The MIST Guidelines: The Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment.

BACKGROUND: Lumbar spinal stenosis (LSS) can lead to compression of neural elements and manifest as low back and leg pain. LSS has traditionally been treated with a variety of conservative (pain medications, physical therapy, epidural spinal injections) and invasive (surgical decompression) options. Recently, several minimally invasive procedures have expanded the treatment options. METHODS: The Lumbar Spinal Stenosis Consensus Group convened to evaluate the peer-reviewed literature as the basis for making minimally invasive spine treatment (MIST) recommendations. Eleven consensus points were clearly defined with evidence strength, recommendation grade, and consensus level using U.S. Preventive Services Task Force criteria. The Consensus Group also created a treatment algorithm. Literature searches yielded 9 studies (2 randomized controlled trials [RCTs]; 7 observational studies, 4 prospective and 3 retrospective) of minimally invasive spine treatments, and 1 RCT for spacers. RESULTS: The LSS treatment choice is dependent on the degree of stenosis; spinal or anatomic level; architecture of the stenosis; severity of the symptoms; failed, past, less invasive treatments; previous fusions or other open surgical approaches; and patient comorbidities. There is Level I evidence for percutaneous image-guided lumbar decompression as superior to lumbar epidural steroid injection, and 1 RCT supported spacer use in a noninferiority study comparing 2 spacer products currently available. CONCLUSIONS: MISTs should be used in a judicious and algorithmic fashion to treat LSS, based on the evidence of efficacy and safety in the peer-reviewed literature. The MIST Consensus Group recommend that these procedures be used in a multimodal fashion as part of an evidence-based decision algorithm.

Lumbar spinal stenosis: therapeutic options review.

Lumbar spinal stenosis (LSS) functionally impacts significant numbers of Americans per year. Current estimates place the number of Americans suffering from senescent lumbar spinal stenosis at 400,000. The prevalence of this disorder in patients ranging from 60 to 69 years of age is very high. Forty-seven percent of this age group have mild to moderate stenosis, and 19.7% have severe stenosis. As the baby boomer generation gets older, 10,000 individuals attain the age of 65 years every day in United States. LSS is becoming very common and will be a major healthcare issue as the population ages. Although LSS is not life threatening, it can cause substantial disability with limitations to performing daily activities, and thus, the associated negative impact on quality of life (QOL). This article reviews the pathophysiology and current treatment options for LSS, focusing on evidence-based treatment options.

Anatomic surgical management of chronic low back pain.

OBJECTIVE: To review spine surgery management strategies for patients with chronic low back pain (CLBP) that has failed to respond to all nonsurgical treatment options. MATERIALS AND METHODS: Literature review was conducted for spine surgery in the treatment of CLBP without compressive anatomical disease. The main diagnosis identified was degenerated disc disease, and surgical options targeted for the treatment of CLBP were reviewed. RESULTS: The history of current spine intervention for CLBP was reviewed, including various surgical options. Surgical treatment options for patients with CLBP include lumbar fusion, lumbar disc arthroplasty, and dynamic stabilization. Lumbar fusion remains the most frequent spine surgery performed for CLBP, but questions still exist regarding its efficacy in comparison with conservative care or interventional pain management. Lumbar disc arthroplasty and dynamic stabilization can both be considered only for select patients with CLBP, and their uses are currently limited. CONCLUSION: Despite the number of spine surgeries that have been performed for CLBP, the surgical outcome still remains questionable. Until a precise identification of the cause of CLBP in any given patient can be precisely determined, surgical solutions will continue to be less than optimal.

An overview of thermal necrosis: present and future.

Introduction: Many orthopaedic procedures require drilling of bone, especially fracture repair cases. Bone drilling results in heat generation due to the friction between the bone and the drill bit. A high-level of heat generation kills bone cells. Bone cell death results in resorption of bone around bone screws.Methods: We searched in the literature for data on parameters that influence drilling bone and could lead to thermal necrosis. The points of view of many orthopaedists and neurosurgeons based upon on previous practices and clinical experience are presented.Results: Several potential complications that lead to thermal necrosis are discussed and highlighted.Discussion: Even in the face of growing evidence as to the negative effects of heat induction during drilling, simple and effective methods for monitoring and cooling in real-time are not in widespread usage today. For that purpose, we propose some suggestions for the future of bone drilling, taking note of recent advances in autonomous robotics, intelligent systems and computer simulation techniques.Conclusions: These advances in prevention of thermal necrosis during bone drilling surgery are expected to reduce the risk of patient injury and costs for the health service.

Spinal angiolipomas: A puzzling case and review of a rare entity.

Patients with spinal epidural abscesses (SEAs) may have a variable presentation. Such an infection has a typical appearance on magnetic resonance imaging (MRI) and enhances with gadolinium. We present a case that was a diagnostic challenge where pre- and intra-operative findings resulted in conflicting impressions. The mimicker was a spinal angiolipoma (SAL). The authors then provide a thorough review of this rare spinal neoplasm. A 55-year-old man presented with back pain, paresis, paresthesia, and urinary retention. MRI was indicative of a longitudinal epidural thoracic mass with a signal homogeneous to nearby fat, curvilinear vessels, and lack of enhancement. Although at emergent surgery, the lesion was found to contain abundant purulent material. Microbiology was positive for methicillin-resistant Staphylococcus aureus and consistent with SEA without evidence of neoplasia. While the imaging features were suggestive of an angiolipoma, the findings at surgery made SEA more likely, which were validated histopathologically. The diagnosis of SEA is often clear-cut, and the literature has reported only a few instances in which it masqueraded as another process such as lymphoma or myelitis. The case highlights SEA masquerading as an angiolipoma, and further demonstrates to clinicians that obtaining tissue diagnosis plays a crucial role diagnostically and therapeutically. SALs, on the other hand, are slow-growing tumors that can be infiltrating or noninfiltrating. They typically present with chronic symptoms and T1-MRI shows an inhomogeneous picture. Complete surgical excision is standard of care and patients tend to do well afterward.

Percutaneous thoracolumbar decompression combined with percutaneous pedicle screw fixation and fusion: a method for treating spinal degenerative pain in a biplane angiography suite with the avoidance of general anesthesia.

BACKGROUND: Spondylytic degeneration of the axial lumbar spine is a major cause of pain and disability. Recent advances in spinal surgical instrumentation, including percutaneous access and fusion techniques, have made possible the performance of instrumented fusion through small incisions. By blending strategies of interventional pain management, neuroradiology, and conventional spine surgery, it is now feasible to treat spinal axial pain using permanent fixation techniques and local anesthesia in the setting of a fluoroscopy suite using mild sedation and local anesthesia. METHODS: The author presents a series of percutaneous thoracolumbar fusion procedures performed in a biplane neuroangiographic suite and without general anesthesia for the treatment of spondylytic pain. All procedures utilized pedicle screw fixation, harvesting of local bone autograft, and application of bone fusion material. RESULTS: In this series of 13 patients, a statistically significant reduction of pain was seen at both the 2-week post-operative timepoint, as well as at the time of longest follow-up (mean 40 weeks). DISCUSSION: The advanced and rapid imaging capabilities afforded by a neuroangiographic suite can be safely combined with percutaneous fusion techniques so as to allow for fusion therapies to be applied to patients where the avoidance of general anesthesia is desirable.

Endovascular treatment of vertebral column metastases using intra-arterial Cisplatin: pilot experience.

Background and Importance. Treatment of spinal column metastatic tumors is challenging, especially in the setting of progressive disease despite previous radiation and chemotherapy. Intra-arterial chemotherapy is an uncommonly used but established treatment for head and neck cancers, retinoblastoma, and glioblastoma. The author reports extension of the IAC concept to vertebral metastatic tumors. Clinical Presentation. Two patients with intractable spinal pain secondary to spinal metastatic involvement at T11-L1 segments were treated with intra-arterial injections of cisplatin, with simultaneous sodium thiosulfate chelation. The first patient, a 60-year old female with metastatic lung carcinoma underwent, three cycles of therapy over a 9-week period; the treated regions demonstrated bone remodeling and sclerosis. The second case was a 40-year old male with malignant pheochromocytoma, who underwent a single treatment and succumbed 5 weeks later from progressive widespread disease. Both patients reported significant pain relief and neither of them exhibited a decline in neurologic function. Conclusion. The intra-arterial delivery of cisplatin appeared to be well tolerated in the two cases. In the case with the longest survival, the treated vertebral segments became more sclerotic, consistent with biomechanical stabilization. Endovascular treatment of spinal metastases may hold promise, especially as newer categories of biologic agents become more widely available.

Long-term results of percutaneous lumbar decompression for LSS: two-year outcomes.

OBJECTIVE: The aim of this report was to evaluate the long-term effectiveness and safety of mild lumbar decompression for the treatment of neurogenic claudication associated with lumbar spinal stenosis. This technique uses a percutaneous dorsal approach to remove small portions of ligament and lamina, thereby restoring space and decompressing the spinal canal. MATERIALS AND METHODS: Two-year data are reported for 45 patients treated with mild decompression at 11 US sites. Outcome measures included the Visual Analog Scale (VAS), Oswestry Disability Index, and Zurich Claudication Questionnaire. Safety was monitored throughout the procedural and follow-up period for all patients. Interim data are included for these patients at 1 week, 6 months, and 1-year follow-up. RESULTS: Seventy-one percent of patients reported improvement in VAS at the end of the reporting period. At 2 years, patients demonstrated a statistically significant reduction of pain as measured by VAS, and improvement in physical function and mobility was significant as measured by Zurich Claudication Questionnaire and Oswestry Disability Index. Tukey honestly significant different test found significant improvement in all outcome measures from baseline to each follow-up interval. Further, major improvement occurred by 1-week follow-up and showed no difference between each subsequent follow-up, signifying considerable stability and durability of the initial result over time. No major device or intraprocedural adverse events were reported. DISCUSSION: In this report of 2-year follow-up on 45 patients treated with mild percutaneous lumbar decompression, patients experienced statistically significant pain relief and improved functionality.

A novel method for treatment of lumbar spinal stenosis in high-risk surgical candidates: pilot study experience with percutaneous remodeling of ligamentum flavum and lamina.

OBJECT: treatment of lumbar spinal stenosis (LSS) in chronically ill or debilitated patients is challenging. The percutaneous remodeling of ligamentum flavum and lamina (PRLL) technique is a novel method for decompression of the hypertrophic ligamentum flavum component of LSS that is performed using a fluoroscopically guided percutaneous approach, local anesthesia, and minimal sedation. METHODS: fourteen patients deemed to be at high risk for complications related to open spine surgery and general anesthesia were treated using the PRLL technique. Prospectively collected visual analog scale (VAS) and Oswestry Disability Index (ODI) data were analyzed at the most recent follow-up. The average follow-up duration was 23.5 weeks. RESULTS: a statistically significant improvement in VAS scores was observed, with a reduction in pain of 53% compared with preoperative levels. In contrast, the ODI scores failed to improve. CONCLUSIONS: this pilot series points to a potential new therapeutic option for LSS in high-risk surgical patients.

MiDAS I (mild Decompression Alternative to Open Surgery): a preliminary report of a prospective, multi-center clinical study.

BACKGROUND: Neurogenic claudication due to lumbar spinal stenosis is a common problem that can be caused by many factors including hypertrophic ligamentum flavum, facet hypertrophy, and disc protrusion. When standard medical therapies such as pain medication, epidural steroid injections, and physical therapy fail, or when the patient is unwilling, unable, or not severe enough to advance to more invasive surgical procedures, both physicians and patients are often left with a treatment dilemma. Patients in this study were treated with mild, an ultra-minimally invasive lumbar decompression procedure using a dorsal approach. The mild procedure is performed under fluoroscopic imaging to resect bone adjacent to, and achieve partial resection of, the hypertrophic ligamentum flavum with minimal disruption of surrounding muscular and skeletal structure. OBJECTIVE: To assess the clinical application and patient safety and functional outcomes of the mild lumbar decompression procedure in the treatment of symptomatic central canal spinal stenosis. STUDY DESIGN: Multi-center, non-blinded, prospective clinical study. SETTING: Fourteen US spine specialist practices. METHODS: Between July 2008 and January 2010, 78 patients were enrolled in the MiDAS I Study and treated with the mild procedure for lumbar decompression. Of these patients, 6-week follow-up was available for 75 patients. OUTCOME ASSESSMENT: Visual Analog Score (VAS), Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and SF-12v2 Health Survey. Outcomes were assessed at baseline and 6 weeks post-treatment. RESULTS: There were no major device or procedure-related complications reported in this patient cohort. At 6 weeks, the MiDAS I Study showed statistically and clinically significant reduction of pain as measured by VAS, ZCQ, and SF-12v2. In addition, improvement in physical function and mobility as measured by ODI, ZCQ, and SF-12v2 was statistically and clinically significant in this study. LIMITATIONS: This is a preliminary report encompassing 6-week follow-up. There was no control group. CONCLUSIONS: In this 75-patient series, and in keeping with a previously published 90-patient safety cohort, the mild procedure proved to be safe. Further, based on near-term follow-up, the mild procedure demonstrated efficacy in improving mobility and reducing pain associated with lumbar spinal canal stenosis.

Unintentional vascular uptake in fluoroscopically guided, contrast-confirmed spinal injections: a 1-yr clinical experience and discussion of findings.

OBJECTIVE: Documentation of vascular uptake on spinal injection in the context of negative aspiration and negative passive filling of blood into the hub of the needle. DESIGN: A total of 1,295 consecutive outpatients receiving fluoroscopically guided, contrast-confirmed injection in a multispecialty practice over a 1-yr time frame were retrospectively reviewed with passive observation for inadvertent vascular uptake, passive filling, and required repositioning. RESULTS: Positive vascular uptake was seen in 2-13% of cases with variable degrees of aspiration, passive filling, and required needle repositionings to avoid vascular uptake. CONCLUSION: Negative aspiration and allotment for passive filling is inadequate to confirm the absence of vascular injection. Spinal injection will never be risk free. The safest method is fluoroscopically guided, contrast-confirmed injection, which should be considered the current standard of care.