Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge

Recently, the sacroiliac joint (SIJ) has gained increased attention as a source of persistent or new pain after lumbar/lumbosacral fusion. The underlying pathophysiology of SIJ pain may be increased mechanical load, iliac crest bone grafting, or a misdiagnosis of SIJ syndrome. Imaging studies show more frequent degeneration of the SIJ in patients with lumbar/lumbosacral fusion than in patients without such fusion. Using injection tests, it has been shown that SIJ pain is the cause of persistent symptoms in a considerable number of patients after fusion surgery. Recent articles reporting on surgical outcomes of SIJ fusion include a high percentage of patients who had lumbar/lumbosacral fusion or surgery before, although well-controlled clinical studies are necessary to assess the efficacy of surgical treatment. Taking these findings into consideration, the possibility that the SIJ is the source of pain should be considered in patients with failed back surgery syndrome after lumbar/lumbosacral fusion.     

Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws

STUDY DESIGN: An analysis of lumbosacral fusions for high-grade spondylolisthesis fusions with reduction and long fusions to the sacrum in ambulatory adults. OBJECTIVE: To assess the clinical and radiographic results of lumbosacral fusions using bilateral S1 and iliac screws. SUMMARY OF BACKGROUND DATA: S1 screws often fail with lumbosacral fusions, whereas L5-S1 pseudarthrosis is common in patients with deformity. MATERIALS AND METHODS: A total of 81 patients (38 revision, 43 primary) with minimum 2-year follow-up (average, 4.2 years; range, 2.0-7.1 years) underwent L5-S1 fusion using S1 and iliac screws (158 screws). Forty-nine of 81 constructs (61%) included an anterior load-sharing/fixation device. Group 1 included isthmic spondylolisthesis (n = 42), whereas Group 2 included long fusions (> or =3 levels) to the sacrum (n = 39). In Group 2, 15 patients (Group 2A) were fused from L1, L2, or L3 to the sacrum (3-5 levels, average 3.3 levels) and 24 patients (Group 2B) were fused from the thoracic spine to the sacrum (6-17 levels, average 11.5 levels). Twelve patients had pseudarthrosis at L5-S1. A patient questionnaire was completed. RESULTS: A total of 36 of the 38 revision patients had previous iliac crest harvesting, yet iliac screws were placed in 34 of 36 patients. Overall, 78 of 80 patients had iliac crest harvesting (one not attempted). None had loss of screw fixation or iliac crest fracture after harvesting. Four of the 81 patients (4.9%) had pseudarthrosis at L5-S1 after reconstruction. This included solid fusion in 10 of 12 patients presenting with L5-S1 pseudarthrosis. Fourteen percent of patients experienced some discomfort over the iliac screws; however, only one patient required screw removal. CONCLUSIONS: Bilateral iliac screws coupled with bilateral S1 screws provide excellent distal fixation for lumbosacral fusions with a high fusion rate (95.1%) in high-grade spondylolisthesis and long fusions to the sacrum. Previous iliac crest harvesting does not prevent ipsilateral screw placement (34 of 36 patients) or additional iliac harvesting (78 of 80 patients).     

Outcome of distraction interference arthrodesis of the sacroiliac joint for sacroiliac arthritis

Background:

After lumbar or lumbosacral fusion for various spine disorders, adjacent segment disease has been reported. Most of the studies have focused on proximal segment disease. The author has reported sacroiliac joint degeneration in these patients. Based on our own experiences with an increasing number of patients with sacroiliac joint (SIJ) arthralgia after multi-level lumbar or lumbosacral fusion procedures, we evaluated a surgical procedure called distraction arthrodesis of the SIJ for patients with refractory severe pain of the SIJ.

Materials and Methods:

Nineteen (19) consecutive patients were recruited and evaluated prospectively after undergoing distraction arthrodesis of the SIJ. The inclusion criteria for the surgical procedure were degeneration of the SIJ and failed conservative treatment. Magnetic resonance imaging (MRI) scans and CT scans were performed in all cases. The clinical outcome was assessed using the Visual Analog Scale and the Oswestry Disability Index (ODI). CT scans were performed postoperatively and again at the final followup to evaluate assess fusion. The data was analyzed using the SPSS software (version 10.0; SPSS, Chicago, IL) and statistical analysis was performed. The P values were based on the Student t-test.

Results:

The mean followup was 13.2 months. All patients had an instrumented lumbar or lumbosacral fusion. The overall fusion rate of SIJ was 78.9% (15/19 joints). All patients demonstrated significant improvement in VAS and ODI scores compared to preoperative values. The mean VAS score was 8.5 before surgery and was 6 at final followup, demonstrating 30% improvement. The mean ODI scores were 64.1 before surgery and 56.97 at the final followup, demonstrating 12% improvement.

Conclusions:

Refractory sacroiliac pain as a result of multi-level fusion surgery can be successfully treated with minimally invasive arthrodesis. It offers a safe and effective treatment for severe SIJ pain. Careful patient selection is important.     

Pelvic joint fusions in patients with chronic pelvic girdle pain: a 23-year follow-up

Purpose

Fusion of the sacroiliac joints (SIJ) has been a treatment option for patients with severe pelvic girdle pain (PGP). The primary aims were to evaluate the long-term outcomes in patients who underwent SIJ fusion and to compare 1-year outcomes with long-term outcomes. The secondary aim was to compare patients who underwent SIJ fusion with a comparable group who did not.

Methods

This study includes fifty patients that underwent SIJ fusion between 1977 and 1998. Function (the Oswestry disability index; ODI), pain intensity (visual analogue scale; VAS) and health-related quality of life (SF-36) were determined according to a patient-reported questionnaire. The questionnaire scores were compared with previously recorded 1-year outcomes and with questionnaire scores from a group of 28 patients who did not undergo SIJ fusion.

Results

The patients who underwent SIJ fusion reported a mean ODI of 33 (95 % CI 24–42) and a mean VAS score of 54 (95 % CI 46–63) 23 years (range 19–34) after surgery. Regarding quality of life, the patients reported reduced physical function, but mental health was not affected in the same manner. The patients with successful 1-year outcomes (48 %) retained significantly improved function and reduced pain levels compared with the subgroup of patients with unsuccessful 1-year outcomes (28 %). The patients who underwent surgery did not differ from the non-surgery group in any outcome at the long-term follow-up.

Conclusions

Patients treated with SIJ fusion had moderate disability and pain 23 years after surgery, and the 1-year outcomes were sustained 23 years after surgery. Although many fused patients reported good outcome, this group did not differ from the comparable non-surgical group.     

Transforaminal lumbar interbody fusion: technique, complications, and early results

OBJECTIVE: To demonstrate the safety, surgical efficacy, and advantages of the transforaminal approach for lumbar interbody fusion when combined with pedicle screw fixation. METHODS: We retrospectively reviewed the records of 22 patients (age range, 34-63 yr; mean, 49 yr) with Grade I or II spondylolisthesis who underwent transforaminal lumbar interbody fusion. Nineteen patients presented with low back pain and associated radiculopathy, and three presented with low back pain only. Transforaminal lumbar interbody fusion was performed at L4-L5 in 8 patients, L5-S1 in 11 patients, L3-L4 and L4-L5 in 2 patients, and L4-L5 and L5-S1 in 1 patient. Periodic follow-up took place 1 to 12 months after surgery (mean, 5.3 mo). Decompression is performed according to clinical circumstances. Pedicle screws are placed, and a discectomy is carried out. The cartilaginous endplates are removed. The interspace is gradually distracted, resulting in lost disc height being regained, and interbody fusion cages are positioned. The pedicle screw-and-rod construct is then compressed, restoring lumbar lordosis. RESULTS: Low back pain completely resolved in 16 patients, moderate relief from pain was achieved in 5 patients, and the pain was unchanged in one patient. Nonneurological complications included intraoperative durotomy in one patient and postoperative wound infection in two. In one patient, postoperative mild L5 motor paresis resolved. One patient had a temporary brachial plexopathy due to intraoperative positioning, and one patient had peripheral polyneuropathy secondary to prolonged intraoperative blood pressure cuff inflation. CONCLUSION: Transforaminal lumbar interbody fusion is a safe and effective method for achieving circumferential spinal fusion via a single-stage procedure. This procedure is particularly useful in restoring disc space height and lumbar lordosis.     

Early sacral stress fracture after reduction of spondylolisthesis and lumbosacral fixation: case report

OBJECTIVE AND IMPORTANCE: Early sacral fracture is an extremely rare complication of instrumented lumbosacral fusion seen in older, osteopenic women. Previous reports have attributed the problem to the use of multisegmental (three or more levels) fixation, with the transfer of stress forces from rigid spinal implants to the sacrum. We report the only case, to the best of our knowledge, of early sacral fracture after a two-level lumbosacral fusion and the only case of early sacral fracture after reduction of spondylolisthesis. CLINICAL PRESENTATION: A patient presented with a sudden recurrence of low back and buttock pain a few days after lumbosacral decompression, reduction of L5-S1 Grade II spondylolisthesis, and instrumented L5-S1 fusion, including posterior lumbar interbody fusion. A transverse sacral fracture was found on plain x-rays 4 weeks later. INTERVENTION: Symptoms improved with brace therapy and medical treatment for osteoporosis. CONCLUSION: Early sacral fracture is a rare cause of pain after instrumented lumbosacral fusion. Although the transfer of loads from rigid spinal implants to adjacent segments is particularly problematic for multisegmental fusions, patients with short-segment constructs may also be affected. Active reduction of spondylolisthesis may provide additional adjacent segment stress contributing to this complication.     

Lateral branch blocks as a treatment for sacroiliac joint pain: A pilot study

BACKGROUND AND OBJECTIVES: Pain arising from the sacroiliac (SI) joint is a common cause of low back pain for which there is no universally accepted, long-term treatment. Previous studies have shown radiofrequency (RF) procedures to be an effective treatment for other types of spinal pain. The purpose of this study was to determine the efficacy of reducing SI joint pain by percutaneous RF lesioning of the nerves innervating the SI joint. METHODS: Eighteen patients with confirmed SI joint pain underwent nerve blocks of the L4-5 primary dorsal rami and S1-3 lateral branches innervating the affected joint. Those who obtained 50% or greater pain relief from these blocks proceeded to undergo RF denervation of the nerves. RESULTS: Thirteen of 18 patients who underwent L4-5 dorsal rami and S1-3 lateral branch blocks (LBB) obtained significant pain relief, with 2 patients reporting prolonged benefit. At their next visit, 9 patients who experienced >50% pain relief underwent RF lesioning of the nerves. Eight of 9 patients (89%) obtained >/=50% pain relief from this procedure that persisted at their 9-month follow-up. CONCLUSIONS: In patients with SI joint pain who respond to L4-5 dorsal rami and S1-3 LBB, RF denervation of these nerves appears to be an effective treatment. Randomized, controlled trials are needed to further evaluate this procedure.     

Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome

The purpose of this retrospective study was to evaluate the clinical and radiological outcome of bilateral sacroiliac joint (SIJ) fusion, using a new technique, in patients with a chronic SIJ syndrome. Seventeen patients with chronic low back pain, with a positive response to specific diagnostic tests for the SIJ, were considered candidates for bilateral sacroiliac fusion. The surgical indication was based on the results of local anaesthetic joint infiltration, temporary external fixation or bone scan. Ten patients had had previous surgery on the lumbar spine. Bilateral posterior SIJ fusion was performed with internal fixation and decortication of the sacroiliac joint, using a separate approach to each joint. Local bone grafting was performed. At the time of follow-up (on average 39 months after surgery), 3 patients reported moderate or absent pain, 8 marked pain and 6 severe pain. Seven patients showed a symptomatic non-union; union occurred in only 6 cases. Eighteen percent of the patients were satisfied, but in the other 82% the results were not acceptable. Reoperation was performed in 65% of the patients. Our results with bilateral posterior SIJ fusion were disappointing, which may be related with difficulties in patient selection, as well as with surgical technique. Better diagnostic procedures and possibly other surgical techniques might provide more predictable results, but this remains to be demonstrated.     

Anterior fibular strut grafting for the treatment of pseudoarthrosis in spondylolisthesis

Ten patients with a failed posterior spinal fusion for symptomatic spondylolisthesis were treated with retroperitoneal anterior lumbosacral interbody fusion. A fibular strut allograft was placed, followed by posterolateral fusion and instrumentation. The mean follow-up was 40 months (range 24-60 months). All patients complained of back pain and leg pain before surgery. All patients achieved solid fusion at L5-S1. One patient developed pseudoarthrosis at L4-5 and improved symptomatically with no postoperative complications.     

Sacroiliac joint luxation after pedicle subtraction osteotomy: report of two cases and analysis of failure mechanism

Background

Sagittal decompensation after pedicle subtraction osteotomy (PSO) is considered as late onset complication. Several mechanisms have been suggested, but little attention has been paid to the caudal end of lumbar instrumented fusion, especially sacral iliac joint (SIJ) deterioration.

Methods

Clinical histories and radiographic sagittal parameters of two patients with SIJ luxation after PSO are presented. The biomechanical failure mechanism and risk factors are analysed.

Results

Two patients underwent correction of fixed anterior sagittal imbalance by PSO, followed by pseudarthrosis revision surgery. Both of them sustained persistent sacroiliac pain, progressive recurrence of anterior imbalance and progressive pelvic incidence (PI) increase around 10°. An acute bilateral SIJ luxation occurred in both patients leading to sharp increase or PI around 20°. One patient was treated by SIJ fusion and the other patient was placed on non-weight-bearing crutch ambulation for 1 year. Both patients had a high preoperative PI (95° and 78°). A theoretical match between lumbar lordosis (LL) and PI was not achieved by PSO. Osteopenia was present in both patients. Computed tomography evidenced L5–S1 pseudarthrosis and sacroiliac joint violation by pelvic or sacral ala screws.

Conclusion

Patients with high PI might seek for further compensation at their SIJ when lacking LL after PSO. Chronic anterior imbalance might lead to progressive weakening of sacroiliac ligaments. Initial circumferential lumbosacral fusion and accurate iliac screw fixation might reduce stress on implants, risk for pseudarthrosis, implant failure and finally SIJ deterioration. Bone mineral density should further be investigated preoperatively.

     

腰椎融合术后骶髂关节源性下腰痛的诊断和治疗

目的探讨腰椎融合术后骶髂关节病变的特点、治疗方法与疗效。方法回顾性分析34例因腰椎管狭窄、腰椎间盘突出、腰椎滑脱曾行后路减压、后外侧或椎体间植骨融合及椎弓根内固定术,术后随访12～48个月（平均30．6个月）出现新的难治性持续性下腰痛症状的病例。运用骶髂关节内封闭进行诊断性治疗。阳性标准：疼痛缓解75％（采用视觉模拟评分法进行定量分析）。结果阳性率为26．5％,术后腰痛部位不同于术前以及融合范围包含L5、S1是具有统计学意义（P〈0．05）。结论腰椎融合术后下腰痛可能部分是由骶髂关节病变引起的,骶髂关节内封闭是当前诊断和治疗骶髂关节源性下腰痛的最有效的方法。     

Early Results of Sacro–Iliac Joint Fixation Following Long Fusion to the Sacrum in Adult Spine Deformity

Background

The sacro–iliac joint (SIJ) is the largest joint in the human body. When the lumbar spine is fused to the sacrum, motion across the SIJ is increased, leading to increased degeneration of the SIJ. Degeneration can become symptomatic in up to 75% of the cases when a long lumbar fusion ends with a sacral fixation. If medical treatments fail, patients can undergo surgical fixation of the SIJ.

Questions/Purposes

This study reports the results of short-term complications, length of stay, and clinical as well as radiographic outcomes of patients undergoing percutaneous SIJ fixation for SIJ pain following long fusions to the sacrum for adult scoliosis.

Methods

A retrospective review of all the patients who underwent a percutaneous fixation of the SIJ after corrective scoliosis surgery was performed in a single specialized scoliosis center between the years 2011–2013. Ten SIJ fusions were performed in six patients who failed conservative care for SIJ arthritis. Average age was 50 (range 25–60 years). The patients were 15.3 years in average after the original surgical procedure (range 4–25 years). Average post-operative follow-up was 10.25 months (range 15–4 months). The medical charts of the patients were reviewed for hospital stay, complications, pre- and post-operative pain, quality of life, and satisfaction with surgery using the visual analogues score (VAS), Scoliosis Research Society (SRS)22 and Oswestry Disability Index (ODI) questionnaires. Images were reviewed for fixation of the SIJ, fusion, and deviation of the implants from the SIJ.

Results

There were no complications in surgery or post-operatively. Discharge was on post-operative day 2 (range 1–4 days). Leg VAS score improved from 6.5 to 2.0 (P < 0.005; minimal clinically important difference (MCID) 1.6). Back VAS score decreased from 7.83 to 2.67 mm (P < 0.005; MCID 1.2). ODI scores dropped from 22.2 to 10.5 (P = 0.0005; MCID 12.4). SRS22 scores increased from 2.93 to 3.65 (P = 0.035; MCID 0.2) with the largest increases in the pain, function, and satisfaction domains of the questionnaires.

Conclusion

Fixation of the SIJ in patients that fail conservative care for SIJ arthritis after long fusions ending in the sacrum provides a reduction in back pain and improved quality of life in the short and medium range follow-up period.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9374-4) contains supplementary material, which is available to authorized users.     

Absence de fiabilité des tests cliniques et des blocs pour le diagnostic positif de l’origine sacro-iliaque d’une douleur

Mapping studies of pain elicited by injections into the sacroiliac joints (SIJs) suggest that sacroiliac joint syndrome (SIJS) may manifest as low back pain, sciatica, or trochanteric pain. Neither patient-reported symptoms nor provocative SIJ maneuvers are sensitive or specific for SIJS when SIJ block is used as the diagnostic gold standard. This has led to increasing diagnostic use of SIJ block, a procedure in which an anesthetic is injected into the joint under arthrographic guidance. However, several arguments cast doubt on the validity of SIJ block as a diagnostic gold standard. Thus, the effects of two consecutive blocks are identical in only 60% of cases, and the anesthetic diffuses out of the joint in 61% of cases, often coming into contact with the sheaths of the adjacent nerve trunks or roots, including the lumbosacral trunk (which may contribute to pain in the groin or thigh) and the L5 and S1 nerve roots. These data partly explain the limited specificity of SIJ block for the diagnosis of SIJS and the discordance between the pain elicited by the arthrography injection and the response to the block. The limitations of provocative maneuvers and SIJ blocks may stem in part from a contribution of extraarticular ligaments to the genesis of pain believed to originate within the SIJs. These ligaments include the expansion of the iliolumbar ligaments, the dorsal and ventral sacroiliac ligaments, the sacrospinous ligaments, and the sacrotuberous ligaments (sacroiliac joint lato-sensu). They play a role in locking or in allowing motion of the SIJs. Glucocorticoids may diffuse better than anesthetics within these ligaments. Furthermore, joint fusion may result in ligament unloading.     

Documentation of outcomes for sacroiliac joint fusion: does prior spinal fusion influence the outcome?

Purpose

The purpose of this prospective case series (level II) was to determine the clinical outcomes of anterior SIJ fusion, comparing the outcomes of patients who had prior spinal fusions at any level compared to patients who have not.

Methods

This prospective study included 25 patients who underwent SIJ fusion with anterior plate fixation. All patients had failed non-operative treatment, had a positive Patrick test, and positive response to intra-articular SIJ injections with greater than 50 % pain relief. Patients had follow-up at 3, 6, 9 and 12 months where they completed Oswestry disability index (ODI) and Short Musculoskeletal Functional Assessment (SMFA) surveys. Outcome data are available for 19 patients who completed pre-operative and 12-month follow-up surveys. Their average time of the final follow-up was 1.1 years (range 10–33 months).

Results

Significant improvements between pre-operative and the final follow-up in ODI (p = 0.007) and SMFA (p = 0.01) were observed; the ODI assessed outcomes in patients who had previous spinal fusion surgery were significantly worse than those that did not at the final follow-up (p = 0.04).

Conclusion

Patients who have not undergone prior spinal fusion surgery, regardless of age, gender, and BMI have better outcomes following anterior SIJ fusion.     

Spinal fusion for back pain: a clinical and radiological review.

Eighty-one patients who had spinal fusions performed for back pain over a 7-year period were reviewed; 74% were satisfied with the outcome of their surgery, mainly because of the degree of pain relief obtained. Based on lateral radiographs of the fusion area in flexion and extension, there was a 34% pseudarthrosis rate in first-time fusions. However, there was no clear relationship between the integrity of fusion and clinical success, indicating that many factors other than bony fusion influence the eventual outcome of the operation.     

Sacral fracture as a rare early complication of lumbosacral spondylodesis

A 57 year old patient with secondary cortisone induced osteoporosis war surgically treated by means of posterior lumbar interbody fusion with internal fixation from L4-S1 for symptomatic instability in the level L4/5 after previous dorsal stabilisation L5/S1. After an unapparent initial postoperative phase, the patient complained of severe pain in the low back and gluteal region 9 day after surgery. Radiographs as well as CT-scans showed a horizontal fracture of the sacrum. After a short period of immobilisation the patient was carefully remobilised with an orthesis and the pain gradually subsided. Conventional radiographs one year later showed complete consolidation of the fracture and a good clinical result. There are only two literature reports with together 3 cases of patients attaining an early sacral fracture after spondylodesis. The main cause seems to be the unphysiological biomechanical stress placed on the osteoporotic sacrum after moresegmental spondylodesis. Further risk factors seem to be adipositas, female gender and age. Despite the rarity of sacral fractures after lumbosacral fusion, this complication should at least be considered in the differential diagnosis in patients who complain of persisting or sudden-onset pain after surgery.     

Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain

Mapping studies of pain elicited by injections into the sacroiliac joints (SIJs) suggest that sacroiliac joint syndrome (SIJS) may manifest as low back pain, sciatica, or trochanteric pain. Neither patient-reported symptoms nor provocative SIJ maneuvers are sensitive or specific for SIJS when SIJ block is used as the diagnostic gold standard. This has led to increasing diagnostic use of SIJ block, a procedure in which an anesthetic is injected into the joint under arthrographic guidance. However, several arguments cast doubt on the validity of SIJ block as a diagnostic gold standard. Thus, the effects of two consecutive blocks are identical in only 60% of cases, and the anesthetic diffuses out of the joint in 61% of cases, often coming into contact with the sheaths of the adjacent nerve trunks or roots, including the lumbosacral trunk (which may contribute to pain in the groin or thigh) and the L5 and S1 nerve roots. These data partly explain the limited specificity of SIJ block for the diagnosis of SIJS and the discordance between the pain elicited by the arthrography injection and the response to the block. The limitations of provocative maneuvers and SIJ blocks may stem in part from a contribution of extraarticular ligaments to the genesis of pain believed to originate within the SIJs. These ligaments include the expansion of the iliolumbar ligaments, the dorsal and ventral sacroiliac ligaments, the sacrospinous ligaments, and the sacrotuberous ligaments (sacroiliac joint lato-sensu). They play a role in locking or in allowing motion of the SIJs. Glucocorticoids may diffuse better than anesthetics within these ligaments. Furthermore, joint fusion may result in ligament unloading.     

42例腰椎融合术后难治性下腰痛的治疗体会

目的探讨腰椎融合术后骶髂关节病变的特点及治疗方法与疗效。方法回顾性分析42例因腰椎退变性滑脱、腰椎椎间盘突出、腰椎椎管狭窄曾行后路减压、后外侧或椎体间植骨融合及椎弓根内固定术,术后随访12～72个月(平均42.6个月)出现新的难治性持续性下腰痛症状的病例。本研究运用骶髂关节内封闭进行诊断性治疗。阳性标准:疼痛缓解≥75%,采用疼痛视觉模拟量表(visual analogue scale,VAS)进行定量分析。结果阳性12例(28.57%),是否融合L5/S1、术后疼痛缓解期是否≥3个月与诊断阳性率相关,有统计学意义(P<0.05)。结论腰椎融合术后下腰痛部分可能是由骶髂关节病变引起的,L5/S1融合可能促进骶髂关节发生退变。症状以下腰痛症状为主者,手术应慎重。     

The role of radiofrequency in the treatment of mechanical pain of spinal origin

Radiofrequency (RF) ablation is a method that has been gaining popularity over the past few years among spinal surgeons. It has a role when dealing with pain of spinal origin, either mechanical or neuropathic, after conservative treatment has failed. In the present study, 122 patients with a minimal follow up of 1 year were examined at our institution after having undergone RF heat lesion of the medial branch for mechanical spinal pain (low back pain, thoracic pain or cervical pain). They were followed up 1, 3, 6 and 12 months after treatment. Twenty-two of them were additionally followed up at 18 months. After 1 month, 91 patients (75%) were satisfied with the results. After 3 months, 87 patients (71%) had significant pain relief, while in 35 patients (29%) there was no improvement. After 6 months of follow-up, 80 patients (66%) had pain relief and in 42 patients (34%) there was no effect. At 12-months follow-up, 77 patients (63%) showed good results and 45 patients (37%) had no effect. In the case of the 22 patients who were followed for 18 months, all showed significant pain relief. Minor complications occurred in 27 patients (22%), who had transient discomfort and burning pain. We concluded that RF is a safe and partially effective procedure for mechanical back pain.     

Unilateral spondylolysis combined with contralateral lumbar pediculolysis in a military parachutist

A few cases of unilateral pediculolysis combined with contralateral spondylolysis have been reported, and most of them were related to athletic activities. A case of unilateral spondylolysis combined with contralateral lumbar pediculolysis in a military parachutist is reported. A 34-year-old man experienced low back pain and right sciatica for 3 months. Radiographs revealed a left spondylolysis combined with a right pediculolysis of the L5 vertebra. The patient had parachuted >300 times in the last 5 years. Interbody fusion of L5-S1 was performed, and the patient was free of pain after surgery.