Tag: back pain

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Effect of Lumbar Discectomy or Lumbar Decompression on Axial Back Pain: Results of a Meta-Analysis

World Neurosurg. (2023) 177:109-121

This meta-analysis evaluated the impact of lumbar disk herniation and lumbar spinal stenosis (LSS) on axial back pain and the extent of improvement of axial and radicular pain following lumbar decompression and discectomy surgery in patients with low back pain (LBP).

METHODS: A systematic search for published literature between January 2012 and January 2023 was made on PubMed, Google Scholar, and Cochrane library database on 31 st January 2023.

Original articles that included patients with lumbar disc herniation or LSS who underwent lumbar discectomy or lumbar decompression respectively were included in the study.

RESULTS: A total of 71 studies including 16,770 patients with LBP undergoing lumbar discectomy or decompression surgery were included in the metaanalysis. The pooled standard mean difference between postoperative and preoperative: Visual Analog Scale scores for leg pain was L5.14 with 95% confidence interval (CI): L6.59 to L3.69 (P-value [ 0) and for back pain was L2.90 with 95% CI: L3.79 to L2.01 (P value [ 0), Numerical pain Rating Scale for leg pain was L1.64 with 95% CI: L1.97 to L1.30 (P-value<0.01) and for back pain was L1.58 with 95% CI: L1.84 to L1.32 (P-value <0.01), Oswerty Disability Index score was L4.76 with 95% CI: L6.22 to L3.29 (P-value [ 0) and the Japanese Orthopaedic Association score was 3.45 with 95% CI: 0.02 to 6.88 (P value 0) at follow-up.

CONCLUSIONS: This meta-analysis provides evidence that lumbar discectomy and decompression are effective in improving axial LBP in patients with lumbar disk herniation and LSS.

 

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Influence of Time of Discharge and Length of Stay on 30-Day Outcomes After Elective Anterior Cervical Spine Surgery

Neurosurgery 90:734–742, 2022

Encouraging early time of discharge (TOD) for medical inpatients is commonplace and may potentially improve patient throughput. It is unclear, however, whether early TOD after elective spine surgery achieves this goal without a consequent increase in re-presentations to the hospital.

OBJECTIVE: To evaluate whether early TOD results in increased rates of hospital read- mission or return to the emergency department after elective anterior cervical spine surgery.

METHODS: We analyzed 686 patients who underwent elective uncomplicated anterior cervical spine surgery at a single institution. Logistic regression was used to evaluate the relationship between sociodemographic, procedural, and discharge characteristics, and the outcomes of readmission or return to the emergency department and TOD.

RESULTS: In multiple logistic regression, TOD was not associated with increased risk of readmission or return to the emergency department within 30 days of surgery. Weekend discharge (odds ratio [OR] 0.33, 95% CI 0.21-0.53), physical therapy evaluation (OR 0.44, 95% CI 0.28-0.71), and occupational therapy evaluation (OR 0.32, 95% CI 0.17-0.63) were all significantly associated with decreased odds of discharge before noon. Disadvantaged status, as measured by area of deprivation index, was associated with increased odds of readmission or re-presentation (OR 1.86, 95% CI 0.95-3.66), although this result did not achieve statistical significance.

CONCLUSION: There does not appear to be an association between readmission or return to the emergency department and early TOD after elective spine surgery. Overuse of inpatient physical and occupational therapy consultations may contribute to decreased patient throughput in surgical admissions.

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Outcomes following discectomy for lumbar disc herniation in patients with substantial back pain

J Neurosurg Spine 33:623–626, 2020

Patients 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.

METHODS The 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.

RESULTS A 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.

CONCLUSIONS Patients 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.

 

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Stem cell injections for axial back pain: a systematic review of associated risks and complications with a case illustration of diffuse hyperplastic gliosis resulting in cauda equina syndrome

J Neurosurg Spine 31:906–913, 2019

Axial low-back pain is a disease of epidemic proportions that exerts a heavy global toll on the active workforce and results in more than half a trillion dollars in annual costs. Stem cell injections are being increasingly advertised as a restorative solution for various degenerative diseases and are becoming more affordable and attainable by the public. There have been multiple reports in the media of these injections being easily available abroad outside of clinical trials, but scientific evidence supporting them remains scarce. The authors present a case of a serious complication after a stem cell injection for back pain and provide a systematic review of the literature of the efficacy of this treatment as well as the associated risks and complications.

METHODS A systematic review of the literature was performed using the PubMed, Google Scholar, and Scopus online electronic databases to identify articles reporting stem cell injections for axial back pain in accordance with the PRISMA guidelines. The primary focus was on outcomes and complications. A case of glial hyperplasia of the roots of the cauda equina directly related to stem cell injections performed abroad is also reported.

RESULTS The authors identified 14 publications (including a total of 147 patients) that met the search criteria. Three of the articles presented data for the same patient population with different durations of follow-up and were thus analyzed as a single study, reducing the total number of studies to 12. In these 12 studies, follow-up periods ranged from 6 months to 6 years, with 50% having a follow-up period of 1 year or less. Most studies reported favorable outcomes, although 36% used subjective measures. There was a tendency for pain relief to wane after 6 months to 2 years, with patients seeking a surgical solution. Only 1 study was a randomized controlled trial (RCT).

CONCLUSIONS There are still insufficient data to support stem cell injections for back pain. Additional RCTs with longterm follow-up are necessary before statements can be made regarding the efficacy and safety.

 

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Back pain improvement after decompression without fusion or stabilization in patients with lumbar spinal stenosis and clinically significant preoperative back pain

lumbar stenosis

J Neurosurg Spine 25:596–601, 2016

The relief of leg symptoms by surgical decompression for lumbar stenosis is well supported by the literature. Less is known about the effect on back pain. Some surgeons believe that the relief of back pain should not be an expected outcome of decompression and that substantial back pain may be a contraindication to decompression only; therefore, stabilization may be recommended for patients with substantial preoperative back pain even in the absence of well-accepted indications for stabilization such as spondylolisthesis, scoliosis, or sagittal malalignment. The purpose of this study is to determine if patients with lumbar stenosis and substantial back pain—in the absence of spondylolisthesis, scoliosis, or sagittal malalignment—can obtain significant improvement after decompression without fusion or stabilization.

Methods Analysis of the National Neurosurgery Quality and Outcomes Database (N2QOD) identified 726 patients with lumbar stenosis (without spondylolisthesis or scoliosis) and a baseline back pain score ≥ 5 of 10 who underwent surgical decompression only. No patient was reported to have significant spondylolisthesis, scoliosis, or sagittal malalignment. Standard demographic and surgical variables were collected, as well as patient outcomes including back and leg pain scores, Oswestry Disability Index (ODI), and EuroQoL 5D (EQ-5D) at baseline and 3 and 12 months postoperatively.

Results The mean age of the cohort was 65.6 years, and 407 (56%) patients were male. The mean body mass index was 30.2 kg/m2, and 40% of patients had 2-level decompression, 29% had 3-level decompression, 24% had 1-level decompression, and 6% had 4-level decompression. The mean estimated blood loss was 130 ml. The mean operative time was 100.85 minutes. The vast majority of discharges (88%) were routine home discharges. At 3 and 12 months postoperatively, there were significant improvements from baseline for back pain (7.62 to 3.19 to 3.66), leg pain (7.23 to 2.85 to 3.07), EQ-5D (0.55 to 0.76 to 0.75), and ODI (49.11 to 27.20 to 26.38).

Conclusions Through the 1st postoperative year, patients with lumbar stenosis—without spondylolisthesis, scoliosis, or sagittal malalignment—and clinically significant back pain improved after decompression-only surgery.

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Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain

spinal-cord-stimulation-for-the-treatment-of-chronic-back-and-leg-pain

Neurosurgery 79:667–677, 201

Pain relief with spinal cord stimulation (SCS) has focused historically on paresthesias overlapping chronically painful areas. A higher level evidence supports the use of SCS in treating leg pain than supports back pain, as it is difficult to achieve adequate paresthesia coverage, and then pain relief, in the low back region. In comparison, 10-kHz high-frequency (HF10 therapy) SCS therapy does not rely on intraoperative paresthesia mapping and remains paresthesia-free during therapy. OBJECTIVE: To compare long-term results of HF10 therapy and traditional lowfrequency SCS.

METHODS: A pragmatic randomized, controlled, pivotal trial with 24-month follow-up was conducted across 11 comprehensive pain treatment centers. Subjects had Visual Analog Scale scores of$5.0/10.0 cmfor both back and leg pain, and were assigned randomly (1:1) to receive HF10 therapy or low-frequency SCS. The primary end point was a responder rate, defined as $50% back pain reduction from baseline at 3 months with a secondary end point at 12 months (previously reported). In this article, 24-month secondary results are presented. Non-inferiority was first assessed, and if demonstrated the results were tested for superiority.

RESULTS: In the study, 198 subjects were randomized (101 HF10 therapy, 97 traditional SCS). One hundred seventy-one subjects (90 HF10 therapy, 81 traditional SCS) successfully completed a short-term trial and were implanted. Subjects averaged 54.96 12.9 years old, 13.6 6 11.3 years since diagnosis, 86.6% had back surgery, 88.3% were taking opioid analgesics. At 3 months, 84.5% of implanted HF10 therapy subjects were responders for back pain and 83.1% for leg pain, and 43.8% of traditional SCS subjects were responders for back pain and 55.5% for leg pain (P , .001 for both back and leg pain comparisons, noninferiority and superiority). At 24 months, more subjects were responders to HF10 therapy than traditional SCS (back pain: 76.5% vs 49.3%; 27.2% difference, 95% CI, 10.1%-41.8%; P, .001 for non-inferiority and superiority; leg pain: 72.9% vs 49.3%; 23.6% difference, 95% CI, 5.9%-38.6%; P , .001 for non-inferiority and P = .003 for superiority). Also at 24 months, back pain decreased to a greater degree with HF10 therapy (66.9% 6 31.8%) than traditional SCS (41.1% 6 36.8%, P , .001 for non-inferiority and superiority). Leg pain also decreased to a greater degree with HF10 therapy (65.1% 6 36.0%) than traditional SCS (46.0% 6 40.4%, P , .001 for non-inferiority and P = .002 for superiority).

CONCLUSION: This study demonstrates long-term superiority of HF10 therapy compared with traditional SCS in treating both back and leg pain. The advantages of HF10 therapy are anticipated to impact the management of chronic pain patients substantially.

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Lumbar Total Disc Replacement for Discogenic Low Back Pain

Lumbar Total Disc Replacement for Discogenic Low Back Pain

Spine 2015;40:1873–1881

A prospective, multicenter, randomized, controlled, investigational device exemption (IDE) noninferiority trial.

Objective. The aim of this study was to evaluate the comparative safety and effectiveness of lumbar total disc replacement (TDR) in the treatment of patients with symptomatic degenerative disc disease (DDD) who are unresponsive to nonsurgical therapy.

Summary of Background Data. Lumbar TDR has been used to alleviate discogenic pain and dysfunction while preserving segmental range of motion and restoring stability. There is a paucity of data available regarding the comparative performance of lumbar TDR.

Methods. Patients presenting with symptomatic single-level lumbar DDD who failed at least 6 months of nonsurgical management were randomly allocated (2:1) to treatment with an investigational TDR device (activL1, n=218) or FDA-approved control TDR devices (ProDisc-L or Charité, n=106). The hypothesis of this study was that a composite effectiveness outcome at 2 years in patients treated with activL would be noninferior (15% delta) to that in controls.

Results. The primary composite endpoint of this study was met, which demonstrated that the activL TDR was noninferior to control TDR (P<0.001). A protocol-defined analysis of the primary composite endpoint also confirmed that activL was superior to controls (P=0.02). Radiographic success was higher with activL versus controls (59% vs. 43%; P<0.01). Mean back pain severity improved by 74% with activL and 68% with controls. Oswestry Disability Index scores decreased by 67% and 61% with activL and controls, respectively. Patient satisfaction with treatment was over 90% in both groups at 2 years. Return to work was approximately 1 month shorter (P=0.08) with activL versus controls. The rate of device-related serious adverse events was lower in patients treated with activL versus controls (12% vs. 19%; P=0.13). Surgical reintervention rates at the index level were comparable (activL 2.3%, control 1.9%).

Conclusion. The single-level activL TDR is safe and effective for the treatment of symptomatic lumbar DDD through 2 years.

Level of Evidence: 2

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Schmorl’s nodes: current pathophysiological, diagnostic, and therapeutic paradigms

Schmorl's nodes

Neurosurg Rev (2014) 37:39–46

Schmorl’s nodes were first described by the pathologist Christian Schmorl in 1927 as a herniation of the nucleus pulposus through the cartilaginous and bony endplate into the vertebral body. Although such lesions present most commonly as incidental findings in asymptomatic patients (or in patients with back or radicular pain due to other etiology), there have been several reports emphasizing the deleterious effects of the inflammatory response and endplate changes elicited by the herniation of for such reasons, Schmorl’s nodes have been occasionally implicated in the etiology of chronic axial pain as well as in pathological osteoporotic fractures.

In this article, a thorough literature review about the most relevant historical studies on Schmorl’s nodes previously published is performed. Furthermore, the authors provide an overview about the recent advances in basic science research on the pathophysiology of such lesions, as well as on current diagnostic and therapeutic paradigms.

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Oxiplex Reduces Leg Pain, Back Pain, and Associated Symptoms After Lumbar Discectomy

SPINE Volume 37, Number 8, pp 631–641

Study Design. Prospective, randomized, blinded clinical trial.

Objective. To evaluate effectiveness of Oxiplex gel for reduction of pain and associated symptoms after lumbar discectomy.

Summary of Background Data. Oxiplex gel (carboxymethylcellulose, polyethylene oxide, and calcium) is used during discectomy to coat the surgical site for reduction of pain and symptoms after lumbar discectomy.

Methods. Patients undergoing single-level lumbar discectomy performed by laminectomy or laminotomy and randomized to receive either surgery plus Oxiplex gel (treatment group) or surgery alone (control group) were assessed 6 months after surgery using (1) a quality of life questionnaire (Lumbar Spine Outcomes Questionnaire [LSOQ]) and (2) clinical evaluations.

Results. There were no statistically significant differences in baseline demographics, surgical procedures, LSOQ scores, and clinical evaluations between treatment (N = 177) and control (N = 175) groups. More gel-treated patients were satisfied with outcome of their surgical treatment than control patients ( P = 0.05). The geltreated group showed greater reductions in pain and symptoms from baseline compared with surgery-only controls. Additional benefits of gel were consistently shown in reduction of leg and back pain at 6 months in the patient population having substantial back  pain at baseline (greater than or equal to the median LSOQ pain score of 63). In that population, there was a statistically signifi cant reduction of leg pain and back pain ( P < 0.01) in the treatment group compared with controls. Fewer patients in the treatment group had abnormal musculoskeletal physical examinations at 6 months compared with controls. There were no cases of cerebrospinal fluid leaks and no differences in laboratory values or vital signs. Patients in the treatment group had less hypoesthesia, paraesthesia, sensory loss, and fewer reoperations during the 6-month follow-up than controls (1 vs . 6).

Conclusion. These data demonstrate improvements in clinical  outcomes resulting from the use of Oxiplex gel in discectomy procedures for treatment of lumbar disc herniation.

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Microdiscectomy Improves Pain-Associated Depression, Somatic Anxiety, and Mental Well- Being in Patients With Herniated Lumbar Disc

Neurosurgery 70:306–311, 2012 DOI: 10.1227/NEU.0b013e3182302ec3

Emotional distress and depression are common psychological disturbances associated with low-back and leg pain. The effects of lumbar discectomy on pain, disability, and physical quality of life are well described. The effects of discectomy on emotional distress and mental well-being are less well understood.

OBJECTIVE: To assess the effect of microdiscectomy on depression, somatization, and mental well-being in patients with herniated lumbar discs.

METHODS: Patients undergoing surgical discectomy for single-level, herniated lumbar disc were prospectively evaluated preoperatively, and at 6 weeks and 3, 6, and 12 months postoperatively. Back and leg pain, depression, somatic perception, and mental well-being were assessed.

RESULTS: One hundred patients were enrolled. All were available for 1-year follow-up. Preoperatively, the visual analog scale for low-back pain (BP-VAS), visual analog scale for leg pain (LP-VAS), Zung Self-Rating Depression Scale (ZUNG), Modified Somatic Perception Questionnaire (MSPQ), and Medical Outcomes Short Form-36 mental component summary scale (SF-36-MCS) were 6.3 6 2.5, 6.3 6 2.5, 19 6 11, 9 6 7, and 4 6 14. BP-VAS and LP-VAS significantly improved by 6 weeks. Significant improvement in SF-36-MCS was observed by 6 weeks postoperatively, improvement in MSPQ score was observed 3 months postoperatively, and improvement in the ZUNG depression score was observed 12 months postoperatively. No statistical difference occurred during the remainder of follow-up for any outcome measured once improvement reached statistical significance. Eighteen patients were somatized preoperatively, 67% of which were nonsomatized 1 year postoperatively. Ten patients were clinically depressed preoperatively, 70% of which were nondepressed 1 year postoperatively. Improvement in SF-36-MCS, ZUNG, and MSPQ correlated (P , .001) with improvement in BP-VAS and LP-VAS.

CONCLUSION: The majority of patients somatized or depressed preoperatively returned to good mental well-being postoperatively. Improvement in pain and overall mental wellbeing was seen immediately after discectomy. Improvement in somatic anxiety and depression occurred months later. Microdiscectomy significantly improves pain-associated depression, somatic anxiety, and mental well-being in patients with herniated lumbar disc.

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Long-term back pain after a single-level discectomy for radiculopathy: incidence and health care cost analysis

J Neurosurg Spine 12:178–182, 2010.(DOI: 10.3171/2009.9.SPINE09410)

Object. The most common spinal procedure performed in the US is lumbar discectomy for disc herniation. Long- term disc degeneration and height loss occur in many patients after lumbar discectomy. The incidence of mechanical back pain following discectomy varies widely in the literature, and its associated health care costs are unknown. The authors set out to determine the incidence of and the health care costs associated with mechanical back pain attributed to segmental degeneration or instability at the level of a prior discectomy performed at their institution.

Methods. The authors retrospectively reviewed the data for 111 patients who underwent primary, single-level lumbar hemilaminotomy and discectomy for radiculopathy. All diagnostic modalities, conservative therapies, and operative treatments used for the management of postdiscectomy back pain were recorded. Institutional billing and accounting records were reviewed to determine the billed costs of all diagnostic and therapeutic measures.

Results. At a mean follow-up of 37.3 months after primary discectomy, 75 patients (68%) experienced minimal to no back pain, 26 (23%) had moderate back pain requiring conservative treatment only, and 10 (9%) suffered severe back pain that required a subsequent fusion surgery at the site of the primary discectomy. The mean cost per patient for conservative treatment alone was $4696. The mean cost per patient for operative treatment was $42,554. The esti- mated cost of treatment for mechanical back pain associated with postoperative same-level degeneration or instability was $493,383 per 100 cases of first-time, single-level lumbar discectomy ($4934 per primary discectomy).

Conclusions. Postoperative mechanical back pain associated with same-level degeneration is not uncommon in patients undergoing single-level lumbar discectomy and is associated with substantial health care costs.

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