News Category: General Spine

The Pfirrman grading system is used to determine the severity of disc degeneration. This is based on magnetic resonance imaging studies and disc height. It was designed to grade the discs of younger persons, with a mean age of 40 years. Grades one through five can be used for each individual disc graded. The authors of this study felt that an expanded grading system would be more appropriate in grading disc degeneration in the elderly population. The authors sought to study the reliability of an expanded grading system, one with eight rather than five grades.

The study involved analyzing 260 lumbar spine discs in 52 subjects, with a mean age of 73 years. Three radiologist were used to read MRI examinations. Interreader, and intrareader reliability was evaluated to assess if the modified Pfirrman grading system could be useful.

Intervertebral discs consist of the inner portion, the nucleus pulposus, the outer annulus fibrosus, and the cartilage endplates. The nucleus pulposus contains a compounds called proteoglycans. These proteoglycans exert a swelling pressure when combined with water. This helps the disc to cushion the spine. This also gives the disc its height, separating one vertebra from the other. When the disc starts to degenerate,proteoglycans are decreased. This causes the disc to contain less water. The disc height will start to decrease and can be evaluated by imaging such as the MRI. The eight grades of the modified Pfirrman system represent a progression from a normal disc, grade one, to severe disc degeneration, grade eight.

The modified Pfirrman grading system for disc degeneration in the elderly was found to have reliability in this study. It was determined to be easy to understand and use.

This study reports on the long-term results of non-operative treatment for thoracic and lumbar burst fractures of the vertebrae. A burst fracture is caused by a high-energy load down through the spine. The vertebra breaks into tiny pieces. Bone fragments may move into the spinal canal or soft tissues around the spine.

All of the patients included had burst fractures of the thoracic or lumbar spine. Everyone was treated conservatively. No one had any neurologic problems associated with the burst fracture.

Patients were treated with bracing with or without bed rest. This was the standard of care for the patients injured early in the study. With the use of MRIs and CT scans today, some of those patients might have been treated surgically by the current standards.

Results were measured using pain levels, X-rays, function, and work capacity. X-rays showed the disc spaces and disc height as well as the position of the vertebrae. Results were gathered up to 41 years after the injury. This is the longest follow-up on record for spinal burst fractures treated nonoperatively.

Almost half of the patients (45 per cent) reported excellent results. They did not have any back pain or disability. One-third (33 per cent) had mild pain. Slightly more than 10 per cent had moderate pain. Another 11 per cent had severe pain with loss of function.

The authors concluded that patients with burst fractures do not have more back pain than adults of the same age who did not have a fracture. Conservative care for burst fractures of the spine in patients without neurologic problems is successful.

This holds true even years later and for patients whose discs were damaged at the time of the initial injury. Some patients may want to have surgery for faster pain relief and recovery. They may be able to return to work sooner with less short-term loss of function and income. But in the end (long-term), the results are the same.

A recent study reported 2.4 billion work days were lost to physical problems causing disability. Another 1.3 billion days were lost to mental disorders. The survey showed that of all the conditions possible, neck and back pain were the most common causes of lost productivity.

Not all neck and back problems were the direct result of a true physical problem. Social factors, beliefs, and psychologic factors were also an important part of these conditions.

Workers were asked about days missed from work due to cancer, heart disease, diabetes, arthritis, and other mental and physical disorders. Over half responded that one or more of these problems kept them from work. On average, at least 30 disability days for each worker per year were reported.

Musculoskeletal problems, especially neck and back problems were at the top of the list. Many of the people had other problems as well. These are referred to as comorbidities. Comorbid illnesses are common among workers who lose work time due to disability.

The authors concluded that more money should be spent on research to reduce and/or eliminate neck and back problems. At the same time, other disabling conditions should be taken into account. A big picture view of human discomfort leading to work disability is important when planning future allocation of research funding and focus.

Schwannomas, benign (not cancerous) tumors that affect the peripheral nerves, make up about 10 percent of cases of soft tissue tumors. Their correct diagnosis is important because schwannomas can be mistaken for malignant (cancerous) peripheral nerve sheath tumors. The malignant tumors require that a surgeon remove considerably more tissue when removing them (a wide resection), than does surgery for a schwannoma.

Researchers have found an indicator that may suggest a schwannoma, called a target sign. However, the target sign is also sometimes seen of the malignant tumors.

The authors of this study wanted to see if findings from under the microscope would be backed up with findings from imaging studies, such as magnetic resonance imaging (MRI). The researchers studied the records of 199 schwannomas in 177 patients (76 males), aged between six to 84 years. Eighteen of the patients had several tumors; 59 tumors were in the arms, 94 tumors in the legs, 30 tumors in the trunk, and 16 in other locations. One hundred four were located in the between muscles (intermuscular, 61 in the muscle (intramuscular), 18 beneath the skin (subcutaneous), and 16 elsewhere. These patients were compared with 782 patients who had other soft tumor removed (control group). All patients in the study group, except for 6, had marginal, or limited, resection of the schwannomas. The six other patients had a wide resection because their surgeons suspected that the patients may have a malignant tumor.

Records showed that MRI was performed for all patients, enhanced computed tomography imaging, or CT scans, were performed in 74 cases, and ultrasound in 32.

Upon reviewing the imaging tests and the macroscopic findings, the researchers found that typical schwannomas showed a biphasic (2-sided) pattern that was similar to what the researchers found on the imaging. Of the schwannomas, 162 showed “a biphasic pattern of a central yellowish fibrous area and a peripheral myxoid [mucus-like] area.”

The researchers report that they were able to define the target sign by MRI as a distinct mass that corresponded with the biphasic pattern. With this, they believe that this is useful in helping diagnose the presence of a schwannoma.

The study did have some weaknesses, the researchers pointed out. A proportion (11 percent) of the cases were excluded because MRI was not available nor were the researchers able to obtain follow-up clinical data.

There is a problem getting enough bone graft material for some operations. Major reconstructive spine surgery is increasing in the older adult groups. The need for sufficient bone graft has led researchers to look for suitable substitute materials.

In this article, calcium phosphate products used to replace bone graft in spine surgery are reviewed and compared. Calcium phosphate has been used in the past as a cement and a ceramic in bone surgery. It has the ability to stimulate bone growth.

There are many forms of calcium phosphate. Different structures, uses, and biodegradability are reported for various compounds. Studies are being done to find ways to inject blood cells into the calcium phosphate. This could help more bone cells to grow.

The authors report that beta-tricalcium phosphate has a good record as a bone substitute. Its porous surface promotes bone ingrowth. It can be used as a bone extender when large amounts of bone graft is needed for such as for spine surgery.

There aren’t enough studies yet to draw firm conclusions about other types of calcium phosphate products. Surgeons are encouraged to stay abreast of the various products available. Characteristics of bone substitutes and outcomes should be examined carefully when using these products.

Complex and involved operations to fuse the spine place the patient under anesthesia for a long time. In this study, surgeons explore the option of doing a staged (two-part) operation.

The goal is to reduce the risk of complications from too much anesthesia. The biggest risk of this procedure is blindness. Staying in a prone (face down) position required for spinal fusion for more than six hours has been linked with this and other complications.

In the first stage, headless pedicle screws or K-wire placeholders were inserted. The placeholders keep the pathway open for screw insertion, which is done in stage two. Stage one was done using interventional radiology (IR). This means imaging is used to guide the surgeon as the hardware is inserted under the skin without an open incision.

The second stage was done at least a week later. This stage was open surgery with an incision through the skin and soft tissues over the spine. K-wires were removed and the hole for the screw was made larger. Pedicle screws and rods were placed to complete the fusion.

Steps involved in both stages were described in detail. Some parts of the procedure changed over the course of the study. This was because the techniques evolved and improved. The authors identified the slight changes in methods as Sequence one and Sequence two.

The results of this study showed that this new approach is possible without risking patient safety. Accuracy of wire and screw placement was between 96 and 100 per cent. There was one case of infection and no other serious complications.

It’s not clear yet what all the advantages may be of a staged procedure for spinal fusion. The length of time under anesthesia for two operations may be more than if the entire procedure was done at one time. But the time for each individual operation will be less than six hours.

There may be other advantages of performing spinal fusion in two separate sections. Less exposure to radiation is a benefit for both the patient and the hospital staff. The surgeon may have greater accuracy in placing the screws with a staged procedure. There may be some cost savings with decreased operating room time.

The authors will continue studying this method to better understand all the risks and advantages. Further reports are forthcoming. For now, they strongly advise the use of imaging radiology when placing screws or K-wire fragments. Close communication is needed between the surgeon and the radiologist for accurate placement of these devices.

Degenerative scoliosis (curvature of the spine) in older adults affects the lumbar spine. Surgery to fuse the spine may be needed. Complications are a major problem in this age group after surgery for adult degenerative scoliosis.

In this study, researchers from Korea report on early and late complications of this treatment. Early problems were defined as anything occurring within the first three months after surgery. Patients were followed for at least two years for later complications.

Early complications can include blood clots, infection, and a paralyzed bowel. Some patients also experience nerve damage or problems breathing shortly after surgery.

Later, screw loosening and failure of the fusion may be reported. Other late complications include pseudoarthrosis (movement at the fusion site) and degeneration at the next vertebral level.

In this group of 47 patients, the overall complication rate was 68 per cent. Older patients (65 years old and older) were more likely to have early complications. Men and women were affected equally. Patients with other problems such as heart disease, diabetes, or high blood pressure were more likely to have problems early on.

Blood loss during the operation was the biggest risk factor for early complications. Fusion at more than five levels also increased the risk of early problems. These two risk factors are linked as blood loss increases with an increased number of levels fused.

The only risk factor the authors could identify for late complications was severity of the scoliosis. Poor improvement was seen most often in patients with the greatest imbalance of the normal spinal curvature. Having early complications did not increase the risk of problems developing later.

One way to find out what treatment works best for a condition is to perform a systematic review of the literature. To do this, researchers use computer searches to find published studies on specific topics.

In this article, the results of a systematic review for nonsurgical treatment of adult scoliosis was reported. Two physicians from the University of Rochester School of Medicine in Rochester, New York conducted the search. They used three main health care, nursing, and allied health databases.

The subject was confined to adults with spinal deformity from degenerative scoliosis. Nonoperative treatment that was reviewed included bracing or casting, physical therapy, chiropractic care, and steroid or epidural injections.

The authors give a report after a careful search and analysis. They say that none of these conservative methods was effective or more effective than any other treatment approach. Most of the evidence was based on very small case reports or expert opinion.

In some studies, the results showed good improvement but too much information was left out of the article to consider the data valid or reliable.

In other cases, treatment did not show any long-term carry over of improvement, but no mention was made of whether or not the patients followed through with the program required. Overall, the studies showed very weak evidence that conservative care for adult scoliosis is effective.

It appears that doctors must make their own decisions in this area. And they must do so without the benefit of guidelines backed by research. Clinical research is needed to help sort out the best approach to conservative care for adults with degenerative scoliosis or other deformity.

Not everyone needs surgery for a herniated disc. People who are able to cope with the pain may be able to hold on until the condition gets better. But for those who can’t wait for the slow improvement, surgery is a sensible choice.

Sometimes the decision is made based on the patient’s needs. For example, if physical activity or work is affected too much, surgery may be very valuable. But more and more studies are showing that if a patient can wait it out, their symptoms will gradually get better and go away. It may take three to six months. But the natural course of herniated disc is one of slow recovery.

In fact, spine surgeons are finding that one-year after the start of painful symptoms, patients have the same result whether they have surgery or opt for nonsurgical care. Up until the late 1990s, the rate of disc surgery was the highest it’s ever been. Since then, the guidelines have changed.

The timing for disc surgery is now suggested only for patients with severe sciatica. This is especially true for those who have not gotten relief from symptoms after six months or more. Microdiscectomy can still be done after months of severe, disabling back and leg pain. Patients who delay surgery have just as good of results. This is the case when compared to patients who have surgery within the first two weeks of symptoms.

The bottom-line is that the window of opportunity for surgical intervention is much more wide open than previously believed. The results of studies suggest that patients should be given enough information to make informed decisions about treatment. Severity of symptoms, patient values and expectations, and personal circumstances will guide those decisions.

Calcium crystal deposits are common problems in joint cartilage and synovial fluid. Not much is known about similar deposits in the intervertebral discs. The discs are fluid-filled pads between the vertebrae (bones of the spine).

In this study, disc material removed from 208 patients with disc disease were examined under microscope. The researchers looked for crystal deposits. They counted how many times they found crystal deposits. This is called the incidence. They also studied each component in the disc specimen.

The presence of calcium crystals is important. They can disrupt the natural flow of cells, enzymes, and fluid within any structure, including the discs. Crystals in the disc speed up any degenerative process already going on.

The results of this study showed about a 15 per cent incidence of crystals. The authors report the crystals were all sizes and shapes with various other features. Some crystals looked like scratches on glass. Others were needle- or star-shaped.

The crystals were not unusual in any way. The scientists did see that the more degeneration there was in the disc, the fewer crystal deposits were present. This is called an inverse relationship.

It appears that crystal deposits occur in the discs at about the same rate as occurs in joint fluid and cartilage. The process seems to be age-related and occurs more often after age 60. Crystals may be linked to disc tears and herniation. Future studies to understand how the crystals form may help prevent disc degeneration.

It used to be when someone was experiencing chronic lower back pain, they were told to rest in bed until they felt better. This chronic lower back pain occurs in up to 10 percent of people who have an acute (sudden) non-specific lower back pain. Doctors noticed, however, that patients who stayed in bed could end up with other problems because of their inactivity. This is particularly important among the elderly. Disuse of the muscles could lead to weight gain and obesity, decreased muscle strength and decreased heart function.

The researchers in this study looked at 3 separate issues regarding disuse and chronic lower back pain: 1) the development of disuse within 1 year of the onset of back pain, 2) the development of physical deconditioning within 1 year of onset of back pain, and 3) which factors may predict a change in physical activity in daily life (PAL) over the year.

One hundred twenty four patients who had acute back pain for between 4 and 7 weeks were followed for 1 year. One hundred six patients (58 males) completed the study; the average age was 46.7 years, with a range between 35.6 and 51.9 years. The researchers used the Visual Analog Scale (VAS) for rating pain, the Pain Catastrophizing Scale (PCS) for psychological concerns about further pain, the Tampa scale for kinesiophobia (TSK) for fear of movement and reinjury, and PAL was measured using a device that recorded body movements. This device was worn by the patients during the waking hours for 7 uninterrupted days.

After 1 year, 67.9 percent of the patients still complained of back pain. They were classified as “patients with CLBP.” The other patients were classified as “recovered subjects.” When the study started, the average level of pain intensity reported by patients with CLBP was 41 and at follow up it was 26.5 TSK was 35 at study start and 32.6 at follow up. PCS was 17 at study start, 9 at follow up. PAL was 8.4 at study start, and 8.5 at follow up. For the recovered patients, average pain intensity at study start was 31, 0 at follow up. TSK at study start was 34, 31 at follow up. PCS at study start was 14, 8 at follow up. PAL at study start was 8.4, 8.3 at follow up.

The researchers noted that there was no difference in PAL between the patients who recovered and those who did not, so their original premise that patients with back pain would have lower levels of daily physical activity was wrong. Taking the findings into account, the authors pointed out that it should not be recommended to use a patient’s level of activity to determine treatment for chronic lower back pain because they could maintain the equivalent of activity to someone without pain. They concluded that there is no evidence so far that shows that patients with chronic lower back pain will suffer from disuse.

The treatment of chronic neck and back pain remains a challenge. Very few treatment methods have been effective. Neuroreflexotherapy (NRT) is one of those treatments that has been proven helpful.

NRT therapy is the implantation of surgical staples in trigger points. Trigger points are hyperirritable spots within muscles that can cause chronic pain. In this study, researchers from Spain report on the results of NRT with over 1,500 patients.

The goal of the study was to find factors that might predict who can benefit from NRT and the results of treatment. Although this treatment method has been proven effective, it is not used outside of Spain yet. And even within the Spanish National Health Service, its use is spreading very slowly. The authors suggest this is because NRT has been financed by public and nonprofit organizations.

Based on studies showing the success of NRT, it has been used in Spain since December 2003. NRT is used with anyone with neck or back pain lasting more than 14 days. Results were based on pain levels and disability before and after treatment. Everyone was rechecked at six and 12 weeks after the implants were put in place.

Treatment failure was defined as being no better or worse than before treatment. Failure rates were about 10 per cent for local pain and 14.5 per cent for disability. Most of the patients reported improvement and were satisfied with the treatment.

Patients who had longer pain duration or shorter time with implants in place had the worst results. Patients with neck pain seemed to respond better to NRT compared to patients with middle-to-lower back pain. Patients with the most severe symptoms had the most improvement.

Based on the results of this study the authors suggest that early referral has the best results with NRT. Predicting success was easier than predicting failure. Factors linked with worse prognosis can be used to help rank patients for treatment. But predicting who won’t benefit isn’t possible yet.

Osteoporosis, thinning of the bone, is a serious disorder because it can lead to fractures, particularly in the spine. The risk of osteoporosis and fractures increase with age. Bone mass peaks in a person between 20 and 30 years old and then it begins to decrease. Vertebral bones, or bones in the spine, deteriorate more quickly than the rest of the body’s bones. Women develop osteoporosis more than do men and as they age, their risk of vertebra fractures rises and, considering the growing population and the longer people are living, the incidence of the fractures could multiply by four in the near future.

Another risk is that of having another fracture after already having one. Studies have shown that a woman who has a vertebral fracture has a four to seven times higher risk of having another fracture within six to 18 months, compared with women who haven’t had any fractures. Add to this the discomfort and pain that are caused by the fractures, this can severely impact a person’s daily activities and quality of life.

While most people can manage the pain with opioids, controlled medications like morphine, some people are unable to take them because of side effects, or they shouldn’t take them because of other health problems. Twenty percent of patients who take opioids experience side effects like vomiting, nausea or dizziness.

In this study, researchers wanted to know the effects of intrathecal opioid medications delivered directly to the spine by pump to oral (by mouth) medications. The medication was injected slowly over a long period of time directly to the spine where the pain is concentrated. The researchers treated 19 women and five men who were, on average 74 years old. The patients all had advanced osteoporosis and a history of taking oral and/or transdermal (patch on the skin) medications, and severe side effects or drug addiction.

At the start of the study, the patients underwent a magnetic resonance imaging (MRI) scan so the researchers could see the damage to the vertebrae. The patients were asked to complete two questionnaires: the Visual analog scale (VAS) and the Quality of Life Questionnaire of the European Foundation of Osteoporosis (QUALEFFO). The questionnaires measured their pain levels (VAS) and their ability to manage every day life (QUALEFFO).

The trial started slowly. Patients who were still taking morphine by mouth had their dose cut in half. All the patients were hospitalized for the first three days of the trial. The first dose of intrathecal morphine was a low dose for the first day. The medication, given through a catheter inserted into the spinal area, was increased slowly as the oral morphine was gradually lowered. The right dosage for each patient was reached when the patient reported that their VAS had dropped by half.

Six days after the trial began, the patients returned for the first follow-up. Side effects were treated with the appropriate medication. During the trial five patients complained of vomiting and three complained of itching. When the pump was used alone, only three patients complained of nausea. One patient developed an infection where the catheter was inserted, two had their catheters dislodged. The researchers found that after one year of intrathecal morphine, the patients’ VAS dropped around five point, from about 8.7 to 3.6. Their functional scores dropped from about 114.7 to 92.1. What was also noticed was that none of the patients needed any additional pain medication.

The authors conclude that while many patients respond well to oral morphine, there are many who cannot tolerate it or cannot take it. Because chronic pain can have such a significant impact on the quality of life, other methods of pain relief must be found. Using morphine intrathecally seems to reduce the side effects quite a bit. The authors say that by introducing the morphine increases very gradually, the risk of side effects drops. They feel that this use of morphine should be offered as another method of pain control in this population.

Treating cancer patients can be a very complex process. They are often seeing multiple physicians who view things differently. In this article, a new model is proposed to help doctors plan treatment for patients with cancer. In particular, the cancer has metastasized (spread) to the cervical spine (neck).

The NOMS model considers four areas: neurologic, oncologic, mechanical, and systemic disease. Most cancer patients of this type are seen by a surgeon, radiation oncologist, and medical oncologist. If every specialist treating the patient uses this model, it may be easier to see what is the best treatment choice for each patient.

For example, a patient with lung cancer has severe neck pain. MRIs show the cancer has spread to the cervical spine. There is a fracture of one vertebrae and the bone has slipped forward. The traction from the movement of the bone pulls on the spinal cord. This causes pressure on the spinal cord.

Using the NOMS model, the patient is assessed as follows:

In this review article, the history and development of bone grafting is presented. Spinal fusion requires the use of bone graft material. Usually bone is taken from the patient’s own pelvic bone. This is called an iliac crest autograft. This type of bone graft material has been done since 1911. It remains the preferred choice or gold standard for posterior spinal fusions.

In 1965, scientists discovered bone morphogenetic proteins (BMPs). Studies now show that BMPs can help bone growth and fusion just as well as iliac crest autografts. Research has been able to identify three ways the biology of bone works.

First is osteoconduction. This refers to the way bone graft material builds a scaffold. This scaffold is the framework for bone to fill in around the area in need of new bone growth for bone fusion. Donor bone from cadavers, coral, and ceramics are examples of osteoconductive materials.

Allograft is the most common osteoconductive material. The bone is taken from a cadaver (donor after death). It works best when used as a graft extender. For example, the surgeon may take a damaged or diseased vertebral bone out of the spine. It is replaced with a titanium cage. The patient’s bone is crushed and put back inside the mesh cage. Allograft materials are then placed around the fusion site for its osteoconductive abilities.

The second type of cell that helps bone growth is called osteopromotive. These materials don’t build a scaffold. Instead, they have several growth factors that help enhance the fusion process once it’s already started. Studies have shown that osteopromotive substances don’t help spinal fusion and may even inhibit fusion.

The third bone-making process is called osteoinduction. This refers to the fact that some materials can actually cause new bone to form where bone doesn’t already exist. Autograft bone and the new BMPs fall into this category. Studies show the best fusion results occur when combining autografts with BMPs. Together, these materials give a 97 per cent fusion rate in the spine.

Research is ongoing to find better ways to use BMPs. The authors predict that it’s only a matter of time before BMPs replace autografts as the gold standard in spinal fusions. There’s less blood loss, shorter time in the operating room, and no pain or problems at the graft site.

The standard of care for early onset of neck and back pain is advice to stay active. In this report, researchers in Sweden compare this standard of care with naprapathic care for neck and back pain.

Naprapathic uses manual therapy such as joint mobilization and manipulation, massage, and stretching. The goal is to treat the muscular and skeletal systems. The focus is on shortened tissues around the spine and joints causing pain and disability.

Two groups of patients were compared. The first (Index) group received six naprapathic treatments over a period of six weeks. Advice on physical activity, prevention, and ergonomics was also given to these patients. Ergonomics is a way to reduce fatigue and improve work performance. This is done by improving the design of the workplace.

The second group was the control group. They were given advice based on studies. The studies were evidence-based also known as best practice. The care and support offered was to empower the patient. Understanding the importance of keeping active and living as normally as possible at work and play is the strategy. Advice on exercises and general information for pain control and coping were added.

Pain and disability were used as the main measures of results. The patients were also asked to rate their perceived recovery (better, much better, worse, much worse, same). The authors report that the Index group improved the most in all areas.

After 12 weeks, more patients in the Index group said they were very much improved compared to the control group. Patients in the control group did improve, just not as much. Decrease in pain and improved function were still present in the Index group at the end of the follow-up period.

The authors suggest that combined manual therapy made it possible for patients in the Index group to do more physical activity. They conclude that naprapathic care for back and neck pain improves the success rate of recovery. Naprapathic may be an acceptable option for treatment for people with this type of problem.

Keeping up with the latest developments in pain management can be a challenge. The American Society of Interventional Pain Physicians (ASIPP) helps doctors with this. Every two years, a committee updates the ASIPP guidelines. The focus is on the evaluation and management of chronic pain.

The committee recently released the 2007 updated guidelines. They review studies on every type of treatment for pain relief. They compiled the evidence for treatment that gives short-term, moderate, and long-term pain relief.

In this most recent update, the task force reviewed all of the minimally invasive (MI) spinal procedures. These experts offered current and helpful recommendations based on the limited data.

There was no change or improvement in the use of spinal (facet) joint injections. Likewise, there was nothing new to suggest for the use of radiofrequency neurotomy or intradiscal electrothermal therapy (IDET). And there were no updates regarding the use of percutaneous disc decompression, spinal cord stimulation, and intrathecal implants for pain control.

But even reporting that there’s no new evidence about a procedure can be helpful. Doctors using these techniques are reassured that they are on the right track in patient care.

The work of the committee also helps point out areas where further research is needed. There is a need for more studies using fluoroscopy to administer epidural injections. Fluoroscopy is a type of X-ray imaging that allows the surgeon to see inside the spine to guide the needle to the right spot.

Doctors hope for more studies on the treatment of chronic sacroiliac pain, intradiscal therapies, and newer percutaneous disc decompression. Guidelines offered based on limited evidence should be approached with caution.

The documents can be viewed on-line at www.guideline.gov. Type in: ASIPP in the search window.

The National Cancer Data Base keeps records from over 1,400 cancer program registries in the United States. The data base sends out regular reports on the most common cancers, but not so often on the less frequently occurring cancers. Because the care of patients with these cancers such as osteosarcoma (cancer of the bone), chondrosarcoma (cancer of the cartilage), and Ewing’s sarcoma (bone cancer usually found in the long bones) is changing, it is important to have reports of these types of tumors as well.

In this report, the authors identified the epidemiology (patterns and causes) and survival data of the three cancers. They searched the database and found that 35,265 bone or joint cancers were reported from 1,656 hospitals over a 19-year period. Of these, the researchers found that 26,437 cases fit into one of the three cancers: osteosarcoma (11,9961), chondrosarcoma (9,606), and Ewing’s sarcoma (4,870). They noted that the cancers increased in incidence over the 19 years. There were 697 cases of sarcoma reported in 1985 and 1,796 in 1997.

When looking at the epidemiology, more males than females were diagnosed with any of the three sarcomas, with Ewing’s sarcoma being the one with the highest difference: six males to every four females. Half of all patients with Ewing’s sarcoma (50 percent) and almost as many with osteosarcoma (40 percent) were children between 10 and 19 years old. Chondrosarcoma was most common among patients over 40 years old.

Most tumor sites were in the long bones in the leg, particularly for osteosarcoma and Ewing’s sarcoma. Staging information was recorded for some patients; the most common was stage I for chondrosarcoma, stage II for osteosarcoma and Ewing’s sarcoma.

The researchers looked at the treatments given to the patients, which varied considerably even within the same type of cancer. For chondrosarcoma, 69 percent of patients underwent surgery only, while for Ewing’s sarcoma, 24 percent received surgery and chemotherapy, and 23 percent received chemotherapy and radiotherapy. Eighteen percent had chemotherapy alone and 15 percent had a combination of all three. Only 46 percent of patients with osteosarcoma underwent surgery and chemotherapy combined.

Finally, when looking at the survival data, the researchers found that survival data were only available for a five-year period, between 1985 and 1998. The relative survival rate for osteosarcoma was 53.9 percent, for chondrosarcoma 75.2 percent, and for Ewing’s sarcoma 50.6 percent.

The authors hope this study will encourage continuation of this data collection.

Schwannomatosis is a new classification of disorders in the neurofibromatosis disorder. Neurofibromatosis affects the nerve cells and can cause tumors to grow on the nerves. It can also cause deformities of the skin and bones. A schwannoma is a benign (not cancerous) tumor that grows from beneath the nerve sheath (covering). Schwannomatosis is a disorder with many schwannomas that can appear on any nerve on the body except for the vestibular nerve, or the nerve that controls balance. The tumors are painless but as they grow, they can press on the nerves and cause pain.

In this article, the authors describe four patients with schwannomatosis, reviewing their symptoms and treatment. The first patient, patient 1, was a 31-year-old man who had a history of tumors on the nerve sheath. He came in with a progressively growing large mass on the left forearm and masses on both sides of the neck. The doctors also found that the patient had a tumor compressing his spinal cord, as well as a fww others in the arm that were only visible through magnetic resonance imaging (MRI). The second patient, patient 2, was a 37-year-old woman and patient 1’s sister. She had already had several surgeries to remove schwannomas from her arms and legs. This time, she came in because she was not able to walk after experiencing lower leg pain and weakness in both legs for the past month, and she had had loss of bladder control. The doctors found a large mass behind her right knee and one in her back that was pressing on the spinal nerves.

The third patient, patient 3, was a 44-year-old man who complained of increasing numbness, tingling, and pain in both hands and feet, and he had been unsteady on his feet for the past year. He also had a history of having tumors removed, as well as cancer of the rectum. Finally, the last patient, patient 4, was a 55-year-old man who complained of gradually increasing dizziness, hearing loss, and tinnitus (ringing in the ears). Thirty-five years earlier, he had had a schwannoma removed from his right cheek.

All four patients were treated with surgery, but patient 2 had to receive medication to reduce the swelling as well. All four patients recovered. Patient 1 did not have all the tumors removed and will have more treatment as they begin to cause symptoms. Patient 2 was able to walk again after surgery but was left with a bit of difficulty. The numbness and tingling remained in patient 3, and patient 4’s outcome wasn’t reported. The generally accepted treatment for schwannomas is surgery, but only if the tumors are causing problems.

The authors discussed the patients’ outcomes, stating that the removal of the tumors were successful and that none of the patients had worsened after the surgeries. After the schwannomas were tested, the patients were all diagnosed with schwannomatosis. This was important to note because the presence of multiple schwannomas does not immediately indicate a diagnosis of schwannomatosis.

Vertebral compression fractures, or VTF, are fairly common among older people and they can be very painful, leading to difficulty moving around. People who have VTF can see a significant decline in their health and it can lead to death. VTF are most often caused by osteoporosis, thinning of the bones, or some sort of trauma. The usual way of treating VTF is through conventional treatments such as bed rest, pain medications, bisphosphonates (medications that strengthen the bone), or back bracing. However, for many people, this doesn’t provide enough relief or slow down the progression.

This nonrandomized study investigated the outcomes of 21 patients with painful VTF that hadn’t responded to conservative treatment. The investigators wanted to compare the outcomes of patients who underwent vertebroplasty (PV) with those who had balloon kyphoplasty (KP). Both procedures strengthen the bone through an injection of a cement compound into the area that has fractured. KP is a technique that resulted from modifying PV. With KP, a balloon is inserted within the collapsed area before the cement compound is injected. The advantage is the lower incidence of leakage.

All patients in the study, men and women, had fractures for six months or fewer. Their level of pain was measured by Visual Analog Scale before the procedure at one and 48 hours after the procedure, and again at one, three, and six months after. Functional improvement was measured by Oswestry Disability Index (ODI) before the procedure and six months after. The authors also looked for complications.

After analyzing the patients’ results, the researchers found that the pain scores before the procedures significantly dropped after the procedures. Before, all patients reported an average score of 8.6 out of 10 for pain. After the procedure, the pain scores were down to an average of 0.55 in the KP group and 0.70 in the PV group. Results were similar in functional improvement. Before the procedure, the PV group had an average of 74 percent disability and the KP group, 77 percent. After the procedure, the PV group had an average of 24 percent disability and the KP group, 23 percent.

Leakage of the cement compound happened five times in patients who underwent PV, but no symptoms resulted. There were no neurological problems reported in any patient in either group.

The authors concluded that although the reason for the pain relief from these procedures isn’t clearly understood yet, they are effective treatments for patients with VTF. The significantly reduce the level of pain and improve the functional ability. The researchers point out that the procedures should be done early in the course of the disease before too much structural damage has occurred.