HADS and SOMS-2 brief score evaluation can prevent unnecessary minimal invasive spine interventions - a prospective blinded observational clinical trial.

INTRODUCTION: To test the hypothesis, whether HADS/SOMS is practical in a spine surgery consultation setting and that patients with CLBP, but a high-risk of psychic comorbidities using above screenings will not improve after minimal-invasive spine interventions (MIS). METHODS: n = 150 completed HADS and SOMS prior to the acquisition of history and examination. Primary outcome was improvement by numeric rating scale (NRS), Pain disability index (PDI) and oswestry disability index (ODI) at baseline and 6 months after intervention. In case of sciatica due to disc herniation epidural neurolysis, for facet or SI-joint-syndrome, radiofrequency and for discogenic pain intradiscal electrothermal therapy (IDET) was performed. RESULTS: 6 months after interventions, pat. with a high-risk of anxiety or depression showed no clinically important improvements in NRS, PDI and ODI, whereas in the low-risk group all 3 parameters were significantly reduced. We found a statistically significant difference in the improvement of NRS (p < 0·05), PDI (p < 0·001), ODI (p < 0·001) between high- and low-risk HADS-anxiety and depression groups and in the improvement of NRS and PDI (p < 0·05) between high- and low-risk SOMS-2-subgroups. CONCLUSIONS: In this group of CLBP patients, the easy-to-administer HADS/SOMS reliably predicted outcome after MIS due to the detection of somatoform comorbidities. Thus, 30 out of 150 patients were invasively treated without improvement. This is alarming not only because of unnecessary MIS being performed on these individuals, but also because it represents an inefficient allocation of increasingly limited healthcare funds. LEVEL OF EVIDENCE: II.

[Spine injections in athletes]. / Wirbelsäulennahe Injektionstherapie im Sport.

A major proportion of athletes have intermittent acute low back pain at some stage of their sport life. Some athletes develop chronic low back pain, which may be a major source of failing in sports. Facet, epidural and intradiscal steroid injections for specific pain generators in the spine show different short- and long-term results. They can improve low back pain for specific pain generators experienced by back pain patients and might be able to help some of these athletes to avoid open surgery and shorten the time until return to sports (RTS). Facet and intradiscal steroid injections provide only short-term effects in axial low back pain and should therefore be considered with caution, whereas the different forms of epidural steroid injections for sciatica caused by radicular compression seem to be a well-proven adjuvant treatment option within a conservative therapeutic regimen. An overview of the literature related to the use of different steroids has shown that non-particulate steroids provide better results regarding safety and avoidance of major complications, especially when used at the cervical spine. However, in Germany the use of these steroids is still off-label and patients have to provide their informed consent prior to injection. In summary, careful use of spinal injections within a conservative physiotherapeutic regimen seems to improve chronic back pain and, in turn, reduce the time of RTS.

Spinal Injections, Epidural Neurolysis and Denervation for Specific Low Back Pain and Sciatica. / Injektionstherapie, Katheter und Denervation beim spezifischen Rückenschmerz ­ was ist bewiesen?

BACKGROUND: Many members of the adult population suffer acute low back pain at some stage in life. A specific cause is found in only a rather small number of these patients. Some of the patients develop chronic low back pain and this is a major source of disability. On the other hand, there has been a great increase in Germany in the number of spinal operations due to degenerative spine disease and, in turn, unnecessary surgery on the spine is under debate. METHODS: This is a narrative review of different minimally invasive spine procedures in the treatment of specific low back pain. The effectiveness of spinal injections, radiofrequency of the facet joints as well as epidural adhesiolysis/neurolysis are described. An analysis of the literature was performed via PubMed, Medline and the Cochrane Database. RESULTS: Facet-, epidural and intradiscal steroid injections for specific pain generators in the degenerative spine show different short- and long-term results; they are able to improve low back pain in specific patients with chronic low back pain and may be able to prevent some of these patients from having to undergo open surgery. Furthermore, there are promising results from interventions such as epidural neurolysis for sciatica and radiofrequency of the medial branch of the dorsal root for the treatment of axial facet-related back pain. Facet and intradiscal steroid injections give only short-term effects in axial low back pain and should therefore only be considered reluctantly, whereas the different forms of epidural steroid injections in patients with sciatica due to radicular compression offer a well proven adjuvant treatment option within a conservative therapeutic regimen. The overview of the literature with the use of different steroids has shown that use of non-particulate steroids show better results with respect to the safety and avoidance of major complications, especially when used at the cervical spine. However, in Germany the use of these steroids is still off label and patients have to give informed consent prior to injection. In summary, careful use of spinal injections and interventions within a conservative physiotherapeutic regimen seem to improve chronic back pain and, in turn, to be able to prevent some patients from having to undergo spine surgery.

[Rehabilitation after Traumatic Fracture of Thoracic and Lumbar Spine]. / Rehabilitation nach traumatischen Frakturen der Brust- und Lendenwirbelsäule.

On the basis of the S2-k guideline "Rehabilitation after traumatic fractures of the thoracic und lumbar spine without neurologic disorder", this article gives an overview of target-oriented rehabilitation of patients with minor fractures or those with column stability and unstable spinal fractures which are stabilised by surgery. To obtain early social and job related reintegration, outpatient or inpatient rehabilitation has to start immediately after treatment in hospital. Rehabilitation must be orientated towards the biopsychosocial model of ICF and has to be adapted for the patient. The overall goal of rehabilitation is functional restoration of patient health to enable participation in society, life and job. Individual goals may change during rehabilitation, because of differential progress in therapy. Pain management must be orientated towards individual requirements and mental health has to be tested early, especially in polytrauma patients. Disorders have to be treated by psychotherapy, because psychic stress supports chronification of pain. Generally early exercise and physiotherapy are recommended in the guideline, with patient education for health-seeking behavior. Otherwise an orthesis device is not really necessary for treatment of a stable fracture. To improve the outcome of rehabilitation aftercare, treatment has to be arranged during rehabilitation, especially for employed patients.

Percutaneous epidural lysis of adhesions in chronic lumbar radicular pain: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Chronic radicular pain can occur after disc pathology and failed back surgery. An evidence-based effective therapeutic option is not available nor does a gold standard exist. OBJECTIVES: A randomized controlled trial to analyze the clinical efficacy of percutaneous epidural lysis of adhesions in chronic radicular pain. STUDY DESIGN: Prospective randomized placebo controlled interventional trial. Power calculation based on a feasibility trial. SETTING: Medical university centers. METHODS: Within 4 years a total of 381 patients with chronic radicular pain lasting longer than 4 months which failed to respond to conservative treatments were screened and 90 patients were enrolled. They were randomly assigned to receive either percutaneous neurolysis or placebo with concealed allocation in permuted blocks of 4 to 8, stratified by treatment center. The primary outcome measure was the differences in percent change of Oswestry Disability Index (ODI) scores 3 months after intervention. Secondary outcome measures were difference in percent change of ODI scores and Visual Analog Scale (VAS) 6 and 12 months after intervention and success rates defined as at least 50% reduction in ODI scores and VAS scores (mean change from baseline) at 3, 6, and 12 months after treatment. Explorative, 2-sided group comparisons for baseline characteristics between active treatment and controls were done using the t-test for 2 independent samples for quantitative data and Fisher's exact test for binary data. RESULTS: The ODI and VAS scores as well as the success rates for ODI vs VAS were significantly better 3, 6, and 12 months in the lysis group vs the control group. The ODI in the lysis group improved from 55.3 ± 11.6 to 26.4 ± 10.8 after 3 months. The placebo group improved from 55.4 ± 11.5 to 41.8 ± 14.6 (P < 0.01). VAS improved from 6.7 ± 1.1 to 2.9 ± 1.9 in the active group and from 6.7 ± 1.1 to 4.8 ± 2.2 (P < 0.01) after placebo. Twelve month follow-up shows further improvement, the differences remain significant. In multiple linear regression, forward and backward variable selection methods resulted in the same covariate model confirming the univariate result for group comparison in the primary analysis. No severe side effects occurred but minor transient neurological effects such as partial sensomotoric deficits did. One dura puncture and one catheter displacement were found. LIMITATIONS: Specific effects of single treatment components cannot be specified because there was no imaging examination after treatment. CONCLUSION: Based on the findings of our study as well as other studies, we believe the minimally invasive percutaneous adhesiolysis procedure should be the first choice treatment option for patients with chronic lumbosacral radicular pain who present with clinical history and findings similar to those of the patients enrolled in our study.

Medial branch blocks versus pericapsular blocks in selecting patients for percutaneous cryodenervation of lumbar facet joints.

BACKGROUND AND OBJECTIVES: At many institutions, it is not practically feasible to perform a series of controlled or placebo-controlled medial branch blocks on several facet joints in order to select patients for facet joint rhizotomy. As for uncontrolled blocks, there is no proof that medial branch blocks are superior to other types of blocks. This study was performed to compare medial branch blocks to simple pericapsular blocks for the selection of patients for lumbar facet joint cryodenervation. METHODS: Patient selection was based on history, imaging, and physical examination. Diagnostic blocks were either medial branch blocks or pericapsular blocks. Percutaneous medial branch cryodenervation was performed by use of a Lloyd Neurostat 2000. Outcome parameters were low back pain (visual analog scale [VAS]), limitation of activity (Macnab), and overall satisfaction. A total of 26 patients were recruited, 13 for each group. Follow-up was 6 months. RESULTS: Patients who had been selected by medial branch blocks had better pain relief than did patients who had been diagnosed by use of pericapsular blocks. At 6 weeks and at 3 months after treatment, these results reached statistical significance (VAS 2.2 v 4.2, P < .05). CONCLUSIONS: Our results suggest that uncontrolled medial branch blocks are superior to pericapsular blocks in selecting patients for facet joint cryodenervation, but both blocks work. If serial controlled blocks cannot be used, lumbar facet joint pain remains a diagnostic dilemma.

Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial.

BACKGROUND: Epidural neuroplasty seems to be one of the promising minimally invasive techniques for adhesiolysis in patients with chronic sciatica with or without low back pain. However, because no data exist from randomized studies the aim was to investigate whether this procedure is superior to conservative treatment with physiotherapy. METHODS: A total of 99 patients with chronic low back pain were enrolled in this study and randomly assigned into either a group with physiotherapy (n = 52) or a second group undergoing epidural neuroplasty (n = 47). Patients were assessed before and 3, 6, and 12 months after treatment by a blinded investigator. RESULTS: After 3 months, the visual analog scale (VAS) score for back and leg pain was significantly reduced in the epidural neuroplasty group, and the need for pain medication was reduced in both groups. Furthermore, the VAS for back and leg pain as well as the Oswestry disability score were significantly reduced until 12 months after the procedure in contrast to the group that received conservative treatment. CONCLUSIONS: Epidural neuroplasty results in significant alleviation of pain and functional disability in patients with chronic low back pain and sciatica based on disc protrusion/prolapse or failed back surgery on a short-term basis as well as at 12 months of follow-up.

Influence of orthopedic particulate biomaterials on inflammation and synovial microcirculation in the murine knee joint.

The purpose of the present study was to examine changes in the synovial microcirculation as well as synovial tissue responses to exposure to titanium, polymethylmethacrylate (PMMA), ceramic (Al(2)O(3)), cobalt-chromium alloy (Co-Cr), and polyethylene (PE) particles in an in vivo model. The particulate biomaterials were injected into the left knee joint of female Balb/c mice and assessment of the synovial microcirculation using intravital fluorescence microscopy as well as histological evaluation of the synovial tissue response were performed on day 7 after particle administration. Intravital microscopic measurements revealed that all tested biomaterials caused significantly (p < 0.05) enhanced leukocyte-endothelial cell interactions and an increase of functional capillary density compared to controls. In the histological examination PMMA, Al(2)O(3), PE, and Co-Cr particles provoked significantly (p < 0.05) enhanced inflammatory tissue responses in comparison to tissue from control animals. Titanium particles showed significantly (p < 0.05) less leukocyte-endothelial cell interactions than the other particulate biomaterials and caused significantly (p < 0.05) minor membrane thickening compared to PE and PMMA particles. In conclusion, all tested particulate biomaterials were capable of inducing inflammatory responses in the present study. Our data suggest that titanium particles may cause less leukocyte activation and inflammatory tissue responses than other particulate biomaterials used in total joint arthroplasty.

Long-term anaesthesia using inhalatory isoflurane in different strains of mice-the haemodynamic effects.

The aim of this study was to establish a simple and safe method of anaesthesia for intravital microcirculatory observations in small laboratory animals. The usefulness of isoflurane inhalation anaesthesia has been investigated in different strains of mice commonly used in experimental medicine. These were the hairless (hr/hr, n = 12), the BALB/c (n = 12) and the nude mouse (nu/nu, n = 3). Anaesthesia was maintained by mask inhalation of isoflurane vaporized at concentrations of up to 4% in the induction phase, at 1.5% during acute surgical procedures and at 0.8-1.3% during prolonged experimental observations. Isoflurane was vapoured in a N(2)O/O(2) mixture and saturated with 32-36% F(i)O(2). During observations the body temperature was kept constant at 37 degrees C. The tail artery was cannulated for monitoring of mean arterial blood pressure (MAP) and heart rate (HR). To maintain the body fluid balance, isotonic saline was administered at a constant rate of 0.2 ml/h. Arterial blood samples were drawn for blood-gas analysis at the end of the experiments. All animals survived the anaesthesia protocol lasting between 3 and 6.5 h. During isoflurane inhalation, no breathing complications or changes in systemic circulatory parameters were observed. Mean values of MAP and HR were 79+/- 3 mmHg and 486+/- 13 min(-1), respectively, over the entire observation period. A moderate acidosis was recorded in animals under isoflurane anaesthesia, with alterations of arterial blood pH, p(a)O(2) and pCO(2) values (7.29+/- 0.06, 130+/- 19 mmHg and 35.6+/- 4.7 mmHg, respectively). In conclusion, inhalation anaesthesia with isoflurane is useful for experimental studies in the mouse due to (1) the simplicity of administration of the anaesthetic, (2) the rapid induction of anaesthesia, (3) easy control of the depth of anaesthesia, (4) the low percentage of complications, and (5) stable MAP and HR during observations lasting several hours. The proposed technique is especially suitable for observations of the microcirculation under intravital fluorescence microscopy.

Observer variabilities of radiological classifications of calcified deposits in calcifying tendinitis of the shoulder.

The radiological morphology of calcified deposits in calcifying tendinitis of the shoulder is classified according to Patte and Goutallier and according to Mole et al. The results of these classifications influence the choice of therapeutic procedures. In this study, the intraoberserver reproducibility and interobserver reliability of these classifications were determined. Plain anteroposterior radiographs of shoulders from 100 patients with symptomatic calcified deposits of the rotator cuff were classified according to the criteria of Patte and Goutallier as well as to the criteria of Mole et al, by six independent observers, twice within four months. The kappa values of intraoberserver reproducibility and interobserver reliability were calculated. Classification of Patte and Goutallier: intraoberserver reproducibility, mean kappa value 0.458 (standard deviation 0.098); interobserver reliability, mean kappa values 0.4 (first test) and 0.354 (second test). Classification of Mole et al: intraoberserver reproducibility, mean kappa value 0.402 (standard deviation 0.092); interobserver reliability, mean kappa values 0.239 (first test) and 0.191 (second test). Both classifications demonstrated a satisfactory to sufficient intraobserver reproducibility. The classification of Patte and Goutallier showed a satisfactory interobserver reliability, whereas the classification of Mole et al had a satisfactory to insufficient interobserver reliability. Studies dealing with both classifications should therefore be interpreted carefully.