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Central sensitisation is assumed to be one of the underlying mechanisms for chronic low back pain. Because central sensitisation is not directly assessable in humans, the term ‘human assumed central sensitisation’ (HACS) is suggested. The objectives were to investigate what definitions for HACS have been used, to evaluate the methods to assess HACS, to assess the validity of those methods, and to estimate the prevalence of HACS. Database search resulted in 34 included studies. Forty different definition references were used to define HACS. This review uncovered twenty quantitative methods to assess HACS, including four questionnaires and sixteen quantitative sensory testing measures. The prevalence of HACS in patients with chronic low back pain was estimated in three studies. The current systematic review highlights that multiple definitions, assessment methods, and prevalence estimates are stated in the literature regarding HACS in patients with chronic low back pain. Most of the assessment methods of HACS are not validated but have been tested for reliability and repeatability. Given the lack of a gold standard to assess HACS, an initial grading system is proposed to standardize clinical and research assessments of HACS in patients with a chronic low back.

Lumbar disc herniation (LDH) with radicular pain is a common and complicated musculoskeletal disorder. Our previous study showed that LDH-induced methylglyoxal (MG) accumulation contributed to radicular pain. The underlying mechanisms through which MG accumulates are poorly understood. In the present study, we found that both MG and tumor necrosis factor-alpha (TNF-ɑ) levels in the herniated disc of patients with radicular pain were significantly increased, and the activity of Glyoxalase 1 (GLO1), the rate-limiting enzyme that metabolizes MG, was decreased. In rats, the LDH model was mimicked by implantation of autologous nucleus pulposus (NP) to the left lumbar five spinal nerve root. The mechanical allodynia was observed in LDH rats. Besides, MG and TNF-ɑ levels were increased, and GLO1 activity was significantly decreased in the implanted NP. In cultured rat NP cells, stimulation with the inflammatory mediator TNF-ɑ reduced GLO1 activity and expression. These results suggested that TNF-ɑ-induced GLO1 activity decrease contributed to MG accumulation in the herniated disc of patients with radicular pain.

ObjectivesImplantation of a dorsal column stimulator (DCS) for axial spine and radicular pain is a commonly performed procedure. Despite the benefits of this device to reduce pain and improve quality of life, some patients elect to have the device explanted. The purpose of this study is to describe pre-operational factors among patients who elected to have their DCS explanted and how these factors are associated with reason for explantation.Materials and MethodsWe conducted a retrospective descriptive study using the database of a private outpatient orthopedic clinic. We included all patients who had a DCS explanted between January 1, 2007 and June 19, 2014. Data was collected on patient demographics, past medical and back surgery history, as well as details of implantation, permanent device implantation, and subsequent explantation. Reasons for explantation were categorized as: inadequate pain control using three categories (with no device-related pain/discomfort, with device-related pain/discomfort, or inadequate pain control and patient wants MRI), or pain resolved.ResultsA consecutive sample of 100 subjects who underwent explantation of a DCS was identified for review. Of these 100 subjects, 14 were excluded. Based on our data, we hypothesize that sex (57% female, 43% male) degenerative disc disease (72%), previous back surgery (70%), BMI classified as overweight (subject average = 28.3), history of tobacco usage (57%), and history of narcotic use (80%) may be potential risk factors for explantation.ConclusionsWith respect to clinical evaluation of patients as candidates for spinal cord stimulator implantation, we cannot recommend that any of the evaluated variables be considered a contraindication to proceeding with a trial procedure. Future studies are planned to compare these data to a control group of subjects to establish risk factors predisposing individuals to explantation of a DCS.

A 37-year-old right-handed woman sought care for a dull headache present for 6 months, which was followed by the development of radicular pain in the left leg radiating down the back of her leg into her foot, with associated left foot numbness. Magnetic resonance imaging of the lumbar spine showed an enhancing lesion within the conus. She was referred for neurosurgical evaluation and underwent magnetic resonance imaging of the entire neuraxis, which showed an enhancing lesion in the left cerebellum. She underwent a left cerebellar debulking surgical procedure. Postoperative diplopia developed for approximately 1 month and then subsequently resolved. She walked with a walker after surgery, with progressive deterioration in gait. Two months after surgery a postural tremor developed in the left arm and leg. She was referred for neurologic evaluation. Pathologic evaluation of cerebellar tissue showed foamy histiocytes and xanthomatous cells that stained positive for CD68 (KP1). Staining for CD1a was negative. Tissue immunohistochemistry for the BRAF V600E sequence variation was negative. No hyponatremia was detected. Positron emission tomography/computed tomography of the body from vertex to toes indicated hypermetabolism in the distal femur and proximal tibia. Examination and imaging findings were consistent with a diagnosis of multifocal Erdheim-Chester disease. The patient was initially treated with pegylated interferon, with clinical and radiographic progression. She was subsequently treated with vemurafenib and dexamethasone, with continued radiologic progression. Treatment with radiotherapy and cladribine were also unsuccessful. At that point, next-generation sequencing of cerebellar tissue showed a BRAF V471F sequence variation. She was then treated with trametinib, which resulted in a decrease in size of the cerebellar lesion and growth stabilization of the conus lesion. Histiocytic neoplasms are a heterogeneous group of multisystem disorders, primarily including Erdheim-Chester disease, Langerhans cell histiocytosis, and Rosai-Dorfman disease. Although initially thought to represent inflammatory processes, recent insights into their genomic architecture have shown that they are derived from macrophage-lineage neoplasms.

Lumbar disc herniation is a common disorder in adults that is accompanied by lower back and radicular pain. A 32-year-old man visited our clinic with 1-week history of persistent lower back pain and weakness in his right big toe. Magnetic resonance imaging (MRI) of his lumbar spine revealed herniated discs at L3/L4, L5/S1 and L4/L5, where a right-sided intraspinal mass lesion deep to the L4 vertebral body was causing compression of the nerve root. The patient underwent conservative treatment and reported no symptoms referrable to his back or leg 4 months later. Follow-up MRI showed no herniation of the nucleus pulposus at the L4/L5 level or lesion deep to the vertebral body of L4, whereas no changes had occurred to the status of the herniated L3/L4 and L5/S1 discs. The present case and a literature review show that a sequestered lumbar disc herniation can regress within a relatively short timeframe without surgery. The authors emphasise the utility of conservative therapy for patients who do not have a definitive surgical indication.

To understand the pathophysiology of L5-S1 loss of lordosis and retrolisthesis by comparing 2 commonly assumed physiological weight-bearing postures.This was a prospective comparative study of whole-body standing and slump sitting EOS radiographs in clinic patients presenting with back pain or lower limb radicular pain. Patients with prior spinal intervention, malignancy, trauma, inflammatory diseases, transitional lumbosacral vertebra, pregnancy, and L5-S1 retrolisthesis or spondylolisthesis from nondegenerative causes were excluded. C7 sagittal vertical axis, global cervical angle, global thoracic angle, global lumbar angle, thoracolumbar angle, T1-slope, pelvic incidence, pelvic tilt, sacral slope, L5-S1 angle, L5-S1 vertebral translation, L5-S1 disc height, and presence of L4-5 vertebral translation were measured. Univariate and multivariate analyses were performed to identify predictors of L5-S1 lordosis loss and retrolisthesis.L5-S1 loss of lumbar lordosis (7.02 ± 9.90°, P0.001), retrolisthesis (0.07 ± 0.411 cm, P0.001), and loss of disc height (0.10 ± 0.23 cm, P0.001) occurred when changing from standing to slump sitting along with other sagittal profile changes (P0.001). Taller L5-S1 disc height (odds ratio [OR] 2.57, P = 0.04), larger lumbar range-of-motion change (OR 3.82, P = 0.012), lower sacral slope on sitting (OR 2.50, P = 0.043), and presence of L4-5 spondylolisthesis (OR 2.75, P = 0.032) were predictive of larger L5-S1 lordosis loss (7°) on multivariate analysis, while larger lumbar range-of-motion change (OR 2.21, P = 0.050) and presence of L4-5 spondylolisthesis (OR 3.08, P = 0.023) were predictive of greater L5-S1 retrolisthesis (0.07 cm).Degenerative L5-S1 loss of lordosis and retrolisthesis likely result from long-standing lower lumbar spine bending forces against the posterior ligamentous complex with slump sitting, predisposed by a negatively sloped sacrum and increased lumbar flexibility.

Introducción. La lumbalgia en los niños y adolescentes es relativamente frecuente, sin embargo la hernia discal lumbar es rara, se reportan menos de 2500 casos en la literatura anglosajona desde 1945. Caso clínico: masculino de 13 años de edad, con dolor lumbar con irradiación radicular L5 izquierda inmediato a traumatismo directo durante práctica deportiva, la resonancia magnética mostró hernia discal L4/L5, agregándose paresia de músculos inervados por raíz L5 izquierda, por lo que se le efectúa discoidectomía, y rehabilitación con recuperación de fuerza muscular de músculos involucrados. Conclusiones. La hernia discal lumbar en niños y adolescentes es poco frecuente, se asocia a trauma en 2/3 de los casos; el estudio de elección es la resonancia magnética; el tratamiento conservador generalmente es efectivo para los pacientes en estas etapas de la vida; el tratamiento quirúrgico eta indicado ante pobre respuesta del conservador.

Congenital vertebral synostosis (CVS) is a rare developmental condition due to failure of vertebral segmentation. Vertebrae and their intervertebral discs differentiate and resegment at the time of organogenesis during fetal life. Failure of this embryological process can result in the limitation of mobility of the involved segment. This inappropriate segmentation thus results in vertebral fusion or a block vertebra with subsequent vertebral synostosis. Long-term, such segmental fusion can increase osteoarthritis at levels below and above the fused segment due to excessive wear on these joints. Presentations can include congenital kyphosis and scoliosis. Patients may present with back and radicular pain, and possible myelopathy CVS usually occurs, in order of frequency, in the cervical, lumbar, and thoracic vertebral levels. This paper reviews congenital lumbar synostosis with associated findings and its clinical implications and embryological significance. A case illustration is also included.

Background. Dorsopathy is a group of diseases of the musculoskeletal system and connective tissue associated with degenerative diseases of the spine. Risk groups for the development of dorsopathies include people with a sedentary lifestyle, people working in difficult conditions, athletes, military personnel, people with obesity. Clinical classification of dorsopathies involves their division according to the affected level (cervical, thoracic, lumbosacral). Objective. To describe the management of patients with back pain. Materials and methods. Analysis of literature data on this topic. Results and discussion. Cervicocranialgias, related to dorsopathies, include vertebral artery syndrome (VAS) and extravasal artery compression (EAC). VAS is a complex of cerebral, vascular and autonomic disorders that occur due to the damage of the sympathetic plexus of vertebral artery, deformation of the wall or changes in its lumen. In turn, EAC involves the compression of blood vessels by bone abnormalities, muscles, osteophytes of the cervical vertebrae, scars, tumors, and so on. Lower back pain (LBP) is one of the most common dorsopathies. Its prevalence has doubled in the last decade. The mechanism of aseptic inflammation in dorsopathies includes such links as the release of proinflammatory mediators, activation of peripheral nociceptors, production of cyclooxygenase-2 and the formation of prostaglandins. Pain in dorsopathies is classified into nociceptive (caused by the excitation of nociceptors in damaged tissues), neuropathic (caused by damage to the central or peripheral nervous system) and psychogenic (caused by primary mental disorders). By duration, LBP is classified into acute (3 months). According to the etiology, the following subspecies are distinguished: radicular (disc herniation, spondylosis, vertebral canal stenosis), specific (cancer, infection, fracture, equine tail syndrome) and nonspecific (myogenic disorders, facet syndrome). In the presence of so-called symptoms of red flags, it is recommended to conduct imaging examinations according to the indications. Such symptoms include pain development at the age of 55 years, recent back injury, progressive character, deterioration or lack of dynamics after keeping horizontal position, prolonged use of glucocorticoids, history of malignant tumors, osteoporosis, intravenous drugs injection, immunodeficiency, weight loss, fever, focal neurological symptoms, pain on palpation of the spine, spinal deformity. The symptoms of yellow flags predict pain chronization. The latter include certain work-related circumstances, beliefs, behaviors, and affective symptoms. The main causes of non-specific back pain include muscular-tonic pain syndrome (MTPS), myofascial pain syndrome (MFPS), arthropathies. Microcirculatory disorders, caused primarily by the reflex muscle spasm, play a significant role in the development of pain in these conditions. MTPS develops on the background of degenerative-dystrophic changes in the spine, ligaments and muscles as a result of exposure to provoking factors (significant physical exertion, injuries, sudden movements, prolonged stay in a static position, general or local hypothermia). Chronization of MTPS leads to the development of MTFS. Ischemic muscle spasm leads to the spasm of arteries and dilation of venules with impaired microcirculation and accumulation of inflammatory mediators. In turn, radicular ischemia develops with radicular pain. Venous plexus, which is compressed at the stage of stenosis without signs of direct compression of the root, is the most vulnerable structure of the intervertebral space. Treatment of LBP includes bed rest, sleep on a hard surface, the use of non-specific anti-inflammatory drugs, local administration of local anesthetics, muscle relaxants, B vitamins, therapeutic exercises and surgical treatment. Restoration of microcirculation makes it possible to influence the pathogenesis of radiculoischemia. Drugs that improve microcirculation and hemodynamics are included in the domestic clinical protocol for the treatment of dorsalgia. Reosorbilact (“Yuria-Pharm”) improves substance exchange between blood and tissues and helps to remove metabolic products. These effects are based on the opening of precapillary sphincters on the background of this solution use. For dorsalgia, it is also advisable to prescribe Latren (“Yuria-Pharm”) – a combination of pentoxifidine and Ringer’s lactate. Latren inhibits the aggregation of blood cells, increases the elasticity of erythrocytes, promotes vasodilation, normalizes the electrolyte composition of blood plasma. To eliminate endothelial dysfunction, Tivortin (“Yuria-Pharm”) is prescribed, which promotes vasodilation. The use of the listed above infusion drugs influences the pathogenesis of the process, eliminating dorsalgia. Conclusions. 1. LBP is one of the most common dorsopathies. 2. Pain in dorsopathies is classified into nociceptive, neuropathic and psychogenic. 3. Microcirculatory disorders play a significant role in the development of nonspecific LBP. 4. Combined use of Reosorbilact, Latren and Tivortin influences the pathogenesis of the process, eliminating dorsalgia.

Purpose Lumbar transforaminal selective nerve root injection (SNRI) is effective for controlling radicular pain. However, when a patient occasionally experiences severe foraminal stenosis, osteophytes cover the outside opening of the neural foramen, preventing clinicians from inserting a needle tip within the neural foramen. Patients and methods An 81-year-old man complained of left L5 radicular pain (left thigh and calf) due to severe left L5-S1 foraminal stenosis. After failure of conventional transforaminal SNRI in the left L5 due to severe degenerative change in the lumbar spine, SNRI was performed using a Racz catheter. After inserting a 16-gauge cannula via the sacral hiatus, the Racz catheter was inserted. The tip of the catheter was positioned near the left L5 nerve root. After confirming the location of the needle tip using a contrast dye, 20 mg (40 mg/mL) of triamcinolone with 0.5 mL of 1% lidocaine and 2 mL of normal saline was injected. Results Immediately after the procedure, the patient's pain completely disappeared. During the 1- and 2-month follow-ups, the patient reported only slight pain in the thigh and calf. Conclusion When it is not possible to perform a conventional transforaminal SNRI, SNRI using a Racz catheter can be an effective treatment option for controlling lumbar radicular pain.

Chronic pain affects roughly 50 million Americans, or 20.4% of the national population, and is a huge economic burden on society. Spinal cord stimulation (SCS) is a cost-effective interventional treatment modality for patients with chronic neuropathic and radicular pain. It is traditionally reserved for patients suffering from post-laminectomy syndrome, complex regional pain syndrome, or chronic back pain that is refractory to other less invasive techniques. There have been a few cases describing the use of SCS at higher levels to successfully obtain coverage of visceral abdominal pain. Here we describe an interesting case of a patient who suffered from chronic back pain and radiculopathy with post-laminectomy syndrome as well as chronic abdominal pain. We describe the use of high-frequency SCS to alleviate the patient's post-laminectomy pain as well as his abdominal pain. Our case describes SCS use with multi-level lead placement targeting both post-laminectomy pain and abdominal pain. We describe a strategy that can be useful to patients with concurrent pain from more than one source. Our case also adds to the growing evidence supporting the use of SCS for treating chronic visceral pain syndromes.

Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X‑rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.

The aim of this study was to determine the asymmetry of cervical multifidus (MF) and longus colli (LC) muscles in patients with unilateral chronic radicular neck pain (CRNP) and healthy subjects using ultrasonography.Ninety five individuals (50 patients with unilateral CRNP and 45 healthy subjects) participated in this study. The size of the cervical MF and LC muscles; anterior posterior dimension (APD) and lateral dimension (LD); were bilaterally measured in a relaxed state using ultrasonography.Patients with CRNP showed greater asymmetry in the cervical MF and LC muscles size than the healthy subjects. The mean percentages differences between sides for MF and LC muscles size was higher in patients than that of healthy subjects (for both APD and LD; P0.05). The ratio of smaller to larger dimensions of the cervical MF and LC muscles for patients were significantly less than that of healthy controls (for both APD and LD; P0.05).The results indicated that cervical MF and LC muscles showed higher asymmetry between sides and lesser ratio of smaller size to larger size in patients with CRNP as compared with healthy subjects. Current results confirmed the presence of MF and LC muscles atrophy in subjects with CRNP.

BACKGROUND Spinal anesthesia using a surface landmark-guided technique can be challenging in patients with anatomical alterations of the lumbar spine; however, it is unclear whether using ultrasonography can decrease the technical difficulties in these populations. We assessed whether an ultrasound-assisted technique could reduce the number of needle passes required for block success compared with the landmark-guided technique in patients with abnormal spinal anatomy. METHODS Forty-four patients with abnormal spinal anatomy including documented lumbar scoliosis and previous spinal surgery were randomized to receive either surface landmark-guided or preprocedural ultrasound-assisted spinal anesthesia. All spinal procedures were performed by 1 of 3 experienced anesthesiologists. The primary outcome was the number of needle passes required for successful dural puncture. Secondary outcomes included the success rate on the first pass, total procedure time, periprocedural pain scores, and the incidences of radicular pain, paresthesia, and bloody tap during the neuraxial procedure. Intergroup difference in the primary outcome was assessed for significance using Mann-Whitney U test. RESULTS The median (interquartile range [IQR; range]) number of needle passes was significantly lower in the ultrasound group than in the landmark group (ultrasound 1.5 [1-3 {1-5}]; landmark 6 [2-9.3 {1-15}]; P < .001). First-pass success was achieved in 11 (50.0%) and 2 (9.1%) patients in the ultrasound and landmark groups, respectively (P = .007). The total procedure time, defined as the sum of the time for identifying landmarks and performing spinal anesthesia, did not differ significantly between the 2 groups (ultrasound 141 seconds [115-181 seconds {101-336 seconds}]; landmark 146 seconds [90-295 seconds {53-404 seconds}]; P = .888). The ultrasound group showed lower periprocedural pain scores compared with the landmark group (ultrasound 3.5 [1-5 {0-7}]; landmark 5.5 [3-8 {0-9}]; P = .012). The incidences of complications during the procedure showed no significant differences between the 2 groups. CONCLUSIONS For anesthesiologists with experience in neuraxial ultrasonography, the use of ultrasound significantly reduces the technical difficulties of spinal anesthesia in patients with abnormal spinal anatomy compared with the landmark-guided technique. Our results can lead to practical suggestions that encourage the use of neuraxial ultrasonography for spinal anesthesia in such patients.

Background: Low back pain is the most common cause of disability in people under 45 years of age. In such patients, spinal injections allow a functional assessment of the anatomic structures that are suspected to be the cause of pain. To minimize the complications and maximize test of accuracy, spinal injections are best performed with imaging guidance. Aim of Study: The aim of the study is to evaluate the role of CT guided spinal injections in management of chronic low back pain. Methods and Material: 120 patients with chronic low back pain after failure of adequate conservative treatment for at least 6 months were enrolled in this study. We excluded patients with focal discs herniation, motor deficit, and bleeding tendency. All our study population were subjected to pain scoring by Revised Oswestry disability index before and after 1 month of injections, standard X-rays, MRI of the lumbar spine and appropriate CT guided spinal injection was done using a combined solution of anesthetic and long acting steroid. Results: 35% of the patients had low backache with radicular pain, 65% had low back pain with no radicular pain. We performed facet joint injection in 20% of our patients, selective nerve root block in 20%, sacroiliac joint injection in 27.5% of our patients and 32.5% underwent combined injections. The mean value of Revised Oswestry disability index before injections was 27.6 and 16.9 after injections of all patients group. There were overall significant improvement in pain relief as well as physical, occupational and psycho-logical status during 6 months follow-up. Conclusion: CT guided facet joint injection, sacroiliac joint injection, selective nerve root block could be effective modality in management of chronic low back pain and its sequels.

Background The optimal management of lumbar synovial cysts (LSCs) has always been controversial. Open or minimally invasive partial hemilaminotomy as a direct decompression approach has been widely studied, whereas to our knowledge, there has been no report of an indirect decompression method for LSC. Case Description A 60-year-old male complained of chronic low back pain for 2 years. He reported that the pain had been getting worse and started radiating to the bilateral posterior thighs and right lateral calf for 6 months. An ovoid lesion with a hyperintense center attached to the medial side of the right facet joint at the L4-5 level, as well as L4-5 dynamic instability, were found with magnetic resonance imaging and lumbar x-ray examinations, respectively. L4-5 oblique lumbar interbody fusion combined with anterior fixation was performed. After surgery, the patient felt distinct pain relief and was discharged on the third day postoperatively. Three months later, lumbar magnetic resonance imaging and 3-dimensional computed tomography were performed again. The L4-5 disk height and foraminal height recovered from 7.1–12.3 mm and 14.8–18.5 mm, respectively. No evidence of a cyst was disclosed. The patient did not complain of any low back pain or radicular pain during the 12-month follow-up. Conclusions Indirect decompression surgery may be a new option for the management of LSC, especially in those with lumbar instability and that communicate with the facet joint. Further research with a larger and more comprehensive sample population is required.

BACKGROUND We aimed to evaluate the effect of bipolar pulsed radiofrequency (PRF) in patients with chronic cervical radicular pain who were refractory to monopolar PRF and transforaminal epidural steroid injection (TFESI). METHODS Twenty patients with chronic cervical radicular pain who were unresponsive to monopolar PRF and TFESI were included and underwent bipolar PRF of their cervical dorsal root ganglion (DRG). Treatment outcomes were evaluated using the Numeric Rating Scale (NRS) for cervical radicular pain before treatment and 1, 2, and 3 months post-treatment. Successful pain relief was defined as ≥50% reduction in the NRS score compared with the score prior to treatment. Furthermore, at 3 months post-treatment, patient satisfaction levels were evaluated; those with very good (score =7) or good (score =6) results were considered to be satisfied with the bipolar PRF procedure. RESULTS Cervical radicular pain was significantly reduced at 1, 2, and 3 months post-PRF (P

Merkel cell carcinoma is a cutaneous neuroendocrine malignancy that has an aggressive nature. Classically, it affects the elderly Caucasian population with a predilection for the sun-exposed areas of the body. Pathogenesis has been linked to ultraviolet radiation, immunosuppression, and the Merkel cell polyomavirus. Definitive diagnosis entails histologic evaluation and immunohistochemical staining. With its generalized appearance and tendency for metastasis, a high index of suspicion must be utilized. In this case, we present the unique presentation of Merkel cell carcinoma as a rapidly enlarging lymph node with metastatic disease to the spinal column presenting as new-onset low back and radicular pain.

Background Percutaneous endoscopic surgery is a common technique used for the treatment of disk herniation and spinal stenosis. In this report, we present a patient who underwent percutaneous endoscopic decompression due to spinal metastasis. Case Description A 72-year-old female patient with a known diagnosis of lung cancer presented to our clinic with a 10-day history of severe pain in the left leg and a 5-day history of muscle weakness in the left thigh. The patient had a history of multiple organ metastasis and multiple spinal metastasis. On neurologic examination, left hip flexion and extension were graded 2/5. Radiologic workup revealed compression on the left L3 nerve root caused by vertebral metastasis. The patient was planned for a percutaneous full-endoscopic interlaminar decompression due to her clinical condition. The tumor surrounding the left L3 nerve root was removed via endoscopic punch, which resulted in rapid relief of her back pain postoperatively. Adjunct physical therapy was recommended after discharge. Conclusions Percutaneous full-endoscopic interlaminar decompression can be an alternative minimally invasive treatment option in selected patients with radicular pain and neurologic deficit caused by spinal metastasis.

Background There is presently insufficient data on small groups of patients, without focus on time since herniation occurred and without establishing a valid method of measurement for signal intensity (SI) of a lumbar disc herniation (LDH) in a standard magnetic resonance imaging (MRI). SI could be reported in relation to SI of nucleus pulposus of herniated intervertebral disc, nucleus pulposus of a healthy “control” intervertebral disc, cerebral spinal fluid, or anterior anulus fibrosus. It is not known which signal intensity ratio (SIR) shows the highest correlation with time since onset of pain and how SIR of different Combined Task Forces (CTF)-types of herniation develop over time. Methods Out of 1053 patients, we enrolled 151 patients to a retrospective single-center analysis of standard MRIs of consecutive patients treated for LDH from February 2008 to December 2017 with confirmed (surgery, injection, or electrophysiologic testing) radicular pain by LDH and known exact date of onset of pain. We excluded patients 70 years, with chronical pain syndrome, spinal deformity, and history of prior spinal surgery on the affected spinal level. Because data did not show normal distribution, we assessed correlation by Spearman rank correlation coefficient. Correlation (R) and coefficient of correlation (CC) are reported. Results SI of LDH referenced by SI of nucleus pulposus of the affected intervertebral disc and CTF type “extrusion” showed the highest correlations with time since onset of pain (R: −0.893; CC: 79.7), followed by CTF-type “sequestration” (R: −0.356; CC: 12.7). Conclusions SIR of extrusion referenced by nucleus pulposus of the affected intervertebral disc does show a high correlation with days since onset of herniation and may be applied to monitor changes of SI of LDH after herniation in standard MRIs of the lumbar spine.

BACKGROUND CONTEXT Hospitals and policy makers have placed increasing importance on patient satisfaction with medical care. Minimal research exists on patient satisfaction in the context of epidural steroid injections (ESIs) for radicular pain. PURPOSE Describe patient satisfaction with ESIs for the treatment of radicular pain and identify patient demographic and clinical characteristics associated with patient satisfaction. STUDY DESIGN/SETTING This was a retrospective study conducted at a large, academic medical center. METHODS This was a single-center retrospective study of prospectively collected registry data including patients treated with ESIs from August 2006 to May 2018. The primary outcomes were: overall Press Ganey (PG) score, patient satisfaction with the physician, and likelihood to recommend both the physician and the practice. Age, body mass index, Charlson Comorbidity Index, immediate change in pain, sex, spinal segmental level of injection, prior opioid use, insurance status, and ethnicity were compared with the four PG measures of satisfaction using both univariable and multivariable regression analysis. No sources of funding were used for this project. The authors report no conflict of interest in relation to this manuscript. RESULTS Two-hundred ninety patients underwent 377 injections. Overall, patients were highly satisfied; 86% recommend their physician and 85% recommend the practice, each with the highest possible PG score. The median overall PG score was 97.2 (interquartile range [IQR]: 89.3, 100), and the median physician satisfaction score was 100 (IQR: 95, 100). The median immediate reduction in pain was 3 points (IQR: −5,−2) on the numerical rating scale scale postinjection. Increased age was associated with increased satisfaction with the physician (reported rate ratios [Relative Risk (RR)] for dissatisfaction: 0.73, 95% confidence interval [CI]: 0.58, 0.93, p=.011) and increased likelihood to recommend the physician (odds ratio: 1.46, 95% CI: 1.06, 2.01, p=.022) in multivariable analysis. Medicare as opposed to private insurance was associated with higher dissatisfaction with the physician (RR: 2.04, 95% CI: 1.15, 3.61, p=.014) and decreased likelihood to recommend the practice (RR: 0.38, 95% CI: 0.15, 0.94, p=.037). CONCLUSIONS The present data, based on PG scores, demonstrated that ESIs are associated with greater patient satisfaction with increasing age, but lower satisfaction in patients with Medicare compared with private insurance when controlling for other demographic factors. Satisfaction was not associated with the degree of pain relief.

Background Spinal angiolipomas (SALs) are benign tumors that usually present a slow progressive spinal cord or radicular compression. Acute myelopathy or acute aggravated radicular syndrome are exceedingly rare. Case Description The authors report an original case with sudden aggravated radicular pain caused by hemorrhagic SALs. A 54-year-old woman presented with a 2-month history of mild back pain, and the pain was significantly aggravated after a therapeutic back massage. Neurologic examination showed pain and hyperalgesia between T4 and T7 dermatome, from back to front, just like a band. Spinal magnetic resonance imaging (MRI) showed a dorsally located epidural lesion (T4–T6) and a small intratumoral hemorrhage at the lower part of the tumor. A bilateral T4–T6 laminectomy was performed to achieve total excision of the tumors. Histologic examination showed that the tumors were composed of mature adipose tissue and vascular tissue as angiolipomas. The postoperative course was uneventful with complete neurologic recovery 4 days after the surgery. MRI at 1-year follow-up indicated no recurrence. Conclusions SALs are unusual benign tumors that are composed of mature fatty tissue and abnormal blood vessels; sudden aggravated spinal cord or radicular compression syndrome is rare. MRI is the best choice in the diagnosis of SALs. Surgery may be performed in different ways depending on the type of SALs, and the prognosis is generally good.

The sacroiliac joint is a complex, variable, and irregular structure, thought to be the source of 15% to 30% of low back, pelvic, and radicular pain. Several predisposing factors, including prior spinal surgery and particularly lumbar fusion, can contribute to joint inflammation and acceleration of joint degeneration. Evaluation of the sacroiliac joint as a pain generator using history and physical alone can prove difficult, because a number of other pathologies can have a similar presentation. Whereas a number of tests are used to examine the joint, no single test alone has proven validity. Imaging alone has also not been proven efficacious, particularly in nonspondyloarthropathy-mediated pain. Although no "gold standard" exists, diagnostic sacroiliac joint block has been shown to be a useful confirmatory tool in assessing sacroiliac (SI) joint-mediated pain. Sacroiliac joint injection with local anesthetic and steroids can be used as a possible therapeutic endeavor to manage pain and inflammation.

OBJECTIVEPostoperative C5 palsy affects 7%–12% of patients who undergo posterior cervical decompression for degenerative cervical spine pathologies. Minimal evidence exists regarding the natural history of expected recovery and variables that affect palsy recovery. The authors investigated pre- and postoperative variables that predict recovery and recovery time among patients with postoperative C5 palsy.METHODSThe authors included patients who underwent posterior cervical decompression at a tertiary referral center between 2004 and 2018 and who experienced postoperative C5 palsy. All patients had preoperative MR images and full records, including operative note, postoperative course, and clinical presentation. Kaplan-Meier survival analysis was used to evaluate both times to complete recovery and to new neurological baseline—defined by deltoid strength on manual motor testing of the affected side—as a function of clinical symptoms, surgical maneuvers, and the severity of postoperative deficits.RESULTSSeventy-seven patients were included, with an average age of 64 years. The mean follow-up period was 17.7 months. The mean postoperative C5 strength was grade 2.7/5, and the mean time to first motor examination with documented C5 palsy was 3.5 days. Sixteen patients (21%) had bilateral deficits, and 9 (12%) had new-onset biceps weakness; 36% of patients had undergone C4–5 foraminotomy of the affected root, and 17% had presented with radicular pain in the dermatome of the affected root. On univariable analysis, patients’ reporting of numbness or tingling (p = 0.02) and a baseline deficit (p < 0.001) were the only predictors of time to recovery. Patients with grade 4+/5 weakness had significantly shorter times to recovery than patients with grade 4/5 weakness (p = 0.001) or ≤ grade 3/5 weakness (p < 0.001). There was no difference between those with grade 4/5 weakness and those with ≤ grade 3/5 weakness. Patients with postoperative strength < grade 3/5 had a < 50% chance of achieving complete recovery.CONCLUSIONSThe timing and odds of recovery following C5 palsy were best predicted by the magnitude of the postoperative deficit. The use of C4–5 foraminotomy did not predict the time to or likelihood of recovery.

Background: Extraforaminal lumbar disc herniation (ELDH) amounts of 7%–12% of all lumbar disc herniations. Although they have already been widely described, an optimal treatment is still under discussion in the literature. Objective: We describe a novel application of navigation using 2D/3D imaging system to plan an adequate surgical trajectory and performing a neuronavigated microdiscectomy in ELDH that has not been previously described. Methods: This is a retrospective study in a single institution. Between February 2017 and July 2020, a total of 12 patients (7 males and 5 females), with a mean age of 56 years (range 49–71 years), have been treated because of ELDH through a far lateral microdiscectomy using 2D/3D imaging system-assisted neuronavigation (O-arm). Results: No intraoperative and/or postoperative complications were recorded. Patients presented a mean preoperative Visual Analog Scale (VAS) score of 7.83 ± 0.83 (range 7–9). At the day of discharge, leg pain VAS score effectively improved, decreasing to a mean value of 1.83 ± 0.83 (range 1–3). Further, low back and radicular pain improvement was recorded at 1-, 6-, and 12-month follow-up, respectively. Conclusion: We described a novel use of 2D/3D imaging system navigation in the microsurgical treatment of ELDH that has not previously reported. This technique is safe and effective and provides more intraoperative details compared to fluoroscopy, which can be crucial for the success of the procedure and to reduce complications and particularly indicated in complex cases with altered anatomy.

Background To discuss the rare event of spontaneous resolution of a lumbar ganglion cyst, a personal case report and 25 cases culled from the literature were described in detail. We focused on demographic, classification, clinical and radiological findings, treatment, outcome and radiological resolution. Case summary A 51-year-old man presented to our observation with complaints of low back and right leg pain. Lumbar magnetic resonance imaging (MRI). showed a L4-L5 ganglion cyst. The patient was referred to medical therapy and bracing. After 4 wk, he showed a complete resolution of pain. The complete spontaneous resolution of the cyst was demonstrated by the followed-up MRI. Conclusion Spontaneous resolution of lumbar ganglion is very rare and only 26 cases, including ours, were reported in literature. Different degrees of biomechanical impairment seem to play a fundamental role in the pathogenesis. Related symptoms are essentially represented by low back and/or radicular pain, without significant neurological disorders. Anti-inflammatory drugs, light unloading exercises and brace could be recommended to administrated pain and decrease facet loads. Mean time for clinical improvement was 7 mo, while MRI disappearance occurred in an average time of 11 mo. Therefore, surgery should be applied when conservative treatment, prolonged at least 6 mo, fails.

Vertebral hemangiomas (VHs) are very common radiological findings, and the majority of them are completely asymptomatic and harmless. However, although rarely, they can present as locally aggressive, symptomatic lesions, and requiring surgery. In these cases, early diagnosis and treatment are mandatory to avoid serious complications and invasive surgery; however, there is no consensus about the best therapeutic option. Minimally-invasive percutaneous techniques have recently gained interests as a therapeutic option. A case of a 58-year-old male with a symptomatic aggressive VH of L5 presenting with untractable low back and radicular pain without neurological deficits is reported. An early percutaneous procedure with selective embolization combined with biportal kyphoplasty of L5 was performed. No complications and a very low-intraoperative bleeding were reported. The patient has been monitored for the following 5 years with a good outcome and with no signs of recurrence. This case report highlights the importance of making the right diagnosis and the advantages of an early percutaneous treatment with selective embolization and augmentation to avoid major open surgery with high risks.

Background Data: Recurrent lumbar disc herniation means re-herniation of disc on the same site and at the same level where a previous discectomy had been performed: recurrent lumbar disc herniation occurs in 7% to 24% of patient underwent discectomy. Tow mean surgical options after reherniated lumbar disc are revision discectomy alone or revision discectomy with fusion discectomy alone in recurrent lumbar disc herniation may not be an efficient treatment without fusion. Objective: To evaluate the efficacy and safety of revision discectomy with fusion in management of recurrent lumbar disc. Study Design: Retrospective study reviewed all patient underwent revision discectomy with fusion, they were 40 patients operated for recurrent lumbar disc from September 2014 to April 2018 in Al-Azhar University Hospital Damietta. Pre- and post-operative data collection and analysis of the outcome were completed based on the “Japanese Orthopedic Association score” (JOAs), and radiographic follow-up. Patients and Methods: 40 patients (30 male and 10 female) underwent revision discectomy with fusion as surgical management for reherniated lumbar disc from September 2014 to April 2018. All patients presented with low back pain and radicular pain with mean duration of 18 months. The patients were investigated by standard plain X-ray CT SCAN and MRI of the lumbar spine. All patients had a discectomy and postero-lateral fusion in revision surgery. These patients followed post operatively clinically for improving pain and neural function, and radiologically for disc removal stability and fusion. Results: The age ranged from 30 to 60 years, mean age was 45 years, male to female ratio 3:1. Follow-up ranged from 18 - 30 months with a mean follow-up 24 months. 30 patients had an excellent outcome, 6 patients had a good outcome, 2 patients had a fair outcome, and 2 patients had a poor outcome. Conclusion: Recurrent lumbar disc herniation occurs in 7% to 24% of patient underwent discectomy. Revision surgery when indicated can be done by various techniques. Revision discectomy with fusion for reherniated lumbar disc is effective and safe with confident results.

Lower back pain is generally most common musculoskeletal complaints in routine clinical practice now a days. Lower back pain is most significant reason behind development of walking disability. Irritation and pressure on nerve root in lumbar region leads to Lumbar sacral radiculopathy andits very painful condition. Reason behind radiculopathy can be herniating disc in lumbar region, vertebral defect or disintegration and neural foramen size decrease.Epidural steroid injection is effective treatment for lumbar pain. Study objective is to assess the efficacy of hypertonic saline in radicular lower back pain.Numerical Rating Scale (NRS) and Oswestry Disability Index (ODI) was used as data collecting tools. comparison between intervention and control group for pain score at three and six months. With p value =0.04 and 0.02 respectively for 3 and 6 months. shown pain was reduced gradually at 3 and 6 months. As conclusion wasSuperior and longer duration of effect was observed with addition of hypertonic saline along with steroid in lumbar radiculopathy. And this can be used as a major cost-effective adjuvant.

Introduction Langerhans cell histiocytosis (LCH) in spine is a benign disorder that mainly affects children and is rare in adults. The treatment of LCH in adults is still controversial. The literature is drought with reports regarding management of LCH in adults with pathological fracture. We report a case of LCH at L5 vertebra in an adult patient treated with posterior stabilization, decompression, and anterior corpectomy and reconstruction. Case presentation A 30-year-old manual laborer working in Middle East, presented to us with severe pain in the lower back (VAS-8) with the right lower limb radiculopathy for 6 months. Radiological investigations revealed to have a solitary osteolytic lesion with pathological fracture at L5 vertebral body. MRI showed hyperintense lesion in T2 sagittal images and hypointense in T1 sagittal images in L5 vertebral body. PET scan showed metabolically active lesion involving L5 vertebra body and right ischium. CT-guided biopsy from L5 vertebral body was performed, but was inconclusive. The patient underwent surgical management in the form of posterior stabilization L4-S1 and transpedicular biopsy. The sample was sent for frozen section and confirmed the presence of neoplasia but did not provide sufficient information about the nature of pathology. Intraoperatively, the decision was made to do anterior excision biopsy, corpectomy, and reconstruction with titanium mesh cage filled with cement. The precise diagnosis of LCH was established on histopathological examination and confirmed with immunohistochemistry positivity for CD1a and S100. The patient had immediate relief of his back pain and radicular pain. He was able to resume his daily activities at 1 month after the surgery. At 2-year follow-up patient was asymptomatic and no local recurrence was noticed. Conclusion Surgical excisionfor LCH in adults should be considered in patients with refractory low back pain with pathological fracture, neurological deficits, or spinal instability.

The paper presents the experience of surgical treatment of 58 patients with discogenic lumbosacral radiculitis. The aim of the surgical treatment was to eliminate the compression of the spinal roots of the herniated disc with the subsequent stabilization of the spinal-motor segment with implantable interspinous system COFLEX. Indications for surgical treatment were persistent radicular pain syndrome, which was not stopped by conservative methods of treatment, and disco-radicular conflict in the area of the interested vertebral-motor segment, confirmed by radiation research methods. In the diagnosis, the following research methods were used: clinical and neurological examination, survey and functional spondylography of the lumbar spine, computed tomography with contrast myelography, morphometric and statistical methods. The effectiveness of treatment was evaluated in 49 patients (84 % of operated) one and a half years after surgery. All patients showed complete regression of neurological deficit and satisfactory standing of the implanted interstitial dynamic system COFLEX in the operated vertebral-motor segment. Thus, the use of the implantable COFLEX dynamic system for the above indications is the choice method for operating surgeons, in which it is assumed that the function of the interested vertebral-motor segment is preserved.

Introduction and Objectives: The present study was undertaken with the objective to study the functional outcome with Oswestry Disability Index and VAS in patients with degenerative lumbar canal stenosis who underwent unilateral laminotomy and bilateral decompression of the canal. Materials and Methods: The cases were the patients who underwent microsurgical treatment for degenerative lumbar canal stenosis, between the age group of 40 to 60 during 2008 – 2010 were taken for the study. Patients with a history of low back pain, neurogenic claudication, radicular pain with single level canal stenosis and without spinal instability were included in the study. The patients underwent a thorough preoperative clinical and radiological examination at the department. VAS- Visual Analog Scale and Oswestry Disability Index and Neck Disability Index (0-10 scale) were used to assess the functional outcome. Results: 45 patients were included in our study. 42.2% were between 60-70 yrs. Males were more compared to females, 82 % people presented with neurogenic claudication pain and the pain was bilateral in 70 %. The duration was ranging from 6 months to 1 year. The functional outcome analyzed with VAS and ODI which showed progressive improvement in the values at the end of 1 year follow up the difference showed a p- value of had recurrence of the symptoms and did not develop any spinal instability. Conclusion: The functional outcome measured with VAS and ODI showed strongly significant as well as analysis showed immediate improvement with bilateral symptoms, canal stenosis at the L4-5 level. However good results noted in follow -up with a female who was having bilateral symptoms and stenosis at L5 S1 level. Keywords: Lumbar Canal Stenosis, ODI Scores, VAS scale, Neurogenic Claudication, Laminotomy

Introduction: There are many causes for low back ache. One of these causes is lumbosacral radiculopathy. Here the pain is usually a low back ache which is radiating in the distribution of the corresponding root. The sensory symptoms will be in a dermatomal distribution and the motor weakness will be in a myotomal distribution. The main electrophysiological parameters which can be used are tibial H reflex , tibial and peroneal F waves and EMG. The treatment options are conservative management with drugs and exercise, invasive procedures like epidural steroid injection and surgical interventions. Objectives: To find out the percentage of people with lumbosacral radiculopathy getting improvement in their pain symptom , disability status and electrophysiological parameters with the conservative management in a follow up period of 6 months. Material and Methods: Study design: It is a prospective experimental (interventional) study with pre/post design Study population: Patients with age between 18yrs and 80 years with radicular pain from the lower back in the lumbosacral distribution Sample size: 76 Sampling procedure: Random sampling of patients fulfilling inclusion and exclusion criteria Study procedure: Direct examination, history with nerve conduction and EMG studies and questionnaire with follow up at the end of 3and 6 months Analysis: Data analysis was carried out using IBM SPSS software V 25. Disability score, compound muscle action potential score and f waves were assessed and compared using paired t test. A p value was taken as the threshold for statistical significance. Results: Considering the pain, 78.9% of the patients got improvement at the end of 3 months and 65.8% of the patients got improvement at the end of 6 months, with the conservative management. Considering the disability, 100% of the patients got improvement at the end of 3 months and 98.7% of the patients got improvement at the end of 6 months. The proportion of the patients who got improvement

Introduction: Cervical radiculopathy is a neurological disfunction wherein a nerve root in the cervical spine becomes inflamed with disc herniation and uncovertebral osteophytes accounting for the majority of cases. The standard surgical treatment for this cervical radiculopathy till now is posterior lamino foraminotomy and anterior discectomy with or without fusion. This study describe the outcome of a minimally invasive anterior cervical disc preserving technique of upper vertebral transcorporeal anterior microforaminotomy to treat cervical radiculopathy Cervical. Objective: To Evaluate the clinical and radiological outcome of disk preserving functional cervical disk surgery. Material and Methods: This is a prospective non randomised hospital based study. The study population included 11 patients operated for cervical radiculopathy with the new technique at the department of Neurosurgery, Manipal Hospital, Bangalore during July 2007 to June 2010. The patients were followed up from 8 to 30 months with a mean follow up of 17 months for clinical and radiological outcome. Results: The mean age of the patient was 40.099.71 years. The majority of the patients (five) were in 31-40 age groups. Male patients (63.6%) were more as compared to females. All patients in this study had neck pain, radicular pain and weakness. Clinical symptoms were between 1 to 3months. The mean preoperative visual analogue scale score was 8.55 and postoperative score was 1.18. The VAS score reduced significantly postoperatively and it was statistically significant. There was no significant reduction in the disc height postoperatively. Conclusion: The Disk preserving functional cervical disk surgery is a minimal invasive procedure with the least complications and adequate motion at the operated site. Keywords: Cervical Disk Surgery, Cervical radiculopathy, Disk preserving, Disk Herniation

Objective Pulsed radiofrequency stimulation at the dorsal root ganglion is used for treatment of radicular pain; however, its mechanism for neuropathic pain treatment has not been fully elucidated. Here, we investigated whether pulsed radiofrequency stimulation affects the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, which play a critical role in synaptic plasticity. Methods Neuropathic pain was studied using a radicular neuropathic pain model (43 female Sprague-Dawley rats; 200–250 g). In total, 28 rats were assigned to the following groups for fraction analysis: a control group, a control + pulsed radiofrequency stimulation group, a disc pain group, and a disc pain + pulsed radiofrequency stimulation group. For nonfraction analysis of Glutamate A1 (GluA1) and GluA2 subunits, a total of 15 female Sprague-Dawley rats were assigned to a control group, a disc pain group, and a disc pain + pulsed radiofrequency stimulation group. Pulsed radiofrequency stimulation and subsequent analysis were conducted three days after surgery. Results AMPA receptor subunits, GluA1 and GluA2, in the radicular neuropathic pain model were upregulated compared with those in the control group three days after surgery. Pulsed radiofrequency stimulation induced the translocation of GluA1 and GluA2 subunits from the synaptosome to cytosol without a change in the total amount of AMPA receptors in the dorsal horn. Conclusions Our results demonstrated that pulsed radiofrequency stimulation affected the synaptic plasticity corresponding to long-term depression. Thus, we show that long-term depression from pulsed radiofrequency stimulation is associated with analgesic effects in the radicular neuropathic pain model following peripheral inflammation.

BackgroundBack pain is a frequent complaint among the individuals in the society. It significantly affects the daily activities and the social and psychological life aspects leading to an economic health burden. Epiduroscopy is a relatively new minimally invasive technique that is used as a diagnostic and therapeutic tool in cases of chronic back pain.Aim of the studyTo evaluate the extent of long-term benefit of epiduroscopy in patients with refractory chronic back pain with/without radiculopathy.Materials and methodsRetrospective data of 148 patients with failed back surgery syndrome (FBSS) and/or symptomatic lumbosacral disc prolapse who underwent epiduroscopy were collected. A 50% reduction in the visual analog scale (VAS) score was set as the primary outcome. Pre- and post-procedure analgesic use, quality of sleep, and changes in the activities of daily livings (ADLs) after 1-year follow-up were reviewed. Incidence and types of complications were recorded.ResultsThe mean age of the studied sample was 56.6 years with a higher percentage of females (61.5%). Patients having radicular pain represented 45.1%. Disc prolapse was prevalent (61.5%) compared to patients with FBSS (38.5%). A reduction of 50% or more in VAS score was reached in 52.7% (p< 0.01). This reduction was more evident in younger patients (p= 0.004). There was an improvement in ADLs (p< 0.01), quality of sleep (p< 0.05), and analgesic intake (p< 0.05).ConclusionEpiduroscopy is a relatively recent, safe, and minimally invasive tool that showed effectiveness in the difficult to treat patients with back pain with/without radiculopathy especially in FBSS.