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Study Design: Retrospective cohort.Purpose: To investigate the impact of meeting a patient’s preoperative expectations for back or leg pain or the achievement of minimum clinically important difference (MCID) on patient satisfaction following lumbar fusion.Overview of Literature: Few studies have compared if MCID achievement or meeting preoperative expectations for pain reduction affects patient satisfaction.Methods: A surgical database was reviewed for eligible patients who underwent lumbar fusion. Patient satisfaction and Visual Analog Scale (VAS) for back and leg pain were the outcomes of interest. Meeting expectations was calculated as a difference of ≤0 between preoperative expectations and postoperative VAS scores. MCID achievement was calculated by comparing changes in VAS scores with established values. Meeting preoperative expectations or MCID achievement as predictors of patient satisfaction was evaluated using regression analysis.Results: A total of 134 patients were included in this study. Patients demonstrated significant improvements in VAS back and VAS leg (pp≤0.024). Meeting VAS leg expectations and MCID achievement both demonstrated a significant association with patient satisfaction at all postoperative timepoints (all, p≤0.02). No differences between MCID achievement and meeting expectations as predictors of satisfaction were noted.Conclusions: The majority of patients achieved MCID and had their back and leg pain expectations met by 1 year. Both measures were significant predictors of patient satisfaction and suggest that MCID achievement may act as a suitable substitute for patient satisfaction.

OBJECTIVE Lumbar discectomy is a frequently performed procedure to treat sciatica caused by lumbar disc herniation. Multiple surgical techniques are available, and the popularity of minimally invasive surgical techniques is increasing worldwide. Clinical outcomes between these techniques may not show any substantial differences. As lumbar discectomy is an elective procedure, patients’ own preferences play an important role in determining the procedure they will undergo. The aims of the current study were to determine the relative preference weights patients apply to various attributes of lumbar discectomy, determine if patient preferences change after surgery, identify preference heterogeneity for choosing surgery for sciatica, and calculate patient willingness to pay for other attributes. METHODS A discrete choice experiment (DCE) was conducted among patients with sciatica caused by lumbar disc herniation. A questionnaire was administered to patients before they underwent surgery and to an independent sample of patients who had already undergone surgery. The DCE required patients to choose between two surgical techniques or to opt out from 12 choice sets with alternating characteristic levels: waiting time for surgery, out-of-pocket costs, size of the scar, need of general anesthesia, need for hospitalization, effect on leg pain, and duration of the recovery period. RESULTS A total of 287 patients were included in the DCE analysis. All attributes, except scar size, had a significant influence on the overall preferences of patients. The effect on leg pain was the most important characteristic in the decision for a surgical procedure (by 44.8%). The potential out-of-pocket costs for the procedure (28.8%), the wait time (12.8%), need for general anesthesia (7.5%), need for hospitalization (4.3%), and the recovery period (1.8%) followed. Preferences were independent of the scores on patient-reported outcome measures and baseline characteristics. Three latent classes could be identified with specific preference patterns. Willingness-to-pay was the highest for effectiveness on leg pain, with patients willing to pay €3133 for a treatment that has a 90% effectiveness instead of 70%. CONCLUSIONS Effect on leg pain is the most important factor for patients in deciding to undergo surgery for sciatica. Not all proposed advantages of minimally invasive spine surgery (e.g., size of the scar, no need of general anesthesia) are necessarily perceived as advantages by patients. Spine surgeons should propose surgical techniques for sciatica, not only based on own ability and proposed eligibility, but also based on patient preferences as is part of shared decision making.

OBJECTIVE Augmented reality (AR) is a novel technology which, when applied to spine surgery, offers the potential for efficient, safe, and accurate placement of spinal instrumentation. The authors report the accuracy of the first 205 pedicle screws consecutively placed at their institution by using AR assistance with a unique head-mounted display (HMD) navigation system. METHODS A retrospective review was performed of the first 28 consecutive patients who underwent AR-assisted pedicle screw placement in the thoracic, lumbar, and/or sacral spine at the authors’ institution. Clinical accuracy for each pedicle screw was graded using the Gertzbein-Robbins scale by an independent neuroradiologist working in a blinded fashion. RESULTS Twenty-eight consecutive patients underwent thoracic, lumbar, or sacral pedicle screw placement with AR assistance. The median age at the time of surgery was 62.5 (IQR 13.8) years and the median body mass index was 31 (IQR 8.6) kg/m2. Indications for surgery included degenerative disease (n = 12, 43%); deformity correction (n = 12, 43%); tumor (n = 3, 11%); and trauma (n = 1, 4%). The majority of patients (n = 26, 93%) presented with low-back pain, 19 (68%) patients presented with radicular leg pain, and 10 (36%) patients had documented lower extremity weakness. A total of 205 screws were consecutively placed, with 112 (55%) placed in the lumbar spine, 67 (33%) in the thoracic spine, and 26 (13%) at S1. Screw placement accuracy was 98.5% for thoracic screws, 97.8% for lumbar/S1 screws, and 98.0% overall. CONCLUSIONS AR depicted through a unique HMD is a novel and clinically accurate technology for the navigated insertion of pedicle screws. The authors describe the first 205 AR-assisted thoracic, lumbar, and sacral pedicle screws consecutively placed at their institution with an accuracy of 98.0% as determined by a Gertzbein-Robbins grade of A or B.

Congenital afibrinogenemia is a rare autosomal recessive blood disorder that accompanies thrombotic complications and is associated with bleeding tendency. The management of these opposing complications remains a challenge. Endovascular treatment (EVT) for peripheral arterial thrombosis has not been described in previous studies. A 57-year-old man with congenital afibrinogenemia developed back pain and left lower leg pain. The cause of the pain was confirmed to be renal infarction and lower extremity arterial thrombosis by Doppler ultrasound and contrast-enhanced computed tomography. He was treated with EVT for the lower extremity arterial thrombosis, leading to an excellent short-term improvement without bleeding.

IntroductionExercise-related leg pain (ERLP) may be caused by chronic exertional compartment syndrome (CECS), occurring mainly in athletes and military recruits. In military populations, the effectiveness of surgical treatment in CECS is debated. The purpose of this study is to assess the outcome of surgical treatment for CECS in Alrijne Hospital (the Netherlands), a civilian hospital with supraregional referral function.MethodsA historic cohort study was performed on patients with ERLP who were suspected for CECS and were referred for intracompartmental pressure measurement (ICPM) from 2013 to 2017 (n=160). Patient demographics, ICPM and survey response were analysed.ResultsThe mean delay before visitation was 29.0±30.3 months. When comparing surgical-treated patients with CECS with conservative-treated patients with ERLP, surgical-treated patients were more satisfied, reported better recovery towards former level of performance (2.8±2.0 vs 3.9±1.7 and 2.5±1.6 vs 3.2±1.4 on a 7-point Likert scale, respectively) and better subjective injury status (79.3±22.6 vs 63.5±27.4 using the Single Assessment Numeric Evaluation score). Treatment satisfaction was 75.0% in surgical-treated CECS versus 51.4% in conservative-treated ERLP.ConclusionCivilian patients report improved functional outcomes after fasciotomy for CECS. Future research should focus on non-invasive diagnostic options and methods to determine which treatment is the most appropriate for each individual patient.

Objective After percutaneous endoscopic lumbar discectomy (PELD), most patients with lumbar disc herniation (LDH) experience relief from the typical symptoms of low back and leg pain. However, for a small number of patients, these symptoms are relieved immediately after surgery but aggravated soon after, and then relieved after short‐term full rest or conservative treatment. The aim of the study was to demonstrate this short‐term recurrent phenomenon, termed rebound pain. Methods A retrospective study was conducted on 144 patients who underwent single‐segment PELD from May 2017 to June 2020. Postoperative patients were divided into a rebound pain group and a non‐rebound pain group. For the former group, general information, symptom characteristics and visual analogue score (VAS) changes in rebound pain were summarized. For both groups, postoperative efficacy was evaluated by recent VAS of low back and leg pain in the remission stage, the Oswestry disability index (ODI) and the modified MacNab criteria at the last follow‐up. Logistic regression analysis was used to identify predictors for rebound pain. Results The VAS and ODI exhibited significant improvements at the last follow‐up of average 15.4 months (P 45 days was found as a protective factor for rebound pain (p = 0.031). Conclusion Although rebound pain with multiple characteristics and a short duration had no significant effect on long‐term postoperative efficacy, its high incidence often caused unnecessary concern in both patients and doctors. As a result, careful differentiation of rebound pain from other postoperative complications is needed., For patients with lumbar disc herniation, most received relief from low back and leg pain after percutaneous endoscopic lumbar discectomy (PELD). However, 10.4% of patients had short‐term pain recurrence after PELD, termed rebound pain, which could be alleviated by adequate rest and conservative treatment.

Objective: To determine if a brief, one-on-one pain neuroscience education (PNE) session delivered by a physical therapist (PT) can influence depression. Methods: A convenience sample of patients with persistent low back pain (LBP) (n = 23) attending PT with moderate to severe depression (Patient Health Questionnaire-9 [PHQ-9]) participated in the study. Patients received a standardized, one-on-one 30-minute PNE session by a PT with pre- and post-intervention measures of low back and leg pain (Numeric Pain Rating Scale [NPRS]), pain catastrophization (Pain Catastrophization Scale [PCS]), pain knowledge (Revised Neurophysiology of Pain Questionnaire [rNPQ] and depression (PHQ-9). Results: Immediately following PNE, all measures improved, with low back and leg pain not being significant (pback = 0.345 and pleg = 0.633), while pain catastrophization (p = 0.047), pain knowledge (p = 0.001) and depression (p = 0.004) reaching significant improvements. The PNE session shifted various patients to lower levels of depression, with 21.8% of the patients’ improvement in depression meeting or exceeding the minimal clinical important difference. Conclusion: PNE may be a safe, clinically effective way to help a subgroup of patients attending PT with depression. More studies are needed to further explore the results from this pilot study.

Chronic leg pain is a common problem for young soldier-athletes. Differential diagnosis of this issue is extensive and includes more common entities such as medial tibial stress syndrome and tibial stress fracture and other scarce causes. Therefore, making a correct diagnosis proves to be vital for appropriate care. This topic discusses the case of a 36-year-old soldier who was diagnosed with a schwannoma of the left tibial nerve as a rare cause of leg pain. Its literature is scarce and intends to add further data about recommendations for investigation and management for this kind of lesion.

Background:Lumbar sympathetic block is used in inoperable peripheral vascular disease. The block acts as a vasodilator by decreasing sympathetic tone and improves tissue oxygenation and helps in ulcer healing. No guidelines exist till date for its use in patients with chronic leg pain and ulcers. The management of patients with unreconstructable distal disease with rest pain has always been difficult. Lumbar sympathetic block helps to abolish this rest pain. Aims and Objectives: 1. To study the effectiveness of lumbar sympathetic block 2. To study the ideal level for needle insertion for 100% success rate. 3. To follow up the patients for 1 week, 4 weeks and 12 weeks for relief of symptoms. 4. To study the safety of the block and note the complications. Materials and Methods: After approval of ethical committee, this retrospective study was conducted from Pain Clinic Records over the past two years. Total number of patients studied were 30 over past 2 years. Data Collection: Demographic Data and VAS score was recorded Preblock walking distance was recorded. CT guided lumbar sympathetic block was given. Results and Conclusion: Lumbar sympathetic block was very useful, safe and effective method to decrease the rest pain in patients presented to pain OPD of our hospital. Follow up for 3 months showed healing of ulcers in some of these patients.

The aim is to assess the frequency of falls and intrinsic fall risk factors in patients requiring pacemakers. Methodology. The research was conducted from November 2020 to February 2021. Participated patients were hospitalized at the LUHS hospital Kauno Klinikos Department of Cardiology and required heart pacemaker implantation. Total 82 patients participated in the study. The questionnaire was composed by the authors of the research. The study was obtained by the Bioethics Permit of the Medical Academy of LUHS (No. BEC-SL (B) -42). Results. Almost half of the patients fell (45.1%) at least once a year. Elderly patients (65 years and older) are more likely to experience falls than patients under 65 years of age p=0,006. Elderly patients are more often exposed to various internal risk factors of falls: urination at night (82,9 %), weakness (82,9 %), dizziness (76,8 %). Perceived decreased leg muscle strength was found in both women and men (69.6% and 52.8%, respectively, p = 0.002). Patients older than 65 years and therefore

Background. Femur fractures in adolescents are rare. Severe vitamin D deficiency has important implications for bone health. We describe the case of a 13-year-old boy with autism spectrum disorder (ASD) who presented with low-impact bilateral femur fractures in the setting of severe vitamin D deficiency. Case Presentation. A 13-year-old boy with ASD presented with bilateral leg pain after an unwitnessed fall. Laboratory investigations revealed severe hypocalcemia (S. calcium 4.9 mg/dL) and severe vitamin D deficiency (25(OH)D

AIM: This was a prospective double-blinded randomized comparative study. Several authors have reported the efficacy of platelets derivatives for spinal union. However, the use of PRP and PRF for bone fusion with TLIF has not been fully explored. METHODS: Standard open TLIF surgery was performed on 80 patients, randomized in three groups, TLIF and local bone were used in 40 patients (control group) and TLIF, local bone, and PRP were used in 20 patients (PRP group) and PRF was used in 20 patients (PRF group). Radiological parameters were assessed by X-ray after 3 months post-operative to evaluate the position of the screws and cage migration and by CT scans at 6 months and 12 months postoperatively. Patients, surgeons, and post-surgical analysis were blinded. RESULTS: VAS scores for lower back pain and leg pain were statistically significant between the three groups preoperatively. The VAS scores of back pain improved after 12 months and were statistically significant (p < 0.001) and the VAS score of leg pain improved compared with preoperatively in the three groups during the 6- and 12-month follow-up postoperatively, however, the three groups, VAS scores for leg pain were not significantly different. After 1-year follow-up, significantly more patients achieved definite fusion, when implanted platelets derivatives compared with the control group, but with no significance regarding fusion rates. CONCLUSION: We advocated using platelet derivative as a fusion enhancer modality which is cost and time saving. It appears to be a complementary step that ensures better outcome for the patients.

Objective To assess the clinical efficacy of one‐stage percutaneous endoscopic lumbar discectomy (PELD) for symptomatic double‐level contiguous adolescent lumbar disc herniation (ALDH). Methods This retrospective study included 16 patients who presented with back and/or leg pain due to double‐level disc herniation underwent PELD for symptomatic lumbar disc herniation (0.27%,16/5877) from January 2014 to September 2019. After follow‐up period of 17.3 months in average, numeric rating scale (NRS) scores and modified Macnab criteria were used to assess the preoperative and postoperative clinical results. Quantitative data were expressed as mean standard deviation (SD) and the data for the variation in the NRS scores before and after the operation were compared using the Wilcoxon two‐sample test. Analyses were performed with IBM SPSS Statistics for Windows, version 19.0 (IBM, Armonk, NY, USA). Values of P, Adjustment of working cannula intraoperatively for symptomatic double‐level contiguous adolescent lumbar disc herniation.

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.

Background: An increasing number of lumbar spine conditions are treated surgically. Such intervention, however, is commonly thought to be more effective in addressing leg pain than low back pain. Patient expectations may also contribute to self-reported surgical outcomes. Questions/Purposes: We sought to compare the expectations of patients in 2 groups undergoing lumbar spine surgery: those with predominantly low back pain and those with predominantly leg pain. We also sought to evaluate how these expectations were fulfilled for each group. Methods: We carried out a retrospective analysis of prospectively collected data from a prior study in which patients scheduled for lumbar spine surgery at a single institution completed validated surveys preoperatively and at 2 years postoperatively, including a 20-item survey on expectations for lumbar spine surgery. The patients were enrolled in the study between February 2010 and August 2012, and were divided into 2 cohorts: a “Back > Leg” group that consisted of patients with back pain that was isolated or greater than leg pain, and a “Leg ≥ Back” group that consisted of patients with leg pain that equaled or exceeded back pain. The primary analysis compared composite expectation scores (range, 0–100) between groups. Results: A total of 366 patients were deemed eligible for the study; of these, 162 patients were allocated to the Back > Leg group and 204 patients were allocated to the Leg ≥ Back group. Patients in the Leg ≥ Back group had a greater mean preoperative expectation score compared with those in the Back > Leg group. Multivariate analysis demonstrated that higher preoperative expectations were associated with leg pain symptoms after controlling for disease diagnosis. Both groups reported similar proportions of fulfilled expectations. Conclusion: Patients with predominantly leg pain hold greater preoperative expectations for lumbar spine surgery than do patients with predominantly back pain. That these patient groups reported similar fulfillment of their expectations at 2 years postoperatively illustrates the greater clinical outcomes achieved among patients who presented with predominantly leg pain.

The use of a Viabahn VBX endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) to exclude chronically thrombosed inferior vena cava (IVC) filters refractory to exclusion with self-expanding stents was evaluated. The mean duration of TrapEase IVC (Cordis, Milpitas, Calif) implantation was 7.6 years (range, 2-11 years). Symptoms included leg pain, edema, color changes, and back pain. The mean Villalta score and venous clinical severity score were 17 (range, 13-23) and 13 (range, 11-15), respectively. Indirect ultrasound evidence of stent patency was demonstrated at a mean of 8 months after intervention. The mean Villalta score and venous clinical severity score had decreased by 13 and 10, respectively, at a mean of 9.5 months after intervention. Iliocaval reconstruction with Viabahn VBX balloon expandable stent-graft exclusion of chronically thrombosed TrapEase IVC filters is safe, with favorable short-term results.

A 59-year-old man presented to the emergency department with fever and chills that began 6 weeks earlier, when a symptomatic deep vein thrombosis (DVT) of the right posterior tibial vein had been diagnosed. The patient had also noticed word-finding difficulties and mild headache for the week before

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

OBJECTIVEIn 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.METHODSPatient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated.RESULTSPatients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323).CONCLUSIONSThere was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.

Study design Observational multicenter study. Objective The aim of this study was to evaluate changes in pain during sexual activity after surgery for lumbar spinal stenosis (LSS). Summary of background data There are limited data available on sexual function in patients undergoing surgery for LSS. Methods Data were retrieved from the Norwegian Registry for Spine Surgery. The primary outcome was change in pain during sexual activity at 1 year, assessed by item number eight of the Oswestry disability index questionnaire. Secondary outcome measures included Oswestry Disability Index, EuroQol-5D, and numeric rating scale scores for back and leg pain. Results Among the 12,954 patients included, 9908 (76.5%) completed 1-year follow-up. At baseline 9579 patients (73.9%) provided information about pain during sexual activity, whereas 7424 (74.9%) among those with complete follow-up completed this item. Preoperatively 2528 of 9579 patients (26.4%) reported a normal sex-life without pain compared with 4294 of 7424 patients (57.8%) at 1 year. Preoperatively 1007 (10.5%) patients reported that pain prevented any sex-life, compared with 393 patients (5.3%) at 1 year. At baseline 7051 of 9579 patients (73.6%) reported that sexual activity caused pain, and among these 3145 of 4768 responders (66%) reported an improvement at 1 year. A multivariable regression analysis showed that having a life partner, college education, and working until time of surgery were predictors of improvement in pain during sexual activity. Current tobacco smoking, pain duration >12 months, previous spine surgery, and complications occurring within 3 months were negative predictors. Conclusion This study clearly demonstrates that a large proportion of patients undergoing surgery for LSS experienced an improvement in pain during sexual activity at 1 year.Level of Evidence: 2.

Summary: Due to monotonous movement patterns, muscular hypertrophy, and increased cardiac output peripheral vasculature of athletes are subject to extreme stresses during athletic performance. Individuals suffering from exercise induced non-traumatic lower leg pain may display underlying vascular pathology such as external iliac artery endofibrosis. Therefore, it is essential in the course of to discriminate vascular from non-vascular findings and prime the correct diagnostic path within the course of clinical examination. In this regard, interdisciplinary thinking and profound knowledge in exercise-associated pathologies of the musculoskeletal, nervous and vascular system is indispensable. Consequently, provocation testing displays an indispensable diagnostic tool and has to be continued until symptoms occur, or complete exhaustion is attained. Finally, selective assessment of conservative and surgical treatment options, as well as its ethical evaluation, are of major importance in order to protect, preserve and promote the health and physical integrity of our patients who are keen to perform.

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

Aims To study the associations of lumbar developmental spinal stenosis (DSS) with low back pain (LBP), radicular leg pain, and disability. Methods This was a cross-sectional study of 2,206 subjects along with L1-S1 axial and sagittal MRI. Clinical and radiological information regarding their demographics, workload, smoking habits, anteroposterior (AP) vertebral canal diameter, spondylolisthesis, and MRI changes were evaluated. Mann-Whitney U tests and chi-squared tests were conducted to search for differences between subjects with and without DSS. Associations of LBP and radicular pain reported within one month (30 days) and one year (365 days) of the MRI, with clinical and radiological information, were also investigated by utilizing univariate and multivariate logistic regressions. Results Subjects with DSS had higher prevalence of radicular leg pain, more pain-related disability, and lower quality of life (all p < 0.05). Subjects with DSS had 1.5 (95% confidence interval (CI) 1.0 to 2.1; p = 0.027) and 1.8 (95% CI 1.3 to 2.6; p = 0.001) times higher odds of having radicular leg pain in the past month and the past year, respectively. However, DSS was not associated with LBP. Although, subjects with a spondylolisthesis had 1.7 (95% CI 1.1 to 2.5; p = 0.011) and 2.0 (95% CI 1.2 to 3.2; p = 0.008) times greater odds to experience LBP in the past month and the past year, respectively. Conclusion This large-scale study identified DSS as a risk factor of acute and chronic radicular leg pain. DSS was seen in 6.9% of the study cohort and these patients had narrower spinal canals. Subjects with DSS had earlier onset of symptoms, more severe radicular leg pain, which lasted for longer and were more likely to have worse disability and poorer quality of life. In these patients there is an increased likelihood of nerve root compression due to a pre-existing narrowed canal, which is important when planning surgery as patients are likely to require multi-level decompression surgery. Cite this article: Bone Joint J 2021;103-B(1):131–140.

Schwannomas are benign, well-encapsulated and slow growing tumor arising from Schwann cells of the peripheral nerve sheath. They commonly saw in the head and neck, rarely from deep peroneal nerve in the lower limb. We present a case of 42-year-old active national hockey coach, who presented with mild pain and numbness over lateral aspect of left leg for 2 years. The pain was provoked by sporting activities, and was initially relieved by analgesics, until recently, hence his presentation. MRI was done and showed well-defined oval lesion within the deep intermuscular fascia between tibialis anterior and extensor halluces longus muscles. He had an open dissection, and the histology showed a diagnosis of schwannoma. Post-operative healing was uneventful, the pain and numbness improving after 12 months.

The World Health Organisation (WHO) defined low back pain (LBP) as pain or discomfort that is localized between the costal margin and above the inferior gluteal folds, with or without leg pain. In the world, it is estimated that the prevalence of LBP ranges from 1.4% to 20.0%. In 2013, around 24.7% of workers in Indonesia had experienced occupational diseases caused by low back pain. Based on the Riset Kesehatan Dasar (RKD) survey pada in 2018, 31.4% of Indonesians have used traditional medicine, with manual treatment skill, the type of traditional medicine effort, most widely used (65.3%) and one of it is cupping therapy. Cupping (therapy) also named Hijamah. Cupping therapy is one of the alternative medicines that uses vacuum cups on the cupping point of the skin surface. Although the mechanism of action of cupping therapy is still unclear, there are several reported effects of cupping therapy including increasing skin blood flow, changing skin biomechanical properties, increasing the pain threshold, increasing local anaerobic metabolism, reducing inflammation, and modulating the immune system. cellular. According to research conducted by Volpato et al. (2019) demonstrated the effectiveness of cupping therapy in reducing pain perception and improving function in individuals with low back pain.

Introduction Low‐back or leg pain in patients suffering from failed back surgery syndrome (FBSS) is often severe, having a major impact on functionality and quality of life. Despite conservative and surgical treatments, pain can be persistent. An alternative treatment option is epiduroscopy, a minimally invasive procedure based on mechanical adhesiolysis of epidural fibrosis. As epidural fibrosis is speculated to be a major contributor in the pathophysiologic process of FBSS, this review evaluates the effectiveness of epiduroscopy in FBSS patients. Methods and materials A systematic literature search was performed in PubMed, Embase, and Cochrane databases. Critical appraisal was performed using validated tools. Meta‐analysis was performed using generic inverse variance analysis. Results From the 286 identified articles, nine studies were included. The visual analogue scale (VAS) average was 7.6 at baseline, 4.5 at 6, and 4.3 at 12 months. The Oswestry Disability Index (ODI) average was 61.7% at baseline, 42.8% at 6, and 46.9% at 12 months. An average of 49% of patients experienced significant pain relief at 6 and 37% at 12 months. Meta‐analysis showed a pooled VAS mean difference of 3.4 (2.6 to 4.1; 95% confidence interval [CI]) and 2.8 (1.6 to 4.0; 95% CI) and pooled ODI mean difference of 19.4% (12.5 to 26.4%; 95% CI) and 19.8% (13.8 to 25.9%; 95% CI) at 6 and 12 months, respectively. Conclusion Current literature demonstrates a clinically relevant reduction in pain and disability scores at 6 to 12 months after mechanical adhesiolysis in FBSS patients. The quality of evidence is moderate, and the level of recommendation is weak. Practitioners should consider the benefits of epiduroscopy after weighing the risks for individual patients with FBSS.

Purpose Transforaminal lumbar interbody fusion (TLIF) is a widely accepted surgical procedure for degenerative disk disease. While numerous studies have analyzed complication rates and risk factors this study investigates the extent to which complications after TLIF spondylodesis alter the clinical outcome regarding pain and physical function. Methods A prospective clinical two-center study was conducted, including 157 patients undergoing TLIF spondylodesis with 12-month follow-up (FU). Our study classified complications into three subgroups: none (I), minor (IIa), and major complications (IIb). Complications were considered “major” if revision surgery was required or new permanent physical impairment ensued. Clinical outcome was assessed using visual analog scales for back (VAS-B) and leg pain (VAS-L), and Oswestry Disability Index (ODI). Results Thirty-nine of 157 patients (24.8%) had at least one complication during follow-up. At FU, significant improvement was seen for group I (n = 118) in VAS-B (–50%), VAS-L (–54%), and ODI (–48%) and for group IIa (n = 27) in VAS-B (–40%), VAS-L (–64%), and ODI (–47%). In group IIb (n = 12), VAS-B (–22%, P = 0.089) and ODI (–33%, P = 0.056) improved not significantly, while VAS-L dropped significantly less (–32%, P = 0.013) compared to both other groups. Conclusion Our results suggest that major complications with need of revision surgery after TLIF spondylodesis lead to a significantly worse clinical outcome (VAS-B, VAS-L, and ODI) compared to no or minor complications. It is therefore vitally important to raise the surgeon´s awareness of consequences of major complications, and the topic should be given high priority in clinical work.

Introduction Persistent back/and or leg pain is a common outcome after spinal surgery (otherwise known as failed back surgery syndrome [FBSS]). Studies have shown that spinal cord stimulation (SCS) at 10 kHz provides effective analgesia in FBSS patients with both back and leg pain symptoms and in those with predominant back pain. This study is the first to evaluate the therapy in FBSS patients with predominant leg pain. Methods The safety and efficacy of 10 kHz SCS was evaluated in an uncontrolled, open‐label, prospective study of FBSS patients with predominant leg pain in the Netherlands. Follow‐ups were performed at 1, 3, 6, and 12 months post implantation. Results Sixty out of 68 patients (88%) experienced sufficient pain relief during a stimulation trial. Of these, 58 proceeded to permanent implantation of a 10 kHz SCS system. After 12 months of treatment, 80% of patients experienced ≥ 50% reduction in baseline leg pain, and a similar proportion (76%) experienced ≥ 50% reduction in baseline back pain. At least two‐thirds of patients were also leg pain and back pain remitters (visual analog scale [VAS] ≤ 2.5 cm). The therapy was also associated with a general improvement in patients’ quality of life, as measured by secondary outcomes including disability, perception of health improvement, mental well‐being, and satisfaction. A positive impact on opioid consumption was also observed. Conclusions Consistent with previous findings, 10 kHz SCS for the treatment of FBSS patients with predominant radicular symptoms is safe and effective and is associated with improved quality of life.

Some of the improvements in DH, FH, and SLL achieved intraoperatively during lateral lumbar interbody fusion surgery were lost by the postoperative 1-week follow-up. An intraoperative radiograph can predict radiographic and clinical outcomes of the 2-year follow-up. The difference between preoperative DH and intraoperative DH should be4.18 mm.Retrospective cohort study The aim of this study was to evaluate whether the intraoperatively estimated parameters, as calculated on a cross-table lateral radiograph, are maintained in an upright position at discharge and at 2 years postoperatively and to identify the appropriate disc height (DH) to achieve substantial clinical benefit. The amount of correction retained following lateral lumbar interbody fusion (LLIF) surgery had not been reported. A single-center, consecutive series of patients who underwent single-level LLIF with at least 2 years of follow-up were retrospectively reviewed. Upright standardized preoperative, 1-week, and 2-year postoperative radiographs, as well as intraoperative lateral radiographs, were analyzed for DH, foraminal height (FH), and segmental lumbar lordosis (SLL) at the index level. Clinical outcomes were compared between preoperatively and 1 week and 2 years postoperatively. In total, 89 patients were evaluated (mean follow-up, 42.8 months [range, 24–83 months]). DH decreased from 12.5 ± 2.7 mm intraoperatively to 11.7 ± 3.1 mm at 1 week postoperatively, FH decreased from 15.9 ± 3.6 mm to 15.1 ± 3.6 mm, and SLL decreased from 13.6° ± 1.7° to 12.4° ± 1.7°. A linear correlation between intraoperative and 2-year postoperative parameters was found (R2 = 0.552, 0.518, and 0.616, respectively). Clinical outcomes, including back pain, leg pain, and Oswestry Disability Index (ODI), significantly improved 2 years postoperatively. The optimal cutoff point for substantial clinical benefit thresholds for the ODI was a 4.18 mm increase in DH (sensitivity, 64.3%; specificity, 80.3%; area under the curve, 0.793; 95% confidence interval, 0.642–0.855). Some of the improvements in DH, FH, and SLL achieved intraoperatively during LLIF surgery were lost by the postoperative 1-week follow-up. An intraoperative radiograph can predict radiographic and clinical outcomes of the 2-year follow-up. The difference between preoperative DH and intraoperative DH should be4.18 mm. Level of Evidence: 4.

Background The newly proposed low back pain treatment requires case classification according to the pain mechanism (nociceptive, neuropathic or nociplastic) to determine the most effective therapeutic approach. However, there is a lack of objective tools for distinguishing these pain mechanisms. The aim of the study was to identify which symptoms, signs, and standard diagnostic parameters would allow predicting the nociplastic pain (NP) subtype among low back leg pain (LBLP) patients. Methods A retrospective analysis of an LBLP case–control study database was carried out. The presence of NP was assumed if the patient presented with myofascial pain syndrome (MPS) and developed a short-term intensive vasodilatation reaction in the perceived lower leg pain area after provocation by a minimally invasive procedure. Clinical data and standard LBLP diagnostic parameters were analyzed to classify patients as NP (+) vs NP (-). Next, to predict NP probability, logistic regression analysis and a diagnostic classification tree were constructed. Results NP was confirmed in 43.75% of LBLP patients. Women represented 95.24% of all NP (+) patients. The diagnostic classification tree indicated that NP was highly probable if the LBLP subject was female and the result of a positive straight leg raise (SLR) test was lower than 45 degrees. If the SLR test result was greater than or equal to 45 degrees, a negative result on the Bragard test would have diagnostic value. This classification tree was approved to a certain extent in the logistic regression model (deviance residuals, min: −1.8519; 1Q: −0.5551; median: −0.1907; 3Q: 0.6565 and max: 2.1058) but should be verified in a larger group of subjects. Conclusion Female sex, but not clinical data or standard diagnostic parameters, is indicative of nociplastic pain in LBLP patients. More sophisticated statistical methods, based on directly measurable parameters, should be proposed to distinguish NP involvement in LBLP.

Solitary fibrous tumor in the lumbar spine is a rare pathology with non-specific radiographic features, sometimes resulting in misdiagnosis. Our patient was a 41-year old female who presented with low back pain and bilateral leg pain. Initial MRI showed a lesion misdiagnosed for a sequestered disc at the mid L4-5 level, which was subsequently characterized appropriately and treated surgically, with resolution of symptoms. Pathologic diagnosis was most consistent with a solitary fibrous tumor due to STAT 6 and CD 34 reactivity. Long-term follow up is recommended in these patients to monitor tumor recurrence and evidence of metastasis.

Supplemental digital content is available in the text., BACKGROUND Many patients with lower limb edema do not tolerate traditional higher-pressure compression devices and require alternative devices for edema control. METHODS Two systems were evaluated for control of bilateral or unilateral lower limb edema: an elasticized longitudinal stockinette (ELS; EdemaWear; Compression Dynamics, Omaha, Nebraska) and an elasticized tubular bandage (ETB; Tubigrip; Mölnlycke Health Care, Norcross, Georgia). Twenty-five patients were recruited; patients with bilateral edema (n = 12) wore the ELS on one limb, and the ETB on the other. Patients with unilateral edema (n = 13) were randomized to wear either the ELS or ETB. Edema measurements, leg pain, and patient preference were recorded. RESULTS There were 14 females (56%) and 11 males (44%); mean age was 66 years (range, 32-88 years); and mean body mass index was 40.4 kg/m2 (range, 26.1–66.9 kg/m2). Patients with bilateral edema wearing ELS had a foot-to-leg circumference between 25.5 and 42.9 cm pre-ELS that remained essentially unchanged at 2 weeks. The five patients with unilateral edema using ELS had a 24.3– to 43.7-cm circumference pre-ELS and 24.2- to 42.6-cm range at 2 weeks. The patients with bilateral edema using ETBs had a foot-to-leg circumference of 25.5 to 43.7 cm before treatment, unchanged 2 weeks later. The eight patients with unilateral edema using ETB had a 25.4- to 45.3-cm circumference pre-ETB and 24.8– to 42.0-cm range post-ETB. Mean pain levels decreased from 1.0 at week 0 to 0.5 at week 2. More patients preferred ELS (17/23, 78.3%) over ETB (5/23, 21.7%). CONCLUSIONS Both systems were easy to apply and provided low compression without increased pain. The ELS was preferred by more patients (78.3%) than ETB (21.7%).

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.

Adolescent idiopathic scoliosis is considered as the most common type of scoliosis. A 13-year-old female complained of bilateral leg pain, left > right, and severe headache. She was referred to an orthopaedic physical therapy clinic. Spinal X-ray revealed right thoracolumbar scoliosis with Cobb angle of about 48°. The primary curve was in the lumbar vertebrae, directed to the left, and the secondary curve was in the thoracic vertebrae, directed to the right. Two surgeons recommended corrective surgery, while one recommended physiotherapy for 6 months. The third surgical opinion was based on magnetic resonance imaging that presented normal cervical spine, mild scoliotic deformity of lower dorsal vertebrae with right-sided convexity and of lumbar vertebrae with left-sided convexity, L4–5 broad based posterior and left posterolateral disc protrusion, and L5–S1 mild central posterior disc protrusion. At the final evaluation after 18 months of a corrective exercise program, the patient reported no symptoms at rest or with exercises. The improvement was evidenced by Cobb angle change from 48° to 21°, pelvic shift, and general spinal flexibility and strength. The current case report describes a specific corrective exercise protocol adapted to a case of adolescent idiopathic scoliosis that presented with bilateral leg pain.

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.

Purpose Causes of low back-related leg pain (LBLP) can be complex and diverse. A detailed medical history, physical examination, laboratory tests, and imaging are necessary to accurately distinguish the pathomechanisms of LBLP and determine the most appropriate treatment. Case In this study, we report the first documented case in which the combination of dry needling (DN) and percutaneous endoscopic lumbar discectomy (PELD) was used for a patient with active myofascial trigger points (MTrPs) in the gluteus minimus muscle as well as L3-4 lumbar disc herniation (LDH). This 63-year-old woman complained of LBLP for 3 months. After careful examination and analysis, we determined this pain originated from two active MTrPs in the gluteal region and not LDH in L3-4. We first performed MTrPs DN, and the patient's LBLP was relieved completely. We then performed PELD at the L3-4 level for residual numbness on the medial and anterior aspect of the left lower limb. Finally, the patient received a satisfactory result. Conclusion The gluteal MTrPs test may be used as a routine examination for patients with LBLP, especially when clinical findings are discordant with imaging results.

OBJECTIVEPatients with lumbar disc herniation (LDH) typically present with lower-extremity radiculopathy. However, there are patients who have concomitant substantial back pain (BP) and are considered candidates for fusion. The purpose of this study was to determine if patients with LDH and substantial BP improve with discectomy alone.METHODSThe DaneSpine database was used to identify 2399 patients with LDH and baseline BP visual analog scale (VAS) scores ≥ 50 who underwent a lumbar discectomy at one of 3 facilities between June 2010 and December 2017. Standard demographic and surgical variables and patient-reported outcomes, including BP and leg pain (LP) VAS scores (0–100), Oswestry Disability Index (ODI), and European Quality of Life–5 Dimensions Questionnaire (EQ-5D) at baseline and 12 months postoperatively, were collected.RESULTSA total of 1654 patients (69%) had 12-month data available, with a mean age of 48.7 years; 816 (49%) were male and the mean BMI was 27 kg/m2. At 12 months postoperatively, there were statistically significant improvements (p < 0.0001) in BP (72.6 to 36.9), LP (74.8 to 32.6), ODI (50.9 to 25.1), and EQ-5D (0.25 to 0.65) scores.CONCLUSIONSPatients with LDH and LP and concomitant substantial BP can be counseled to expect improvement in their BP 12 months after surgery after a discectomy alone, as well as improvement in their LP.

A 38-year-old G1P0 presented to the Vascular Lab at 32 weeks gestation for evaluation of persistent left lower extremity edema. The patient reported a 1-month history of left leg pain and swelling after a long car trip. Of note, she had 3 negative lower extremity ultrasounds at outside imaging facilities over the previous 6 weeks. Left lower extremity venous duplex was performed with B-mode, color, power, and spectral Doppler using a linear 12-3 MHz transducer and curvilinear 5-1 MHz transducer. Images were documented using Intersocietal Accreditation Commission Vascular Testing (IAC VT) protocol. Left lower extremity duplex revealed continuous flow in the bilateral common femoral veins. Right common iliac and external iliac vein Doppler waveforms demonstrated spontaneous and phasic flow. Left proximal common iliac and external iliac veins revealed continuous flow. Acute, occlusive deep venous thrombosis (DVT) was identified in the left distal common iliac vein. The left common iliac vein was enlarged, measuring 2.2 cm compared with the contralateral common iliac vein measuring 1.4 cm. Ultrasonographic infrainguinal demonstration of acute DVT is straightforward and usually achievable with standard ICA VT protocol. However, imaging of the proximal pelvic venous circulation can be more elusive, particularly in the pregnant patient. Therefore, it is imperative to assess the spectral Doppler waveforms and to investigate pelvic venous flow. Because of the sonographer’s attention to the common femoral waveforms, additional focused pelvic imaging was performed and located acute, occlusive iliac DVT as the cause of significant edema.

Chronic exertional compartment syndrome (CECS) is one of the wide range of causes of exercise-related leg pain in athletes. It is defined as a transient increase in compartment pressures during activity, which causes pain, because of the inability of the fascial compartments to accommodate and is usually relieved by cessation of exercise. Exercise-induced leg pain in the athletic population is a common complaint, with reports of up to 15% of all runners arriving to initial evaluation with this presentation. Often, this lower-extremity exertional pain is grouped into the common term of "shin splints" by athletes, which is a nondiagnostic term that implies no specific pathology. It may, however, encompass much of the differential for CECS, including medial tibial stress syndrome, muscle strain, and stress fracture. Improving diagnostic techniques, as well as treatments, will continue to help athletes and patients with leg pain in the future.

Congenital absence of the inferior vena cava is an uncommon venous anomaly with treatment algorithms consisting of predominately medical management. We present a case of a 36-year-old man with venous ulcers who had failed conservative treatment for recurrent venous ulcers. From a catheter directed approach, we were able to develop an extravascular retroperitoneal space and perform an iliocaval reconstruction with Wallstents. At 1-year postoperatively, his leg pain and edema had resolved, and had achieved resolution of his venous ulceration.