A nationwide neurosurgical inter-disciplinary service for cancer-related refractory pain.

PURPOSE: Neurosurgical ablative procedures, such as cordotomy and cingulotomy, are often considered irreversible and destructive but can provide an effective and individualized solution for cancer-related refractory pain, when all other approaches have been unsuccessful. This paper provides an in-depth exploration of a novel approach to managing refractory cancer pain. It involves an interdisciplinary team led by a neurosurgeon at a renowned national referral center. METHODS: a retrospective analysis of the medical records of all sequential patients who underwent their initial evaluation at our interdisciplinary refractory cancer pain clinic from February 2017 to January 2023. RESULTS: A total of 207 patients were examined in the clinic for a first visit during the study period. All patients were referred to the clinic due to severe pain that was deemed refractory by the referring physician. The mean age was 61 ± 12.3 years, with no significant sex difference (P = 0.58). The mean ECOG Performance Status score was 2.35. Conservative measures had not yet been exhausted in 28 patients (14%) and 9 patients were well controlled (4%). Neurosurgical ablative procedures were recommended for 151 (73%) of the patients. Sixty-six patients (32%) eventually underwent the procedure. 91 patients (44%) received a negative recommendation for surgery. Thirty-five patients (17%) were referred for further invasive procedures at the pain clinic. CONCLUSION: An Interdisciplinary cooperation between palliative care specialists, pain specialists, and neurosurgeons ensures optimal patient selection and provides safe and effective neurosurgery for the treatment of refractory cancer-related pain.

The effect of subcutaneous fat and skin-to-lamina distance on complications and functional outcomes of minimally invasive lumbar decompression.

PURPOSE: Minimally invasive lumbar decompression (MIS) in obese pzatients is technically challenging due to the use of longer tube retractors. The purpose of this study was to evaluate the impact of the thickness of the soft tissue and subcutaneous fat on complications, revisions, and patient-reported functional outcomes after MIS. METHODS: This is a retrospective analysis of 148 consecutive patients who underwent minimally invasive lumbar decompression at our institute between 2013 and 2017 and had at least one year of follow-up. Analysis was performed five times, each time the study group was defined by another measure of adiposity: BMI > 30, skin to lamina distance at the site of surgery and at L4 > 6 cm, and subcutaneous fat thickness at the site of surgery and at L4 > 3 cm. Outcomes included intraoperative complications (durotomy or neurological deficit), possibly inadequate decompression (residual disc, reoperation), length of stay, return to the emergency room or readmission, postoperative medical complications, and functional outcomes: visual analog scores for back and leg pain, and Oswestry Disability Index (ODI). RESULTS: Patients with a thicker layer soft tissue had a significantly higher burden of comorbidities than controls, including higher prevalence of cardiovascular disease (p = 0.002), diabetes (p < 0.001), hypertension (p < 0.001) and higher ASA scores (p = 0.002). Nevertheless, there was no significant difference between the patient groups in surgical and medical complications, functional outcomes, and other assessed outcomes. CONCLUSION: Our results indicate that minimally invasive lumbar decompression is safe and effective for patients with a thick layer of soft tissue and subcutaneous fat.

Facet overhang: A novel parameter in the pathophysiology of multifidus muscle atrophy.

The relationship between degenerative zygapophysial joint (facet) arthropathy and multifidus muscle atrophy has not been rigorously evaluated. The purpose of this study was to determine if specific morphological features of degenerative facet arthropathy are correlated with multifidus muscle atrophy. We retrospectively reviewed medical records and imaging studies of patients with lumbar spinal stenosis. Facet overhang, bridging osteophyte formation, facet effusion, and facet angles were evaluated by univariable and multivariable regression to identify independent associations with deep and superficial parts of the multifidus total cross-sectional area (tCSA), functional cross-sectional area (fnCSA), and fatty infiltration (FI). Facet overhang was classified as severe in 50 females (53.2%) versus 56 males (36.9%) (p = 0.030). Severity of facet overhang and female sex were independently associated with smaller deep part of the multifidus tCSA and fnCSA as well as higher FI, reflecting greater atrophy of the deep region compared to total muscle mass. In comparison, severe facet overhang (p < 0.001; OR = 3.47, 95% CI = 2.13-5.66) and female sex (p < 0.001; OR = 4.19, 95% CI = 2.58-6.79) were independently associated only with higher superficial part of the multifidus FI, reflecting muscle steatosis without significant lean muscle atrophy. In patients with degenerative lumbar spinal stenosis, facet overhang is an independent risk factor for deep part of the multifidus atrophy. Bridging osteophyte formation, facet effusion, and facet angles were not independently associated with deep part of the multifidus atrophy.

Minimally Invasive Resection of Benign Osseous Tumors of the Spinal Column: 10 Years' Experience and Long-Term Outcomes of a Specialized Center.

Background and Objectives: Benign osseous tumors of the spinal column comprise about 10% of all spinal tumors and are rare cause for surgery. However, these tumors pose various management challenges and conventional surgery may be associated with significant morbidity. Previous reports on minimally invasive resection of these lesions are rare. We report a series of patients managed by total resection of benign osseous spine tumors using MIS techniques. Surgical decisions and technical considerations are discussed. Materials and Methods: A retrospective evaluation of prospectively collected data of patients who underwent minimally invasive surgery for removal of benign osseous vertebral tumors. Demographic, clinical and radiographic features, operative details and final pathological reports were summarized. Primary outcomes were completeness of tumor resection and pain relief assessed by VAS for back and leg pain. Secondary outcome measures were recurrence of tumor on repeat post-operative MRI and postoperative unstable deformity on standing scoliosis X-rays. Results: This series included 32 cases of primary osseous spine tumors resected by minimally invasive techniques. There were 17 males and 15 females aged 5-68 years (mean 23.3). The follow-up period was 8-90 months (mean 32 months) and the preoperative symptoms duration was 9-96 months. Axial spinal pain was the presenting symptom in all the patients. Five patients also complained about radicular pain and four patients had antalgic scoliosis. The tumor involved the thoracic spine in 12 cases, the lumbar segment in 11, the cervical in 5 and the sacral area in 4 cases. Complete tumor removal was performed in all patients. No procedure-related complications were encountered. Histopathology showed osteoid osteoma in 24 patients, osteoblastoma in 5 patients, and fibrous dysplasia, fibroadenoma and eosinophilic granuloma in one case each. All patients experienced significant pain relief after surgery, and had stopped pain medications by 12 months postoperatively. No patient suffered from tumor recurrence or spinal deformity. Conclusions: Minimally invasive surgery is feasible for total removal of selected benign vertebral tumors and may have some advantages over conventional surgical techniques.

Stable Low-Grade Degenerative Spondylolisthesis Does Not Compromise Clinical Outcome of Minimally Invasive Tubular Decompression in Patients with Spinal Stenosis.

Background and Objectives: In recent literature, the routine addition of arthrodesis to decompression for lumbar spinal stenosis (LSS) with concomitant stable low-grade degenerative spondylolisthesis remains controversial. The purpose of this study is to compare the clinical outcome, complication and re-operation rates following minimally invasive (MIS) tubular decompression without arthrodesis in patients suffering from LSS with or without concomitant stable low-grade degenerative spondylolisthesis. Materials and Methods: This study is a retrospective review of prospectively collected data. Ninety-six consecutive patients who underwent elective MIS lumbar decompression with a mean follow-up of 27.5 months were included in the study. The spondylolisthesis (S) group comprised 53 patients who suffered from LSS with stable degenerative spondylolisthesis, and the control (N) group included 43 patients suffering from LSS without spondylolisthesis. Outcome measures included complications and revision surgery rates. Pre- and post-operative visual analog scale (VAS) for both back and leg pain was analyzed, and the Oswestry Disability Index (ODI) was used to evaluate functional outcome. Results: The two groups were comparable in most demographic and preoperative variables. VAS for back and leg pain improved significantly following surgery in both groups. Both groups showed significant improvement in their ODI scores, at one and two years postoperatively. The average length of hospital stay was significantly higher in patients with spondylolisthesis (p-value< 0.01). There was no significant difference between the groups in terms of post-operative complications rates or re-operation rates. Conclusions: Our results indicate that MIS tubular decompression may be an effective and safe procedure for patients suffering from LSS, with or without degenerative stable spondylolisthesis.

Long-Term Pain Characteristics and Management Following Minimally Invasive Spinal Decompression and Open Laminectomy and Fusion for Spinal Stenosis.

Background and Objectives: To compare the long-term pain characteristics and its chronic management following minimally invasive spinal (MIS) decompression and open laminectomy with fusion for lumbar stenosis. Materials and Methods: The study cohort included patients with a minimum 5-year postoperative follow-up after undergoing either MIS decompression or laminectomy with fusion for spinal claudication. The primary outcome of interest was chronic back and leg pain intensity. Secondary outcome measures included pain frequency during the day, chronic use of non-opioid analgesics, narcotic medications, medical cannabinoids, and continuous interventional pain treatments. Results: A total of 95 patients with lumbar spinal stenosis underwent one- or two-level surgery for lumbar spinal stenosis between April 2009 and July 2013. Of these, 50 patients underwent MIS decompression and 45 patients underwent open laminectomy with instrumented fusion. In the fusion group, a higher percentage of patients experienced moderate-to-severe back pain with 48% compared to 21.8% of patients in the MIS decompression group (p < 0.01). In contrast, we found no significant difference in the reported leg pain in both groups. In the fusion group, 20% of the patients described their back and leg pain as persistent throughout the day compared to only 2.2% in the MIS decompression group (p < 0.05). A trend toward higher chronic dependence on analgesic medication and repetitive pain clinic treatments was found in the fusion group. Conclusions: MIS decompression for the treatment of degenerative spinal stenosis resulted in decreased long-term back pain and similar leg pain outcomes compared to open laminectomy and instrumented fusion surgery.

Spinal manifestations of Neurofibromatosis type 1.

BACKGROUND: Neurofibromatosis type 1 (NF1) patients may present a wide spectrum of spinal pathologies. Osseous changes may lead to severe deformities with significant implications on growth and quality of life. Neurogenic tumors and soft tissue abnormalities may cause neuropathic pain and dysfunction ranging from minor paresthesias to profound motor and sensory deficits. Advanced imaging such as whole-body MRI, and volumetric tumor burden assessment have an evolving role in the evaluation and follow-up of patients with high spinal tumor load. Novel biological agents that target the hyperactivated ras pathway are currently under investigation and are reshaping current and future treatment paradigms. Surgical interventions for benign and malignant tumors, as well as deformity correction remain pivotal in treatment frameworks and require careful assessment by a dedicated multidisciplinary team. PURPOSE: In this manuscript we review the various spinal manifestations of NF1 patients, indication for surgical intervention and oncological treatments.

Acute Presentation of Cervical Myelopathy Following Manipulation Therapy.

BACKGROUND: Spinal manipulation therapy (SMT) is commonly used as an effective therapeutic modality for a range of cervical symptoms. However, in rare cases, cervical manipulation may be associated with complications. In this review we present a series of cases with cervical spine injury and myelopathy following therapeutic manipulation of the neck, and examine their clinical course and neurological outcome. We conducted a search for patients who developed neurological symptoms due to cervical spinal cord injury following neck SMT in the database of a spinal unit in a tertiary hospital between the years 2008 and 2018. Patients were assessed for the clinical course and deterioration, type of manipulation used and subsequent management. A total of four patients were identified, two men and two women, aged 32-66 years. In three patients neurological deterioration appeared after chiropractic adjustment and in one patient after tuina therapy. Three patients were managed with anterior cervical discectomy and fusion while one patient declined surgical treatment. Assessment for subjective and objective evidence of cervical myelopathy should be performed prior to cervical manipulation, and suspected myelopathic patients should be sent for further workup by a specialist familiar with cervical myelopathy (such as a neurologist, a neurosurgeon or orthopedic surgeon who specializes in spinal surgery). Nevertheless, manipulation therapy remains an important and generally safe treatment modality for a variety of cervical complaints. This review does not intend to discard the role of SMT as a significant part in the management of patients with neck related symptoms, rather it is meant to draw attention to the need for careful clinical and imaging investigation before treatment.

Stand-alone anterior interbody fusion for substitution of iliac fixation in long spinal fixation constructs.

INTRODUCTION: The use of distal sacral anchorage solely, in long spinal fusions, may lead to substantial complications. Extending the fixation down to the ilium and the addition of anterior column support are both used to facilitate construct stability and improve fusion rates. In the current study, we aimed to determine whether supplementation of long thoracolumbar fixation constructs with stand-alone anterior interbody fusion (ALIF) cage with embedded screws can eliminate the biomechanical need for iliac screws fixation biomechanically. METHODS: Seven lumbopelvic human cadavers (L1-full pelvis) were used. All specimens were tested with the following fixation constructs: bilateral L1-S1, bilateral L1-S1 with unilateral iliac screw, and bilateral L1-S1 with bilateral iliac screw. The three constructs were tested with and without the addition of stand-alone ALIF cage. We evaluated the multidirectional rigidity and the axial S1 screw strain. RESULTS: The addition of an ALIF cage solely did not affect rigidity and resulted in mixed S1 screw strain results. One iliac screw was superior to ALIF in rigidity and inferior in S1 screws strain. Bilateral iliac fixation produced similar rigidity and lower S1 screws strain than unilateral iliac fixation. When ALIF was combined with bilateral iliac screws, it resulted in equal rigidity and lower S1 screws strain. CONCLUSION: Our results do not support stand-alone ALIF cage as a substitute for iliac fixation in in long posterior lumbosacral fusion. They do support the use of stand-alone ALIF for the supplementation of bilateral iliac fixation in long lumbosacral fusions.

Analysis of mechanical failure associated with reoperation in spinal fusion to the sacrum in adult spinal deformity.

BACKGROUND: Long fusion to the sacrum has been demonstrated to increase the mechanical failure rate after adult spinal deformity (ASD) surgery, and these mechanical failures are the most common etiology for reoperation. The purpose of this study was to determine the incidence and risk factors for mechanical failure associated with reoperation after spinal fusion to the sacrum in ASD. METHODS: The study included 76 patients with ASD who underwent spinal fusion surgery including the sacrum at a single institution between 2005 and 2010. The inclusion criteria were a minimum age of 20 years and fusion of ≥ 5 levels. The terminal event was defined as either the first reoperation for mechanical failure or a minimum of 2 years following surgery in patients who did not undergo reoperation. RESULTS: The cumulative reoperation rate for mechanical failure was 37 % (n = 28). The procedure survival rate was 79 % at 1 year and 72 % at 2 years. Mechanical failures consisted of proximal junctional complications in 16 patients and pseudarthrosis in 12 patients. Proximal junctional kyphosis (PJK) was the most frequent cause (n = 15), and seven patients were diagnosed with fractures at the UIV or one level above the UIV. Multivariate analysis identified the following as independent factors predicting mechanical failure: three or more comorbidities, smoking, and a preoperative sagittal vertical axis of >95 mm. SRS-22r and ODI scores were lower in patients with mechanical failure. CONCLUSION: Overall, 37 % of the patients who underwent ASD surgery involving the sacrum required reoperation for mechanical failure. The most frequent form of mechanical failure associated with reoperation was surgical PJK. Significant risk factors for mechanical failure included medical comorbidities, smoking, and severe preoperative sagittal imbalance. Critical mechanical failure may have a negative influence on health status.

Platelet-rich plasma did not improve early healing of medial collateral ligament in rats.

BACKGROUND: The medial collateral ligament (MCL) is the most frequently injured ligament of the knee. Platelet-rich plasma (PRP) is a relatively new treatment option developed to enhance the healing response after injury to different tissue types. This study aimed at investigating whether the addition of PRP to MCL tears in rats would alter healing both biomechanically and histologically. METHODS: Bilateral full-thickness tears of the MCL were surgically induced in the knees of 32 rats. Right ligament was saturated with PRP (n = 32, study group), and the left ligament was saturated with saline (n = 32, control group). The animals were killed 3 weeks later and the surgical sites were evaluated by gross inspection, biomechanically and histologically. RESULTS: There was no gross difference in the mass of granulation tissue, load to failure, stiffness and displacement between the study and control groups. Histological examination by means of maturity score revealed no significant differences between the study and control groups. CONCLUSION: The addition of PRP to a healing MCL did not improve any of the outcome measures in this model.

Unilateral versus bilateral iliac screws for spinopelvic fixation: are two screws better than one?

OBJECT: Long-segment spinal instrumentation ending at the sacrum places substantial biomechanical stress on sacral screws. Iliac (pelvic) screws relieve some of this stress by supplementing the caudal fixation. It remains an open question whether there is any clinically significant difference in sacropelvic fixation with bilateral versus unilateral iliac screws. The primary purpose of this study was to compare clinical and radiographic complications in the use of bilateral versus unilateral iliac screw fixation. METHODS: The authors retrospectively reviewed 102 consecutive spinal fixation cases that extended to the pelvis at a single institution (University of California, San Francisco) in the period from 2005 to 2012 performed by the senior authors. Charts were reviewed for the following complications: reoperation, L5-S1 pseudarthrosis, sacral insufficiency fracture, hardware prominence, iliac screw loosening, and infection. The t-test, Pearson chi-square test, and Fisher exact test were used to determine statistical significance. RESULTS: The mean follow-up was 31 months. Thirty cases were excluded: 12 for inadequate follow-up, 15 for lack of L5-S1 interbody fusion, and 3 for preoperative osteomyelitis. The mean age among the 72 remaining cases was 62 years (range 39-79 years). Forty-six patients underwent unilateral and 26 bilateral iliac screw fixation. Forty-one percent (n = 19) of the unilateral cases and 50% (n = 13) of the bilateral cases were treated with reoperation (p = 0.48). In addition, 13% (n = 6) of the unilateral and 19% (n = 5) of the bilateral cases developed L5-S1 pseudarthrosis (p = 0.51). There were no sacral insufficiency fractures. Thirteen percent (n = 6) of the unilateral and 7.7% (n = 2) of the bilateral cases developed postoperative infection (p = 0.70). CONCLUSIONS: In a retrospective single-institution study, single versus dual pelvic screws led to comparable rates of reoperation, iliac screw removal, postoperative infection, pseudarthrosis, and sacral insufficiency fractures. For spinopelvic fixation, placing bilateral (vs unilateral) pelvic screws produced no added clinical benefit in most cases.

Opiates do not violate the viability and proliferative activity of human articular chondrocytes.

Articular cartilage injuries present a challenge for the clinician. Autologous chondrocyte implantation embedded in scaffolds are used to treat cartilage defects with favorable outcomes. Autologous serum is often used as a medium for chondrocyte cell culture during the proliferation phase of the process of such products. A previous report showed that opiate analgesics (fentanyl, alfentanil and diamorphine) in the sera have a significant inhibitory effect on chondrocyte proliferation. In order to determine if opiates in serum inhibit chondrocyte proliferation, twenty two patients who underwent knee arthroscopy and were anesthetized with either fentanyl or remifentanil were studied. Blood was drawn before and during opiate administration and up to 2 h after its discontinuation. The sera were used as medium for in vitro proliferation of both cryopreserved and freshly isolated chondrocytes, and the number and viability of cells were measured. There was no difference in the yield or cell viability between the serum samples of patients anesthetized with fentanyl when either fresh or cryopreserved human articular chondrocytes (hACs) were used. Some non-significant reduction in the yield of cells was observed in the serum samples of patients anesthetized with remifentanil when fresh hAC were used. We conclude that Fentanyl in human autologous serum does not inhibit in vitro hAC proliferation. Remifentanil may show minimal inhibitory effect on in vitro fresh hAC proliferation.

An international survey on anterior cruciate ligament reconstruction practices.

PURPOSE: Bone-patellar-tendon-bone (BPTB) autografting fixed with metal interference screws (IS) is the gold standard for anterior cruciate ligament (ACL) reconstruction. Advances in surgical technology provide a wide choice of grafts, fixation devices and surgical approaches. METHODS: Two-hundred and sixty-one orthopedic surgeons of ten subspecialties from 57 countries were surveyed on their choice of graft and fixation device, the number of reconstructed bundles, and arthroscopic portal. Their preferences were analyzed according to country of origin, field of expertise and seniority, and compared to current publications. RESULTS: Hamstring autografting was the most popular choice (63 %), then BPTB (26 %) and allograft (11 %). The anteromedial portal was preferred over the traditional transtibial portal (68 % versus 31 %). Two-thirds reported routinely performing a single-bundle graft reconstruction, compared to one-third who used the double-bundle technique. The Endo-button was the most common graft fixation method (40 %), followed by the bioabsorbable IS (34 %), metallic IS (12 %), rigidfix (10 %) and others (4 %). The preferences of hamstring tendon grafting and the anteromedial portal are not supported in the literature. Responses from North American and European surgeons were different from all the others. CONCLUSIONS: Surgeon preferences in ACL reconstruction differ considerably worldwide. Common practice is not always supported by evidence-based publications.

Surgical approach and prosthesis fixation in hip arthroplasty world wide.

BACKGROUND: Hip arthroplasty is one of the most common and successful surgical procedures worldwide. Component design and materials as well as surgical techniques constantly evolve. There is no consensus among surgeons regarding the ideal surgical approach and method of fixation. MATERIALS AND METHODS: 292 orthopedic surgeons of 10 subspecialties from 57 countries were surveyed on their choice of surgical approach and prosthesis fixation in hip arthroplasty. Their preferences were analyzed according to country of origin, field of expertise and seniority, and compared to current publications. RESULTS: The response rate was 95-98 %. Surgeons were split between the posterior approach (45 %) and the direct lateral approach (42 %) followed by the anterior approach (10 %) or other (3 %). North American surgeons favored the posterior approach more often than Europeans (69 % compared to 36 %, P < 0.0001) and surgeons from other countries (69 % compared to 45 %, P = 0.01). Sixty-eight percent of all surgeons routinely used noncemented hip prosthesis while 16 % use cemented and 16 % hybrid fixation. Noncemented fixation was preferred among surgeons from Europe and North America compared to other countries (73 % compared to 55 %, P < 0.05). There were no significant differences based on subspecialty, seniority or the number of years of experience. CONCLUSIONS: The most common surgical approaches in use in hip arthroplasty are posterior and lateral. Anterior approach is used by a minority of orthopedic surgeons for that purpose. Cementing hip prosthesis is falling out of favor among orthopedic surgeons worldwide. The trend toward un-cemented hip arthroplasty is not well supported in the current literature.

[Hip arthroscopy: differential diagnosis of pain around the hip joint].

Hip arthroscopy is one of the most highly evolving surgical techniques in recent years. It plays a major role in the diagnosis and treatment of a broad spectrum of hip pathologies. The evaluation of the painful hip requires meticulous history taking, elaborated physical examination, and basic and advanced imaging modalities. The differential diagnosis includes a continuously growing number of diagnoses. Once considered an "operation looking for indications", the current indications for hip arthroscopy are based on a better understanding of pathologies around the hip joint. The results of recently published intermediate and long term clinical outcome studies are encouraging. Ongoing, comprehensive understanding of the correlation between pathologies and clinical presentation will improve the surgical technique, which in turn may become a joint preserving operation.

Does Tobacco Smoking Affect the Postoperative Outcome of MIS Lumbar Decompression Surgery?

BACKGROUND: Tobacco smoking is a major cause of morbidity and mortality worldwide. Several authors reported a significant negative impact of smoking on the outcome of spinal surgeries. However, comparative studies on the effect of smoking on the outcome of minimally invasive (MIS) spinal decompression are rare with conflicting results. In this study, we aimed to evaluate clinical outcomes and postoperative complications following MIS decompression in current and former smoking patients compared to those of non-smoking patients. METHODS: We used our prospectively collected database to retrospectively analyse the records of 188 consecutive patients treated with MIS lumbar decompression at our institution between November 2013 and July 2017. Patients were divided into groups of smokers (S), previous smokers (PS) and non-smokers (N). The S group and the PS group comprised 31 and 40 patients, respectively. The N group included 117 patients. The outcome measures included perioperative complications, revision surgery and length of stay. Patient-reported outcome measures included a visual analogue scale (VAS) for back pain and leg pain, as well as the Oswestry disability index (ODI) for evaluating functional outcomes. RESULTS: Demographic variables, comorbidity and other preoperative variables were comparable between the three groups. A comparison of perioperative complications and revision surgery rates showed no significant difference between the groups. All groups showed significant improvement in their ODI and VAS scores at 12 and 24 months following surgery. As shown by a multivariate analysis, current smokers had lower chances of improvement, exceeding the minimal clinical important difference (MCID) in ODI and VAS for leg pain at 12 months but not 24 months postoperatively. CONCLUSIONS: Our findings show that except for a possible delay in improvement in leg pain and disability, tobacco smoking has no substantial adverse impact on complications and revision rates following MIS spinal decompressions.

Low Back Pain Patients' Perceptions Regarding Their Own Radiology Reports: Pre-Intervention Survey.

Purpose: While advanced medical technology and unlimited access to medical information might benefit and empower patients, these same advantages may pose some risks, especially in the cases where patients have direct access to advanced imaging studies. The aim of this work was to evaluate three domains related to patients with lower back pain: the patients' perceptions, misconceptions and the experience of anxiety-related symptoms following direct access to their thoraco-lumbar spine radiology report. An additional aim was the assessment of possible associations with catastrophization. Patients and Methods: Patients who were referred to the spine clinic, following the completion of a CT or MRI of their thoraco-lumbar spine were surveyed. Patient perceptions of the importance of having direct access to their imaging report and of the concern they attribute to the medical terms found in their report were evaluated using a set of questionnaires. The medical terms severity scores were then correlated to a reference clinical score created for the same medical terms by spine surgeons. Lastly, patients' anxiety-related symptoms and Pain Catastrophizing Scale (PCS) after reading their radiology report were evaluated. Results: Data from 162 participants (44.6% female), with mean age of 53.1 ± 15.6 years, were collected. Sixty-three percent of the patients stated that reading their report helped them gain better understanding of their medical condition and 84% agreed that having early access to the report helped improve communication with the physician. Patients' degree of concern associated with the medical terms in their imaging report ranged between 2.07 and 3.75, on a scale of 1-5. The patient's degree of concerns were significantly higher for six common medical terms and significantly lower in one, when compared to experts' opinions. A mean (± SD) of 2.86±2.79 anxiety-related symptoms was reported. The mean Pain Catastrophizing Scale (PSC) score was 29.18 ±11.86, ranging from 2 to 52. Both the degree of concerns and the number of symptoms reported were significantly associated with the PCS. Conclusion: Direct access to radiology reports might provoke anxiety symptoms, especially in patients with a tendency for catastrophic thinking. Increasing awareness amongst spine clinicians and radiologist about possible risks associated with direct access to radiology reports could contribute to preventing patients' misconceptions and unnecessary anxiety-related symptoms.

Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success.

BACKGROUND: The shoulder is regarded as the most commonly dislocated major joint in the human body. Most dislocations can be reduced by simple methods in the emergency department, whereas others require more complicated approaches. We compared the efficacy, safety, pain, and duration of the reduction between the Milch technique and the Stimson technique in treating dislocations. We also identified factors that affected success rate. METHODS: All enrolled patients were randomized to either the Milch technique or the Stimson technique for dislocated shoulder reduction. RESULTS: The study cohort consisted of 60 patients (mean age, 43.9 years; age range, 18-88 years) who were randomly assigned to treatment by either the Stimson technique (n = 25) or the Milch technique (n = 35). Oral analgesics were available for both groups. The 2 groups were similar in demographics, patient characteristics, and pain levels. The first reduction attempt in the Milch and Stimson groups was successful in 82.8% and 28% of cases, respectively (P < .001), and the mean reduction time was 4.68 and 8.84 minutes, respectively (P = .007). The success rate was found to be affected by the reduction technique, the interval between dislocation occurrence and first reduction attempt, and the pain level on admittance. CONCLUSIONS: The success rate and time to achieve reduction without sedation were superior for the Milch technique compared with the Stimson technique. Early implementation of reduction measures and low pain levels at presentation favor successful reduction, which--in combination with oral pain medication--constitutes an acceptable and reasonable management alternative to reduction with sedation.

Is the Erector Spinae Plane Block Effective for More than Perioperative Pain? A Retrospective Analysis.

Introduction: The thoracic Erector Spinae Plane Block (ESPB) is an ultrasound-guided block that has gained popularity and is widely used in acute pain setups. However, data regarding its role in chronic and cancer-related pain are anecdotal. Material and Methods: The study is a retrospective analysis of patients who underwent ESPB. The cohort was divided into subgroups based on three determinants: etiology, pain type, and chronicity. Results: One hundred and ten patients were included, and genders were affected equally. The average age was 61.2 ± 16.1 years. The whole group had a statistically significant reduction in a numerical rating scale (NRS) (7.4 ± 1.4 vs. 5.0 ± 2.6, p-value > 0.001). NRS reduction for 45 patients (41%) exceeded 50% of the pre-procedural NRS. The mean follow-up was 7.9 ± 4.6 weeks. Baseline and post-procedure NRS were comparable between all subgroups. The post-procedural NRS was significantly lower than the pre-procedural score within each group. The proportion of patients with over 50% improvement in NRS was lower for those with symptom duration above 12 months (p-value = 0.02). Conclusions: Thoracic ESPB is a simple and safe technique. The results support the possible role of ESPB for chronic as well as cancer-related pain.