Journal of Spine

Back pain could be arising from a variety of pathological changes involving a multiple number of tissues including the bony spine itself and its surrounding muscles, nerves and vascular tissues involved. In a complex situation, back pain is still experienced in spite of serious attempts to remove the pathology or counteract the abnormal activities related. Nowadays, when conventional attempts fail to give good relief, acupuncture is commonly applied. Review of past experiences gives good support to the use of acupuncture for back pain. The theories behind the effectiveness of acupuncture remain hypothetical but the practice itself is safe and often effective. One would expect better outcome from this old traditional technique if more communication can be established between the acupuncturists the surgeons and therapists, and if puncturing practices could be standardized.

Background: Advances in the care and rehabilitation of patients with spinal cord injuries (SCI) have resulted in extended survival. As SCI patients age, chronic lower extremity ischemic complications are resulting in amputations. The literature relating to lower extremity amputation and prosthesis in SCI patients is sparse. Limb amputation may cause weight distribution imbalances, leading to back pain and increased risk of pressure ulcer formation. Lower extremity amputation challenges skin management, sitting balance, functional range and body image.

Case Description and Methods: We report a systematic retrospective review of a disability adaptation equipment entrepreneur with T4 AIS B paraplegia patient who underwent right transfemoral amputation because of poor wound healing in the setting of severe peripheral vascular disease. The prosthetic prescription included a total-contact socket with a knee-flexed formed prosthesis, mirroring the opposite limb. The socket design allowed decompression of the right ischium and secured the patient in the wheel chair for seated reach and leverage in work. The patient consistently used the prosthesis over 10 years and recognized a variety of benefits including improved seating stability, functional reach, transfers, cosmesis, dressing options and body image, and documented increase in community activity.

Conclusion: Lower extremity prosthesis fitting for patients with SCI and amputation can improve posture, seating, transfers, static and dynamic balance, participation in functional activities, and community reintegration.

Clinical Significance: Active patients with paraplegia and new transfemoral amputation should be offered a trial of a prothesis to enhance mobility. Many of the medical and functional consequences of amputation after SCI can be prevented with careful prosthesis selection, prescription, and training patients in the use of lower extremity prosthesis.

The most important complication of spinal cord lesions above T6 level is the phenomenon of Autonomic Hyperreflexia (AH). Symptoms and signs of AH result from the predominant parasympathetic excitation above the level of injury, and sympathetic excitation below the level of injury. Various noxious and nonnoxious stimuli below the level of injury can thus trigger off a mass autonomic response. The main triggering factor of AH is related with the urinary tract. The main treatment of AH is removal of the triggering factors. The development of intraoperative AH and hypertension can be prevented either by general anesthesia, which blunts autonomic reflexes, or regional anesthesia (spinal or epidural), which blocks afferent and autonomic efferent neural impulses.

Given the variety of anatomic and physical variations that exist, the biomechanics of Adolescent Idiopathic Scoliosis (AIS) comprise a complex topic. Representing the fundamental mechanism behind the three-dimensional deformities observed in this condition, AIS develops as a result of these complex interactions between pathoanatomy and the developmental biomechanics of the spine. The progressive nature of the deformity relates to the interplay between bony anatomical alterations and the surrounding soft tissue response. Various classification systems have evolved to better understand AIS and provide guidance for its management, and myriad techniques have been developed to address the correction of spinal deformity in these patients. For appropriately selected patients, the treating surgeon must exploit all biomechanical advantages available t counteract these deforming forces, and it is important that the biomechanics contributing to the progression of this condition be understood and corrected. All aspects of the case, including preoperative positioning and implant utilization, play a role in the amount of correction that can be obtained and maintained. These implants affect— and are affected by the forces present on the deformed spine, and manipulation of the surrounding anatomy may aid in obtaining the best surgical outcome.

Introduction: The gold standard in the treatment of lumbar degenerative spinal diseases is the posterolateral fusion with rod and screws. Semi-rigid systems were first designed to stabilize the abnormal segment and to unload degenerated discs and facet joints. One commonly observed consequence of fusing spinal motion levels has been adjacent segment disease (ASD). Due to prevention of ASD is a complicated and controversial topic, the aim of this study was to assess the role of combined dynamic and rigid posterolateral fixation systems in prevention of ASD.

Patients and Methods: A total of 76 adult patients with various lumbar spine pathologies, treated with posterior fusion and pedicle screw fixation between T12 and sacrum were included in this study. The prevalence of radiological and clinical ASD was measured and the functional outcome of the patients was evaluated using the Oswestry questionnaire.

Results: Evidence of radiographic ASD was noted in 6 of the 76 patients (7.9%), of whom one patient was symptomatic (16.67%). The mean preoperative Oswestry score was 27.2 ± 20.7 and the mean postoperative Oswestry score was 15.4 ± 20.3. There was a significant difference between the 2 scores (p=0.027). The mean postoperative lumbar lordosis was -53° ± 2.08 and the pelvic incidence 61° ± 3.12. Related to the complications, 6 patients with superficial wound infections, one patient with deep venous thrombosis (DVT), and one patient with ASD were reported.

Discussion: In our study, the very low incidence of ASD is achieved by the mean of preservation of the top facet joint, correction and preservation of coronal and sagittal balance, preservation of motion in the lumbar spine with the use of semi-rigid devices, and early rehabilitation accompanying by the training of the patient regarding to the body balance. Semi-rigid fixation significantly reduces the risk of screw fracture by the absorption of the stress on the interpedicular damper and enhances the bone fusion by maintaining constraints on the cages which remain under a compressive load.

Purpose: Literature is ambiguous on the incidence of deep venous thrombosis and pulmonary embolism by neurosurgical patients. The objective of this systematic review is to assess the incidence of thromboembolic complications associated with neurosurgical interventions, evaluate current prophylaxis methods and propose a prophylaxis strategy.

Methods: PubMed, Embase and Cochrane Central were searched systematically and studies involving neurosurgical procedures describing postoperative complications DVT and PE. The risk of bias was assessed using (adjusted) Cowley criteria.

Results: Twenty studies (14 case series, 3 comparative studies, 3 RCT’s) were included, describing 8905 neurosurgical patients. Without prophylaxis the incidence of DVT was reported in 28% of neurosurgical cases (range 21-34%). Studies that provided any kind of prophylaxis, in which clinical evaluation was used to diagnose DVT, reported a 2.5% incidence of DVT (range 0 to 5%), however, when systematically assessed with ultrasound the occurrence was 6.4% (range 0-17%). Pulmonary embolism was presented in 0 to 4% of all cases. Venous thromboembolic events were more frequent in intracranial procedures compared to spinal procedures. Patients, receiving a combination of low molecular weight heparins and compression stockings, showed a 50% lower incidence of DVT than patients receiving mechanical or chemical prophylaxis alone.

Conclusion: Optimal antithrombotic prophylaxis regime in neurosurgical interventions lowers the incidence of DVT’s from 28% to about 3 to 6%. We recommend a combination of LMWH and compression stockings for intracranial procedures. For spinal procedures this same prophylactic regimen is indicated, however it is defendable to choose single treatment with LMWH or compression stockings alone.

Summary:

There is a paucity of published literature involving the incidence and management of tandem spinal stenosis (TSS). A retrospective study evaluating both the incidence and surgical management of TSS with simultaneous decompressive surgery in different regions of the spine was performed in a busy university degenerative spine treatment center. Simultaneous spinal surgery is associated with high perioperative morbidity, but appears to be safe and effective in this small subset of adult patients.

Introduction: Tandem spinal stenosis is defined as spinal stenosis that involves 2 different regions of the spine with the stenosis typically appearing the cervical and lumbar spine. The purpose of this study is review the existing literature and to evaluate the safety and efficacy of simultaneous decompressive surgery in different regions of the spine in a small subset of adult patients who require surgical treatment for TSS.

Methods: During the period from 2003-2010, 1023 consecutive patients were treated surgically for symptomatic spinal stenosis by the same surgeon (RWM) at a university medical center. 9 of the 1023 patients (0.88%) had signs, symptoms and imaging studies consistent with the diagnosis of tandem spinal stenosis (TSS). Each of the 9 patients presented with clinical manifestations of TSS to include neurogenic claudication, complex gait disorder, and a mixed pattern of diffuse upper and lower motor neuron signs and symptoms. All 9 TSS patients underwent simultaneous decompressive surgery in different regions of the spine performed by the same fellowship-trained spinal surgeon (RWM) and his team. The average age of the patients was 67 yrs (range 52-81 yrs). 7 patients had combination cervical/lumbar stenosis and 2 patients had combination thoracic/lumbar stenosis. Operative times, blood loss, length of hospital stay, major and minor complications, and preoperative pain scores were recorded for all patients. The average follow-up was 24 months (range 6-48 months). Functional outcomes (NDI and Oswestry scores), pain, and satisfaction scores were recorded at the time of ultimate follow-up. Addtionally, preoperative pain scores were compared with pain scores at ultimate follow-up.

Results: Mean operative time was 2 hours 39 minutes (range 1 hr 51 min - 4 hrs 17 min). Blood loss for the simultaneous procedures averaged 558 cc (range 150 –1300 cc). Hospital stay length averaged 7.4 days (range 3-18 days) and 6 patients required prolonged postop rehabilitation. There were no major postoperative complications in all 9 patients. 7 patients (78%) were available for long-term follow-up at average 24 months postop. Analog pain scores demonstrated an average 5-point improvement at ultimate followup, and there was a statistically significant difference between preoperative and postoperative analog pain scores (Preop 7.8, Postop 1.9, p=0.0001). Functional outcomes at the time of ultimate follow-up demonstrated an average NDI score of 15.6 points (range 2-25) and an Oswestry score of 21 points (range 8-34)- both consistent with mild disability. Scores for patient satisfaction scores were high, averaging 8.7 points on a 0-10 scale.

Conclusion: The incidence of TSS among patients requiring surgery for spinal stenosis is extremely low, and there is a paucity of existing literature on this topic. Simultaneous surgery in different regions of the spine appears to be an effective treatment option for the few patients who present with the classic findings of TSS. In this case series, patient morbidity is higher than reported for isolated spinal decompressive procedures. However, functional outcomes do not appear to be adversely affected by the simultaneous technique, and patient satisfaction is high.

Significance: Simultaneous decompressive surgery is a viable treatment option for the small subset of adult patients who present with symptomatic TSS.

Objective: The purpose of this study was to compare the efficacy of growth guidance techniques (single and dual growing rods, Vertical Expandable Prosthetic Titanium Rod-VEPTR) on shoulder balance, in the surgical treatment of early-onset scoliosis.

Methods: Thirty six patients with early-onset scoliosis (EOS) due to various etiologies who were operated on in two different institutions were included in the study and they were divided in 3 groups. Group 1 consisted of 11 patients (mean age 7.5 years) who were treated with a single growing rod, Group 2 had 13 patients (mean age 8.1 years) who were treated with dual growing rods, and Group 3 consisted of 12 patients (mean age 4.1 years) who were treated with VEPTR technique. The coracoid height difference (CHD), clavicular tilt angle difference (CTAD) and clavicula-rib cage intersection difference (CRID) were measured on standing anteroposterior X-ray images in the preoperative, early postoperative and the last follow-up periods. Data obtained from these measurements were subject to statistical analysis.

Results: The average postoperative follow up period was 3.04 (range: 2.3 to 4.8) years for Group 1, 2.23 (range: 1 to 3.1) years for Group 2 and 2.18 (range: 1 to 3.2) years for Group 3. Clinical improvement in shoulder balance was obtained for Group 1 and Group 2 post-operatively, but there was no significance in the comparison among the three groups.

Conclusion: The effect of growth guidance techniques on shoulder balance remains unpredictable in the surgical treatment of early-onset scoliosis.

The use of spinal cord stimulator has been supported by the evidence-based studies at moderate level to control varying etiologies of pain. Infections are the most serious complications encountered in spinal cord stimulator implantation. The intent of this article is to present available studies and literature for surgical techniques to reduce the risks of postoperative wound infection for spinal cord implantation.

Surgical approaches to the neural foramen and the lateral extraforaminal space in the lumbar spine are required to treat far lateral disc herniations and shwannomas. The MetRx tubular retractor system facilitates a minimally invasive technique that directly targets the region delineated by Kambin’s triangle. This study presents technical modifications, described in a step-wise fashion, to previously published approaches.

We reviewed the charts of 47 patients that underwent surgery for pathology located in Kambin’s Triangle using the modified technique described here. Important technical adjustments include docking on the pars interarticularis, minimal shaving of the lateral pars and inferior articulating process, and palpation of the pedicle as a reference point for opening the ligamentumflavum and locating the exiting nerve. Potential pitfalls and strategies to avoid them are also noted.

All 47 patients reported a successful outcome with the procedure, there were no complications or revisions, and all were discharged home within 24 hours of the procedure. Key elements of the procedure were highlighted with supporting illustrations and intra-operative imaging.

The minimally-invasive approach performed through MetRx tubular retractors is a safe and successful surgical method for treating pathology localized in the neural foramen and lateral extraforaminal space between L1- L5 vertebrae.

Objective: This research aims to provide a complete spine digital model, including vertebral anthropometrics, posture and kinematics to inform biomechanics models.

Background: There is limited integration of published literature on quantitative anatomy, anthropometrics and posture data in current digital models. Most studies Preclude the interconnected nature of the spine.

Method: A literature review from the disciplines of anatomy, manipulative therapy, anthropometrics, occupational ergonomics, biomechanics and forensic science was conducted. The data was unified into a single normative model of the sub-axial spine using a normalisation protocol. A related kinematics meta-analysis was conducted. Results: 2D orthographic drawings were produced from 590 individual measurements, informing a 3D model. New data relating to vertebral spatial coordinates are published. The kinematics data was applied to the 3D model, interconnecting spine regions. Range of Motion [ROM] ratios of movement were calculated throughout the spine. Intervertebral measurements were extrapolated, providing new data. To the best of our knowledge this digital model is the first to quantify skeletal anthropometrics, posture and kinematics.

Conclusion: The model data and the limitations discussed provide a roadmap for other spine model researchers. New basic science anatomical research is needed, revisiting quantitative anatomy and kinematics studies, using interrelated 3D digital technologies, within a standardised protocol framework for researcher to adhere to. From usercentric design, biomechanical engineering to rehabilitation care, quantification of spine anthropometrics at vertebral level and their spatial profile under motion is key. Existing publications in biomechanics, by computer scientists and mathematicians often limits to a few studies or excludes the basic science of human spine anatomy, vertebral anthropometrics, posture and kinematics, choosing to focus on functional mathematics principles. The present research provides a unified model and a potentially powerful tool in quantifying and visualising these attributes. It complements biomechanics research towards better informed and more complex models of the spine.

Background: Muscles of the human paraspinal region have been the focus of attention in patients with Adolescent Idiopathic Scoliosis (AIS). Despite the description of differences in muscle histology on the two sides of the scoliotic curve, there is no consensus on the significance of such findings. The purpose of this study was to assess changes in the thoracic wall muscles, including the paraspinal and the intercostal muscles (not previously described in the literature) in patients with AIS, and examine their relationship to the curvature.

Methods: The paraspinal and external intercostal muscles on both sides of the scoliotic curve were biopsied in 29 patients with AIS. Tissues were studied under light microscopy and submitted to morphometric examination.

Results: Both muscles on the concave side of the curve were characterized by a greater percentage of type 2 (fast twitch) fibers and a smaller mean fiber diameter than the contralateral muscles. Fiber diameter in the concavity, for both muscles, showed an inverse relationship to the Cobb angle.

Conclusion: Patients with AIS present variations in the microstructure of both paraspinal and intercostals muscles, with similar changes. This suggests that the process of AIS is broadly based; it affects more than one muscle group in the thoracic wall, and is not confined to the paraspinal region. The new findings on the intercostal muscles may be related to the rotation component of the scoliotic curve. Results suggest the possibility that an imbalance between muscle and vertebral growth may lead to the deformity through a bowstring phenomenon.

Introduction: Lower back and leg pain are frequently seen pathologies in pregnancy. However, a small proportion of these complaints develop in association with lumbar disc hernias. Due to maternal and fetal factors, diagnosis and treatment during pregnancy has to be different than for non-pregnant patients.

Methods: A 36 year old, 28-week pregnant patient presented with ever-increasing pain in the right leg, lower back, and reduced power in the extensor hallucis longus. The patient had undergone surgery at another clinic about 2.5 years ago because of right L4-5 disc herniation. Therefore the patient was evaluated by lumbar magnetic resonance images [MRI]. The MRI determined the right L4-5 recurrent disc herniation.

Results: The patient underwent successful surgery in the lateral decubitus position under general anesthesia. No complications developed in mother or fetus.

Conclusion: Recurrent lumbar disc herniation during pregnancy has not been reported. A lumbar micro-discectomy procedure for a pregnant patient resulted in a successful clinical outcome.

The use of regional analgesia techniques for postoperative analgesia in spine surgery is less frequently used in comparison with conventional oral and parenteral treatment. This may be explained by the fact that surgery is mostly performed under general anesthesia. Although objections of the surgeon are comprehensible, there is a growing number of studies using regional techniques for the treatment of pain after this surgery. When postoperative analgesia is the focus then regional techniques can be initiated at any time-point of the procedure while all ages and types of surgery, even extensive scoliosis fusion may benefit from it. The present overview will focus on the feasibility of (loco)regional techniques to be used for postoperative analgesia, medications used alone or in combination, as a single bolus or through persistent catheters and with special attention to pain relief following scoliosis repair. In general neuraxial techniques offer lower pain scores and/or less need for opioid rescue in comparison with systemic conventional analgesia although much less benefit may be noticed in patients operated for spinal fusion than for disc surgery, laminectomy and adolescent scoliosis correction. The actual literature provides little evidence with respect to the best timing of initiation, the best route nor the best dose in relationship to the type of surgery. Besides neuraxial techniques several alternatives have found their way in this type of intervention. As all techniques described offered variable success rates, future research is mandatory to determine their superiority over general anesthesia and conventional pain therapy modalities.

Introduction: The surgical management of degenerative and malformative spinal deformities takes into account the pelvic and spinal parameters. This concept is not applied in traumatology.

Purpose: To adapt the correction of traumatic kyphosis deformity to the type of backs in function of pelvic incidence and to study the influence of the shape of backs on the localization, the type of fracture, the correction, and the loss at follow-up.

Methods: It is a prospective study of 80 patients operated from February 2005 to December 2010. Mean folloupup was 52 months (18-72). Patients were treated by the same surgeon by a posterior osteosynthesis using in situ contouring technique. We evaluated kyphosis deformity according the shape of backs assessed by the value of the pelvic incidence (PI) calculated in lying position.

Results: Our patients were classified with low PI (type 1, 2) in 35% of cases and high PI (type 3, 4) in 57% of cases. No significant difference was found in the repartition of fracture levels, type of fracture and the kyphosis deformity. However, the number of patients with good correction and with loss at follow-up was important in high pelvic incidence (p<0.001).

Discussion: Neurologic status is not the only point of decision in chirurgical treatment. The kyphosis deformity in trauma is also an important point, but this angle is not always easy to measure. The relationship between deformities with injury level of spine depends on type of backs. A patient with trauma (lying position), pelvic incidence is the only angle which gives an idea about the shape of backs. According to Roussouly’s classification, type 1 (long thoracolumbar kyphosis) and type 2 (flat), the correlation at the injury level is not necessary, but for type 3 and 4 (with harmony curvature), the correlation seems logical.

Purpose: Determine the long-term clinical outcome of the laser reconstruction of intervertebral discs (LRD) in patients with chronic degenerative spine diseases.

Methods: Ninety-seven patients with chronic back and neck pain caused by single and multi-level spinal discs degeneration were treated with non-ablative laser irradiation (1.56 μm Er:glass fiber laser) of the nucleus pulposus and the inner third of the annulus fibrosus through percutaneous needle puncture. The results were analyzed during five years after LRD by the means of clinical observation, radiological and biomechanical testing. Three surgical biopsies of the laser-irradiated disks were examined by the morphological methods. Subjective estimation of LRD influence of the patients’ life quality and back pain intensity has been performed with validated questionnaires of SF-36 and VAS.

Results: Majority of the patients, who underwent LRD procedure, demonstrated an essential improvement in their health state, including decreasing of spine discs instability, pain relief and the general quality of their lives. There were no any complications related to the use of LRD. Five-year outcome have shown positive dynamics of MRI features of the treated discs in 77% of patients as well as an improvement in the SF-36 total score and VAS in 92 and 95.9% of patients respectively. The histological results have proved the growth of hyaline like cartilage in laser-treated zone.

Conclusions: Five years outcome observations demonstrate stable positive structural changes in the intervertebral discs as well as the significant improvement in subjective feelings of the life quality and pain relief for the majority of the patients.