An in vitro analysis of the size and shape of cryolesions for facet joint denervation.

OBJECTIVES: Lumbar facet joint syndrome (LFJS) is the cause of lower back pain in 15-54% of the patients. Clinical studies of cryotherapy for LFJS have reported promising outcomes. However, few studies have focused on the technical aspects of cryoneurolysis for LFJS. The aim of the study was to determine the size and shape of cryolesions in vitro and to determine how they are affected by the duration of freezing, size of the cryoprobe and distance and angulation to an osseous boundary layer. MATERIALS AND METHODS: Two different cryolesion generators were used. Cryolesions were generated in tempered physiologic NaCl solution in the vicinity of an osseous surface. The size of the cryoprobes, duration of freezing, distance to the bone surface and angulation of the probe were studied. Cryolesions were recorded with a video camera during their emergence. Images at distinct time points were analysed using digital image processing software. RESULTS: The probe size, the system in use and the duration of the freezing cycle were the main determinants for the size of the cryolesion. The vicinity of the osseous boundary resulted in a modest increase in the size of the cryolesion. Angulation of the cryoprobe towards the osseous boundary is of minor importance for the size of the contact area to the nerve. CONCLUSION: For cryoneurolysis of LFJS, duration of freezing, temperature and probe size are the main determinants of lesion size and thus the probability of success of the procedure. A tangential approach of the probe is not essential.

Cryoneurolysis for zygapophyseal joint pain: a retrospective analysis of 117 interventions.

PURPOSE: Lumbar facet joint syndrome (LFJS) is the cause of pain in 15-54% of the patients with low-back pain. There are few studies of cryotherapy for LFJS, focusing mainly on pain scores rather than further outcome measures. The aim of the study was to determine the long-term outcome after cryoneurolysis of lumbar facet joints, looking at pain scores, pain-related impairment patient satisfaction, and pain-related anxiety/depression. METHODS: The study design was a retrospective observational study. In a 4-year period, 117 cryoneurolyses were performed in 91 patients under CT guidance in the prone position. Data from patient charts and questionnaires pre- and post-treatment were evaluated. RESULTS: The mean pain rating sank from 7.70 before treatment to 3.72 post treatment. In the post-interventional 3 months follow-up, this value rose to 4.22. At follow-up (mean 1.7 years, range 6-52 months), the mean visual analogue scale (VAS) was 4.99. The pain disability index revealed statistically significant improvements in the following items: familiar and domestic duties, recreation, social activities, profession and vitally indispensable activities (p < 0.05). Hospital anxiety and depression scale (HADS) scores for depression showed a statistically significant decline after therapy, whereas scores for anxiety did not. A subgroup of patients who did not benefit from cryoneurolysis had elevated depression scores. CONCLUSIONS: Cryoneurolysis for LFJS can lead to favourable results with sustained pain relief, amelioration of pain-related disability and reduction of depression scores.

CRPS I following artificial disc surgery: case report and review of the literature.

We report a case of type 1 complex regional pain syndrome (CRPS I) of the left leg following the implantation of an artificial disc type in the L4/5 segment of the lumbar spine using a midline left-sided retroperitoneal approach. This approach included the mobilisation of the sympathetic trunk with incision and resection of the intervertebral disc. The perioperative and immediate postoperative periods were uneventful, but on the second postoperative day the patient complained of a progressive allodynia of the whole left leg in combination with weakness of the limb. Neurological examination did not reveal any radicular deficit or paresis. A sympathetic reaction following the mobilisation of the sympathetic trunk during the ventral preparation of the spine was suspected and investigated further. A diagnosis of CRPS I was proposed, and the patient was treated with analgesia, co-analgesics for pain alienation, and systemic corticosteroid therapy. A computed tomography-guided sympathetic block and lymphatic drainage were performed. Following conservative orthopaedic rehabilitation therapy, the degree of pain, allodynia, weakness, and swelling were reduced and the condition of the patient was ameliorated. The cost-benefit ratio of spinal arthroplasty is still controversial. The utility of this paper is to debate a possible cause of a painful complication, which can invalidate the results of a successful operation.

Chronic low back pain: course of disease from the patient's perspective.

Chronic back pain often leads to permanent disability and-apart from significant human suffering-also creates immense economic costs. There have been numerous epidemiological studies focussing on the incidence and the course of chronic low back pain. Less attention has been paid to the impact of subjective perception of the disease and the degree of healthcare use of these patients. The aim of this study was to gather data about patients with chronic low back pain and compare these data with patients suffering from chronic pain in other body regions. The first 300 pain questionnaires collected by the interdisciplinary pain centre at the University Hospital in Freiburg between January 2000 and September 2001 were analysed. This pain questionnaire is a modified version of the pain questionnaire of the DGSS (Deutsche Gesellschaft zum Studium des Schmerzes-German Chapter of the IASP). It collects demographic and socioeconomic information, as well as information regarding the course of the disease, and the subjective description of pain and the pain-related impairment. The subjective view of the course of disease, shows differences between patients with low back pain and patients with chronic pain of other origin, particularly regarding physical strain as the assumed cause of pain, but also regarding the frequency of prior treatments and cures. The subjective perception of the course of the pain disorder in patients with low back pain compared to patients with chronic pain in other parts of the body shows differences mainly related to the capacity for physical exertion. The frequency of ineffective prior treatments and cures underlines the necessity for early initiation of effective pain treatment aimed at prevention of the pain disorder becoming chronic.

CT-guided cervical selective nerve root block with a dorsal approach.

BACKGROUND AND PURPOSE: Cervical transforaminal blocks are frequently performed to treat cervical radicular pain. These blocks are performed mostly under fluoroscopy, but a CT-guided technique has also been described. The aim of this study was to review the results of CT-guided CSNRB by using a dorsal approach, to describe the contrast patterns achieved with this injection technique, and to estimate the degree of specificity and sensitivity. MATERIALS AND METHODS: We used a CT-guided technique with a dorsal approach leading to a more extra-than transforaminal but a selective nerve root block as well. Of 53 blocks, we performed 38 for diagnostic and 15 for therapeutic indications. Pain relief was measured hourly on a VAS. The distribution of contrast and the angle of the trajectory of the injection needle were analyzed as well as the degree of pain relief. RESULTS: Contrast was found in the intraforaminal region in 8 (15%) blocks, extraforaminally in 40 (78%) blocks, and intraspinally in 3 (6%) blocks. The mean angle between the needle and the sagittal plane was 26.6° (range, from 1° to 50°). The mean distance between needle tip and nerve root was 4.43 mm (range, 0-20 mm). Twenty-six (68.4%) of the 38 diagnostic blocks led to a decrease in the pain rating of >50%. There were no complications or unintended side effects, apart from occasional local puncture pain. CONCLUSIONS: We conclude that CT-guided CSNRBs using a dorsal approach are feasible and that they are sensitive and specific.

Cervical CT-guided, selective nerve root blocks: improved safety by dorsal approach.

Cervical transforaminal blocks are frequently performed as a treatment of cervical radicular pain. These blocks are performed mostly under fluoroscopy, but a CT-guided technique also has been described. We describe a modification that leads to a more extraforaminal than transforaminal and equally selective nerve root block.

Differential diagnosis of primary malignant bone tumors in the spine and sacrum. The radiological and clinical spectrum: minireview.

Although primary malignant tumors of the spine and sacrum are described in all orthopedic textbooks, it is still remarkable how little attention is paid to differential diagnosis of persisting lower back pain and how to detect in special the underlying tumor disease. Chordoma, osteosarcoma, chondrosarcoma, plasmacytoma, lymphoma and Ewing's sarcoma, their radiological manifestation, age distribution and preferred location in the spine and sacrum are reviewed and discussed.

Spontaneous healing of pathologic humerus fracture caused by a cartilaginous tumor.

Conservative treatment of pathologic fractures of the long bones have been reported very infrequently, especially when fracture is caused by an tumour. This report highlights the possibility of an nonoperative treatment of a pathologic humerus fracture caused by an cartilaginous tumour with radiographic criterions of an chondrosarcoma.

Skeletal metastasis in tricholemmal carcinoma.

Tricholemmal carcinoma is an extremely rare cutaneous adnexal tumor, not exceeding 1-2 cm in diameter in some reported cases. The few reports describe only a greater histologic malignancy. Some cases of recurrences have been reported, and metastasis of the soft tissue was described once by Amaral et al in 1984. In the current patient with tricholemmal carcinoma of the right distal thigh, the primary tumor was unusually large. The first detected metastasis was localized in the right inguinal lymph nodes. Five years after diagnosis of tricholemmal carcinoma a metastasis of the left tibia and fibula were diagnosed. To our knowledge, an osseous metastasis in tricholemmal carcinoma has not been described. It is possible that a relationship between the extraordinary size and the osseous metastasis exists in the current patient.

Differential diagnosis of benign tumors and tumor-like lesions in the spine. Own cases and review of the literature.

Although benign tumors and tumor-like lesions of the spine are shown in every orthopedic teaching book, it is often surprising how little attention is paid to the differential diagnosis and diagnostic investigations, respectively, since surgical treatment and postoperative control depends on exact diagnosis. Clinically the importance of this fact can not be over-emphasized. The most common complaint is pain, either local or radicular in nature. Bone deviations are diagnosed radiologically. Different types of benign bone tumors and tumor-like lesions of the spine including osteochondroma, osteoblastoma, osteoid osteoma, aneurysmal bone cyst, eosinophilic granuloma, hemangioma, and giant cell tumor, their appearance relation to the age and location in the spine were reviewed and the common histologic subtypes described. Clinical, laboratory and histopathologic findings, radiologic inclusive MRT and scintigraphic features are evaluated. Diagnostic investigations including the invasive techniques of CT guided needle biopsy, Yamshidi needle biopsy and costotransversectomy for biopsy are shown. Treatment including radiation, chemotherapy and the surgical procedure as well as the postoperative treatment of patients with benign tumors and tumor-like lesions of the spine are discussed.

Distribution of immunocompetent cells in decidua of controlled and uncontrolled (choriocarcinoma/hydatidiform mole) trophoblast invasion.

PROBLEM: Pregnancy has been considered as a model of successfully controlled tissue invasion where trophoblast cells infiltrate the maternal decidua without being rejected or without destroying the tissue. In choriocarcinoma (CC) and hydatidiform mole (HM), a dysregulation of invasive (malignant/benign) trophoblast cells is present. Immunocompetent cells (IC) are known to be involved in rejection pathways of malignant cells and can also be identified in early pregnancy decidua. The aim of the present study was to identify the phenotype of IC in decidua of women with normal pregnancy (NP), CC and HM. METHODS: Immunocompetent cells were detected by immunohistochemistry in decidual tissue from first trimester NP (n = 10), CC (n = 12) and HM (n = 11) using antibodies against CD8+, CD3+, CD56+, CD68+ cell surface markers and mast cell tryptase (MCT). A scaled eye piece was used for cell counting to obtain semiquantitative results. Statistical analysis was performed using Wilcoxon rank/Mann-Whitney tests. RESULTS: We observed a significantly increased number of lymphocytes positive for CD8, CD3 and MCT positive granulocytes in CC and HM compared with the samples from NP (all P < or = 0.001). Lymphocytes positive for natural killer (NK) cell marker CD56 were significantly decreased in CC and HM versus NP (P < or = 0.001). The number of CD68 positive cells (macrophages) were not significantly different among the tissue pools. CONCLUSION: The increase of CD8/CD3 T cells and mast cells in CC and HM and the decrease of CD56 cells, compared with NP, suggests the necessity of a balance between T and NK cells in controlling trophoblast invasion.

Heme oxygenases in pregnancy II: HO-2 is downregulated in human pathologic pregnancies.

PROBLEM: We previously reported a diminished expression of the heme-degrading enzymes heme oxygenases (HO)-1 and HO-2 in decidua and placenta from mice undergoing Th1-mediated abortion, strongly indicating the protective effect of HO in murine pregnancy maintenance. Here we investigated whether the expression of HO-1 and HO-2 is also reduced at the feto-maternal interface of pathologic human pregnancies. METHOD OF STUDY: Immunohistochemistry was used to detect HOs expression in placental and decidual first-trimester tissue from patients with: spontaneous abortion (n = 14), choriocarcinoma (n = 14), hydatidiform mole (H-mole) (n = 12), compared with normally progressing pregnancies (n = 15). Further, we investigated early third-trimester decidual and placental tissue from patients with pre-eclampsia (n = 13) compared with fetal growth retardation (n = 14) as age-matched controls. RESULTS: In first trimester tissue, we observed a significant reduction of HO-2 expression in invasive trophoblast cells, endothelial cells, and syncytiotrophoblasts in samples from patients with spontaneous abortion compared with normal pregnancy. H-mole samples showed a diminished expression of HO-2 in invasive trophoblast cells and endothelial cells in comparison with NP, whereas choriocarcinoma samples showed no significant differences compared with the control. In third trimester tissue, HO-2 was also reduced in syncytiotrophoblasts and invasive trophoblast cells from pre-eclampsia compared with samples from fetal growth retardation. HO-1 expression was diminished in all pathologies investigated; however, the differences did not reach levels of significance. CONCLUSIONS: Our data indicate that HOs play a crucial role in pregnancy and low expression of HO-2, as observed in pathologic pregnancies, may lead to enhanced levels of free heme at the feto-maternal interface, with subsequent upregulation of adhesion molecules, allowing enhanced inflammatory cells migration to the feto-maternal interface.

Synovial osteochondromatosis of the hip joint. Etiology, diagnostic investigation and therapy.

Synovial osteochondromatosis (Reichel's syndrome) of the hip joint is an unusual entity that is difficult to diagnose in the initial stages. In the beginning the condition is characterized by recurrent pain in the affected joint with negative radiographic and MR findings. The first stage shows only synovial reaction without loose bodies. In the second stage radiography is negative because of cartilaginous bodies, and even in the third stage radiography is negative in one third of cases although osseous bodies are present. After diagnosis surgery is indicated to prevent damage to the joint. We review the etiology, clinical findings and differential diagnosis especially types of secondary synovial chondromatosis and discuss ultrasound, radiologic, MR and scintigraphic features and laboratory findings. We describe the surgical treatment and postoperative treatment of patients with synovial osteochondromatosis with moderate signs of secondary osteoarthritis.

Historical perspective: history of spinal surgery.

The surgical treatment of spinal disorders did not develop before the 1970s of the last century. Previously limited technical possibilities and the danger of infections spinal surgery could not spread wider. This article reviews the history of spinal surgery from first trials as mentioned in the papyrus Smith in 1550 B.C. in Egypt to advanced techniques of today.