Investigating non-operative treatment options for lumbar spinal stenosis.
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Back Pain↗
Biomedical subjects
Vinod K Podichetty
Publications and source records attributed to Vinod K Podichetty.
Placement of percutaneous pedicle screws without imaging guidance.
Pedicle screw (PS) instrumentation provides an exceptionally rigid construct to promote fusion in cases of spinal trauma and degenerative disease. Although the safety of traditional open techniques for PS placement has been well documented, there are no large series in the literature in which the safety of percutaneously placed PSs has been examined. Because the advantages of minimally invasive spine surgery are becoming more widely recognized, especially in regard to the lessening of morbidity caused by pain and blood loss, there will be a greater demand for spine surgeons to place PSs percutaneously. During a 2-year period, the authors placed 287 PSs percutaneously with the aid of intraoperative fluoroscopy. Only one of these screws was later found to have breached the spinal canal, yielding a breach rate of 0.35% for percutaneously placed PSs (one of 287).
Bone Screws↗
Complications associated with minimally invasive decompression for lumbar spinal stenosis.
OBJECTIVE: Surgical strategies for the decompression of lumbar spinal stenosis have evolved to include minimally invasive techniques providing for adequate and safe decompression while reducing perioperative morbidity. Retrospective case series analysis of 220 consecutive patients with lumbar spinal stenosis who underwent microscopic or microendoscopic minimally invasive decompression was performed. The objective was to evaluate the risks associated with performing a minimally invasive decompression for spinal stenosis in a large group of patients. METHODS: Two hundred twenty patients with symptomatic neurogenic claudication from lumbar spinal stenosis failing nonoperative treatment received a minimally invasive decompression surgery. Intraoperative data, postoperative data through hospital discharge, and clinical follow-up were analyzed. RESULTS: The average age was 74.2 years (range 49-98 years). There were 379 spinal levels decompressed in 220 patients. Sixty-nine patients (31.4%) had a grade 1 degenerative spondylolisthesis. One hundred sixty-eight patients (76%) received spinal anesthesia, and 52 received general anesthesia. Eighty-seven patients (40%) had a preoperative American Society of Anesthesiologists score of 3 or 4. Average operative blood loss was 92 mL. There were 17 intraoperative durotomies (4.5% rate). The average length of stay before discharge was 1.2 days. Ten patients went to inpatient rehabilitation at discharge. One hundred ninety-four patients (88.2%) were discharged within 24 hours. There were five readmissions within the first month after discharge, four of those for medical complications. There were 24 minor complications and 14 major complications. Forty-two patients (19%) took no oral or parenteral narcotic pain medications in the postanesthesia to discharge period. CONCLUSION: Minimally invasive decompression strategies for spinal stenosis seem consistently to result in short hospital lengths of stay, minimal requirements for narcotic pain medications, and a low rate of readmission and complications.
Aged↗
Thoracic microendoscopic discectomy: a human cadaver study.
STUDY DESIGN: Feasibility analysis of percutaneous posterolateral thoracic microendoscopic discectomy in a human cadaver model. OBJECTIVE: To describe a new, minimally invasive, posterolateral approach to the thoracic spine for the treatment of disc herniations. SUMMARY OF BACKGROUND: Thoracoscopic discectomy offers surgeons direct ventral access to thoracic disc herniations but requires entry into the chest. Many surgeons favor a posterolateral approach to the thoracic spine, thereby avoiding morbidity associated with entry into the thoracic cavity. By adapting minimal access surgical techniques to the thoracic spine, effective treatment of thoracic disc herniations should be possible and may help expedite recovery. METHODS: Two cadaveric human torsos were used. Using simple adaptations of our standard lumbar microendoscopic discectomy technique, endoscopic discectomies were performed throughout the mid and lower thoracic spine. Operative time was recorded. The extent of the discectomy as well as the extent of bony removal was evaluated using computed tomography myelography. RESULTS: Nine discectomies were performed in two cadaveric specimens, from T5-T6-T9-T10. Operative times ranged from 46 to 77 minutes (mean 60 minutes). The procedure required removing 3.4 mm (+/-1.9 mm) of the ipsilateral facet, which amounted to 35.4% (+/-17.5%) of the facet complex. Canal decompression averaged 73.5% (+/-7.9%). CONCLUSIONS: Thoracic microendoscopic discectomy allows for a posterolateral approach to thoracic disc herniation without entry into the chest cavity that consistently gives access to the majority of the canal while requiring only a minimal amount of bone removal. This technique provides an approach angle similar to that obtained with other posterolateral discectomy techniques while limiting the morbidity associated with exposure.
Arthroscopy↗
Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion with instrumentation.
OBJECT: The authors have developed a novel technique for percutaneous fusion in which standard microendoscopic discectomy is modified. Based on data obtained in their cadaveric studies they considered that this minimally invasive interbody fusion could be safely implemented clinically. The authors describe their initial experience with a microendoscopic transforaminal lumbar interbody fusion (METLIF) technique, with regard to safety in the placement of percutaneous instrumentation, perioperative morbidity, and early postoperative results. METHODS: The METLIF procedure was performed unilaterally in 20 patients with single-level lumbar spondylolisthesis or pure mechanical back pain with endoscopic assistance, hemilaminectomy, unilateral facetectomy, and microdiscectomy. Two interbody grafts were placed via the lateral exposure of the disc space. Bilateral percutaneous pedicle screws were then inserted. Compared with patients who had undergone single-level posterior LIF at the same institutions, intraoperative blood loss, hospital length of stay (LOS), and postoperative narcotic agent use were significantly lower in the METLIF group. The mean LOS for the percutaneous fusion group was 3.4 days (5.1 days in those who underwent PLIF; p < 0.02). There have been no procedure-related complications in this series to date. CONCLUSIONS: The METLIF technique provided an option for percutaneous interbody fusion similar to that in open surgery while minimizing destruction to adjacent tissues. This technique was safe and exhibited a trend toward decreased intraoperative blood loss, postoperative pain, total narcotic use, and the risk of transfusion.
Adult↗
Effectiveness of salmon calcitonin nasal spray in the treatment of lumbar canal stenosis: a double-blind, randomized, placebo-controlled, parallel group trial.
STUDY DESIGN: Double-blind, randomized, placebo-controlled study to assess the effectiveness of calcitonin nasal spray on symptoms and function in patients with lumbar canal stenosis. OBJECTIVE: To compare effectiveness of calcitonin administered by nasal spray with placebo in patients with clinically symptomatic lumbar canal stenosis. SUMMARY OF BACKGROUND DATA: Lumbar canal stenosis is the most common reason for spine surgery in individuals over 65 years of age. Nonoperative approaches have been not well studied and limited primarily to physical therapy exercises. Several small trials in the past have suggested that subcutaneous and intramuscular calcitonin is an effective nonsurgical option in treating the symptoms of spinal stenosis patients. Only three trials were randomized and placebo-controlled. METHODS: Fifty-five patients with clinical lumbar canal stenosis (pseudoclaudication), confirmatory MR imaging, and pain intensity index (VAS) of > or =6 were randomized to either placebo or intranasal calcitonin daily for 6 weeks, followed by an open label 6-week extension, during which all patients received active drug. Outcome parameters performed at baseline, 6 weeks, and 12 weeks, included pain intensity index, walking time and distance to pain, SF-36, and Oswestry disability index. RESULTS: Thirty-six patients received calcitonin, and 19 placebo. Eight (14.54%) calcitonin and 4 (7.27%) placebo patients withdrew from the study. The mean baseline pain score for calcitonin group was 7.8 and 7.5 for placebo. Comparisons at week 6 showed no statistically significant difference in the change in pain intensity (VAS) between calcitonin group (-2.9) and placebo (-2.4) (P = 0.4382) from baseline. There was no significant difference in walking time to pain (calcitonin -10.0 seconds; placebo +32.2 seconds; P = 0.5136). Walking distance to pain showed a mean improvement of +91.4 ft in the calcitonin group and +254.7 ft in the placebo group (P = 0.4948). No significant difference was observed in the SF-36 score between the treatment groups. Using a threshold of at least 50% reduction in pain from baseline to 6 weeks, 12 of 29 (41.37%) of calcitonin patients were considered responders versus 7 of 18 (38.88%) of placebo patients (P = 0.4238) CONCLUSIONS: In this first ever largest randomized placebo-controlled parallel group trial of nasal calcitonin in spinal stenosis, nasal calcitonin was not superior to placebo in treating the symptoms of spinal stenosis at 6 weeks. Based on this study, nasal calcitonin does not appear to have a role in nonoperative treatment of lumbar canal stenosis.
Administration, Intranasal↗
The preoperative and postoperative assessment and care of patients with back pain.
Changing health care regulations and funding have led healthcare providers to develop new ways of providing care for patients who have back pain, while consuming fewer hospital resources. As no consensus exists for a transcendent model of preoperative and postoperative assessment and care, clinicians must define their objectives clearly for effective patient care. These include, but are not limited to, acquiring pertinent medical information, consultations, and laboratory testing necessary to assess perioperative risk; optimizing the patient's condition and developing an appropriate perioperative care plan; and educating the patient about intraoperative care and postoperative management to reduce preoperative anxiety. Clinical circumstances and specific tests for patients who have back pain meet the criteria for good screening opportunities and should be used effectively for pre- and postoperative care.
Back Pain↗
Vertebral compression fractures: manage aggressively to prevent sequelae.
New drugs to treat osteoporosis, along with two new minimally invasive surgical procedures, are important options for preventing vertebral compression fractures and treating severe back pain and disability. However, the mainstay treatments remain cautious use of analgesics, limited bed rest, and physical rehabilitation.
Bone Cements↗
Lumbar canal stenosis: start with nonsurgical therapy.
Although surgery is widely viewed as the definitive therapy for lumbar spinal stenosis, no randomized trials have compared surgical vs medical treatment. One study found that 60% of surgically treated patients improved, compared with 30% of those treated nonsurgically. We believe an initial nonsurgical approach is advisable for most patients.
Adrenal Cortex Hormones↗
e-Talking to patients: connecting with the health care consumer.
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Attitude of Health Personnel↗