Search Results (52)

Background: Bertolotti syndrome describes a painful lumbosacral transitional vertebra (LSTV) with a pseudoarticulation between an enlarged lateral process of the caudal lumbar vertebra (L5) and ilium or sacrum. It often presents with chronic lower back pain with or without radiculopathy. The current literature emphasizes Bertolotti as a differential diagnosis in young adults. However, it is presumably underdiagnosed in middle-aged and older patients. Treatment ranges from conservative treatment with physiotherapy, infiltration, and radiofrequency ablation to surgical interventions. Case Description: In this case illustration, we present the diagnostic and therapeutic challenges in a 48-year-old female triathlete with persistent left gluteal pain caused by Bertolotti syndrome. When conservative treatment with physiotherapy, infiltrations, thermocoagulation, and radiofrequency ablation of the pseudoarticulation failed, microsurgical reduction of the hypertrophic transverse process was performed. This minimally invasive intervention achieved satisfactory pain relief of at least 70% one year after surgery, allowing the patient to resume her athletic activities. Conclusions: Bertolotti syndrome should be considered a potential differential diagnosis in patients of all ages. Since many patients endure years of misdiagnosis, adequate treatment is crucial upon diagnosis. If conservative measures fail, surgical treatment such as “processectomy” or spinal fusion should be evaluated. This case follows the CARE reporting guidelines. Full article

Endoscopic spine surgery (ESS) has traditionally been employed for lumbar disc herniation (LDH). Recent innovations in surgical methods and technologies have expanded its range to address other spinal pathologies, providing minimally invasive solutions with potential clinical benefits. Our review aims to summarize the applications, clinical outcomes, and limitations of ESS beyond LDH, focusing on its role in complex spinal conditions such as stenosis, thoracic disc herniation, spinal tumors, synovial cysts, and failed back surgery syndrome. A thorough review of the literature was conducted to assess and summarize the current evidence regarding ESS applications for spinal conditions beyond LDH surgery. Areas of focus included innovations in technology and technique, as well as comparisons with conventional open surgical methods. ESS shows notable potential across different spinal conditions by providing minimally invasive alternatives to traditional open surgery. Its use could be associated with reduced surgical morbidity, shorter recovery times, and improved patient outcomes. In particular, ESS is versatile in addressing both degenerative and neoplastic conditions of the spine. Despite this, challenges such as technical complexity, steep learning curves, and limited indications for certain pathologies remain as barriers to wider adoption. ESS is evolving in spine surgery, extending its utility beyond LDH surgery. While the current evidence largely supports its clinical efficacy, further studies are needed to address the present limitations and optimize its application. Future developments in surgical training and technology will likely enhance its adoption and broaden its clinical indications. Full article

Objective: This study aimed to evaluate the outcomes and predictive factors of I-125 radioactive plaque therapy for recurrent and refractory retinoblastoma (Rb) cases that failed primary systemic chemotherapy and focal therapies. Methods: A retrospective study of 20 eyes with intraocular Rb treated with I-125 radioactive plaque therapy (Apex dose 45 Gy) from 2013 to 2023 was conducted. Data on tumor characteristics, treatments, and outcomes were collected over a follow-up period of at least one year. Results: There were 11 (55%) males and 8 (40%) patients who had bilateral disease. All 20 treated eyes (100%) showed initial tumor regression, while long-term tumor control and eye salvage were achieved in 14 eyes (70%). Six eyes (30%) experienced uncontrollable tumor recurrence after a mean of 6 months (range: 3–12 months) after plaque therapy. Recurrence included main tumor activity in six eyes and additional resistant vitreous seeds in two of them. Poor predictive factors for eye salvage included Group D at diagnosis (p = 0.044), active vitreous seeds at the time of plaque therapy ((p = 0.045), tumor thickness >5.0 mm (p = 0.045), and tumor base dimension >12 mm (p = 0.023). Post-plaque complications included cataracts in seven eyes (35%), tumor hemorrhage in six eyes (30%), retinal detachment in four eyes (20%), radiation retinopathy in three eyes (15%), and neovascular glaucoma in one eye (5%). Five (83%) of those with tumor hemorrhage had plaque surgery performed within less than 6 months of the last cycle of systemic chemotherapy. At a mean follow-up of 36 months (range: 12–96 months), five eyes (25%) were enucleated, and high-risk pathological features were identified in three eyes, including post-laminar optic nerve infiltration (one eye) and massive choroidal invasion (two eyes). All patients were alive and free of metastasis except one patient (5%) whose parents refused enucleation and came back with extra-scleral extension and bone marrow metastasis and eventually passed away. Conclusions: I-125 radioactive plaque therapy is a valuable salvage treatment for recurrent and refractory retinoblastoma, achieving tumor control and eye salvage in 70% of cases with an acceptable safety profile. However, the observed recurrence rate (30%) at an apex dose of 45 Gy suggests a need for dose optimization and individualized treatment strategies. Identifying high-risk features, such as Group D disease, active vitreous seeds, and larger tumors, is crucial for patient selection and outcome prediction. Future research should explore alternative dosing strategies, combination therapies, and improved predictive models to enhance long-term tumor control while minimizing complications. Full article

Background/Objectives: Many patients evaluated by shoulder specialists suffer from intractable pain, neuropathy, and weakness. The pectoralis minor (PM) remains the only scapula muscle to receive lower trunk (C8-T1) input. We propose a novel syndrome: the Human Disharmony Loop. This model portrays how this unique PM innervation causes scapular dyskinesia, which deranges the anatomy of the upper limb girdle and produces a refractory symptom complex of pain, neuropathy, and weakness. We hypothesize that certain patients with historically intractable symptoms of the upper limb girdle may benefit from PM tenotomy. Methods: Ten patients of diverse etiologies presented with a similar constellation of complaints. The patients included a female athlete, a female with macromastia, a male bodybuilder, and patients with post-radiation breast cancer, post-operative shoulder arthroplasty, interscalene block injury, cervical spine disease, persistent impingement after rotator cuff repair, direct traction injury, and occupational disorder. All patients exhibited coracoid tenderness, scapula protraction with internal rotation and anterior tilt, and pain involving the neck, shoulder, and upper back. The patients demonstrated varying degrees of arm neuropathy, subacromial impingement, and occipital headaches. The patients failed all prior treatments by multiple subspecialists, including surgery. Each patient underwent isolated open PM tenotomy. Results: In all ten patients, PM tenotomy substantially reduced shoulder, upper back, and neck pain, cleared concomitant neuropathy, restored full motion, and eradicated occipital headaches. The response to surgery was rapid, dramatic, and durable. Conclusions: The unique asymmetric neurologic innervation to the sole ventral stabilizer of the scapula, the pectoralis minor, predisposes the human shoulder to neurologic and musculoskeletal imbalance. This produces the Human Disharmony Loop: a clinical syndrome spanning from the neck to the fingertips, with chronic pain, neuropathy, and weakness. These challenging patients may benefit dramatically from isolated PM tenotomy. Full article

Background/Objectives: Lumbar disk herniation (LDH) significantly affects quality of life due to lower back and radiating leg pain. Surgical intervention, such as discectomy, is effective for symptom relief when conservative measures fail; however, psychological factors like anxiety, depression, and maladaptive coping strategies may negatively impact surgical outcomes. This study aims to assess the role of preoperative psychological evaluations in predicting postoperative recovery and to identify key psychological and functional predictors of surgical success. Methods: A prospective study was conducted on 888 patients undergoing microdiscectomy for LDH at Mater Olbia Hospital between December 2020 and December 2023. Preoperative evaluations included the Visual Analog Scale, Symptom Checklist 90-R, Oswestry Disability Index, and Short Form 36. Logistic regression models and ROC curve analysis were used to identify significant predictors of outcomes and evaluate model accuracy. Results: Preoperative pain levels and emotional well-being emerged as the strongest determinants of postoperative improvement in the Oswestry Disability Index. The predictive model demonstrated high specificity (90.2%) in identifying patients likely to benefit from surgery. Clinically significant improvements were achieved by 69% of patients, highlighting the importance of psychological and functional assessments. Conclusions: Preoperative psychological assessment is critical in predicting outcomes of lumbar disk herniation surgery. Addressing psychological factors preoperatively enhances recovery, supports personalized treatment planning, and improves patient education. These findings advocate for an integrated care model that considers both physical and psychological health, optimizing surgical outcomes and patient satisfaction. Full article

Background and Objectives: The International Society for Modulation defines persistent spinal pain syndrome type 2 (PSPS-type 2), formerly known as failed back surgery syndrome, as a condition where patients continue to experience pain or develop new pain following spinal surgery intended to alleviate back or lower-limb discomfort. PSPS-type 2 is characterized by pain and significant disability, affecting quality of life. Spinal cord stimulation has proven effective in treating this syndrome, although the role of psychological factors, such as pain catastrophizing and central sensitization, remain unclear. This study seeks to examine the potential connection between psychosocial responses and both functionality and pain perception in patients with persistent spinal pain syndrome type 2 who have undergone spinal cord stimulation treatment. Materials and Methods: A single-site, cross-sectional study was conducted on individuals diagnosed with persistent spinal pain syndrome type 2 who were receiving spinal cord stimulation. Study participants were required to meet specific eligibility criteria and were assessed for disability, pain perception, fear of movement, pain catastrophizing, and central sensitization. The spinal cord stimulation procedure involved the placement of electrodes at vertebral levels T8–T11 for precise pain control, with a particular focus on targeting the dorsal root ganglion to alleviate chronic pain. Results: Thirty-seven patients with persistent spinal pain syndrome type 2 have undergone spinal cord stimulation treatment for 4.68 ± 5.25 years. Clinical assessments indicated a pain perception score of 5.6 ± 1.96, Central Sensitization Inventory score of 42.08 ± 18.39, disability score of 37.62 ± 16.13, fear of movement score of 33.11 ± 8.76, and pain catastrophizing score of 28.43 ± 13.14. Finally, pain catastrophizing was significantly associated with pain perception (β = 0.075 and p = 0.008) and disability (β = 0.90 and p < 0.01). Conclusions: Catastrophizing plays a crucial role in pain perception and disability among patients with persistent spinal pain syndrome type 2 receiving spinal cord stimulation. Integrating psychological interventions may improve clinical outcomes for these patients. Full article

Background: Spinal cord stimulation (SCS) has emerged as an effective treatment for managing chronic pain that is unresponsive to traditional therapies. While SCS is well documented for conditions like failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS), its effectiveness in managing pain related to spinal cord injuries (SCI) is less studied. This study aims to assess the efficacy of SCS in alleviating SCI-related pain and improving patients’ quality of life, filling a gap in the existing literature. Methods: This cohort study included 15 adult patients with traumatic and non-traumatic SCIs, treated between 2016 and 2022. Patients received SCS implants after either a trial or direct implantation. Pain levels were assessed using visual analog scale (VAS) scores, while quality of life was evaluated using the EuroQol five-dimensional (EQ-5D) scale. The SCS devices were implanted at different spinal levels, with various stimulation protocols applied, including high-frequency stimulation (10 kHz). Results: In patients with traumatic SCI, the mean VAS score decreased from 8.6 to 4.5, with 71% reporting more than 50% pain relief. Non-traumatic SCI patients experienced a reduction from 8.5 to 2.5, with all showing more than 50% pain relief. EQ-5D scores improved in both groups. A 49% reduction in pain medication usage was also observed, though one patient required revision surgery due to an adverse event. Conclusions: SCS significantly reduces pain and improves quality of life for SCI patients, particularly with high-frequency protocols. While promising, further research is needed to optimize patient selection and stimulation parameters for better long-term outcomes. Full article

Laminectomy is a commonly performed surgical procedure by orthopedic and neurosurgeons, aimed at alleviating nerve compression and reducing pain. However, in some cases, excessive proliferation of fibrous scar tissue in the epidural space post-surgery can lead to persistent and intractable lower back pain, a condition known as Failed Back Surgery Syndrome (FBSS). The persistent fibrous tissue causes both physical and emotional distress for patients and also makes follow-up surgeries more challenging due to reduced visibility and greater technical difficulty. It has been established that the application of biomaterials to prevent epidural fibrosis post-lumbar surgery is more beneficial than revision surgeries to relieve dural fibrosis. Hydrogel-based biomaterials, with their excellent biocompatibility, degradability, and injectability and tunable mechanical properties, have been increasingly introduced by clinicians and researchers. This paper, building on the foundation of epidural fibrosis, primarily discusses the strategies for the preparation of natural and polymeric biomaterials to prevent epidural fibrosis, their physicochemical properties, and their ability to mitigate the excessive proliferation of fibroblasts. It also emphasizes the challenges that need to be addressed to translate laboratory research into clinical practice and the latest advancements in this field. Full article

Postoperative discitis (POD) accounts for 20% to 30% of all cases of pyogenic spondylodiscitis, while POD may be mis-or-under-diagnosed, due to the vague related symptomatology and the non-specific imaging findings. Most studies report infection rate of less than 1%, which increases with the addition of non-instrumented fusion to 2.4% to 6.2%. It remains controversial whether POD is caused by an aseptic or infectious process. Positive cultures are presented only in 42–73% of patients with Staphylococcus species being the most common invading organisms, while Staphylococcus aureus is isolated in almost 50% of cases. The onset of POD symptoms usually occurs at 2–4 weeks after an apparently uneventful operation. Back pain and muscle spasms are usually refractory to bed rest and analgesics. Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging diagnostic technique. Antimicrobial therapy depends on the results of tissue cultures, and along with bracing represents the mainstay of management. Surgical intervention is necessary in patients failing conservative treatment. For the majority of cases, extensive surgical debridement, antibiotic therapy, and orthosis immobilization are effective in eliminating the infection. According to this, we recommend an Algorithmic approach for the management of POD. Postoperative infections after spinal surgery pose a certain clinical challenge, and in most cases can be treated conservatively. Nevertheless, disability may be persistent, and surgery could be necessary. The purpose of this concise review is to describe the manifestation of post-discectomy infection, its pathogenesis and particularly a rational approach for its management. Full article

Background and Objectives: In case of the ineffectiveness of pharmacological and non-pharmacological treatments in managing chronic neuropathic pain, spinal cord stimulation (SCS) with BurstDR™ stimulation may reduce pain and increase the quality of life. The term “burst” refers to a series of stimulation impulses that are compressed into small packets and separated by intervals of latency. Materials and Methods: A group of 30 consecutive patients who received the BurstDR™ stimulator using the minimally invasive percutaneous method was selected. Patients selected for our study underwent numerous spinal surgeries before SCS implantation. In the study, analgesics and co-analgesics and their doses used by patients before and 6 months after SCS implantation were examined and compared. Using the visual analogue scale (VAS), pain was compared before and after the procedure. Patients` quality of life was assessed using the Oswestry Disability Index (ODI). Results: We observed a significant reduction in opioid daily doses by an average of 32.4% (±36.1%) and a reduction in paracetamol daily doses by an average of 40% (±33.4%). There was a reduction in pregabalin doses as well. Ketoprofen daily dose reduction was 85.4 mg. The mean VAS difference before and after procedure was 3.9 (±2.3), and the mean difference in ODI was 12.9 (±9), which benefits operative treatment. The VAS and ODI results were statistically significant as well. Conclusions: According to our research, BurstDR™ stimulation improves the quality of life by reducing doses of analgesics and the level of pain. Full article

Introduction: Chronic pain after spinal surgery (CPSS), formerly known as failed back surgery syndrome, encompasses a variety of highly incapacitating chronic pain syndromes emerging after spinal surgery. The intractability of CPSS makes objective parameters that could aid classification and treatment essential. In this study, we investigated the use of cerebral diffusion-weighted magnetic resonance imaging. Methods: Cerebral 3T diffusion-weighted (DW-) MRI data from adult CPSS patients were assessed and compared with those of healthy controls matched by age and gender. Only imaging data without relevant artefacts or significant pathologies were included. Apparent diffusion coefficient (ADC) maps were calculated from the b0 and b1000 values using nonlinear regression. After skull stripping and affine registration of all imaging data, ADC values for fifteen anatomical regions were calculated and analyzed with independent samples T-tests. Results: A total of 32 subjects were included (sixteen CPSS patients and sixteen controls). The mean ADC value of the spinothalamic tract was found to be significantly higher in CPSS patients compared with in healthy controls (p = 0.013). The other anatomical regions did not show statistically different ADC values between the two groups. Conclusion: Our results suggest that patients suffering from CPSS are subject to microstructural changes, predominantly within the cerebral spinothalamic tract. Additional research could possibly lead to imaging biomarkers derived from ADC values in CPSS patients. Full article

The introduction of the term Persistent Spinal Pain Syndrome (PSPS-T1/2), replacing the older term Failed Back Surgery Syndrome (FBSS), has significantly influenced our approach to diagnosing and treating post-surgical spinal pain. This comprehensive review discusses this change and its effects on patient care. Various diagnostic methods are employed to elucidate the underlying causes of back pain, and this information is critical in guiding treatment decisions. The management of PSPS-T1/2 involves both causative treatments, which directly address the root cause of pain, and symptomatic treatments, which focus on managing the symptoms of pain and improving overall function. The importance of a multidisciplinary and holistic approach is emphasized in the treatment of PSPS-T1/2. This approach is patient-centered and treatment plans are customized to individual patient needs and circumstances. The review concludes with a reflection on the impact of the new PSPS nomenclature on the perception and management of post-surgical spinal pain. Full article

Spinal epidural fibrosis is one of the typical features attributable to failed back surgery syndrome, with excessive scar development in the dura and nerve roots. The microRNA-29 family (miR-29s) has been found to act as a fibrogenesis-inhibitory factor that reduces fibrotic matrix overproduction in various tissues. However, the mechanistic basis of miRNA-29a underlying the overabundant fibrotic matrix synthesis in spinal epidural scars post-laminectomy remained elusive. This study revealed that miR-29a attenuated lumbar laminectomy-induced fibrogenic activity, and epidural fibrotic matrix formation was significantly lessened in the transgenic mice (miR-29aTg) as compared with wild-type mice (WT). Moreover, miR-29aTg limits laminectomy-induced damage and has also been demonstrated to detect walking patterns, footprint distribution, and moving activity. Immunohistochemistry staining of epidural tissue showed that miR-29aTg was a remarkably weak signal of IL-6, TGF-β1, and DNA methyltransferase marker, Dnmt3b, compared to the wild-type mice. Taken together, these results have further strengthened the evidence that miR-29a epigenetic regulation reduces fibrotic matrix formation and spinal epidural fibrotic activity in surgery scars to preserve the integrity of the spinal cord core. This study elucidates and highlights the molecular mechanisms that reduce the incidence of spinal epidural fibrosis, eliminating the risk of gait abnormalities and pain associated with laminectomy. Full article

There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. In fact, there is no specific ICD-10-CM diagnostic code to classify and define discogenic pain as a unique source of pain distinct from other recognized sources of chronic low back pain including facetogenic, neurocompressive including herniation and/or stenosis, sacroiliac, vertebrogenic, and psychogenic. All of these other sources have well-defined ICD-10-CM codes. Corresponding codes for discogenic pain remain absent from the diagnostic coding vernacular. The International Society for the Advancement of Spine Surgery (ISASS) has proposed a modernization of ICD-10-CM codes to specifically define pain associated with lumbar and lumbosacral degenerative disc disease. The proposed codes would also allow the pain to be characterized by location: lumbar region only, leg only, or both. Successful implementation of these codes would benefit both physicians and payers in distinguishing, tracking, and improving algorithms and treatments for discogenic pain associated with intervertebral disc degeneration. Full article

Pain generator-based lumbar spinal decompression surgery is the backbone of modern spine care. In contrast to traditional image-based medical necessity criteria for spinal surgery, assessing the severity of neural element encroachment, instability, and deformity, staged management of common painful degenerative lumbar spine conditions is likely to be more durable and cost-effective. Targeting validated pain generators can be accomplished with simplified decompression procedures associated with lower perioperative complications and long-term revision rates. In this perspective article, the authors summarize the current concepts of successful management of spinal stenosis patients with modern transforaminal endoscopic and translaminar minimally invasive spinal surgery techniques. They represent the consensus statements of 14 international surgeon societies, who have worked in collaborative teams in an open peer-review model based on a systematic review of the existing literature and grading the strength of its clinical evidence. The authors found that personalized clinical care protocols for lumbar spinal stenosis rooted in validated pain generators can successfully treat most patients with sciatica-type back and leg pain including those who fail to meet traditional image-based medical necessity criteria for surgery since nearly half of the surgically treated pain generators are not shown on the preoperative MRI scan. Common pain generators in the lumbar spine include (a) an inflamed disc, (b) an inflamed nerve, (c) a hypervascular scar, (d) a hypertrophied superior articular process (SAP) and ligamentum flavum, (e) a tender capsule, (f) an impacting facet margin, (g) a superior foraminal facet osteophyte and cyst, (h) a superior foraminal ligament impingement, (i) a hidden shoulder osteophyte. The position of the key opinion authors of the perspective article is that further clinical research will continue to validate pain generator-based treatment protocols for lumbar spinal stenosis. The endoscopic technology platform enables spine surgeons to directly visualize pain generators, forming the basis for more simplified targeted surgical pain management therapies. Limitations of this care model are dictated by appropriate patient selection and mastering the learning curve of modern MIS procedures. Decompensated deformity and instability will likely continue to be treated with open corrective surgery. Vertically integrated outpatient spine care programs are the most suitable setting for executing such pain generator-focused programs. Full article