Back pain in patients with degenerative spine disease and intradural spinal tumor: what to treat? when to treat?

BACKGROUND: Back pain is common in industrialized countries and one of the most frequent causes of work incapacity. Successful treatment is, therefore, not only important for improving the symptoms and the quality of life of these patients but also for socioeconomic reasons. Back pain is frequently caused by degenerative spine disease. Intradural spinal tumors are rare with an annual incidence of 2-4/1,00,000 and are mostly associated with neurological deficits and radicular and nocturnal pain. Back pain is not commonly described as a concomitant symptom, such that in patients with both a tumor and degenerative spine disease, any back pain is typically attributed to the degeneration rather than the tumor. OBJECTIVE: The aim of the present retrospective investigation was to study and analyze the impact of microsurgery on back/neck pain in patients with intradural spinal tumor in the presence of degenerative spinal disease in adjacent spinal segments. METHODS: Fifty-eight consecutive patients underwent microsurgical, intradural tumor surgery using a standardized protocol assisted by multimodal intraoperative neuromonitoring. Clinical symptoms, complications and surgery characteristics were documented. Standardized questionnaires were used to measure outcome from the surgeon's and the patient's perspectives (Spine Tango Registry and Core Outcome Measures Index). Follow-up included clinical and neuroradiological examinations 6 weeks, 3 months and 1 year postoperatively. RESULTS: Back/neck pain as a leading symptom and coexisting degenerative spine disease was present in 27/58 (47 %) of the tumor patients, and these comprised to group under study. Patients underwent tumor surgery only, without addressing the degenerative spinal disease. Remission rate after tumor removal was 85 %. There were no major surgical complications. Back/neck pain as the leading symptom was eradicated in 67 % of patients. There were 7 % of patients who required further invasive therapy for their degenerative spinal disease. CONCLUSIONS: Intradural spinal tumor surgery improves back/neck pain in patients with coexisting severe degenerative spinal disease. Intradural spinal tumors seem to be the only cause of back/neck pain more often than appreciated. In these patients suffering from both pathologies, there is a higher risk of surgical overtreatment than undertreatment. Therefore, elaborate clinical and radiological examinations should be performed preoperatively and the indication for stabilization/fusion should be discussed carefully in patients foreseen for first time intradural tumor surgery.

Spinal magnetic resonance imaging with reduced specific absorption rate in patients harbouring a spinal cord stimulation device - A single-centre prospective study analysing safety, tolerability and image quality.

BACKGROUND: Spinal cord stimulation (SCS) is an accepted treatment in patients with failed back surgery (FBS), complex regional pain syndrome (CRPS) and persistent radicular pain following surgery. In order to avoid patient hazards or device malfunction manufacturers advise to abstain from magnetic resonance imaging (MRI) in patients with implanted electrodes or pulse generators. METHODS: In a prospective study, 13 patients harbouring an implanted Medtronic Spinal Cord Stimulation (SCS) device underwent MRI (1.5 T) of the lumbar (n=13), the cervical (n=2) or the thoracic spine (n=1) following the development of new spinal symptoms. An adapted MRI protocol was used limiting the transmitted energy and specific absorption rate. Tolerability and safety were assessed by means of a standardized patient evaluation form documenting pain on a visual analogue scale (0-10), neurologic deficit, and discomfort during the scan. In addition, overall satisfaction with the examination procedure was rated on a Likert scale (1-5). Image quality was rated independently and blinded to the presence of a SCS device by the radiologist and the surgeon as equivalent, superior or inferior compared to the standard spine MRI examination. RESULTS: None of the 13 patients investigated by the modified spinal MRI protocol experienced new neurological deficits, worsening of symptoms or a defect/malfunction of the implant device. Three patients (23.1 %) reported transient warm sensation in the location of the electrode and in one case intermittent slight tingling in the lower extremities. Overall satisfaction with the examination was 1.13 ± 0.34 according to Likert scale (1-5). The image quality was rated - not statistically significant - slightly inferior to standard lumbar spine imaging (0.82 ± 0.54) with a kappa value of 0.68 between the two investigators. MRI examinations detected relevant and new lesions in 9 (69.2 %) patients which affected treatment in 8 (61.5 %) individuals. CONCLUSION: Using a protocol with a reduced specific energy absorption rate, spinal MRI examinations in patients with SCS can be considered safe. The current view that neurostimulators are a general contraindication to MR examinations has to be reconsidered in patients with new or progressive spinal symptoms.

The assessment of complications after spine surgery: time for a paradigm shift?

BACKGROUND CONTEXT: Recent years have witnessed a shift in the assessment of spine surgical outcomes with a greater focus on the patient's perspective. However, this approach has not been widely extended to the assessment of complications. PURPOSE: The present study sought to quantify the patient-rated impact/severity of complications of spine surgery and directly compare the incidences of surgeon-rated and patient-reported complications. STUDY DESIGN: Prospective study of patients undergoing surgery for painful degenerative lumbar disorders, being operated in the Spine Center of an orthopedic hospital. PATIENT SAMPLE: A total of 2,303 patients (mean [standard deviation] age, 61.9 [15.1] years; 1,136 [49.3%] women and 1,167 [50.7%] men). PATIENTS: Core Outcome Measures Index, self-rated complications, bothersomeness of complications, global treatment outcome, and satisfaction. Surgeons: Spine Tango surgery and follow-up documentation forms registering surgical details and complications. METHODS: PATIENTS completed questionnaires before and 3 months after surgery. Surgeons documented complications before discharge and at the first postoperative follow-up, 6 to 12 weeks after surgery. RESULTS: In total, 615 out of 2,303 (27%) patients reported complications, with "bothersomeness" ratings of 1%, not at all; 22%, slightly; 26%, moderately; 34%, very; and 17%, extremely bothersome. PATIENTS most commonly reported sensory disturbances (35% of those reporting a complication) or ongoing/new pain (27%) followed by wound healing problems (11%) and motor disturbances (8%). The surgeons documented complications in 19% of patients. There was a minimal overlap regarding the presence or absence of complications in any given patient. CONCLUSIONS: Most complications reported by the patient are perceived to be at least moderately bothersome and are, hence, not inconsequential. Surgeons reported lower complication rates than the patients did, and there was only moderate agreement between the ratings of the two. As with treatment outcome, complications and their severity should be assessed from both the patient's and the surgeon's perspectives.

A comparison of patient and surgeon preoperative expectations of spinal surgery.

STUDY DESIGN: Cross-sectional study of agreement between patients' and surgeons' expectations of the outcome of spinal surgery. OBJECTIVE: Patients' satisfaction after spinal surgery depends, in part, on whether their expectations of surgery are fulfilled. Whether the patient always fully understands the key messages conveyed by the surgeon, to formulate realistic expectations, is not known. This study evaluates the level of agreement in expectations declared preoperatively by the patient and the surgeon. SUMMARY OF BACKGROUND DATA: Previous studies have investigated the importance of realistic expectations for the patients' satisfaction with surgical treatments, but there is still a need for a more detailed analysis in the field of spinal surgery. METHODS: The study included 225 German-speaking patients (92 men and 133 women; mean ± SD [range] age, 62 ± 15 [15-90] yr) and their treating spinal surgeons (N = 7). Following the preoperative informed consent consultation, the patient and the surgeon independently completed a questionnaire about baseline neurological status and realistic expectations regarding various patient-orientated outcomes (axial pain (back/neck), radiating pain (leg/arm), pain medication usage, sensory and motor function, and the ability to work, do household activities, and play sports). Concordance was given by percent agreement and κ coefficients. RESULTS: Agreement between the patient and the surgeon about the existence of spine-related neurological deficits occurred in 75% (sensory) and 61% (motor) cases. The patient but not the surgeon reported a sensory deficit in 20% cases and motor deficit in 35% cases; for 4% to 5% cases, the physician reported such a deficit that the patient was seemingly unaware of. The patients consistently had higher expectations than the surgeons, especially for back or neck pain and function (work, household activities, and sports); weighted κ values for agreement were low, ranging from 0.097 to 0.222. CONCLUSION: The findings demonstrate wide discrepancies between the patient and the surgeon regarding the expected result of surgery. They highlight the need for clearer explanations of the association between the spinal problem and neurological deficits and the improvement that can be expected in pain and function after surgery. Systematic, routine evaluation of outcomes should assist in deriving the information necessary to document the improvement achieved and to formulate realistic expectations of surgery.

A comparison of outcomes of cervical disc arthroplasty and fusion in everyday clinical practice: surgical and methodological aspects.

Randomised controlled trials (RCTs) of cervical disc arthroplasty vs fusion generally show slightly more favourable results for arthroplasty. However, RCTs in surgery often have limited external validity, since they involve a select group of patients who fit very rigid admission criteria and who are prepared to subject themselves to randomisation. The aim of this study was to examine whether the findings of RCTs are verified by observational data recorded in our Spine Center in association with the Spine Society of Europe Spine Tango surgical registry. Patients undergoing fusion/stabilisation or disc arthroplasty for degenerative cervical spinal disease were selected for inclusion. They completed a questionnaire pre-operatively and at 12 and 24 months follow-up (FU). The questionnaire comprised the multidimensional Core Outcome Measures Index (COMI; 0-10 scale) and, at FU, questions on global outcome and satisfaction with treatment (5-point scales, dichotomised to "good" and "poor"), re-operation and patient-rated complications. The surgeon completed a Spine Tango Surgery form. The outcome data from 266 (208 fusion, 58 arthroplasty) out of 284 eligible patients who had reached 12 months FU, and 169 (139 fusion, 30 arthroplasty) out of 178 who had reached 24 months FU, were included. Patients with cervical disc arthroplasty were younger [46 (SD 8) years vs 56 (SD 11) years for fusion; P < 0.05], had less comorbidity (P < 0.05), more often had only mono-segmental pathology (69% arthroplasty, 47% fusion) and only one type of degenerative pathology (69% arthroplasty, 46% fusion). Surgical complication rates were similar in each group (arthroplasty, 1.5%; fusion, 2.6%). The reduction in the COMI score was significantly greater in the arthroplasty group (at 12 months, 4.8 (SD 3.0) vs 3.7 (SD 2.9) points for fusion, and at 24 months 5.1 (SD 2.8) vs 3.8 (SD 2.9) points; each P < 0.05). In the arthroplasty group, a "good" global outcome was recorded in 90% patients (at 12 months) and 93% (at 24 months); in the fusion group the figures were 80 and 82%, respectively (group differences at each timepoint, P > 0.09). Satisfaction with treatment was similar in both groups (89-93%), at each timepoint. In multiple regression analysis, treatment group was of borderline significance as a unique predictor of the change in COMI at FU (P = 0.059 at 12 months, P = 0.055 at 24 months) in a model in which known confounders (age, comorbidity, number of affected levels) were controlled for. Being in the arthroplasty group was associated with an approximately 1-point greater reduction in the COMI score at FU. The results of this observational study appear to support those of the RCTs and suggest that, in patients with degenerative pathology of the cervical spine, disc arthroplasty is associated with a slightly better outcome than fusion. However, given the small size of the difference, its clinical relevance is questionable, especially in view of the a priori more favourable outcome expected in the arthroplasty group due to the more rigorous selection of patients.