MR Neurography of Lumbosacral Plexus: Incremental Value Over XR, CT, and MRI of L Spine With Improved Outcomes in Patients With Radiculopathy and Failed Back Surgery Syndrome.

BACKGROUND: Lower back pain is often evaluated using magnetic resonance imaging (MRI) and conventional imaging, which provide incomplete information about the etiology of pain and lead to less than optimal management. HYPOTHESIS: MR neurography (MRN) of the lumbosacral (LS) plexus renders a more accurate diagnosis, alters the management strategy, and clinical outcomes of radiculopathy or failed back surgery Syndrome (FBSS) patients when compared to the conventional imaging modalities. STUDY TYPE: Retrospective, cross-sectional. POPULATION: A total of 356 patients (mean age 65.8 ± 12.3; 48.9% female) from single university hospital over 6 years with MRN of LS plexus were included from a cohort of 14,775 total patients with lumbar spine MR imaging. ASSESSMENT: Conventional imaging obtained before and after MRN of LS plexus was reevaluated and categorized into three levels based on extent of imaging findings' correlation to presenting clinical symptoms (contributory levels). Clinical notes were reviewed for changes in ordering provider's recommended management and subsequent patients' symptom level pre-MRN to post-MRN. FIELD STRENGTH/SEQUENCE: A 5 T and 3.0 T. T1-weighted (T1W), T2-weighted (T2W), short T1 inversion recovery (STIR), T1 turbo spin echo (T1 TSE), T2 spectral attenuated inversion recovery (T2 SPAIR). STATISTICAL TESTS: Chi-squared test. Statistical significance was set at P < 0.05. RESULTS: A total of 356 total patients (174 females) with mean age ± SD was 65.8 ± 12.3 years, 4.2% of patients imaged with lumbar spine MRI. Definitely contributory studies among X-rays, computed tomography, MRI, and MRN were 3 of the 129 (2.3%), 3 of the 48 (6.2%), 35 of the 184 (19.0%), and 283 of the 356 (79.8%), respectively. Pre-MRN vs. post-MRN led to change in recommendation in 219 of the 356 (61.5%) patients and 71 of the 99 (71.7%) patients had improved symptoms. CONCLUSION: MRN of the LS plexus can provide more corroborative image findings for symptom correlation compared to other imaging modalities for accurate diagnosis, effects patient management and leads to positive clinical outcomes in a small subset of patients with radiculopathy or FBSS. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 5.

Functional Connectivity Magnetic Resonance Imaging Sequences in Patients With Postsurgical Persistent Spinal Pain Syndrome Type 2 With Implanted Spinal Cord Stimulation Systems: A Safety, Feasibility, and Validity Study.

BACKGROUND: Chronic pain has been associated with alterations in brain connectivity, both within networks (regional) and between networks (cross-network connectivity). Functional connectivity (FC) data on chronic back pain are limited and based on heterogeneous pain populations. Patients with postsurgical persistent spinal pain syndrome (PSPS) type 2 are good candidates for spinal cord stimulation (SCS) therapy. We hypothesize that 1) FC magnetic resonance imaging (fcMRI) scans can be safely obtained in patients with PSPS type 2 with implanted therapeutic SCS devices and that 2) their cross-network connectivity patterns are altered and involve emotion and reward/aversion functions. MATERIALS AND METHODS: Resting-state (RS) fcMRI (rsfcMRI) scans were obtained from nine patients with PSPS type 2 implanted with therapeutic SCS systems and 13 age-matched controls. Seven RS networks were analyzed, including the striatum. RESULTS: Cross-network FC sequences were safely obtained on a 3T MRI scanner in all nine patients with PSPS type 2 with implanted SCS systems. FC patterns involving emotion/reward brain circuitry were altered as compared with controls. Patients with a history of constant neuropathic pain, experiencing longer therapeutic effects of SCS, had fewer alterations in their connectivity patterns. CONCLUSIONS: To our knowledge, this is the first report of altered cross-network FC involving emotion/reward brain circuitry in a homogeneous population of patients with chronic pain with fully implanted SCS systems, on a 3T MRI scanner. All rsfcMRI studies were safe and well tolerated by all nine patients, with no detectable effects on the implanted devices.

The dimensions of "failed back surgery syndrome": what is behind a label?

BACKGROUND: The term failed back surgery syndrome (FBSS) has been criticized for being too unspecific and several studies have shown that a variety of conditions may underlie this label. The aims of the present study were to describe the specific symptoms and to investigate the primary and secondary underlying causes of FBSS in a contemporary series of patients who had lumbar spinal surgery before. METHODS: We used a multilevel approach along three different axes defining symptomatic, morphological, and functional pathology dimensions. RESULTS: Within the study period of 3 years, a total of 145 patients (74 f, 71 m, mean age 51a, range 32-82a) with the external diagnosis of FBSS were included. Disk surgery up to 4 times and surgery for spinal stenosis up to 3 times were the commonest index operations. Most often, the patients complained of low back pain (n = 126), pseudoradicular pain (n = 54), and neuropathic pain (n = 44). Imaging revealed osteochondrosis (n = 61), spondylarthrosis (n = 48), and spinal misalignment (n = 32) as the most frequent morphological changes. The majority of patients were assigned at least to two different symptomatic subcategories and morphological subcategories, respectively. According to these findings, one or more functional pathologies were assigned in 131/145 patients that subsequently enabled a specific treatment strategy. CONCLUSIONS: FBSS has become rather a vague and imprecisely used generic term. We suggest that it should be avoided in the future both with regard to its partially stigmatizing connotation and its inherent hindering to provide individualized medicine.

Magnetic Resonance Imaging Exploration of the Human Brain During 10 kHz Spinal Cord Stimulation for Failed Back Surgery Syndrome: A Resting State Functional Magnetic Resonance Imaging Study.

INTRODUCTION: Apart from the clinical efficacy of high frequency spinal cord stimulation at 10 kHz, the underlying mechanism of action remains unclear. In parallel with spinal or segmental theories, supraspinal hypotheses have been recently proposed. In order to unveil hidden altered brain connectome patterns, a resting state functional magnetic resonance imaging (rsfMRI) protocol was performed in subjects routinely treated for back and/or leg pain with high-frequency spinal cord stimulation (HF-SCS) HF-SCS at 10 kHz. METHODS: RsfMRI imaging was obtained from ten patients with failed back surgery syndrome who were eligible for HF-SCS at 10 kHz. Specifically-chosen regions of interest with different connectivity networks have been investigated over time. Baseline measurements were compared with measurements after 1 month and 3 months of HF-SCS at 10 kHz. Additionally, clinical parameters on pain intensity, central sensitization, pain catastrophizing, and sleep quality were correlated with the functional connectivity strengths. RESULTS: The study results demonstrate an increased connectivity over time between the anterior insula (affective salience network) and regions of the frontoparietal network and the central executive network. After 3 months of HF-SCS, the increased strength in functional connectivity between the left dorsolateral prefrontal cortex and the right anterior insula was significantly correlated with the minimum clinically important difference (MCID) value of the Pittsburgh sleep quality index. CONCLUSION: These findings support the hypothesis that HF-SCS at 10 kHz might influence the salience network and therefore also the emotional awareness of pain.

Twiddler's Syndrome and Neuromodulation-Devices: A Troubled Marriage.

OBJECTIVE: The occurrence of Twiddler's syndrome in subjects with neurostimulator devices is poorly understood and might be influenced by age, sex, BMI, use of medication or psychologic disorders. METHODS: Two hundred thiry-five patients who received a neuromodulator were included in this retrospective study in a period between 2008 and 2015. The subjects were divided into a group of Twiddler's syndrome patients (TS) and a group of non-Twiddler's patients (NTS). Outcome measures were gender, age at implantation, type of neuromodulation, use of antipsychotics, antidepressants and opioids, the presence of other psychologic disorders and BMI. RESULTS: Both groups differ significantly in age (p = 0.024), weight (p = 0.001) and BMI (p = 0.001). No statistical difference was found in the type of neuromodulation (p = 0.537), gender (p = 0.368), the use of antipsychotics (p = 0.071), antidepressants (p = 0.097), and opioids (p = 1). Forward stepwise logistic regression of all variables showed that age of implementation (p = 0.029), the use of antipsychotics (p = 0.022) and BMI (p = 0.001) were statistically significant for predicting Twiddler's syndrome. CONCLUSION: Twiddler's syndrome is an uncommon complication of neuromodulation implantable devices. Younger age, use of antipsychotics, and high BMI are risk factors that can be used to facilitate rapid diagnosis and treatment.

[Postoperative spinal column]. / Postoperative Wirbelsäule.

STANDARD PROCEDURE: As a rule, postoperative imaging is carried out after spinal interventions to document the exact position of the implant material. INFORMATION: Imaging is absolutely necessary when new clinical symptoms occur postoperatively. In this case a rebleeding or an incorrect implant position abutting a root or the spinal cord must be proven. In addition to these immediately occurring postoperative clinical symptoms, there are a number of complications that can occur several days, weeks or even months later. These include the failed back surgery syndrome, implant loosening or breakage of the material and relapse of a disc herniation and spondylodiscitis. REVIEW: In addition to knowledge of the original clinical symptoms, it is also important to know the operation details, such as the access route and the material used. RECOMMENDATION: In almost all postoperative cases, imaging with contrast medium administration and corresponding correction of artefacts by the implant material, such as the dual energy technique, correction algorithms and the use of special magnetic resonance (MR) sequences are necessary. RECOMMENDATION: In order to correctly assess the postoperative imaging, knowledge of the surgical procedure and the previous clinical symptoms are mandatory besides special computed tomography (CT) techniques and MR sequences.

The postsurgical spine. / La columna poscirugía.

Failed back surgery syndrome is the persistence or reappearance of pain after surgery on the spine. This term encompasses both mechanical and nonmechanical causes. Imaging techniques are essential in postoperative follow-up and in the evaluation of potential complications responsible for failed back surgery syndrome. This review aims to familiarize radiologists with normal postoperative changes and to help them identify the pathological imaging findings that reflect failed back surgery syndrome. To interpret the imaging findings, it is necessary to know the type of surgery performed in each case and the time elapsed since the intervention. In techniques used to fuse the vertebrae, it is essential to evaluate the degree of bone fusion, the material used (both its position and its integrity), the bone over which it lies, the interface between the implant and bone, and the vertebral segments that are adjacent to metal implants. In decompressive techniques it is important to know what changes can be expected after the intervention and to be able to distinguish them from peridural fibrosis and the recurrence of a hernia. It is also crucial to know the imaging findings for postoperative infections. Other complications are also reviewed, including arachnoiditis, postoperative fluid collections, and changes in the soft tissues adjacent to the surgical site.

The percutaneous stabilisation of the sacroiliac joint with hollow modular anchorage screws: a prospective outcome study.

PURPOSE: The use of percutaneous iliosacral screw fixation as a treatment of sacroiliac joint pain has been reported to be successful. This study was a prospective single surgeon series to evaluate the short-term outcomes of patients who underwent percutaneous sacroiliac joint stabilisation. METHODS: Between July 2004 and February 2011, 73 patients underwent percutaneous sacroiliac joint fusion in our unit. All patients completed a short form (SF)-36 questionnaire, visual analogue pain score and Majeed scoring questionnaire prior to treatment and at last follow-up. RESULTS: 55 patients (9 male and 46 female) completed follow-up. The average follow-up period was for 36.18 months (range 12-84). The mean preoperative SF-36 scores were 26.59 for physical health and 40.38 for mental health. The mean postoperative SF-36 scores were 42.93 for physical health and 52.77 for mental health. The mean visual analogue pain scores were 8.1 preoperative and 4.5 postoperative. The mean pelvic specific scoring were 36.9 preoperative and 64.78 postoperative. We noted that patients who had previous instrumented spinal surgery did significantly worse than those who had not. We had two nerve root-related complications. CONCLUSION: We conclude that in selected patient group who respond positively to CT-guided injection, a percutaneous SI joint stabilisation is beneficial in effecting pain relief and functional improvement.

L5-S1 disc replacement after two previous fusion surgeries for scoliosis.

Following scoliosis surgery, lumbar motion segment degeneration below the level of fusion is not uncommon. Especially long fusions extending to the mid and lower lumbar spine increase the likelihood of degeneration of the remaining motion segments. The management for these patients is controversial and depends on the clinical presentation and level of degeneration. The increasing confidence in motion-preserving technology leads to a dilemma on whether to fuse the remaining lumbar levels or risk utilising disc arthroplasty to preserve the remaining motion segments and facilitate coronal balance in patients with previous long fusion for scoliosis. We present an interesting case of a 44-year-old lady, who underwent two-stage corrective surgery for progressive idiopathic scoliosis at the age of 22 years. In the first stage, she had T11-L3 anterior fusion, whilst in the second stage posterior fusion was done from T5 to L3. At 22 years after the initial surgery, she presented with worsening low back pain and bilateral L4 radicular symptoms. MRI scan confirmed severe disc degeneration at L3-4 and L5-S1 levels with preserved L4-5 disc. She initially underwent L3-L4 decompression and posterolateral fusion at that level, which relieved her radicular symptoms. However, she had persistent pain at the lumbosacral junction with Modic I changes. The options of an anterior L5-S1 fusion or disc replacement were considered and discussed with the patient. The disc replacement option was decided upon with the patient, as anterior fusion was judged to increase the risk of coronal imbalance. At the 1-year follow-up, she reported significant improvement in the back pain. The radiographs at 1 year showed satisfactory position and function of the artificial disc replacement. The disc was flexed laterally, accommodating the coronal balance of the spine. We conclude that L5-S1 motion segment can be preserved with artificial disc replacement in patients with previous long fusion for scoliosis surgery. The real difficulty arises when choosing between disc replacement and extension of fusion. In our patient, the disc replacement has worked well so far. However, the disc is clearly at a mechanical disadvantage, and loss of function in the mid- or long term would not be surprising.

Placement of Surgical Spinal Cord Stimulation Leads Using Spinal Process Splitting Laminotomy: Technical Note.

OBJECTIVE: Spinal cord stimulation has become an established method within the therapy of chronic pain allowing for significant pain relief. Surgical leads usually must be implanted via a surgical procedure involving unilateral or bilateral muscle detachment and partial laminectomy. METHODS: We present the application of a novel minimal invasive microsurgical approach for lead placement, which combines the beneficial advantages of anatomic midline lead placement while preserving the midline structures, avoiding muscle detachments, and thus ensuring spinal stability: spinal process splitting laminotomy. CONCLUSIONS: The spinal process splitting laminotomy technique can be successfully applied to introduce the surgical leads for spinal cord stimulation.

The Correlation of Epidural Fibrosis with Epiduroscopic and Radiologic Imaging for Chronic Pain after Back Surgery.

BACKGROUND: Chronic low back pain is observed frequently after lumbar spinal surgery. Epidural fibrosis has been implicated in the etiology of persistent pain after back surgery. The incidence of epidural fibrosis increases as the number and extent of spinal surgery increases. Epidural fibrosis can be detected by conventional radiologic methods [e.g., lumbosacral magnetic resonance imaging (MRI) with gadolinium], but these methods are insufficient to reveal the presence of epidural adhesions. Imaging of the epidural cavity using an epiduroscope is one of the best methods for visualizing the spinal cavity without damaging anatomic structures. OBJECTIVES: To evaluate the correlation between the type and number of surgery and the degree of epidural fibrosis and to compare epidural fibrosis in epiduroscopic and MRI findings in patients with failed back surgery syndrome (FBSS). STUDY DESIGN: A prospective trial. SETTING: A university hospital. METHODS: This study included 61 patients with persistent low back pain and/or radicular pain for at least 6 months, despite lumbar surgery and conservative treatment, and who accepted epiduroscopic imaging. All patients were evaluated in a physical examination using a visual analog scale (VAS) per the elapsed time after surgery. The patients were divided into 3 groups according to the number and type of surgeries. Epidural fibrosis was rated using MRI with gadolinium and epiduroscopy. RESULTS: When the relationship between admission symptoms and epidural fibrosis was evaluated, MRI findings of fibrosis were found to be significantly higher in all patients with both lumbar and radicular pain symptoms at the confidence level of 95% (P = 0.001). The degree of fibrosis detected using epiduroscopy was grade 1 and 2 in almost all patients who presented with low back pain only, only radicular pain, or only distal paresthesia (P = 0.001). In the correlation analysis between the duration of the postoperative period (4.13 ± 2.97 years) and the degree of fibrosis detected using MRI and epiduroscopy, a statistically significant relationship was found at the confidence level of 95% (P < 0.05). As the number and extent of spinal surgeries increased, the incidence of MRI fibrosis increased, which is compatible with the literature (P = 0.001) There was a statistically significant relationship between the degree of fibrosis as detected using MRI and epiduroscopy at the confidence level of 95% (P < 0.05). Differently, we observed that 6 patients had grade 1 fibrosis as diagnosed using epiduroscopy, whereas none had fibrosis on MRI. LIMITATIONS: We did not have a control group. Further studies are required to demonstrate the relevance of these 2 imaging techniques (epiduroscopy and MRI) in terms of detecting epidural fibrosis in patients with FBSS.  CONCLUSIONS: Epiduroscopic imaging seems to be more sensitive than MRI in detecting grade I epidural fibrosis in patients with FBSS. Thus, the possibility of low-grade epidural fibrosis as a source of pain after back surgery, should be kept in mind in normally reported MRIs. Treatment should be planned accordingly.

Effects of spinal cord stimulation on voxel-based brain morphometry in patients with failed back surgery syndrome.

OBJECTIVE: Despite the clinical effectiveness of Spinal Cord Stimulation (SCS), potential structural brain modifications have not been explored. Our aim was to identify structural volumetric changes during subsensory SCS, in patients with Failed Back Surgery Syndrome (FBSS). METHODS: In this cohort study, twenty-two FBSS patients underwent a magnetic resonance imaging protocol before SCS and 3 months after SCS. Clinical parameters were correlated with volumetric changes, calculated with voxel-based morphometry. RESULTS: After 3 months, a significant volume decrease was found in the inferior frontal gyrus, precuneus, cerebellar posterior lobe and middle temporal gyrus. Significant increases were found in the inferior temporal gyrus, precentral gyrus and the middle frontal gyrus after SCS. Additionally, significant increases in volume of superior frontal and parietal white matter and a significant decrease in volume of white matter underlying the premotor/middle frontal gyrus were revealed after SCS. A significant correlation was highlighted between white matter volume underlying premotor/middle frontal gyrus and leg pain relief. CONCLUSIONS: This study revealed for the first time that SCS is able to induce volumetric changes in gray and white matter, suggesting the reversibility of brain alterations after chronic pain treatment. SIGNIFICANCE: Volumetric brain alterations are observable after 3 months of subsensory SCS in FBSS patients.

Minimally invasive interbody fusion for revision lumbar surgery: technical feasibility and safety.

STUDY DESIGN: Retrospective chart review of one surgeon's practice. OBJECTIVE: We evaluate the perioperative morbidity of 43 patients undergoing minimally invasive lumbar interbody fusion to differentiate risks between primary and revision surgery candidates. SUMMARY OF BACKGROUND DATA: Minimally invasive approaches to the lumbar spine have rapidly evolved and the technical feasibility and safety of minimally invasive interbody fusion is well established. Revision surgery is technically more challenging and may cause avoidance of such approaches because of altered anatomy and absent bony landmarks. Description of minimally invasive surgery approaches among revision patients and the feasibility of such techniques demands clarification. METHODS: Forty-three consecutive minimally invasive transforaminal lumbar interbody fusions (TLIFs) and posterior lumbar interbody fusions (PLIFs) were reviewed. Estimated blood loss, operative time, and complication rates were compared between primary and revision patients using Student t tests. RESULTS: Seventeen revision surgery cases (40%) were compared with 26 primary surgeries (60%) to elucidate differences in operative time, estimated blood loss, and complications. Demographic variables were similar in both groups. Estimated blood loss trended higher among the PLIF group and among revision cases, though no statistical significance was observed. A higher rate of complications, most notably incidental durotomy, was observed among revision cases in both PLIF and TLIF patients. One patient undergoing primary surgery had an intraoperative pedicle fracture, and 1 patient undergoing revision surgery had an asymptomatic screw malposition. No patients had a major complication, nerve injury, infection, or conversion to an open procedure. CONCLUSIONS: Minimally invasive lumbar interbody fusion by revision surgery is technically feasible and is not associated with more blood loss or neurologic morbidity. However, revision surgery has a higher minor perioperative complication rate, particularly of incidental durotomy. These outcomes demand significant experience before attempting minimally invasive revision surgery in the lumbar spine.

Monoradiculopathy and secondary segmental instability caused by postoperative pars interarticularis fracture: a case report.

Instability can develop after lumbar spinal surgery. What is also known as secondary segmental instability is one of the important causes of failed back syndrome. In this paper, we described a 45-year-old female patient who was diagnosed with secondary segmental instability caused by left L3 pars interarticularis fracture after a high lumbar disc surgery and was subsequently treated with re-operation. We evaluated the clinical course, diagnosis, and treatment methods for secondary segmental instability caused by postoperative pars interarticularis fracture. Furthermore, we emphasized the importance of preserving the pars interarticularis during upper lumbar disc surgeries in order to avoid a potential stress fracture.

Magnetic Resonance Neurography of the Lumbosacral Plexus in Failed Back Surgery Syndrome.

STUDY DESIGN: Retrospective clinical case series. OBJECTIVE: To study the role of magnetic resonance neurography (MRN) of the lumbosacral plexus in management of patients with failed back surgery syndrome (FBSS). SUMMARY OF BACKGROUND DATA: FBSS is one of the major problems in health care, affecting up to 40% of patients after spine surgery. To date, no imaging modality has been used to effectively classify nerve compression, because nerve injuries are challenging to detect on conventional lumbar spine magnetic resonance imaging (MRI). To our knowledge, no previous studies have addressed the use of MRN in FBSS or compared it to lumbar spine MRI. METHODS: From 203 consecutive 3 T MRN studies of lumbosacral plexus in 1 year, 12% (25/203) presented as FBSS. Demographic data, number of previous lumbar MRIs and their findings, MRN findings, interval between MRI and MRN, pre-and post-MRN diagnosis, pain levels, and treatments were recorded. Changes in diagnosis, treatment, and outcomes after MRN were determined. RESULTS: The final sample of 25 patients had a mean age 62 ±â€Š15 and male to female ratio 1:1.08. Approximately 88% (22/25) had previous lumbar MRI, of which 27% had 3 or more. Most common imaging findings were neuroforaminal stenosis 22.6% (7/31) on MRI and neuropathy 22.9% (19/83) on MRN. Mean interval between MRI and MRN was 13.9 ±â€Š28.3 months. Lumbar MRIs were inconclusive in 36% (8/22). MRN detected 63% (52/83) more findings and changed the diagnosis and treatment in 12% and 48% of FBSS cases, respectively. Favorable outcomes were recorded in 40% to 67% of patients following MRN-guided treatments. CONCLUSION: FBSS is a complex problem and MRN of lumbosacral plexus impacts its management by better directing source of symptoms. LEVEL OF EVIDENCE: 4.

Failed back surgery syndrome: a new strategy by the epidural injection of MESNA.

PURPOSE: Evaluate the efficacy and safety of MESNA (sodium 2-mercaptoethanesulfonate) injection into the epidural space in the FBSS. METHODS: We designed a prospective phase II longitudinal study. Six consecutive patients were enrolled. Patients underwent one peridural injection per week for 3 weeks. NRS and ODI were investigated before and 48 h after injections, and at 1 week, 1 month and 2 months after the last procedures. Opioids intake is investigated before procedures and 1 week, 1 month and 3 months after the last procedures. Lumbosacral MRI is performed before the first procedure, at the end and 3 months after the last procedures. RESULTS: From baseline, at 3 months, NRS in standing, sitting and lying position improved, respectively, of 34.29, 30.56 and 26.47%; ODI improved of 20.3%; the average decrease in morphine intake was 20.54%. No difference in MR images was found. Conclusions Our preliminary results suggest that MESNA might be an efficacy alternative to common practice.

Segmental Spinal Myoclonus Complicating Lumbar Transforaminal Epidural Steroid Injection.

OBJECTIVE: Lumbar transforaminal epidural steroid injection is commonly used for treating lumbar radicular pain. We report a case of segmental spinal myoclonus that developed during lumbar transforaminal epidural injection with local anesthetic and steroid. CASE REPORT: A 58-year-old woman with failed back surgery syndrome presented with low back and right L3 and L4 radicular pain. As she had responded well previously to diagnostic selective nerve root injection with local anesthetic at the right L3 and L4 levels, lumbar transforaminal epidural steroid injection at the same levels was scheduled. During injection of ropivacaine and triamcinolone at the right L3-4 intervertebral foramen, she complained of back pain and immediately developed involuntary contraction of her right hip. The procedure was terminated. No new neurological deficit was detected when she was examined 15 minutes after the procedure. There were no abnormalities from blood tests and magnetic resonance imaging of the lower thoracic and lumbar spine. A neurologist subsequently made the clinical diagnosis of segmental spinal myoclonus. The myoclonus improved over 1 month and eventually resolved completely. CONCLUSIONS: Segmental spinal myoclonus is a rare complication after lumbar transforaminal epidural steroid and local anesthetic injection. Pain physicians should be aware of this potential complication.

Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain: A Randomized Clinical Trial.

Importance: Effective treatments for chronic spinal pain are essential to reduce the related high personal and socioeconomic costs. Objective: To compare pain neuroscience education combined with cognition-targeted motor control training with current best-evidence physiotherapy for reducing pain and improving functionality, gray matter morphologic features, and pain cognitions in individuals with chronic spinal pain. Design, Setting, and Participants: Multicenter randomized clinical trial conducted from January 1, 2014, to January 30, 2017, among 120 patients with chronic nonspecific spinal pain in 2 outpatient hospitals with follow-up at 3, 6, and 12 months. Interventions: Participants were randomized into an experimental group (combined pain neuroscience education and cognition-targeted motor control training) and a control group (combining education on back and neck pain and general exercise therapy). Main Outcomes and Measures: Primary outcomes were pain (pressure pain thresholds, numeric rating scale, and central sensitization inventory) and function (pain disability index and mental health and physical health). Results: There were 22 men and 38 women in the experimental group (mean [SD] age, 39.9 [12.0] years) and 25 men and 35 women in the control group (mean [SD] age, 40.5 [12.9] years). Participants in the experimental group experienced reduced pain (small to medium effect sizes): higher pressure pain thresholds at primary test site at 3 months (estimated marginal [EM] mean, 0.971; 95% CI, -0.028 to 1.970) and reduced central sensitization inventory scores at 6 months (EM mean, -5.684; 95% CI, -10.589 to -0.780) and 12 months (EM mean, -6.053; 95% CI, -10.781 to -1.324). They also experienced improved function (small to medium effect sizes): significant and clinically relevant reduction of disability at 3 months (EM mean, -5.113; 95% CI, -9.994 to -0.232), 6 months (EM mean, -6.351; 95% CI, -11.153 to -1.550), and 12 months (EM mean, -5.779; 95% CI, -10.340 to -1.217); better mental health at 6 months (EM mean, 36.496; 95% CI, 7.998-64.995); and better physical health at 3 months (EM mean, 39.263; 95% CI, 9.644-66.882), 6 months (EM mean, 53.007; 95% CI, 23.805-82.209), and 12 months (EM mean, 32.208; 95% CI, 2.402-62.014). Conclusions and Relevance: Pain neuroscience education combined with cognition-targeted motor control training appears to be more effective than current best-evidence physiotherapy for improving pain, symptoms of central sensitization, disability, mental and physical functioning, and pain cognitions in individuals with chronic spinal pain. Significant clinical improvements without detectable changes in brain gray matter morphologic features calls into question the relevance of brain gray matter alterations in this population. Trial Registration: clinicaltrials.gov Identifier: NCT02098005.