Diagnostic and prognostic significance of miR-486-5p in patients who underwent minimally invasive surgery for lumbar spinal stenosis.

BACKGROUND: This study aimed to investigate the expression and clinical value of microRNA miR-486-5p in diagnosing lumbar spinal stenosis (LSS) patients and predicting the clinical outcomes after minimally invasive spinal surgery (MISS) in LSS patients, and the correlation of miR-486-5p with inflammatory responses in LSS patients. METHODS: This study included 52 LSS patients, 46 patients with lumbar intervertebral disk herniation (LDH) and 42 healthy controls. Reverse transcription quantitative PCR was used to detect miR-486-5p expression. The ability of miR-486-5p to discriminate between different groups was evaluated by receiver-operating characteristic analysis. The visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scores at 6 months postoperatively were used to reflect the clinical outcomes of LSS patients. Enzyme-linked immunosorbent assay was used to measure the levels of inflammatory factor [interleukin-1ß (IL-1ß) and tumor necrosis factor-α (TNF-α)]. The correlation of miR-486-5p with continuous variables in LSS patients was evaluated by the Pearson correlation coefficient. RESULTS: Expression of serum miR-486-5p was upregulated in LSS patients and had high diagnostic value to screen LSS patients. In addition, serum miR-486-5p could predict the 6-month clinical outcomes after MISS therapy in LSS patients. Moreover, serum miR-486-5p was found to be positively correlated with the levels of IL-1ß and TNF-α in patients with LSS. CONCLUSION: miR-486-5p, increased in LSS patients, can function as an indicator to diagnose LSS and a predictive indicator for the clinical outcomes after MISS therapy in LSS patients. In addition, miR-486-5p may regulate LSS progression by modulating inflammatory responses.

Association of Protein and Genetic Biomarkers With Response to Lumbar Epidural Steroid Injections in Subjects With Axial Low Back Pain.

OBJECTIVE: The purpose of this observational study was to examine the association of protein and genetic biomarkers with pain and pain-related disability in individuals with axial low back pain undergoing epidural steroid injections. DESIGN: Forty-eight adults with axial low back pain undergoing an epidural steroid injection were recruited from an academic medical center. Blood samples were assayed at baseline and follow-up for plasma proteins and functional single-nucleotide polymorphisms associated with pain. Data regarding pain and function were collected at baseline and follow-up. The characteristics of responders (defined as 50% improvement in pain score) and nonresponders were compared, and the association between response and baseline biomarkers was examined. RESULTS: Thirty-five percent of subjects were responders to injection. Responders had lower baseline plasma levels of chondroitin sulfate 846 and higher neuropeptide Y and serotonin levels than nonresponders, and baseline neuropeptide Y level correlated with change in disability levels. In addition, subjects with the variant allele for the catechol-O-methyltransferase single-nucleotide polymorphism demonstrated increased odds of responding to the injection. CONCLUSIONS: These data identify candidates who may have utility for patient selection for spinal procedures and provide support for exploration in prospective studies to assess and validate their predictive ability.

Two GWAS-identified variants are associated with lumbar spinal stenosis and Gasdermin-C expression in Chinese population.

The aim of this study is to investigate the expression levels of genome-wide association studies (GWAS)-identified variants near Gasdermin-C (GSDMC) and its association with lumbar disc degeneration (LDD) in a Chinese population. In accordance with previously reported findings, our study involved the top 4 variants; rs6651255, rs7833174, rs4130415, and rs7816342. A total of 800 participants, 400 LDD patients and 400 controls were involved in the study. The LDD patients were divided into two mutually exclusive subgroups: subgroup 1: lumbar disc herniation; subgroup 2: lumbar spinal stenosis. Genotyping were performed using TaqMan assay, and Enzyme-Linked Immunosorbent Assay (ELISA) used to measure the plasma GSDMC levels, while quantitative reverse-transcription (qRT)-PCR and immunohistochemistry (IHC) were used to evaluate the GSDMC expression levels. Among the studied variants, there were no statistically significant differences in allelic and genotypic frequencies between LDD patients and their controls (all P > 0.05). However, the subgroup analysis revealed a significant association between rs6651255 and rs7833174 in patients with lumbar spinal stenosis (subgroup 2). Furthermore, the max-statistic test revealed that the inheritance models of two variants of lumbar spinal stenosis were represented by the recessive model. The plasma and mRNA expression levels of GSDMC were significantly higher in patients with lumbar spinal stenosis compared with the control group (P < 0.05). Furthermore, the CC genotypes of rs6651255 and rs7833174 were significantly associated with increased plasma expression levels of GSDMC in patients with lumbar spinal stenosis (P < 0.01). Two GWAS-identified variants (rs6651255 and rs7833174) near GSDMC were associated with a predisposition to lumbar spinal stenosis. GSDMC protein and mRNA expression levels may have prognostic qualities as biomarkers for the existence, occurrence or development of lumbar spinal stenosis.

The effectiveness of vitamin D supplementation in functional outcome and quality of life (QoL) of lumbar spinal stenosis (LSS) requiring surgery.

STUDY DESIGN: This is a retrospective cohort comparative study. BACKGROUND: Vitamin D supplementation is considered to be associated with good functional outcome. Thus, a few studies have proposed vitamin D supplementation is benefit to the functional outcome in LSS requiring surgery. The purpose of this study is to identify the prevalence of vitamin D deficiency in patients with LSS requiring surgery, and to compare the differences between the cases whether vitamin D is supplemented and vitamin D is not supplemented in terms of a QoL during postoperative 2 year. METHODS: All patients with LSS who underwent surgery from March 1, 2015 to August 31, 2016 were enrolled. Among them, 61 patients with vitamin D deficiency were divided into two groups (supplemented group (A) and non-supplemented group (B)). Functional outcomes using Oswestry Disability Index (ODI) and Rolland Morris Disability Index (RMDQ) and QoL using SF-36 were evaluated at 12-month and 24-month follow-up periods. Differences in functional score and SF-36 between the vitamin D supplemented and non-supplemented group were compared. RESULTS: Among the total 102 patients, 78 patients (76.5%) had vitamin D deficiency. Of the 78 patients, 61 patients were included, 27 patients were group A and 27 patients were group B. There was no difference in age and 25-OHD level between the two groups (all 0 > 0.05). Group A were better functional outcomes at 2 years after surgery (p < 0.05). On the QoL, group A were higher score than group B from 12 month later after surgery (p < 0.05). CONCLUSIONS: Vitamin D deficiency was highly prevalent in LSS patients (76.5%). Assessment of serum 25-hydroxyvitamin D (25(OH)D) is recommended in LSS needing surgical intervention and active treatment vitamin D supplementation and maintenance of normal range should be considered for better postoperative functional outcome and QoL.

Intra-individual association between C-reactive protein and insulin administration in postoperative lumbar spinal canal stenosis patients: A retrospective cohort study.

The association of intra-individual variability in insulin requirements with C-reactive protein levels among acute phase patients remains unclear. This retrospective cohort study aimed to evaluate this association. Patients with type 2 diabetes undergoing surgery for lumbar spinal canal stenosis were included in the study. We analyzed 286 records of 49 patients using the linear mixed effects model. The model showed C-reactive protein levels to be significantly associated with insulin requirements, with an effect size of 0.60 U/day for an elevation of 1 mg/dL. The effect size was increased in patients with higher hemoglobin A1c levels. Our findings imply that C-reactive protein levels could be a useful clinical biomarker when blood glucose levels are controlled in acute phase patients.

Study protocol for a randomised controlled trial with clinical, neurophysiological, laboratory and radiological outcome for surgical versus non-surgical treatment for lumbar spinal stenosis: the Uppsala Spinal Stenosis Trial (UppSten).

INTRODUCTION: Symptomatic lumbar spinal stenosis is the most common indication for spinal surgery. However, more than one-third of the patients undergoing surgery for lumbar stenosis report dissatisfaction with the results. On the other hand, conservative treatment has shown positive results in some cases. This trial will compare the outcomes of surgical versus non-surgical treatment for lumbar stenosis. The study includes a multidimensional follow-up, aiming to study the association between outcome and other studied parameters, mainly electromyography and nerve conduction. Moreover, it may contribute to a better understanding of the pathophysiology of lumbar stenosis and to the development of future pharmacological treatments. METHODS AND ANALYSIS: UppSten is a single-centre randomised controlled trial in which 150 patients with symptomatic lumbar spinal stenosis will be randomised into one of two treatment arms. The patients in the surgical arm will undergo laminectomy; the patients in the non-surgical arm will be given a structured physical training programme. The primary outcome of the study will be the Oswestry Disability Index. Secondary outcomes will include motor amplitude and degree of denervation activity obtained by means of nerve conduction studies and electromyography. Patient-reported outcome measures will be also used as secondary outcomes. Blood sample analysis and the investigation of potential inflammation markers are the additional secondary outcome parameters. Laboratory evaluation will include blood sample collection before the treatment initiation and after 6 months. Flavum ligament biopsies will be performed in the surgical group. Finally, tertiary outcomes will include neurophysiological measures, the objective walking ability and radiological evaluation. ETHICS AND DISSEMINATION: The study is approved by the Local Ethics Committee (Dnr 2017-506), the Hospital's Clinical Trials Committee (2018-0001) and the National Biobank Council and Uppsala Biobank (BbA-827-2018-025). The results will be presented in peer-reviewed journals and at international conferences. TRIAL REGISTRATION NUMBER: NCT03495661.

Factors associated with lumbar spinal stenosis in a large-scale, population-based cohort: The Wakayama Spine Study.

OBJECTIVE: Patients with lumbar spinal stenosis (LSS) who have radiographically similar degrees of stenosis may not necessarily exhibit equivalent symptoms. As part of a cross-sectional study, we examined factors associated with symptomatic LSS (sLSS) in the general population of Japan. METHODS: We evaluated 968 participants (men, 319; women, 649) between 2008 and 2010. Orthopedic surgery specialists diagnosed sLSS using interview results, medical examinations, and imaging findings. LSS was radiographically graded using a 4-level scale. Additionally, we examined basic anthropometry, smoking habits, alcohol consumption, ankle-brachial index values (ABI), and glycosylated hemoglobin (HbA1c) levels. We grouped patients with moderate and severe radiographic LSS, and compared the indicated factors on the basis of the presence/absence of sLSS. Data were evaluated using multiple logistic regression analyses. RESULTS: Radiographically, 451 participants had moderate and 288 severe stenosis. Clinically, 92 participants were diagnosed with sLSS, including 36 with moderate and 52 with severe stenosis. In the moderate stenosis group, participants with sLSS had significantly higher rates of diabetes mellitus (DM) and lower ABIs than did non-LSS participants. Although sLSS participants tended to be older (p = 0.19), there were no significant differences in the sex distribution, body mass index values, or in the percentages of participants who were drinkers/smokers. In the severe stenosis group, there were no differences in any of the evaluated factors. Multiple logistic regression showed that DM (odds ratio [OR], 3.92; 95% confidence interval [CI], 1.52-9.34]) and low ABI (1 SD = 0.09; OR, 1.36; 95% CI, 1.04-1.81) were significantly associated with LSS in the moderate stenosis group. CONCLUSIONS: DM and low ABIs are significantly associated with sLSS in patients with moderate radiographic stenosis. Neither factor is associated with sLSS in patients with severe stenosis. Notably, the effects of intrinsic factors on symptomology may be masked when anatomic stenosis is severe.

Systemic effects of epidural steroid injections for spinal stenosis.

This analysis of the lumbar epidural steroid injections for spinal stenosis multicenter randomized controlled trial data identifies the degree of and risk factors for cortisol suppression after epidural steroid injections in older adults with spinal stenosis. Four hundred patients aged 50 years and older with back or leg pain and central lumbar spinal stenosis completed baseline demographic and psychosocial measures. Morning serum cortisol levels were measured at baseline and 3 weeks after initial injection. Patients were randomized to receive epidural injections of either local anesthetic with corticosteroid (n = 200) or local anesthetic only (n = 200). The specific corticosteroid was chosen at the treating physician's discretion (methylprednisolone, betamethasone, triamcinolone, or dexamethasone). Thirty-two patients (20.3%) treated with corticosteroid experienced cortisol reduction at 3 weeks of >50% compared with 10 patients (6.7%) treated with lidocaine only (adjusted treatment effect = 3.5, 95% confidence interval: 1.6-7.9, P = 0.002). The effect on 3-week cortisol changes did not differ by demographic or patient-level characteristics. Those treated with methylprednisolone or triamcinolone had an average 3-week cortisol reduction of 41.0% (P = 0.005) and 41.6% (P < 0.001) from baseline, respectively, whereas patients treated with betamethasone or dexamethasone were not significantly different than comparable patients in the lidocaine arm. The higher rates of cortisol suppression at 3 weeks in those receiving epidural corticosteroid injections, particularly with longer-acting insoluble corticosteroid formulations, are consistent with sustained systemic absorption of corticosteroid.

Changes in HbA1c levels and body mass index after successful decompression surgery in patients with type 2 diabetes mellitus and lumbar spinal stenosis: results of a 2-year follow-up study.

BACKGROUND CONTEXT: Lumbar spinal stenosis (LSS) can hinder a patient's physical activity, which in turn can impair glucose tolerance and body weight regulation in patients with type 2 diabetes mellitus (DM-2). Therefore, successful lumbar surgery could facilitate glycemic control and body weight regulation. PURPOSE: This study aimed to evaluate the effects of postoperative improvement in physical activity on body mass index (BMI) and hemoglobin A1c (HbA1c) level in patients with LSS and DM-2 over a 2-year follow-up period. STUDY DESIGN: Prospective longitudinal observational study. PATIENT SAMPLE: Patients with LSS and DM-2. OUTCOME MEASURES: Visual analogue scale (VAS) scores for back pain and leg pain, Oswestry Disability Index (ODI) scores, Japanese Orthopaedic Association (JOA) scores, JOA Back Pain Evaluation Questionnaire (JOABPEQ) sections, BMI, and blood analysis for HbA1c were carried out. METHODS: A total of 119 patients were enrolled for analysis of the effect of successful decompression surgery on changes in HbA1c levels and BMI. The VAS score, ODI score, JOA score, JOABPEQ, BMI, HbA1c were reassessed at 6 months, 1 year, and 2 years after surgery. Additionally, correlations between changes in HbA1c and changes in the ODI, JOA, JOABPEQs, and BMI were analyzed. RESULTS: The overall values of HbA1c before and at 6 months, 1 year, and 2 years after the surgery were 7.08±0.94%, 6.58±0.87%, 6.59±0.79%, and 6.59±0.79%, respectively (p-values; 6 months: .024; 1 year: .021; 2 years: .038). In the not well-controlled sugar (non-WCS) group (preoperative HbA1c>6.5%), the difference between pre- and postoperative HbA1c was highly statistically significant (p<.01). The overweight group (preoperative BMI≥25) showed statistically significant BMI reduction in the second year after surgery (p=.034). The postoperative HbA1c changes are strongly correlated with the improvements of ODI, JOA, and JOABPEQ after surgery. CONCLUSIONS: The present study demonstrates that in patients with DM-2 and LSS, successful lumbar surgery may facilitate glycemic control by enabling an increase in the patient's level of physical activity. Additionally, it could help reduce body weight in overweight (BMI>25) patients with DM-2 and LSS.

Microendoscopy-assisted muscle-preserving interlaminar decompression for lumbar spinal stenosis: clinical results of consecutive 105 cases with more than 3-year follow-up.

STUDY DESIGN: A retrospective review of data collected prospectively on patients who underwent microendoscopy-assisted muscle-preserving interlaminar decompression (MILD) for lumbar spinal stenosis. OBJECTIVE: To evaluate the clinical results including surgical invasiveness and reduction rate of facet joint with a follow-up of more than 3 years. SUMMARY OF BACKGROUND DATA: Hatta et al reported microscopic posterior decompression procedure, MILD for lumbar spinal stenosis with reference to the cervical central approach put forth by Shiraishi. Mikami et al applied spinal microendoscopy to MILD procedure (microendoscopy-assisted MILD). METHODS: One hundred five consecutive patients, who underwent microendoscopy-assisted MILD, participated in this study. Operative time, blood loss, visual analogue scale (VAS), serum creatine kinase and C-reactive protein, surgical complications, reduction rate of the facet joint, Japanese Orthopaedic Association score, and Short-Form 36 were evaluated. RESULTS: The operative time was 99.3 minutes and the intraoperative bleeding was 15.7 mL on average. The mean VAS score to assess surgical site pain was 20.6 mm on postoperative day 1. The mean serum creatine kinase on postoperative day 1 and C-reactive protein on postoperative day 3 were 145.4 IU/L and 2.7 mg/dL, respectively. Surgical complications were identified in 2 cases, cauda equina injury and dural tear. The mean reduction rate of the facet joint was 3%. The follow-up rate was 83.3% and the mean follow-up period was 52.7 months. The Japanese Orthopaedic Association score improved significantly from 14.8 to 23.7 points on average. Significant improvements in Short-Form 36 were observed in all subscales except in General Health. Revision surgical procedures were performed in 8 cases at the operated level including 4 of juxtafacet cyst, 3 of disc herniation, and 1 of insufficient decompression. CONCLUSION: Microendoscopy-assisted MILD is a minimally invasive procedure and favorable clinical results can be expected for lumbar spinal stenosis. LEVEL OF EVIDENCE: 4.

[Comparison of traumatic related index in serum between minimally invasive and open transforaminal lumbar interbody fusion for tissue injury].

OBJECTIVE: To compare the difference of traumatic related index in serum and its significance between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open TLIF. METHODS: Sixty patients were enrolled by the entry criteria between May and November 2012, and were divided into MIS-TLIF group (n = 30) and open TLIF group (n = 30). There was no significant difference in gender, age, type of lesions, disease segment, and disease duration between 2 groups (P > 0.05). The operation time, intraoperative blood loss, and postoperative hospitalization time were recorded, and the pain severity of incision was evaluated by visual analog scale (VAS). The serum levels of C-reactive protein (CRP) and creatine kinase (CK) were measured at preoperation and at 24 hours postoperatively. The levels of interleukin 6 (IL-6), IL-10, and tumor necrosis factor alpha (TNF-alpha) in serum were measured at preoperation and at 2, 4, 8, and 24 hours after operation. RESULTS: The operation time, intraoperative blood loss, and postoperative hospitalization time of MIS-TLIF group were significantly smaller than those of open TLIF group (P < 0.05), and the VAS score for incision pain in MIS-TLIF group was significantly lower than that of open TLIF group at 1, 2, and 3 days after operation (P < 0.05). The levels of CRP, CK, IL-6, and IL-10 in MIS-TLIF group were significantly lower than those in open TLIF group at 24 hours after operation (P < 0.05), but there was no significant difference between 2 groups before operation (P > 0.05). No significant difference was found in TNF-alpha level between 2 groups at pre- and post-operation (P > 0.05). CONCLUSION: Compared with the open-TLIF, MIS-TLIF may significantly reduce tissue injury and systemic inflammatory reactions during the early postoperative period.

Changes in vitamin D status after surgery in female patients with lumbar spinal stenosis and its clinical significance.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: To demonstrate the changes in vitamin D status after surgery in female patients with lumbar spinal stenosis (LSS), and its correlation with surgical outcomes. SUMMARY OF BACKGROUND DATA: In patients with LSS, general health including walking ability and nutritional status can be markedly improved by decompressive surgery. It can be hypothesized that such improvement may have a positive effect on their vitamin D status. METHODS: In total, 31 female patients who underwent decompression and instrumented posterolateral fusion for LSS were enrolled. Serum 25-hydroxyvitamin D (25-OHD) level was measured before the surgery and at 1 year postoperative visit. According to serum 25-OHD level, patients were classified into 3 groups: (1) deficient group, when 25-OHD level was less than 20 ng/mL (< 50 nmol/L); (2) insufficient group, when 25-OHD level was between 20 to 30 ng/mL (50 nmol/L ≤ 25-OHD < 75 nmol/L); (3) and normal group, when 25-OHD level was 30 ng/mL or more (≥ 75 nmol/L). The Oswestry Disability Index (ODI) score and health-related quality of life (EQ-5D) were compared according to the level of 25-OHD at 1 year postoperatively. RESULTS: Preoperatively, there were 20 patients in the deficient group, 11 patients in the insufficient group and no patient in the normal group. There were no differences in age, body mass index, preoperative ODI scores, preoperative EQ-5D index scores, and EQ-5D visual analogue scale scores between the 2 groups. Mean preoperative 25-OHD level was 15.8 ng/mL (range, 5.2-29.4 ng/mL) and increased to 19.5 ng/mL (range, 6.3-47.7 ng/mL) 1 year after surgery (P = 0.075). Significant increase of 25-OHD was noted only in the deficient group (P = 0.017). Postoperatively, there were 18 patients in the deficient group, 8 patients in the insufficient group, and 5 patients in the normal group. In the postoperative deficient group, postoperative ODI scores and EQ-5D index scores showed significantly worse outcomes than those in the other groups. The changes in serum 25-OHD level were significantly correlated with the changes in ODI scores (r = -0.580; P = 0.001) and with the changes in EQ-5D index scores (r = 0.379; P = 0.035). In all the groups, postoperative ODI scores (r = -0.665; P < 0.001) and EQ-5D index scores (r = 0.601; P < 0.001) were significantly correlated with postoperative 25-OHD level. CONCLUSION: Vitamin D deficiency was common in patients with LSS. However, vitamin D status was improved after decompressive surgery, and postoperative 25-OHD level was significantly correlated with surgical outcomes.

Effects of epidural steroid injections on blood glucose levels in patients with diabetes mellitus.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: To evaluate the effects of epidural steroid injections (ESIs) on blood glucose levels in patients with diabetes mellitus. SUMMARY OF BACKGROUND DATA: ESIs are commonly used in the treatment of multiple spinal disorders. Corticosteroid injections have been evaluated in the total joints and hand literature showing systemic effects to diabetics. METHODS: Diabetic patients who were scheduled for an ESI were given an opportunity to enroll in our IRB-approved study. We collected the patient's most recent hemoglobin A(1c) (hA(1c)) and then asked them to track their blood glucose numbers at least twice per day for 2 weeks prior to and after their ESIs. RESULTS: We noted a statistically significant increase in blood glucose levels in diabetic patients (n = 30) after ESI. The mean blood glucose level prior to ESI was 160.18 ± 47.46, and, after ESI, it was 286.13 ± 111.11. This represents an average 125.96 ± 100.97 increase in blood glucose levels after injection. Using a nonlinear mixed effect model, the estimated half-life of this increase was 1.06 days (95% CI 0.80, 1.58), meaning that the patients were back within their normal standard deviation mean glucose levels within 2 days of injection. There was no association between observed glucose level change and preinjection hA(1c) levels or age (Spearman = 0.0326 and -0.1091 separately), indicating that there is no correlation between preinjection hA(1c) levels and systemic response to ESI. CONCLUSION: ESIs were noted to cause a significant increase in the blood glucose levels in diabetics. There was no correlation between preinjection diabetic control, represented by hA(1c) levels, and postinjection response. Diabetics who are candidates for ESI should be counseled that a blood glucose increase may be apparent post intervention, but effects should not last longer than approximately 2 days.

Comparative analysis of serum proteomes of degenerative scoliosis.

Degenerative scoliosis (DS) is an important degenerative lumbar disease causing spinal dysfunction and affecting the quality of life of the elderly, and is associated not only with severe back or leg pain but also with complicated surgical outcomes. The pathogenesis of DS is still unknown. Therefore, it is very important to ascertain the etiology of degenerative scoliosis and establish related molecular markers predicting and controlling the scoliosis. For the first time, we used two-dimensional fluorescence DIGE to compare the serum proteome profiles of 12 DS patients and controls. Proteins found to be differentially expressed were identified by MALDI-TOF mass spectrometric analysis, coupled with database interrogation. Eleven spots that were differentially expressed in the sera of DS patients were found, and eight gene products were identified among these spots. Clusterin, CLU cDNA FLJ57622, ALB cDNA FLJ50830, Hypothetical short protein, HLA-A MHC class 1 antigen. (Fragment), ALB 23 kDa protein, Isoform 1 of G protein-regulated inducer of neurite outgrowth 1 (GPRIN I)and Ficolin-3 were down-regulated in the sera of DS patients. The decreased levels of Clusterin and Ficolin-3 were confirmed by Western blot. The information obtained with this proteomic analysis will be very useful in understanding the pathophysiology of DS as well as in finding candidates as drug targets of DS. These results may provide a novel approach for the pathogenesis study of DS.

The clinical value of B-type natriuretic peptide (BNP) in predicting nocturnal low back pain in patients with concurrent lumbar spinal stenosis and cardiopulmonary dysfunction (Vesper's Curse): a clinical case series.

OBJECTIVE: To test the hypothesis that B-type natriuretic peptide is elevated in patients with both lumbar spinal stenosis and cardiopulmonary dysfunction who reported sleep-interrupting low back pain, the "symptomatic group," as compared with an analogous cohort not experiencing nocturnal low back pain, i.e., the "control group." B-type natriuretic peptide is a hormonal product of the myocardium, which increases with an elevation in blood volume. Even without clinical symptoms, the more the myocardial stretch, the higher the B-type natriuretic peptide. DESIGN: In both groups, all of the patients were identified as having lumbar spinal stenosis and a history of cardiopulmonary dysfunction. However, all of the symptomatic group reported initially falling asleep and then experiencing sleep interrupting low back pain. However, in both groups, their cardiac status remained clinically stable. Main outcome measures included both the B-type natriuretic peptide titer and lumbar spinal magnetic resonance imaging. RESULTS: There were 10 patients with nocturnal pain and eight who were pain-free at night. The magnetic resonance imaging in both cohorts demonstrated a spectrum of moderate to severe lumbar spinal stenosis. Their previous cardiac history varied from the presence of arrhythmias to that of congestive heart failure. Other risk factors including age, among others, were similar in both cohorts. The mean B-type natriuretic peptide titer in the control group was 67.88 +/- 46.58 pg/ml. In the symptomatic group it was significantly elevated to 136.90 +/- 62.14 pg/ml. CONCLUSIONS: In this clinical care series, the B-type natriuretic peptide titer was significantly increased in the symptomatic group as compared with the control group. The standard error of the mean was 19.65 in this group and 16.47 in the control group. An elevated B-type natriuretic peptide reflects a decrement in cardiac efficiency which may not be clinically evident. It also has a profound hypotensive effect because of its diuretic, natriuretic, and vascular dilatory properties. As a direct consequence of the increased right heart filling pressure, retrograde engorgement of the paravertebral plexus of veins surrounding the spinal neural elements may occur. Dilation of these valveless veins within an already stenotic spinal canal may induce the symptoms of Vesper's Curse, i.e., sleep-disrupting lumbar pain as a symptom of spinal stenosis in patients with a history of cardiopulmonary disease.

Changes of interleukin-6 and related factors as well as gastric intramucosal pH during colorectal and orthopaedic surgical procedures.

OBJECTIVE: To investigate the changes of perioperative serum levels of interleukin-6 (IL-6), C-reactive protein (CRP), and cortisol, as well as gastric intramucosal pH (pHi) and plasma lactate, aiming to compare systemic changes and tissue perfusion during colorectal and orthopaedic surgical procedures. METHODS: Twenty patients were randomly assigned to two groups, 10 cases of operation on vertebral canal, 10 cases of colorectal radical operation. Venous blood was drawn at 1 day before operation, 2, 4, and 6 hours following skin incision, and 1 day after operation, in order to measure serum IL-6, CRP, and cortisol. pHi and plasma lactate were also measured at the same time points. RESULTS: Serum concentrations of IL-6 and cortisol increased gradually following operation, reaching the peak value at 6 hours from the beginning of operation. CRP was not detectable until the first day after operation. Peak concentration of IL-6 had positive relationship with CRP. These variables changed more significantly in colorectal group than that in orthopaedic group (P < 0.05). pHi decreased gradually, reaching the lowest level at 4 hours from the beginning of operation, and to more extent in colorectal group than that in orthopaedic group (P < 0.05). CONCLUSION: IL-6 may reflect tissue damage more sensitively than CRP. Colorectal surgery might induce systemic disorder to more extent, in terms of immuno-endocrinal aspect as well as tissue perfusion, reflected with pHi.

[Fibrinolytic activity and adhesive syndromes of the lumbar vertebral canal]. / Attività fibrinolitica e sindromi aderenziali del canale vertebrale lombare.

The recent studies, related in medical literature, indicate a reduced activity of fibrinolysis in patients with low back-pain caused by multiple factors (lumbar disc disease, post-laminectomy, post myelography) and suggest a new pathogenetic hypothesis of this disease and new therapeutic implications. The authors conducted a research based on the study of fibrinolysis in patients affected by post-surgical lumbar adhesive syndrome, with the aim of finding, eventually, a relationship between reduced fibrinolytic activity and clinical symptoms. The results are referred and discussed.

Impaired fibrinolytic activity in defined chronic back pain syndromes.

Fibrinolytic activity was studied in 34 patients who had chronic low-back pain of defined types (spondylosis, post-laminectomy and postmyelography-proven arachnoiditis, postlaminectomy and postmyelography-possible arachnoiditis, chronic prolapsed intervertebral disc (PID), spinal stenosis, and nonspecific low-back pain). Fibrinolysis was significantly impaired in the back pain patients as a whole compared with matched controls. Similar changes were observed in all the different back pain syndromes. In the smaller subgroups, these did not reach significance but were significant in spondylosis, proven arachnoiditis, and nonspecific back pain. It is suggested that the abnormal persistence of a defect in fibrinolytic activity, leading to fibrin deposition and chronic inflammation, may be an important factor in the chronicity of many back pain syndromes.