News Category: General Spine

The authors present the first case report of Castleman disease with a unique presentation. A large tumor grew alongside the spine through the neural foramen (opening for nerves and blood vessels). It was located in the thoracic spine. MRI and clinic results led doctors to think it was a nerve sheath tumor.

Castleman disease is named after Dr. Castleman who first described the condition in 1956. It is a rare type of tumor made up of plasma cells in the lymph fluid from the immune system. The cause is unknown. Very rarely (only 13 cases have ever been reported), Castleman disease affects the central nervous system. Only four cases of the spine have ever been reported.

In this case, a 19-year old woman went to the doctor because of a cough, nausea, and vomiting. Chest X-ray showed a large mass along the right side of her spine. MRI pinpointed it at the T7-8 level extending into the neural foramen on the right side.

Surgery to remove the tumor was done. A small piece of tissue was taken for pathologic exam. That’s when they found out what it was. They were unable to remove it, so she had radiation treatment instead. Radiotherapy was successful. One year later, the patient was symptom- and tumor free.

With more and more people having spine surgery, the number of cases of wound infection has also increased. In this report, surgeons from St. Louis University tell about their experience using vacuum-assisted closure (VAC) to treat wound infections.

VAC consists of a spongy foam dressing cut into the shape of the wound and placed directly over the opening. The dressing must make firm and even contact with the entire wound surface. Part of the VAC system is a pump that is used to remove fluid and debris from the wound site. A drain tube is inserted through the foam dressing into the wound. Any excess fluid or wound debris is taken out through the tube.

Eleven patients who had posterior spinal surgery and developed a wound infection were included in the review. All were treated with antibiotics until the wounds were healed. Before applying the VAC, the infected and necrotic (dead) tissue was removed. The wound site was irrigated (cleaned out) with saline (salt solution).

A wound VAC was placed on the open wound and changed every 48 hours. VAC therapy continued until the wound closed. This took anywhere from two to five weeks. Ten of the 11 patients had complete healing. One patient did not return for follow-up.

Preventing infections is an important goal after spinal surgery. The surgeon must assess patient and operative risk factors before doing the operation. If an infection does occur, a quick response is needed to avoid having to remove the hardware used to help fuse the spine.

The VAC system removes bacteria and keeps new bacteria from entering the wound. Removing excess fluid helps improve circulation for faster healing. Other studies show that VAC helps decrease the size of the wound making healing more likely.

Infection after spinal surgery is fairly common. A new treatment for deep infections of the spine is discussed in this study. This treatment is called vacuum-assisted closure (VAC). It is a negative pressure dressing with a special suction device to remove drainage.

Sixteen patients with spinal wound infections were treated with VAC at the Cleveland Spine Clinic in Ohio. They all received intravenous antibiotic therapy as well. Thirteen of the patients were followed for at least three months. The VAC device was used anywhere from 90 days up to two years.

The results of individual cases are presented. Patients ranged in age from 14 to 76 years old. Spine surgery was done to correct a deformity from scoliosis in a young woman and for degenerative scoliosis in an older woman. One man had kidney cancer that had spread to his spine. Another middle-aged man had infections of the disc (discitis) and vertebral bones (osteomyelitis).

The authors report their study was too small in number and too short of a follow-up time to present the effectiveness of VAC. There were some complications from blood loss in their patients. One patient developed problems from a piece of packing strip from the dressing. It was left inside the wound after the VAC was removed.

VAC has been used with success in other operations such as heart, orthopedic, and plastic surgeries. The authors suggest that the VAC system should be used with caution in spinal wound infections. There are risks of bleeding with VAC. Failure of the wound to close may require additional surgery. It can also be a fatal complication of VAC.

Are obese patients at increased risk for complications during and after spine surgery? In this study, 86 cases of elective thoracic and lumbar spine fusions in obese patients were examined for such problems.

The same surgeon operated on all the patients. All complications (small or large) were included. Examples include wound infection, blood clots, heart attacks or strokes, and pneumonia. Nerve pain or nerve palsy was also included.

Anything that delayed recovery or added time to the hospital stay was also counted as a complication. All problems that occurred in the first 30 days of surgery were included.

The researchers looked to see which factors might be important. Age, sex, height, weight, and body mass index (BMI) were assessed. The presence or absence of diabetes and high blood pressure were also considered. And the number of spinal segments fused (one or more) and type of fusion performed were factored in.

The results showed an overall complication rate of about 37 per cent. At least one in every three patients had a problem. Almost half the patients had high blood pressure but this did not seem to increase their risk of problems. Problems were more likely to occur in older patients.

The higher the BMI, the greater the risk of problems. Very obese patients were also at risk for nerve palsies. Staying in one position too long with the pressure of body weight on the nerve caused the problem.

The authors offer two conclusions from this study. First, obesity should be considered a risk factor when planning spine surgery. And second, care should be taken with very obese patients to limit the amount of time in one position. Support and padding for the arms and legs may help. These steps may help prevent position-related nerve palsies.

Tuberculosis (TB) is most commonly known as a lung disease. But the bones can be affected, too, a condition called osseous or skeletal TB. The number of people with TB has increased in the last 10 years. HIV positive patients have the highest incidence of skeletal TB now.

The authors of this study suspected spinal TB might be present at more than one spinal level. And they suggested there might be multiple skip lesions. In other words, the vertebrae aren’t all affected in a row. There might be one or two vertebrae with TB then one or more unaffected vertebrae before another vertebrae is diseased.

They suggested routine whole spine MRI would show the true incidence of this problem. To test out this theory, they did had whole spine MRIs on all patients with acute spinal infections. The study was carried out for five years.

Nearly three-fourths of the patients tested (71.4 per cent) were positive for multiple level spinal TB. Many of the patients had no symptoms at the additional sites of disease.

The results of this study were dramatic. Previous reports of multiple level spinal TB suggested a one to 10 per cent incidence. Using whole body MRI shows that the problem is much greater than previously thought. Any part of the spine can be affected.

The authors suggest whole body MRI for all patients suspected of having a spine infection. Early detection is the key to reducing other problems cause by this infection.

Patients with chronic neck or back pain try many different treatments in an effort to reduce pain. When nerve damage is part of the problem, pain relief is even more complex. Treatment with prescription drugs is less than satisfactory. Two-thirds of all patients don’t get even moderate pain relief.

Surgery to heat the nerve tissue and cut off painful signals to the brain doesn’t work either. According to recent studies, the patient can end up with more pain as the nervous system finds ways around the nerve that was destroyed.

In this editorial, Dr. T. S. Jensen from the Department of Neurology and Pain Research Center in Denmark offers a review of studies done and an opinion of a new treatment. The new treatment proposed for chronic pain is called pulsed radiofrequency (PRF).

PRF delivers short lasting pulses of electrical currents. The voltage is high enough to be in the radiofrequency range. PRF heats (but does not destroy) the nerve tissue. This fact makes it a non-destructive procedure. How it works to reduce pain remains unknown at this time.

Dr. Jensen reports that early studies show good short-term results of PRF. He offers the opinion that there isn’t enough evidence (yet) to use PRF routinely for chronic neck pain. Further research is needed to find out the best way to use PRF and how it works.

Neurologic symptoms can occur within hours of spinal surgery. They are usually a sign of an epidural hematoma. A hematoma is a collection or pool of blood contained within a small space. The epidural space is inside the spinal canal between the vertebral bone and the spinal cord.

Hematomas are caused by internal bleeding. The area inside the spinal canal is small enough that any extra fluid puts pressure on the spinal cord or spinal nerves. The result can be severe neurologic problems.

Delayed epidural hematoma after spinal surgery can occur but is very rare. In this report, four cases are reviewed. Similar neurologic symptoms as in an acute case were present days to weeks later.

Risk factors for delayed epidural hematoma may include older age and previous spinal surgery. The use of nonsteroidal antiinflammatory drugs (NSAIDs) can also lead to blood loss during the operation.

Surgeons are advised to be aware that a delayed epidural hematoma after spinal surgery is possible. Severe pain or neurologic signs and symptoms days to weeks later should be evaluated right away. Surgery to take pressure off the neural tissue is important.

When cancer spreads or metastasizes to the spine, fracture can occur. The vertebral bone collapses. Pain and neurologic problems often develop. The best treatment for these problems is still being studied.

The fractured vertebra can be repaired with cement injected into the center. But how much cement should be used? Should the tumor be removed first? How much tumor should be taken out?

In this study, researchers used a 3-D computer model of the lumbar spine to try different amounts of tumor removal and cement. Results of an earlier study using cadaver models provided some baseline information for the computer model.

Twelve different methods of tumor ablation (removal with laser) were used. In some cases, 30 per cent of the tumor was removed. In other models, up to 60 per cent was taken out. Three measures of cement volume were tested with each of the tumor volumes. The model tested the sensitivity of fracture risk for each tumor and cement volume.

The results of this study made it possible to develop guidelines for cement fill in patients with spinal metastases. The goals are to control pain and restore vertebral stability. Tumor removal is done first. The amount of cement injected depends on how much tumor is still left — not the size of the hole where the tumor was.

The authors warn against over filling the vertebra. The metastatic disease can affect adjacent bones. If the fractured vertebra is too stiff from the cement, the next bone may be at increased risk of fracture. When properly applied, full restoration of spine stability is possible with this treatment.

Surgeons from The Boston Spine Group and Thomas Jefferson University reviewed 200 articles on the treatment of osteoporosis in the spine. In this review, they share their findings on risk factors and current research on this topic. Treatment with and without surgery is presented.

The number of men and women affected by osteoporosis continues to rise in the U.S. Age is the biggest risk factor for both genders. Menopause is a major risk factor for women. Anyone who has had an osteoporotic vertebral compression fracture (OVCF) is at five-times the risk of having another.

Prevention is advised and is most cost-effective. When OVCFs occur, treatment is usually nonsurgical. Some people have no symptoms of OVCF at all. Most patients have back pain for six to eight weeks. Bed rest should be limited to no more than one to three days. Pain relievers, bracing, and movement are the main management options.

Surgery may be needed for those patients whose pain and disability persist. There are several surgical options. These include vertebroplasty and balloon tamp reduction (also known as kyphoplasty).

Both vertebroplasty and kyphoplasty inject cement into the vertebral body. Pain relief and improved function are common results from this treatment. Other surgical treatments considered include spinal cord decompression and instrumentation with hooks or screws to hold the bones together.

Studies show surgical treatment of the osteoporotic spine is problematic. Choosing the right patients for each surgical option is the key to a good result. In the future, new materials and medications may be available to improve bone density and strength and more effectively prevent OVCFs.

There’s a group of arthritic conditions with a genetic link called the spondyloarthropathies (SpA). SpA includes ankylosing spondylitis (AS), reactive arthritis, psoriatic arthritis, and enteropathic arthritis.

In this article, rheumatologists from the Albert Einstein Medical Center in Philadelphia give an update on the latest treatment for SpA. A review of each condition is included.

History, cause, and symptoms are presented for each disease. Specific clinical tests and imaging studies are also provided. Lab studies aren’t usually diagnostic. The SED rate and C-reactive protein (CRP) levels are often elevated. But these are just indicators of inflammation and don’t tell the doctor what exactly is wrong.

Early treatment of SpA is usually with medications to relieve symptoms. New biologic agents such as the TNF-alpha-antagonists have made the management of these diseases much easier. Other drugs such as nonsteroidal antiinflammatories (NSAIDs) and disease modifying antirheumatic drugs (DMARDs) are also helpful.

Physical therapy and exercise remain important parts of the treatment program. Sometimes steroid injections are used for single joints with persistent painful swelling. There’s no known cure for SpA. Once the diagnosis is made, treatment is a matter of managing the symptoms and improving function.

Spinal cord stimulation (SCS) is a treatment method used to give patients long-term relief from pain caused by benign conditions. Quality of life and function are improved when chronic pain is under control.

Unfortunately, there is a 30 to 75 per cent rate of adverse events (AEs). There is a cost of those problems in terms of reducing success rate and increasing the total amount spent on health care. These are two reasons to find ways to improve the performance of SCS.

In this study Canadian researchers calculated the exact cost for 160 patients who had been treated with SCS in the last 10 years. Primary care and hospital costs were both included. The average cost of implanting each SCS, the cost of its upkeep every year, and the cost of any problems that come up were all added up.

Costs ranged from $130 up to $22,406 per patient. The average cost in Canada under the government health care program was $23,205. Routine annual maintenance was $3600. Costs were slightly higher for patients who wanted the implant taken out. This step was requested for many reasons but usually because of complications.

This was one of the first studies to look at costs associated with SCS. The authors point out the high rate of AEs and rising costs of those AEs. Total costs may be considerably under the U.S. fees due to the Canadian structure for assigning health care costs.

Improved technologies have already helped reduce the cost of complications from SCS. The authors propose additional measures that can be taken to further decrease the health care costs associated with this type of treatment.

For example, the implanted pulse generator is less likely to get displaced or shifted when put in the abdominal wall compared to the gluteal (buttock) region. Plastic anchors can be replaced with a soft silicone anchor if the plastic anchor is causing any discomfort.

In this article, two well-known orthopedic surgeons from Rush University Medical Center in Chicago review three groups of nonfusion technologies. These include 1) total disc replacements (TDRs), 2) prosthetic nuclear implants (PNIs), and 3) posterior stabilization devices (PSDs).

When conservative care fails to reduce back pain and restore function, spinal fusion is often the final treatment plan. But long-term studies show that loss of motion at the fused level transfers the stress load to the vertebra above or below.

Degeneration of the next level has led to the development of these three alternatives to spinal fusion. The TDR reduces pressure on the nerves and restores the height of the disc. Near normal motion is also preserved. TDRs are available for the cervical spine (neck) and lumbar spine (low back).

New TDR designs have resulted in special coatings for the endplates to improve tissue compatibility and bone ingrowth. A special covering reduces friction and catches any metal ions or debris that occur.

Nuclear implants replace just the inner core of the disc. Scientists have found that degenerative changes in the disc begin inside the nucleus. If this part of the disc can be replaced early before there is a large tear or collapse of the disc space, then the patient may be spared a later disc herniation.

There are different types of nuclear implants. Some are inserted inside the disc. Others act as a filler and are injected into the space after the nuclear material has been removed. Once injected, the substance hardens into a strong but elastic mass.

Just exactly what is “disc degeneration”? Having a working definition of degenerative disc disease (DDD) would be very useful. It would help researchers look for risk factors. It would give a legal way to tell the difference between normal changes and a disease process.

Toward this goal of writing a definition, the authors of this report review disc anatomy, metabolism, healing, and aging. The causes of DDD are also included along with a discussion of disc prolapse and pain.

For the medical professional, disc degeneration is defined as an aberrant cell-mediated response to progressive structural failure. For the patient, this means too much of a load on the disc damages it and starts a series of responses at the cellular level. The result is even more disruption and damage to the disc.

Anything that can weaken a disc or keep it from healing can lead to DDD. Usually this is injury or wear and tear from repeated bending, twisting, and compression. But increasing age, poor nutrition, and genetics can weaken some discs enough that even a small thing like a cough or a sneeze can lead to disruption of the disc.

Age-related changes can be distinguished from a damaged or degenerative disc. With aging, the disc structure remains intact and painless. When pain occurs and/or structural failure is seen, then the condition is called a “disease.” Structural failure could be disc collapse, prolapse, or fissures.

In this study, researchers review five years’ worth of results from using epidural spinal cord stimulation (SCS) units. All patients had chronic, intractable pain. The specific focus of the study was to identify causes of hardware failure. The hope is to design a better unit with fewer patient complications.

SCS systems consist of wires and electrodes (leads). They are implanted in the spine. Most of the 289 patients in this study had a diagnosis of complex regional pain syndrome (CRPS). The SCS unit was in the cervical (neck) or thoracic (mid-back) spine.

There were many problems with the SCS systems. Almost half of the patients had to have at least one more surgery. One of the most common causes of system failure was lead breakage.

Unit migration was also reported. Migration means it moved from where it was implanted and shifted to someplace else. Infection and poor pain control were two other complications. In some cases, the unit had to be repositioned because of pain or discomfort from the location of the device.

The authors took a close look at the causes and types of SCS failure. They noticed that surgical leads were more likely to break compared to percutaneous (under the skin) leads. A higher rate of lead migration and breakage in the cervical spine may be due to greater motion in this area.

Motion-induced stress on the SCS device is a major challenge to hardware engineers. The authors suggest with an overall hardware failure rate of 33.5 per cent, new designs for the hardware are needed. Patients should be told the risks of failure with SCS before having this operation. Success of revision surgeries is not optimal either.

In countries with limited health care services or a national health care system, patients don’t always get treated. This is especially true when the problem isn’t life-threatening or there’s no risk of permanent damage. This type of health delivery plan may adversely affect chronic pain patients.

In this study researchers from Finland look at the cost-utility results of treatment for neck and back problems. Cost-utility is a good way to measure how effective treatment is based on the cost. Patients with neck or back pain having surgery for disc problems or spinal stenosis were included.

Patients filled out a survey with questions about 15 areas of health status. The questions were about moving, seeing, hearing, and sleeping. Eating, mental function, and sexual activity were also included. The survey was completed before and after the operation.

The goal was to measure the effectiveness of the surgery based on changes in health-related quality of life (HRQOL). Change in HRQOL was compared to the cost of the treatment. The authors also looked at change in HRQOL for patients who were treated within 60 days. This was compared to patients whose treatment was delayed more than 60 days.

Results showed an improvement in HRQOL for patients in both groups. The patients who had lumbar surgery had the best results. Patients reported their health improved in the areas of sleeping, daily activities, and pain or discomfort.

Mood (depression and distress) was also better. For those patients who answered the questions, sexual activity was also improved. In cases where the surgery was delayed, the cost per unit of improved quality was doubled.

The authors conclude that the cost-utility of surgery for neck and back pain caused by disc problems or stenosis is favorable. Delaying treatment decreases the cost-utility. This information may help health care planners made decisions about future services offered when care is limited or resources are scarce.

Health care professionals such as doctors, nurses, and physical therapists often treat patients based on what they learned in school. Physical therapists (PTs) are trying to match evidence in research about what works for low back pain (LBP) with what PT students are taught in school.

For example, spinal manipulation has been shown to help patients with acute low back pain. Physical therapists are taught these techniques but don’t use them as often as they should.

The authors say that a lack of understanding of the latest research findings may be why PTs aren’t using manual therapy techniques with acute LBP patients. Including evidence-based treatment methods like spinal manipulation in PTs training may be the best way to increase its use.

In this study the authors present one model for teaching and monitoring the use of thrust spinal manipulation. The model includes four basic steps:

Patients with AS can suffer severe changes in the spine. Some may become so bent forward they can no longer lie down flat, stand up straight, or look where they’re going. Surgery to fuse the spine in a more upright position is often advised.

Opening wedge osteotomy (OWO) is one operation used to correct the deformity. In this procedure, several vertebra are cut loose and tipped backward. This is called sagittal rotation. Metal rods and screws are used to hold the bones in this position. The effect is to extend or straighten the spine.

This is the first report of sagittal translation (ST) of the vertebra as a result of the operation. In ST the tilted vertebra slide forward over the vertebra below. The authors document how often this happens and suggest how this change might affect patients.

In this study of the 127 adults having an OWO, 27 percent developed ST. The authors suggest this may be one way the vertebra shifts to further correct the spine. ST may be linked to the amount of tilt or correction.

The elasticity and tension of the soft tissues around the OWO may also be a factor. If the soft tissues are tight and hold back the tilt or rotation, then ST may be more likely to occur.

The authors advise surgeons to watch for ST after OWO. Further surgery may be needed to prevent or treat neurologic problems from the ST. More studies are needed to measure and grade ST. Predicting the results of SR may help prevent problems like ST.

Years ago any illness or condition with a connection between the mind and body was labeled psychosomatic and dismissed as a “mental” not physical problem. Since then more and more studies have shown biologic, neurologic, and chemical pathways exist between the brain and the body.

A recent study from the Netherlands has shown that some patients with chronic low back actually get better with a psychologic approach rather than physical treatment such as exercise or strength training. The method used is called cognitive behavioral therapy (CBT). It involves a change in attitude and some changes in behavior.

Some say this is a major break through in treating back pain patients. Others say it’s too soon to tell. Follow-up after the study only lasted 10 weeks. The positive benefits may not continue. It could be the patients responded to the personal attention they got from joining a treatment group.

Long-term results are important and must be available before adopting this program for everyone. In fact, researchers are actively trying to match which patients respond best to each individual kind of treatment. It’s likely that some patients respond better than others to CBT — the goal is to identify who are these patients and treat them accordingly.

Doctors from Seoul, Korea present an unusual case of synovial cyst in the spine. Cysts of this type are usually located in the hand or wrist. Synovial fluid from the joint leaks out and forms a pouch or cyst. Synovial cysts are different from ganglion cysts because the synovial cyst has a synovial lining.

In this case a 56-year-old woman with a 15 year history of severe pain down both legs (radiculopathy) was treated with surgery for a synovial cyst. The cyst was identified on MRI. During the operation the surgeons could see the cyst was wrapped around the nerve root like a wedding ring.

The surgeons removed part of the bone (laminectomy) and removed the facet joints on both sides. The cyst was removed. It was separate from the facet joint next to it and pressing on the L45 nerve root. A synovial cyst without a link or opening to the facet joint is a rare but possible cause of radiculopathy from nerve root compression.

Facet joints in the spine allow movement in flexion, extension, and rotation. Degeneration of these joints can (but doesn’t always) cause pain. In fact doctors are still puzzled as to why normal-appearing joints can be painful for some people, while degenerating joints don’t cause any problems for others.

In this article, doctors review the results of recent studies on the source of facet joint pain. Animal studies show special receptors called nociceptors located at the joints and in the muscles and tendons near the joints. The nociceptors transmit messages of pain.

Nociceptors in the joints are different from nociceptors in the muscles. Messages from the joints aren’t even sent if the problem isn’t significant. And when the message is sent, the pathway is very slow.

In one study of rabbits, researchers injected carrageenan (causes joints to stiffen) into the facet joints. They found inflammatory changes in the joint capsule and space around the muscles. There was an increase in firing or discharge of the facet-joint neurons as a result proving that facet joints can be the source of the pain.

Other studies focused on whiplash injuries also show facet joints as the pain generator. Facet joints in the cervical spine (neck) appear to be more sensitive and painful than similar joints in the lumbar spine (low back). This may help explain why there are so many cases of post-whiplash syndrome.

It’s not clear yet if the joint capsule is being pinched, compressed, stretched or strained. A study of goats applied various strains and stretches to joint capsules. Some nociceptors responded early when a low level of strain was applied. Others fired only with high strains more typical of a whiplash injury.

The common consensus from all the studies reviewed is that injury or overstretching of the joint capsule may be the most likely source of chronic pain after a whiplash injury. High strains cause nociceptors to fire with after shocks. Damaged nerve endings in the capsule may lead to pain that doesn’t go away. Finding the source of pain linked with whiplash injuries may help researchers find better ways to treat it.