary report

The authors discuss their successful preliminary experience with 36 cases of cervical spondylotic disease by performing facetal distraction using specially designed Goel cervical facet spacers. The clinical and radiological results of treatment are analyzed. The mechanism of action of the proposed spacers and the rationale for their use are evaluated. Between 2006 and February 2010, 36 patients were treated using the proposed technique. Of these patients, 18 had multilevel and 18 had single-level cervical spondylotic radiculopathy and/or myelopathy. The average follow-up period was 17 months with a minimum of 6 months. The Japanese Orthopaedic Association classification system, visual analog scale (neck pain and radiculopathy), and Odom criteria were used to monitor the clinical status of the patient. The patients were prospectively analyzed. The technique of surgery involved wide opening of the facet joints, denuding of articular cartilage, distraction of facets, and forced impaction of Goel cervical facet spacers into the articular cavity. Additionally, the interspinous process ligaments were resected, and corticocancellous bone graft from the iliac crest was placed and was stabilized over the adjoining laminae and facets after adequately preparing the host bone. Eighteen patients underwent single-level, 6 patients underwent 2-level, and 12 patients underwent 3-level treatment. The alterations in the physical architecture of spine and canal dimensions were evaluated before and after the placement of intrafacet joint spacers and after at least 6 months of follow-up. All patients had varying degrees of relief from symptoms of pain, radiculopathy, and myelopathy. Analysis of radiological features suggested that the distraction of facets with the spacers resulted in an increase in the intervertebral foraminal dimension (mean 2.2 mm), an increase in the height of the intervertebral disc space (range 0.4-1.2 mm), and an increase in the interspinous distance (mean 2.2 mm). The circumferential distraction resulted in reduction in the buckling of the posterior longitudinal ligament and ligamentum flavum. The procedure ultimately resulted in segmental bone fusion. No patient worsened after treatment. There was no noticeable implant malfunction. During the follow-up period, all patients had evidence of segmental bone fusion. No patient underwent reexploration or further surgery of the neck. Distraction of the facets of the cervical vertebra can lead to remarkable and immediate stabilization-fixation of the spinal segment and increase in space for the spinal cord and roots. The procedure results in reversal of several pathological events related to spondylotic disease. The safe, firm, and secure stabilization at the fulcrum of cervical spinal movements provided a ground for segmental spinal arthrodesis. The immediate postoperative improvement and lasting recovery from symptoms suggest the validity of the procedure.     

Spinal epidural stimulation for central pain caused by spinal cord lesion]

Epidural spinal cord stimulation was carried out in 4 patients with denervation caused by spinal cord lesion, and we reviewed previously reported cases. Initial result showed at 1 week in 100% of our cases, but about 1/3 of the cases, even those with the same denervation caused by spinal cord lesion, had no pain relief at this stage in previously reported cases. In our cases, excellent pain relief was gained temporarily, even though the painful area and the spinal cord lesion were separated somatotopically in 2 cases (case 3, 4). Temporary success bore no relationship to quality and duration of pain. In all cases except case 1, a rapidly decreasing effectiveness was noted, and finally no pain relief was gained at all after 4, 3 and 5 months, respectively. In case 1 there was persistent pain relief estimated at 70-80% after 19 months, only when the spinal cord was stimulated. Epidural stimulation also produced sensations in the painful area. Spinal cord stimulation would suppress at least the dorsal horn neurons which were destroyed by various kinds of diseases. A decline in effectiveness with time would occur due to essential causes of the deafferentation pain, such as anatomical and regeneration factors.     

The results of a primary and staged pantalar arthrodesis and tibiotalocalcaneal arthrodesis in adult patients

Twenty-three patients (twenty-seven feet) with either a primary or staged pantalar arthrodesis or a tibiotalocalcaneal arthrodesis were evaluated to determine their clinical status. The main indication for the operation was the presence of severe pain unresponsive to non-operative treatment. Fourteen feet (twelve patients) had a pantalar arthrodesis; a fusion of the ankle, subtalar, talonavicular and calcaneocuboid joints. Half the feet in this group had either a triple arthrodesis or an ankle fusion performed at an earlier time. The remaining seven feet had all joints fused during the same operation. Thirteen feet (eleven patients) had a tibiotalocalcaneal arthrodesis. Two of these feet had an ankle arthrodesis performed four and six years previously. The other eleven had the ankle and subtalar joints fused during the same operation. All patients were followed for a mean of fifty-five months (14 to 159 months) from the time of their final arthrodesis procedure. Overall, twenty-three of the twenty-seven feet achieved a solid arthrodesis of all joints operated upon. Four feet had a failure of fusion of only a single joint and all were in the pantalar group. The mean time to radiographic fusion was twenty-three weeks and resulted in a plantigrade foot with an average tibia-floor angle of 87 degrees. Complications occurred in ten feet (37%); of which there were three deep infections; two ankles and one subtalar joint. These arthrodeses procedures resulted in marked relief of the patients' preoperative pain, the main indication for performing the surgery. Postoperatively there was no pain in eleven feet, mild occasional pain in thirteen feet, and moderate pain in only three feet. However, when all parameters of our clinical rating scale were evaluated, only five patients had an excellent clinical result, nine were rated good, three were rated fair and six patients had a poor result. These operations must be considered to be salvage procedures. They are technically difficult to perform and major complications may occur. Pain relief appears to be the main indication for performing these operations, and may account for whatever improvement occurs in the patient's function.     

Attempted scapholunate arthrodesis for chronic scapholunate dissociation

We report a retrospective review of seven patients with chronic scapholunate dissociation treated with attempted scapholunate arthrodesis. All procedures were done between 1978 to 1983 by one surgeon. Seven patients with follow-up of nine months or greater were available for review. Follow-up for the four patients with successful operations averaged seventy-seven months. Average age was 34 years (range from 19 to 46). Only one patient demonstrated radiographic fusion. Of the remaining six patients, three had no further wrist pain. The other three operations were total failures requiring other procedures for pain relief. For all patients, flexion-extension are decreased an average of 4 degrees. Grip strength averaged 88% of the unaffected side. Lateral scapholunate angle improved from an average preoperative angle of 70 degrees to a postoperative angle of 59 degrees. We conclude that this procedure is not a predictable method to treat scapholunate dissociation.     

Safety and efficacy of implant removal for patients with recurrent back pain after a failed degenerative lumbar spine surgery

The etiology of failed degenerative lumbar spine surgery may include a wide array of conditions. There is a group of patients who have recurrence of back pain despite a solid fusion in the absence of any obvious pain generator. Implant removal in those patients is a controversial optional treatment. The purpose of this study was to evaluate the efficacy and safety of implant removal and to determine the possible predictors of its efficacy. Twenty-five patients (10 M, 15 F) with an average age of 44 (18 to 74) were retrospectively evaluated. All patients had prior titanium posterior pedicle screw instrumentation and fusion for lumbar degenerative disorders. Twenty patients with increase in pain during palpation of the operative side underwent a preoperative anesthetic injection at the site of their trigger points. Patients' clinical charts, operative notes, and preoperative x-rays were evaluated. Relief of pain was evaluated by the percent Visual Analog Scale (VAS) pain change due to implant removal. Functional improvement was rated on a five-point scale. Predictors of pain relief were analyzed by using bivariate analysis. A P value <0.05 was considered significant. Average follow-up period was 20 (12 to 37) months. The median time after the index operation and the recurrence of pain was 13.5 (1 to 119) months. VAS decrease after implant removal was 50% (P<0.001). Functional improvement was reported by 84% of patients. One patient developed a superficial infection managed successfully. Bivariate analysis showed that percent VAS change after injection, months free of pain after the index operation, and provocation of pain by palpation were significant predictors for pain relief (P<0.05). Removal of the implant may be an efficient and safe procedure for carefully selected patients and the most consistent predictor of its efficacy is the percent pain relief after the diagnostic injection of the painful operative side.     

Degenerative Lumbar Spinal Stenosis: Results of Operative Treatment

The results of decompressive laminectomy in 22 patients with degenerative lumbar spinal stenosis are reported. The average follow-up period was 29 months. Twelve of the 15 patients with marked stenosis (a minimum anteroposterior (a.p.) diameter of the spinal canal in extension of 10 mm or less) and all 7 patients with moderate stenosis (a minimum a.p. diameter between 11-14 mm) obtained relief from leg pain. A pseudovascular syndrome was observed in 12 of the 15 patients with marked and in 2 of the 7 patients with moderate spinal stenosis. Of these patients, 10 obtained increased (7 patients unlimited) walking distance postoperatively. Vertebral fusion was not performed in any of the patients. Slight vertebral slip (2-5 mm) occurred postoperatively in 4 out of 20 patients whose follow-up examination included dynamic roentgenogram of the spine.

Five of the 15 patients with marked spinal stenosis also suffered from severe osteoarthritis of the hip. Total hip replacement subsequent to laminectomy was performed in 4 patients and excellent results were achieved for both the spinal and the hip operations.     

Degenerative lumbar spinal stenosis: results of operative treatment

The results of decompressive laminectomy in 22 patients with degenerative lumbar spinal stenosis are reported. The average follow-up period was 29 months. Twelve of the 15 patients with marked stenosis (a minimum anteroposterior (a.p.) diameter of the spinal canal in extension of 10 mm or less) and all 7 patients with moderate stenosis (a minimum a.p. diameter between 11--14 mm) obtained relief from leg pain. A pseudovascular syndrome was observed in 12 of the 15 patients with marked and in 2 of the 7 patients with moderate spinal stenosis. Of these patients, 10 obtained increased (7 patients unlimited) walking distance postoperative. Vertebral fusion was not performed in any of the patients. Slight vertebral slip (2--5 mm) occurred postoperatively in 4 out of 20 patients whose follow-up examination included dynamic roentgenogram of the spine. Five of the 15 patients with marked spinal stenosis also suffered from severe osteoarthritis of the hip. Total hip replacement subsequent to laminectomy was performed in 4 patients and excellent results were achieved for both the spinal and the hip operations.     

Unilateral transforaminal posterior lumbar interbody fusion.

A prospective analysis of consecutive patients who had lumbar fusion using the unilateral transforaminal posterior lumbar interbody fusion with pedicle screw fixation is presented to assess the clinical and radiographic outcomes of the transforaminal posterior lumbar interbody fusion procedure and describe the technique and indication in the treatment of degenerative disease of the lumbar spine. Forty patients treated with transforaminal posterior lumbar interbody fusion for degenerative diseases of the lumbar spine (with anterior column deficiency) were followed up for a minimum of 3 years (mean, 3.4 years; range, 3-3.9 years). Radiographic assessment included plain and flexion and extension radiographs. Clinical outcome was based on pain relief, ability to do activities of daily living, and return to work. Thirty-six patients (90%) had solid fusions and at latest followup, segmental lordosis has increased in all patients. Eighty-five percent of patients had excellent or good clinical outcome(s). The unilateral transforaminal posterior lumbar interbody fusion provides bilateral anterior column support through a unilateral approach. The patients had high fusion rates and patient satisfaction as reported with similar complications found in other methods commonly used for spinal decompression and stabilization.     

Decompression, fusion, and instrumentation surgery for complex lumbar spinal stenosis

Between 1990 and 1993, 54 consecutive patients were treated with decompression, fusion and instrumentation surgery for complex lumbar spinal stenosis. The mean age of the patients was 60 years. The average followup was 39 months. Clinically, there was one deep wound infection, and three mechanical failures. There were two staged operations. There were three revision surgeries performed for mechanical reasons. Of the 47 patients who completed the questionnaire, 96% of patients were very satisfied or somewhat satisfied with the operation, 98% were satisfied with relief of pain, 94% were satisfied with their ability to walk, 89% were satisfied with their strength, and 94% were satisfied with balance. Survivorship analysis (failure endpoint was revision surgery) revealed that at the end of 4 years, the patient had a 92% chance of not undergoing revision surgery for any reason (mechanical and infectious), and a 94% chance of not undergoing revision surgery for mechanical reasons. Lumbar decompression, fusion, and instrumentation surgery seems to be efficacious in patients with complex lumbar spinal stenosis (associated previous lumbar spine operations with evidence of radiographic instability, radiographic evidence of junctional stenosis after surgery, radiographic evidence of instability, degenerative spondylolisthesis greater than Grade I with instability, if present, and degenerative scoliosis with a curve greater than 20 degrees).     

Adult idiopathic scoliosis treated by posterior spinal fusion and Harrington instrumentation

Ninety-one patients with idiopathic scoliosis, who underwent posterior spinal fusion and instrumentation from January 1977 to December 1982, were reviewed. All patients were 20 years or older at the time of surgery and none had undergone a prior surgical procedure. Indications for surgery included pain, progressive deformity, and pulmonary symptoms. All patients had a posterior spinal fusion with Harrington instrumentation and autogenous iliac bone graft, with the addition of segmental wiring in only eight. No patient had an anterior fusion or fusion to the sacrum. Follow-up averaged 3.5 years (range: 2-7 years). The average correction at the time of surgery was 38%, and 32% at the time of last follow-up. Seventy-nine percent of the patients reported complete relief of the symptom(s) for which they had surgery. There were 34 complications in 30 (33%) patients. Pseudarthrosis occurred in 14 (15%), requiring 15 additional procedures to achieve a solid arthrodesis. Urinary tract infection occurred in 8 (9%) patients and Harrington hook dislodgement in 5 (5%). One patient sustained a partial paraparesis with recovery to a minimal deficit. No deaths occurred. Although largely successful, posterior fusion with Harrington instrumentation for adult scoliosis has a significant incidence of pseudarthrosis and instrumentation problems.     

Progression of idiopathic thoracolumbar scoliosis after breast reconstruction with a latissimus dorsi flap: a case report

STUDY DESIGN: A report of a patient in whom progressive symptomatic thoracolumbar scoliosis developed after breast reconstruction with a latissimus dorsi myocutaneous flap. OBJECTIVES: To present the first reported case of progressive symptomatic scoliosis after breast reconstruction with a latissimus dorsi myocutaneous flap and to suggest that latissimus flap harvest may be contraindicated in patients with preexisting scoliosis. SUMMARY OF BACKGROUND DATA: Latissimus dorsi myocutaneous flap harvest incorporated into several surgical operations including breast reconstruction has been presented as a relatively benign procedure without significant biomechanical consequence. Nevertheless, various anatomic and animal studies have suggested an important role for balanced latissimus function in terms of proper spinal alignment. Long-term follow-up evaluation of patients after latissimus flap harvest is insufficient and fails to address the specific issue of spinal deformity. METHODS: Postoperative radiographs demonstrated significant progression of the patient's thoracolumbar scoliosis as compared with radiographs taken before her latissimus harvest. Curve progression accompanied by development of severe and disabling back pain were considered indications for surgical curve correction and stabilization. RESULTS: At the time of 1-year follow-up assessment after posterolateral spinal fusion and instrumentation, the patient had experienced complete relief from her back pain and satisfactory spinal fusion. CONCLUSIONS: Although a cause and effect relation cannot be established, this case study suggests that latissimus harvest may have a destabilizing effect on the thoracolumbar spine in the long term, especially in patients with preexisting scoliosis. Alternative procedures should be considered in these patients.     

Long-term results by epidural spinal electrical stimulation (ESES) in patients with inoperable severe lower limb ischaemia

Arterial reconstruction is the treatment of choice for patients with severe lower limb ischaemia, but may at times be technically impossible. Thirty-two consecutive patients with impending (n = 24) or already established (n = 8) distal arteriosclerotic or diabetic lower limb gangrene, in whom vascular surgery was either technically impossible or had failed, were treated with epidural spinal electrical stimulation (ESES) for 27 +/- 16 (S.D.) months. All patients had severe rest pain, which was reduced by ESES in 91% of the cases. Improved ulcer healing was noted in 58% of the patients who had skin ulceration. Eighty-three percent of those patients who did not have established gangrene when ESES was started, retained their leg after 1 year, and 54% after 3 years. These results suggest that ESES often provides pain relief and improves skin healing in patients with impending arteriosclerotic or diabetic gangrene in whom vascular surgery is impossible or has failed. Epidural spinal electrical stimulation (ESES) does not affect the progression of established gangrene but may provide pain relief. The observed outcome of severe limb ischaemia in this study could be used to compare with those after arterial reconstruction performed in patients with poor run-off vessels, and may allow us to examine the natural history of this disease when adequate pain relief is provided. The results reported here and the previously reported enhancement of cutaneous blood flow in severely ischaemic extremities by ESES may suggest, that ESES enhances limb salvage by improving skin blood flow.     

Failure of external spinal skeletal fixation to improve predictability of lumbar arthrodesis.

BACKGROUND: Whether lumbar arthrodesis can relieve isolated low-back pain in the absence of focal neurological findings or instability is unclear. The results of published studies are also inconsistent with regard to whether temporary back-pain relief with external spinal skeletal fixation can predict lasting back-pain relief after arthrodesis. This report presents the results, with regard to clinical benefit and complications, of more than 100 external spinal skeletal fixation procedures undertaken as a prelude to lumbar arthrodesis. METHODS: The records of all patients who underwent external spinal skeletal fixation between 1989 and 1999 were reviewed with attention to perioperative complications, pain relief from the test procedure, the clinical benefit from a subsequent arthrodesis, and the functional status after the arthrodesis. Analyzed data included the frequency of neurological complications and infections and the benefit (Prolo score) after staged spinal arthrodesis in patients who underwent arthrodesis after temporarily experiencing pain relief with the test procedure. RESULTS: A total of 103 external spinal skeletal fixation procedures were undertaken. Neurological complications occurred in two procedures (2%); one resulted in permanent sciatica. Infections occurred in five patients (5%). Sixty patients experienced pain relief during the external fixation test, but only twenty-seven of forty-nine patients who went on to have an arthrodesis and had sufficient follow-up reported that they were doing well at a minimum of one year later. In no case did the external spinal skeletal fixation procedure cause a permanent increase in low-back pain. CONCLUSIONS: On the basis of this analysis, external spinal skeletal fixation should not be used as a predictor of pain relief after lumbar arthrodesis.     

Treatment of lumbosacral radicular pain with epidural steroid injections

Fifty patients with an average age of 47 years received epidural steroid injections for lumbosacral radicular pain due to disk herniation or spinal stenosis. All patients had failed previous conservative treatment. Mean follow-up was 24 months (range: 12-36 months). Immediately after injection, all 50 patients reported various degrees of relief from leg and back pain. At the last follow-up examination, 68% of patients were asymptomatic, 20% had no change in preinjection radicular symptoms, and 12% had various degrees of relief. No significant correlation was found between pain relief, age, or number of injections. Early pain relief may be anticipated after epidural steroid injections in 80% of patients with radicular symptoms due to disk herniation or spinal stenosis.     

Ductal drainage or resection for chronic pancreatitis

We report a 10 year review comparing the results of pain relief after three procedures for chronic pancreatitis: Whipple pancreatoduodenectomy, modified Puestow side-to-side longitudinal pancreaticojejunostomy and distal pancreatic resection. Results of follow-up review at 6 months, 2 years and 5 years were tabulated. Five year follow-up data were available on more than 80 percent of patients. The proportion of good results for pain relief decreased with the passage of time regardless of the procedure performed. Although equally good results are obtained after either pancreatoduodenectomy or pancreaticojejunostomy, we conclude that in the presence of a dilated duct, the procedure of choice is pancreaticojejunostomy. If the duct is not dilated, we then favor pancreatoduodenectomy, after which the pain relief is significantly better (p = 0.05) than after distal resection. Our data show that, for all factors evaluated, the poorest pain relief was obtained after distal resection. Therefore that procedure has limited value when used specifically for relief of pain in chronic pancreatitis, except in the uncommon circumstance when the disease is confined to the distal part of the gland. Our study also shows that patients who have more radical distal resection have no better pain relief than those who have 50 percent distal resection.     

A new microsurgical reoperation for failed lumbar disc surgery

This paper reports a consecutive series of 103 patients operated upon over a 4.2-year period (from November 1978 through January 1983). These patients were initially operated upon by other orthopedic and neurologic surgeons without relief of their sciatic pain. The average duration of symptoms prior to microsurgical reoperation was 35.9 months. The average number of reoperations per patient was 1.4. The median follow-up time was 27 months (range 1-50 months). Preoperative evaluation included examination, CAT scan, myelogram, and electromyogram. Average postoperative hospital stay without spinal fusion was 5.1 days. Two techniques were used: a unilateral decompression and a bilateral intersegmental decompression. Results are compared. A classification of operative findings is given. Eight patients in the series received spinal fusion as part of their procedure. Microsurgical reoperation benefited 80.6% of the 103 patients.