Surgical Treatment of Patients with Sacroiliac Joint Syndrome: Comparative Study of Two Implants. / Operative Behandlung von Patienten mit Iliosakralgelenksyndrom: Vergleichsstudie zweier Implantate.

The treatment of patients with ISJ dysfunction is difficult due to the multifactorial causes of pain and various problems in clarification. Treatment includes physical therapy, corticosteroids, prolotherapy, radiofrequency denervation and sacroiliac joint fusion. A new option for the surgical treatment of ISG dysfunction is the Torpedo implant system. For a safe fusion, only 2 implants are needed, which are available in lengths of 30-50 mm. The new implant system has been tested in pilot studies for efficacy and biocompatibility with good results. For further documentation for the Torpedo implant system, a comparative study against the iFuse system was carried out.Two different implants were used: Group 1: Deltacor Torpedo, Group 2: iFuse implants (Si-Bone). The data generated during admission and subsequent check-ups (VAS, ODI, opioid use) were entered into an evaluation file set up for this purpose. Follow-up appointments were set at 1 month, 3, 6 and 12 months postoperatively.The data of 65 patients were evaluated comparatively. In all comparisons, only very small effect sizes were found with regard to the differences in the decrease in pain intensities, so that equivalent effectiveness of the two methods could initially be postulated from a clinical point of view. Most patients in both groups reported taking opioids to treat pain before surgery. According to the decrease in pain intensity, opioid treatment could be discontinued in some patients after the operation. After 12 months, the number of patients treated with opioids decreases to 23% in group 1 and to 17% in group 2. The success of the fusions with the two methods can also be proven by image documentation, from which the position of the implants can also be clearly recognised. In no case was there any loosening.Overall, the evaluation of this study allows the conclusion that both implant systems can be successfully used for the treatment of patients with ISJ syndrome. The present results should be confirmed in further comparative studies with the proposed evaluation methods.

One-year results of minimally invasive fusion surgery of the sacroiliac joint as an alternative treatment after failed endoscopic thermal coagulation.

BACKGROUND: While pain in the severe sacroiliac joint (SIJ) is a common cause of lower back pain, SIJ disease is often overlooked as a diagnosis. OBJECTIVE: This study examines the extent of sufficient long-term pain relief and functional improvement in patients with SIJ syndrome that are treated with thermocoagulation. Some patients treated with thermocoagulation noted initial improvement, but the functionality and pain relief had limited duration and efficacy. Patients with insufficient improvement were recommended to undergo fusion surgery as an option for better and longer lasting results. METHOD: Patients with a long history of back or pelvic problems were selected for the study. Endoscopic thermal coagulation of the SIJ was carried out. The follow-up examinations took place after 1, 3, 6, 12 months. In patients with insufficient pain relief and functionality after thermocoagulation, a fusion surgery was performed. The results of the fusion surgery were documented over a 12-month follow-up period. To carry out the statistical evaluation visual analog scale (VAS), Oswestry-Disability-Index (ODI) and the consumption of opioids were recorded. RESULTS: Forty-eight patients were included. The mean VAS values 12 months after thermocoagulation were 68.9. The ODI after 12 months was very near or somewhat higher than their baseline prior to the thermocoagulation. Thus, a fusion surgery was recommended. Thirty-three patients agreed to the fusion operation. The VAS values 12 months after fusion surgery decreased to 53.1. Analogous to the VAS values, the Oswestry index (ODI) showed a significant improvement after the fusion operation. CONCLUSION: The success of surgical intervention in 88% of the SIJ syndrome patients with inadequate results 12 months after thermocoagulation proves the superiority of SIJ fusion surgery. This study showed long-lasting pain relief by an average of 65% and a median improvement in functional impairments of 60%. In view of these results, fusion surgery should be considered for patients without sufficient success of thermocoagulation.

[Minimally invasive arthrodesis of the sacroiliac joint (SIJ)]. / Minimal-invasive Arthrodese des Iliosakralgelenks (ISG).

OBJECTIVE: Pain reduction and improvement in quality of life with sacroiliac joint (SIJ) fusion. INDICATIONS: Chronic SIJ-associated pain; positive response to SIJ injection with local anesthetic; positive SIJ provocation tests; failed conservative therapy over 6 months. CONTRAINDICATIONS: Non-SIJ-associated pain; tumor/infection/unstable fracture in the implantation area; malformations; tumor or osteolysis of the sacrum or ilium bone; active infection at the implantation site; allergy to metal components; secondary gain from illness, request for a pension; inadequately treated osteoporosis. SURGICAL TECHNIQUE: Transarticular placement of Kirschner's wires through the SI joint via minimally invasive lateral approach. Guided preparation of implant site over Kirschner's wires and implantation of 3 triangular, transarticular titanium implants for SIJ fusion. POSTOPERATIVE MANAGEMENT: Deep vein thrombosis prophylaxis. 3 weeks partial weight-bearing and then moving on to full weight-bearing. X­ray controls at defined intervals. Physiotherapy. RESULTS: We enrolled 26 patients who were followed up over the period of 4 years. The evaluated endpoints were low back pain on the visual analog scale (VAS 0-10), grade of disability with the Oswestry Disability Index (ODI) and quality of life with the EuroQOL-5D. At 4 years, mean low back pain improved compared to preoperative (VAS preoperative 8.4, VAS 4 years postoperative 4.6). Mean improvements in ODI (ODI preoperative 58.1, ODI 4 years postoperative 32.1) and EQ-5D (preoperative 0.5, after 4 years 0.7) could be evaluated over the long-term period of 4 years. Satisfaction rates were high and the proportion of subjects taking opioids decreased at the 4­year follow-up (preoperative 82%, postoperative 39%). Implant loosening could not be detected on plain radiograph.

[Minimally invasive implantation technique of a system for spinal cord stimulation]. / Minimal-invasive Implantationstechnik eines Systems zur epiduralen Rückenmarkstimulation.

OBJECTIVE: Spinal cord stimulation (SCS) targets structures of the dorsal column and dorsal horn of the spinal cord with electrical impulses, thereby, modulating pain perception. For chronic pain patients, e.g., in failed back surgery syndrome (FBSS), the aim is to achieve pain relief and enable patients to improve their quality of life. INDICATIONS: Failed back surgery syndrome, complex regional pain syndrome (CRPS) type I and II, therapy-refractory ischemic pain, neuropathic pain syndromes (e.g., phantom limb pain). CONTRAINDICATIONS: Identification of degenerative alterations as the cause of pain; untreated mental illness. SURGICAL TECHNIQUE: A two-stage implantation technique is performed. Initially, after percutaneous implantation of epidural leads a trial period with stimulation by an external pulse generator is evaluated. Following verification of pain relief, a subcutaneous internal pulse generator is implanted. FOLLOW-UP: Early mobilization and adjustment of stimulation parameters. RESULTS: In all, 19 consecutive patients with FBSS were treated by high frequency SCS (HF-SCS) and included in a prospective prognostic study. In 18 patients, an internal pulse generator (IPG) for HF-SCS was permanently implanted. Therapy success was assessed using the Oswestry Disability Index (ODI), visual analogue pain scale (VAS) and painDetect questionnaire. Neuropathic pain of the legs versus the back (median values: VAS leg 71 mm, VAS back 69 mm) was dominant in the patients at a preoperative mean ODI of 63%. With HF-SCS therapy, a pronounced pain reduction was seen and persisted in the follow-up after 6 months (VAS leg 18 mm, VAS back 24 mm). The ODI showed an improvement to a mean of 24% after 6 months.

Spine Examination during COVID-19 Pandemic via Video Consultation. / Telemedizinische Wirbelsäulenuntersuchung während der COVID-19-Pandemie.

INTRODUCTION: During the current COVID-19 pandemic video consultations are increasingly common in order to minimize the risk of infection for staff and patients. The aim of this study was to evaluate the feasibility of a spine examination via video. METHODS: A total of 43 patients were recruited. Each participant underwent a video-based (VB) and a conventional face-to-face (FTF) spine examination. Pain intensity, active range of motion, inspection, a neurophysiologic basic exam and provocations tests were evaluated using video-based and face-to-face methods. RESULTS: The intra-rater reliability (IRR) was measured between both examinations. Good to very good IRR values were obtained in inspection (Kappa between 0,752 und 0,944), active range of motion and basic neurophysiological examination (Kappa between 0,659 und 0,969). Only moderate matches were found in specific provocation tests (Kappa between 0,407 und 0,938). A video-based spine examination is a reliable tool for measuring pain intensity, active range of motion and a basic neurophysiologic exam. CONCLUSION: A basic spine examination during a video consultation is possible. A good agreement of the test results between video-based and face-to-face examination could be found.

Implants for Vertebral Body Replacement - Which Systems are Available and Have Become Established. / Wirbelkörperersatz ­ welche Systeme sind am Markt, was hat sich bewährt?

Since the first vertebral body replacement operations over 50 years ago until now, there were developed numerous methods and implants. Vertebral body replacement after corpectomy nowadays is a standard procedure in spinal surgery. At the beginning mainly bone grafts were used. Due to continuous development, PMMA and titanium implants were developed. Nowadays various expandable and non-expandable implants are available. Numerous implants can still be justified. The question arises which methods and systems are on the market and which ones have proven themselves? This article describes and compares the advantages and disadvantages of each implant type.

Vertebral Bone Marrow-Derived Mesenchymal Stromal Cells from Osteoporotic and Healthy Patients Possess Similar Differentiation Properties In Vitro.

Osteoporosis is a disease characterized by low bone mass and an increased risk of fractures. Although several cellular players leading to osteoporosis have been identified, the role of mesenchymal stromal cells (MSC) is still not fully elaborated. The aim of this study was, therefore, to isolate and characterize MSCs from vertebral body of healthy non-osteoporotic and osteoporotic patients, with a particular focus on their osteogenic differentiation potential. Isolated MSCs were characterized by their osteogenic, adipogenic, and chondrogenic differentiation, as well as surface marker expression, proliferation behavior, and immunomodulatory capacity. The mineralization process was confirmed using Alizarin Red S and alkaline phosphatase (ALP) stains and further evaluated by determining ALP activity, mineral deposition, and free phosphate ion release. MSCs from both healthy and osteoporotic patients showed common fibroblast-like morphology and similar proliferation behavior. They expressed the typical MSC surface markers and possessed immunomodulatory capacity. Both groups demonstrated solid trilineage differentiation potential; osteogenic differentiation was further confirmed by increased ALP activity, deposition of inorganic crystals, phosphate ion release, and expression of osteoblast marker genes. Overall, MSCs from osteoporotic and non-osteoporotic patients showed neither a difference in general MSC features nor in the detailed analysis regarding osteogenic differentiation. These data suggest that vertebral body MSCs from osteoporotic patients were not impaired; rather, they possessed full osteogenic potential compared to MSCs from non-osteoporotic patients.

Endoscopic facet joint denervation for treatment of chronic lower back pain.

OBJECTIVES: Percutaneous radiofrequency is an established method for treatment of chronic low back pain of intervertebral facet etiology. Endoscopic techniques have the advantage of visualization of the facet joint and the dorsal medial ramus and thus allow for more accurate denervation. It was thus hypothesized that pain reduction is vaster and longer enduring. PATIENTS AND METHODS: A total of 98 consecutive patients that underwent endoscopic facet joint denervation (EFJD) were included in this study. Prior to intervention and for follow-up, patients were asked to complete VASpain, ODI, COMI and EQ5D questionnaires. RESULTS: VASpain was reduced significantly (EFJD: p < 0.001) at last follow-up. Values for ODI, COMI and EQ5D showed significant improvements towards subjective well-being at last follow-up. CONCLUSION: EFJD is a promising technique for the treatment of facet joint syndrome caused CLBP as it contributes to sustaining significant pain reduction and improvement of subjective quality of life parameters.

Characterization and Comparison of Human and Ovine Mesenchymal Stromal Cells from Three Corresponding Sources.

Currently, there is an increasing focus on mesenchymal stromal cells (MSC) as therapeutic option in bone pathologies as well as in general regenerative medicine. Although human MSCs have been extensively characterized and standardized, ovine MSCs are poorly understood. This limitation hampers clinical progress, as sheep are an excellent large animal model for orthopedic studies. Our report describes a direct comparison of human and ovine MSCs from three corresponding sources under the same conditions. All MSCs presented solid growth behavior and potent immunomodulatory capacities. Additionally, we were able to identify common positive (CD29, CD44, CD73, CD90, CD105, CD166) and negative (CD14, CD34, CD45, HLA-DR) surface markers. Although both human and ovine MSCs showed strong osteogenic potential, direct comparison revealed a slower mineralization process in ovine MSCs. Regarding gene expression level, both human and ovine MSCs presented a comparable up-regulation of Runx2 and a trend toward down-regulation of Col1A during osteogenic differentiation. In summary, this side by side comparison defined phenotypic similarities and differences of human and ovine MSCs from three different sources, thereby contributing to a better characterization and standardization of ovine MSCs. The key findings shown in this report demonstrate the utility of ovine MSCs in preclinical studies for MSC-based therapies.

Treatment with and without stabilizing lumbar spinal orthosis after one- or two-level spondylodesis: A randomized controlled trial.

BACKGROUND AND OBJECTIVE: Musculature affected during spondylodesis surgery may benefit and recover faster if supported by spine orthosis postoperatively. METHODS: This prospective study included 50 consecutive patients undergoing one- or two-level spondylodesis. The intervention group received a lumbar spine orthosis (n= 23), while the control group remained without orthosis (n= 27). Patients were assessed for pain (Visual Analogue Scale, VAS), Oswestry Disability index (ODI) as well as the use of analgesics. RESULTS: Patients wearing an orthosis postoperatively reported a higher degree of subjective stability. However, both intervention as well as control group did not show any significant differences for each of the follow-up points regarding VAS, ODI or the use of analgesics. CONCLUSION: Wearing an orthosis has neither impact on subjective pain, the need for analgesics nor for postoperative functionality. However, patients reported that they profited from wearing the orthosis by feeling more stable, thereby nicely improving their postoperative mobility. Thus, novel patient reported outcome measures have to be developed to assess these features in future studies.

An Overview of the Current State of Pediatric Scoliosis Management.

Historically pediatric scoliosis represents a condition deeply rooted within the origins of orthopedic surgery. Today only a few subspecialized surgeons treat pediatric scoliosis patients. In severe cases surgery can hold progression of and correct pathologic spinal curvature. The goal of this article is to provide an overview of the current state of pediatric scoliosis management. It aims to increase the attention of general physicians and orthopedic surgeons to a niched but rather frequently encountered pediatric pathology to facilitate early recognition and diagnosis. A thorough research of literature was conducted to summarize the different scoliosis types, their etiology and presentation. Classification, normal human growth phases and curve progression risk have been further elaborated. Finally, current treatment options with their benefits, shortcomings and complications were laid out and discussed. Among the etiological groups a focus was put on idiopathic scoliosis, in particular adolescent idiopathic scoliosis as the most frequently encountered subtype.

A prospective, international, randomized, noninferiority study comparing an implantable titanium vertebral augmentation device versus balloon kyphoplasty in the reduction of vertebral compression fractures (SAKOS study).

BACKGROUND CONTEXT: Balloon kyphoplasty (BKP) is a commonly performed vertebral augmentation procedure for painful osteoporotic vertebral compression fractures (OVCFs). OBJECTIVE: This study aimed to support a non-inferiority finding for the use of a titanium implantable vertebral augmentation device (TIVAD) compared to BKP. STUDY DESIGN: Prospective, parallel group, controlled comparative randomized study. PATIENT SAMPLE: Patients who presented with one or two painful OVCFs located between T7 and L4 aged <3 months, failed conservative treatment, and had an Oswestry Disability Index (ODI) score ≥30/100 were eligible for the study. OUTCOME MEASURES: The primary composite endpoint was defined as: reduction in VCF fracture-related pain at 12 months from baseline and maintenance or functional improvement (ODI) at 12 months from baseline, and absence of device-related adverse event or surgical reintervention. If the primary composite endpoint was successful, a fourth component (absence of adjacent level fracture) was added for analysis. If the analysis of this additional composite endpoint was successful, then midline target height restoration at 6 and 12 months was assessed. Secondary clinical outcomes included back pain intensity, ODI score, EQ-5D index score (range 0=death to 1=full health) and EQ-VAS score (range 0-100). METHODS: Patients were recruited in 13 hospitals across 5 countries and were randomly assigned (1:1) to either TIVAD or BKP with electronic randomization as described in the protocol. A total of 152 patients with OVCFs were initially randomized. Eleven patients were excluded (six met exclusion criteria, one with evidence of tumor, and four patients had T score out of requested range). Anterior vertebral body height ratio, midline vertebral body height ratio, and Cobb angle were measured preoperatively and postoperatively by an independent imaging core lab. Adjacent and subsequent fractures and safety parameters were recorded throughout the study. Cement extravasation was evaluated on X-rays. All patients were followed at screening at 5 days, 1 month, 6 months, and 12 months postoperatively. This study was supported by Vexim SA. Seven authors received study-specific support less than $10,000 per year and seven authors received no study-specific support. RESULTS: Among the 141 patients (78.7% female, mean age 73.3±9.5 years) who underwent surgery (TIVAD=68; BKP=73), 126 patients (89.4%) completed the 12-month follow-up period (TIVAD=61; BKP=65). The analysis of primary endpoint on the ITT population demonstrated non-inferiority of the TIVAD to BKP. The analysis of the additional composite endpoint demonstrated the superiority of TIVAD over BKP (p<0.0001) at 6 months (88.1% vs. 60.9%) and at 12 months (79.7% vs. 59.3%). Midline VB height restoration was more improved for TIVAD than for BKP at 6 months (1.14±2.61 mm vs. 0.31±2.22 mm); p=0.0246) and 12 months after surgery (1.31±2.58 mm vs. 0.10±2.34 mm; p=0.0035). No statistically significant differences were shown between procedures for improvement in functional capacity and quality of life. Pain relief was significantly more marked in the TIVAD group compared to the BKP group at 1 month (p=0.029) and at 6 months (p=0.021) after surgery. No patient required surgical reintervention or retreatment at the treated level. No symptomatic cement leakage was reported. Adverse events were similar for both groups (41.2% in the TIVAD group and 45.2% in the BKP group). The incidence of adjacent fractures was significantly lower after the TIVAD procedure than after BKP (12.9% vs. 27.3%; p=0.043). CONCLUSIONS: Study results demonstrated non-inferiority of the TIVAD to the predicate BKP with an excellent risk/benefit profile for results up to 12 months.

The Kellgren and Lawrence Score as a helpful tool for the indication for total disc replacement at the cervical spine.

BACKGROUND: Several studies showed encouraging results after total disc replacement (TDR) in patients with cervical-brachial syndrome (CBS). OBJECTIVE: The aim of this study was to supplement the existing documentation of results after total disc replacement and to underline the importance of the correct indication. METHODS: The clinical and radiological outcome of 34 patients was evaluated in a 2-year follow-up by several parameters as the Visual Analogue Scale (VAS) for pain, the Neck Disability Index (NDI) and the Kellgren and Lawrence Score. RESULTS: The median values for NDI changed from 65% (20-90) before surgery to 20% (0-86) 2 years after surgery (p< 0.0001). Pain intensity had an average rate of reduction from 8.4 ± 2 cm (VAS scale 0-10 cm) to 2.9 ± 2 cm (p< 0.0001). A median of 1 (0-3) was calculated for the Kellgren and Lawrence Score in the affected segment preoperatively. Due to loosening in five cases the TDR was removed and changed into anterior cervical decompression and fusion (ACDF). In all of these five cases a preoperative Kellgren and Lawrence Score of 2 or 3 was calculated and five of five patients (100%) were smokers. CONCLUSION: The use of TDR in nonsmoking patients with a low preoperative Kellgren and Lawrence Score of 0-1 lead to a clinically and radiologically successful outcome.

Randomized Trial of Sacroiliac Joint Arthrodesis Compared with Conservative Management for Chronic Low Back Pain Attributed to the Sacroiliac Joint.

BACKGROUND: Sacroiliac joint pain is increasingly recognized as a cause of low back pain. We compared the safety and effectiveness of minimally invasive sacroiliac joint arthrodesis using triangular titanium implants and conservative management in patients with chronic sacroiliac joint pain. METHODS: This study was a prospective, multicenter randomized controlled trial of adults with chronic sacroiliac joint pain assigned to either conservative management or sacroiliac joint arthrodesis with triangular titanium implants. The study end points included self-rated low back pain (visual analog scale [VAS]), back dysfunction (Oswestry Disability Index [ODI]), and quality of life. Ninety percent of subjects in both groups completed the study. RESULTS: Between June 6, 2013, and May 15, 2015, 103 subjects were randomly assigned to conservative management (n = 51) or sacroiliac joint arthrodesis (n = 52). At 2 years, the mean low back pain improved by 45 points (95% confidence interval [CI], 37 to 54 points) after sacroiliac joint arthrodesis and 11 points (95% CI, 2 to 20 points) after conservative management, with a mean difference between groups of 34 points (p < 0.0001). The mean ODI improved by 26 points (95% CI, 21 to 32 points) after sacroiliac joint arthrodesis and 8 points (95% CI, 2 to 14 points) after conservative management, with a mean difference between groups of 18 points (p < 0.0001). Parallel improvements were seen in quality of life. In the sacroiliac joint arthrodesis group, the prevalence of opioid use decreased from 56% at baseline to 33% at 2 years (p = 0.009), and no significant change was observed in the conservative management group (47.1% at baseline and 45.7% at 2 years). Subjects in the conservative management group, after crossover to the surgical procedure, showed improvements in all measures similar to those originally assigned to sacroiliac joint arthrodesis. In the first 6 months, the frequency of adverse events did not differ between groups (p = 0.664). By month 24, we observed 39 severe adverse events after sacroiliac joint arthrodesis, including 2 cases of sacroiliac joint pain, 1 case of a postoperative gluteal hematoma, and 1 case of postoperative nerve impingement. The analysis of computed tomographic (CT) imaging at 12 months after sacroiliac joint arthrodesis showed radiolucencies adjacent to 8 implants (4.0% of all implants). CONCLUSIONS: For patients with chronic sacroiliac joint pain due to joint degeneration or disruption, minimally invasive sacroiliac joint arthrodesis with triangular titanium implants was safe and more effective throughout 2 years in improving pain, disability, and quality of life compared with conservative management. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Spondylitis - Spondylodiscitis - an Update. / Spondylitis ­ Spondylodiszitis ­ ein aktuelles Update.

Spondylodiscitis is an infection of the intervertebral disc with subsequent infection of the adjacent vertebral bodies. The main causes are 3 pathogen groups: bacteria, particularly tuberculosis pathogens, fungi and parasites. In pyogenic spondylodiscitis, infections with Staphylococcus aureus are the most common, with an incidence of up to 80%. Mortality is around 2 - 3%. Infections with tuberculosis are often associated with psoas and paravertebral abscesses. Neurological deficits are registered in up to 50% of patients. For microbiological diagnostic testing, blood cultures are used for aerobic and anaerobic bacteria. However, histological examination leads significantly more frequently to positive pathogen detection. In tissue samples, results with 16S rRNA PCR results are clearly superior to results from microbiological examination. The MRI exhibits high sensitivity and specificity and is therefore superior to other radiological methods. Elimination of the infection, pain reduction and stabilisation of the spine are the main objectives of any treatment. A standardised antibiotic therapy for spondylodiscitis has not been clearly defined. Pathogen detection is important, with focused antibiotic therapy. Antibiotic therapy should initially be administered intravenously for 2 - 4 weeks. This should be followed by oral administration for 6 - 12 weeks. In the case of antibiotic-resistant infections with neurological deficiencies, it is recommended to perform a surgical procedure, with careful debridement and instrumentation as well as i. v. administered antibiotics for 3 weeks followed by three month oral antibiotic treatment. Surgical procedures are indicated with neurological deficits, progressive increase in spinal deformities, failure of conservative therapy with insufficient pain relief and unreliable pathogen identification. The selection of the surgical procedure should mainly be based on the extent and localisation of bone destruction and the individual circumstances of the patients. The prognosis is good if there is a clear reduction in CRP and ESR in the first few weeks.

Heterotopic Ossification - Complication or Chance? / Heterotope Ossifikation ­ Komplikation oder Chance?

So far, there has been no clear explanation of the pathophysiological relationships in the development of HO. There is little experimental data dealing with the post-traumatic inflammatory response in terms of a balance between the repair of damaged muscle cells and the opposite response in its development. There are numerous indications regarding possible predisposing factors, such as existence of surrounding tissue hypoxia or the function of pro-angiogenic (VEGF e.g.) and osteoinductive (BMP e.g.) factors. These different scientific approaches offer the opportunity to clinically intervene. In our opinion, early intervention seems to make the most sense in terms of effectiveness and recurrence of HO. An important pathomechanism seems to be chronic inflammation. Currently, non-steroidal anti-inflammatory drugs are the most commonly prescribed prophylaxis drugs. The effectiveness and efficacy of non-steroidal anti-inflammatory drugs is limited by the time-limited release and the side effect potential. Therefore, it is interesting to focus future research towards the cross-talks between immunosuppressive downregulation of the inflammatory response and its effect on the balance between muscle regeneration and the development of HO.

High-Frequency Spinal Cord Stimulation for the Treatment of Chronic Low Back and Leg Pain: Implantation Technique of Percutaneous Leads and Implantable Pulse Generator.

Spinal cord stimulation (SCS) is an evidence-based, reversible but invasive procedure for the treatment of chronic pain syndromes: for example, in patients with failed-back-surgery syndrome or complex regional pain syndrome. A more recent, similar technique uses high-frequency stimulation for SCS and follows a different mechanism of action that does not result in paresthesia. This Technical Note and video present surgical instructions of a "2-way cut-down" technique for a high-frequency SCS trial period and permanent implantation of an implantable pulse generator.

Suitability of Administrative Databases for Durotomy Incidence Assessment: Comparison to the Incidence Associated With Bone-Removal Devices, Calculated Using a Systemic Literature Review and Clinical Data.

BACKGROUND: Durotomy is a major complication of spinal surgery, potentially leading to additional clinical complications, longer hospitalization, and increased costs. A reference durotomy incidence rate is useful for the evaluation of the safety of different surgical aspects. However, the literature offers a wide range of incidence rates, complicating this comparison. Theoretically, a reference incidence value can be extracted from administrative databases, containing a large number of procedures. However, it is suspected that these databases suffer from underreporting of complications. This study aims to evaluate durotomy incidence using several large-scale databases and to assess the ability to use it as a reference by comparison to durotomy incidences directly associated with 4 bone removal devices, including the commonly used high-speed drill. METHODS: Durotomy overall incidence was estimated from several administrative databases using different methods in order to achieve minimal and maximal estimations. Durotomy incidences for 3 bone removal devices were derived using literature meta-analysis, and the incidence for the fourth device was calculated using clinical data. RESULTS: The incidence range of durotomy according to the databases was 2.8-3.5%. The calculated incidence of durotomy for the studied devices was 0.4-2.91%. The highest rate, 2.91%, is associated with the commonly used high-speed drill combined with Kerrison Rongeur and bone punches. Since bone-removal devices are just one of the possible causes of dural tears, the general incidence is expected to be higher than the incidence associated with the devices, yet even the maximal estimation, 3.5%, was only slightly higher, suggesting that the speculation of underreporting of dural tears to these databases is probably true, as also supported by the mostly higher incidences reported in the literature. CONCLUSIONS: Hospital administrative databases seem to show a lower-than-reasonable incidence of durotomy, suggesting possible underreporting. Researchers should therefore use this tool with caution. Reduction of the absolute durotomy incidence by approximately 2.5% can be achieved by improving the safety of bone-removal devices.

Risk Factors for Continued Opioid Use in Conservative Versus Surgical Management of Low Back Pain Originating From the Sacroiliac Joint.

STUDY DESIGN: Secondary analysis of data from a randomized controlled trial. OBJECTIVES: To identify risk factors for continued opioid use after conservative management (CM) or minimally invasive surgical management (MISM) of low back pain (LBP) originating from the sacroiliac joint. METHODS: Patients were randomized either to CM (n = 49) or MISM (n = 52). We documented opioid use, pain intensity (visual analogue scale [VAS]), Oswestry Disability Index (ODI), and the Zung depression score (Zung Self-Rating Depression Scale) at baseline and at months 3 and 6 after treatment initiation. RESULTS: Compared with opioid nonusers, opioid users at baseline had higher mean levels of disability (ODI 61.5, standard deviation [SD] 13.3 vs ODI 51.5, SD 12.8; P < .01) and higher depression scores (Zung 48.5, SD 8.5, vs Zung 42.2, SD 7.2; P < .01). At 6 months, opioid users had higher 6-month pain levels (VAS 60.4, SD 24.0, vs VAS 42.4, SD 28.2; P < .01), higher disability scores (ODI 50.5, SD 16.2, vs ODI 32.7, SD 19.3; P < .01) and higher depression scores (Zung 47.6, SD 8.0, vs Zung 38.8, SD 8.9; P < .01). Risk factors for continued opioid use at 6 months were patient age (odds ratio [OR] for age = 0.91; P = .02) and an increase in LBP (OR 1.08; P = .02) in the CM group and a lack of improvement in depression scores (OR 1.12; P = .03) in the MISM group. CONCLUSIONS: In our patient cohort, the risk of continued opioid use in the treatment of LBP increased not only with pain intensity but also with levels of depression during the course of treatment.