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The recently published "Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-Related Complaints: Systematic Review and Meta-Analysis"1 questions whether the current practice of epidural steroid injections (ESIs) for patients suffering from lumbosacral radicular syndrome should continue. Considering the high number of epidural steroid injections that are performed yearly, the methodology may require further assessment. The authors make some statement about the evolution, the cause and the treatment algorithm of lumbosacral radicular pain, that are not completely correct. The papers included in this review are not all of high scientific quality. Papers dealing with patients who suffer lumbosacral radicular pain of 6 weeks to 21 months, which is for beyond the recommended period for the indication of sub-Acute lumbosacral radicular pain. More than one-Third of the studies included in this systematic review reported no medical imaging prior to performing the epidural injection. This heavily compromises the results of the study and the validity of the recommendation. The use of minimal important change (MIC) as an outcome parameter is inappropriate because this outcome measurement was developed to identify clinically meaningful changes within groups or individuals, not to determine significant changes between groups The authors performed 40 meta-Analyses, but most of them were based on 1-3 RCTs. Whereas meta-Analyses containing few studies can yield useful information when the studies evaluate similar patient populations, the procedures are standardized, and the outcome measures are similar, performing meta-Analyses in the presence of significant study heterogeneity, as is present in ESI clinical trials, is a roadmap for showing a biased lack of efficacy.

This study aimed to assess the factors that influence The Oswestry Disability Index (ODI) clinical outcomes in patients with Lumbal Spinal Stenosis (LSS) after Percutaneous Stenoscopic Lumbar Decompression (PSLD). A total of 92 patients were analyzed for factors that affecting ODI clinical outcome. These factors were age, sex, body mass index, cigarette consumption, alcohol consumption, sports history, pain onset, radicular pain, VAS pain score, paresis and paresthesia symptoms, duration and conservative management, length of operation, duration of treatment, recurrence of pain, and duration of postoperative healing. Data were collected by direct examination, questionnaires, in-depth interviews, and patient medical records. A Pearson correlation or Spearman Rank test and independent T-test or Mann Whitney was conducted to determine the significant relationship between these factors and ODI clinical outcomes. Multiple linear regression was performed to find out which factor most influences ODI clinical outcome. Some factors influence ODI outcome in the sample as resulted by statistical analysis. From the statistic analysis, only three factors that influence the ODI postoperative there was age (p=0.003), VAS preoperative (p=0.001), and ODI preoperative (p=0.001). There was no statistical significance found in the other factors with p>0.005. Factors influencing clinical outcomes by ODI in patients with lumbar spinal stenosis after PSLD was the age of the patient, preoperative ODI, and preoperative VAS.

OBJECTIVES The aim of this study was to retrospectively investigate factors predicting a successful outcome after ozone chemonucleolysis (OCN) in patients with radicular pain and poor response to conservative treatments. METHODS Univariable and multivariable logistic regression analysis was used to identify the predictors of good outcome after OCN. Good outcome was defined as 33% Oswestry Disability Index (ODI) reduction (model 1) or 13-point ODI improvement (model 2) at 1 month after OCN. RESULTS Two hundred seventy-three patients were analyzed. A significant pain reduction (pre-operative Numerical Rating Scale [NRS] 6.7 ± 1.5, postoperative NRS 2.6 ± 2.2, P

Objective This retrospective study aims to compare the clinical and radiological outcomes of posterolateral fusion (PLF) with transforaminal lumbar interbody fusion (TLIF + PLF) for the treatment of patients with low-grade spondylolisthesis. Methodology A total of 77 adult patients ≥18 years with low-grade spondylolisthesis, Meyerding grades I and II, were assigned into two groups: 36 patients treated with PLF and 41 patients treated with TLIF + PLF. The PLF group is composed of the patients that were operated with pedicle screw and the TLIF + PLF group is composed of the ones that were operated with fixation and TILF by autografting. Clinical evaluation was performed using the spino-pelvic sagittal balance, Numeric Rating Scale, Oswestry Disability Index, blood loss, operation times, and postoperative hospital stay of the PLF vs TLIF groups. The incidences of postoperative low back pain and radicular pain in the two groups were also recorded. Radiography was performed preoperatively and postoperatively to assess spino-pelvic parameters. Results Significant restoration of spino-pelvic sagittal balance was observed in the TLIF group after surgery, and all spino-pelvic sagittal balance parameters showed significant improvement in the TLIF group after surgery, while in the PLF group, all spino-pelvic sagittal parameters had improved except the segmental angle lordosis (p = 0.316), which showed no significant difference after surgery in the PLF group. Postoperative pelvic incidence and pelvic tilt significantly improved in the TLIF group in comparison to PLF groups. Hence, TLIF can achieve better postoperative spino-pelvic sagittal balance parameters than PLF. There was no difference in the complication rates for each group. Both groups achieved significant improvement in postoperative clinical outcomes, and there was no significant difference in the incidence of postoperative low back pain or radicular pain between the two groups. Conclusion Both surgical procedures PLF and TLIF were effective. PLF and TLIF can result in improved clinical and radiological outcomes for patients treated for low-grade spondylolisthesis. TLIF can achieve better restoration of spino-pelvic sagittal balance parameters than PLF alone.

STUDY DESIGN Prospective clinical pilot study and cadaveric study. OBJECTIVE The aim of this study was to evaluate the spread of an ultrasound-guided interfascial plane blocks (UGIPBs) and its potential efficacy for cervical radiculopathy. SUMMARY OF BACKGROUND DATA Cervical radiculopathy is a common disorder, potentially leading to severe pain and disability. Conservative treatment with cervical epidural steroid injections (ESI) is limited by concerns regarding their safety. UGIPBs are used in cervical surgical procedures as part of the multimodal postoperative analgesia regimen however, were not described for cervical radiculopathy. METHODS Twelve patients with acute cervical radicular pain who failed conservative treatment and were candidates for surgery were offered a cervical retrolaminar injection. A solution of 4 mL lidocaine 0.5% and 10 mg dexamethasone was injected, assisted by ultrasound guidance, at the posterior aspect of the cervical lamina corresponding to the compressed nerve root level. Additionally, a cadaver study was carried to evaluate the contrast spread and infiltration into near structures, both anatomically and radiographically. RESULTS Twelve patients underwent the procedure, with a mean follow-up time of 14.5 weeks. Average numerical rating scale improved from 7.25 at baseline to 2.83 following the injection (P

Introducción: La enfermedad de Parkinson afecta principalmente a personas >65 años. El cuadro degenerativo lumbar en el contexto de un canal estrecho sumado a la alteración neuromuscular y la mala calidad ósea, favorece al desequilibrio sagital y coronal. Los pacientes que necesitan cirugía tienen altas tasas de revisión y reoperación con técnicas instrumentadas y no instrumentadas. El objetivo de este estudio fue evaluar la técnica quirúrgica de descompresión mínimamente invasiva en pacientes con enfermedad de Parkinson y dolor radicular o claudicación neurogénica en los miembros inferiores. Materiales y Métodos:Se evaluó a pacientes con diagnóstico de canal lumbar estrecho y enfermedad de Parkinson tratados quirúrgicamente. El procedimiento se indicó por síntomas de canal estrecho o estenosis foraminal de causa degenerativa. Todos fueron tratados con una cirugía descompresiva a través de una hemilaminectomía mínimamente invasiva mediante retracción tubular y asistencia con microscopia. Resultados: De enero de 2015 a diciembre de 2017, se trató a 6 pacientes con enfermedad de Parkinson y canal lumbar estrecho. Se descomprimieron 12 niveles en total, todos estuvieron internados

Background Spinal schwannomas are commonly presented with minor symptoms, including radicular pain, sensory deficits, and minor neurologic deficit. Acute neurologic deterioration is uncommon. Case Description In this study, a case of cauda equina schwannoma presented with acute neurologic deficit after movement of spinal schwannoma is presented. Conclusions It is noted that movement of spinal schwannoma and resultant acute neurologic deterioration should be considered during the follow-up.

Background/ImportanceUltrasound (US)-guided cervical selective nerve root injections (CSNRI) have been proposed as an alternative to fluoroscopic (FL) -guided injections. When choosing US guidance, the proceduralist should be aware of potential issues confirming vertebral level, be clear regarding terminology, and up to date regarding the advantages and disadvantages of US-guided CSNRI.ObjectiveReview the accuracy and effectiveness of US guidance in avoiding vascular puncture (VP) and/or intravascular injection (IVI) during CSNRI.Evidence ReviewQueries included PubMed, CINAHL and Embase databases from 2005 to 2019. Three authors reviewed references for eligibility, abstracted data, and appraised quality.FindingsThe literature demonstrates distinct safety considerations and limited evidence of the effectiveness of US guidance in detecting VP and/or IVI. As vascular flow and desired injectate spread cannot be visualized with US, the use of real-time fluoroscopy, and if needed digitial subraction imaging, is indicated in cervical transforaminal epidural injections (CTFEIs). Given the risk of VP and/or IVI, the ability to perform and to retain FL images to document that the procedure was safely conducted is valuable in CTFEIs.ConclusionUS guidance remains to be proven as a non-inferior alternative to FL guidance or other imaging modalities in the prevention of VP and/or IVI with CTFEIs or cervical selective nerve root blocks. There is a paucity of adequately powered clinical studies evaluating the accuracy and effectiveness of US guidance in avoiding VP and/or IVI. US-guided procedures to treat cervical radicular pain has limitations in visualization of anatomy, and currently with the evidence available is best used in a combined approach with FL guidance.

Spinal cord stimulation (SCS) is an established therapy for chronic neuropathic pain and most frequently utilised for Failed Back Surgery Syndrome (FBSS). BurstDR™ also known as DeRidder Burst-SCS, a novel waveform, has demonstrated superiority to conventional tonic stimulation of the thoracic spine in FBSS. There are case reports of an improvement in multidimensional pain outcomes using DeRidder Burst-SCS in the cervical spine for chronic neck and cervical radicular pain. The safety and efficacy of cervical DeRidder Burst-SCS stimulation still however remain undetermined. This is a prospective, multicentre feasibility trial evaluating the safety and therapeutic efficacy of DeRidder Burst-SCS stimulation for the treatment of chronic intractable neck pain with or without radiation to the arm, shoulder, and upper back. After baseline evaluation, subjects will undergo an SCS trial using the Abbott Invisible Trial system according to standard clinical procedures. During the trial phase, SCS leads will be implanted in the cervical epidural space. At the end of the SCS trial, subjects experiencing at least 50% pain relief will be considered for permanent implant. Pain intensity, medication usage, and other multidimensional pain outcomes will be collected. The timing of these will be at baseline, end of the SCS trial and at 3-, 6-, and 12-month visits. Incidence of adverse events will be collected throughout the study duration. The results of this feasibility study will validate the efficacy and safety of DeRidder Burst-SCS stimulation in the cervical spine. The results obtained in this study will potentially be used to generate a level 1 evidence-based study with formal statistical hypotheses testing. www.clinicaltrials.gov Identifier: NCT03159169.

Background: Chronic lumbar radicular pain often accompanies neuropathic pain. The treatment may follow a screening for probable neuropathic pain rather than the definitive diagnosis, which is often difficult in daily practice. However, interventional management may have limited effects on symptoms in patients with neuropathic radicular pain refractory to conservative treatments. The purpose of this study is to evaluate the factors associated with successful responses after lumbar epidural intervention in patients with chronic lumbar neuropathic radicular pain determined by Douleur Neuropathique 4 (DN4). Methods: We retrospectively reviewed 221 chronic lumbar radicular pain patients using a DN4 questionnaire prior to the epidural interventional procedure. The patients were divided into two groups according to the DN4 questionnaire

Introduction: Lumbar radiculopathy is a common complaint of patients presenting to spine clinic. A variety of conditions can lead to compression of the nerve roots, the most common cause is disc herniation. Selective Nerve Root block (SNRB) injections have been used in everyday clinical practice.Methods: Fifty patients with lumbar radicular pain were enrolled in the study as per the inclusion criteria. Patients were assessed clinically, neurologic evaluation done and pain quantified by Visual analogue scale (VAS) and the Oswestry Disability Index (ODI). They were reassessed after SNRB immediately, at 3 weeks and 6 weeks using the same outcome measures.Results: Majority of patients (40 out of 49) demonstrated improvement after SNRB).The degree of improvement in the VAS was significantly greater and statistically significant (P

Objective Minocycline is known to reduce microglial activation, suggesting that it may reduce neuropathic pain. We reviewed studies in humans that evaluated the effectiveness of minocycline in alleviating neuropathic pain. Methods We searched the PubMed, Embase, Cochrane library, and SCOPUS databases for papers published before January 06, 2021, using the search words minocycline and pain. The inclusion criteria for the selection of articles were (1) minocycline administered to humans and (2) minocycline administered to control neuropathic pain. Results The primary literature search yielded 2299 relevant papers. Based on the assessment of the titles, abstracts, and full-text, nine publications were selected for this review. Only four of the nine studies showed a positive pain-reducing outcome after minocycline administration. Two of the three studies on chemotherapy-induced neuropathic pain showed a positive pain-reducing effect. Minocycline was effective in controlling pain from diabetic and leprotic neuropathies. However, minocycline was not effective in controlling lumbar radicular pain and pain resolution after carpal tunnel release. Conclusion Our review provides evidence that minocycline may have some potential for reducing neuropathic pain. Further high-quality studies need to be conducted to validate this potential.

Objective The aim of this study was to invastigate the efect of the sacralization on the results of transforaminal epidural steroid injection for radicular low back pain. Materials and methods The study included 64 patients diagnosed with radicular low back pain due to unilateral and singlelevel lumbar disk herniation. Patients were divided into 2 groups: patients with sacralization (Group S) and patients without lumbosacral transitional vertebrae (Group A). Injection was applied to the relevant level. Patients were evaluated with Numeric Rating Scale and Modifed Oswestry Disability Index before, at week 3 and month 3 after the procedure. Sacralization presence was determined by MRI. Sacralization was categorized by anteroposterior lumbar radiography using Castellvi classifcation. Treatment success was considered as≥50% reduction in NRS scores. Results Numeric Rating Scale and Modifed Oswestry Disability Index scores decreased in both groups on both week 3 and month 3 (p0.05). Treatment success in the third month was 44.8% in Group S and 65.6% in Group A. Conclusion Transforaminal epidural steroid injection is an efective and safe method for radicular low back pain. Sacralization presence should be evaluated before treatment considering that it may be a risk factor reducing treatment success.

Transient ischemic attack (TIA) of spinal cord (SC) is very rare and characterized by sudden onset of paralysis, sensory loss, back pain. We present a patient with acute painful paraplegia and symptoms resolved within a few hours. We identified 10 patients in literature search. Five of them were male, the mean age of patients was 53.8. Para paresis/pleji was present in all. Only two patients did not have radicular pain. Vascular risk factors were hypertension in five patients, smoking in five and diabetes mellitus in one. TIA period ranged from 1 min to 24 h. The most common etiology was aortic dissection (n=6). Four patients had aortic thrombosis. Six patients were treated with medical and surgical methods; other four were treated with only medically. SC ischemia and aortic diseases should be kept in mind in short term/persistent acute spinal syndromes with pain.

Background The frequency with which sensory disturbances occur in patients with radicular leg pain and disc herniation is not well known, and the efficacy of tests to identify such changes are not firmly established. The presence of sensory disturbances is a key sign of nerve root involvement and may contribute to the diagnosis of a lumbar disc herniation, identify patients for referral to spinal imaging and surgery, and improve disease classification. Questions/purposes In this study, we sought: (1) to determine the frequency with which abnormal sensory findings occur in patients with lumbar disc herniation-related radicular pain, using a standard neurological sensory examination; (2) to determine what particular standard sensory test or combination of tests is most effective in establishing sensory dysfunction; and (3) to determine whether a more detailed in-depth sensory examination results in more patients being identified as having abnormal sensory findings. Methods Between October 2013 and April 2016, 115 patients aged 18 to 65 years referred to secondary health care with radicular leg pain and disc herniation were considered potentially eligible for inclusion in the study. Based on these inclusion criteria, 79% (91) were found eligible. Ten percent (11) were excluded because of other illness that interfered with the study purpose, 3% (3) because of cauda equina syndrome, 2% (2) because of spinal stenosis, 2% (2) because of prior surgery at the same disc level, and 2% (2) because of poor Norwegian language skills. Three percent (4) of the patients did not want to participate in the study. Of the 91 eligible patients, 56% (51) consented to undergo a comprehensive clinical examination and were used for analysis here. The sample for the purposes of the present study was predetermined at 50. These patients were first examined by a standard procedure, including sensory assessment of light touch, pinprick, vibration, and warmth and cold over the back and legs. Second, an in-depth semiquantitative sensory testing procedure was performed in the main pain area to assess sensory dysfunction and improve the detection of potential positive sensory signs, or sensory gain of function more precisely. Sensory loss was defined as sensations experienced as distinctly reduced in the painful side compared with the contralateral reference side. In contrast, sensory gain was defined as sensations experienced as abnormally strong, unpleasant, or painful and distinctly stronger than the contralateral side. Ambiguous test results were coded as a normal response to avoid inflating the findings. The proportions of abnormal findings were calculated for each sensory modality and for all combinations of the standard examination tests. Results The standard examination identified at least one abnormal finding in 88% (45 of 51) of patients. Sensory loss was present in 80% (41), while sensory gain was present in 35% (18). The combination of pinprick and light touch identified all patients who were classified as having abnormal findings by the full standard examination. The semiquantitative procedure identified an additional three patients with an abnormal finding. Conclusion We suggest that the combination of pinprick and light touch assessment is an adequate minimal approach for diagnostic and classification purposes in patients with lumbar radicular pain. Level of evidence Level I, diagnostic study.

BackgroundDisease-modifying anti-rheumatic drugs (DMARDs) are used in the management of rheumatoid arthritis (RA) and are classified as conventional DMARDs and biologic agents. A concern with DMARDs is the increased risk of infection after surgery. A practice advisory from the American Society of Anesthesiologists recommend alternatives to neuraxial injections in patients who are immunocompromized. We describe a patient who was on several DMARDs and developed inflammatory reactions in her bilateral paraspinal muscles and lumbar spine after an epidural steroid injection (ESI).Case presentationThe patient was a 79-year-old woman; she was taking methotrexate, adalimumab and prednisone for her RA. She had a left L5-S1 paramedian ESI for her L5 radiculitis. After relief of her back and radicular pain for 5 weeks, she had an acute exacerbation of her back pain. MRI showed bilateral paraspinal fluid accumulations and enhancement in her ligamentum flavum. Cultures of the aspirated fluid and biopsy specimens were negative for fungal, aerobic and anaerobic organisms. A repeat MRI 2 months later showed diminution of the fluid collection but with a new fluid accumulation near the left L4-5 facet and left L4 pedicle. Repeat cultures and gram stain of the specimens taken from the pedicle and the paraspinal muscles were negative. The patient was followed by her rheumatologist and in the pain clinic until resolution of her symptoms.ConclusionsSeveral society guidelines recommend the continuation of methotrexate but stoppage of the biologic DMARDS before surgery. The occurrence of an intense inflammatory reaction after an ESI in our patient calls for additional research on the subject and shared decision-making between the pain physician, patient and rheumatologist especially in patients on several DMARDs.

Introduction: A very common problem that we come across is that of lower backache in middle aged and elderly, in which disc prolapse is far more prevalent in the population than realised. However, radicular steps like spine surgery is a frightening concept for most. In our world, where technology has undergone such advances, offering a concept like day care spine surgery that too under local anaesthesia for relief of radicular pain, will be a welcome breath. This treatment option not only works faster than epidural injection or oral pain relievers, but also is a more permanent mode of treatment in a tertiary care centre where patient load is a big issue. Objectives: The aim of this study was to determine the success and surgical outcome of percutaneous transforaminal lumbar endoscopic discectomy on patients with disc prolapse and benefit to the hospital due to rapid turnover of patients. Material and Methods: Total 20 patients were followed and reviewed in Civil Hospital, Ahmedabad from between July to December 2016. Visual Analog Scale (VAS) was used to assess relief from pain and radiculopathy and Macnab’s criteria to know the patient satisfaction. Results: At the end of 6 weeks, mean post-operative VAS was 3 as compared to pre-operative 8.8 Macnab’s criteria gave excellent and good results in 80% individuals. Mean hospital stay was 1.2days with no complications like dural tear or infection. One patient underwent open discectomy. Conclusion: Transforaminal lumbar endoscopic discectomy is a novel technique for most of the government tertiary care centres with many patients but lacking advanced technology. Inspite of having a steep learning curve and high one time cost of instruments, it could become gold standard as it relieves symptoms immediately reducing surgical and anaesthetic complications. It being a day care procedure results in rapid turnover of patients. Keywords: Transforaminal, Lumbar discectomy, Percutaneous endoscopic.

Background. The arsenal of physical methods for correcting pathological skin scars is quickly replenished, but the results of their use are often unsatisfactory. An inadequate approach to therapy, without taking into account the evaluation of their effectiveness, leads to relapses and increased growth of scar tissue or the absence of a clinically significant effect of many of them and requires strict scientific evidence in the course of benign scientific studies. Aims: Comprehensive (qualitative, quantitative, structural) analysis of evidence-based research in electronic evidence-based research databases (PEDro, PubMed, e-Library) and systematic review databases (Cochrane Library) for the period from 2000 to 2020. The clinical effects and suggested mechanisms of action of currently proven therapeutic physical factors in the treatment of patients with coronary heart disease are considered in detail. The most studied of the physical methods with proven effects are high-intensity laser technologies of high-intensity laser therapy (47%), fractional radiofrequency therapy (14%), microneedling (9%) and microdermabrasion (8%), which cause the most pronounced remodeling of the extracellular matrix of the skin in the area of scars. Conclusion. It is necessary to regularly generalize and analyze existing evidence-based studies, as well as perform new high-quality randomized controlled clinical trials to study the impact of physical correction methods on post-acne scars, which serve as the basis for developing clinical recommendations.

A patient with a prior history of intradural schwannoma and disc herniation presented with radicular pain after being hit in the thigh by a dog’s tail. She was worked up and found to have a tumor of her right sciatic nerve. The tumor was resected and histology was consistent with schwannoma. The dog’s tail acted as a Tinel’s sign maneuver and led to timely identification of her peripheral nerve tumor. Peripheral nerve schwannomas can present in unusual forms, and Tinel’s maneuver may be a useful tool in diagnosis.

Endoscopic cervical foraminotomy is increasingly used for cervical spondylotic radiculopathy (CSR), but there is great concern about radiation exposure because of the heavy dependence of this surgical method on fluoroscopy. The objective of this study was to introduce in detail an advanced surgical technique of keyhole foraminotomy via a percutaneous posterior full-endoscopic approach as a treatment for CSR and investigate its clinical outcomes. We retrospectively reviewed 33 consecutive patients with CSR who underwent keyhole foraminotomy via a percutaneous posterior full-endoscopic approach from October 2015 to April 2017. The patients' general characteristics, including operative time, blood loss, hospital stay, complications, and recurrence, were obtained. Clinical outcomes were evaluated using the visual analogue scale (VAS) for radicular pain, the neck disability index (NDI) for functional assessment, and the modified MacNab criteria for patient satisfaction. All operations were successfully performed (mean operation time, 62 min), with no measurable blood loss or severe related complications. The mean follow-up was 25 months. The VAS and NDI scores were significantly improved as compared with those in the preoperative period (preoperative vs. final follow-up: 7.6±1.6 vs. 3.83±7.34 for VAS, P

Background: There are different surgical modalities designed to manage aggressive vertebral hemangioma (VH) that causes neurological symptoms. The selection of the best approach is still controversial. It is crucial to safely achieve neurological recovery with the elimination of the risk of recurrence. The combined use of surgical decompression and vertebroplasty is one of the surgical modalities that are used to manage these cases. Patients and Methods: From January 2012 to January 2019, nine patients with aggressive VH were retrospectively included in the study. All of them were operated upon using combined surgical decompression and vertebroplasty. We evaluated all the patients preoperatively, immediate postoperative, 1 month, and 12 months later. Clinical and radiological outcomes were assessed. Results: Affected spinal levels were dorsal in six cases and lumbar in three cases. There was no postoperative worsening of the preoperative neurological status. For the cases presented with sciatica, the mean VAS score has dropped from 8.33 preoperatively to 2.67 postoperatively. One month later, all of them are free from the radicular pain. For the cases presented with myelopathy, they regain their motor power in both lower limbs over a period of 4 weeks with a mean Nurick grade of 1.17. The postoperative radiological studies revealed near total occlusion of the VH with the maintenance of the vertebral body height. No clinical or radiological signs of spinal instability or recurrence are observed over the period of follow-up. Conclusions: The combined use of surgical decompression and vertebroplasty is considered a safe and effective modality in the management of aggressive VHs.

The authors reported complete regression of a large hemorrhagic lumbar synovial cyst following posterior spinal fusion without direct cystic resection. A 64-year-old woman suffered from sudden onset of the left buttock pain radiating to the left leg after waking up in the morning following the previous history of a minor accident 2 months ago. Magnetic resonance imaging (MRI) of the lumbosacral spine showed a large extradural round mass originating from the left facet joint at the level of L3–L4. The mass was hyperintense on T1-weighted images and hypointense on T2-weighted images, probably compatible with hemorrhagic joint-related cyst. Surgical treatment was chosen for her because of persistent left radicular pain with no responding to medications. The patient underwent decompressive laminectomy, subtotal facetectomy, instrumented fusion, and only tissue biopsy due to severe adherence of the mass and dura. Histopathological examination was consistent with a hemorrhagic synovial cyst. The radicular pain completely disappeared after the surgery. Follow-up MRI of the lumbosacral spine obtained 6 months after the surgery demonstrated complete resolution of the hemorrhagic cyst. Complete resolution of hemorrhagic synovial cyst seems to correlate with subtotal facetectomy, probably resulting in leakage of cyst content and subsequent resorption of the cyst wall. In addition, hematoma within the synovial cyst may resolve spontaneously over time.

Background Persistent or recurring radicular pain after lumbar surgery is a clinical condition of failed back surgery syndrome (FBSS) that seriously affects the life quality of patients. Conventional medication and physiotherapy do not fully relieve this pain. A simpler, safer, and less invasive option is lumbar selective nerve root block or paravertebral block. Here, we share our experience regarding lumbar paravertebral block for a patient with FBSS, which successfully alleviated radicular pain after lumbar surgery. Case presentation An 80-year-old man with left lower limb radicular pain diagnosed as L4-5, L5-S1 intervertebral disc protrusion, spinal canal stenosis, and degenerative scoliosis underwent lumbar surgery. Four months after surgery, he experienced left lower limb radicular pain. After designing the puncture route based on X-ray film, we performed a combined ultrasound-guided L4 and L5 paravertebral block. With his improved pain control, his functional status and ability to perform daily activities also markedly improved. Conclusion Real-time ultrasound-guided lumbar paravertebral block performed with a pre-designed route on X-ray film can provide a simple and safe way to relieve radicular pain in FBSS.

BACKGROUND The incidence of lumbar intervertebral disc prolapse (LDP) is increasing in the current practice of neurosurgery. But prospective studies to assess the risk factors in the final outcome of surgical procedures adopted while treating LDP are not many. We wanted to analyze the risk factors and their role in the prognosis and functional improvement after surgery in patients with Lumbar Disc Herniation. METHODS 200 patients with LDP subjected to different surgical procedures were studied prospectively in the Department of Neurosurgery, in a tertiary teaching hospital during the period of April 2017 to March 2019. The demographic profile, risk factors and the surgical procedures adopted were noted. The Macnab criteria were used to determine the clinical outcome after surgery. All patients were followed for a period 6 months postoperatively for the presence of complications and final functional outcome after surgery. RESULTS Mean age of the patients was 44.7 ± 4.65 years. Males were 113 / 200 (56.50 %) and females were 87 / 200 (43.5 %). Low back pain was present in 187 (93.50 %) patients, radicular pain was seen in 171 / 200 (85.5 %) patients. L4 - L5 interspace was involved in 122 / 200 (61.0 %) patients; disc was extruded in 91 / 200 (45.5 %) patients; disc protrusion was observed in 81 / 200 (40.5 %) patients. According to Macnab criteria, in this study excellent outcome was seen in 129 / 200 patients (64.5 %); the outcome was Good in 56 patients (22.5 %), Fair in 8 (4 %) patients, and Poor in 7 cases (3.5 %). Better surgical outcomes were associated with younger patients (p < 0.001), non-diabetics (p = 0.024), absence of bowel and bladder involvement (p < 0.001), protruded disc prolapse (p = 0.036), and disc prolapse precipitated by lifting inappropriate weight (p = 0.001). 85.4 % of the MIS group had excellent outcomes, when compared to 39.1 % in the laminectomy group (p - < 0.001). CONCLUSIONS Lumbar Disc Herniation was commonly observed in the middle age with a male predilection. Risk factors like age, overweight, high BMI and diabetes mellitus had poor outcomes. Surgery for LDH was safe with a success rate of (92.5 %). KEYWORDS Intervertebral Disc, Prolapse, Radicular Pain, Low Back Ache

Lumbar disc herniation (LDH) is a common cause of low back pain and radicular pain. The aim of our study was to evaluate the regression of LDH in patients who are considered to require surgical treatment but prefer conservative treatment. Patients who presented between January 2018 and June 2020 and who did not accept the recommended surgical treatment following a diagnosis of LDH based on clinical and radiological findings were retrospectively reviewed. All 12 of the patients included in the study showed spontaneous regression of LDH during outpatient clinical follow-up. Our study included 12 patients (seven male and five female). The mean age was 46.5 (the youngest was 30 years old; the oldest was 70 years old). Regression was observed at the L2-L3 level in two patients (10%), at the L4-L5 level in four patients (40%), and at the L5-S1 level in six patients (50%). On the follow-up examination of all patients, the severity of their pain was evaluated with the Visual Analogue Scale, and all patients described a reduction in pain (min: 2, max: 8). Ten patients described radicular pain at the initial examination, eight patients received physical therapy and rehabilitation treatment before the follow-up examination, and nine patients described neuropathic pain at the follow-up examination. Spontaneous regression of LDH is rare. While conservative treatments provided partial improvement in the complaints of these patients, conservative treatments usually cannot prevent the development of neuropathic pain.

Ultrasound-guided cervical nerve root block is the technique of injecting local anesthetic or steroid into the intertubercular groove outside of the cervical foramen under real-time ultrasound guidance. It has established diagnostic and therapeutic employment for patients suffering symptoms caused by cervical disc disorders and foraminal stenosis. Measures of selective nerve root blockade would have vital clinical utility, especially in multilevel disease or combined with atypical symptoms, where subjective assessment is difficult. This case reported a 47-year-old male patient who suffered from severe radicular pain confined to the index and middle fingers, with weakness of the right upper extremity. He was successfully treated with selective C6, C7 nerve root under ultrasound guidance. For confirmation of the proper analgesia range, laser speckle contrast imaging (LSCI) and infrared thermography (IT) were both constructed over the dorsum of the hands and forearms during the procedure. The results of the off-line analysis suggested LSCI and IT might be considered as alternative measurements for the selective cervical nerve root.

Summary of Background DataNo study has evaluated the relationship between contrast dispersion patterns and outcomes after fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI).ObjectivesDetermine whether contrast dispersion patterns predict pain and functional outcomes after CTFESI.MethodsSecondary analysis of data collected during two prospective studies of CTFESI for the treatment of refractory radicular pain. Contrast dispersion patterns visualized by true anteroposterior (AP) projections during CTFESIs were categorized by flow: 1) completely external to the lateral border of the neuroforamen (zone 1); 2) within the neuroforamen but without entry into the lateral epidural space (zone 2); and 3) with extension into the lateral epidural space (zone 3). At baseline and at 1 month post-CTFESI, neck pain, arm pain, and “dominant index pain” (the greater of arm or neck pain) were evaluated using a numeric rating scale (NRS); physical function was assessed using the Five-Item Version of the Neck Disability Index (NDI-5).ResultsOne-month post-CTFESI, neck pain, arm pain, and “dominant index pain” reductions of ≥50% were observed in 39.4% (95% confidence interval [CI], 28.2–51.8), 55.6% (95% CI, 43.0–67.5), and 44.1% (95% CI, 32.7–56.2) of participants, respectively. Regarding “dominant index pain,” 72.7% (95% CI, 40.8–91.2), 39.4% (95% CI, 24.2–57.0), and 37.5% (95% CI, 20.5–58.2) of participants reported ≥50% pain reduction when zone 1, zone 2, and zone 3 contrast flow patterns were observed. Contrast dispersion zone was not significantly associated with subgroup differences in neck pain, arm pain, or NDI-5 scores (P>0.05).ConclusionImprovements in pain and function 1 month after treatment with CTFESI did not differ significantly based on the contrast dispersion pattern. Future study is needed to confirm or refute these findings in other procedural settings, in broader patient populations, and with longer-term outcome assessment.

A case of resection of a large dumbbell-shaped nerve sheath tumor at L1/L2 via a direct lateral minimally invasive approach is described. The tumor was removed via a lateral, subdiaphragmatic, rib-sparing, retropleural, retroperitoneal approach. The thoracolumbar junction can be challenging via the lateral approach and to the best of our knowledge this is the first report of excision of a paravertebral tumor via this approach. We believe this provided the benefits of direct operative trajectory and exposure, excellent tumor access, and avoided the need for facetectomy and extended spinal instrumentation across the thoracolumbar junction. Complete tumor excision was achieved with preserved motor function and improvement in radicular pain and sensory neurological deficit.

Varicella-zoster virus (VZV) presenting as a radicular pain in the thoracic region is not uncommon, but the presentation in the lumbar and thigh region is not frequently seen. Characteristic segmental vesicular–bullous rash in a dermatomal distribution associated with pain and allodynia is a prominent feature. The pain appears before rash. It is not uncommon for clinicians to misdiagnose radicular pain caused by VZV due to prolapsed disc. We report two patients who presented to us with complaints of back pain with leg radiculopathy that were initially treated for discogenic radiculopathy and rash was wrongly attributed to hot fomentation. This case report emphasizes the importance of including varicella-zoster radiculitis in the differential diagnosis of radicular pain and clinical examination of every rash. Physical examination is must if the patient complains of rash. Appropriate and timely diagnosis can prevent unnecessary investigations.

BACKGROUND Lumbar juxtafacet cysts are benign lesions that grow at the level of facet joints or within neighboring structures. Recently, there is an ongoing trend toward less invasive procedures for treating degenerative spine diseases. Here we report a multicenter study of full-endoscopic surgery for juxtafacet cyst removal. METHODS We prospectively collected patients with a diagnosis of lumbar juxtafacet cyst surgically treated in 3 institutions between January 2017 and August 2019. Patients of any sex and age were eligible if they had a single level unilateral lumbar juxtafacet cyst, invalidating radicular pain lasting >6 weeks, adequate imaging, and failed percutaneous or conservative treatment. Age at diagnosis; sex; preoperative, postoperative, and 6-month leg pain; surgical and medical complications; spine instability (preoperatively and at 6 and 12 months); and follow-up time were collected. RESULTS Thirty-five patients were enrolled. Median operative time was 78 minutes, and mean leg pain went from a preoperative value of 6.8 (standard deviation [SD] = 1.2) to a postoperative value of 3.4 (SD = 1.1, P

Background Since 1929, only 171 epidural hemangioma cases have been reported. We report five epidural hemangiomas and review cases reported over the past decade in terms of radiological features and clinical findings. Methods Among patients operated on for spinal tumors at our hospital between 2009 and 2020, five had epidural hemangiomas. We retrospectively examined patient records and images and reviewed relevant English literature in PubMed from 2009 to 2019. Eighty-seven epidural hemangioma cases were reported in the last 10 years. Results Among 87 cases, the average age was 49.58 years; 43 and 44 cases were male and female, respectively. The most common lesion level was thoracic (59.8%), while common symptoms were back pain (42.5%); numbness, hypoesthesia, or anesthesia (37.9%); paraparesis (34.5%); and radicular pain (20.7%). On magnetic resonance imaging (MRI), 77.1% showed hypo-isointensity on T1-weighted image (WI), hyperintensity on T2WI, and homogenous enhanced patterns with contrast. Total resection was performed in most cases, with good clinical outcomes. Preoperative embolization was performed in four cases, with good surgical outcomes. The median follow-up duration of postoperative MRI was 16 months, and no case had recurrence. Conclusions Epidural hemangiomas are extremely rare and may be difficult to diagnose preoperatively. They should be considered if a dumbbell-shaped or epidural hypervascular lesion is noted. The treatment of choice for epidural hemangioma is total resection, with most cases having good clinical outcomes. Preoperative embolization may be useful for reducing bleeding. Although there were almost no recurrences after resection, careful follow-up for longer periods is required.

Percutaneous endoscopic interlaminar discectomy (PEID) is widely used as a minimally invasive procedure that shows satisfying outcomes for the treatment of L5/S1 and even L4/5 disc herniation. PEID can be divided into direct and indirect approaches according to the established method of the working channel. The direct approach mainly utilizes the puncture needle directly through the intervertebral space into the intervertebral disc under non-direct vision and insertion of the guidewire into the puncture needle to guide the dilator and working channel to retract the ligamentum flavum, dural sac and nerve roots. This approach requires a skilled puncture technique, as damage to the nerve roots and dural sac can easily occur. Therefore, we improved this interlaminar access procedure; we placed the puncture target at the inferior endplate and performed preoperative epidurography to expose the spinal nerve roots and dural sac after the puncture needle was passed through the ligamentum flavum. Then, we positioned the puncture needle at the posterior edge of the superior centrum. Finally, we inserted the working sleeve for the operation. This approach is convenient and effectively reduces the learning curve and intraoperative complications. The aim of this study was to introduce the procedure and investigate the safety and efficacy of full-endoscopic interlaminar discectomy via an inferior endplate approach for the treatment of lumbar disc herniation.We performed full-endoscopic interlaminar discectomy via the inferior endplate approach in 321 patients who satisfied our inclusion criteria during the period from May 2014 to May 2017. All operations were completed under local anaesthesia. Under fluoroscopic guidance, we performed epidurography to expose the spinal nerve roots and dural sac. The working sleeve and endoscope were then introduced into the inferior endplate of the superior centrum. Herniated disc material was removed using forceps and a laser under clear endoscopic visualization. We retrospectively evaluated the 321 patients with more than 30 (range 12-48) months of follow-up. The therapeutic effects were assessed using scores of the visual analogue scale (VAS), Oswestry disability index (ODI), Macnab standard and infrared thermal imaging.The mean VAS score for radicular pain improved from 6.3 ± 1.01 preoperatively to 1.01 ± 0.35 at the final follow-up (P0.01). The mean ODI score improved from 85.5 ± 12 preoperatively to 12.4 ± 3.7 at the final follow-up (P0.01). According to the Macnab standard, the excellent and good outcome scores were 96.5%. The infrared thermal imaging scores indicated that the skin temperature of both lower extremities significantly improved 1 week after surgery compared with the preoperation temperature (P0.01).The inferior endplate approach for percutaneous endoscopic interlaminar discectomy provides a safe and very effective alternative for the treatment of lumbar disc herniation.

Pedicle fractures are rare and usually associated with repetitive stress, high-speed trauma, osteoporosis, unilateral spondylolysis, or instrumentation surgery. A review of the current literature on bilateral pedicle fractures of the lumbar spine revealed only a few cases listed as a complication of instrumentation or excessive decompression surgery. The authors present the clinical case of a 49-year-old man with exacerbating low-back pain and intermittent L5 radicular pain. The known comorbidities were rather remarkable for systemic lupus erythematosus and osteopenia. Radiological investigations revealed an acute bilateral pedicle fracture of L5 without any evidence of preexisting spondylolysis. An off-label minimally invasive fracture reduction and fixation was performed using traction screws and intraoperative navigation. The patient reported instant pain relief and did not show any sensorimotor deficits at discharge. The postoperative CT scan revealed an ossification of the former fracture after 3 months, with great 1-year follow-up outcome. This is the first documented report on the effectiveness of traction screws used in a patient with bilateral pedicle fractures of the L5 vertebra. This minimally invasive technique represents a promising treatment option in selected cases by sparing segmental fusion.

Context: Many inflammatory cytokines are also elevated in degenerated or herniated intervertebral discs. Among biomarkers, interleukin-6 (IL-6) plays an essential role in the inflammatory process of disc herniation. Some studies have suggested that an increase in serum IL-6 levels occurs in sustained radicular pain. Aims: The aim of this study was to determine the relationship between changes in IL-6 serum level and pain and disability index in patients with radicular pain in acute herniated lumbar disc before and after lumbar disc surgery. Settings and Design: This is a descriptive-analytic prospective study to examine the association between IL-6 serum levels on pain and disability before and after the surgery in patients admitted with acute herniated lumbar intervertebral discs from 2015 to 2018 in Imam Khomeini Hospital, Sari, Mazandaran, Iran. Subjects and Methods: The blood level of IL-6, the severity of pain based on visual analog score, and disability based on the Oswestry disability index were measured before and 3 months after surgery. Statistical Analysis Used: All data were analyzed using SPSS version 24. Results: Thirty-two patients were enrolled in the study. Seventeen patients were male. The mean age was 39.53 ± 8.89 years. IL-6 concentration, 4.36 and 1.16 pg/ml were determined as cutoff before and after the surgery. Conclusions: The acceptable sensitivity and specificity of IL were obtained in this study. Our findings revealed that IL-6 could be used as a biomarker for predicting postoperative pain relief and disability improvement.