International journal of spine surgery
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The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.(1-6) The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.(7.) ⋯ Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.(12) Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not "burn bridges" for a more conventional approach and it adds to the surgical armamentarium of FBSS. Fig. 3Cadaver Illustration of Foraminal Stenosis (courtesy of Wolfgang Rauschning). As the disc narrows, the superior articular process impinges on the exiting nerve and DRG, creating lateral recess stenosis, lumbar spondylosis, and facet arthrosis.
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Disc herniation is the most common cause for spinal surgery and many clinicians employ epidural steroid injections with limited success. Intradiscal injection of ozone gas has been used as an alternative to epidural steroids and surgical discectomy. Early results are positive but long-term data are limited. ⋯ Intradiscal ozone injection may enable patients to address their pain without multiple epidural injections and surgery. The benefit of ozone is durable and does not preclude future surgical options. The risk reward profile for this treatment is favorable.
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Anterior cervical discectomy and fusion (ACDF) is the gold standard for treating symptomatic cervical disc degeneration. Cervical total disc replacements (TDRs) have emerged as an alternative for some patients. The purpose of this study was to evaluate the safety and effectiveness of a new TDR device compared with ACDF for treating single-level cervical disc degeneration. ⋯ This study adds to the literature supporting cervical TDR as a viable option to ACDF in appropriately selected patients with disc degeneration.
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Pedicle screws are widely used in adolescent idiopathic scoliosis (AIS) surgeries. Pedicle screw malposition may lead to serious vascular and neurologic complications. Knowledge of the morphometric anatomy of the thoracic and lumbar vertebrae is essential for the surgeon while implanting pedicle screws. It has been reported that there is a reduction of pedicle width at the concavity of the curve in AIS patients. However, it is unclear if gender plays a role in this pedicle width pattern. The goal of this study is to assess the vertebrae morphology in a more homogeneous group of AIS patients - female patients with Lenke type 1 curve. ⋯ The vertebrae morphology in Lenke type 1 female AIS patients is substantially different from the vertebrae in normal spines especially at the apex and in the upper thoracic region. This is consistent with some previous reports which did not distinguish between male and female patients. Our findings suggest that gender does not play a major role in the vertebrae morphology pattern of AIS patients. Furthermore, recognizing this pattern is critical in order to optimize pedicle screw instrumentation and may allow for some leeway adjustments in the pedicle screw trajectory regardless of the methods of implantation.
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Conventional diagnosis between axial and foraminal stenosis is suboptimal and long-term outcomes limited to posterior decompression. Aware state Transforaminal Endoscopic Lumbar Decompression and Foraminoplasty (TELDF) offers a direct aware state means of localizing and treating neuro-claudicant back pain, referred pain and weakness associated with stenosis failing to respond to conventional rehabilitation, pain management or surgery. This prospective survivability study examines the outcomes 10 years after TELDF in patients with foraminal stenosis arising from degeneration or failed back surgery. ⋯ The long term outcome of TELDF in severely disabled patients with neuro-claudicant symptoms arising from foraminal stenosis which had failed to respond to conventional rehabilitation, surgery or chronic pain management suggests that foraminal pathology is a major cause of lumbar axial and referred pain and that TELDF should be offered as primary treatment for these conditions even in the elderly and infirm. The application of TELDF at multiple levels may further widen the benefits of this technique.