Endoscopic facet debridement for the treatment of facet arthritic pain--a novel new technique.

STUDY DESIGN: Retrospective, observational, open label. OBJECTIVE: We investigated the efficacy of facet debridement for the treatment of facet joint pain. SUMMARY OF BACKGROUND DATA: Facet joint disease, often due to degenerative arthritis, is common cause of chronic back pain. In patients that don't respond to conservative measures, nerve ablation may provide significant improvement. Due to the ability of peripheral nerves to regenerate, ablative techniques of the dorsal nerve roots often provide only temporary relief. In theory, ablation of the nerve end plates in the facet joint capsule should prevent reinnervation. METHODS: All patients treated with endoscopic facet debridement at our clinic from 2003-2007 with at least 3 years follow-up were included in the analysis. Primary outcome measure was percent change in facet-related pain as measured by Visual Analog Scale (VAS) score at final follow-up visit. RESULTS: A total of 174 people (77 women, 97 men; mean age 64, range 22-89) were included. Location of facet pain was cervical in 45, thoracic in 15, and lumbar in 114 patients. At final follow-up, 77%, 73%, and 68% of patients with cervical, thoracic, or lumbar disease, respectively, showed at least 50% improvement in pain. Mean operating time per joint was 17 minutes (range, 10-42). Mean blood loss was 40 ml (range, 10-100). Complications included suture failure in two patients, requiring reclosure of the incision. No infection or nerve damage beyond what was intended occurred. CONCLUSIONS: Our results demonstrate a comparable efficacy of endoscopic facet debridement compared to radiofrequency ablation of the dorsal nerve branch, with durable results. Large scale, randomized trials are warranted to further evaluate the relative efficacy of this surgical treatment in patients with facet joint disease.

Percutaneous laser disc decompression for thoracic disc disease: report of 10 cases.

BACKGROUND: Discogenic pain or herniation causing neural impingement of the thoracic vertebrae is less common than that in the cervical or lumbar regions. Treatment of thoracic discogenic pain usually involves conservative measures. If this fails, conventional fusion or discectomy can be considered, but these procedures carry significant risk. OBJECTIVES: To assess the efficacy and safety of percutaneous laser disc decompression (PLDD) for the treatment of thoracic disc disease. METHODS: Ten patients with thoracic discogenic pain who were unresponsive to conservative intervention underwent the PLDD procedure. Thoracic pain was assessed using the Visual Analog Scale (VAS) scores preoperatively and at 6-month intervals with a minimum of 18-months follow-up. Patients were diagnosed and chosen for enrollment based on abnormal MRI findings and positive provocative discograms. Patients with gross herniations were not included. RESULTS: Length of follow-up ranged from 18 to 31 months (mean: 24.2 mo). Median pretreatment thoracic VAS score was 8.5 (range: 5-10) and median VAS score at final follow-up was 3.8 (range: 0-9). Postoperative improvement was significant with a 99% confidence interval. Of interest, patients generally fell into two groups, those with significant pain reduction and those with little to no improvement. Although complications such as pneumothorax, discitis, or nerve damage were possible, no adverse events occurred during the procedures. LIMITATIONS: The study is limited by its small size and lack of a sham group. Larger controlled studies are warranted. CONCLUSIONS: With further clinical evidence, PLDD could be considered a viable option with a low risk of complication for the treatment of thoracic discogenic pain that does not resolve with conservative treatment.

Endoscopic thoracic laminoforaminoplasty for the treatment of thoracic radiculopathy: report of 12 cases.

BACKGROUND: Spinal stenosis of the thoracic spine is less common than that of the cervical and lumbar regions. Due to the close proximity to thoracic and abdominal organs, surgical operations can be difficult and carry a greater risk of complications. The most efficacious intervention for thoracic stenosis, whether central or foraminal, refractory to conservative management is uncertain. We aimed to evaluate the efficacy of endoscopic laminoforaminoplasty (ELFP) in the treatment of thoracic radiculopathy. METHODS: Twelve patients with radicular pain involving the lower thoracic levels (at or below T6) were treated with ELFP. RESULTS: Seven of twelve patients showed marked improvement in pain scores. Average follow-up scores were 2.9 and 12.08 on the Visual Analog Scale (VAS) and Oswestry Disability Index, respectively. The significance was 0.005 between the pre and post surgical data. One patient with moderate symptoms, two with severe symptoms, and two with crippling symptoms did not report significant improvement on VAS or Oswestry. No complications were encountered. CONCLUSIONS: Endoscopic laminoforaminoplasty offers an alternative to fusion or conventional laminotomy with similar success rates. Patients additionally benefit from a decrease risk of complications, short hospital stay, and faster recovery.

Endoscopic laminoforaminoplasty success rates for treatment of foraminal spinal stenosis: report on sixty-four cases.

BACKGROUND: Foraminal stenosis is an important cause of radicular and generalized back pain. In patients who do not respond to conservative interventions, endoscopic spinal surgery provides similar results to open surgical approaches with lower rates of complication, postoperative pain, and shorter duration of hospital stay. METHODS: We performed a prospective, open, uncontrolled trial of 64 patients to evaluate endoscopic laminoforaminoplasty for the treatment of refractory foraminal stenosis. RESULTS: Fifty-nine percent of patients had at least 75% improvement in Oswestry Disability Index (Oswestry) and Visual Analog Scale (VAS) scores. All patients were discharged the day of surgery. Dural leaks occurred in two patients, which were repaired intraoperatively. No other adverse events occurred. CONCLUSIONS: Endoscopic laminoforaminoplasty appears to be a safe alternative to open decompression in patients with spinal foraminal stenosis; additional controlled trials are warranted.

Surgical considerations of entire lumbar spine hardware removal via a minimally invasive approach.

A retrospective analysis of 13 patients who underwent endoscopic hardware removal to resolve residual foraminal stenosis issues was performed to determine the feasibility and validity of utilizing endoscopic techniques to entirely remove spinal hardware. Tubular retractors were utilized for the procedure with a diameter of 15 to 18 mm. Surgical times ranged from 58 to 268 minutes, with the largest time delay being the need to cut the crossbars in vivo due to stripped screws, bony overgrowth, or bent hardware. Entire hardware systems can be removed via an endoscopic approach. Blood loss averaged around 90 cc but surgical times were over an hour for most procedures. Endoscopic removal of entire hardware systems can be accomplished but it offers little advantage over conventional hardware removal. The main advantages include reduced trauma and the ability of the surgery to be performed on an outpatient basis.

Effects of unilateral endoscopic facetectomy on spinal stability.

There are various definitions for spinal instability and its exact clinical usefulness is uncertain. Facetectomy has been considered a potential source of instability via conventional approaches. Studies have suggested that if the ligament structure of the spine is maintained then instability may not occur with an endoscopic facetectomy. This study is a prospective analysis of 10 patients who underwent unilateral endoscopic facetectomy for the treatment of severe foraminal stenosis to determine whether endoscopic facetectomies result in instability. The patients underwent pre and postsurgical x-rays that were evaluated via a specialized computer program that determined whether or not there was any altered mobility between the 2 sets of x-rays. These were compared with controls to determine whether instability was present. Of the 10 endoscopic facetectomy patients, none had any statistically significant change in sagittal rotational or translational motion when compared to controls. Thus, endoscopic removal of a unilateral facet joint does not necessarily cause spinal instability possibly because of the reduction in tissue damage associated with an endoscopic approach and the maintenance of the ligament structure of the spine.

Intradiscal injection of hematopoietic stem cells in an attempt to rejuvenate the intervertebral discs.

This study is a prospective analysis of 10 patients who underwent intradiscal injection of hematopoietic precursor stem cells (HSCs) obtained from their pelvic bone marrow in an attempt to rejuvenate the disc. Several studies in animals express the ability to regrow disc tissue with possible regenerative effects. No human studies have been done to date. Patients were randomly offered the option of this study, and ten patients with confirmed disc pain via provocative discograms underwent intradiscal HSC injections. After the intradiscal injection of HSCs, all of the patients underwent a 2-week course of hyperbaric oxygen therapy. These patients were followed up at 6- and 12- month intervals to determine their degree of pain relief from this procedure. Of the 10 patients, none achieved any improvement of their discogenic low back pain after 1 year. In conclusion, although animal studies suggest possible regeneration of disc via HSC injections, living human studies reveal that this effect does not correlate with reduced pain, and thus intradiscal HSC injection appears to be of little value.

Sacroiliac joint debridement: a novel technique for the treatment of sacroiliac joint pain.

OBJECTIVE: This study was a retrospective analysis of 38 patients who underwent sacroiliac joint debridement (SJD) as a treatment for confirmed sacroiliac joint (SI joint) pain. BACKGROUND DATA: This is a new, unpublicized, minimally invasive (we define minimally invasive as a surgery with an incision of less than 1 inch) surgical technique. There are no prior studies on this surgery, but the surgery is compared to SI joint fusion surgery, which offers a success rate of 50-70% in larger studies. METHODS: Thirty-eight patients with confirmed SI joint pain via a preoperative modified SI joint injection underwent SJD. These patients were followed up at 12-month intervals to determine their degree of pain relief from this surgery. RESULTS: Of the 38 patients, 61% of these patients had 50-100% reductions of their VAS and 53% had >75% improvement for >2 years. No complications were noted. Histology sections of the removed tissues revealed a non-inflammatory degenerative musculo-tendinous tissue similar to a chronic tendonitis. CONCLUSIONS: SJD is a reasonable treatment option for SI joint pain, which has a low complication rate and a success rate similar to SI joint fusion. Sacroiliac joint pain may be related to a degenerative musculo-tendinous condition of the surface of the joint on the iliac side.

Complications associated with cervical endoscopic discectomy with the holmium laser.

OBJECTIVES: Our aim was to determine the rate of surgical complications associated with cervical endoscopic discectomy (CED). BACKGROUND DATA: There are no studies that state the degree of complications after CED. MATERIALS AND METHODS: Forty-one patients underwent CED with holmium laser. RESULTS: Two out of 41 patients incurred vascular compromise during the procedure. One patient developed recurrent laryngeal nerve damage. One patient developed discitis, and two patients complained of a "clicking" sensation postoperatively. CONCLUSIONS: Although CED has a relatively high success rate, there is a 15% rate of complications associated with the procedure. Most of the complications were minor (such as vascular compromise, recurrent laryngeal nerve injury, and postoperative "clicking" sensations), but there was one case of severe discitis, and there is the potential of serious complication from both vascular compromise and neural injury.

Sometimes (what seems to be) a heart attack is (really) a pain in the neck.

A 31-year-old patient complained of severe crushing chest pain that radiated to his left arm and jaw. After admission to the hospital, tests revealed a normal electrocardiogram, normal treadmill, normal coronary arteriogram, and normal cardiac enzymes. However, the patient continued to have pain, which was relieved by sublingual and intravenous nitroglycerine. He was discharged from the hospital with a diagnosis of "musculoskeletal" chest pain, taking nonsteroidal anti-inflammatory drugs, muscle relaxants, and narcotics. Two weeks later, the patient returned with worsening symptoms. Cardiac work-up was again negative. Thoracic and cervical spine radiographs were ordered for possible discogenic pain. After abnormalities were found on cervical radiographs, magnetic resonance imaging (MRI) was ordered, and the patient was referred to an orthopedic surgeon. Further work-up revealed a herniated disk at C6-C7, with radicular pain. Surgery on the suspect disk totally relieved the patient's pain.

Screening for Helicobacter pylori and nonsteroidal anti-inflammatory drug use in medicare patients hospitalized with peptic ulcer disease.

BACKGROUND: Peptic ulcer disease has well-defined causes, with most cases related to Helicobacter pylori infection and nonsteroidal anti-inflammatory drug use. OBJECTIVES: To report performance rates on measures of care related to peptic ulcer disease in hospitalized Medicare patients and to identify improvement opportunities. METHODS: Retrospective study of 2267 Medicare beneficiaries hospitalized with peptic ulcer disease. Data were obtained from 2 sources: medical records (n = 1580) from 80 hospitals--16 hospitals in each of 5 states (Alabama, Florida, Louisiana, Tennessee, and Texas)-and a national random sample (n = 687). Three measures of care were evaluated: (1) rate of diagnostic screening or treatment for H. pylori infection, (2) rate of screening for nonsteroidal anti-inflammatory drug use on admission to the hospital, and (3) rate of assessment of risk factors for recurrence. RESULTS: The rate of screening or treatment for H. pylori infection was 52.9% to 59.8% among the 5 states and 55.6% in the national random sample. The rate of screening for nonsteroidal anti-inflammatory drug use was 64.6% to 75.4% among the states and 73.4% in the national random sample. The rate of assessment at discharge from the hospital for additional risks for ulcer recurrence was 66.1% to 73.6% among the states and 70.9% in the national random sample. CONCLUSIONS: Based on hospital records, slightly more than half of the Medicare patients admitted with diagnoses studied are being considered for H. pylori eradication. If recurrence of this disease is to be reduced, physicians must adopt current screening and treatment recommendations.