Perceptions in orthopedic surgery on the use of cannabis in treating pain: a survey of patients with spine pain (POSIT Spine).

BACKGROUND: Back pain is the leading cause of disability worldwide. Despite guidelines discouraging opioids as first-line treatment, opioids remain the most prescribed drugs for back pain. There is renewed interest in exploring the potential medical applications of cannabis, and with the recent changes in national legislation there is a unique opportunity to investigate the analgesic properties of cannabis. METHODS: This was a multi-center survey-based study examining patient perceptions regarding cannabis for spine pain. We included patients presenting with back or neck pain to one of three Orthopedic clinics in Ontario. Our primary outcome was perceived effect of cannabis on back pain, while secondary outcomes were perceptions regarding potential applications and barriers to cannabis use. RESULTS: 259 patients participated in this study, 35.3% (90/255) stating they used cannabis medically. Average pain severity was 6.5/10 ± 0.3 (95% CI 6.2-6.8). Nearly three-quarters were prescribed opioids (73.6%, 148/201), with oxycodone/oxycontin (45.9% 68/148) being the most common, and almost half of (49.3%, 73/148) had used an opioid in the last week. Patients estimated cannabis could treat 54.3% ± 4.0 (95% CI 50.3-58.3%) of their spine pain and replace 46.2% ± 6. 6 (95% CI 39.6-52.8%) of their current analgesics. Age (ß = - 0.3, CI - 0.6-0.0), higher pain severity (ß = 0.4, CI 0.1-0.6) and previous cannabis use (ß = 14.7, CI 5.1-24.4) were associated with a higher perceived effect of cannabis. Patients thought cannabis would be beneficial to treat pain (129/146, 88.4%), and reduce (116/146, 79.5%) or eliminate opioids (102/146, 69.9%). Not considering using cannabis for medical purposes (65/150, 43.3%) was the number one reported barrier. CONCLUSIONS: Patients estimated medical cannabis could treat more than half of their spine pain, with one in three patients already using medical cannabis. 79% of patients also believe cannabis could reduce opioid usage. This data will help support more research into cannabis for musculoskeletal pain.

Comparison of full-endoscopic and tubular-based microscopic decompression in patients with lumbar spinal stenosis: a randomized controlled trial.

PURPOSE: We aimed to demonstrate non-inferiority in terms of functional outcomes in patients with lumbar spinal stenosis who underwent full-endoscopic decompression compared with tubular-based microscopic decompression. METHODS: This prospective, randomized controlled, non-inferiority trial included 60 patients with single-level lumbar spinal stenosis who required decompression surgery. The patients were randomly assigned in a 1:1 ratio to the full-endoscopic group (FE group) or the tubular-based microscopic group (TM group). Based on intention-to-treat analysis, the primary outcome was the Oswestry Disability Index score at 24 months postoperative. The secondary outcomes included the visual analog scale (VAS) score for back and leg pain, European Quality of Life-5 Dimensions (EQ-5D) score, walking time, and patient satisfaction rate according to the modified MacNab criteria. Surgery-related outcomes were also analyzed. RESULTS: Of the total patients, 92% (n = 55) completed a 24-month follow-up. The primary outcomes were comparable between the two groups (p = 0.748). However, the FE group showed a statistically significant improvement in the mean VAS score for back pain at day 1 and at 6, 12, and 24 months after surgery (p < 0.05). No significant difference was observed in the VAS score for leg pain, EQ-5D score, or walking time (p > 0.05). Regarding the modified MacNab criteria, 86.7% of patients in the FE group and 83.3% in the TM group had excellent or good results at 24 months after surgery (p = 0.261). Despite the similar results in surgery-related outcomes, including operative time, radiation exposure, revision rate, and complication rate, between the two groups (p > 0.05), less blood loss and shorter length of hospital stay were observed in the FE group (p ≤ 0.001 and 0.011, respectively). CONCLUSION: This study suggests that full-endoscopic decompression is an alternative treatment for patients with lumbar spinal stenosis because it provides non-inferior clinical efficacy and safety compared with tubular-based microscopic surgery. In addition, it offers advantages in terms of less invasive surgery. Trial registration number (TRN): TCTR20191217001.

Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non-inferiority randomized control trial.

BACKGROUND CONTEXT: Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy. PURPOSE: To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations. STUDY DESIGN / SETTING: Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers. PATIENT SAMPLE: Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population. OUTCOME MEASURES: Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals. METHODS: Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 µg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate. RESULTS: In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group. CONCLUSIONS: Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.

Causes of Residual Back Pain at Early Stage After Percutaneous Vertebroplasty: A Retrospective Analysis of 1,316 Cases.

BACKGROUND: Percutaneous vertebroplasty (PVP) is now well accepted in the treatment of painful osteopathic vertebral compression fractures (OVCF), providing early pain relief and strengthening of the bone of the vertebrae. However, some patients still experienced severe back pain after PVP. OBJECTIVES: To analyze the possible reason for unsatisfactory back pain relief (UBPR) after PVP at early stage. STUDY DESIGN: Retrospective analysis. SETTING: Hong-Hui Hospital in Xi'an. METHODS: Between March 2013 and January 2015, a total of 1,316 patients with OVCF were treated by PVP at our Hospital. Demographics, clinical data, and surgical data were collected to analyze the factors associated with UBPR after PVP. RESULTS: Sixty cases complained of UBPR, and the prevalence was 4.6%. Univariate analyses showed that preoperative bone mineral density (BMD), number of fractures, cement distribution and volume injected per level, lumbodorsal fascia contusion, and depression were associated with UBPR after PVP (P < 0.001). Multivariate analysis revealed that preoperative BMD (odds ratio [OR], 3.577; P = 0.029), lumbodorsal fascia contusion (OR, 3.805; P = 0.002), number of fractures (OR, 3.440; P < 0.001), cement volume injected per level (OR, 0.079; P < 0.001), cement distribution (OR, 3.009; P = 0.013), and depression (OR, 3.426; P = 0.028) were independently associated with UBPR after PVP at the early postoperative stage. LIMITATIONS: A further prospective controlled study is needed to explore the association between the different degrees of the aforementioned factors and UBPR after PVP. CONCLUSIONS: Preoperative low BMD, lumbodorsal fascial injury, multiple segment PVP, insufficient cement injected volume, unsatisfactory cement distribution, and depression were strong risk factors associated with UBPR after PVP in patients with OVCF. KEY WORDS: Unsatisfactory back pain relief, residual back pain, percutaneous vertebroplasty.

Long-term Radiological and Clinical Outcomes After Using Bone Marrow Mesenchymal Stem Cells Concentrate Obtained With Selective Retention Cell Technology in Posterolateral Spinal Fusion.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study was to evaluate the long-term clinical and radiological outcomes of the use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology using Cellect with a particular collagen scaffold, Healos for posterolateral spinal fusion. SUMMARY OF BACKGROUND DATA: With the increasing rate of spinal fusion, the problem of pseudarthrosis, which contributes to recurrent pain with patient disability, is considered to be the most common cause of revision lumbar spine surgery. Intensive research is being carried out to develop an alternative source of bone grafting and improve the spinal fusion rate. METHODS: A retrospective review of hospital records was performed. Identified patients were contacted to have a clinical and radiological evaluation follow-up. Clinical outcome was evaluated using visual analog scales for the back pain (VAS), Oswestry Disability Index (ODI) scores, and quality of life (EQ-5D) questionnaire. Radiological outcome was evaluated by performing dynamic flexion/extension lateral views and calculation of segmental Cobb angle. Any implant-associated complication was reported. Computed tomography (CT) scans were also performed. RESULTS: Twenty-one patients were included and all patients achieved successful fusion. The mean difference of the segmental Cobb angle was 0.48° (range 0.3°-0.7°). Computed tomography scans showed solid bilateral fusion with bridging bone (Grade I) in all patients, but solid unilateral fusion with bridging bone (Grade II) was detected for one patient at one level. Patients started to resume working activities within a mean period of 3.5 months. The VAS score for the residual back pain was 4.1 ±â€Š2.1, whereas the ODI was 10.5 ±â€Š5.6 points, and the mean disability index was 21.1%. CONCLUSION: The use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology could be considered as an effective means for augmenting spinal fusion. LEVEL OF EVIDENCE: 3.

Peripheral Nerve Stimulation for Back Pain.

Peripheral nerve stimulation (PNS) generally refers to stimulation of a named nerve via direct placement of a lead next to the nerve either via a percutaneous or open approach; in peripheral nerve field stimulation (PNFS), leads are subcutaneously placed to stimulate the region of affected nerves, cutaneous afferents, or the dermatomal distribution of the nerves which converge back to the spinal cord. Recently, there has been a renewed interest in using the PNS approach for many otherwise refractory pain conditions; however, PNFS appears to be more effective for the management of low back pain and therefore more attractive. Here we discuss procedural details of PNFS trial and implant, and provide scientific and clinical rationale for placing PNFS electrodes at a certain depth under the skin. We also summarize results of published studies on use of PNFS in the management of low back pain and list the criteria that are used for proper patient selection. Our experience and the published studies provide evidence that PNFS is a safe and well-tolerated pain control option for intractable pain conditions, including chronic low back pain. Notably, achieving efficacious pain relief relies on correct patient selection and the optimal placement of the leads, ensuring, in particular, a lead depth of 10-12 mm from the surface to maximize the target sensation (mediated by fast-adapting Aß fibers) of PNFS, which is believed to be most effective for the pain relief.

Patients' expectations of lumbar spine surgery.

PURPOSE: Patients undergoing lumbar spine surgery are a heterogeneous population and their expectations of surgery are likely to vary depending on individual and group characteristics. Our goal was to assess associations between expectations and demographic, psychological, and clinical characteristics in patients undergoing lumbar spine surgery. METHODS: Shortly before surgery (mean 7 ± 3 days) 420 patients completed the valid and reliable Hospital for Special Surgery, Lumbar Spine Surgery Expectations Survey, which encompasses physical and psychological expectations; scores range from 0 to 100, higher scores reflect greater expectations. Patients completed additional surveys addressing multiple variables, including disability due to pain with a modified version of the Oswestry Disability Index (ODI). RESULTS: The mean age was 55 ± 15 years, 57 % were men, and most surgery was for painful conditions. The mean Expectations Survey score was 72 ± 20 (range 2.5-100). In multivariate analysis, patients had higher scores (i.e., greater expectations) if they were younger (OR 1.02, CI 1.01, 1.04; p = .002), were not widowed (OR 4.9; CI 1.5, 15.5; p = .007), had prior chiropractic care (OR 1.8; CI 1.1, 2.8; p = .02), had worse ODI scores (OR 2.3; CI 1.5, 3.5; p = .0001), and had worse mental health scores (OR 1.8; CI 1.2, 2.8; p = .006). In additional multivariate analyses, worse ODI score was the clinical variable most closely associated with expecting more Expectations Survey items and expecting more improvement per item. CONCLUSIONS: There were wide variations in expectations among patients. Multiple demographic, psychological, and clinical characteristics were associated with expectations, with disability due to pain being the most consistently associated variable.

Back pain in adults.

This article provides a summary of the many causes of back pain in adults. There is an overview of the history and physical examination with attention paid to red flags that alert the clinician to more worrisome causes of low back pain. An extensive differential diagnosis for back pain in adults is provided along with key historical and physical examination findings. The various therapeutic options are summarized with an emphasis on evidence-based findings. These reviewed treatments include medication, physical therapy, topical treatments, injections, and complementary and alternative medicine. The indications for surgery and specialty referral are also discussed.

Ozonoterapia y síndrome de cirugía fallida de espalda / No disponible

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Vertebroplasty and kyphoplasty under local anesthesia: review of 91 patients.

AIM: Vertebroplasty (VP) and kyphoplasty (KP) are minimally invasive methods for the treatment of vertebral compression fractures (VCF). In this study, we aimed to present our experience with VP and KP performed under local anesthesia and percutaneously. MATERIAL AND METHODS: Between 2002 and 2008, 91 patients (total 112 vertebrae) with VCF due to osteoporosis, tumor and trauma underwent VP or KP. After radiological and routine evaluations, all patients were operated under local anesthesia. Mean operation time was 20 minutes per vertebrae. We never stopped the operation because of intolerance of any patient and all of them were discharged on the day of operation or the next day except one. RESULTS: All patients had severe back pain. Mean preoperative Visual Analogue Scale (VAS) score for pain was 8.3 and the mean postoperative value was 2.7. Mean anterior wall and mid-vertebral body heights increased by 32% and 43%, respectively. The mean kyphotic angle decreased from 15.4 to 11.2. Cement leakage was observed in 4 patients and one of them underwent an open operation (decompression and stabilization) because of cement leakage to the epidural space. There was no other complication. CONCLUSION: Vertebroplasty and kyphoplasty are safe, effective and minimally invasive procedures. Elderly patients can thefore avoid the potential complications of general surgery and be mobilized and discharged early.

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.

Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial.

OBJECTIVE: We analyzed the cost-effectiveness and cost-utility of treating failed back-surgery syndrome using spinal cord stimulation (SCS) versus reoperation. MATERIALS AND METHODS: A disinterested third party collected charge data for the first 42 patients in a randomized controlled crossover trial. We computed the difference in cost with regard to success (cost-effectiveness) and mean quality-adjusted life years (cost-utility). We analyzed the patient-charge data with respect to intention to treat (costs and outcomes as a randomized group), treated as intended (costs as randomized; crossover failure assigned to a randomized group), and final treatment costs and outcomes. RESULTS: By mean 3.1-year follow-up, 13 of 21 patients (62%) crossed from reoperation versus 5 of 19 patients (26%) who crossed from SCS (P < 0.025) [corrected]. The mean cost per success was US $117,901 for crossovers to SCS. No crossovers to reoperation achieved success despite a mean per-patient expenditure of US $260,584. The mean per-patient costs were US $31,530 for SCS versus US $38,160 for reoperation (intention to treat), US $48,357 for SCS versus US $105,928 for reoperation (treated as intended), and US $34,371 for SCS versus US $36,341 for reoperation (final treatment). SCS was dominant (more effective and less expensive) in the incremental cost-effectiveness ratios and incremental cost-utility ratios. A bootstrapped simulation for incremental costs and quality-adjusted life years confirmed SCS's dominance, with approximately 72% of the cost results occurring below US policymakers' "maximum willingness to pay" threshold. CONCLUSION: SCS was less expensive and more effective than reoperation in selected failed back-surgery syndrome patients, and should be the initial therapy of choice. SCS is most cost-effective when patients forego repeat operation. Should SCS fail, reoperation is unlikely to succeed.

Spinal cord stimulation for failed back surgery syndrome and other disorders.

Chronic pain is a complex condition that requires a multi-disciplinary approach to management. Spinal cord stimulation (SCS) has evolved into a relatively easily implemented, reversible technique with low morbidity for the management of chronic, intractable pain in selected patients. Percutaneous placement of electrode arrays, under local anaesthesia. supported by programmable, implanted electronics has been a major technical advance. Multicenter prospective studies were conducted and demonstrated that SCS. as a neuromodulation procedure, is indeed a superior method for treatment of chronic pain if the patients are selected with caution and a proper strategy. Future development of innovative electrodes and pulse generation systems will continue to improve this therapy.

Treatment of multilevel degenerative disc disease with intradiscal electrothermal therapy.

Intradiscal electrothermal therapy is a frequently performed procedure for the pain of internal disc disruption. It is typically performed on one to two discs; the discal treatment is followed by a long period of rest and rehabilitation. In patients with multilevel disc disease, intradiscal electrothermal therapy is either not contemplated or only one to two discs are treated at a time. This approach therefore either denies these patients the potential benefits of intradiscal electrothermal therapy or significantly prolongs the period of pain and disability. A 25-year-old female patient presented with internal disc disruption at four lumbar disc levels, diagnosed by provocative discography and post discography CT scan. All these discs were treated simultaneously by intradiscal electrothermal therapy. The patient tolerated the procedure well and responded favourably with significant and prolonged decrease in her symptoms. She reported sustained reduction in her pain and showed no clinical evidence of early neurological or infectious complications during 18 months of follow-up. This report indicates that intradiscal electrothermal therapy can be performed at multiple levels at a single sitting, compared to intradiscal electrothermal therapy performed at one to two discs at a time, this approach may obviate the need for surgery and may reduce the duration of pain and disability incurred. However, the influence of multilevel intradiscal electrothermal therapy on long-term complications or outcome is not known.

Neurostimulation for chronic neuropathic back pain in failed back surgery syndrome.

Failed back surgery syndrome (FBSS) is defined as persistent or recurrent pain, mainly in the lower back and/or legs, even after previous anatomically successful spinal surgery. Treatment of such patients is difficult, with conservative therapy and repeated back surgery often proving unsuccessful at providing adequate pain relief. Spinal cord stimulation (SCS) is a minimally invasive procedure that allows physicians and patients to inexpensively evaluate the response to therapy before permanent implantation. Both trial stimulation and permanent implantation are fully reversible. Early treatment with SCS has been shown to be very effective in well-selected FBSS patients and should be considered instead of reoperation. Clinical studies have demonstrated that SCS provides a sustained, long-term, 50% or more reduction in pain in over 60% of patients and allows concomitant pain medication to be reduced. The substantial improvements in quality of life and functional status permit many patients to return to work. Patients express great satisfaction with SCS and minimal side effects are observed. Moreover, SCS has been shown to be a cost-effective alternative to conventional therapies. Thus, SCS is the treatment of choice in medically refractory FBSS patients where recurrent neuropathic pain persists after surgery and analgesics are no longer effective or accompanied by intolerable side effects.