Search

Objective To describe outcomes of awake transforaminal endoscopic surgical treatment for patients presenting with lumbar radiculopathy after laminectomy. Methods Awake endoscopic decompression surgery was performed on 538 patients over a 5-year period (2014–2019). Transforaminal endoscopic discectomy and foraminotomy was performed in 128 patients who had previously undergone laminectomy surgery. Results At 2-year follow-up, preoperative visual analog scale score for leg pain improved from 7.0 ± 1.4 to 2.0 ± 1.3 and Oswestry Disability Index score improved from 41.4% ± 11.9% to 12.4% ± 11.9% in 118 patients. During the 2-year follow-up period, 10 patients (7.8%) required repeat surgery at the treated level. Conclusions The results of a minimally invasive awake endoscopic procedure are presented for the treatment of lumbar radiculopathy after lumbar laminectomy in a series of patients.

OBJECTIVE Ten kilohertz spinal cord stimulation (SCS) is usually initiated in a single-bipolar configuration over the radiological reference point T9/T10 intervertebral disc space for neuropathic back and leg pain. Cascade is a duty-cycled, multi-bipolar contact configuration across an entire eight-contact lead. Potential advantages by using a broader area of SCS coverage include mitigation against minor lead migration and a reduction in the need for reprogramming. We report here the results of a retrospective case series of 114 patients using Cascade. MATERIALS AND METHODS Retrospective data were collected over two years. We selected patients with neuropathic back with or without/leg pain who had a trial of SCS. Pain assessments using Numerical Rating Scales (NRS) and Patient Global Impression of Change (PGIC) scores were collected at baseline, six months, and last follow-up beyond 12 months (mean 15.1 months). Patients were programmed with 10 kHz SCS using Cascade during the trial, which was continued unless reporting inadequate pain relief. Morbidity and deviations from Cascade programming were also obtained. RESULTS At six months, 87 of 97 (90.6%) patients with active devices were using Cascade and 58 of 72 (81%) patients at the last follow-up >12 months. There was a significant reduction in back NRS (8.3 vs. 3.9 [p 12 months back (8.3 vs. 3.95 [p

Objective We evaluated the cost-effectiveness of wireless spinal cord stimulation (Wireless SCS) with single stage "direct to permanent" implantation vs. screening with temporary electrodes and an external pulse generator followed by implantation of a system for long-term use (IPG SCS). Materials and methods We created a cost model that takes a 2019 United States (U.S.) payer perspective and is based on IPG SCS cost models for subjects with chronic back and/or leg pain. Our six-month decision tree includes the screening trial period (success ≥50% relief) and leads to various levels of pain relief with or without complications for IPG SCS and Wireless SCS and without complications for conventional medical management (CMM). Every three months in the follow-on 15-year Markov model (with costs and quality-adjusted life years discounted 3.5% annually), subjects remain stable or transition to deteriorated health or death. Subjects who fail SCS receive CMM. After 60 Markov cycles, a 100,000-sample simulation reveals the impact of maximum willingness-to-pay (WTP) from $10,000 to $100,000 per quality-adjusted life year on net monetary benefit (NMB). Sensitivity analyses considered the impact of the Wireless SCS screening success rate, Wireless SCS device cost, and IPG SCS device longevity. Results Compared with IPG SCS, Wireless SCS offers higher clinical effectiveness at a lower cost and a higher NMB for our WTP thresholds and is, thus, dominant. Wireless SCS is also cost-effective compared with CMM. Results remain robust with 1) Wireless SCS screening success rates as low as 85% (dominant), 2) the cost of the Wireless SCS devices as high as $55,000 (cost-effective), and 3) IPG SCS devices lasting 12 years (dominant). Conclusions In this model, compared with IPG SCS or with CMM, Wireless SCS is a superior strategy.

OBJECTIVES: High-dose spinal cord stimulation (HD-SCS) revealed positive results for obtaining pain relief in patients with failed back surgery syndrome (FBSS). However, it is less clear whether HD-SCS also is able to reduce pain medication use. The aim of this registry-based cohort study is to explore the impact of HD-SCS on pain medication use in FBSS patients. MATERIALS AND METHODS: Data from the Discover registry was used in which the effectiveness of HD-SCS was explored in neurostimulation-naïve FBSS patients as well as in rescue patients. All neurostimulation-naïve FBSS patients positively responded to a four-week SCS trial period in which at least 50% pain relief and 50% medication reduction were obtained. Medication use was measured with the Medication Quantification Scale III (MQS) in 259 patients at baseline and at 1, 3, and 12 months of HD-SCS. Additionally, defined daily doses (DDD) and morphine milligram equivalents (MME) were calculated as well. RESULTS: One hundred thirty patients reached thevisit at 12 months. In neurostimulation-naïve patients, a statistically significant decrease in MQS (χ2 = 62.92, p

Objective To retrospective review a series of patients with ependymomas of filum terminale (FTEs) who underwent microsurgical resection and had long-term follow-up. Methods Five adults with FTEs were surgically treated and enrolled in the study. Clinical manifestations, imaging data, intraoperative findings, and postoperative outcome were recorded. Results Six FTEs were discovered on preoperative lumbar magnetic resonance imaging, with 1 rare case of a single FTE accompanied by a neurofibroma. Gross total resection was achieved in all patients; en bloc excision was carried out in 2 patients for 2 FTEs and 1 neurofibroma, while piecemeal resection was done in 3 patients for 4 FTEs. Most preoperative symptoms were relieved soon after surgery; 1 patient with urination difficulty achieved complete recovery 1 year postoperatively. Tumor recurrence was found in 1 patient 54 months after her first surgery. Conclusions FTEs are rare subdural extramedullary tumors. Patients usually present initially with back and leg pain. Elaborate microsurgical manipulations and intraoperative electrophysiologic monitoring are helpful in ensuring satisfactory excision and neurological prognosis. Regular long-term follow-up is recommended for all postoperative patients.

Background Lumbar spine fusion surgery is traditionally performed with rigid fixation. Because the rigidity is often supraphysiologic, semirigid rods were developed. To the best of our knowledge, a comprehensive evaluation of rod material type on surgical outcomes has yet to be conducted. Methods A systematic review based on PRISMA guidelines was conducted across 3 electronic databases. After examination for inclusion and exclusion criteria, data were extracted from the studies. Results Seventeen studies, including 1399 patients, were included in this review. The mean rigid rod fusion rate is 92.2% and 95.5% for semirigid rods (P = 0.129). The mean improvement in back pain was 60.6% in rigid rods and 71.6% in semirigid rods. The improvement in leg pain was 81.9% and 77.2%, respectively. There were no differences in visual analog scale back pain score (P = 0.098), visual analog scale leg pain score (P = 0.136), or in functional improvement between rigid and semirigid rods (P = 0.143). There was no difference (P = 0.209) in the reoperation rate between rigid rods (13.1%) and semirigid rods (6.5%). There was a comparable incidence of adjacent segment disease (3%), screw fracture (1.7%), and wound infection (1.9%) between rod material types. Conclusions There is a moderate level of evidence supporting that surgical intervention results in high fusion rates regardless of rod material type. Surgical intervention improves back pain, leg pain, and function, with neither material type showing clear superiority. There are comparable rates of reoperation, development of adjacent segment disease, development of mechanical complications, and incidence of infection in both rigid and semirigid rods. Further studies regarding rod material type are warranted.

OBJECTIVES:A substantial proportion of patients have recently reported pain reduction levels of ≥80% following treatment with Evoked Compound Action Potential (ECAP) spinal cord stimulation (SCS). The additional health-related quality of life (HRQoL) utility gain that can be achieved in this patient group is unclear. The aim of this study is to quantify the HRQoL utility values seen in a remission health state (defined as ≥80% pain reduction) and contrast with more traditional health states of

Hard or calcified discs are often adherent to surrounding nerve tissue. The whole herniated disc is difficult to remove by pulling part of the hernia mass, which makes obtaining good results through endoscopic treatment difficult. The purpose of this study was to describe the details of the transforaminal endoscopic lumbar discectomy technique for a hard or calcified disc and report the clinical results.From October 2016 to June 2019, 43 consecutive cases diagnosed as hard or calcified lumbar disc herniation at our institution and treated with transforaminal endoscopic discectomy were evaluated. Endoscopic decompression was performed in patients with hard or calcified lumbar disc herniation.The preoperative visual analog scale score for leg pain (mean ± standard deviation) was 7.09 ± 1.74. The score improved to 2.55 ± 1.35 at 1 week postoperatively, 1.88 ± 1.29 at 4 weeks postoperatively, and 1.58 ± 1.0 at 26 weeks postoperatively (P0.01 for all). The preoperative Oswestry Disability Index (mean ± standard deviation) was 55.4 ± 23.04, which improved to 30.89 ± 13.64 at 1 week postoperatively, 23.08 ± 11.64 at 4 weeks postoperatively, and 16.42 ± 9.76 at 26 weeks postoperatively (P0.01 for all). Two patients developed a dural laceration. Both patients were discharged after several hours of observation. None of the patients had postoperative infection, epidural hematoma, or delayed neurological deterioration.Transforaminal endoscopic discectomy could be an effective treatment method for a selected group of patients with hard or calcified lumbar disc herniation.

Anatomical barriers (e.g., pedicles, narrow foramina) can hinder direct access to, and removal of, disc fragments that have migrated far downward. Using transforaminal full-endoscopic lumbar discectomy (FELD), we devised a modified technique, the suprapedicular retrocorporeal approach, for herniations in which the disc has migrated to the axilla of the traversing nerve roots. In the present report, we have described our preliminary results.Soft, highly downward-migrated disc herniation was treated with transforaminal FELD through the suprapedicular retrocorporeal approach in 22 patients from June 2017 to May 2019. The clinical outcomes were evaluated, including the preoperative and postoperative visual analog scale scores for the back and leg, Oswestry disability index, and MacNab criteria for surgical success.The affected discs were at L4-L5 in 14 patients, L3-L4 in 6 patients, and L5-S1 in 2 patients. In each case, the affected disc was successfully removed using the suprapedicular retrocorporeal approach. The mean follow-up was 18.1 ± 5.7 months. The mean visual analog scale scores for back and leg pain improved significantly (P0.05 for both). The mean Oswestry disability index had decreased from 62.5 ± 14.2 preoperatively to 10.5 ± 5.9 postoperatively (P0.05). Using the MacNab criteria, 13 patients reported excellent outcomes and 9, good outcomes. No complications or recurrence developed during follow-up.The suprapedicular retrocorporeal technique is a feasible and effective surgical option in transforaminal FELD for the treatment of herniation in which the disc has migrated to the axilla of the traversing nerve roots.

Introduction Muscular hernias in the lower limb are a rare entity that have seldom been described in the literature, from 1929 about 200 cases of muscle hernias have been described. Case Here, we present a case of tibialis anterior muscle hernia and discuss the aetiology behind the same. Furthermore, we attempt to amalgamate existing knowledge to provide some guidance for investigation and management of this important diagnostic consideration. Conclusion Lower limb hernias are rare but should be considered as a differential for unidentified lower limb swellings. There is no clear consensus in literature about treatment, so every case must be individualized.

BACKGROUND Lumbar juxtafacet cysts are benign lesions that grow at the level of facet joints or within neighboring structures. Recently, there is an ongoing trend toward less invasive procedures for treating degenerative spine diseases. Here we report a multicenter study of full-endoscopic surgery for juxtafacet cyst removal. METHODS We prospectively collected patients with a diagnosis of lumbar juxtafacet cyst surgically treated in 3 institutions between January 2017 and August 2019. Patients of any sex and age were eligible if they had a single level unilateral lumbar juxtafacet cyst, invalidating radicular pain lasting >6 weeks, adequate imaging, and failed percutaneous or conservative treatment. Age at diagnosis; sex; preoperative, postoperative, and 6-month leg pain; surgical and medical complications; spine instability (preoperatively and at 6 and 12 months); and follow-up time were collected. RESULTS Thirty-five patients were enrolled. Median operative time was 78 minutes, and mean leg pain went from a preoperative value of 6.8 (standard deviation [SD] = 1.2) to a postoperative value of 3.4 (SD = 1.1, P

Children with spinal problems present to a wide range of healthcare providers. These providers include the emergency department, their GPs, physiotherapy and the paediatric medical and surgical clinics (including orthopaedics). They may present with a variety of symptoms, but the common complaints are: back pain, leg pain or a change in back shape (spinal deformity). Some children may experience a combination of these problems. A systematic approach to the history and examination with knowledge of the common spinal conditions in children will allow you to select the best investigations. This will maximize the chance of making the correct diagnosis and providing appropriate care. This article aims to give an overview, appropriate for surgeons in the early years of their training.

Patient-reported outcomes measures (PROMs) are critical in evaluating the effectiveness of surgical spine interventions. The Oswestry Disability Index (ODI) is commonly used but tedious to administer routinely. The EuroQol-5 Dimensions (EQ-5D) questionnaire is easier to administer but not traditionally used to measure spine surgical results. This study aimed to investigate the correlation of commonly administered PROMs in lumbar tubular microdecompression patients, and to consider whether ODI could be predicted from remaining PROMs.This study examined 304 index lumbar tubular microdecompression patients with PROMs collected at routine intervals. Spearman correlation coefficients were calculated for each pairwise combination of the following PROMs: ODI, EQ-5D index, leg pain visual analog scale (VAS), low back pain VAS, health state item. Linear regression modeling was conducted to predict ODI from the remaining four PROMs.The patients had a mean age of 65.55 ± 12.97 years and 46.4% were male. Each combination of PROMs demonstrated a statistically significant pairwise correlation (P0.001). ODI showed strong correlation with EQ-5D index (r = -0.77), leg pain VAS (r = 0.73), and back pain VAS (r = 0.65), but weak correlation with health state item (r = -0.33). Forwards stepwise model selection yielded a multiple linear regression model including all four PROMs predictors, with an adjusted R2 of 0.690. There was strong correlation between predicted and observed ODI (r = 0.83, P0.001).ODI can be predicted from EQ-5D, leg and low back pain VAS, and health state items with moderate accuracy. The added utility of capturing ODI routinely may not out-weigh the challenges in doing so.

Background Lumbosciatica is a common condition that affects patients' quality of life. Objective To determine the efficacy of Vojta Therapy and transcutaneous electrical nerve stimulation (TENS) in the treatment of lumbosciatica. Methods A "pre-post" quasi-experimental pilot study was carried out on 12 patients between 31 and 74 years of age who had been diagnosed with lumbosciatica and referred to the Physiotherapy Unit of the Quintanar de la Orden Health Center. Subjects were prescribed either TENS or Vojta, assigned alternately (6:6). All patients received one session of 30 min per day for 15 days. Tests to evaluate pain, disability, functionality, and radiculopathy were performed. Results The differences between pre-post measures and improvement after both treatments were analyzed with nonparametric tests. Significant improvements were noted after both treatments in indices for pain, disability, and flexibility, with the exception of disability after TENS, according to the Roland-Morris test (p = 0.066). Improvements in radiculopathy (Lasegue sign) were only observed with Vojta (p = 0.031). An overall decrease in scores obtained after Vojta was observed with respect to those obtained after TENS (difference V-T): pain according to the Visual Analog Scale (V-T = 2.84; p = 0.033) or Oswestry back pain (V-T = 2.67; p = 0.030) and leg pain tests (V-T = 3.25; p = 0.063); disability according to Oswestry (V-T = 28.33; p = 0.005) and Roland-Morris (V-T = 5.67; p = 0.044); flexibility according to Schober (average gain V-T = 0.43; p = 0.292) and the fingertips to floor distance test (V-T = 7.5; p = 0.016). Conclusions Vojta Therapy led to significantly greater improvements in pain, disability, flexibility, and radiculopathy than TENS. Future studies will require larger samples to confirm these findings.

Background Low back pain is a common presentation among pregnant women. Case This case report highlights two women who developed excessive low back radicular nerve symptoms during pregnancy as the initial presentation of proximal venous thromboembolism. Conclusion The use of Doppler ultrasound imaging or magnetic resonance imaging is suggested for women presenting with severe clinical symptoms of radicular low back or leg pain in pregnancy to rule out thromboembolism and guide patient management.

Background Previous studies in our department demonstrated that gait retraining as part of a conservative treatment program for service members with exercise-related leg pain can lead to persistent changes in vertical ground reaction forces while running in shoes and boots. It is not known which gait retraining cue has the largest effect and whether a combination of cues is advantageous. Methods During a single gait retraining session, 12 male heel striking patients were given three cues in isolation: Cue 1. Change to a ball-of-foot strike; Cue 2. Increase cadence to 180 steps per minute; Cue 3. Stand up taller; and finally, all three cues combined. Runs were performed on an instrumented treadmill at 10 km/h, 1% incline and in running shoes. The three cues were randomly introduced. Measurements, taken during 30-second episodes, were stride length, cadence, and six force variables: maximum force (N) and maximum pressure (N/cm2) on the heel, mid-foot and fore-foot. Findings Each cue, i.e., each change in running technique, caused a different pattern of changes among the six force variables, mostly reductions. In isolation, cue 1 produced the largest reduction of force and pressure on the heel, resulting percentages 45.8 and 67.2 respectively (p = 0.00, p = 0.00). Overall, the combination of cues 1 + 2 + 3 ranked first in reducing forces for four of the six force variables. Interpretation Three commonly used gait retraining cues, when applied in isolation, all resulted in a reduction of most vertical ground reaction forces. The combination of the three cues is advantageous.

Background Patients with back-related leg pain exhibit nociceptive and neuropathic characteristics. Few studies have investigated the combination of interventions considering these characteristics. Objectives To investigate if the addition of neurodynamic exercises (EEN) to extension-oriented exercises (EE) promotes additional benefits in individuals with back-related leg pain and a directional preference. Methods Patients will be randomized to either EE or EEN. Patients from both groups will receive 7 sessions over 3 weeks. Low back and leg pain, function, quality of life, disability, and global perceived effect will be evaluated at baseline, 3 weeks after randomization and 1-month follow-up. A linear mixed model will be used for outcomes analysis.

Introduction The burst waveform, a recent innovation in spinal cord stimulation (SCS), can achieve better outcomes than conventional tonic SCS, both for de novo implants and as a salvage therapy. Burst stimulation delivers more energy per second than tonic stimulation, which is a consideration for battery consumption. The clinical effectiveness of an energy-conserving strategy was investigated. Methods Subjects were experienced users of BurstDR SCS for back and leg pain. Three 2-week stimulation paradigms were presented in blinded random order: standard (continuously delivered) BurstDR, microdosing A: 5 sec of BurstDR alternating with 5 sec of no stimulation, and microdosing B: 5 sec of BurstDR alternating with 10 sec of no stimulation. The primary outcome for each paradigm was change in pain ratings, and secondary outcomes included changes in scores for quality of life, satisfaction, and preference. Results Twenty-five subjects assessed all three stimulation paradigms. There were no significant differences in pain (visual analog scale) or quality of life (EQ-5D) when comparing standard burst outcomes with those of microdosing A and, separately, microdosing B. Microdosing paradigms were graded with slightly higher level of satisfaction and were generally preferred above standard burst stimulation. Discussion These results suggest that the use of energy-efficient burst microdosing stimulation paradigms with alternating stimulation-on and stimulation-off periods can provide clinically equivalent results to standard burst stimulation. This is important for extending SCS battery life. Further research is needed to comprehensively characterize the clinical utility of this approach and the neurophysiological mechanisms for the maintenance of pain relief during stimulation-off periods.

Objective This study is aimed to comprehensively assess the prevalence and distribution of thoracic disc herniation (TDH) or thoracic hypertrophied ligamentum flavum causing stenosis (HLFS) by magnetic resonance image (MRI) in patients with back or leg pain. Methods The study participants included 2212 patients who underwent MRI evaluation for back or leg pain. The prevalence and distribution of TDH or thoracic HLFS were assessed using lumbar MRI with cervicothoracic sagittal images. The presence of TDH or HLFS and the clinical parameters such as age, sex, lumbar surgical need, and thoracic operation were retrospectively reviewed. Logistic regression analysis of the data was followed. Results The prevalence rates of TDH and thoracic HLFS in all patients were 6.5% (145/2212) and 19.0% (421/2212), respectively. The prevalence of TDH was demonstrated as a relatively even distribution across age groups, higher in male participants (8.0%) than in female participants, and more frequent in patients with lumbar surgical lesions (8.2%) than without surgical lesions. Whereas, the prevalence of thoracic HLFS tended to increase with age, was higher in female participants (21.6%) than in male participants, and had no association with presence of lumbar surgical lesions. The most frequently involved segments of TDH and HLFS were T8/9 and T10/11, respectively. Six of 145 patients with TDH and 15 of 421 patients with HLFS underwent surgery. Conclusions The prevalence of TDH had a significant association with the presence of lumbar surgical lesions and no association with age. The prevalence of thoracic HLFS had a strong association with age and no association with lumbar surgical lesions.

Interlaminar percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive technique to treat soft disc herniation. However, the currently used single working channel does not allow for safe nerve root retraction. This study aims to describe the rotate and retract technique for safe nerve root retraction during L5-S1 interlaminar PELD.A total of 17 patients who underwent interlaminar PELD with the rotate and retract technique between November 2016 and August 2017 were retrospectively evaluated. Both pre- and postoperative visual analog scale (VAS) scores (back and leg) and Oswestry Disability Index (ODI) scores were used for clinical assessment.The mean preoperative VAS scores for back and leg pain were 3.84 ± 1.15 (range, 2-6) and 8.7 ± 0.2 (range, 8-10), respectively. The mean preoperative ODI score was 64.2 ± 13.2 (range, 48-90). The mean VAS scores for back and leg pain decreased to 1.24 ± 1.34 (range, 0-6) and 1.15 ± 0.65 (range, 0-4), respectively, at the last follow-up (P0.001). The mean ODI score also improved to 13.2 ± 5.1 (range, 9-29) at the last follow-up (P0.001).The rotate and retract technique for interlaminar PELD is an effective maneuver for the treatment of L5-S1 disc herniations in selected patients if performed by experienced surgeons.

Background Context\ud Evidence is lacking on the prognosis and prognostic factors of back-related leg pain and sciatica in patients seeing their primary care physicians. This evidence could guide timely appropriate treatment and referral decisions.\ud \ud Purpose\ud The present study aims to describe the prognosis and prognostic factors in primary care patients with low back-related leg pain and sciatica.\ud \ud Study Design\ud This is a prospective cohort study.\ud \ud Patient Sample\ud The present study included adults visiting their family doctor with back-related leg pain in the United Kingdom.\ud \ud Outcome Measures\ud Information about pain, function, psychological, and clinical variables, was collected. Good outcome was defined as 30% or more reduction in disability (Roland-Morris Disability Questionnaire).\ud \ud Methods\ud Participants completed the questionnaires, underwent clinical assessments, received a magnetic resonance imaging scan, and were followed-up 12 months later. Mixed-effects logistic regression evaluated the prognostic value of six a priori defined variable sets (leg pain duration, pain intensity, neuropathic pain, psychological factors, clinical examination, and imaging variables). A combined model, including variables from all models, examined independent effects. The National Institute for Health Research funded the study. There are no conflicts of interest.\ud \ud Results\ud A total of 609 patients were included. At 12 months, 55% of patients improved in both the total sample and the sciatica group. For the whole cohort, longer leg pain duration (odds ratio [OR] 0.41; confidence interval [CI] 0.19–0.90), higher identity score (OR 0.70; CI 0.53–0.93), and patient's belief that the problem will last a long time (OR 0.27; CI 0.13–0.57) were the strongest independent prognostic factors negatively associated with improvement. These last two factors were similarly negatively associated with improvement in the sciatica subgroup.\ud \ud Conclusions\ud The present study provides new evidence on the prognosis and prognostic factors of back-related leg pain and sciatica in primary care. Just over half of patients improved at 12 months. Patient's belief of recovery timescale and number of other symptoms attributed to the pain are independent prognostic factors. These factors can be used to inform and direct decisions about timing and intensity of available therapeutic options.

Background/Objective Multilevel spondylolysis is a rare cause of progressive lower back pain, and patients who fail conservative management are treated surgically. Direct repair methods can maintain mobility and lead to decreased morbidity compared with spinal fusion in single-level spondylolysis. In this paper, we present a patient with nonadjacent multilevel spondylolysis who underwent the “smiley face” technique of direct multilevel repair without fusion using 3-dimensional intraoperative spinal navigation. Methods Bilateral spondylolysis at L3 and L5 with associated spondylolisthesis in a 50-year-old male was repaired using the “smiley face” technique. Patient-reported outcomes, including the Oswestry Disability Index (ODI) and visual analog scale scores for back and leg pain, were assessed preoperatively along with 6 weeks and 4 months postoperatively. Results Postoperative computed tomography imaging showed precise screw insertion and rod placement along with stable hardware alignment in follow-up imaging. The patient's ODI and lower back visual analog scale scores decreased from 25 to 8 and 7.5 to 4, respectively, correlating to an excellent outcome on ODI. Conclusion Direct repair and avoidance of fusion is possible and can provide good functional outcomes in patients with nonadjacent multilevel spondylolysis and associated spondylolisthesis.

We often observe patients with antiphospholipid syndrome (APS) presenting with both venous and arterial thrombi. Anticoagulant therapy is effective for venous and peripheral arterial embolisms in these patients; however, it has opposite effects when applied for thoracic aortic mural thrombosis because of the risk of new arterial embolisms. Recently, thoracic endovascular aortic repair (TEVAR) has been used to prevent arterial embolisms due to aortic thrombosis. However, we generally hesitate to implant artificial materials in patients in a hypercoagulable state because this can cause new thrombi to develop. Here, we present a case of successful treatment by anticoagulant therapy and TEVAR in an APS patient presenting with pulmonary embolisms (PEs) and multiple arterial embolisms due to thoracic aortic mural thrombosis. A 46-year-old man was referred to our hospital due to dyspnea and leg pain. Since contrast-enhanced computed tomography revealed PEs, thoracic aortic mural thrombosis, and lower limb arterial embolisms, we administered anticoagulation therapy. Three days later, contrast-enhanced computed tomography revealed new arterial embolisms in the right kidney. To prevent further arterial embolisms due to thoracic aortic mural thrombosis, we performed emergent TEVAR in addition to anticoagulant therapy. Thereafter, no venous or arterial embolisms recurred during the 13-month follow-up period.

Objective To compare the clinical outcomes of patients with recurrent lumbar disk disease undergoing percutaneous endoscopic lumbar diskectomy or minimally invasive transforaminal lumbar interbody fusion at a single clinic. Methods From January 2008 to January 2014, 401 consecutive patients with first recurrence of lumbar disk herniation were treated with percutaneous endoscopic lumbar diskectomy (PELD) or minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). These data collected prospectively for analysis were clinical and radiographic results after revision surgery and complications. Results During the follow-up period, postoperative data between both groups showed no significant differences in the mean total postoperative visual analog scale score for leg pain, Japanese Orthopaedic Association score, and Oswestry Disability Index score. The recovery rate was 92.3% in the PELD and 97.4% in the MIS-TLIF group. Regarding satisfactory rate, the PELD group (91.3%) was lower than the MIS-TLIF group (95.2%). Six cases of dural tear were observed in the MIS-TLIF group. The second recurrence occurred in 12 patients in the PELD group. In the PELD group, 1 patient suffered from permanent neurologic deficit. One case of postoperative intervertebral infection was captured in the MIS-TLIF group. Conclusions Both PELD and MIS-TLIF showed favorable clinical outcomes for recurrent disk herniation. Compared with MIS-TLIF, PELD has the following several advantages: 1) performed under local anesthesia; 2) performed with very few approach-related complications, such as dural tear; and 3) rare possibility of fusion disease, such as adjacent segment. However, PELD is also faced with several problems, such as 1) the relative higher rate of postoperative long-term chronic low back pain, and (2) the possibility of recurrence, despite the opportunity being low.

Introduction Managing subchondral bone defects in proximal tibia fractures after plateau reduction is an important consideration. ChronOS Inject is a recently developed calcium phosphate bone substitute that shows relatively fast osteointegration. Hypothesis Using chronOS Inject during internal fixation of proximal tibial fractures provides a satisfactory treatment option that is both clinically and radiologically safe. Patients and methods Patients enrolled in this study were treated with chronOS Inject bone void filler, during internal fixation of proximal tibial fractures. Patients were evaluated preoperatively and at 6 weeks, 6 and 12 months postoperative. Radiographic union was assessed using plain films supplemented by CT scans. Pain, function and adverse events were collected at all visits. A total of 36 patients were enrolled in the study and treated according to a predetermined protocol. Seven of the 36 patients (19.4%) were lost to follow-up. Results Successful radiographic union was achieved in 27/29 (93.1%) of patients at final follow-up. Articular subsidence of > 2 mm only occurred in one patient. Statistical analysis showed significant improvements both in leg pain and knee function. Progress in knee function was observed in 93.1% (27/29) of patients from 6 weeks to 12 months. No product-related complications were reported. Conclusions Successful union was achieved based on radiographic criteria as well as clinical outcomes. When managing bone defects after internal fixation of proximal tibial fractures, the use of chronOS Inject resulted in significant improvement of knee function and reduction of leg pain. Level of evidence Level IV, prospective observational study.

Background High frequency stimulation (HFS) may provide pain relief without the paresthesias typical of traditional low-frequency Spinal cord stimulation (SCS). Methods A consecutive single-center series of patients was retrospectively reviewed to evaluate safety and efficacy of HF10 therapy. In this 24-month study, 62 patients with variables pathologies (44 patients with back failure surgery syndrome (FBSS), 18 patients with chronic peripheral neuropathic pain in the lower limbs (NeppL) were included to be treated with HF10. Pain outcomes were compared from preoperative baseline and at the conclusion of each study period. Clinical features, outcomes and complications were reviewed. Results 62 patients completed this study. All patients had a successful trial before the definitive implantation of a spinal cord stimulator at the low dorsal level. The mean follow-up period was 11 months, ranging from 6 to 24 months. 6 patients showed no change from baseline visual analogue scale (VAS) after permanent implant and 2 had improved during the trial but was aggravated after the permanent implant placement. At 1 month, 63% of implanted HF10 therapy subjects were responders and 77% at 6 months. The average baseline, trial and postoperative Visual Analogue Scale (VAS) was 8.1, 3.6 and 4.2 respectively. When compared to the baseline, the average reduction achieved during the VAS trial was 4.5 points, accounting for a 56% pain reduction. The long-term failure rate was 22%. Conclusions This study generated preliminary evidence showing improved VAS current pain scores in absence of paresthesias and increase patient satisfaction with HF10 spinal cord stimulation.

Piriformis syndrome is an uncommon cause of buttock and leg pain. Some treatment options include the injection of piriformis muscle with local anesthetic and steroids. Various techniques for piriformis muscle injection have been described. Ultrasound allows direct visualization and real time injection of the piriformis muscle. We describe 5 consecutive patients, diagnosed of piriformis syndrome with no improvement after pharmacological treatment. Piriformis muscle injection with local anesthetics and steroids was performed using an ultrasound technique based on a standard technique. All 5 patients have improved their pain measured by numeric verbal scale. One patient had a sciatic after injection that improved in 10 days spontaneously. We describe an ultrasound-guided piriformis muscle injection that has the advantages of being effective, simple, and safe.

ObjectivesTransforaminal percutaneous endoscopic lumbar discectomy (PELD) for high-grade migrated disc herniation has been regarded as a challenging task, but because of the remarkable improvement in navigable instruments and advanced epiduroscopic technique, it can be used for the treatment of high- or very high-grade migrated disc herniation. The purpose of this study was to describe in detail the standardized technique of transforaminal PELD for very high-grade migrated disc herniation and demonstrate the clinical results.MethodsVery high-grade lumbar migrated disc herniation was defined as a disc migration beyond the inferior margin of the pedicle. Thirteen consecutive patients with very high-grade lumbar migrated disc herniation were treated with transforaminal PELD, which has three stages: (1) direction-oriented transforaminal approach, (2) release of periannular anchorage, and (3) epiduroscopic fragmentectomy with navigable instruments. The surgical outcomes were assessed using the visual analogue pain score (VAS), Oswestry disability index (ODI), and modified Macnab criteria.ResultsThe operated levels were L3-4 in 2 (15.4%) patients, L4-5 in 10 (76.9%), and L5-S1 in 1 (7.7%). The directions of migration were cranial in 8 patients and caudal in 5. The mean VAS for leg pain improved from 7.86±1.28 preoperatively to 2.54±1.51 at 6 weeks postoperatively and 1.85±1.07 at 1year postoperatively (P

May-Thurner syndrome most commonly involves compression of the left common iliac vein by the right common iliac artery and can result in leg pain and swelling as well as potentially precipitate deep venous thrombosis. These symptoms can be exacerbated by additional vascular abnormalities. This is a case report of a 91-year-old woman with intractable massive left lower extremity edema that interfered with walking. She was diagnosed with concurrent May-Thurner syndrome and pelvic arteriovenous fistula. Treatment with embolization of the fistula and stenting of the left common iliac vein relieved her symptoms and allowed her to walk again.

Objective Compare therapeutic response of patients to conventional versus high-frequency spinal cord stimulation (SCS). Methods Twelve patients with back and leg pain who met standard clinical criteria for a trial of conventional SCS (low-frequency stimulation [LFS]) participated in a half-day session of high-frequency stimulation (HFS) during their weeklong conventional trial. HFS consisted of frequencies ranging from 50 Hz to 4 kHz, or 100 Hz to10 kHz, at constant voltage settings increasing from 0.5 V to 10 V. Visual Analog Scale scores from 0 to10 were recorded, along with notes of any clinical discomfort and open patient comments. Results Two of 12 patients had no benefit from either LFS or HFS. In the remaining 10 patients, paresthesias were significantly altered by HFS, and four experienced complete elimination of paresthesias. Five patients preferred HFS to LFS, with an additional three preferring both equally. Abrupt sensation to the onset of HFS was described in six patients, and in ten patients, HFS allowed maximum voltage stimulation of 10 V without discomfort. The four patients who did not have a successful trial of stimulation had significantly longer duration of pain compared to the eight patients who went on to permanent implant (11.2 vs. 4.3 years, P = 0.04). Conclusions HFS significantly altered the feeling of paresthesias in the majority of patients (ten of 12), was preferred to LFS in five of 12 patients, and non-inferior to LFS in eight of 12 patients. Both 4 kHz and 10 kHz stimulation allowed patients to benefit from HFS. HFS allowed maximum voltage stimulation without discomfort.

Increased tissue pressure within a fascial compartment may be the result from any increase in volume within its contents, or any decrease in size of the fascial covering or its distensibility. This may lead to symptoms of leg tightness, pain or numbness brought about by exercise. There are multiple differential diagnoses of exercise induced leg pain and the proper diagnoses of chronic exertional compartment syndrome (CECS) is made by a careful history and by exclusion of other maladies and confirmed by compartment syndrome testing as detailed in this text. Surgical fasciotomies for the anterior, lateral, superficial and deep posterior compartments are described in detail along with ancillary procedures for chronic shin splints that should allow the athlete to return to competitive activity.

Objective Angioleiomyoma is a rare benign painful soft tissue tumor, whose knee location is rare. Due its rarity, and not characteristic aspect on MRI the preoperative diagnosis is difficult. Methods We performed a systematic review of the literature, including a case of venous type angioleiomyoma that we have recently managed. Results A total of 24 published papers with 30 cases (including our illustrative case) were identified and included in our review. The mean patient age was 42.3 years (range18-63). The average size of the lesion was 17.8 mm. The presenting symptom was leg pain in 90% of cases. On magnetic resonance imaging (MRI), the lesion appeared isointense in T1 in 80% of cases and hyperintense on T2 in 90% of cases. Avid homogeneous enhancement after gadolinium administration was detected in 94% of cases. All patients underwent surgery and total resection was achieved in 100% of cases. No recurrence was observed after a mean follow-up of 19.5 months. Conclusion Angioleiomyoma occurs rarely in the knee and generally is associated with localized or radiating pain. The preoperative diagnosis is difficult also after completion of MRI study and requires high index of suspicion. Angioleiomyoma widens the spectrum of soft tissue lesions of the extremities and should be included in the differential diagnosis of lesions in this area.

Study Objective This video demonstrates a targeted nervous system evaluation in the setting of a uterine and ovarian conserving surgery Design N/A Setting A single surgical center within a large integrated healthcare system. Patients or Participants The patient is a 49-year-old perimenopausal woman with dysmenorrhea and a left ovarian cyst who presented for evaluation of new onset left hip and leg pain. The left ovarian cyst was first noted 4 years ago and the patient declined surgery at that time, instead opting for surveillance with repeat imaging which now demonstrated an interval increase in the cyst size. The patient had an extensive evaluation for her leg pain including MRI and nerve conduction studies which were all unremarkable. The patient declined medical management or definitive surgical treatment of the suspected endometriosis. She opted for a diagnostic laparoscopy and left ovarian cystectomy. Interventions The patient underwent an uncomplicated diagnostic laparoscopy and left ovarian cystectomy. Given the characteristics of her symptoms, care was taken intra-operatively to examine specific nerves within the lumbosacral plexus. Measurements and Main Results No overt pathology was noted along the sacral, genitofemoral, or obturator nerves. Conclusion In summary, this video demonstrates steps for performing a targeted evaluation of the pelvic nervous system based on patient's symptoms.

This chapter reviews nonoperative management of patients with radiographic evidence of degenerative spondylolisthesis. Degenerative spondylolisthesis is associated with multiple pain generators causing low back and leg pain. Biopsychosocial comorbidities should be recognized and treated appropriately. Physical therapy may be effective and should be the first line of treatment. Spinal injections can assist in confirming and treating the source of low back and leg pain. Spinal cord stimulation may provide relief in properly selected patients. The management of degenerative spondylolisthesis requires a comprehensive team approach to assess and treat all possible pain generators and underlying biopsychosocial factors.

BACKGROUND CONTEXT Traditionally, adult spinal deformity (ASD) has been treated with long segment fusions with the goal of restoring sagittal and coronal alignment. Long segment fusions can be associated with high rates of complications and morbidity. Some patients are reluctant to undergo large procedures. Others have comorbidities excluding them as good surgical candidates for long fusions. PURPOSE To compare baseline and postoperative HRQL and radiographic outcomes and revisions and complications in small vs longer fusions for ASD. STUDY DESIGN/SETTING Retrospective analysis of a prospective, multicenter database PATIENT SAMPLE Surgical ASD patients OUTCOME MEASURES ODI, SF36-PCS, SRS22, NRS back and leg pain. METHODS A prospective database of operative ASD patients who completed two year follow up was analyzed. Prior thoracolumbar fusions were excluded. Patients were divided into short fusions (SF: £3 levels) and long fusions (LF: ³6 levels). LF and SF patients were compared in baseline alignment. Propensity matching (PSM) controlling for baseline alignment (TPA and maximum coronal cobb) was performed to compare SF and LF in HRQL improvement, postop alignment and complications. Subanalysis of SF identified which patients were more likely to have successful surgery. The level of significance was p RESULTS A total of 298 patients met inclusion criteria (SF n=20, mean levels fused 2.13; LF n=275, mean fusion levels 12.33). Prior to PSM, LF had greater PT, coronal cobb, and TPA. Following PSM, LF had better improvements in PILL (20.8 vs 3.37), PT (8.57 vs 0.21), TPA (8.68 vs 2.07), and coronal cobb (17.3 vs 5.33) all p CONCLUSIONS This study shows that a more limited fusion could be an alternative to the more traditional long segment fusion in carefully selected patients with adult spinal deformity since there were fewer complications but similar short-term (2-year) satisfaction rates and HRQL improvements. Patients undergoing long fusions had better improvements in alignment. The majority of sagittal only deformities undergoing short fusions required revision surgery. The durability of short fusions in the setting of ASD needs to be investigated with long term studies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

In individuals presenting with leg pain & discoloration, Phlegmasia cerulea dolens (PCD) must be ruled out as it is a limb & life-threatening emergency. We present a case of PCD in a patient with May Thurner Syndrome (MTS). 83-year-old female with hypertension & type 2 diabetes presented with one

BACKGROUND CONTEXT The opioid crisis in the US is currently catastrophic. A large number of patients use opioids preoperatively. PURPOSE The goal of this study is to look at a group of patients who were on opioids prior to adult spinal deformity surgery, and compare outcomes in those who ceased and those who continued opioid use post operatively. We also aim to identify factors associated with postoperative opioid cessation. STUDY DESIGN/SETTING Retrospective review of a prospective multicenter database of ASD patients. PATIENT SAMPLE A total of 296 surgical ASD patients who were using opioids (daily or weekly) prior to surgical intervention. OUTCOME MEASURES Post-operative opioid cessation or decreased use, HRQOL (SF-36, ODI, back pain, leg pain), and patient satisfaction. METHODS A multicenter prospective database of surgical ASD patients was reviewed. Opioid use was measured using the SRS-22r Q11. We included all surgical ASD patients who using opioids pre-operatively (daily or weekly) and completed 2-year follow up. Patients were divided based on 2-year opioid use: decreased/ceased vs continued. Groups were compared in regards to demographics, radiographic parameters, HRQL, invasiveness of surgery, complications, re-operations, and satisfaction. RESULTS Our database had a total of 1,281 surgical patients, out of which 760 were eligible for 2-year follow up. Of those eligible, 578 (76.05%) completed their 2-year follow up. A total of 547 of these patients answered SRS22R-Q11 at baseline at 2-years (with the remainder choosing to not answer this question). There were 296 (54.11%) of 547 ASD patients undergoing surgery reported using opioids preoperatively. Of those, 171 (57.8%) had decreased or ceased opioids 2 years after surgical intervention. Those who decreased/ceased had a higher proportion of females (83.83% vs 72.00%, p=0.014). There was no other statistically significant difference in demographics (BMI, co-morbidities, age, prior spine surgery, smoking) or radiographic parameters (PI-LL, SVA, PT). Those who decreased/ceased opioids had higher baseline SF-36 MCS – vitality (38.31 vs 35.69, p=0.03), with no difference in the remainder of the baseline HRQL scores (back and leg pain, ODI, SF-36 PCS). There were less 3COs performed in those who decreased/ceased (13.45% vs 25.60%, p=0.013). The groups had similar major complications and re-operations, and similar postop radiographic parameters. Patients that reduced/ceased had significantly better HRQL scores 2 years post operatively: back NSR (3.47 vs 5.3, p=0.0001), leg NSR (2.7 vs 3.95, p=0.0006), SF-36 MCS (50.61 vs 44.62, p=0.0002), SF-36 PCS (39.98vs 31.19, p=0.0001), and ODI (27.9 vs 44.62, p=0.0001). They were more likely to reach MCID (ODI 68.64% vs 27.42%, PCS 75.47% vs 39.17% p=0.0001) and be satisfied with surgery (84.7% vs 71.3%, p=0.003). CONCLUSIONS In ASD patients using opioids pre-operatively, only 57.8% will decrease or cease use at 2-years despite similar correction, complications and reoperations. Those who decrease or cease post op have better HRQL scores and are more satisfied with surgery. Future research should focus on identifying those at risk of continued opioid use and developing strategies for successfully tapering. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Lumbar disc herniations are relatively common and often a source of leg pain, paresthesias, or weakness. Fortunately, the natural history outcome of lumbar radiculopathy due to a disc herniation is favorable, and most patients (70%-80%) improve with nonoperative care. Surgical intervention is indicated in patients who continue to have severe pain despite conservative treatment, and outcomes have been shown to be quite favorable in terms of alleviating leg pain and returning to function. There appears to be no difference in outcomes when comparing minimally invasive surgery or tubular discectomy vs open discectomy, and surgeons should offer the procedure that they are most comfortable and technically competent at performing in an effort to minimize complications. Finally, there is an abundant amount of literature that supports that elite athletes can successfully return to sport after undergoing a lumbar microdiscectomy.

Degenerative spine conditions can be asymptomatic but may present as back pain, leg pain, or both. Back pain is common, affecting over 80% of the population at some point. Many cases resolve with the passage of time, early rehabilitation and physiotherapy. Leg pain can either be referred, stenotic or radiculopathic in nature. Serious causes should be detected with the use of ‘red flags’ and surgery reserved for only the most severe cases that have not responded to conservative measures. The clinical features, investigations and management of the common degenerative spine pathologies are discussed here.

Objective We performed a study to compare the severity of surgical stress between microscopic and microendoscopic decompressive laminotomy performed via a unilateral approach in patients with lumbar spinal canal stenosis (LSCS). Materials and methods A total of 41 patients received decompressive laminotomy for lumbar spinal stenosis. Twenty patients received microscopic decompressive laminotomy (MDL), and 21 patients received microendoscopic decompressive laminotomy (MEDL). The pre- and postoperative Japanese Orthopaedic Association (JOA), and Visual Analogue Scale (VAS) lower leg pain scores were evaluated. The other variables studied were the length of the operation, blood loss, length of hospital stay, the reaction of the CRP and WBC levels, the dosage of non-steroidal anti-inflammatory drugs (NSAIDs) used and surgical complications. Results The clinical analyses of the surgical outcomes were evaluated after a minimum two-year follow-up. The pre-and postoperative JOA scores and VAS in the MDL and MEDL groups were statistically similar. There were statistically significant differences found between the lengths of the operation time, blood loss, length of hospital stay, the reaction of CRP, and the pain indicated by the dosage of NSAIDs. The length of the operation time was longer in the MEDL group, and the other variables were greater in the MDL group. Conclusions The MEDL procedure is less invasive and safer than the MDL procedure. Hence, MEDL is an effective technique for treating symptomatic LSCS patients.

Introduction: Colchicine is the mainstay for the treatment of FMF, which is an auto-inflammatory disease mainly with relapsing polyserositis. Despite daily doses of 2 mg ormore each day, approximately 5% to 10% of the patients continue to suffer from its attacks. In this study, we aimed to investigate the depression and attack features in patients withFMF who have colchicine resistance (CR).Patients e Methods: CR was defined for FMF patients with 2 or more attacks within the last6 months period while using 2 mg/day colchicine. Eighteen patients (9 Female/9 Male) wereenrolled into the CR group and 41 patients were enrolled into the control group (12 Male/29Female). Demographic, clinical e laboratory findings, treatment adherence, and the BeckDepression Inventory (BDI) scores were evaluated. Results: The age of onset of FMF was significantly lower in the CR group (12.3 yrs vs. 16.9 yrs, P = 0.03). Disease duration was longer in the CR group (P = 0.01). Abdominal and leg pain dueto exercise were significantly more frequent in the CR group versus controls (83% vs. 51%;P = 0.02 e 88% vs. 60%; P = 0.04, respectively). Patients with BDI scores over 17 points weremore frequent in the CR group compared to controls (50% vs. 34.1%; P < 0.001).Discussion: We found that: (1) the age of disease onset was lower and (2) the disease durationwas longer in CR group. Pleuritic attacks, hematuria e proteinuria were more frequent in CRpatients. We propose that depression is an important factor to consider in the susceptibilityto CR. © 2014 Elsevier Editora Ltda.

Objective In addition to dysmenorrhea, dyspareunia, and subfertility, pain in the lower extremities has been described to be a further complaint in women affected by endometriosis, and lysis of nerve entrapment was thought to be associated with amelioration of leg pain. Therefore, we aimed to compare the prevalence of cyclic leg pain and pain intensity between women with endometriosis and without endometriosis, and to evaluate the effect of laparoscopic surgery. Study design Forty-four women with endometriosis and 58 controls were included in a prospective, controlled clinical trial at a University hospital/tertiary referral center. Participants were asked to complete questionnaires the day before and six to nine weeks after laparoscopy. The prevalence and intensity of leg pain and improvement after laparoscopic surgery, quantified according to a visual analog scale (VAS) score, were evaluated. We also recorded involvement of dermatomes, the presence and intensity of dysmenorrhea, and correlations between age, stage of endometriosis (rAFS-score), and preoperative VAS scores. Results Before surgery, more women were affected by leg pain in the endometriosis group, compared to the control group (45.5% and 25.9%, respectively). Preoperative VAS scores for leg pain, however, were not significantly different between the two groups. A moderate correlation in the preoperative VAS scores between leg pain and dysmenorrhea was observed. After laparoscopy, we found a significant improvement in leg pain intensity in both groups. The mean difference in the VAS score for pain reduction between the study group and the control group was 0.74 (95% CI: −0.61–2.08), which was not statistically significant. Conclusions The prevalence of leg pain is increased in endometriosis, while leg pain intensity is not, compared to women without endometriosis. Laparoscopic surgery—even without preparation and decompression of nerve tissue—is associated with an improvement in pain intensity in women with endometriosis, as well as in the group without endometriosis.

Objective Spinal cord stimulation (SCS) is expected to have analgesic effects in patients with neuropathic pain, ischemic pain, or mixed pain. The type of leg pain caused by lumbar spinal stenosis (LSS) is considered as mixed pain, which is expected to respond to SCS. However, there is no established view on the usefulness of SCS in the management of this type of pain. Therefore, we aimed at evaluating the efficacy of SCS against leg pain associated with LSS. Materials and Methods Data were collected retrospectively for the period from January 2003 to December 2011 from 91 patients with LSS-associated leg pain enrolled to the SCS trial. SCS implantation was performed in patients who responded to the trial and desired to receive this therapy. Results The response rate (percentage of patients showing 50% or greater alleviation of pain) in the trial was 65% (59/91 patients). SCS implantation was performed on 41 patients. The percentage of patients who showed a good response (definition is SCS continued for one year or longer after implantation) was 95% (39/41). Conclusion SCS seemed to be effective against leg pain associated with LSS. Thus, SCS should be actively adopted in indicated patients as a method of treatment intermediate between conservative therapy and surgical therapy.