Response to Preoperative Steroid Injections Predicts Surgical Outcomes in Patients Undergoing Fusion for Isthmic Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The decision to pursue operative intervention for patients with isthmic spondylolisthesis is complex. Although steroid injections are a well-accepted therapeutic modality that may delay or obviate surgery, little is known regarding their ability to predict surgical outcomes. SUMMARY OF BACKGROUND DATA: Here, we examine whether improvement after preoperative steroid injections can accurately predict clinical outcomes after surgery. METHODS: A retrospective cohort analysis was performed on adult patients undergoing primary posterolateral lumbar fusion for isthmic spondylolisthesis between 2013 and 2021. Data were stratified into a control (no preoperative injection) group and an injection group (received a preoperative diagnostic and therapeutic injection). We collected demographic data, peri-injection visual analog pain scores (VAS) pain scores, PROMIS pain interference and physical function scores, Oswestry Disability Index, and VAS pain (back and leg). Student t test was utilized to compare baseline group characteristics. Linear regression was performed comparing changes in peri-injection VAS pain scores and postoperative measures. RESULTS: Seventy-three patients did not receive a preoperative injection and were included in the control group. Fifty-nine patients were included in the injection group. Of patients who received an injection, 73% had >50% relief of their preinjection VAS pain score. Linear regression revealed a positive interaction between the injection efficacy and postoperative pain relief as measured by VAS leg scores ( P <0.05). There was also an association between injection efficacy and back pain relief, though this did not achieve statistical significance ( P =0.068). No association was found between injection efficacy and improvement in Oswestry Disability Index or PROMIS measures. CONCLUSIONS: Steroid injections are often utilized in the nonoperative therapeutic management of patients with lumbar spine disease. Here, we demonstrate the diagnostic value of steroid injections in predicting postoperative leg pain relief in patients undergoing posterolateral fusion for isthmic spondylolisthesis.

Jitteriness/anxiety syndrome caused by coadministration of celecoxib, a selective COX-2 inhibitor, with escitalopram and trazodone in a patient with depression and spondylolisthesis.

Antidepressant-induced jitteriness/anxiety syndrome is characterized as anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, and (hypo)mania, which appear immediately after initiation or increased dosage of an antidepressant. This report describes a case of the jitteriness/anxiety syndrome caused by the coadministration of celecoxib with escitalopram and trazodone in a patient with depression and spondylolisthesis. The depression of a patient, a woman in her 60 s, had been in remission at least for 5 years under treatment using escitalopram and trazodone. Immediately after coadministration of celecoxib because of her buttock and limb pain, she showed anxiety, agitation, akathisia, insomnia, irritability, aggressiveness, impulsivity, and hypomania. These symptoms disappeared after the discontinuation of celecoxib. The present case suggests that coadministration of celecoxib with escitalopram and trazodone can cause the jitteriness/anxiety syndrome, presumably via a pharmacokinetic interaction of celecoxib with these antidepressants and/or the effects of celecoxib on serotonergic neurotransmission.

Sex Differences in Opioid Use in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis Undergoing Lumbar Decompression and Fusion.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To investigate sex differences in opioid use after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis. SUMMARY OF BACKGROUND DATA: Recent studies have demonstrated higher prevalence of chronic pain states and greater pain sensitivity among women compared with men. Furthermore, differences in responsivity to pharmacological and non-pharmacological treatments have been observed. Whether sex differences in perioperative opioid use exists in patients undergoing lumbar fusion for symptomatic stenosis or spondylolisthesis remains unknown. METHODS: An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1,2, or 3-level index lumbar decompression and fusion procedures between 2007 and 2016. Records were searchable by International Classification of diseases diagnosis and procedure codes, and generic drug codes specific to Humana. Opioid use 6-months prior to through 2-years after index surgery was assessed. The primary outcome was sex differences in opioid use after index lumbar surgery. The secondary outcome was independent predictors of prolonged opioid use after lumbar fusion. RESULTS: Of the 13,257 participants (females: 7871, 59.8%), 58.4% of women used opioids compared with 56.9% of men prior to index surgery. At 1-year after surgery, continuous opioid use was observed in 67.1% of women compared with 64.2% of men (P < 0.001). Within 2-years postoperatively, opioid use was observed in 83.1% of women versus 82.5% men. In a multivariate logistic regression analysis, female sex (odds ration [OR] 1.14, 95% confidence interval [CI]: 1.058-1.237), obesity (OR 1.10, 95% CI: 1.004-1.212), and preoperative narcotic use (OR 3.43, 95% CI: 3.179-3.708) was independently associated with prolonged (>1 yr) opioid use after index surgery. CONCLUSION: We observed a higher prevalence of chronic opioid use among women following lumbar fusion surgery. Female sex was independently associated with prolonged opioid use after index surgery. LEVEL OF EVIDENCE: 3.

Comprehensive non-surgical treatment decreased the need for spine surgery in patients with spondylolisthesis: Three-year results.

BACKGROUND: Non-surgical treatment is the primary approach to degenerative conditions of the lumbar spine and may involve multiple modalities. There is little literature to guide an evidence-based approach to care. OBJECTIVE: To determine the effectiveness of CNT (comprehensive non-surgical treatment) in patients with degenerative spondylolisthesis (DS) and spondylolytic spondylolisthesis (SS), and to identify predictor variables for success of CNT in avoiding surgery. METHODS: All patients who underwent CNT for spondylolisthesis (n: 203) were included. CNT consisted of patient education, pain control with transforaminal epidural steroid injections (TFEs) and/or medications, and exercise programs. RESULTS: Surgical and non-surgical patients were similar in age, smoking status, comorbidity scores, facet joint widening, and translation of spondylolisthesis. After CNT, only 21.6% of patients with DS and 31.3% of patients with SS chose to have surgery in 3-years follow-up. The non-surgical group reported significantly better pain relief (73.6% vs 55%) after TFEs for a longer period (152.8 vs 45.6 days) and lower opioid use than the surgical group (28.2% vs 55.3%). CONCLUSIONS: CNT is effective in spondylolisthesis and more successful in DS than SS. CNT may decrease the need for surgery, particularly in patients who report pain relief greater than 70% for average five months after TFEs.

False localizing sign caused by schwannoma in cervical spinal canal at C1-2 level: A case report.

RATIONALE: False localizing sign means that the lesion, which is the cause of the symptom, is remote or distant from the anatomical site predicted by neurological examination. This concept contradicts the classical clinicoanatomical correlation paradigm underlying neurological examinations. PATIENT CONCERNS: A 54-year-old man consulted for the right sciatica-like leg pain that had aggravated 1 year ago. Radiological examinations revealed degenerative spondylolisthesis with instability and right-sided recess stenosis at the L4-5 level. After initial improvement following 3 transforaminal epidural steroid injections with gabapentin and antidepressant medication, there was a recurrence of the symptoms a year later, along with wasting of the right leg for several months. Physical examination revealed difficulty in heel-walking and a weakness of extension of the right big toe; tendon reflexes were normal. Lumbar spine radiographs revealed no new findings. The initial course of treatment was repeated, but was ineffective. DIAGNOSES: Further cervicothoracic spine evaluations revealed a right-sided intradural-extramedullary mass and myelopathy at the C1-2 level. INTERVENTIONS: The cervical mass was surgically resected and identified histopathologically as a schwannoma. OUTCOMES: Immediately after surgery, sciatica-like pain and weakness of right leg were completely resolved. LESSONS: It is difficult to make an accurate diagnosis if there are symptoms caused by false localizing sign. Additionally, it is even more difficult to diagnose false localizing sign accurately when there is a co-existing lumbar lesion that can cause the similar symptoms.

The effectiveness and safety of nonsurgical integrative interventions for symptomatic lumbar spinal spondylolisthesis: A randomized controlled multinational, multicenter trial protocol.

BACKGROUND: Surgery is generally accepted as the main therapeutic option for symptomatic lumbar spondylolisthesis. However, new nonsurgical therapeutic options need to be explored for this population. OBJECTIVES: The objective of this study is to assess the effectiveness and safety of a 5-week Mokhuri treatment program compared with conventional nonsurgical treatments for symptomatic lumbar spondylolisthesis. METHODS: This is a study protocol for a multinational, multicenter clinical randomized controlled trial comparing the effectiveness and safety of 5 weeks of nonsurgical integrative treatments (a Mokhuri treatment program consisting of Chuna, acupuncture, and patient education) with nonsurgical conventional treatments (drugs for pain relief, epidural steroid injections, and physical therapy). Clinical outcomes including visual analogue scale (VAS) scores ranging from 0 to 100 for low back pain and leg pain, EQ-5D scores, Oswestry disability index (ODI) scores, Roland-Morris Disability Questionnaire (RMDQ) scores, Zurich Claudication Questionnaire (ZCQ) scores, walking duration and distance without leg pain, and a 5-minute treadmill test, and the ratio between the actual duration of participation and the originally scheduled duration in each group, the presence of any additional spondylolisthesis treatments, the types of concomitant treatments during the follow-up period, and adverse events (AEs) will be assessed at 7 weeks, 18 weeks, 30 weeks, 54 weeks, and 102 weeks after the end of the treatments. CONCLUSION AND DISCUSSION: The results of this study will provide clinical evidence on nonsurgical integrative interventions for patients with symptomatic lumbar spondylolisthesis. CLINICAL TRIAL REGISTRY:: clinicaltrials.gov (NCT03107468).

The effect of transforaminal epidural steroid injections in patients with spondylolisthesis.

BACKGROUND: Transforaminal epidural steroid injection (TFE) is a widely accepted non-surgical treatment for pain in patients with spondylolisthesis. However, the effectiveness of TFE has not been compared in patients with degenerative (DS) and isthmic spondylolisthesis (IS). OBJECTIVE: To compare the effectiveness of bilateral TFEs in DS and IS. METHODS: Patients who underwent bilateral TFEs for spondylolisthesis at University of California San Francisco Orthopaedic Institute from 2009 to 2014 were evaluated retrospectively. RESULTS: DS patients (120 female, 51 male) were significantly older and had higher comorbidity than those with IS (18 female, 14 male). They had better pain relief after TFE than patients with IS (72.11 ± 27.46% vs 54.39 ± 34.31%; p = 0.009). The number of TFEs, the mean duration of pain relief after TFE, follow-up periods, translation and facet joint widening were similar in DS and IS groups (p > 0.05). DS group had higher successful treatment rate (66.1% vs 46.9%, p = 0.009) and longer duration of pain relief (181.29 ± 241.37 vs 140.07 ± 183.62 days, p = 0.065) compared to IS group. CONCLUSIONS: Bilateral TFEs at the level of spondylolisthesis effectively decreased pain in patients. TFEs provided better pain relief for longer duration in patients with DS than for those with IS.

Outcomes of autograft alone versus PEEK+ autograft interbody fusion in the treatment of adult lumbar isthmic spondylolisthesis.

OBJECTIVES: Bone resulting from a complete resection of the posterior arch can be cut into an autograft bone that contains the facet joint structure and morselised bone for interbody fusion. However, whether a strut autograft that contains this trimmed facet joint can produce the same clinical and radiographic outcomes as a cage for interbody fusion remains unclear. The aim of this study was to compare the outcomes of a local facet joint autograft alone to those of polyetheretherketone (PEEK)+autograft for posterior lumbar interbody fusion (PLIF) in the treatment of adult isthmic spondylolisthesis. PATIENTS AND METHODS: A retrospective analysis was performed on 84 patients with single lumbar isthmic spondylolisthesis who were treated with a local facet joint autograft alone (group A; n=44) or PEEK+autograft (group B; n=40) in PLIF with a minimum follow-up period of 24 months. Pain and disability were assessed using the visual analogue scale, Oswestry disability index and Kirkaldy-Willis criteria. In the radiological evaluation, disc height, slippage reduction, and fusion status were examined. Postoperative complications were also monitored. RESULTS: At the last follow-up examination, 84.1% (37/44) of the patients in group A and 82.5% (33/40) of the patients in group B had a good outcome, and there were no significant differences between the two groups. Boh Methods led to significant improvements in disc height, and while PEEK+autograft produced a smaller loss in disc height, the difference was insignificant. The improvements in slippage and the fusion and complication rates between the two groups were similar. CONCLUSION: There were no significant differences in the clinical outcomes or radiographic improvements of both fusion methods in the treatment of adult isthmic spondylolisthesis. An autograft excised from a complete posterior arch containing a facet joint for interbody fusion is effective and affordable for treating isthmic spondylolisthesis.

Predictive Factors for Subjective Improvement in Lumbar Spinal Stenosis Patients with Nonsurgical Treatment: A 3-Year Prospective Cohort Study.

OBJECTIVE: To assess the predictive factors for subjective improvement with nonsurgical treatment in consecutive patients with lumbar spinal stenosis (LSS). MATERIALS AND METHODS: Patients with LSS were enrolled from 17 medical centres in Japan. We followed up 274 patients (151 men; mean age, 71 ± 7.4 years) for 3 years. A multivariable logistic regression model was used to assess the predictive factors for subjective symptom improvement with nonsurgical treatment. RESULTS: In 30% of patients, conservative treatment led to a subjective improvement in the symptoms; in 70% of patients, the symptoms remained unchanged, worsened, or required surgical treatment. The multivariable analysis of predictive factors for subjective improvement with nonsurgical treatment showed that the absence of cauda equina symptoms (only radicular symptoms) had an odds ratio (OR) of 3.31 (95% confidence interval [CI]: 1.50-7.31); absence of degenerative spondylolisthesis/scoliosis had an OR of 2.53 (95% CI: 1.13-5.65); <1-year duration of illness had an OR of 3.81 (95% CI: 1.46-9.98); and hypertension had an OR of 2.09 (95% CI: 0.92-4.78). CONCLUSIONS: The predictive factors for subjective symptom improvement with nonsurgical treatment in LSS patients were the presence of only radicular symptoms, absence of degenerative spondylolisthesis/scoliosis, and an illness duration of <1 year.

What types of degenerative lumbar pathologies respond to nerve root injection? A retrospective review of six hundred and forty one cases.

PURPOSE: Peri-radicular injection is a widely used procedure for treating lumbar radicular pain, but it remains unclear what types of lumbar pathologies respond well to this treatment. We aimed to investigate the efficacy of peri-radicular injection for degenerative lumbar disorders and to determine what types of pathologies respond well to this treatment. METHODS: We reviewed the records of 641 consecutive patients who underwent peri-radicular injection for degenerative lumbar pathologies with mean follow-up of 23.4 months. The pathologies included herniated disc in 286 patients, spinal stenosis in 141, degenerative spondylolisthesis in 136, failed back surgery in 24, isthmic spondylolisthesis in 22, degenerative scoliosis in 18, and foraminal stenosis in 14. Outcome measure was whether or not surgery is avoided by using peri-radicular injection. The rate of obviating surgery was determined in each pathology. RESULTS: Peri-radicular injection obviated surgeries in 331 patients (51.7%). There were no complications related to the procedure, including neurological deterioration, infection, and haematoma. The rate of obviating surgery was 42.0% in disc herniation, 52.9% in degenerative spondylolisthesis, 67.4% in spinal stenosis, 54.5% in isthmic spondylolisthesis, 57.1% in foraminal stenosis, 61.1% in degenerative scoliosis and 54.1% in failed back surgery. Poor outcomes were observed in herniated disc with spinal stenosis (17.9% success), foraminal disc herniation (33.3%), recurrent disc herniation (18.2%) and failed back surgery with instability (33.3%). CONCLUSIONS: This study demonstrated that 51.7% of patients with degenerative lumbar pathologies were successfully treated by peri-radicular injection. Efficacy was limited in cases of herniated disc with spinal stenosis, foraminal disc herniation, recurrent disc herniation and failed back surgery with instability.

Whole cerebrospinal axis infection after lumbar epidural injection: a case report.

PURPOSE: Lumbar epidural injection is a popular treatment for degenerative lumbar disease. Although post-procedural epidural infection is rare, meningitis and epidural abscess are life-threatening conditions, and need additional medical and surgical intervention. The purpose of this article is to report a patient with fatal whole cerebrospinal axis infection after lumbar epidural injections. METHODS: A 64-year-old female patient presented with septic shock and quadriparesis. In the past, this patient had received lumbar epidural injections several times for degenerative spondylolisthesis at L4-5 in another hospital. The magnetic resonance imaging showed epidural abscess, a compressed dura and spinal cord from C1 to S2, and cerebral meningitis. We performed laminectomies and removal of the abscesses. Her mental status was diminished to a deep, drowsy state after three postoperative weeks. Brain computed tomography scans revealed hydrocephalus. Therefore, ventriculoperitoneal shunting was performed. RESULTS: Methicillin resistant Staphylococcus epidermidis was cultured from blood samples. The patient's infection was completely controlled and her mental status improved to alert; however, her quadriparesis remained. CONCLUSIONS: Although lumbar epidural injection is an effective procedure to treat lumbar radicular pain, this procedure can induce fatal complications such as sepsis and epidural abscess. LEVEL OF EVIDENCE: 5.

Zoledronic acid infusion for lumbar interbody fusion in osteoporosis.

BACKGROUND: Clinical outcomes of intravenous (IV) infusion of zoledronic acid (ZOL) for lumbar interbody fusion surgery (LIFS) remain unknown. We investigated the efficacy of IV ZOL on clinical outcome and bone fusion after LIFS. MATERIALS AND METHODS: We retrospectively analyzed 64 patients with both degenerative lumbar spondylolisthesis and osteoporosis who underwent LIFS from January 2007 to April 2010. All patients were followed up for 2 y. Thirty-two were treated with an IV infusion of ZOL 3 d after surgery and a second injection 1 y later, and the other 32 patients did not receive ZOL. Preoperatively and every 3 mo postoperatively, oswestry disability index questionnaire and visual analog scale (VAS) scores for back and leg were compared. Preoperative and final postoperative follow-up to evaluate for subsequent compression fractures were also performed. Pedicle screw loosening, cage subsidence, and fusion rate were documented 2 y after surgery. RESULTS: At 2-y follow-up, a solid fusion was achieved in 75% of the ZOL group and only 56% of the control group. At final follow up, the incidence of final subsequent vertebral compression fractures (19% of the ZOL group and 51% of the control group, P = 0.006), pedicle screw loosening (18% of the ZOL group and 45% of the control group, P = 0.03), and cage subsidence >2 mm (28% of the ZOL group and only 54% of the control group, P = 0.04) were significantly lower in the ZOL group than in the control group. The ZOL group demonstrated improvement in VAS (for leg pain VAS, 2/10 for the ZOL group and 5/10 for the control group; for back pain VAS, 2/10 for the ZOL group and 6/10 for the control group) and oswestry disability index scores (7/25 for the ZOL group and 16/25 for the control group). CONCLUSIONS: ZOL treatment has beneficial effects on instrumented LIFS both radiographic and clinically. Thus, ZOL treatment can be recommended for osteoporosis patients undergoing LIFS.

Two-year outcome of hydroxyapatite mixed with autogenous bone marrow and local bone graft for posterolateral lumbar fusion.

OBJECTIVE: To determine the outcome of hydroxyapatite (HA) mixed with autogenous bone marrow (BM) and local bone graft in posterolateral lumbar fusion. MATERIAL AND METHOD: Twenty-three patients who had posterolateral fusion with posterior instrument using HA mixed with BM and local bone graft between December 2003 and August 2005 were prospective analyzed. Degree of pain using visual analog scale (VAS) was evaluated at preoperative and 2, 4, 6, 9, 12, and 24 postoperative months. Radiographs were assessed for spinal fusion at 4, 6, 9, 12, and 24 postoperative months. RESULTS: The improvement of pain was demonstrated in all patients postoperatively. Radiographic outcomes revealed solid and doubtful fusion in one of 23 patients (4.3%) and 13 of 23 patients (56.5%) at six months respectively. After two-year follow-up, one patient had solid fusion while 22 patients (95.6%) had doubtful fusion. CONCLUSION: Despite the posterolateral lumbar fusion using HA mixed with BM and local bone graft provided good clinical results, the radiographic results of spinal fusion were questionable in most cases.

Minimal access versus open transforaminal lumbar interbody fusion: meta-analysis of fusion rates.

STUDY DESIGN: A quantitative meta-analysis was conducted on published studies reporting fusion rates after open or minimally invasive/mini-open transforaminal lumbar interbody fusion (TLIF) procedures for single or multilevel degenerative disease including stenosis with spondylolisthesis and degenerative disc disease. OBJECTIVES: The primary aim of this study was to establish benchmark fusion rates for open TLIF and minimally invasive TLIF (mTLIF) based on published studies. A secondary goal was to review complication rates for both approaches. SUMMARY OF BACKGROUND DATA: Lumbar fusion for the treatment of degenerative disease has evolved from a purely posterior noninstrumented approach to a combination of anterior and/or posterior surgery with instrumentation. The increasingly popular transforaminal approach has advanced to incorporate minimally invasive spinal techniques. There currently exist no controlled comparisons between open TLIF and mTLIF. METHODS: A Medline search was performed to identify studies reporting fusion rate on open TLIF or mTLIF with instrumentation. A database including patient demographic information, fusion rate, and complication rate was created. Fusion and complication rates were pooled according to whether TLIF was performed with open or minimally invasive technique. Publication bias was assessed with Egger's test, and adjustments were performed using Duval and Tweedie's Trim and Fill algorithm. RESULTS: Twenty-three articles were identified that fit inclusion criteria. In each of the 23 studies, TLIF was performed with pedicle fixation and fusion was evaluated using radiograph or computed tomography scan at minimum 6-month follow-up. Overall, the studies included 1028 patients, 46.8% of which were female. The mean age of all patients was 49.7 (range, 38-64.9), and mean follow-up interval for assessment of fusion was 26.6 months (range, 6-46 months). The usage of recombinant bone morphologic protein was higher in the mTLIF group (50% vs. 12%). Mean fusion rate from 16 studies (716 patients) of open TLIF was 90.9%, whereas mean fusion rate from 8 studies (312 patients) of mTLIF was 94.8%. Complication rate was 12.6% and 7.5% for open and mTLIF, respectively. CONCLUSION: Fusion rates for both open and mTLIF are relatively high and in similar ranges. Complication rates are also similar, with a trend toward mTLIF having a lower rate. This analysis provides clear benchmarks for fusion rates in open and mTLIF procedures for spine surgeons.

A prospective, randomized, controlled, multicenter study of osteogenic protein-1 in instrumented posterolateral fusions: report on safety and feasibility.

STUDY DESIGN: A prospective, randomized, controlled, multicenter clinical study. OBJECTIVE: To evaluate the safety and feasibility of osteogenic protein (OP)-1 in 1-level lumbar spine instrumented posterolateral fusions. SUMMARY OF BACKGROUND DATA: Instrumented posterolateral fusion with the use of autograft is a commonly performed procedure for a variety of spinal disorders. However, harvesting of bone from the iliac crest is associated with complications. A promising alternative for autograft are bone morphogenetic proteins. METHODS: As part of a larger prospective, randomized, multicenter study, 36 patients were included, who received a 1-level instrumented posterolateral fusion of the lumbar spine. All patients had a degenerative or isthmic spondylolisthesis with symptoms of neurologic compression. There were 2 treatment arms: OP-1 combined with locally available bone from laminectomy (OP-1 group) or iliac crest autograft (autograft group). The primary outcome was the fusion rate based on a computed tomography scan after 1-year follow-up. The clinical outcome was measured using the Oswestry Disability Index. Additionally, the safety of OP-1 was evaluated by comparing the number and severity of adverse events that occurred between both groups. RESULTS: Using strict criteria, fusion rates of 63% were found in the OP-1 group and 67% in the control group (P = 0.95). There was a decrease in Oswestry scores at subsequent postoperative time points compared with preoperative values (P > 0.001). There were no significant differences in the mean Oswestry scores between the study group and control group at any time point (P = 0.56). No product-related adverse events occurred. CONCLUSION: The results demonstrate that OP-1 combined with locally obtained autograft is a safe and effective alternative for iliac crest autograft in instrumented single-level posterolateral fusions of the lumbar spine. The main advantage of OP-1 is that it avoids morbidity associated with the harvesting of autogenous bone grafts from the iliac crest.

Evaluation of responsiveness of Oswestry low back pain disability index.

AIM: To assess the response of Oswestry disability index (ODI) among patients undergoing caudal epidural steroid injections for lumbosacral radicular pain. METHODS: A total number of 107 consecutive patients were analysed. ODI was obtained at preassessment and then at 6 weeks post-injection. At follow-up, patients were asked to rate their condition on an ordinal scale as compared to pre-injection based on their response to five questions (much better, better, same, worse, much worse). As a measure of responsiveness, the effect size and standardized response mean (SRM) was calculated. RESULTS: The mean age of the cohort was 58 years. The mean duration of symptoms was 11 months. The mean Pre-injection ODI for 107 patients was 49(95% CI 46-52). The mean post-injection ODI at 6 weeks was 32(95% CI 28-35). The mean change in ODI was 16.9(95% CI 14-19). The mean change in ODI for much better or much worse group was 21.98(95% CI 18-25). The mean change in ODI for better or worse group was 15(95% CI 10-19) (P = 0.01). The mean change in ODI for same group was -0.6(95% CI -10 to 11). The effect size for the whole group was 1.05. The responsiveness as measured by SRM for the whole group was 0.84. CONCLUSION: This study shows that ODI can detect small changes in disability over time in patients undergoing caudal epidural injections for lumbosacral radicular pain. It can also differentiate between small and large changes in the level of disability.

Successful treatment of spondylolisthesis with medicinal herbs.

It has been reported that some herbal medicines may be effective for acute episodes of chronic nonspecific lower back pain. Spondylolisthesis is one of the causes of lower back or neck pain. To our knowledge, successful treatment of symptomatic spondylolisthesis with medicinal herbs has not been previously reported in the published work. A 63-year-old female had suffered from back pain for 4 years. Radiographs revealed spondylolisthesis at the L3 level. In another case, an 82-year-old female suffered from neck pain. X-ray examinations revealed cervical spondylolisthesis at the C4 level. Several herbs were administered to these patients with symptomatic spondylolisthesis according to the guidelines for herbal medicine. Significant improvements in pain were obtained within 4 weeks in both patients. The pain completely disappeared after 20 weeks (case 1) and 6 weeks (case 2) of treatment. Although surgical treatment is often performed for symptomatic spondylolisthesis, the findings of the present cases imply the therapeutic potential of herbal medicine in selected patients.

A rare presentation of sarcoidosis, back pain and spondylolisthesis.

A 48-year old man presented with back pain that was resistant to treatment. An MR scan showed spondylolisthesis at L4-5 and narrowing of the exit foraminae. He had a posterior fusion which did not relieve his symptoms. He continued to have back pain and developed subcutaneous nodules in both forearms. Biopsy from the skin revealed cutaneous sarcoidosis, and one from the lumbar spine showed sarcoidosis granuloma between the bone trabeculae. A CT scan of the abdomen and chest revealed axillary lymphadenopathy, mediastinal enlarged nodes, apical nodular nodes and splenomegaly. The patient was started on large doses of methotrexate and steroids. His angiotensin-converting enzyme and calcium levels returned to normal and the back pain resolved.

Discitis and isthmic spondylolisthesis: a case report.

Spondylolysis and spondylolisthesis are common causes of low back pain in children and adolescents. Disc space infection is less common, but is another cause of severe back pain in this population. The combination of both processes in the same segment is rare. This case report is of a 13-year-old patient with isthmic lumbosacral spondylolisthesis and disc space infection at the same level. A patient who presented with severe low back pain and a radiological picture of isthmic slip with end plate irregularities and anterior bridging osteophyte was diagnosed with disc space infection at the slip level. He was managed with intravenous antibiotics for 6 weeks, followed by oral medication for an additional 2 weeks. At follow-up 28 weeks later, a spontaneous radiological fusion at the slip level was noted with complete relief of his symptoms. The patient was able to resume sports activities. In conclusion, isthmic spondylolisthesis and disc space height infection might coexist. Nonoperative treatment will usually result in spontaneous fusion and the complete relief of symptoms.