The Evidence for Nonoperative Treatment of Lumbar Spinal Diseases / 대한척추외과학회지

STUDY DESIGN: Review article.OBJECTIVES: To assess the evidence for nonoperative treatment of various degenerative spinal degenerative diseases.SUMMARY OF LITERATURE REVIEW: No study has yet evaluated the evidence for preoperative nonoperative treatment of lumbar spinal diseases.METHODS: The evidence regarding nonoperative treatment for each disease was reviewed through NASS guidelines, and the treatment effect compared to surgical treatment was reviewed through the SPORT series. The efficacy of nonoperative treatment according to disease severity and certain special conditions was investigated through corresponding individual articles.RESULTS: No kind of nonoperative treatment could change the fundamental progression of degenerative spinal disease. The natural course of lumbar disc herniation is favorable regardless of treatment. More than 70% of routine cases improve within 6 weeks. However, it does not take a full 6 weeks to decide whether to perform surgery or not. The evidence for transforaminal epidural steroid injections for short-term pain control is grade A. There is grade B evidence for nonoperative treatment with the goal of mid- to long-term pain control. However, we cannot say that those outcomes are better than the natural course of the disease itself. In cases of radicular weakness, the degree of weakness is correlated with the final outcomes, but it is not evident whether the duration of weakness is correlated with surgical outcomes. Early surgery is usually necessary due to intolerable pain, rather than stable motor weakness. The social cost of herniated discs arises from the loss of patients’ productivity, rather than from direct medical expenses. The natural course of spinal stenosis involves provoked pain and the need for palliative care. Unlike disc herniation, rapid deterioration and marked improvement do not occur. The symptoms of mild to moderate lumbar stenosis are unchanged in 70% of cases, improve in 15%, and worsen in 15%. No study has compared nonoperative treatment with the natural course of the disease. There is no evidence for nonoperative treatment of severe stenosis. Epidural spinal injections are effective for controlling short-term pain. Spontaneous recovery of radicular weakness does not occur, and urgent surgery is necessary in such cases. There is no evidence regarding the natural course and nonoperative treatment of degenerative spondylolisthesis. The working group consensus recommends that it should follow the pattern of nonoperative treatment of spinal stenosis when radicular stenosis symptoms are predominant. Overall, 40%–66% of cases of adult bilateral isthmic spondylolysis progress to symptomatic spondylolisthesis. No studies have investigated nonoperative treatment except physical exercise.CONCLUSIONS: Although short-term symptom amelioration can be achieved by nonoperative treatment, the fundamental progression of the disease is not affected. For conditions excluded from most studies, such as prior spine surgery, cauda equina syndrome, progressive neurological deficit, and uncontrollable severe pain associated with instability, deformity, or vertebral fractures, there were not enough studies to reach informed conclusions. Our review found no evidence regarding nonoperative treatment for such conditions. Furthermore, the treatment methods for each disease are not clearly distinguished from each other, and the techniques used for disc herniation have been applied to other diseases without any evidence.

The observation of curative effect of transcranial direct current stimulation on the treatment of pain after lumbar fusion operation / 天津医药

Objective To observe the clinical efficacy of transcranial direct current stimulation (tDCS) in the treatment of pain after lumbar fusion operation. Methods Patients underwent lumbar fusion surgery in the Department of Minimally Invasive Spine Surgery, Tianjin Hospital from January 2016 to December 2016 were retrospective analyzed. They were divided into tDCS group and control group according to the postoperative analgesic strategies. Patients in tDCS group were given flurbiprofen injection combined with tDCS to control postoperative pain, and morphine was used if necessary. The control group was only given flurbiprofen injection combined with morphine analgesia to manage postoperative pain. The data of preoperative and postoperative pain visual analogue score (VAS), oswestry disability index (ODI), opioid analgesics usage and complications before and after operation were recorded. Results Forty-two patients were included in this study. There were 22 patients in tDCS group with the mean age (56.7±10.5) years, and 20 in control group with the mean age (60.3± 9.2) years. There were no significant differences in preoperative VAS and ODI scores between two groups. The VAS and ODI scores at postoperative 24 h and hospital discharge significantly improved in two groups compared with preoperative data. Data of postoperative 24 h VAS score (2.0 ± 1.7), VAS score (2.1 ± 0.9) and ODI score (20.9 ± 6.5) at hospital discharge were significantly lower in tDCS group than those in control group (3.3 ± 1.4, 2.9 ± 1.3 and 25.4 ± 5.3). The dosage of opioid medication use in controlling postoperative pain was reduced about 25％ in tDCS group (P < 0.01). The complications reported in tDCS group included itching under the electrodes, pain, scorching hot and stinging. Conclusion The use of tDCS after lumbar fusion operation can decrease the pain sensation, reduce the usage of opioids, promote the rehabilitation and with no increasing the incidence of related complications, which has the potential probability to replace opioids for chronic pain.

Early Union of Grafted Bone in Ankylosing Spondylitis: Comparative Study with Degenerative Spinal Disease

BACKGROUND: Patients with ankylosing spondylitis (AS) achieve early bone union compared to those with other spinal diseases. This study compared the time to bone union after surgery between AS patients and degenerative spinal disease patients. METHODS: Patients with degenerative spinal diseases (control group) and AS (experimental group) underwent pedicle subtraction osteotomy followed by posterolateral fusion, and decompression and posterolateral fusion, respectively. There were 10 patients in the experimental group. The control group included 26 patients who were less than 50 years of age and underwent two-level autogenous grafting after decompression and spinal fusion. Autogenous grafts and a range of bone substitutes were used in the experimental group, whereas only autogenous grafts were used in the control group. Bone union was determined on the radiographs and 3-dimensional CT scan images. The level of union was assessed using the Lenke's and Christensen's classification systems. RESULTS: In the experimental group, the mean age was 41.3 years (range, 30 to 67 years), the mean follow-up period was 21.7 months (range, 12 to 43 months), and bone union was confirmed at an average of 3.5 months (range, 3 to 5 months) after surgery. In the control group, the mean age was 43.1 years (range, 35 to 50 years), the mean follow-up period was 21.8 months (range, 12 to 74 months), and bone union was observed at an average of 5.6 months (range, 4 to 12 months) after surgery. The difference in the time to bone union between the two groups was significant (p = 0.023). CONCLUSIONS: The union of grafted bone was obtained earlier in patients with AS than in those with degenerative spinal diseases. Therefore, future studies should examine the factors affecting the early union in AS patients.

Results of Multilevel Lumbar Fusion for Degenerative Disorder of the Lumbar Spine / 대한척추외과학회지

PURPOSE: To investigate the causative factors of the complications and clinical results of 82 patients that underwent multilevel fusion due to degenerative lumbar disease. MATERIALS AND METHODS: This was a retrospective study, between October 1994 and July 2001, of 101 patients that had undergone spinal fusion at more than 3 levels, due to degenerative lumbar disease, and excluding 19 patients, which included 8 revisions, 1 postop infection and 10 lost to follow-up. The average age of the 82 patients was 61, ranging from 49 to 81 years. There were 22 men and 60 women, with an average follow up of 35, ranging from 12 to 79 months. Inclusion in the study required a minimum of 1 year of radiographic follow-up, where the lumbar lordotic angle, lateral sagittal angle of the fusion segments, problems associated with instrumentation (screw loosening, breakage and rod breakage), nonunion, fusion level, extension to sacrum, medical comorbidities and their influences on the clinical results were evaluated. Evaluation of the clinical results were quantified using Kirkaldy-Willis'criteria. T-test, Chi-square test and Pearson correlation tests were performed to evaluate the statistical significance, using SPSS version 10.0. RESULTS: 12, 35, 20 and 15 of the 82 patients declared their outcomes to be excellent, good, fair and poor, respectively. The clinical results were statistically associated with the difference between the postoperative and final sagittal angle in the fusion segments (p<0.05). The more fusion segments involved, the more problems associated with the instrumentation occurred. The number of fusion levels affected the clinical results. CONCLUSION: It seems to be difficult to reach satisfactory results in the case of multilevel spinal fusion, which was mostly associated with problems of instrumentation and nonunion, which showed poorer clinical results. Maintenance of the sagittal angle in the fusion segments was challenging when the number of fusion levels was increased.