Spinal cord stimulation in the treatment of failed back surgery syndrome

A significant number of patients undergoing lumbar spine surgery do not obtain pain relief. Such patients with chronic low back or lower extremity pain may be difficult to treat. A frequent component of therapy is the use of spinal cord stimulation to help control pain. With careful patient selection, many patients can achieve reasonable levels of pain relief. We review recent clinical reports, including prospective and randomized studies, that demonstrate up to three quarters of patients implanted with a spinal cord stimulator for the treatment of failed back surgery syndrome may benefit from its use. This technology must not be indiscriminately applied. Careful patient selection and a period of trial stimulation are vital to the successful use of spinal cord stimulation as treatment for chronic pain.     

Cervical actinomycosis with spinal cord compression. Case report and literature review

Cervical actinomycosis with spinal cord compression is extremely rare. The clinical presentation of spinal actinomycosis may be nonspecific and back pain is the most consistent early symptom. Here, we present such a case with fever, pain in the neck and upper back, progressive weakness and numbness in all 4 limbs with difficulty ambulating, constipation and uroschesis. Correct diagnosis is difficult because the clinical and radiological findings of actinomycosis closely resemble metastatic tumors and other infectious processes. Timely surgical debridement and decompression contributed to the prompt improvement of the patient's conditions, and histopathological demonstration of the inflammatory granulation tissue and Gram-positive sulfur-containing filamentous bacteria led to the correct diagnosis of actinomycosis. The diagnosis must be made promptly because delayed treatment can result in irreversible neurologic damage or death. Timely and long-term antibacterial therapy is essential for the complete recovery of the patient with actinomycosis.     

ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home

Background

Spontaneous spinal epidural hematoma is a relatively rare but potentially disabling disease. Prompt timely surgical management may promote recovery even in severe cases.

Case presentation

We report a 34-year-old man with a 2-hour history of sudden severe back pain, followed by weakness and numbness over the bilateral lower limbs, progressing to intense paraparesis and anesthesia. A spinal magnetic resonance imaging scan was performed and revealed an anterior epidural hematoma of the thoracic spine. He underwent an emergency decompression laminectomy of the thoracic spine and hematoma evacuation. Just after surgery, his lower extremity movements improved. After 1 week, there was no residual weakness and ambulation without assistance was resumed, with residual paresthesia on the plantar face of both feet. After 5 months, no residual symptoms persisted.

Conclusions

The diagnosis of spontaneous spinal epidural hematoma must be kept in mind in cases of sudden back pain with symptoms of spinal cord compression. Early recognition, accurate diagnosis and prompt surgical treatment may result in significant improvement even in severe cases.     

Cervical Spine Injuries in Children, Part II: Management and Special Considerations

Background: The diagnosis and management of cervical spine injury is more complex in children than in adults. Objectives: Part I of this series stressed the importance of tailoring the evaluation of cervical spine injuries based on age, mechanism of injury, and physical examination findings. Part II will discuss the role of magnetic resonance imaging (MRI) as well as the management of pediatric cervical spine injuries in the emergency department. Discussion: Children have several common variations in their anatomy, such as pseudosubluxation of C2–C3, widening of the atlantodens interval, and ossification centers, that can appear concerning on imaging but are normal. Physicians should be alert for signs or symptoms of atlantorotary subluxation and spinal cord injury without radiologic abnormality when treating children with spinal cord injury, as these conditions have significant morbidity. MRI can identify injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal X-ray study or CT scan. Conclusion: With knowledge of these variations in pediatric anatomy, emergency physicians can appropriately identify injuries to the cervical spine and determine when further imaging is needed.     

Emergency department care for low back pain: Should we adopt recommendations from primary care guidelines?

ED visits for low back pain are increasing, but the lack of specific guidance for emergency physicians impedes evidence‐based care, and adopting primary care recommendations may not be appropriate. The ED sees a different spectrum of low back pain presentations, where physicians are likely to encounter a larger proportion of patients with an underlying serious pathology or non‐spinal diseases than in primary care. Current low back pain guidelines do not adequately cover screening for these conditions, but making a differential diagnosis is crucial in emergency patients with low back pain. In this article, we also discuss the challenges in developing specific ED guidelines for low back pain, the limited evidence on the profile of these patients and the surprising dearth of randomised trials.     

Outcome of implanted spinal cord stimulation in the treatment of chronic pain: arachnoiditis versus single nerve root injury and mononeuropathy. Brief clinical note

Over a 3 1/2-year period, a series of 20 chronic pain patients with back pain and with documented organic difficulties were treated by means of implanted spinal cord stimulation. Short-term treatment outcome was found to be significantly related to diagnosis, with single nerve root injury and mononeuropathy patients having better treatment outcomes than arachnoiditis patients with multiply injured nerve roots. Outcome was not related to the psychological evaluation, or age, sex, number of previous pain surgeries, pain location, the Minnesota Multiphasic Personality Inventory, or the Pain Assessment Index. Implications for patient selection are discussed.     

Epidurale R��ckenmarkstimulation zur Therapie chronischer Schmerzen

Epidural spinal cord stimulation (SCS) is a reversible but invasive procedure which should be used for neuropathic pain, e.g. complex regional pain syndrome I (CRPS) and for mostly chronic radiculopathy in connection with failed back surgery syndrome following unsuccessful conservative therapy. Epidural SCS can also successfully be used after exclusion of curative procedures and conservative therapy attempts for vascular-linked pain, such as in peripheral arterial occlusive disease stages II and III according to Fontaine and refractory angina pectoris. Clinical practice has shown which clinical symptoms cannot be successfully treated by epidural SCS, e.g. pain in complete paraplegia syndrome or atrophy/injury of the sensory pathways of the spinal cord or cancer pain. A decisive factor is a critical patient selection as well as the diagnosis. Epidural SCS should always be used within an interdisciplinary multimodal therapy concept. Implementation should only be carried out in experienced therapy centers which are in a position to deal with potential complications.     

Neurologic complications of prostate cancer

Neurologic complications continue to pose problems in patients with metastatic prostate cancer. From 15 to 30 percent of metastases are the result of prostate cancer cells traveling through Batson's plexus to the lumbar spine. Metastatic disease in the lumbar area can cause spinal cord compression. Metastasis to the dura and adjacent parenchyma occurs in 1 to 2 percent of patients with metastatic prostate cancer and is more common in those with tumors that do not respond to hormone-deprivation therapy. Leptomeningeal carcinomatosis, the most frequent form of brain metastasis in prostate cancer, has a grim prognosis. Because neurologic complications of metastatic prostate cancer require prompt treatment, early recognition is important. Physicians should consider metastasis in the differential diagnosis of new-onset low back pain or headache in men more than 50 years of age. Spinal cord compression requires immediate treatment with intravenously administered corticosteroids and pain relievers, as well as prompt referral to an oncologist for further treatment.     

脊髓前动脉综合征1例报道并文献复习

目的:探讨脊髓前动脉综合征(ASAS)的临床特点、MRI特点、病因和预后,提高医师对脊髓梗死的认识。方法:回顾1例ASAS患者的临床特点、MRI特点及治疗和预后,并结合文献进行回顾性分析。结果:患者临床表现为急性起病,后背疼痛,双下肢瘫,痛温觉障碍,深感觉和触觉正常,尿潴留及排便障碍,MRI检查弥散序列显示T_(7-8)、T_(11-12)水平脊髓横断前部区域呈高信号影,稍长T2信号,综合治疗后预后良好。搜索既往报道的ASAS患者207例,临床表现特征是急性或亚急性起病,病变水平神经根痛,病变节段以下瘫痪和分离性感觉障碍及植物神经功能障碍,以胸段脊髓梗死多见,发病早期MRI弥散序列检查可显示脊髓梗死范围。207例患者中,病因不明者74例(35.8%)。颈部外伤是年龄18岁患者脊髓梗死的首位病因;主动脉疾病是年龄18～45岁患者脊髓梗死的首位病因,动脉粥样硬化是年龄45岁患者脊髓梗死的首位病因。结论:ASAS较罕见,临床表现和病因差异很大,脊髓MRI检查弥散序列有助早期诊断,早期诊断和综合治疗是改善预后的关键。     

Diagnostik des Rückenschmerzes

Many different diagnostic procedures are used in patients with low back pain. Medical history and clinical examination, X-rays, computed tomography (CT)-scan, magnetic resonance imaging (MRI), diagnostic nerve root blocks and facet injections, functional tests in physiotherapy, strength tests of trunk muscles and work-related performance, and psychological and social evaluation including psychometric tests are only some of them. Despite this large number of procedures available, the scientific literature has not changed its conclusion that in about 80% of all back pain episodes the cause remains unknown. During the course of back pain episodes the relevant factors may change. The cause of the problem or the triggering factor of the pain episode may no longer be important during subacute stages, while others may be decisive for the transition to chronic stages. Thus, assessment of the cause is different from that of prognostic factors. There seems to be no consistent distribution of causes or ongoing factors in the population(s) of patients. While individual social factors may be the one important factor in one patient, functional and structural factors may be significant in another patient. Clinical examination is important, but several problems occur in the evaluation of patients with low back pain. Due to their anatomical location, important bony structures of the lumbar spine, e.g., disks or facet joints, are difficult to access by clinical examination. Additionally, there are only few diagnostic tests during clinical examination that do not rely on the patient's cooperation or communication. The term "unspecific back pain" for the majority of patients is scientifically sound, because it reflects the fact that the cause is unknown. It must be taken into consideration that this term enjoys only limited acceptance by both patients and physicians. Physicians are in charge of certifying work disability by assessing the interference of the patient's illness/disease with the specific requirements of his daily life or job. However, in clinical practice both the job tasks and the patient's abilities to perform these tasks with the given symptoms and signs is still difficult to evaluate and requires further definition.     

Spinale Neurostimulation

After the initial clinical reports of Shealy 1967 dorsal column stimulation (DCS) was first introduced in Germany by Krainick (Freiburg) and Winkelmüller (Hannover) in 1972. At first, the success rate in unselected patients was unsatisfactory. The results improved with careful patient selection and better technical equipment allowing preliminary testing procedures before definitive implantation. The authors' own results in 335 patients treated by intermittent spinal cord stimulation (SCS) with implanted devices between 1972 and 1989 show that long-term beneficial effects can be obtained in pain of neurogenic origin rather than in nociceptor pain. Guidelines for the use of SCS were proposed by the German Society of Neurosurgery in 1990. The best indications and target group are cases with radicular low-back pain after failed back surgery, stump and phantom pain, pain states following partial lesions of brachial/lumbar plexus and peripheral nerves, sympathetic dystrophy and rest pain in peripheral vascular disease (PVD). Possible indications for SCS are pain after incomplete lesions of spinal cord or cauda equina, postherpetic neuralgia, sclerodermia and PVD. Failures must be expected in pain states related to progressive malignant disease and complete deafferentation after spinal lesions or root avulsion.     

Abdominal pain in children

Abdominal pain is one of the most common reasons pediatric patients seek emergency care. The emergency physician must be able to distinguish diagnoses requiring immediate attention from self-limiting processes. Pediatric patients can be challenging, particularly those who are preverbal, and therefore, the clinician must rely on a detailed history from a parent or caregiver as well as a careful physical examination in order to narrow the differential diagnosis. This article highlights several pediatric diagnoses presenting as abdominal pain, including surgical emergencies, nonsurgical diagnoses, and extraabdominal processes, and reviews the clinical presentation, diagnostic evaluation, and management of each.     

Le canal lombaire rétréci: clinique, diagnostic, évolution

Lumbar spinal stenosis can be congenital or acquired. Degenerative changes in the spine and other pathological processes can increase the number of symptoms related to the spinal canal’s narrowness. Various symptoms are induced by this conflict between container and contents. Low back pain, leg pain, numbness and paraesthesia may occur, along with neurological claudication. All clinical signs are influenced by the position of the lumbar spine. Objective neurological deficits relating to axonal alterations are frequently reported, and instability must be considered a factor that impacts severity. Radiological and electrophysiological exams are useful in diagnosis and localisation but do not predict outcome. In most cases, symptoms remains stable, and aggravation occurs in less than 20% of cases. Before choosing medical and surgical options, a therapeutic approach must consider many factors, including comorbidities, physical impairment and disability, and the wishes of patients.     

Spinal cord stimulation for chronic, intractable pain: superiority of "multi-channel" devices

Spinal cord stimulation has evolved over the past 20 years into an easily implemented technique, with low morbidity, for the treatment of intractable, chronic pain in properly selected patients. We report our experience with a series of 62 patients implanted between 1983 and 1987, with percutaneous and laminectomy electrodes, and with single- and "multi-channel" (programmable, multi-contact) devices. Fifty had chronic, intractable low back and leg pain ("failed back surgery syndrome," lumbar arachnoid fibrosis), five had spinal cord injuries, and seven "peripheral" pathology or stump pain. Statistical analysis of these and other patient characteristics and technical factors was undertaken to identify predictors of outcome. All patients were interviewed by a disinterested third party at a mean of 2.14 years following implantation. A majority of patients reported at least 50% sustained relief of pain and indicated that they would go through the procedure again for the same result. There was corresponding improvement in ability to perform various everyday activities, and decrease in use of analgesics. Ten of 40 failed back patients who were disabled before the procedure returned to work postoperatively. Superposition of stimulation paresthesias upon a patient's topography of pain was found to be a statistically significant predictor of successful relief of pain, by linear regression methods. Univariate and multivariate analysis of patient characteristics and technical factors as predictors of outcome demonstrated significant advantages for female patients, and for patients implanted with "multi-channel" devices. With these devices, electrode geometries with central cathode(s) flanked by rostral and caudal anode(s) were favored disproportionately. Technical improvements in implanted spinal cord stimulation devices, in particular the development of multi-contact percutaneous electrode arrays and supporting programmable electronics, have significantly improved clinical results.     

Schmerzsyndrome des Bewegungsapparates

Clinical pain syndromes affecting the locomotor apparatus can become apparent not only in the form of nociceptive pain in the skeleto-mechanical system, but also as neurogenic pain emanating from lesions in the peripheral nerves or nerve roots or as referred pain resulting from disorders of visceral organs. The anatomical structure and basic innervation can contribute to the various characteristics of such deep pain. Within the spinal cord, visceral and somatic afferent fibres converge on nociceptive pathways, resulting in a uniform clinical pain syndrome. The differential diagnosis can be extremely difficult when attempts are made to evaluate its clinical relevance. Pain radiating from deep somatic tissues into the extremities is called "pseudoradicular" pain. Examples are encountered in the "facet syndrome" or the "myofascial pain syndrome". Various types of treatment are available for musculo-skeletal disorders, including physiotherapy, transcutaneous nerve stimulation (TENS) and trigger point infiltration. In clinical practice, however, drug therapy with peripheral analgesics and anti-inflammatory drugs is the form of therapy most often prescribed. There is no doubt that these drugs can help a great deal. However, they have only a symptomatic effect without any influence on the origin or course of the disease. Therefore, a critical evaluation of their benefits and risks is required before treatment with such drugs is instituted.     

Acute Aortic Thrombus Presenting as Cauda Equina Syndrome

BackgroundOcclusive abdominal aortic thrombus is a rare but critical clinical emergency with life-threatening consequences. Clinical presentation may mimic other diagnoses, resulting in a delay in the appropriate investigations for this condition. Spinal arterial involvement is a recognized complication of aortic thrombus and can result in pain, lower limb weakness, and loss of continence. These symptoms are usually associated with local spinal compression or stenosis manifesting as cauda equina syndrome (CES): a clinical finding of disrupted motor and sensory function to the lower extremities and bladder.Case ReportWe present a case of a 60-year-old female patient presenting with back pain, leg weakness, paresthesia, and urinary incontinence. She was urgently investigated for cauda equina syndrome via a magnetic resonance imaging scan of the spine, which subsequently demonstrated a large occlusive abdominal aortic thrombus.Why Should an Emergency Physician Be Aware of This?Nontraumatic acute thrombosis of the aorta is a life-threatening condition that may present with apparent neurological symptoms. In this patient there was both a relevant history and evolving clinical signs pointing toward a vascular etiology; however, the clinical findings were confusing and CES evaluation was prioritized. CES remains a medical emergency requiring urgent investigation and management. However, knowledge of spinal anatomy including vascular supply may help widen the differential. Physicians and associate specialists should consider this at clinical assessment and also when interpreting imaging of the spine. Any delay in diagnosing an aortic thrombosis has the potential for catastrophic clinical consequences.     

Acute thoracoabdominal aortic dissection presenting as painless, transient paralysis of the lower extremities: a case report

Acute dissection of the aorta can be one of the most dramatic of cardiovascular emergencies. Its symptoms can occur abruptly and progress rapidly. Prompt recognition and appropriate intervention is crucial. However, not all aortic dissections present with classic symptoms of abrupt chest, back, or abdominal pain, and the diagnosis may be missed. A 63-year-old woman presented with transient loss of lower extremity motor and sensory function as the only symptom of an acute thoracoabdominal aortic dissection. Aortic dissection presenting as a transient neurologic syndrome is quite unusual. The sudden onset of weakness and parasthesia can result from the interruption of blood flow to the spinal cord. These symptoms of acute spinal cord ischemia, suggestive of a serious cardiovascular event, must be recognized and thoroughly investigated.     

Acute Nontraumatic Spinal Intradural Hematoma in a Patient on Warfarin

Background

Nontraumatic spinal intradural extramedullary hematomas are extremely rare. When they occur, they can rapidly lead to spinal cord or cauda equina compression and have devastating consequences.

Objective

The aim here was to report a case of this rare phenomenon and discuss the etiology, imaging, management, and outcome of intradural hematomas.

Case Report

We describe the case of a 76-year-old man on warfarin therapy who presented with severe lower back pain and flaccid paraparesis. Blood tests revealed an international normalized ratio of 6.0. A magnetic resonance imaging result suggested an intradural hematoma extending from L1 to L4 and compressing the spinal cord and cauda equina. Emergency surgical decompression revealed an extensive intradural extramedullary hematoma, which was evacuated. The patient showed only minor neurologic improvement 6 months postoperatively.

Conclusions

Coagulopathy-induced spinal hemorrhage should be included in the differential diagnosis for patients presenting with signs of acute spinal cord compression.     

Locoregional anesthesia and anticoagulation

Spinal hematoma is a rare and potentially catastrophic complication of spinal or epidural anesthesia. Risk factors include traumatic needle/catheter placement, sustained anticoagulation in an indwelling neuraxial catheter, and catheter removal during therapeutic levels of anticoagulation. Generally, a patient’s coagulation status should be optimized at the time of spinal or epidural needle/catheter placement, and the level of anticoagulation should be monitored during epidural catheterization. Signs of cord compression, such as severe back pain, progression of numbness or weakness, and bowel and bladder dysfunction, warrant immediate radiographic evaluation. A delay in diagnosis and intervention of spinal hematoma may lead to irreversible cord ischemia.