Occipitocervical Fusion.

Occipitocervical fusion is a surgical technique in continuous evolution due to the innovation of devices, operative and instrumentation techniques. The aetiologies responsible for occipitocervical instability are trauma, neoplastic disease, metabolic disease or congenital disease. A variety of stabilization techniques are currently available depending on the type of patient and surgeon's experience. Each of these techniques requires thorough knowledge of the anatomy of the craniovertebral junction.

Occipital Nerve Stimulation for Refractory Pain after Occipitocervical Fusion.

Occipital nerve stimulation (ONS) is electric stimulation of the distal branches of the greater occipital nerve by cylindrical or paddle leads implanted in subcutaneous occipital tissue. This surgical option has emerged as a promising treatment for different types of disabling medical refractory headache and recently also for residual occipital and nuchal pain after previous occipitocervical fusion. The mechanisms of action have not yet been clearly explained: electrical stimulation of the occipital nerve has both peripheral and central effects on the nervous system, which may modulate nociception. ONS is a well-tolerated and safe procedure in comparison with other invasive modalities of treatment. Lead migration/dislodgement is a common complication, but use of new surgical techniques and leads may reduce the rate of this complication.

Spinal Cord Stimulation in Chronic Low Back Pain Syndrome: Mechanisms of Modulation, Technical Features and Clinical Application.

Chronic low-back pain (CLBP) is a common disease with several negative consequences on the quality of life, work and activity ability and increased costs to the health-care system. When pharmacological, psychological, physical and occupational therapies or surgery fail to reduce CLBP, patients may be a candidate for Spinal Cord Stimulation (SCS). SCS consists of the transcutaneous or surgical implantation of different types of electrodes in the epidural space; electrodes are then connected to an Implanted Pulse Generator (IPG) that generates stimulating currents. Through spinal and supraspinal mechanisms based on the "gate control theory for pain transmission", SCS reduces symptoms of CLBP in the almost totality of well-selected patients and its effect lasts up to eight years in around 75% of patients. However, the evidence in favor of SCS still remains weak, mainly due to poor trial methodology and design. This narrative review is mainly addressed to those professionals that may encounter patients with CLBP failing conventional treatments. For this reason, we report the mechanisms of pain relief during SCS, the technical features and some clinical considerations about the application of SCS in patients with CLBP.

Percutaneous intradiscal injection of radiopaque gelified ethanol: short- and long-term functional outcome and complication rate in a consecutive series of patients with lumbar disc herniation.

Lumbar disc herniation (LDH) is a common cause of low back pain (LBP) and/or radicular pain (RP). Over the years, different therapies have been proposed to treat symptomatic LDH, including different minimally invasive techniques and open surgical methods. Recently, percutaneous intradiscal injection of radiopaque gelified ethanol (RGE) DiscoGel® has emerged as an effective therapeutic option in patients with LDH. Nevertheless, only few studies addressed the reliability of this technique. The purpose of this study was to evaluate the efficacy and safety of this procedure. We analysed surgical and outcome data of patients with small or medium LDH treated by DiscoGel between 2012 to 2015. Outcome variables included pain relief, the limitation on physical activity and severity of depression status. Overall, complication rate was defined as the occurrence of any perioperative adverse events. A total of 94 consecutive patients were enrolled in the study. Pain relief was achieved in 90.6% and 88.8% of patients at 1- and 4-year follow-up, respectively. At the last follow-up, at least a satisfactory result was achieved in 92.5% of patients. Similar results were obtained in the limitation on physical activity. Depression status did not significantly change after treatment. There was no mortality, and no patients experienced permanent sequelae. In well-selected patients, DiscoGel has proved effective in maintaining excellent functional results in terms of pain relief and limitation on physical activity while minimizing the overall rate of complications related to these kinds of surgical procedures.

Suspected Pulmonary Embolism after Oxygen-Ozone Therapy for Low Back Pain.

Oxygen-ozone therapy is used to treat degenerative pathology of the spine when surgery is not needed (e.g., removal of a herniated disk). Some authors have described it as a safe and effective procedure in ∼ 70 to 90% of patients. The aim of the therapy is to dehydrate the intervertebral disk and alter its contents. However, this treatment has been associated with some rare but very serious side effects. Both cardiac damage and a case of fulminant septicemia were reported. We describe a case of suspected pulmonary embolism, followed by sudden death, in an elderly woman treated with oxygen-ozone therapy for lumbar pain caused by disk protrusion. We believe a massive pulmonary embolism occurred, probably caused by an intradiskal injection that accidentally punctured a venous vessel and created emboli.

Administration of palmitoylethanolamide in combination with topiramate in the preventive treatment of nummular headache.

Nummular headache has been recently described as a primary disorder characterized by head pain exclusively felt in a small rounded area typically 2-6 cm in diameter, not attributed to another disorder. Both size and shape of the painful area remain constant since the onset of symptoms. A 57-year-old woman presented with a history of focal episodic pain in a circumscribed area on the right parietal region. The administration of standard oral doses of palmitoylethanolamide and topiramate in combination showed an improvement in pain symptoms and on pain measuring scales.