Evaluation of the efficacy and safety of conventional and interlaminar full-endoscopic decompressive laminectomy to treat lumbar spinal stenosis (ENDO-F trial): Protocol for a prospective, randomized, multicenter trial.

Lumbar spinal stenosis is a common spinal degenerative condition. Minimally invasive interlaminar full-endoscopic decompressive laminectomy provides greater patient satisfaction and faster recovery than open decompressive laminectomy. The aim of our randomized controlled trial will be to compare the safety and efficacy of interlaminar full-endoscopic laminectomy and open decompressive laminectomy. Our trial will include 120 participants (60 per group) who will undergo surgical treatment for lumbar spinal stenosis. The primary outcome will be the Oswestry Disability Index measured at 12 months postoperatively. Secondary patient-reported outcomes will include back and radicular leg pain measured via a visual analog scale; the Oswestry Disability Index; the Euro-QOL-5 Dimensions score measured at 2 weeks and at 3, 6, and 12 months postoperatively; and patient satisfaction. The functional measures will include time to return to daily activities postoperatively and walking distance/time. The surgical outcomes will include postoperative drainage, operation time, duration of hospital stay, postoperative creatine kinase (an indicator of muscle injury) level, and postoperative surgical scarring. Magnetic resonance and computed tomography images and simple radiographs will be obtained for all patients. The safety outcomes will include surgery-related complications and adverse effects. All evaluations will be performed by a single assessor at each participating hospital who will be blinded to group allocation. The evaluations will be conducted preoperatively and at 2 weeks and 3, 6, and 12 months postoperatively. The randomized, multicenter design of the trial, blinding, and justification of the sample size will reduce the risk of bias in our trial. The results of the trial will provide data regarding the use of interlaminar full-endoscopic laminectomy as an alternative to open decompressive laminectomy that results in similar surgical findings with less invasiveness. Trial registration: This trial is registered at cris.nih.go.kr. (KCT0006198; protocol version 1; 27 May 2021).

Effect of Ozone Therapy on Epidural Fibrosis in Rats.

OBJECTIVE: To demonstrate the effect of medical ozone therapy on the development of epidural fibrosis. METHODS: A total of 25 Sprague-Dawley male rats were randomly divided into 3 groups: a control group (L3-L4 laminectomy only), a systemic ozone therapy (SOT) group (L3-L4 laminectomy only + intraperitoneal 15 mL [30 µg/mL] ozone), and a local ozone therapy (LOT) group (L3-L4 laminectomy only + subcutaneous 15 mL [30 µg/mL] ozone). Ozone therapy was administered 4 times on a 3-day interval during the wound-healing process, with the first dose immediately administered after surgery. The effects of ozone therapy on vascular endothelial growth factor, inflammation, and epidural fibrosis between groups were evaluated. RESULTS: Staining with vascular endothelial growth factor was significantly less in the group that received SOT compared with the control group (P = 0.021). When the groups were compared in terms of inflammation, it was found that inflammation was less common in the SOT and LOT groups compared with the control group (SOT vs. control: P = 0.004 and LOT vs. control: P = 0.024), whereas inflammation was found to be significantly less in the SOT group compared with the LOT group (P = 0.008). In the histopathologic evaluation of epidural fibrosis, there was no significant difference between the SOT and LOT groups but less epidural fibrosis was observed in both groups compared to the control group (LOT vs. control: P = 0.037; SOT vs. control: P = 0.018). CONCLUSIONS: Medical ozone therapy may be an alternative method that can be used effectively and safely in the prevention of epidural fibrosis after laminectomy.

Spinous Process Splitting Laminectomy for Lumbar Spinal Stenosis: 2D Operative Video.

Degenerative lumbar spinal stenosis involves an acquired reduction in the spinal canal diameter due to osteoarthritic changes on the disk, facet joints, and ligaments and may result in spinal cord or cauda equina compression.1 This process may lead to pain radiating to the legs, neurogenic claudication, and neurologic deficit. First-line treatment includes conservative care such as physical therapy, spinal injections, and lifestyle changes. If this strategy is insufficient to achieve symptom relief, surgical management is recommended.1,2 Surgery generally encompasses a decompression procedure through a posterior approach. There are several techniques to accomplish this in the context of severe bilateral stenosis including standard open laminectomy, unilateral laminectomy with bilateral decompression, and a tubular approach with bilateral decompression (e.g., "over-the-top technique").2 Among these, the spinous process splitting laminectomy has emerged as a strategy that allows decompressing the spinal canal through a familiar anatomy to the surgeon while respecting paravertebral muscles.3,4 This technique involves exposure of the laminae by cutting through the spinous process and then separating both halves and muscles attached at the sides. The main advantage is that the insertion of these paravertebral soft tissues is preserved, the required retraction is reduced and postoperative pain is decreased.4 Moreover, the learning curve to achieve a successful decompression employing the splitting laminectomy is substantially shorter than with other minimally invasive approaches, such as tubular. This video aims to show the steps to perform this technique (Video 1). We report the case of a 74-year-old male who presented with left sciatica and neurogenic claudication. The images showed multilevel degenerative lumbar spinal stenosis, with severe bilateral compression at L4-5, without signs of instability. Surgical alternatives were discussed with the patient, and it was decided to perform an L4-5 spinous process splitting laminectomy. The patient had a good evolution with an unremarkable postoperative course.

A randomized controlled trial of the X-Stop interspinous distractor device versus laminectomy for lumbar spinal stenosis with 2-year quality-of-life and cost-effectiveness outcomes.

OBJECTIVE: Lumbar spinal stenosis (LSS) is a common and debilitating condition that is increasing in prevalence in the world population. Surgical decompression is often standard treatment when conservative measures have failed. Interspinous distractor devices (IDDs) have been proposed as a safe alternative; however, the associated cost and early reports of high failure rates have brought their use into question. The primary objective of this study was to determine the cost-effectiveness and long-term quality-of-life (QOL) outcomes after treatment of LSS with the X-Stop IDD compared with surgical decompression by laminectomy. METHODS: A multicenter, open-label randomized controlled trial of 47 patients with LSS was conducted; 21 patients underwent insertion of the X-Stop device and 26 underwent laminectomy. The primary outcomes were monetary cost and QOL measured using the EQ-5D questionnaire administered at 6-, 12-, and 24-month time points. RESULTS: The mean monetary cost for the laminectomy group was £2712 ($3316 [USD]), and the mean cost for the X-Stop group was £5148 ($6295): £1799 ($2199) procedural cost plus £3349 mean device cost (£2605 additional cost per device). Using an intention-to-treat analysis, the authors found that the mean quality-adjusted life-year (QALY) gain for the laminectomy group was 0.92 and that for the X-Stop group was 0.81. The incremental cost-effectiveness ratio was -£22,145 (-$27,078). The revision rate for the X-Stop group was 19%. Five patients crossed over to the laminectomy arm after being in the X-Stop group. CONCLUSIONS: Laminectomy was more cost-effective than the X-Stop for the treatment of LSS, primarily due to device cost. The X-Stop device led to an improvement in QOL, but it was less than that in the laminectomy group. The use of the X-Stop IDD should be reserved for cases in which a less-invasive procedure is required. There is no justification for its regular use as an alternative to decompressive surgery. Clinical trial registration no.: ISRCTN88702314 (www.isrctn.com).

Use of acupuncture as adjuvant analgesic technique in dogs undergoing thoracolumbar hemilaminectomy.

The aim of this study was to investigate the analgesic efficacy of a preoperative acupuncture treatment in 24 client-owned dogs undergoing thoracolumbar hemilaminectomy. Dogs were randomly assigned to either group A (Acupuncture) or group C (Control). Before skin incision, group A was treated with acupuncture, performed under general anaesthesia for 30 min. Rescue intraoperative fentanyl was administered following a 20% increase in cardiovascular parameters compared to baseline values, measured before incision. An observer masked to the treatment assessed pain, pre- and postoperatively, with the Glasgow (GCPS), the Colorado (CPS) pain scales and a Visual Analogue Scale (VAS); additionally, the mechanical thresholds (MT) were measured with the Electronic von Frey Anaesthesiometer (EVF) at four points located near the herniated disc. The groups were compared with respect to intraoperative cardiovascular and respiratory variables, rescue fentanyl administered in total and at different surgical events (first incision [FI], drilling [DR], disc removal [RE] and skin suturing [ST]), and pre- and postoperative pain scores and MT. Group A received less fentanyl than group C (P = 0.014); this difference was significant at FI P = 0.035) and RE (P = 0.004). The improvement in postoperative CPS score (P = 0.013), VAS score (P = 0.003) and MT (P = 0.001) compared to preoperative values was greater for group A than for group C, whereas the treatment assignment had no effect on postoperative changes in GCPS compared to baseline. Pre-operative acupuncture may help improving perioperative analgesia in dogs with intervertebral disc herniation undergoing thoracolumbar hemilaminectomy.

A novel surgical concept of transforaminal full-endoscopic lumbar undercutting laminectomy (TE-LUL) for central canal stenosis of the lumbar spine with local anesthesia†: A case report and literature review.

Full-endoscopic spinal surgery was first developed for the lumbar herniated nucleus pulposus. Mainly, there are two types in the full-endoscopic lumbar surgery : i.e., transforaminal (TF) and interlaminar approach. The surgery can be done under the local anesthesia for the TF approach ; therefore, we need to further develop the TF approach to variety of the spinal disorders. Recently, the TF full-endoscopic surgery has been applied for the spinal canal stenosis. First, transforaminal full-endoscopic lumbar foraminoplasty for the foraminal stenosis ; then, transforaminal lumbar lateral recess decompression for the lateral recess stenosis has been developed. Finally, we have developed the surgical technique to decompress the central stenosis via TF approach under the local anesthesia. Prior to initiate the clinical case, we have attempted the lumbar undercutting laminectomy using a fresh cadaveric spine. After we technically confirmed that the transforaminal full-endoscopic lumbar undercutting laminectomy (TE-LUL) is possible, we applied the technique to the patient whose lung capacity did not allow general anesthesia. The 72 years old female patient with central canal stenosis could be improved her left leg pain and muscle weakness after TE-LUL under the local anesthesia. In this paper, we introduce the surgical technique of the TE-LUL and discuss of the efficacy of the TE-LUL. J. Med. Invest. 66 : 224-229, August, 2019.

Fully Endoscopic Lumbar Laminectomy and Transforaminal Lumbar Interbody Fusion Under Local Anesthesia with Conscious Sedation: A Case Series.

OBJECTIVE: To evaluate clinical outcomes of a case series of 18 patients who underwent fully endoscopic foraminotomy, laminectomy, and transforaminal lumbar interbody fusion combined with percutaneous screw fixation. METHODS: This was a retrospective case series of a single surgeon. Average age of patients was 66 years (range, 51-82 years). All patients had grade I or grade II spondylolisthesis and severe central canal stenosis. Patients underwent endoscopic transforaminal access through Kambin triangle for foraminotomy, discectomy, endplate preparation, and interbody fusion, which was followed by fully endoscopic unilateral laminectomy and bilateral decompression and percutaneous pedicle screw and connecting rod placement. RESULTS: All procedures were successful without conversion to open surgery. Mean operative time was 168 minutes, and average estimated blood loss was 36 mL. Mean length of hospital stay was 1.2 days. There were no intraoperative or postoperative complications. Comparison of preoperative and final clinical metrics demonstrated that average Oswestry Disability Index score improved from 48 ± 14 (range, 37-61) to 13 ± 11 (range, 0-27) (P < 0.001). Average visual analog scale back pain score improved from 8.1 ± 2.0 (range, 6.8-10.0) to 1.8 ± 0.9 (range, 0.0-3.5) (P < 0.001). Oswestry Disability Index and visual analog scale back pain scores at last follow-up showed 73% and 78% improvement, respectively, from the preoperative period. There were no cases of nonunion clinically or radiographically on final follow-up of >12 months. CONCLUSIONS: Fully endoscopic laminectomy and interbody fusion under conscious sedation is an effective treatment with minimal complications for patients with lumbar spondylolisthesis and severe spinal stenosis.

Schisandrin B attenuates epidural fibrosis in postlaminectomy rats by inhibiting proliferation and extracellular matrix production of fibroblasts.

Laminectomy has been widely considered one of the most common treatments for lumbar disorders. Epidural fibrosis (EF) is a common complication after laminectomy, causing recurrent postoperative pain. Schisandrin B (Sch.B), the active ingredient extracted from Schisandra chinensis Fructus, has been found to have potent antiproliferative and antifibrotic effects on several cells. This study aimed to investigate the effects of Sch.B on the prevention of postlaminectomy EF formation. In vitro, we studied the effects of Sch.B on transforming growth factor beta 1 (TGF-ß1)-induced proliferation and extracellular matrix (ECM) production of primary fibroblasts, as well as its underlying mechanism. We found that Sch.B not only inhibited the proliferation of fibroblasts but also reduced ECM production, including that of connective tissue growth factor, fibronectin, and type I collagen, in a dose-dependent manner. Mechanistically, we found that Sch.B suppressed TGF-ß1-stimulated activation of the Smad2/3 and mitogen-activated protein kinase pathways. Moreover, the in vivo study demonstrated that Sch.B treatment attenuated the progression of EF in a postlaminectomy rat model via reducing the cell number and ECM production of scar tissue. Taken together, these data suggested that Sch.B possesses great potential value as a preventative agent for EF.

Comparison of the Effects of Contractubex Gel and Benzothiazole After Topical Application in an Experimental Model of Epidural Fibrosis in Rats.

BACKGROUND: Postoperative epidural adhesion is a frequent cause of failed back surgery syndrome, manifesting with back and leg pain or neurologic deficits. Development of preventive measures for epidural adhesion after laminectomy is critical to improve outcomes of lumbar surgery. We hypothesized that positive effects of topical application of Contractubex (CTX) gel and benzothiazole (BT) individually and in combination could aid in preventing epidural fibrosis in a rat laminectomy model. METHODS: Rats were randomly assigned to 2 control and 5 experimental groups (n = 8 for each group). The control(-) group received no surgery, whereas the control(+) group underwent laminectomy without any drug administration. In experimental groups, study agents applied to dura mater after laminectomy were 100mgCTX, 2.5%BT, 5%BT; 100mgCTXplus2.5%BT, and 100mgCTXplus5%BT. Laminectomy was performed at the L3 level for all rats. The extent of epidural fibrosis was assessed 4 weeks later macroscopically and histopathologically. Hepatic and renal toxicity of study drugs was assessed histopathologically. RESULTS: Topical CTX and BT individually and in combination reduced epidural fibrosis after laminectomy in rats. Although a meaningful decrease of epidural fibrosis with individual application of CTX and BT (2.5% or 5%) was obtained (P < 0.05), the effect of their combination was more pronounced without meaningful hepatic and renal toxicity (P < 0.05). CONCLUSIONS: Combined use of topical CTX and BT could be a potential therapy for epidural fibrosis. Further research with this agents for the prevention of epidural fibrosis is warranted.

Awake Intradural Spinal Tumor Resection; Case Report and Literature Review.

BACKGROUND: Meningioma is a common slow-growing spinal tumor with a predilection for intradural occurrence. Patients usually present with pain followed by ataxia and sensory and sphincter problems. The gold standard treatment in these cases is gross total microsurgical resection under general anesthesia. However, there exist high-anesthetic-risk patients unsuitable for general anesthesia. Performing spinal surgeries under local anesthesia and sedation has been reported, albeit rarely for mostly minimally invasive procedures but not for open intradural pathologies. CASE DESCRIPTION: We report a 63-year-old woman with critical aortic stenosis, coronary artery disease, and severe chronic obstructive airways disease who presented with 10 months' history of worsening back pain and bilateral leg pain, ataxia, hyperreflexia in lower limbs, as well as altered lower limb sensation. Magnetic resonance imaging revealed a contrast-enhancing intradural lesion at T6/7 with severe spinal cord compression. However, the patient was American Society of Anesthesiologists class IV and her cardiac disease was not amenable to intervention. She underwent thoracic laminectomy and excision of the tumor under local anesthesia and sedation with no significant complications and clinical improvement. CONCLUSION: Our illustrative case and literature review suggest that using local anesthesia and sedation to perform spinal surgeries including intradural tumors is possible even in high-risk patients with good outcome. Our American Society of Anesthesiologists class IV patient tolerated the surgery well with gross total tumor resection and subsequent resolution of the symptoms.

Comparative Induction of Controlled Hypotension by Electroacupuncture at DU20 Acupoint and Remifentanil in Lumbar Laminectomy.

Hypotensive anesthesia is utilized to reduce bleeding during orthopedic surgery. One of the various drugs that have been used to reduce blood pressure is remifentanil. This study was an attempt to compare the effect of remifentanil with that of electroacupuncture (EA) at DU20 on reducing blood pressure. In this randomized controlled clinical trial, 54 patients undergoing lumbar laminectomy were allocated to two groups. Hypotensive anesthesia was performed through infusion of remifentanil 100 µg/kg/min for the control group, and EA at DU20 acupoint with a frequency of 2-10 Hz and intensity of 1-5 mA for the intervention group. Blood pressure, pulse rate, volume of blood lost and the quality of surgical field were evaluated every 10 min. There were no statistically significant differences between the two groups in terms of the changes in mean arterial pressure (MAP), pulse rate, and the quality of surgical field (P > 0.05). Therefore, EA can be as effective as remifentanil to reduce blood pressure in the patients undergoing lumbar laminectomy.

Hemostasis vs. epidural fibrosis?: A comparative study on an experimental rat model of laminectomy.

AIM: The aim of this study was to evaluate the histopathological and biochemical impact and effectiveness of two hemostatic agents, Ankaferd blood stopper (ABS) and Microporous Polysaccharide Hemospheres (MPH), on epidural fibrosis in an experimental rat laminectomy model. MATERIAL AND METHODS: Twenty adult Wistar albino rats were divided into MPH-treated (n=6), ABS-treated (n=6) and control (n=8) groups. Laminectomy of the lumbar spine was performed in all animals and treatment groups were exposed to MPH and ABS while closure was applied in control group as per usual. Epidural fibrosis was evaluated in all groups macroscopically, histopathologically, biochemically and with electron microscopy four weeks later. RESULTS: Statistically, it was found that MPH-treated group had significantly less epidural fibrosis compared to ABS-treated and control groups. CONCLUSION: We compared two hemostatic agents for their propensity to cause adhesions in the present study. Our results show that MPH significantly reduces epidural scar formation and dural adhesion in a rat model of laminectomy while ABS increases postoperative fibrosis.

Impacts of Ultra-early Hyperbaric Oxygen Therapy on Bone Mass of Rats With Complete Spinal Cord Transection.

STUDY DESIGN: Seventy-five SD rats were randomly assigned to four groups: sham-operated group (Sham, n = 15), complete spinal cord transection (CSCT, n = 20) group, hyperbaric oxygenation group 1 (HBO1, n = 20), and hyperbaric oxygenation group 2 (HBO2, n = 20). OBJECTIVE: The aim of this study was to analyze the impacts of ultra-early hyperbaric oxygen therapy on bone mass of rats with CSCT. SUMMARY OF BACKGROUND DATA: Treatment of patients with complete SCI is still an unresolved medical issue and needs to be further investigated. Studies on changes in bone mass as well as osteoporosis prevention after SCI have important clinical significance. METHODS: Rats in the sham group only underwent T10 laminectomy, without damaging the spinal cord. Rats in CSCT, HBO1, and HBO2 groups underwent T10 laminectomy and spinal cord transection at T10 level. Rats in HBO1 and HBO2 groups received three courses of hyperbaric oxygen therapy with 10 days per course starting at 3 and 12 hours after spinal cord injury, respectively. The femoral biomechanical characteristics, the bone calcium, and the bone hydroxyproline (B-HYP) contents were determined. Morphology of the femur bone trabecula and the bone collagen were observed by HE staining and by masson triad color staining, respectively. RESULTS: After 6 weeks of treatment, rats in the CSCT group showed significant decreases in femur structural and material mechanics parameters, calcium and B-HYP contents, (P < 0.01), as well as sparse, fractured, malaligned trabecular bone and collagen compared with rats in the sham group. After treatments, compared with rats in the CSCT and HBO2 groups, rats in HBO1 group showed enhancement in femur structural and material mechanics parameters, calcium and B-HYP contents, (P < 0.05), as well as trabecular bone and collagen with better continuity and neater arrangement. CONCLUSION: Ultra-early HBO therapy can significantly improve bone mass in CSCT rats. LEVEL OF EVIDENCE: N/A.

Three cases of hemiplegia after cervical paraspinal muscle needling.

BACKGROUND CONTEXT: Muscle needling therapy is common for chronic pain management, but the development of unusual complications such as hemiplegia is not well understood. PURPOSE: We report on three cases with hemiplegia after cervical paraspinal muscle needling and propose possible explanations for these unusual complications. STUDY DESIGN: Case report. METHODS: The authors retrospectively reviewed the medical charts from a decade (2002-2013) at Korea University Hospital. The records were systematically searched, and the cases with hemiplegia (grade<3) after needing therapy were collected. No conflict of interest reported. No funding received. RESULTS: A 54-year-old woman, a 38-year-old woman, and a 60-year-old man with hemiplegia by cervical subdural or epidural hematoma after cervical posterior paraspinal muscle needling without direct invasion (intramuscular stimulation, acupuncture, or intramuscular lidocaine) were observed. All patients were taken for emergent decompressive laminectomy, and their postoperative motor function improved substantially. CONCLUSION: Spinal hematoma after muscle needling is unusual but was thought to result after a rupture of the epidural or subarachnoid veins by a sharp increase in blood pressure delivered in the intraabdominal or intrathoracic areas after needling therapy.

Magnetic resonance imaging localization with cod liver oil capsules for the minimally invasive approach to small intradural extramedullary tumors of the thoracolumbar spine.

OBJECT: Accurate intraoperative localization of small intradural extramedullary thoracolumbar (T-1 to L-3 level) spinal cord tumors is vital when minimally invasive techniques, such as hemilaminectomy, are used to excise these lesions. In this study, the authors describe a simple and effective method of preoperative MRI localization of small intradural extramedullary tumors using cod liver oil capsules. METHODS: Thirty-five patients with intradural tumors underwent preoperative MRI localization the evening prior to surgery. Patients were positioned prone in the MRI gantry, mimicking the intraoperative position. Nine capsules were placed in 3 rows to cover the lesion. This localization was used to guide the level for a minimally invasive approach using a hemilaminectomy to excise these tumors. RESULTS: The mean patient age was 51.5 ± 14.3 years, and the mean body mass index was 24.1 ± 3.5 kg/m(2). Twenty-two tumors involved the thoracic spine, and 13 involved the upper lumbar spine from L-1 to L-3. The mean tumor size was 2.2 ± 1.0 cm. Localization was accurate in 34 patients (97.1%). CONCLUSIONS: Accurate localization with the described method is quick, safe, cost-effective, and noninvasive with no exposure to radiation. It also reduces operating time by eliminating the need for intraoperative fluoroscopy.

Effects of unilateral facet fixation and facetectomy on muscle spindle responsiveness during simulated spinal manipulation in an animal model.

OBJECTIVES: Manual therapy practitioners commonly assess lumbar intervertebral mobility before deciding treatment regimens. Changes in mechanoreceptor activity during the manipulative thrust are theorized to be an underlying mechanism of spinal manipulation (SM) efficacy. The objective of this study was to determine if facet fixation or facetectomy at a single lumbar level alters muscle spindle activity during 5 SM thrust durations in an animal model. METHODS: Spinal stiffness was determined using the slope of a force-displacement curve. Changes in the mean instantaneous frequency of spindle discharge were measured during simulated SM of the L6 vertebra in the same 20 afferents for laminectomy-only and 19 laminectomy and facet screw conditions; only 5 also had data for the laminectomy and facetectomy condition. Neural responses were compared across conditions and 5 thrust durations (≤ 250 milliseconds) using linear-mixed models. RESULTS: Significant decreases in afferent activity between the laminectomy-only and laminectomy and facet screw conditions were seen during 75-millisecond (P < .001), 100-millisecond (P = .04), and 150-millisecond (P = .02) SM thrust durations. Significant increases in spindle activity between the laminectomy-only and laminectomy and facetectomy conditions were seen during the 75-millisecond (P < .001) and 100-millisecond (P < .001) thrust durations. CONCLUSION: Intervertebral mobility at a single segmental level alters paraspinal sensory response during clinically relevant high-velocity, low-amplitude SM thrust durations (≤ 150 milliseconds). The relationship between intervertebral joint mobility and alterations of primary afferent activity during and after various manual therapy interventions may be used to help to identify patient subpopulations who respond to different types of manual therapy and better inform practitioners (eg, chiropractic and osteopathic) delivering the therapeutic intervention.

Microscopic supraciliary approach for terminal laminotomy for treatment of hydrocephalus: a preliminary report of eight cases.

AIM: Shunting and endoscopic third ventriculostomy for treatment of hydrocephalus have their own complications which make the management of such patients more difficult. We have examined the subfrontal route to fenestrate lamina terminalis in order to achieve relief of hydrocephalus in eight consecutive patients. MATERIAL AND METHODS: Eight patients with the diagnosis of hydrocephalus were chosen. A supraciliary approach to the central skull base was used to fenestrate the lamina terminalis to allow cerebrospinal fluid egress from the third ventricle to the basal cisterns. RESULTS: Clinical and/or radiological remission of hydrocephalus symptoms were observed in all patients. No complications were encountered in this small series of patients. CONCLUSION: Microsurgical third ventriculo-cisternostomy through a supraciliary might be a reasonable alternative to endoscopic third ventriculostomy. However, a more sample size with controlled subjects is required to draw conclusions and comparisons with other techniques of treatment of hydrocephalus.

Eficacia de la aplicación de ozono epidural y paravertebral a una concentración de 50 µg/ml en pacientes con dolor crónico secundario a síndrome postlaminectomía / No disponible

Introducción: el dolor crónico es una entidad que afecta a la salud física y psicológica de los pacientes. El síndrome postlaminectomía consiste en la aparición o persistencia de dolor lumbar y/o radicular en un paciente que ha tenido uno o más procedimientos quirúrgicos en la columna. Objetivo general: evaluar la efectividad de la administración de ozono epidural y paravertebral, a una concentración de 50 mg/ml, en pacientes con dolor crónico asociado a síndrome postlaminectomía lumbar. Material y métodos: durante el periodo comprendido entre el 15 de julio y el 30 de diciembre del 2010 se realizó un estudio prospectivo, en 30 pacientes de ambos géneros, con edades comprendidas entre los 18 y los 85 años de edad, que tenían un diagnóstico de dolor crónico secundario a síndrome postlaminectomia lumbar. La media de las EVAs iniciales fue 6,8 sobre 10. La primera infiltración se realizó bajo sedación endovenosa y con control fluoroscópico de la región lumbosacra; se administró vía caudal un volumen de 20 ml de ozono a una concentración de 50 mg/ml en el espacio epidural, y en la región muscular paravertebral lumbar bilateral (L3, L4 y L5) se administraron 10 ml de ozono a la misma concentración en cada nivel. En total, el volumen infiltrado fue de 60 ml. La infiltración en la región paravertebral se repitió, al mismo volumen y concentración, en intervalos de 7 días durante 3 semanas consecutivas. Para medir la efectividad del tratamiento se evaluó la intensidad del dolor considerando las medias inicial y final en la escala visual analógica (EVA). Como medida de la funcionalidad se usó el índice de discapacidad de Oswestry, que se registró previo a la infiltración y a las semanas 4 y 8. El análisis estadístico se realizó mediante el programa Statistical 7.0, aplicando el test de Friedman para las dos variables principales, y la estadística descriptiva (media y desviación estándar) para el análisis del resto de los datos. Se tomará como estadísticamente significativa p < 0,05. Resultados: se estudiaron 30 pacientes, todos ellos con dolor moderado (EVAs iniciales de 6,8 sobre 10). Las edades oscilaron entre 34 y 62 años con media y desviación estandar de 50,9 ± 7,2 años. Veintiún pacientes (70%) fueron mujeres y 9 (30%) fueron hombres. Estadísticamente se encontraron diferencias significativas en los valores medios de los índices de Oswestry (F = 10,9058, p = 0,000002) y en los de las EVAs (F = 43,3314, p < 0,01); sin embargo clínicamente no hubo cambios, pues los pacientes siguieron con valores incapacidad y dolor moderados. Conclusiones: la administración de ozono epidural y paravertebral, a concentración de 50 mg/ml, no resultó ser de utilidad en la reducción del dolor crónico y en la mejoría de la funcionalidad en pacientes con afectación moderada secundaria a síndrome postlaminectomía (AU)

Introduction: Chronic pain is a condition that affects the physical and psychological health of patients. Postlaminectomy syndrome is the onset or persistence of back pain and/or radicular pain in a patient who has had one or more surgical procedures on the spine. Objective: To evaluate the effectiveness of the administration of epidural and paravertebral ozone at a concentration of 50 mg/ml in patients with chronic pain associated with lumbar postlaminectomy syndrome. Material and methods: Between July 15 and December 30 2010 a prospective study was carried in 30 patients of both gender, aged between 18 and 85 years, who had a diagnosis of chronic pain secondary to lumbar postlaminectomy syndrome. The average initial EVA score was 6.8/10. The first injection was performed with intravenous sedation under fluoroscopic control of the lumbosacral region; then was administered through a volume flow rate 20 ml of ozone at a concentration of 50 mg/ml in the epidural space and bilateral paravertebral muscles of the lumbar spine (L3, L4 and L5) with 10 ml of ozone at the same concentration at each level. In total, the infiltrated volume was 60 ml. The infiltration of the paravertebral region was repeated at the same volume and concentration, at intervals of 7 days for 3 consecutive weeks. To measure the effectiveness of treatment was evaluated pain intensity considering the average initial and final visual analogue scale (VAS). As measurement for functionality was used the Oswestry Disability Index, which was evaluated prior to infiltration and at 4 and 8 week. Statistical analysis was performed using the Statistical 7.0, using the Friedman test for the two main variables, and descriptive statistics (mean and standard deviation) for the analysis of other data. A p < 0.05 was taken as statistically significant. Results: We studied 30 patients, all with moderate pain (initial EVA 6.8/10). The ages ranged from 34 to 62 years with mean and standard deviation of 50.9 ± 7.2 years. 21 patients (70%) were female and 9 (30%) were men. Statistically significant differences were in the mean Oswestry indices (F = 10.9058, p = 0.000002) and those of the EVAs (F = 43.3314, p < 0.01) however there was no clinical change, as patients continue with moderate disability and pain. Conclusions: Epidural and paravertebral administration of ozone at a concentration of 50 mg/ml, did not prove to be useful in relieving chronic pain and improve functionality in patients with moderate pain secondary to postlaminectomy syndrome (AU)

The utility of bone cement to prevent lead migration with minimally invasive placement of spinal cord stimulator laminectomy leads.

BACKGROUND: Lead migration is a significant concern with spinal cord stimulator (SCS) placement with rates ranging from 10% to 60%. OBJECTIVE: To describe a novel technique using bone cement at the laminotomy site to help prevent lead migration after minimally invasive placement of laminectomy paddle leads and to present our short-term results. METHODS: A review of a prospectively maintained database identified all patients who underwent minimally invasive placement of laminectomy leads with the use of bone cement. All procedures were performed between July 2008 and August 2010 with conscious sedation and local anesthetic. Intraoperative testing was performed to confirm good pain coverage. A small volume of bone cement (1-3 cm) was then placed to cover the laminectomy defect. Radiographic and clinical follow-up was assessed. RESULTS: Forty-two patients (mean age, 58.0 years) underwent 42 procedures. Back pain (88.1%) and leg pain (88.6%) were the most common presenting symptoms. No intraoperative complications were noted. Two patients (4.8%) required removal of their devices because of nonhealing wounds. All patients were followed up for a minimum of 6 months, and no cases of clinical or radiographic lead migration were seen at the time of publication. CONCLUSION: We present a novel technique in the hopes of decreasing the incidence of lead migration after minimally invasive placement of spinal cord stimulator laminectomy paddle leads. Our results have been promising thus far with no cases of lead migration.

The use of intraoperative electrophysiology for the placement of spinal cord stimulator paddle leads under general anesthesia.

BACKGROUND: Placement of spinal cord stimulating paddle leads has traditionally been performed under local anesthesia with intravenous sedation to allow intraoperative confirmation of appropriate placement. It may be difficult to maintain appropriate sedation in certain patients because of medical comorbidities. Furthermore, patients undergoing lead revision frequently have extensive epidural scarring, requiring multilevel laminectomies to place the electrode appropriately. OBJECTIVE: To report our technique of neurophysiologic monitoring that allows these procedures to be performed under general anesthesia. METHODS: Data from 78 patients who underwent electromyography during laminectomy for paddle lead placement were retrospectively reviewed. Seventy patients presented for first-time permanent system placement after a successful trial, and 8 were referred for revision or replacement of previously functioning systems. Surgeries were performed under general anesthesia with fluoroscopic guidance. Electromyography was used to help define the physiological midline of the spinal cord and to guide appropriate lead placement. Somatosensory evoked potentials were used as an adjunct to minimize the possibility of neural injury. RESULTS: Immediately postoperatively, 75 of 78 patients reported that the paresthesia coverage was as good as (or better than) that of the spinal cord stimulation trial. At the long-term follow-up, 1 system was removed for infection, and 6 systems were explanted for lack of efficacy. A total of 64 of the 78 implanted patients reported continued pain relief with stimulator use. Revision surgery was performed in 9 patients. CONCLUSION: The use of intraoperative electrophysiology for the placement of spinal cord stimulation paddle leads under general anesthesia is a safe and efficacious alternative to awake surgery.