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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.

While spinal cord stimulation (SCS) is a well-established therapy to address refractory persistent spinal pain syndrome after spinal surgery (PSPS-T2), its lack of spatial selectivity and reported discomfort due to positional effects can be considered as significant limitations. As alternatives, new waveforms, such as burst stimulation and different spatial neural targets, such as dorsal root ganglion stimulation (DRGS), have shown promising results. Comparisons between DRGS and standard SCS, or their combination, have never been studied on the same patients. “BOOST DRG” is the first prospective, randomized, double-blinded, crossover study to compare SCS vs. DRGS vs. SCS+DRGS. Sixty-six PSPS-T2 patients will be recruited internationally in three centers. Before crossing over, patients will receive each stimulation modality for 1 month, using tonic conventional stimulation. After 3 months, stimulation will consist in switching to burst for 1 month, and patients will choose which modality/waveform they receive and will then be reassessed at 6 and 12 months. In addition to our primary outcome based on pain rating, this study is designed to assess quality of life, functional disability, psychological distress, pain surface coverage, global impression of change, medication quantification, adverse events, brain functional imaging and electroencephalography, with the objective being to provide a multidimensional insight based on composite pain assessment.

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.

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 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

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.

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.

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.

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.

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

Background and purpose — Indication for lumbar disc herniation (LDH) surgery is usually to relieve sciatica. We evaluated whether back pain also decreases after LDH surgery. Patients and methods — In the Swedish register for spinal surgery (SweSpine) we identified 14,097 patients aged 20–64 years, with pre- and postoperative data, who in 2000–2016 had LDH surgery. We calculated 1-year improvement on numeric rating scale (rating 0–10) in back pain (Nback) and leg pain (Nleg) and by negative binomial regression relative risk (RR) for gaining improvement exceeding minimum clinically important difference (MCID). Results — Nleg was preoperatively (mean [SD]) 6.7 (2.5) and Nback was 4.7 (2.9) (p < 0.001). Surgery reduced Nleg by mean 4.5 (95% CI 4.5–4.6) and Nback by 2.2 (CI 2.1–2.2). Mean reduction in Nleg) was 67% and in Nback 47% (p < 0.001). Among patients with preoperative pain ≥ MCID (that is, patients with significant baseline pain and with a theoretical possibility to improve above MCID), the proportion who reached improvement ≥ MCID was 79% in Nleg and 60% in Nback. RR for gaining improvement ≥ MCID in smokers compared with non-smokers was for Nleg 0.9 (CI 0.8–0.9) and ­Nback 0.9 (CI 0.8–0.9), and in patients with preoperative duration of back pain 0–3 months compared with > 24 months for Nleg 1.3 (CI 1.2–1.5) and for Nback 1.4 (CI 1.2–1.5). Interpretation — LDH surgery improves leg pain more than back pain; nevertheless, 60% of the patients with significant back pain improved ≥ MCID. Smoking and long duration of pain is associated with inferior recovery in both Nleg and Nback.

STUDY DESIGN Prospective longitudinal cohort. OBJECTIVES The aim of this study was to determine whether functional treadmill testing (FTT) demonstrates differences between patients treated operatively and nonoperatively for adult symptomatic lumbar scoliosis (ASLS). SUMMARY OF BACKGROUND DATA ASLS has become increasingly prevalent as the population ages. ASLS can be accompanied by neurogenic claudication, leading to difficulty walking. FTT may provide a functional tool to evaluate patients with ASLS. METHODS One hundred and eighty-seven patients who underwent nonoperative (n = 88) or operative treatment (n = 99) of ASLS with complete baseline and 2-year post-treatment FTTs and concurrent patient-reported outcomes were identified. FTT parameters included maximum speed, time to onset of symptoms, distance ambulated, time ambulated, and Back and Leg pain severity before and after testing. RESULTS At baseline, patients treated operatively reported worse post-FTT back pain (4.39 vs. 3.45, P = 0.032) than those treated nonoperatively, despite similar ODI, SRS-22 Pain and Activity domain scores. Mean time ambulated (+2.15 vs. -1.20 P = 0.001), pre-FTT back pain (+0.19 vs. -1.60, P

Objective Presently, there is only limited evidence about the cost-effectiveness of peripheral nerve field stimulation (PNFS) and no evidence to date on the cost-effectiveness of PNFS as an add-on therapy to spinal cord stimulation (SCS). In a multicenter randomized controlled trial, PNFS as add-on therapy to SCS demonstrated clinical effectiveness in treating chronic low back pain in failed back surgery syndrome (FBSS) patients. We report here the cost-effectiveness of PNFS as additional therapy. Materials and Methods Cost-effectiveness analysis was performed from a health-care perspective using the general principles of cost-utility analysis, using empirical data from our multicenter randomized controlled trial on the effectiveness of hybrid SCS + PNFS on low back pain in FBSS patients, who were back pain non-responders to initial SCS-therapy, over a time-horizon of three months. Outcome measures were costs and quality-adjusted life-years (QALYs). Cost and QALYs were integrated using the net monetary benefit (NMB). Differences in costs, effects, and NMB were analyzed using multilevel regression. Uncertainty surrounding the NMB was presented by cost-effectiveness acceptability curves. Results A total of 52 patients implanted with both SCS and PNFS, randomly assigned to a group with PNFS either activated or inactive, completed the controlled part of the study. With mean total costs for the SCS + active PNFS group of euro1813.86 (SD euro109.78) versus euro1103.64 (SD euro123.43) for the SCS + inactive PNFS group at three months, we found an incremental cost-utility ratio of euro25.311 per QALY gained and a probability being cost-effective of more than 80% given a willingness to pay for a QALY of about euro40.000. Conclusions From a Dutch national health-care context, when the willingness to pay threshold is up to 60.000 Euros per QALY, PNFS as an add-on therapy to SCS for the treatment of low back pain in FBSS patients has a high probability of being cost-effective.

Study design A retrospective subgroup analysis of a prospective observational study was carried out. Summary of background data Patients' baseline characteristics may influence the clinical outcomes after minimally invasive lumbar interbody fusion (MILIF). Objective This study aimed to investigate the influence of patient's age and body mass index (BMI) on the clinical outcomes of MILIF for degenerative lumbar disorder. Materials and methods A total of 252 patients underwent MILIF. The clinical outcomes, including time to first ambulation, time to postsurgical recovery, back/leg pain in visual analog scale, Oswestry Disability Index, and EuroQol-5 Dimension, were collected at baseline, 4 weeks, 6, and 12 months. Patients were subgrouped by age (50 y and below: N=102; 51-64 y: N=102; 65 y and above: N=48) and BMI (≤25.0: N=79; 25.1-29.9: N=104; ≥30.0: N=69). Data from baseline to 12 months were compared for all clinical outcomes within age/BMI subgroups. Adverse events (AEs) and serious adverse events (SAEs) were summarized by age and BMI subgroups. Results All age and BMI subgroups showed significant improvements in clinical outcomes at 12 months compared with the baseline. The median time to first ambulation was similar for all subgroups (age groups: P=0.8707; BMI: P=0.1013); older people show a trend of having longer time to postsurgical recovery (age groups: P=0.0662; BMI: P=0.1591). Oswestry Disability Index, back, and leg pain visual analog scale, and EuroQol-5 Dimension were similar in all subgroups at every timepoint. A total of 50 AEs (N=39) were reported, 9 of which were SAEs; 3 AEs and 1 SAE were considered to be related to surgical procedure. No differences were observed in safety by age groups and BMI groups. Conclusion MILIF appears to be safe and effective, independent of age or weight in the treatment of degenerative lumbar disorder. Level of evidence Level II.

Objective This prospective, open-label, multicenter study evaluated the feasibility of spinal cord stimulation (SCS) therapy programming for chronic low back pain that uses multiple electrical pulsed signals (Differential Target Multiplexed). Methods Twenty-five SCS candidates with low back pain equal to or greater than lower limb pain were enrolled at 7 sites in the United States. The subjects evaluated standard and Differential Target Multiplexed programs, each for 4 ± 1 days. A commercially available SCS trial system was used for standard SCS therapy programming. During the trialing of the multiplexed programs, implanted temporary leads were connected to an investigational external trial stimulator system. Results Twenty subjects concluded the study. The mean baseline numeric pain rating scale (NPRS) score for low back pain was 7.4, with a mean age of 62.4 years and mean pain duration of 18.0 years. Significant relief in back pain was observed for both treatments, with significantly better response with multiplexed programming. At the end of the trial period, subjects reported a reduction in their mean NPRS score from baseline to 4.2 after standard programming and to 2.4 after Differential Target Multiplexed programming. The difference between standard and multiplexed programming was significant. The responder rate for low back pain relief was 50% for standard programming and 80% for Differential Target Multiplexed programming. Eighty-five percent of subjects who evaluated both programming approaches preferred Differential Target Multiplexed SCS. Conclusion In this difficult-to-treat patient population, subjects reported significant reduction in chronic back pain when using multiplexed programming. A randomized clinical trial is needed to confirm the results from this feasibility study.

Background High-frequency 10-kHz spinal cord stimulation (10-kHz SCS) has shown promise in multicenter prospective trials for the management of chronic back and leg pain. Traditional spinal cord stimulation (t-SCS) has a long history of effectiveness in chronic neuropathic syndromes but not uncommonly can fail to provide long-term relief, leaving a significant group of patients with unsatisfactory outcomes. There is mounting evidence that 10-kHz SCS may offer relief in this subset of patients. Methods The purpose of this retrospective analysis was to report a single-institution long-term experience of 10-kHz SCS in patients who did not get adequate pain relief with prior t-SCS devices. A temporary trial of 10-kHz SCS was carried out for 7 days, and those experiencing an average of 50% reduction in pain intensity underwent implantation. Patients were classified as moderate responders if relief was 31% to 50% and excellent responders if pain relief exceeded 50%. Results Thirty-one patients who had experienced failed t-SCS primarily from poor paresthesia coverage underwent a trial of 10-kHz SCS and 29 underwent implantation. Twenty-eight patients were available for analysis, with 57.1% experiencing 30% response and 46.4% experiencing excellent response at a median follow-up of 21.2 (±8.4) months. Conclusions This small single-institution study suggests that a significant proportion of patients with previously failed t-SCS may achieve clinically meaningful and durable pain relief with 10-kHz SCS.

Aim: The aim of this case report is to describe ultrasound guidance for caudal epidural steroid injection during pregnancy. Case report: A 29-year-old, 32-week parturient presented with severe back and leg pain with MRI demonstrating herniation of the L5-S1 level. The disabling pain was refractory to conservative therapy, and an ultrasound-guided caudal epidural steroid injection was performed. There was significant pain relief in the first week with an uneventful subsequent pregnancy. Following delivery, the patient had no further recurrence of her presenting symptoms. Conclusion: Severe radiculopathy may be encountered during pregnancy, complicated by a limited number of treatment options. Ultrasound guidance should be considered during performance of caudal epidural injections in feasible cases.

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.

Objective: To evaluate the magnetic resonance (MR) signal intensity changes in the sacrococcygeal region of patients with uterine fibroids treated with high intensity focused ultrasound (HIFU).Materials and Methods: Two hundred and sixty-seven patients with uterine fibroids treated with HIFU between January and December 2016 were retrospectively reviewed. All patients underwent enhanced pre- and post-HIFU MRI. Multivariate analysis was used to assess the relationship between the factors and the signal intensity changes in the sacrum and the soft tissue adjacent to the sacrum.Results: Among the 267 patients, 122 (46%) had MR signal intensity changes in the sacrum and/or the soft tissue adjacent to the sacrum after HIFU. Multivariate analysis showed that the position of the uterus, the distance from the dorsal side of the fibroid to the sacrum, and the ablation efficiency were significantly correlated with MR signal intensity changes in the sacrum and the soft tissue adjacent to the sacrum. Further analysis showed a significant relationship between the location of the MR signal intensity changes and uterine size, the enhancement degree of the uterus. Leg pain was only seen in patients with MR signal intensity changes both in the sacrum and the soft tissue adjacent to the sacrum.Conclusions: The location of the uterus, the distance between the dorsal side of the fibroids to the sacrum, and ablation efficiency have a significant relationship with the MR signal intensity changes. The size of the uterus and the degree of enhancement are related to the locations of MR signal changes.

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.

Introduction/aim:Young patients with Fontan circulation may have low serum 25-hydroxyvitamin D levels, an affected liver, and unhealthy body compositions. This study aimed to explore the association between vitamin D intake/levels, liver biomarkers, and body composition in young Fontan patients.Method:We collected prospective data in 2017 to 2018, obtained with food-frequency questionnaires, biochemical analyses of liver biomarkers, and dual-energy X-ray absorptiometry scans in 44 children with Fontan circulation. Body compositions were compared to matched controls (n = 38). Linear regression analyses were used to investigate associations of biomarkers, leg pain, and lean mass on serum levels of 25-hydroxyvitamin D. Biomarkers were converted to z scores and differences were evaluated within the Fontan patients.Results:Our Fontan patients had a daily mean vitamin D intake of 9.9 µg and a mean serum 25-hydroxyvitamin D of 56 nmol/L. These factors were not associated with fat or lean mass, leg pain, or biomarkers of liver status. The Fontan patients had significantly less lean mass, but higher fat mass than controls. Male adolescents with Fontan circulation had a greater mean abdominal fat mass than male controls and higher cholesterol levels than females with Fontan circulation.Conclusion:Vitamin D intake and serum levels were not associated with body composition or liver biomarkers in the Fontan group, but the Fontan group had lower lean mass and higher fat mass than controls. The more pronounced abdominal fat mass in male adolescents with Fontan circulation might increase metabolic risks later in life.

Background Patients’ perceptions/expectations may be a factor behind medical imaging referral rates. Few studies have investigated the beliefs that might drive expectations of medical imaging. Objectives This study examined whether beliefs of young Australian adults with and without impactful low back pain (LBP) concerning medical scans for LBP align with current evidence. It also investigated if these beliefs were associated with clinical factors (history of impactful LBP, history of previous medical scans, LBP-related disability and the presence of leg pain) or sociodemographic factors (sex, education, income). Design Cross-sectional observational study. Methods 78 participants from the Raine Study with a history of impactful LBP and 85 participants with no history of impactful LBP completed a study-specific questionnaire with five statements concerning beliefs about medical imaging for LBP. All statements were not aligned with current evidence about the use of medical imaging in LBP management. Results Only 15–21% (n = 24–34) of the participants held beliefs that were aligned with current evidence. Participants with a university education had slightly more aligned beliefs compared to those whose highest education was completing secondary school. There was no difference in the beliefs of participants based on their history of impactful LBP, or other clinical or sociodemographic factors. Conclusion As beliefs are likely to drive care-seeking behavior, it is notable that most participants’ views about the role of medical imaging for LBP were not aligned with current evidence. Therefore, this suggests a need for community education, especially for those with lower education.

Background Isolated gastrocnemius tightness has been associated with several foot conditions. We do not know whether gastrocnemius tightness is a normal finding in the developing child or whether tightness is associated with foot symptoms. Recurrent foot and leg pain is common in children, and more knowledge of gastrocnemius tightness is of interest. Methods Passive ankle dorsiflexion was measured with the knee flexed and extended (Silfverskiold test) in 204 Norwegian schoolchildren (408 feet). School classes from 4 different age groups were recruited (5 to 6 years, 8 to 9 years, 11 to 12 years, and 14 to 15 years). Footprints were also recorded in order to assess for any association between foot morphology and dorsiflexion results, specifically, gastrocnemius tightness. Results Ankle dorsiflexion decreased with increasing age. The thresholds for equinus contracture were set at either ≤5° or ≤0° of ankle dorsiflexion when measured with the knee extended, and the Silverskiold test was considered to be positive when ankle dorsiflexion was reduced by ≥10° from the flexed knee position to the extended knee position. The rate of gastrocnemius tightness was 54.9% if the threshold was set at ≤5° and only 3.7% if the threshold was set at ≤0°. The data did not provide evidence of an association between dorsiflexion and footprints. Conclusions Ankle dorsiflexion decreased with increasing age in this population of schoolchildren, highlighting the importance of age-matched norms. A majority had a tight gastrocnemius when the ankle dorsiflexion threshold was set at ≤5°, indicating that isolated gastrocnemius tightness should not be interpreted as a pathological finding. Level of evidence Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Purpose This study aimed to determine whether a fasciectomy for recurrent chronic exertional compartment syndrome of the anterior leg (ant-CECS) after a minimally invasive fasciotomy is safe and beneficial. Methods Demographics and clinical course of patients undergoing a fasciectomy for ongoing exercise-related leg pain (ERLP) after an earlier minimally invasive fasciotomy for ant-CECS were prospectively obtained using questionnaires. Patient-reported severity and frequency of pain, tightness, weakness, cramping, and paresthesia in rest and during exercise were scored before and after surgery. A successful outcome was defined as a self-reported good or excellent result. Results Between January 2013 and March 2019, 24 of the 958 patients evaluated for ERLP were included in the study (15 females; median age, 24 yr; range, 14-37 yr). Intracompartmental pressure values before the minimally invasive fasciotomy and before the fasciectomy were not different. Perioperative findings were fibrotic bands, pseudofascias, or complete fusions of fascial edges. Postoperative superficial wound infections requiring oral antibiotics occurred in four legs. After rehabilitation, the total symptom scores during exercise and resting conditions decreased threefold compared with preoperatively (exercise, 55 ± 5 to 17 ± 3, P < 0.001; rest, 30 ± 4 to 10 ± 2, P < 0.001). All cardinal symptoms decreased significantly, but the largest improvements were reported for pain and tightness. At follow-up (median, 12 months; range, 2-65 months), 79% of patients reported a successful outcome, whereas 75% had returned to physical activity. Conclusion An anterior fasciectomy with associated treatment of correlated pathologies can be safe and beneficial in patients with ongoing ERLP who previously underwent a minimally invasive fasciotomy for ant-CECS.

BACKGROUND Spinal cord stimulation (SCS) is a well-established treatment for chronic intractable pain of the trunk and/or limbs; however, low back pain (LBP) is difficult to treat using traditional SCS. Differential Target Multiplexed spinal cord stimulation (DTM SCS) is an advanced approach inspired from animal studies demonstrating improved pain-related behavior and pain-relevant biological processes. OBJECTIVE The purpose of this study was to compare the effectiveness of DTM SCS and traditional SCS in treating chronic LBP and leg pain (LP). METHODS This prospective, postmarket randomized controlled trial compared DTM SCS to traditional SCS in patients with chronic LBP and LP. Primary end point was LBP responder rate (percentage of subjects with ≥ 50% relief) at 3 months. Noninferiority and superiority were assessed. Other outcomes included mean change in back and leg pain, responder rates, disability, global health, satisfaction, and safety profile throughout the 12-month follow-up. RESULTS One hundred twenty-eight subjects were randomized across 12 centers (67 DTM SCS and 61 traditional SCS). Of the 94 patients implanted, 46 subjects in each group completed the 3-month assessment. LBP responder rate of 80.1% with DTM SCS was superior to 51.2% with traditional SCS (p = 0.0010). Mean LBP reduction (5.36 cm) with DTM SCS was greater than reduction (3.37 cm) with traditional SCS (p

OBJECTIVE: Different approaches in neuromodulation have been used to treat chronic low back pain in failed back surgery syndrome (FBSS) patients. We previously randomized 52 FBSS patients to be treated with spinal cord stimulation (SCS) and additional peripheral nerve field stimulation (PNFS) or SCS alone. At three months, we found a significant reduction of back pain in the PNFS-SCS group compared to the SCS group. In the subsequent open phase part of the study, all patients received optimal SCS and PNFS simultaneously. Here, we present the 12-month follow-up data on back and leg pain.MATERIALS AND METHODS: Data regarding back and leg pain, function, quality of life, patient satisfaction, anxiety and depression, and use of medication were collected by analyzing patients' questionnaires at 12 months and compared with data collected at baseline. Data were analyzed using multilevel regression models.RESULTS: A combined group of 50 subjects completed the 12-month follow-up. Back pain, measured on a 100-mm visual analog scale (VAS), significantly decreased over this period by 30.0 mm (95% CI: [-37.7/-22.4]; p CONCLUSIONS: At 12-month follow-up, PNFS in addition to SCS continues to provide a statistically significant and clinically relevant relief of low back pain in FBSS patients in whom SCS alone is effective for relief of leg pain only.

BACKGROUND: Lumbar disc herniation (LDH) is the most common cause of back and leg pain. We developed a specially designed needle and a minimally invasive interventional procedure to treat LDH. OBJECTIVES: Assess outcomes of procedure and describe our methodology and clinical application. DESIGN: Case series. SETTING: A chronic pain management center. PATIENTS AND METHODS: Patients with LDH underwent fluoroscopically guided interventional interlaminar needling using a specially designed curved round needle. The outcome measures were evaluated three times: before the intervention and at 6 and 12 months after the intervention. MAIN OUTCOME MEASURES: Visual analog scale (VAS) pain score, Oswestry Disability Index (ODI). SAMPLE SIZE: 43 patients. RESULTS: Six months after the intervention, the VAS pain score decreased by 5.1 (2.2) points and the ODI decreased by 30.7% (16.6%) compared to baseline. Twelve months after the intervention, the VAS pain score decreased by 6.2 (1.7) points and the ODI decreased by 36.9% (15.2%) compared to baseline. CONCLUSIONS: This study suggests that fluoroscopically guided interventional interlaminar needling has clinical significance in managing pain resulting from LDH. LIMITATIONS: This was an exploratory case series study. Additional studies and randomized clinical trials are needed to evaluate the efficacy of the technique compared to other treatments. CONFLICT OF INTEREST: None.

A 53-year-old man presented with 2-day history of acute pain, swelling and bluish discoloration of his left lower limb (figure 1). He did not have chest pain, shortness of breath or palpitation. Vital signs were within normal limits and the dorsalis pedis and posterior tibial pulses were palpable. Muscle compartments of the thigh and leg were tense and tender. The thigh and leg pain were exacerbated by knee and ankle motions, respectively. Figure 1 The clinical photo of both lower limbs of the patient. What would …

The purpose of this study was to clarify the clinical impact of sarcopenia on the outcome of minimally invasive lumbar decompression surgery. The records of 130 patients who were >65 years and underwent minimally invasive lumbar decompression surgery were retrospectively reviewed. We collected the Japanese Orthopaedic Association (JOA) score before surgery and at the final follow-up and measured appendicular muscle mass using bioimpedance analysis, hand-grip strength and gait speed. We diagnosed the patients with sarcopenia, dynapenia and normal stages using the European Working Group on Sarcopenia in Older People definition and used cutoff thresholds according to the algorithm set by the Asian Working Group for Sarcopenia. The average age of patients undergoing surgery was 76.9 years old. The JOA score improved from 12.6 points preoperatively to 24.3 points at final follow up. The prevalence of the sarcopenia, dynapenia and normal stages was 20.0, 31.6 and 43.8%. Clinical outcomes, such as JOA score, JOA score improvement ratio, visual analog scale for low back pain, leg pain and numbness, were not significantly different among each group. Multiple regression analysis showed that preoperative JOA score and low physical performance (low gait speed) were independently associated with poor clinical outcomes. The JOA score improved after minimally invasive lumbar decompression surgery even when the patients were diagnosed as being at different stages of sarcopenia. Low physical performance had the greater clinical impact on the clinical outcome of lumbar surgery than low skeletal muscle index.

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.

To measure and compare the total and normalised tibial nerve movements during forward bending in patients with and without failed back surgery syndrome (FBSS) and persistent leg pain following anatomically successful lumbar decompression surgery and demonstrated no psychological stress. Nerve pathomechanics may contribute to FBSS with persistent leg pain following anatomically successful lumbar decompression surgery. Tibial nerve movement during forward bending was measured in two groups of patients following anatomically successful lumbar decompression surgery. FBSS group (N = 37) consisted of patients with persistent leg pain following lumbar surgery, and non-FBSS (N = 37) were patients with no remaining leg pain following lumbar surgery. Total and normalised tibial nerve movement at the popliteal fossa was measured by a previously validated ultrasound imaging technique and compared between the two groups, and also between the painful and non-painful leg within the FBSS group. Both the mean total and normalised tibial nerve movement were significantly decreased in the FBSS group in both legs when compared to the non-FBSS group (P

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.

Objective To examine the results of an anular closure device for prevention of lumbar disc reherniation in daily routine practice. Methods Fifty patients with large anular defects were treated with limited discectomy and a bone‐anchored anular closure device. The device physically occludes the defect in the anulus fibrosus and is intended for prevention of lumbar disc reherniation. Pain scores on a visual analogue scale, back function on the Oswestry Disability Index, and neurological status were noted. Symptomatic reherniation and reoperation rates were assessed at each follow‐up. Surgical findings and complications, device‐related and/or procedure‐related, were recorded. Follow‐up was 6, 12, 26, and 52 weeks. Results Mean anular defect height/width was 4.6 mm/10.1 mm. The overall symptomatic reherniation and reoperation rate was 2%. During the 1‐year follow‐up period, mean back pain decreased from 43 to 8 (P < 0.001), leg pain decreased from 71 to 4 (P < 0.001), and the Oswestry Disability Index decreased from 46 to 5 (P < 0.001). Among 15 patients with preoperative neurological deficits, improvements in neurological function were noted in 14 (93%). There were no serious device‐related complications. Conclusions The presented study shows promising early results in using the anular closure device. The procedure is safe with significantly fewer reherniations than for patients with large anular defects without anular closure. Further studies with longer follow‐up periods are warranted to prove these findings for long‐term outcomes.

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.