The role of Vertebral Augmentation Procedures in the management of vertebral compression fractures secondary to multiple myeloma.

Multiple myeloma (MM) is a systemic disorder characterised by proliferation of B-lymphocytes and plasma cells in the bone marrow. The primary aims of the management of spinal lesions in MM are pain control and fracture stabilisation. Vertebral augmentation procedures (VAP) can be subdivided into percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP). BKP involves the placement of orthopaedic balloons into the fractured vertebral body, creating a void into which polymethylmethacrylate bone cement is injected. This review outlines the management of spinal lesions in patients with MM, with a focus on the comparative risks and efficacy of vertebroplasty (VP) and balloon kyphoplasty (BKP). Soft tissue masses in MM are highly radiosensitive. Bisphosphonates and newer oncological therapies have decreased the indications for palliative radiotherapy, while spinal bracing can be utilised in selected cases to provide stability. BKP and VP provide equivalent long term pain control after MM vertebral compression fractures (VCF). BKP is superior to non-operative management and VP for restoration of vertebral body height and prevention of segmental kyphosis. Current evidence suggests a greater degree of correction of kyphotic deformity and restoration of mid vertebral height (MVH) with BKP when compared with VP. The literature supports the use of BKP even in the presence of posterior vertebral body wall (PVBW) fractures, a group previously considered a contraindication to VAP. Superior functional outcomes have been reported in patients undergoing early versus delayed BKP (<6-8 weeks). Current evidence supports a lower risk of cement extrusion with BKP than with VP, but serious complications following VAP are rare. MM spinal pathology should be managed in a multidisciplinary setting. Surgical decompression and instrumentation are rarely indicated, due to the radio-sensitivity of soft tissue lesions in MM. BKP is a safe and effective procedure for VCF secondary to MM.

Is sequestrectomy a viable alternative to microdiscectomy? A systematic review of the literature.

BACKGROUND: Traditionally, lumbar discectomy involves removal of the free disc fragment followed by aggressive or conservative excision of the intervertebral disc. In selected patients, however, it is possible to remove only the free fragment or sequester without clearing the intervertebral disc space. However, there is some controversy about whether that approach is sufficient to prevent recurrent symptoms and to provide adequate pain relief. QUESTIONS/PURPOSES: This systematic review was designed to pose two questions: (1) Does performing a sequestrectomy only without conventional microdiscectomy lead to an increased reherniation rate; and (2) is there a difference in the patient-reported levels of radicular pain? METHODS: Systematic MEDLINE and EMBASE searches were carried out to identify all articles published in peer-reviewed journals reporting the outcomes of interest for conventional microdiscectomy versus sequestrectomy for lumbar disc herniation from L2 to the sacrum (Level III evidence and above); hand-searching of bibliographies was also performed. A minimum of Level II evidence was required with a followup rate of greater than 75%. Followup in all studies was from 18 to 86 months. Seven studies met the inclusion criteria for this review. The studies were analyzed for operating time, hospital stay, pre- and postoperative visual analog scale, and reherniation rate. RESULTS: Patients in both the microdiscectomy and sequestrectomy groups showed comparable improvement of visual analog scale (VAS) score for leg pain. VAS score improvement ranged from 5.6 to 6.5 points in the microdiscectomy groups and 5.5 to 6.6 in the sequestrectomy group. The reherniation rate in the microdiscectomy group ranged from 2.3% to 11.8% and in the sequestrectomy groups from 2% to 12.5%. CONCLUSIONS: This review of the available literature suggests that, compared with conventional microdiscectomy, microsurgical lumbar sequestrectomy can achieve comparable reherniation rates and reduction in radicular pain when a small breach in the posterior fibrous ring is found intraoperatively.

A Comparative Cohort Study of Lumbar Microdiscectomy in Obese and Nonobese Patients.

STUDY DESIGN: Prospective comparative cohort study. OBJECTIVE: Investigate whether there is a difference in postoperative pain reduction, complication rate, and other markers of operative difficulty in obese and nonobese patients undergoing elective lumbar microdiscectomy by a single spinal surgeon. SUMMARY OF BACKGROUND DATA: Lumbar radiculopathy is a debilitating condition that affects obese and nonobese patients. There is reluctance among some surgeons to perform lumbar microdiscectomy in the obese population. METHODS: Over 3 years a group of 34 obese patients were compared with 34 nonobese patients from the same period. Operative duration, blood loss, unintentional durotomies, infection rate, hospital stay, and pain reduction were compared. RESULTS: Reduction in total pain (control, -82%; obese, -71%) and radicular leg pain (control, -98%; obese, -97%) were similar. The risk of superficial infections was greater in the obese group, but there was no difference in rate of serious complication in our small series. Operative duration was much longer in the obese group (control, 28 min; obese, 70 min), as was total hospital stay. CONCLUSIONS: We found good postoperative pain relief in both groups. There was no difference in radicular leg pain between obese and nonobese patients but total pain due to lumbago was greater preoperatively and postoperatively in the obese group making their total pain greater. There was no evidence of higher serious complication rate that would preclude offering operative lumbar microdiscectomy to obese patients due to their obesity alone. However, operative duration was significantly longer in obese patients and should be considered accordingly.

A Review of the Clinical Utility of Therapeutic Facet Joint Injections in Whiplash Associated Cervical Spinal Pain.

Background and Objective: Whiplash neck injury was described by Crowe in 1928. Whiplash-associated disorder (WAD) is defined as a cervical spinal injury following an acceleration-deceleration mechanism. It is a constellation of symptoms due to psychological factors and neural adaptations, with significant social costs. Review Summary: There are multiple classification systems for WAD in the literature. The Quebec Classification is most reported and is predictive of the likelihood of progression to chronicity. The facet joint has been identified as a pain generator in 50% of cases. We outline the likely anatomical cause of WAD and summarize the protocol of medial branch block injections for diagnostic and therapeutic purposes, as well as the indications for and published results of facet joint ablation in WAD. We also highlight the development of ultrasound as an alternative to computed tomography or fluoroscopy for injection guidance. Conclusions: WAD is a complex condition associated with sensory disturbance, pain, motor chronic pain, and psychological distress. The literature supports a single diagnostic medial branch block followed by a therapeutic facet joint ablation for chronic pain. WAD should be managed in a multidisciplinary fashion, with an early involvement of psychological specialists when required.

Lumbar microdiscectomy versus sequesterectomy/free fragmentectomy: a long-term (>2 y) retrospective study of the clinical outcome.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the long-term outcome of microdiscectomy versus sequestrectomy/free fragmentectomy for lumbar disc herniation. SUMMARY OF BACKGROUND DATA: Conventional lumbar microdiscectomy involves substantial excision of disc material from the intervertebral disc space to prevent reherniation. However, in selected patients removal of free-disc fragment sequestrectomy, without clearing the disc space can be as beneficial as conventional microdiscectomy. METHODS: During the study period, we performed 196 lumbar microdiscectomies for disc herniation. Of these 101 patients met the inclusion criteria for this study. Seventy-seven of 101 patients underwent microdiscectomy and the remaining 24 patients received microscopic sequestrectomy. The following parameters were compared in these 2 groups: operating time, perioperative complications, the pre- and postoperative Visual Analog Scale (VAS), reherniation rate, and the use of analgesics at the time of follow-up. The patients were assessed at the final follow-up. Mean follow-up was 33.4 (24 to 47) months in the sequestrectomy group and 32.4 (24 to 45) months in the microdiscectomy group. RESULTS: The operating time for the microdiscectomy patients was longer than that for the sequestrectomy patients, 32 (19 to 51) versus 24 (15 to 40) minutes. The reherniation rate was slightly lower in the sequestrectomy group than in the microdiscectomy group, 4.17% versus 5.56%. (P=1.00). The complication rate was higher in the microdiscectomy population, 6.4% versus 4.17%. Postoperative improvement in pain in the sequestrectomy group was slightly better than that in the microdiscectomy cohort, VAS 1.6 versus VAS 1.2. (P=0.06). CONCLUSIONS: We argue that microscopic sequestrectomy is more successful with lesser operating time, fewer intraoperative complications, and lesser reherniation rate compared with conventional microdiscectomy in which patients are selected according to well-defined criteria, which is largely dependent on the competence of the annulus/posterior longitudinal ligament.

Chronic Low Back Pain Occurring in Association With Hypermobility Spectrum Disorder and Ehlers-Danlos Syndrome.

BACKGROUND: This review paper outlines recent advances in diagnostic criteria for hypermobility spectrum disorder (HSD) and its association with Ehlers-Danlos syndrome (EDS), as well as current literature on the association between joint hypermobility syndrome and lumbar back pain. We outline the optimal multidisciplinary management of lumbar back pain in the context of joint hypermobility syndrome, as well as the indications and possible side effects of surgical management of patients with these conditions.Several studies have suggested a link between chronic low back pain and hypermobility. HSD has been described as an excessive range of motion in a joint, when accounting for patient demographics. The nomenclature surrounding symptomatic joint hypermobility has varied historically, and various groups, including most notably the international EDS consortium, have introduced new classification schemes to acknowledge the systemic effects of joint hypermobility, which were previously poorly understood. METHODS: Narrative literature review. RESULTS: Not applicable. CONCLUSIONS: Lower back pain experienced in patients on the HSD-EDS spectrum is multifactorial in origin and should not be considered solely in anatomical terms. Caution has been advised in the surgical management of patients on the HSD-hEDS spectrum, particularly where the subtype is unclear. The vascular type of EDS has a particular propensity for severe bleeding complications. Rates of perioperative complications after lumbar spinal surgery in the hypermobile EDS population have been reported to be up to 50%. When hypermobility and chronic lumbar back pain coexist, we advocate management in a multidisciplinary setting involving physiotherapists, pain physicians, surgeons, and psychologists.

When is the appropriate time for surgical intervention of the herniated lumbar disc in the adolescent?

Symptomatic lumbar disc herniation in the adolescent is uncommon. The appropriate treatment in this particular age group is not clear. We conducted a retrospective review of the medical, surgical, and radiological records of six adolescents with symptomatic lumbar disc herniation who underwent microdiscectomy after failed conservative therapy. The mean follow-up was 13 months. All patients improved quickly and returned to their normal activity levels. We suggest that severe pain resulting from a herniated lumbar disc, even without any neurological deficit, is an indication for microdiscectomy in adolescents so that these patients return to full-time education and normal activities as soon as possible.