Cervical surgery rate in neck pain patients with and without acupuncture treatment: a retrospective cohort study.

OBJECTIVE: Surgical treatment of neck pain often entails high costs and adverse events. The present cohort study investigated whether utilisation of acupuncture in neck pain patients is associated with a reduced rate of cervical surgery. METHODS: The Korean National Health Insurance Service National Sample Cohort (NHIS-NSC) database was retrospectively analysed to identify the 2 year incidence of cervical surgery in Korean patients suffering neck pain from 2004 to 2010. The incidence was calculated and compared between patients receiving and not receiving acupuncture treatment using Cox proportional hazards models. Cumulative survival rates were compared using Kaplan-Meier survival analysis. RESULTS: The acupuncture and control groups included 50 171 and 128 556 neck pain patients, respectively. A total of 50 161 patients were selected in each group following propensity score matching with regard to sex, age, income and Charlson comorbidity index. The hazard ratio (HR) for surgery within 2 years was significantly lower in the acupuncture group compared with the control group (HR 0.397, 95% CI 0.299 to 0.527). In addition, subgroup analyses according to gender, age and income revealed consistent results for both men (HR 0.337, 95% CI 0.234 to 0.485) and women (HR 0.529, 95% CI 0.334 to 0.836); the results were consistently observed across all age and income strata. Sensitivity analysis with varying numbers of acupuncture treatments and treatment course duration also consistently indicated lower HRs for surgery within 2 years in the acupuncture group compared with the control group. CONCLUSIONS: A significantly lower HR for cervical surgery was observed in neck pain patients following acupuncture treatment. Acupuncture treatment may therefore be an effective method for managing neck pain, and has the potential to mitigate unnecessary surgery. These findings need to be confirmed by prospective studies.

Clinical Hypnosis in Postoperative, Adult-Onset Dysphagia: A 2-Year Empirical Case Study.

Dysphagia, the perceived impediment to swallowing food, is a common postsurgical symptom that can have debilitating consequences. This study presents the successful treatment of severe esophageal dysphagia with a problem-focused and patient-centered approach to hypnosis, informed by long-term empirical follow-up. The authors describe a case history involving significant and persistent difficulty swallowing for which no medical or surgical treatment could be found. Over the course of 10 sessions, the patient was assessed, treated with imaginal exposure, and instructed in self-hypnosis. Outcomes were measured at treatment conclusion, and 6-, 9-, and 18-month follow-ups. Following hypnosis, the patient exhibited significant and reliable change (RC) in visceral hypersensitivity (RC = -3.16, p = .002), emotional distress (RC = -2.21, p= .03), subjective well-being (RC = 4.14, p< .0001), and posttraumatic symptoms (RC = -3.33, p= .001). Gains were maintained at 18-month follow-up.

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.

Effect of electroacupuncture on thermal pain threshold and expression of calcitonin-gene related peptide, substance P and γ-aminobutyric acid in the cervical dorsal root ganglion of rats with incisional neck pain.

OBJECTIVE: Acupuncture therapy effectively reduces post-surgical pain, but its mechanism of action remains unclear. The aim of this study was to investigate whether expression of γ-aminobutyric acid (GABA) and the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) in the primary sensory neurons of cervical dorsal root ganglia (DRG) are involved in electroacupuncture (EA)-induced analgesia in a rat model of incisional neck pain. METHODS: The pain model was established by making a longitudinal midline neck incision in 60 rats. Another 15 rats underwent sham surgery (normal group). Post-incision, 15 rats remained untreated (model group) and 45 rats underwent EA (frequency 2/100 Hz, intensity 1 mA) at bilateral LI18, LI4-PC6 or ST36-GB34 (n=15 each) for 30 min at 4 hours, 24 hours, and 48 hours post-surgery, followed by thermal pain threshold (PT) measurement. 30 min later, the rats were euthanased and cervical (C3-6) DRGs removed for measurement of immunoreactivity and mRNA expression of SP/CGRP and the GABAergic neuronal marker glutamic acid decarboxylase 67 (GAD67). RESULTS: Thermal PT was significantly lower in the model group versus the normal group and increased in the LI18 and LI4-PC6 groups but not the ST36-GB34 group compared with the model group. Additionally, EA at LI18 and LI4-PC6 markedly suppressed neck incision-induced upregulation of mRNA/protein expression of SP/CGRP, and upregulated mRNA/protein expression of GAD67 in the DRGs of C3-6 segments. CONCLUSIONS: EA at LI18/LI4-PC6 increases PT in rats with incisional neck pain, which is likely related to downregulation of pronociceptive mediators SP/CGRP and upregulation of the inhibitory transmitter GABA in the primary sensory neurons of cervical DRGs.

Safety and Efficacy Study of an Ozone Laser Combined Therapy Using Puncture Needle in the Treatment of Patients With Cervical Spondylosis.

STUDY DESIGN AND METHODS: Fifty-eight patients with cervical spondylosis (CS) were treated with patented technology of ozone laser combined therapy using puncture needle between August 2008 and February 2010. Visual Analogue Scale (VAS) score changes before and 6 months after surgery and MacNab score criteria 6 months after surgery were analyzed. BACKGROUND AND OBJECTIVE: CS normally occurs over the age of 50 and broadly presents as either myelopathy or radiculopathy. Complementary treatment strategies have long been envisaged as a possible alternative in alleviating neck pain associated with CS; however, it is still in moderate use due to lack of adequate and convincing evidence of its safety and efficacy. The current study was to define and understand the therapeutic effects and safety of a newly developed patented technology, ozone, and laser via puncture needle, in the treatment of CS. RESULTS: The VAS score of preoperative neck and shoulder pain was (6.57±1.34) scores, which decreased to 1.80±0.65 at 1-week postsurgery, and was completely alleviated by the end of 1 month (VAS score 0-2 after 1, 3, and 6 mo after surgery) (Kruskal-Wallis rank-sum test, H=1.680, P=0.000). VAS scores did not exhibit any significant rebound within 6 months after surgery (29 patients were excellent; 23 good; and 6 were fair, overall excellent, and good rate of 89.6%). CONCLUSION: Ozone and laser combined therapy via puncture needle for the treatment of CS is safe and effective.

Cryoablation for the treatment of occipital neuralgia.

BACKGROUND: Treatment of occipital neuralgia (ON) can be complex, though many treatment options exist. Cryoablation (CA) is an interventional modality that has been used successfully in chronic neuropathic conditions and is one such option. OBJECTIVE: To study and evaluate the efficacy and safety of cryoablation for treatment of ON. STUDY DESIGN: Retrospective evaluation. SETTING: Academic university-based pain management center. METHODS: All patients received local anesthetic injections for ON. Patients with greater than or equal to 50% relief and less than 2 week duration of relief were treated with CA. RESULTS: Thirty-eight patients with an average age of 49.6 years were included. Of the 38 patients, 20 were treated for unilateral greater ON, 10 for unilateral greater and lesser ON, and 8 for bilateral greater ON. There were 10 men and 28 women, with an average age of 45.2 years and 51.1 years, respectively. The average relief for all local anesthetic injections was 71.2%, 58.3% for patients who reported 50 - 74% relief (Group 1) and 82.75% for patients who reported greater than 75% relief (Group 2). The average improvement of pain relief with CA was 57.9% with an average duration of 6.1 months overall. Group 1 reported an average of 45.2% relief for an average of 4.1 months with CA. In comparison, Group 2 reported an average of 70.5% relief for 8.1 months. The percentage of relief (P = 0.007) and duration of relief (P = 0.0006) was significantly improved in those reporting at least 75% relief of pain with local anesthetic injections (Group 2 vs Group 1). Though no significance in improvement from CA was found in men, significance was seen in women with at least 75% benefit with local anesthetic injections in terms of duration (P = 0.03) and percentage (P = 0.001) of pain relief with CA. The average pain score prior to CA was 8 (0 - 10 visual analog scale, VAS), this improved to 4.2, improvement of 3.8 following CA at 6 months (P = 0.03). Of the 38 patients, 3 (7.8%) adverse effects were seen. Two patients reported post procedure neuritis and one was monitored for procedure-related hematoma. LIMITATIONS: Study limitations include the retrospective nature of the study. Additionally, only the percentage of relief, pain score, and duration of relief were collected. CONCLUSIONS: CA is safe, and should be considered in patients with ON. KEY WORDS: Cryoablation, cryoanalgesia, occipital neuralgia, treatment, adverse effects.

Spinal stimulator peri-electrode masses: case report.

The authors describe a case of delayed spastic quadriparesis caused by a peri-electrode mass following the implantation of a minimally invasive percutaneous spinal cord stimulator (SCS). Prior reports with paddle-type electrodes are reviewed, and a detailed histological and pathophysiological comparison with the present case is made. The patient developed tolerance to a cervical percutaneous SCS 4 months after implantation, followed by the onset of spastic quadriparesis 9 months after implantation. The stimulator was removed, and contrast-enhanced MRI revealed an enhancing epidural mass where the system had been placed, with severe spinal cord compression. Decompression was carried out, and the patient experienced neurological improvement. Pathological examination revealed fibrotic tissue with granulomatous and multinucleated giant cell reactions. No evidence of infection or hemorrhage was found. Professionals treating patients with SCSs or contemplating their insertion should be aware of this delayed complication and associated risk factors.

[Effect of electroacupuncture at different acupoints on expression of cervico-spinal GDNF and BDNF and their receptor genes in neck-incision pain rats].

OBJECTIVE: To observe the effect of electroacupuncture (EA) of "Futu" (LI 18), etc. on the expression of genes of glial cell line-derived neurotrophic factor (GDNF), brain-derived neurotrophic factor (BDNF) and their receptors in the cervico-spinal cord in neck-incision pain rats, so as to study its mechanism underlying incision-pain relief. METHODS: A total of 50 Sprague Dawley male rats were randomly divided into normal, model (incision pain), EA-Futu (LI 18), EA- Hegu (LI 4) - Neiguan (PC 6, LI 4-PC 6) and EA-Zusanli (ST 36)-Yanglingquan (GB 34, ST 36-GB 34) groups (n = 10/group). A 1.5 cm long longitudinal incision was made along the midline of the neck under anesthesia to duplicate neck-incision pain model. Thermal pain threshold (PT) was measured before and after modeling and after the treatment, respectively. EA (1-2 mA, 2 Hz/100 Hz) was applied to bilateral LI 18, PC 6-LI 4 and ST 36-GB 34 for 30 min. The expression of genes of GDNF and its receptor GFRalpha-1, and BDNF and its receptors TrkA, TrkB in the spinal cord (C1 - C4) tissue was detected by quantitative real-time-PCR. RESULTS: In comparison with pre-modeling in the same one group, the thermal PT levels were decreased obviously in the model, LI 18, LI 4-PC 6 and ST 36-GB 34 groups after neck incision (P < 0.05). Compared with the model group, the PT levels were increased markedly in LI 18, LI 4-PC 6 and ST 36-GB 34 groups after the EA treatment (P < 0.05). Correspondingly, the expression levels of spinal GDNF mRNA and GFRalpha-1 mRNA were obviously lower, as well as BDNF mRNA was markedly higher in the model group than in the control group (P < 0.05), and those of TrkA mRNA and TrkB mRNA were increased slightly in the model group than in the control group (P > 0.05). In comparison with the model group, the expression levels of spinal GDNF mRNA and GFRalpha-1 mRNA were up-regulated considerably (P < 0.001), whereas those of BDNF mRNA, TrkA mRNA and TrkB mRNA were decreased slightly (P > 0.05) in the LI 18, LI 4-PC 6 and ST 36-GB 34 groups after EA treatment. CONCLUSION: EA stimulation can significantly suppress pain reaction of neck incision, which is closely associated with its effects in up-regulating the expression of GDNF and its receptor GFRalpha-1 genes in the cervical spinal cord (C1 - C4).

Assessment of the influence of Saunders traction and transcutaneous electrical nerve stimulation on hand grip force in patients with neck pain.

BACKGROUND: Spinal pain syndromes are among the most frequent causes of ill health. Long-lasting sustained overload results in a critical decrease in the distance between neighbouring vertebrae and radiation of pain. The aim of this study was to assess the effect of cervical traction and the TENS method on the strength of painless grip and maximum strength of the arm flexors. MATERIAL AND METHODS: The study included 45 patients with overload-induced cervical pain, ranging in age from 21 to 66 years. The patients underwent a therapy based on the Saunders traction device and the TENS method. The traction force was regulated so that the patient would feel noticeable but painless traction. The TENS procedure was performed using the conventional method. The patients were divided into three groups. The Saunders traction device was used in the first group, transcutaneous electrical nerve stimulation and traction were applied in the second group, while the patients in the third group were received TENS only. Each patient underwent 10 treatment sessions with intervals between sessions not exceeding three days. RESULTS: The results showed the greatest improvement in the strength of painless hand grip. Maximum strength increased only on the left side in the group which received only the traction treatment. CONCLUSIONS: The use of the Saunders cervical traction device produced an increase in painless hand grip strength in patients with cervical spine pain. Both treatments had a limited effect on maximum hand grip strength.

Cervical ependymoma in a male adolescent with neck and back pain.

OBJECTIVE: This case study addresses the clinical presentation, imaging manifestations, and management of an intramedullary ependymoma in an adolescent who presented for chiropractic evaluation with severe neck and back pain. The atypical manifestations of this disorder are emphasized. CLINICAL FEATURES: A 16-year-old male adolescent presented with severe neck and back pain and diffuse paresthesia extending into the dorsum of the forearm and wrist bilaterally. Magnetic resonance imaging revealed an intramedullary mass extending from C1 to C7. Biopsy of this lesion indicated a grade III intramedullary ependymoma. INTERVENTION AND OUTCOME: The patient underwent a successful resection of the tumor with minimal neurological deficit. At 4 months after resection, the follow-up examination yielded minimal discomfort in the neck and upper back, however there was severe cervical kyphosis. Postoperative magnetic resonance imaging revealed no evidence of intramedullary lesion. CONCLUSION: Although it is a rare and slow growing neoplasm, early detection is critical for optimal postoperative functional outcome that is directly related to the preoperative functional status.

Placement of an electrode array as a dural substitute for dorsal column stimulation: technical note.

One the drawbacks of the dorsal column stimulation (DCS) method is that the electrode array and the subsequent electrical stimulation induce proliferation of connective tissue between the array and the dura. In this case report, a patient is presented in whom dural thickening after placement of a DCS electrode array at the C2-C3 level prevented sufficient electrical penetration and thus resulted in treatment failure. The thickened dura was excised and the electronic array was used as a dural substitute. This resulted in efficient DCS and resolution of the pain symptoms.

Cervical intradiscal radiofrequency lesioning: a feasiblity study.

OBJECTIVE: The objective of this benchtop study was to establish if single site, long duration intradiscal radiofrequency (RF) at two different positions could generate adequate heating throughout the intervertebral disc to potentially ablate intradiscal nociceptors. DESIGN: The disarticulated cervical spines from four fresh frozen cadavers were studied. Temperature recording was completed from two different positions of the RF needle. The needle was either placed in the middle of the disc in four discs, or it was inserted in the posterior quarter of the disc, in eight discs. Thermocouple measurements were made every 2 minutes from three positions: middle of the disc, posterolateral aspect of the disc, and in the anterior third of the disc. SETTING: Fluoroscopy suite. MATERIALS: Disarticulated cervical spine specimens. INTERVENTIONS: Intradiscal RF lesioning in the middle and posterior portion of the cervical disc at 85 degrees C for 10 minutes. OUTCOME MEASURES: Local temperature within the disc. RESULTS: Lesioning in either the middle or posterior portion of the disc failed to provide sufficient temperature increases throughout the cervical disc to achieve adequate denervation. CONCLUSIONS: As in the lumbar spine, intradiscal cervical RF provides too focal a thermal profile to effectively denervate the disc even in an ex vivo experiment. Thus, single site, long duration cervical intradiscal RF lesioning in vivo cannot be recommended.

Chronic neck pain: how to approach treatment.

Chronic neck pain is a common patient complaint. Despite its frequency as a clinical problem, there are few evidence-based studies that document efficacy of therapies for neck pain. The treatment of this symptom is based primarily on clinical experience. Preventing the development of chronic neck pain can be achieved by modification of the work environment with chairs that encourage proper musculoskeletal movement. The use of neck supports for sleep and active neck exercises together can improve neck pain. Passive therapies, including massage, acupuncture, mechanical traction, and electrotherapy, have limited benefit when measured by clinical trial results. NSAIDs, muscle relaxants, and pure analgesics are the mainstays of therapy. Local injections of anesthetics with or without soluble corticosteroid preparations offer additional pain relief. The purpose of these agents is to diminish pain to facilitate normal neck movement. Surgical therapy with cervical spine fusion is indicated for the rare patient with intractable neck pain resistant to all nonsurgical therapies.

Retropharyngeal abscess presenting as benign neck pain.

OBJECTIVE: To present a case of an uncommon presentation of cellulitis of the neck as benign neck pain. CLINICAL FEATURES: A 44-year-old man had severe neck pain and headaches for 2 weeks with an unknown cause. Minimal response to chiropractic treatment leads to coordination of treatment with the patient's primary care physician. Laboratory assessment and magnetic resonance imaging initially were viewed as insignificant but were repeated and showed a retropharyngeal abscess. INTERVENTION AND OUTCOME: Chiropractic treatment did not reduce the patient's neck pain as expected. Fusion of C1 to C2 was eventually performed. CONCLUSION: Neck pain is a common reason for patients to seek chiropractic care. This case shows an uncommon differential diagnosis for a patient who does not respond quickly to chiropractic treatment for neck pain.

Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.

OBJECTIVE: The aim of this study was to measure the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain. DESIGN: This study is a retrospective analysis of claims data from a managed-care health plan over a 4-year period. The use rates of advanced imaging, surgery, inpatient care, and plain-film radiographs were compared between employer groups with and without a chiropractic benefit. RESULTS: For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (-32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (-37.2%); plain-film radiography (-23.1%); and inpatient care (-40.1%). On a per-patient basis, the rates were reduced by the following: surgery (-13.7%); CT/MRI (-20.3%); plain-film radiography (-2.2%); and inpatient care (-24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (-49.4%); CT/MRI (-45.6%); plain-film radiography (-36.0%); and inpatient care (-49.5%). Per patient, the rates were surgery (-31.1%); CT/MRI (-25.7%); plain-film radiography (-12.5%); and inpatient care (31.1%). All group differences were statistically significant. CONCLUSION: For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Percutaneous treatment of pediatric aneurysmal bone cyst at C1: a minimally invasive alternative: a case report.

An 11-year-old girl presenting with neck pain was diagnosed as having an aneurysmal bone cyst involving the posterior arch of C1. Minimally invasive treatment was performed with percutaneous injections of calcitonin and methylprednisolone. Two injections separated in time by 2 months were performed with complete sclerosis and ossification of the cyst over a period of 6 months. Such percutaneous sclerosis offers an important primary therapeutic option or an adjunct to surgery of these otherwise vascular cystic masses and should be contemplated as the initial step in the treatment of these benign tumors, especially those in the spine where surgical treatment can involve complex resection and fixation procedures.

Case report: whiplash-associated disorder from a low-velocity bumper car collision: history, evaluation, and surgery.

STUDY DESIGN: Case report of a patient with a whiplash-associated disorder following a bumper car collision. Imaging studies failed to provide an anatomic explanation for the debilitating symptoms. OBJECTIVES: To report a chronic, debilitating pain syndrome after a low-velocity bumper car collision while using complex range-of-motion data for the diagnosis, prognosis, and surgical indication in whiplash-associated disorder. SUMMARY OF BACKGROUND DATA: The controversy of whiplash-associated disorder mainly concerns pathophysiology and collision dynamics. Although many investigations attempt to define a universal lesion or determine a threshold of force that may cause permanent injury, no consensus has been reached. METHODS: Eight years after a low-velocity collision, the patient underwent surgical excision of multiple painful trigger points in the posterior neck. Computerized motion analysis was used for pre- and postoperative evaluations. RESULTS: Surgical treatment resulted in an increase in total active range of motion by 20%, reduced intake of pain medication, doubled the number of work hours, and generally led to a dramatic improvement in quality of life. CONCLUSIONS: This case of whiplash-associated disorder after a low-velocity collision highlights the difficulty in defining threshold of injury in regard to velocity. It also illustrates the value of computerized motion analysis in confirming the diagnosis of whiplash-associated disorder and in the evaluation of prognosis and treatment.

Chiropractic treatment of postsurgical neck syndrome with mechanical force, manually assisted short-lever spinal adjustments.

OBJECTIVE: To describe a case of postsurgical neck pain, after multiple spinal surgeries, that was successfully treated by chiropractic intervention with instrumental adjustment of the cervical spine. CLINICAL FEATURES: A 35-year-old woman had chronic neck pain for over 5 years after two separate surgeries of the cervical spine: a diskectomy at C3/4 and a fusion at C5/6. Surgeries were performed 6 months apart in an attempt to resolve persistent neck pain and spasm of the cervical musculature. Neither surgery was effective in relieving the patient's pain. Five years after the second surgery, a third surgery was recommended by the patient's physicians to alleviate the chronic pain. The patient sought chiropractic evaluation of her condition to avoid further surgical intervention. INTERVENTION AND OUTCOME: The patient was treated with conservative instrumental chiropractic manipulation, consisting of mechanical force, manually assisted short-lever spinal adjustments rendered with an Activator Adjusting Instrument (AAI) II. She comfortably tolerated the treatment and responded favorably to this therapy. All chronic symptoms had resolved within 30 days of instituting the chiropractic instrumental adjustments with an AAI. More interestingly, longitudinal examination over the next 2 years showed that the patient experienced no residual effects or further recurrences of her previous chronic problem after her initial course of chiropractic care. CONCLUSION: Chiropractic treatment of postsurgical neck syndrome may be effectively treated, in certain cases, by mechanical force, manually assisted adjusting procedures with an AAI. The use of instrumental adjustment methodology may provide chiropractic physicians with an effective alternative to manual manipulation in those cases in which the patient's surgical history or presenting symptoms make forceful manipulation of the spine, particularly performed at end range, inappropriate. This approach may be contemplated by physicians faced with managing this type of condition. Further study should be made in this regard, in an academic research setting, to determine the safest and most effective approaches to managing postsurgical patients in a chiropractic setting.

[Acupuncture and other forms of treatment for patients with chronic back pain]. / Akupuntur und andere Therapieformen beim Patienten mit chronischen Wirbelsäulenschmerzen.

As in all pain sites, one has to distinguish between acute and chronic pain in spinal pain syndromes. The treatment of chronic spinal pain is dominated by non-operative procedures. There are three main procedures in this field of treatment: the manual medicine, the therapeutic application of local anesthetics and acupuncture. By manual techniques the pain-producing spinal structures can be recognized and these techniques offer at the same time sufficient treatment options to the patients. Therefore, manual therapeutic strategies are applied at first in a treatment session followed by the therapeutical application of local anesthetics. With this treatment the pain-producing spinal sites are directly influenced with the aim of blocking the nociceptors. Acupuncture is the last step of the treatment cascade in out patients in any case, because acupuncture does not only serve as treatment option for pain relief, but also and even more so has an harmonizing effect upon physical and psychological disturbances. It is absolutely necessary for the patient to lie down for 25 to 30 minutes to reach these goals. More invasive methods are offered to patients unsuccessfully treated by the described methods. These are: X-ray conducted periradicular infiltration, epidural blockades with local anesthetics and steroids, hiatus sacralis blockade, percutaneous radiofrequency denervation of the facet joint and percutaneous lumbar radiofrequency sympathicotomy. The indications for these treatment modalities are discussed as well as technical details regarding the performance. Disc herniation with radicular symptoms, spinal canal stenosis, cervical stenotic myelopathy and degenerative spinal instability may represent indications for surgical intervention. The symptomatology of these diseases is described. The indications for the individual cases and circumstances are discussed. Lastly, the various operative techniques are also described shortly.