PATHOLOGY of FAILED BACK SURGERY SYNDROME L Background and Diagnostic Alternatives
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Transforaminal Endoscopic Discectomy to Relieve Sciatica and Delay Fusion in a 31-Year-Old Man with Pars Defects and Low-Grade Spondylolisthesis
NEUROSURGICAL FOCUS Neurosurg Focus 40 (2):E4, 2016 Transforaminal endoscopic discectomy to relieve sciatica and delay fusion in a 31-year-old man with pars defects and low-grade spondylolisthesis Karthik Madhavan, MD,2 Lee Onn Chieng, BS,2 Christoph P. Hofstetter, MD, PhD,1 and Michael Y. Wang, MD2 1Department of Neurological Surgery, University of Washington, Seattle, Washington; and 2Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida Isthmic spondylolisthesis due to pars defects resulting from trauma or spondylolysis is not uncommon. Symptomatic patients with such pars defects are traditionally treated with a variety of fusion surgeries. The authors present a unique case in which such a patient was successfully treated with endoscopic discectomy without iatrogenic destabilization. A 31-year-old man presented with a history of left radicular leg pain along the distribution of the sciatic nerve. He had a disc herniation at L5/S1 and bilateral pars defects with a Grade I spondylolisthesis. Dynamic radiographic studies did not show significant movement of L-5 over S-1. The patient did not desire to have a fusion. After induction of local anesthesia, the patient underwent an awake transforaminal endoscopic discectomy via the extraforaminal approach, with decompression of the L-5 and S-1 nerve roots. His preoperative pain resolved immediately, and he was discharged home the same day. His preoperative Oswestry Disability Index score was 74, and postoperatively it was noted to be 8. At 2-year follow-up he continued to be symptom free, and no radiographic progression of the listhesis was noted. -
Tuberculous Optochiasmatic Arachnoiditis and Optochiasmatic Tuberculoma in Malaysia
Neurology Asia 2018; 23(4) : 319 – 326 Tuberculous optochiasmatic arachnoiditis and optochiasmatic tuberculoma in Malaysia ¹Mei-Ling Sharon TAI, 3Shanthi VISWANATHAN, 2Kartini RAHMAT, 4Heng Thay CHONG, ¹Wan Zhen GOH, ¹Esther Kar Mun YEOW, ¹Tsun Haw TOH, ¹Chong Tin TAN 1Division of Neurology, Department of Medicine; 2Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Kuala Lumpur; 3Department of Neurology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia; 4Department of Neurology, Western Health, Victoria, Australia. Abstract Background & Objectives: Arachnoiditis which involves the optic chiasm and optic nervecan rarely occurs in the patients with tuberculous meningitis (TBM). The primary objective of this study was to determine the incidence, assess the clinical and neuroimaging findings, and associations, understand its pathogenesis of these patients, and determine its prognosis. Methods: The patients admitted with TBM in the neurology wards of two tertiary care hospitals from 2009 to 2017 in Kuala Lumpur, Malaysia were screened. The patients with OCA and optochiasmatic tuberculoma were included in this study. We assessed the clinical, cerebrospinal fluid (CSF), imaging findings of the study subjects and compared with other patients without OCA or optochiasmatic tuberculoma. Results: Eighty-eight patients with TBM were seen during the study period. Seven (8.0%) had OCA and one (1.1%) had optochiasmatic tuberculoma. Five out of seven (71.4%) patients with OCA were newly diagnosed cases of TBM. The other two (28.6%) had involvement while on treatment with antituberculous treatment (paradoxical manifestation). The mean age of the patients with OCA was 27.3 ± 11.7. All the OCA patients had leptomeningeal enhancement at other sites. All had hydrocephalus and cerebral infarcts on brain neuroimaging. -
Spinal Cord Stimulation in Failed Back Surgery Syndrome: Effects on Posture and Gait—A Preliminary 3D Biomechanical Study
Hindawi Pain Research and Management Volume 2017, Article ID 3059891, 9 pages https://doi.org/10.1155/2017/3059891 Research Article Spinal Cord Stimulation in Failed Back Surgery Syndrome: Effects on Posture and Gait—A Preliminary 3D Biomechanical Study L. Brugliera,1 A. De Luca,2 S. Corna,1 M. Bertolotto,3 G. A. Checchia,4 M. Cioni,5 P. Capodaglio,1 and C. Lentino2,4 1 Istituto Auxologico Italiano, Unita` di Riabilitazione Osteoarticolare, Ospedale S Giuseppe, Strada Cadorna 90, Piancavallo, Italy 2Laboratorio Analisi del Movimento Ospedale Santa Corona di Pietra Ligure, Viale 25 Aprile 38, 17027 Pietra Ligure, Italy 3Centro Terapia del Dolore e Cure Palliative, Dipartimento di Riabilitazione, Ospedale Santa Corona di Pietra Ligure, Viale 25 Aprile 38, 17027 Pietra Ligure, Italy 4Struttura Complessa Recupero e Rieducazione Funzionale, Ospedale Santa Corona di Pietra Ligure, Viale 25 Aprile 38, 17027 Pietra Ligure, Italy 5Scuola di Specializzazione in Medicina Fisica e Riabilitativa, Dipartimento di Scienze Biomediche e Biotecnologiche, Universita` degli Studi di Catania, Piazza Universita2,95131Catania,Italy` Correspondence should be addressed to P. Capodaglio; [email protected] Received 30 March 2017; Revised 21 June 2017; Accepted 1 August 2017; Published 25 September 2017 Academic Editor: Emily J. Bartley Copyright © 2017 L. Brugliera et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We studied 8 patients with spinal cord stimulation (SCS) devices which had been previously implanted to treat neuropathic chronic pain secondary to Failed Back Surgery Syndrome. -
Spinal Arachnoiditis Stephen I
THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCbS REVIEW ARTICLE: Spinal Arachnoiditis Stephen I. Esses and T.P. Morley SUMMARY: A review of the literature points to the many causes of arachnoiditis and the failure of treatment to arrest or reverse its effects. The true incidence cannot be determined, although it is probably lower than might at first appear from the published articles. In the radiological literature the diagnosis seems to derive from an examination of the films alone, often without reference to the clinical findings or appearance at operation. While attempts at treatment are usually unsuccessful, some iatrogenic cases can be prevented by the avoidance of intrathecal steroid injections or unduly rough or repeated surgical exploration of the lumbar vertebral canal. RESUME: Une revue de la litterature indique clairement que I'arachnoidite peut etre due a plusieurs causes et que son traitement est deficitaire. L'incidence reelle de I'arachnoidite ne peut etre determinee, mais elle est probablement inferieure au taux apparent selon les publications. Ainsi dans la litterature radiologique on semble etablir un diagnostic sur la base des films sans tenir compte des aspects clini- ques ou de la presentation chirurgicale. Quoique les essais therapeutiques soient generalement negatifs, on peut prevenir certaines causes iatrogeniques en evitant les injections intrathecals de steroides ou les explorations repetees, ou trop dures, du canal vertebral lombaire. Can. J. Neurol. Sci. 1983; 10:2-10 Feodor Krause (1907) was the first to describe adhesive dense collagen deposition which completely encases the lumbar arachnoiditis. By 1936 Elkington presented a com nerve roots. The roots are deprived of their blood supply plete analysis of forty-one cases under the tide "Meningitis and undergo progressive atrophy. -
Benign Lumbar Arachnoiditis: MR Imaging with Gadopentetate Dimeglumine
763 Benign Lumbar Arachnoiditis: MR Imaging with Gadopentetate Dimeglumine Carl E. Johnson 1.2 MR imaging was performed in 13 patients with benign lumbar arachnoiditis both Gordon Sze3 before and after IV injection of gadopentetate dimeglumine. The arachnoiditis was proved by previous myelography in 12 patients and by noncontrast MR imaging in one patient. The disease was presumably the result of previous myelography and for surgery. It was characterized as mild in two patients, moderate in two patients, and severe in nine patients. Imaging was performed on a 1.5-T unit, and both short and long TR images were obtained before and after contrast administration. Noncontrast MR images demonstrated changes consistent with arachnoiditis in all patients. After contrast, three patients had no enhancement, three patients had minimal enhancement, three patients had mild enhancement, and four patients had moderate enhancement. In no case did contrast enhancement alter the diagnosis or reveal additional findings that could not be seen on the noncontrast images. Gadopentetate dimeglumine enhancement plays little role in the diagnosis of lumbar arachnoiditis. If used for another reason, however, short TR scans may show enhance ment of adherent roots in some cases. In addition, administration of gadopentetate dimeglumine will not cause sufficient enhancement to hinder the detection of arachnoid itis on long TR images and may aid in recognition of adherent roots on short TR images. AJNR 11:763-770, July/August 1990; AJR 155: October 1990 Previous work has shown the utility of gadopentetate dimeglumine in the MR imaging evaluation of neoplastic extradural, intradural, extramedullary, and intra medullary spinal disease [1-7]. -
Failed Back Syndrome Daniel Aghion, MD, Pradeep Chopra, MD, Adetokunbo A
Failed Back Syndrome Daniel Aghion, MD, Pradeep Chopra, MD, Adetokunbo A. Oyelese, MD, PhD APPROXIMATELY 250,000 SURGERIES with predominant complaints of back to significant nerve root injury (2-3%) for low back pain are performed annu- pain.3 This is because it is usually more because more retraction on the neural ally in the USA.1 Approximately 40% straightforward to identify the source of elements is necessary to gain access to of patients undergoing lumbar surgery pain or “pain generator” on an MRI in the the disc pathology. Conversely, excessive continue to report significant pain after case of a pinched nerve causing radicular bone removal as with a laminectomy, in surgery, and a significant portion of these symptoms than it is to identify the pain which a significant amount of facet joint will result in failed back syndrome (FBS). generator causing low back pain. Thus, removal is performed, may lead to spinal FBS is defined as persistent or recurrent many patients with asymptomatic but instability and pain. chronic pain after one or more surgical abnormal appearing degenerated discs FBS after a lumbar fusion can ensue procedures on the lumbosacral spine. The on MRI or with myofascial pain may be due to extensive instrumentation or fu- incidence of true FBS is as high as 15%. subjected to inappropriate lumbar surgery sion across multiple segments. This can Unfortunately, the diagnosis of FBS does with resulting poor outcomes. result in a ‘flat back syndrome’ or loss not point to the actual cause for treatment of normal lumbar lordosis leading to failure. Multiple factors can contribute to One of the most FBS. -
JMSCR Vol||08||Issue||11||Page 472-476||November 2020
JMSCR Vol||08||Issue||11||Page 472-476||November 2020 http://jmscr.igmpublication.org/home/ ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v8i11.81 Cryptococcal meningoencephalitis leading to Binocular visual loss and paraparesis in a patient with advanced HIV Authors Akhil Deshmukh1, Amod Rajendran2, Aravind Reghukumar3*, Athul Gurudas4, Kiran Kumar5 1,2,4,5Department of Internal medicine, Medical College, Thiruvananthapuram, Kerala, India 3Head of the Department of Infectious Diseases, Government Medical College, Thiruvananthapuram, Kerala, India *Corresponding Author Aravind Reghukumar Head of the Department of Infectious Diseases, Government Medical College, Thiruvananthapuram, Kerala, India Abstract Cryptococcus neoformans is the most common invasive fungal infection of the central nervous system in patients with advanced HIV. Neurocryptococcosis usually presents as diffuse meningoencephalitis with ocular involvement occurring as a secondary phenomenon is up to 30 % of cases. Binocular visual loss due to cryptococcal meningoencephalitis being very rare, this case report describes a patient with advanced HIV who developed binocular visual loss and paraparesis as a complication of cryptococcaemia. Even though mechanisms of visual complications in cryptococcal meningitis are still unclear, intracranial hypertension is postulated to be the primary cause while leads to delayed onset of visual loss. Our patient had early onset of binocular painless visual loss in the absence of papilloedema Patient also had features of cryptococcal spinal arachnoiditis which manifested as asymmetric lower limb weakness with urinary retention. In view of binocular visual loss and spinal arachnoiditis, adjunctive corticosteroids were added to the treatment regime consisting of amphotericin deoxycholate and flucytosine, following which the patient made a gradual clinical recovery. -
Abstracts of the 2018 AANS/CNS Joint Section on Disorders of the Spine
Abstracts of the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves Annual Meeting Orlando, Florida • March 14–17, 2018 (DOI: 10.3171/2018.3.FOC-ASPNabstracts) in the tetraplegic SCI population1. We investigate the combined J.A.N.E. Award Presentation effects of two neuromodulation strategies: transcutaneous electri- cal stimulation (TES) and buspirone pharmacological modulation, 100 Lateral Lumbar Interbody Fusion in the Elderly: A 10 for promoting upper limb motor recovery in chronic cervical SCI Year Experience tetraplegic subjects. Methods: A double-blind study protocol was used to deter- Nitin Agarwal MD; Andrew M Faramand MD; Nima Alan mine the effects of cervical electrical stimulation alone or in com- MD; Zachary J. Tempel MD; D. Kojo Hamilton MD; David O. bination with the monoaminergic agonist buspirone on upper limb Okonkwo MD, PhD; Adam S. Kanter MD motor function in subjects with chronic motor complete (ASIA B) cervical injury (n=6). Voluntary upper limb function was Introduction: Elderly patients, often presenting with multiple evaluated through measures of controlled hand contraction, hand- medical comorbidities, are touted to be at an increased risk of post- grip force production, dexterity measures, and validated clinical operative complications. As such, we describe our perioperative assessment batteries. Subjects underwent pre-intervention assess- outcomes in this cohort of patients over the age of 70 following ment followed by three treatment phases with TES and buspirone standalone LLIF. or placebo. A delayed post-treatment testing period was used to Methods: A retrospective query of a prospectively maintained assess for durable improvement in function. database was performed for patients over the age of 70 who under- Results: All subjects demonstrated improvement in hand went standalone LLIF. -
Syringomyelia and Arachnoiditis
106 Journal of Neurology, Neurosurgery, and Psychiatry 1990;53:106-113 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.53.2.106 on 1 February 1990. Downloaded from Syringomyelia and arachnoiditis L R Caplan, A B Norohna, LL Amico Abstract and weakness in his right hand. Months later, Five patients with chronic arachnoiditis he developed sensory loss and weakness of the and syringomyelia were studied. Three hands, more noticeable in the left than the patients had early life meningitis and right. Atrophy, frequent burns, and hand developed symptoms of syringomyelia tremor were reported by the patient. Four eight, 21, and 23 years after the acute years later, the lower extremities became weak, infection. One patient had a spinal dural initially on the right side. He then experienced thoracic AVM and developed a thoracic weakness in the left leg which soon became syrinx 11 years after spinal subarachnoid more severe than in the right. He complained of haemorrhage and five years after surgery a drawing, burning pain in both arms from the on the AVM. A fifth patient had tuber- hands to the radial forearms and from the hips culous meningitis with transient spinal to the toes. cord dysfunction followed by develop- In 1943 (aged 46), he was first evaluated at ment ofa lumbar syrinx seven years later. the Harvard Neurological Unit at Boston City Arachnoiditis can cause syrinx formation Hospital. There was diminished body hair and by obliterating the spinal vasculature burn scars on his fingers. Mental function and causing ischaemia. Small cystic regions cranial nerves were normal except for a slight of myelomalacia coalesce to form left lower facial droop and slighlt leftward cavities. -
Postlumbar Puncture Arachnoiditis Mimicking Epidural Abscess Mehmet Sabri Gürbüz,1 Barıs Erdoğan,2 Mehmet Onur Yüksel,2 Hakan Somay2
Learning from errors CASE REPORT Postlumbar puncture arachnoiditis mimicking epidural abscess Mehmet Sabri Gürbüz,1 Barıs Erdoğan,2 Mehmet Onur Yüksel,2 Hakan Somay2 1Department of Neurosurgery, SUMMARY and had increased gradually before the patient was ğ ı ğ ı A r Public Hospital, A r , Lumbar spinal arachnoiditis occurring after diagnostic referred to us. On our examination, the body tem- Turkey 2Department of Neurosurgery, lumbar puncture is a very rare condition. Arachnoiditis perature was 38.5°C. There was no neurological Haydarpasa Numune Training may also present with fever and elevated infection deficit but a slight tenderness in the low back. The and Research Hospital, markers and may mimic epidural abscess, which is one examination of the other systems was unremarkable. Istanbul, Turkey of the well known infectious complications of lumbar puncture. We report the case of a 56-year-old man with Correspondence to INVESTIGATIONS Dr Mehmet Sabri Gürbüz, lumbar spinal arachnoiditis occurring after diagnostic Laboratory examination revealed elevated erythro- [email protected] lumbar puncture who was operated on under a cyte sedimentation rate (80 mm/h) and C reactive misdiagnosis of epidural abscess. In the intraoperative protein level (23 mg/L) with 9.5×109/L white blood and postoperative microbiological and histopathological cells. Preoperative blood culture for Mycobacterium examination, no epidural abscess was detected. To our and other microorganisms and sputum culture for knowledge, this is the first case of a patient with Mycobacterium were all negative. Non-contrast- postlumbar puncture arachnoiditis operated on under a enhanced T1-weighted sagittal MRI of the patient misdiagnosis of epidural abscess reported in the demonstrated a nearly biconcave lesion resembling literature. -
Role of Litigation
Spinal Cord (2000) 38, 63 ± 70 ã 2000 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/00 $15.00 www.nature.com/sc Scienti®c Review Aspects of the failed back syndrome: role of litigation JMS Pearce*,1 1Hull Royal In®rmary, 304 Beverly Road, Anlaby, East Yorks HU10 7BG Objective: A review that attempts to identify the mechanism and causation of persistent or recurring low back pain. Design: A personal assessment of clinical features with a selective review of the literature. Results: Thirty to forty per cent of our population aged 10 ± 65 years report that back trouble occurs on a monthly basis and in 1% to 8% this interferes with work. A de®nite patho-anatomical cause for the pain is demonstrable in only a minority. It can be deduced that psychosocial factors, including insurance bene®ts are of importance for this variation. Conclusions: Neither non-operative nor surgical procedures have a major impact on the capacity for work in this substantial minority of backache suerers. The main risk factors identi®ed are: Wrong diagnosis, repeated medical certi®cates for sickness bene®ts, failed surgery, symptoms incongruous with signs or imaging, multiple spinal procedures, poor social support and poor motivation, psychological illness, clinical depression before or after injury or operation. Pending compensation and delays in settlement are important additional features in claimants for compensation. For patients with unproven diagnostic labels such as `pain- behaviour', no evidence exists that any type of surgery is cost eective. Spinal Cord (2000) 38, 63 ± 70 Keywords: low back pain; backache; sciatica; lumbar disk; failed back; chronic pain syndrome Introduction Thirty to 40% of our population aged 10 ± 65 years patients who undergo major spinal surgery for other report that back trouble occurs on a monthly basis and reasons, eg for a tumour, start to walk within a week in 1% to 8% this interferes with work. -
Spinal Cord Stimulators (Dorsal Column Stimulators)
Spinal Cord Stimulators (Dorsal Column Stimulators) Date of Origin: 06/2006 Last Review Date: 05/27/2020 Effective Date: 06/01/2020 Dates Reviewed: 07/2007, 10/2007, 10/2008, 07/2010, 07/2011, 07/2012, 05/2013, 07/2014, 03/2016, 06/2017, 08/2018, 05/2019, 05/2020 Developed By: Medical Necessity Criteria Committee I. Description Spinal cord stimulators, also known as dorsal column stimulators, deliver low voltage electrical stimulation to the dorsal columns of the spinal cord in order to block pain sensations. These devices consist of a lead that delivers the electrical stimulation to the spinal cord, an extension wire that conducts the electrical stimulation from the power source to the lead, and a power source which generates the electrical stimulation. Totally implantable spinal cord stimulators are most commonly used; however, there are also spinal cord stimulators which rely on radio frequency and include a transmitter and an antenna which are carried outside the body and a receiver, which is implanted inside the body. Implantation of the spinal cord stimulator is generally a two- step process. This process includes a trial period of stimulation in which an electrode is temporarily implanted in the epidural space. Once treatment is deemed effective, through a significant reduction in pain, the spinal cord stimulator is permanently implanted. Successful spinal cord stimulation may require extensive programming of the neurostimulators to identify the optimal electrode combinations and stimulation channels. Spinal cord stimulator placement is a non-destructive, reversible procedure and thus is often an attractive alternative for patients who have failed other treatment and surgical options.