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1
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Hirsch JA, Sahr DM, Brook AL, Chandra RV, Manfre L, Marcia S, Milburn J, Muto M. Basivertebral nerve ablation meets neurointervention-déjà vu? J Neurointerv Surg 2025; 17:233-235. [PMID: 38653523 DOI: 10.1136/jnis-2024-021484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Diane M Sahr
- Perceive Medical LLC, Minneapolits, Minnesota, USA
| | - Allan L Brook
- Director of Interventional Neuroradiology, Montefiore Medical Center, Bronx, New York, USA
| | - Ronil V Chandra
- Interventional Neuroradiology, Monash Medical Center and Monash University, Clayton, Victoria, Australia
| | - Luigi Manfre
- ESNR Secretary of State, Department Head Minimally Invasive Spine, IOM Mediterranean Oncology Institute, Viagrande-Cantania, Sicily, Italy
| | - Stefano Marcia
- Departmento dei servizi, Radiologia Area Ospedaliera ASL Cagliari, SS Trinita Hospital, Cagliari, Sardinia, Italy
| | - James Milburn
- Department of Radiology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Mario Muto
- Chairman Diagnostic and Interventional Radiology, Cardarelli Hospital, Naples, Italy
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2
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Dai C, Wang S, Zheng L, Wang K, Yu H, Chen Y. Unilateral and Bilateral Percutaneous Vertebroplasty for Thoracolumbar Osteoporotic Vertebral Compression Fracture with Distant Lumbosacral Pain: A Single-Center Retrospective Analysis. World Neurosurg 2025; 195:123687. [PMID: 39824383 DOI: 10.1016/j.wneu.2025.123687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2025] [Accepted: 01/09/2025] [Indexed: 01/20/2025]
Abstract
BACKGROUND Previous studies have found that percutaneous vertebroplasty (PVP) can effectively improve the local pain (LP) of the affected vertebra caused by thoracolumbar osteoporotic vertebral compression fracture (OVCF) regardless of unilateral or bilateral puncture, but there are few reports on whether it is equally effective for the accompanying distant lumbosacral pain. The objective of this study was to analyze the clinical efficacy of unilateral or bilateral PVP in the treatment of thoracolumbar OVCF with distant lumbosacral pain. METHODS The clinical data of patients with single-stage OVCF treated with PVP in our hospital from March 2019 to March 2023 were retrospectively analyzed. According to different intraoperative puncture methods, the whole cohort of patients was divided into unilateral puncture group (52 cases) and bilateral puncture group (40 cases). Preoperative, postoperative, and final follow-up were evaluated using a visual analogue scale (VAS) to assess the degree of LP in the fractured vertebrae and distant lumbosacral pain, respectively. The Oswestry Disability Index (ODI) was used to evaluate functional impairment. At the last follow-up, the proportion of patients who achieved the minimum clinical importance difference and acceptable symptom status on these measures was evaluated. RESULTS The average follow-up time of the 92 patients was 20.1 ± 7.6 months, and the LP, lumbosacral pain VAS score and ODI index at 3 days after surgery, and the last follow-up were significantly improved compared with those before surgery, with statistical differences (P < 0.05), but there was no statistical difference between the above indexes at 3 days after surgery and the last follow-up (P > 0.05). There were no significant differences in LP, lumbosacral pain VAS scores and ODI scores between unilateral puncture group and bilateral puncture group at different time points after surgery (P > 0.05). At the last follow-up, there were no statistically significant differences in the minimum clinical significance of LP, lumbosacral pain VAS score and ODI index and the rate of patients achieving acceptable symptom status between the two groups (P > 0.05). CONCLUSIONS PVP can not only improve the LP and ODI index of the responsible vertebra of OVCF in the thoracolumbar region, but also improve the accompanying distant lumbosacral pain symptoms, and the puncture approach does not affect the improvement of postoperative pain and function.
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Affiliation(s)
- Chen Dai
- Department of Orthopaedics, General Hospital of Northern Theatre Command, Shenyang, China
| | - Shuang Wang
- Department of Orthopaedics, General Hospital of Northern Theatre Command, Shenyang, China
| | - Liang Zheng
- Department of Orthopaedics, General Hospital of Northern Theatre Command, Shenyang, China
| | - Kaiqiang Wang
- Department of Orthopaedics, General Hospital of Northern Theatre Command, Shenyang, China
| | - Hailong Yu
- Department of Orthopaedics, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yu Chen
- Department of Orthopaedics, General Hospital of Northern Theatre Command, Shenyang, China.
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Peng BG, Li YC, Yang L. Role of neurogenic inflammation in intervertebral disc degeneration. World J Orthop 2025; 16:102120. [PMID: 39850033 PMCID: PMC11752484 DOI: 10.5312/wjo.v16.i1.102120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2024] [Revised: 11/29/2024] [Accepted: 12/20/2024] [Indexed: 01/13/2025] Open
Abstract
In healthy intervertebral discs (IVDs), nerves and blood vessels are present only in the outer annulus fibrosus, while in degenerative IVDs, a large amount of nerve and blood vessel tissue grows inward. Evidence supports that neurogenic inflammation produced by neuropeptides such as substance P and calcitonin gene related peptide released by the nociceptive nerve fibers innervating the IVDs plays a crucial role in the process of IVD degeneration. Recently, non-neuronal cells, including IVD cells and infiltrating immune cells, have emerged as important players in neurogenic inflammation. IVD cells and infiltrating immune cells express functional receptors for neuropeptides through which they receive signals from the nervous system. In return, IVD cells and immune cells produce neuropeptides and nerve growth factor, which stimulate nerve fibers. This communication generates a positive bidirectional feedback loop that can enhance the inflammatory response of the IVD. Recently emerging transient receptor potential channels have been recognized as contributors to neurogenic inflammation in the degenerative IVDs. These findings suggest that neurogenic inflammation involves complex pathophysiological interactions between sensory nerves and multiple cell types in the degenerative IVDs. Clarifying the mechanism of neurogenic inflammation in IVD degeneration may provide in-depth understanding of the pathology of discogenic low back pain.
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Affiliation(s)
- Bao-Gan Peng
- Department of Orthopaedics, The Third Medical Center, General Hospital of the Chinese People’s Liberation Army, Beijing 100039, China
| | - Yong-Chao Li
- Department of Orthopaedics, The Third Medical Center, General Hospital of the Chinese People’s Liberation Army, Beijing 100039, China
| | - Liang Yang
- Department of Orthopeadics, Featured Medical Center of Chinese People’s Armed Police Forces, Tianjin 300000, China
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Song JH, Kim H, Kong MJ, Hong YT, Oh SJ, Choi KC. Gamma-Aminobutyric Acid in Rice Bran Extract Exerts Antistress Effects in Mouse Models with Depressive-Like Behaviors. J Med Food 2024; 27:231-241. [PMID: 38502788 DOI: 10.1089/jmf.2023.k.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
Various neurotransmitters are involved in regulating stress systems. In this study, we investigated the effects of gamma-aminobutyric acid-rich rice bran extract (GRBe) in mice stressed by forced swimming and tail suspension tests. Four weeks of oral administration of GRBe (500-2000 mg/kg) reduced the levels of dopamine and corticosterone in the blood and brain while increasing serotonin levels. GRBe was involved not only in stress but also in regulating sleep and obesity-related genes. Modern society experiences diverse and tense lives because of urbanization and informatization, which cause excessive stress due to complicated interpersonal relationships, heavy work burden, and fatigue from the organized society. High levels of stress cause psychological instability and disrupt the balance in the autonomic nervous system, which maintains the body's equilibrium, resulting in cardiovascular and cerebrovascular diseases, hormonal imbalances, and sleep disorders. Therefore, our results suggest that GRBe is a useful substance that can relieve tension by ultimately influencing a depressive-like state by lowering the levels of neuronal substances, hormones, and cytokines involved in stress and sleep disorders.
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Affiliation(s)
- Ji-Hye Song
- Research Group of Personalized Diet, Korea Food Research Institute, Wanju-gun, Korea
| | - Hyunhee Kim
- Department of Biochemistry and Molecular Biology, AMIST, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Jeong Kong
- Department of Biochemistry and Molecular Biology, AMIST, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Taek Hong
- Department of Biochemistry and Molecular Biology, AMIST, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | - Kyung-Chul Choi
- Department of Biochemistry and Molecular Biology, AMIST, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Miller S, Caragea M, Carson D, McFarland MM, Teramoto M, Cushman DM, Cooper AN, Burnham T, McCormick ZL, Conger A. The effectiveness of intradiscal corticosteroid injection for the treatment of chronic discovertebral low back pain: a systematic review. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:33-46. [PMID: 37740319 PMCID: PMC11494378 DOI: 10.1093/pm/pnad127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVE Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain. DESIGN Systematic review. POPULATION Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging. INTERVENTION Fluoroscopically guided or computed tomography-guided IDCI. COMPARISON Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment. OUTCOMES Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index. METHODS Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2). RESULTS Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography. CONCLUSION According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography. STUDY REGISTRATION PROSPERO (CRD42021287421).
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Affiliation(s)
- Scott Miller
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Marc Caragea
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Dan Carson
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Mary M McFarland
- Eccles Health Sciences Library, University of Utah, Salt Lake City, UT 84112, United States
| | - Masaru Teramoto
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Daniel M Cushman
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Amanda N Cooper
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Taylor Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
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Abd-Elsayed A, Chitneni A. Basivertebral nerve ablation. VERTEBRAL AUGMENTATION TECHNIQUES 2024:83-88. [DOI: 10.1016/b978-0-323-88226-2.00018-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Mengis T, Herger N, Heggli I, Devan J, Spirig JM, Laux CJ, Brunner F, Farshad M, Distler O, Dudli S. Bone marrow stromal cells in Modic type 1 changes promote neurite outgrowth. Front Cell Dev Biol 2023; 11:1286280. [PMID: 37965581 PMCID: PMC10641389 DOI: 10.3389/fcell.2023.1286280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/10/2023] [Indexed: 11/16/2023] Open
Abstract
The pain in patients with Modic type 1 changes (MC1) is often due to vertebral body endplate pain, which is linked to abnormal neurite outgrowth in the vertebral body and adjacent endplate. The aim of this study was to understand the role of MC1 bone marrow stromal cells (BMSCs) in neurite outgrowth. BMSCs can produce neurotrophic factors, which have been shown to be pro-fibrotic in MC1, and expand in the perivascular space where sensory vertebral nerves are located. The study involved the exploration of the BMSC transcriptome in MC1, co-culture of MC1 BMSCs with the neuroblastoma cell line SH-SY5Y, analysis of supernatant cytokines, and analysis of gene expression changes in co-cultured SH-SY5Y. Transcriptomic analysis revealed upregulated brain-derived neurotrophic factor (BDNF) signaling-related pathways. Co-cultures of MC1 BMSCs with SH-SY5Y cells resulted in increased neurite sprouting compared to co-cultures with control BMSCs. The concentration of BDNF and other cytokines supporting neuron growth was increased in MC1 vs. control BMSC co-culture supernatants. Taken together, these findings show that MC1 BMSCs provide strong pro-neurotrophic cues to nearby neurons and could be a relevant disease-modifying treatment target.
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Affiliation(s)
- Tamara Mengis
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Nick Herger
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Irina Heggli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Jan Devan
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - José Miguel Spirig
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Christoph J. Laux
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Oliver Distler
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Stefan Dudli
- Center of Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, University of Zurich, Zürich, Switzerland
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
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8
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Wang Q, Jin B, Zhang J. Morphological features of basivertebral foramen among different age groups: Recognition in spine. Front Surg 2023; 10:1115654. [PMID: 37025270 PMCID: PMC10070850 DOI: 10.3389/fsurg.2023.1115654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 02/22/2023] [Indexed: 04/08/2023] Open
Abstract
Background Basivertebral foramen (BF) is a vessel and nerve passage in the posterior wall of vertebral body (VB). Our goal was to report BF's morphological characteristics in different age groups of mainland Chinese adults and to evaluate the relationship between BF's morphology and factors such as age, gender, heavy work, size and level of VB. Methods We enrolled 300 adults among persons who came to our hospital for health examination. We measured BFs and VBs' parameters on T1 weighted sagittal lumbar spine MR images. We also assessed following potential predictors: gender, body height, body weight, body mass index, alcohol use, habits of smoking and drinking, type of work (physical work or non-physical work). A stepwise multivariate linear regression analysis was conducted to identify predictors of BF's height. Results People above 60 have significantly bigger BFHr than those in young adulthood and in the middle ages at all five levels, while they have shallowest BFs, especially at L3. Multiple linear regression resulted in a formula that accounted for 30.1% of the variability in the height of basivertebral foramen. Significant predictors included: gender, age, level, vertebral height and heavy work. Conclusion Age is the highest weight in all factors on the height of BF. BF is closer to the upper endplate. The BF was relatively higher and deeper in the female lumbar spine. Heavywork results in lower BF. Last but not the least, as we supposed, BF gets shallower and higher compare to VB with age. Level of evidence Prognostic level III. See instructions for authors for a complete description of levels of evidence.
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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10
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Santifort KM, Glass EN, Meij BP, Bergknut N, Pumarola M, Gil VA. Anatomic description of the basivertebral nerve and meningeal branch of the spinal nerve in the dog. Ann Anat 2022; 245:152000. [PMID: 36183940 DOI: 10.1016/j.aanat.2022.152000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The existence of the basivertebral nerve and meningeal branch of the spinal nerve has not been proven in dogs to date. The objectives of this study are to 1) determine whether dogs have a meningeal branch of the spinal nerve (MBSN) and a basivertebral nerve (BVN) and to (2) describe anatomical characteristics of these two nerves. Authors also put forward a discussion on the possible clinical relevance of these findings. MATERIAL AND METHODS Dissections were performed on six embalmed dogs at the Veterinary Faculty of Barcelona with the use of stereomicroscopy and microsurgery equipment. RESULTS The MBSN (grossly) and BVN (grossly and histologically) were identified in the cervical, thoracic, and lumbar region in all dog specimens. In addition, other small fibers (suspected nerves) entering the vertebral body through small foramina close to the end plates were identified. Histological examination of the tissues confirmed the presence of nerve fibers (myelinated and unmyelinated) in suspected BVN samples. Results of the present study indicated that dogs have BVNs. Also, suspected nerve fibers were identified among the epidural fat, running from the intervertebral foramina, that likely represent the MBSN. CONCLUSION These findings open up the discussion on extrapolation of treatment options employed in human medicine for "low back pain", such as BVN ablation, which is discussed in this article. Further anatomic and clinical studies of the innervation for the vertebral body, periosteum, vasculature, dorsal longitudinal ligament and anulus fibrosus are necessary to elucidate possible anatomical variants and breed differences as well as potential clinical (e.g., therapeutic) relevance.
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Affiliation(s)
- K M Santifort
- Evidensia Small Animal Hospital Arnhem, Meander 10, 6825 MB Arnhem, the Netherlands; Evidensia Small Animal Hospital Hart van Brabant, Eerste Zeine 112, 5144 AM Arnhem, the Netherlands.
| | - E N Glass
- Red Bank Veterinary Hospital, Section of Neurology and Neurosurgery, 197 Hance Ave, Tinton Falls, NJ 07724
| | - B P Meij
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 108, 3508 TD Utrecht, the Netherlands
| | - N Bergknut
- Evidensia Small Animal Hospital Arnhem, Meander 10, 6825 MB Arnhem, the Netherlands; Evidensia Small Animal Hospital Hart van Brabant, Eerste Zeine 112, 5144 AM Arnhem, the Netherlands
| | - M Pumarola
- Unit of Compared and Murine Pathology, Department of Animal Medicine and Surgery, Faculty of Veterinary Medicine, Universitat Autònoma de Barcelona, Campus UAB, Travessera dels turons s/n, 08193 Bellaterra (Barcelona), Spain
| | - V Aige Gil
- Department of Sanitat i Anatomía Animal, Faculty of Veterinary Medicine, Universitat Autònoma de Barcelona Campus UAB, Travessera dels turons s/n, 08193, Bellaterra (Barcelona), Spain
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11
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Conger A, Burnham TR, Clark T, Teramoto M, McCormick ZL. The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Ablation for the Treatment of Vertebrogenic Low Back Pain: An Updated Systematic Review with Single-Arm Meta-analysis. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S50-S62. [PMID: 35856331 PMCID: PMC9297160 DOI: 10.1093/pm/pnac070] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To provide an estimate of the effectiveness of basivertebral nerve (BVN) radiofrequency ablation (RFA) to treat vertebrogenic low back pain (LBP). DESIGN Systematic review with single-arm meta-analysis. POPULATION Persons ≥18 years of age with chronic LBP associated with type 1 or 2 Modic changes. INTERVENTION Intraosseous BVN RFA. COMPARISON Sham, placebo procedure, active standard care treatment, or none. OUTCOMES The proportion of patients treated with BVN RFA who reported ≥50% pain score improvement on a visual analog scale or numeric rating scale. The main secondary outcome was ≥15-point improvement in Oswestry Disability Index score. METHODS Three reviewers independently assessed articles published before December 6, 2021, in MEDLINE and Embase. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the overall quality of evidence. RESULTS Of the 856 unique records screened, 12 publications met the inclusion criteria, representing six unique study populations, with 414 participants allocated to receive BVN RFA. Single-arm meta-analysis showed a success rate of 65% (95% confidence interval [CI] 51-78%) and 64% (95% CI 43-82%) for ≥50% pain relief at 6 and 12 months, respectively. Rates of ≥15-point Oswestry Disability Index score improvement were 75% (95% CI 63-86%) and 75% (95% CI 63-85%) at 6 and 12 months, respectively. CONCLUSION According to GRADE, there is moderate-quality evidence that BVN RFA effectively reduces pain and disability in most patients with vertebrogenic LBP. Further high-quality studies will likely improve our understanding of the effectiveness of this procedure.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Taylor R Burnham
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Tyler Clark
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
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McCormick ZL, Sperry BP, Boody BS, Hirsch JA, Conger A, Harper K, Lotz JC, Burnham TR. Pain Location and Exacerbating Activities Associated with Treatment Success Following Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trial Data. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S14-S33. [PMID: 35856332 PMCID: PMC9297150 DOI: 10.1093/pm/pnac069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 04/11/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Develop pain location "maps" and investigate the relationship between low back pain (LBP)-exacerbating activities and treatment response to basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP). DESIGN Aggregated cohort study of 296 patients treated with BVN RFA at 33 centers in three prospective trials. METHODS Participant demographics, pain diagrams, and LBP-exacerbating activities were analyzed for predictors using stepwise logistic regression. Treatment success definitions were: (1) ≥50% LBP visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3 months post-BVN RFA. RESULTS Midline LBP correlated with BVN RFA treatment success in individuals with clinically-suspected VEP. Duration of pain ≥5 years (OR 2.366), lack of epidural steroid injection within 6 months before BVN RFA (OR 1.800), lack of baseline opioid use (OR 1.965), LBP exacerbation with activity (OR 2.099), and a lack of LBP with spinal extension (OR 1.845) were factors associated with increased odds of treatment success. Regressions areas under the curve (AUCs) were under 70%, indicative of low predictive value. CONCLUSIONS This study demonstrates that midline LBP correlates with BVN RFA treatment success in individuals with VEP. While none of the regression models demonstrated strong predictive value, the pain location and exacerbating factors identified in this analysis may aid clinicians in identifying patients where VEP should be more strongly suspected. The use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of anterior spinal element pain remain the most useful patient selection factors for BVN RFA.
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Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Beau P Sperry
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Jeffrey C Lotz
- Department of Orthopaedics, University of California San Francisco, San Francisco, California, USA
| | - Taylor R Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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13
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McCormick ZL, Conger A, Smuck M, Lotz JC, Hirsch JA, Hickman C, Harper K, Burnham TR. Magnetic Resonance Imaging Characteristics Associated with Treatment Success from Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trials Data. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S34-S49. [PMID: 35856328 PMCID: PMC9297152 DOI: 10.1093/pm/pnac093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/09/2022] [Accepted: 06/09/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Investigate associations between endplate and motion segment magnetic resonance imaging (MRI) characteristics and treatment outcomes following basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP). DESIGN Aggregated cohort study of 296 participants treated with BVN RFA from three prospective clinical trials. METHODS Baseline MRI characteristics were analyzed using stepwise logistic regression to identify factors associated with treatment success. Predictive models used three definitions of treatment success: (1) ≥50% low back pain (LBP) visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3-months post-BVN RFA. RESULTS The presence of lumbar facet joint fluid (odds ratio [OR] 0.586) reduced the odds of BVN RFA treatment success in individuals with clinically suspected VEP. In patients with a less advanced degenerative disc disease (DDD) profile, a > 50% area of the endplate with bone marrow intensity changes (BMIC) was predictive of treatment success (OR 4.689). Both regressions areas under the curve (AUCs) were under 70%, indicating low predictive value. All other vertebral endplate, intervertebral disc, nerve roots facet joint, spinal segmental alignment, neuroforamina, lateral recesses, and central canal MRI characteristics were not associated with BVN RFA success. CONCLUSIONS In patients with vertebrogenic low back pain with Modic changes, the presence of degenerative findings of the anterior and posterior column was not associated with a clinically important impact on BVN RFA treatment success. None of the models demonstrated strong predictive value, indicating that the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of pain remain the most useful patient selection factors for BVN RFA.
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Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Matthew Smuck
- Department of Orthopedics, Stanford University, Palo Alto, California, USA
| | - Jeffrey C Lotz
- Department of Orthopedics, University of California San Francisco, San Francisco, California, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Colton Hickman
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Taylor R Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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14
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Boody BS, Sperry BP, Harper K, Macadaeg K, McCormick ZL. The Relationship Between Patient Demographic and Clinical Characteristics and Successful Treatment Outcomes After Basivertebral Nerve Radiofrequency Ablation: A Pooled Cohort Study of Three Prospective Clinical Trials. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S2-S13. [PMID: 35856330 PMCID: PMC9297161 DOI: 10.1093/pm/pnac050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Multiple studies have demonstrated the safety and effectiveness of basivertebral nerve radiofrequency ablation (BVN RFA) for improving low back pain related to the vertebral endplate. However, the influence of patient demographic and clinical characteristics on treatment outcome is unknown. DESIGN Pooled cohort study of three clinical trials of patients with vertebral endplate pain identified by Type 1 and/or Type 2 Modic changes and a correlating presentation of anterior spinal element pain. SETTING Thirty-three global study centers. SUBJECTS Patients (n = 296) successfully treated with BVN RFA. METHODS Participant demographic and clinical characteristics were analyzed with stepwise logistic regression to identify predictors of treatment success. Three definitions of treatment success were defined: 1) ≥50% visual analog scale pain improvement, 2) ≥15-point Oswestry Disability Index (ODI) improvement, and 3) ≥50% visual analog scale or ≥15-point ODI improvement from baseline. RESULTS Low back pain of ≥5 years' duration and higher ODI scores at baseline increased the odds of treatment success, whereas baseline opioid use and higher Beck Depression Inventory scores reduced these odds. However, the three regression models demonstrated receiver-operating characteristics of 62-70% areas under the curve, and thus, limited predictive capacity. CONCLUSIONS This analysis identified no demographic or clinical characteristic that meaningfully increased or reduced the odds of treatment success from BVN RFA. On the basis of these findings and the high response rates from the three analyzed trials, we recommend the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of anterior spinal element pain to determine optimal candidacy for BVN RFA.
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Affiliation(s)
| | - Beau P Sperry
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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15
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Conger A, Smuck M, Truumees E, Lotz JC, DePalma MJ, McCormick ZL. Vertebrogenic Pain: A Paradigm Shift in Diagnosis and Treatment of Axial Low Back Pain. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S63-S71. [PMID: 35856329 PMCID: PMC9297155 DOI: 10.1093/pm/pnac081] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/22/2022] [Accepted: 05/01/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Matthew Smuck
- Department of Orthopaedics, Stanford University, Redwood City, CA, USA
| | - Eeric Truumees
- The University of Texas Dell Medical School, Ascension Texas Spine and Scoliosis, Austin, TX, USA
| | - Jeffrey C Lotz
- Department of Orthopaedics, University of California San Francisco, San Francisco, CA, USA
| | | | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
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16
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De Vivo AE, D'Agostino G, D'Anna G, Al Qatami H, Gil I, Ventura F, Manfrè L. Response to letter to the editor: "Methodological concerns of Intra-osseous basivertebral nerve radiofrequency ablation (BVA) for the treatment of vertebrogenic chronic low back pain". Neuroradiology 2022; 64:431-432. [PMID: 35015093 DOI: 10.1007/s00234-021-02871-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/25/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Aldo Eros De Vivo
- Minimally Invasive Spine Therapy Department, Via Penninazzo 7, I.O.M., 95029, Viagrande, Catania, Italy.
| | | | - Gennaro D'Anna
- Radiology Unit, Humanitas Mater Domini, Castellanza, Varese, Italy
| | - Hosam Al Qatami
- Neuroscience Institution, Hamad General Hospital, Doha, Qatar
| | - Ines Gil
- Department of Neuroradiology, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Fausto Ventura
- Minimally Invasive Spine Therapy Department, Via Penninazzo 7, I.O.M., 95029, Viagrande, Catania, Italy
| | - Luigi Manfrè
- Minimally Invasive Spine Therapy Department, Via Penninazzo 7, I.O.M., 95029, Viagrande, Catania, Italy
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17
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McCormick ZL. OUP accepted manuscript. PAIN MEDICINE 2022; 23:S1. [PMID: 35856327 PMCID: PMC9297148 DOI: 10.1093/pm/pnac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Zachary L McCormick
- Correspondence to: Zachary L. McCormick, MD, Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine. 590 Wakara Way, Salt Lake City, Utah, 84108, USA. Tel: 801-587-5458; Fax: 801-587-7111; E-mail:
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18
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Tieppo Francio V, Gill B, Rupp A, Sack A, Sayed D. Interventional Procedures for Vertebral Diseases: Spinal Tumor Ablation, Vertebral Augmentation, and Basivertebral Nerve Ablation-A Scoping Review. Healthcare (Basel) 2021; 9:1554. [PMID: 34828599 PMCID: PMC8624649 DOI: 10.3390/healthcare9111554] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 12/13/2022] Open
Abstract
Low back pain is consistently documented as the most expensive and leading cause of disability. The majority of cases have non-specific etiologies. However, a subset of vertebral diseases has well-documented pain generators, including vertebral body tumors, vertebral body fractures, and vertebral endplate injury. Over the past two decades, specific interventional procedures targeting these anatomical pain generators have been widely studied, including spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation. This scoping review summarizes safety and clinical efficacy and discusses the impact on healthcare utilization of these interventions. Vertebral-related diseases remain a top concern with regard to prevalence and amount of health care spending worldwide. Our study shows that for a subset of disorders related to the vertebrae, spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation are safe and clinically effective interventions to decrease pain, improve function and quality of life, and potentially reduce mortality, improve survival, and overall offer cost-saving opportunities.
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Affiliation(s)
- Vincius Tieppo Francio
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), Kansas City, KS 66160, USA;
| | - Benjamin Gill
- Department of Physical Medicine and Rehabilitation, The University of Missouri, Columbia, MO 65212, USA;
| | - Adam Rupp
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), Kansas City, KS 66160, USA;
| | - Andrew Sack
- Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS 66160, USA; (A.S.); (D.S.)
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS 66160, USA; (A.S.); (D.S.)
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Michalik A, Conger A, Smuck M, Maus TP, McCormick ZL. Intraosseous Basivertebral Nerve Radiofrequency Ablation for the Treatment of Vertebral Body Endplate Low Back Pain: Current Evidence and Future Directions. PAIN MEDICINE 2021; 22:S24-S30. [PMID: 34308955 DOI: 10.1093/pm/pnab117] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Recently, basivertebral nerve (BVN) radiofrequency ablation has been developed for the treatment of chronic low back pain (CLBP) thought to arise from the vertebral body endplates (VEPs). This review describes the relevant neuroanatomy and pathobiology of VEP degeneration and injury, imaging correlates of presumed VEP pain, randomized controlled trials performed, appropriate patient selection, and safety. Anatomic, histological, and clinical evidence supports the concept of the VEP as a source of CLBP and the nociceptive role of the BVN. BVN radiofrequency ablation appears to be an effective treatment for a subset of patients with CLBP and evidence of Modic change types 1 and 2 in the L3 to S1 VEPs who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results.
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Affiliation(s)
- Adam Michalik
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Matthew Smuck
- Division of Physical Medicine & Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Timothy P Maus
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
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20
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McCormick ZL, Hurley R. The Evolution of Radiofrequency Denervation for Pain Indications. PAIN MEDICINE 2021; 22:1465-1467. [PMID: 34051101 DOI: 10.1093/pm/pnab180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Robert Hurley
- Departments of Anesthesiology, and Neurobiology and Anatomy, Wake Forest University School of Medicine, North Carolina, USA
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21
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Conger A, Schuster NM, Cheng DS, Sperry BP, Joshi AB, Haring RS, Duszynski B, McCormick ZL. The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Neurotomy for the Treatment of Chronic Low Back Pain in Patients with Modic Changes: A Systematic Review. PAIN MEDICINE 2021; 22:1039-1054. [PMID: 33544851 DOI: 10.1093/pm/pnab040] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Determine the effectiveness of intraosseous basivertebral nerve radiofrequency neurotomy for the treatment of chronic low back pain with type 1 or 2 Modic changes. DESIGN Systematic review. POPULATION Persons aged ≥18 years with chronic low back pain with type 1 or 2 Modic changes. INTERVENTION Intraosseous basivertebral nerve radiofrequency neurotomy. COMPARISON Sham, placebo procedure, active standard care treatment, or none. OUTCOMES The primary outcome of interest was the proportion of individuals with ≥50% pain reduction. Secondary outcomes included ≥10-point improvement in function as measured by Oswestry Disability Index as well as ≥2-point reduction in pain score on the Visual Analog Scale or Numeric Rating Scale, and decreased use of pain medication. METHODS Three reviewers independently assessed publications before May 15, 2020, in MEDLINE and Embase and the quality of evidence was evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation framework. RESULTS Of the 725 publications screened, seven publications with 321 participants were ultimately included. The reported 3-month success rate for ≥50% pain reduction ranged from 45% to 63%. Rates of functional improvement (≥10-point Oswestry Disability Index improvement threshold) ranged from 75% to 93%. For comparison to sham treatment, the relative risk of treatment success defined by ≥50% pain reduction and ≥10-point Oswestry Disability Index improvement was 1.25 (95% confidence interval [CI]: .88-1.77) and 1.38 (95% CI: 1.10-1.73), respectively. For comparison to continued standard care treatment the relative risk of treatment success defined by ≥50% pain reduction and ≥10-point Oswestry Disability Index improvement was 4.16 (95% CI: 2.12-8.14) and 2.32 (95% CI: 1.52-3.55), respectively. CONCLUSIONS There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Nathaniel M Schuster
- Center for Pain Medicine, Department of Anesthesiology, University of California, San Diego, La Jolla, California, USA
| | - David S Cheng
- Department of Neurological Surgery, University of Southern California, Los Angeles, California, USA
| | - Beau P Sperry
- University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Anand B Joshi
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - R Sterling Haring
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
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Tieppo Francio V, Sherwood D, Twohey E, Barndt B, Pagan-Rosado R, Eubanks J, Sayed D. Developments in Minimally Invasive Surgical Options for Vertebral Pain: Basivertebral Nerve Ablation - A Narrative Review. J Pain Res 2021; 14:1887-1907. [PMID: 34188535 PMCID: PMC8236249 DOI: 10.2147/jpr.s287275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022] Open
Abstract
Historically, intervertebral disc degeneration has been the etiological target of chronic low back pain; however, disc degeneration is not necessarily directly associated with pain, and many other anatomical structures are potential etiologies. The vertebral endplates have been postulated to be a source of vertebral pain, where these endplates become particularly susceptible to increased expression of nociceptors and inflammatory proliferation carried by the basivertebral nerve (BVN), expressed on diagnostic imaging as Modic changes. This is useful diagnostic information that can help physicians to phenotype a subset of low back pain, which is known as vertebral pain, in order to directly target interventions, such as BVN ablation, to this significant pain generator. Therefore, this review describes the safety, efficacy, and the rationale behind the use of BVN ablation, a minimally invasive spinal intervention, for the treatment of vertebral pain. Our current literature review of available up-to-date publications utilizing BVN ablation in the treatment of vertebral pain suggests that there is limited, but moderate-quality evidence that this is an effective intervention for reduction of disability and improvement in function, at short- and long-term follow-up, in addition to limited moderate-quality evidence that BVN RFA is superior to conservative care for pain reduction, at least at 3-month follow-up. Our review concluded that there is a highly clinical and statistically significant treatment effect of BVN ablation for vertebral pain with clinically meaningful benefits in pain reduction, functional improvements, opioid dose reduction, and improved quality of life. There were no reported device-related patient deaths or serious AEs based on the available literature. BVN ablation is a safe, well-tolerated and clinically beneficial intervention for vertebral pain, when proper patient selection and surgical/procedural techniques are applied.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - David Sherwood
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric Twohey
- Gundersen Health System Transitional, La Crosse, WI, USA
| | - Brandon Barndt
- Department of Physical Medicine and Rehabilitation, Temple University and Moss Rehabilitation, Philadelphia, PA, USA
| | - Robert Pagan-Rosado
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - James Eubanks
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center, Kansas City, KS, USA
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23
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Smuck M, Khalil J, Barrette K, Hirsch JA, Kreiner S, Koreckij T, Garfin S, Mekhail N. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. Reg Anesth Pain Med 2021; 46:683-693. [PMID: 34031220 PMCID: PMC8311085 DOI: 10.1136/rapm-2020-102259] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/26/2021] [Indexed: 11/25/2022]
Abstract
Introduction Vertebral endplates, innervated by the basivertebral nerve (BVN), are a source of chronic low back pain correlated with Modic changes. A randomized trial comparing BVN ablation to standard care (SC) recently reported results of an interim analysis. Here, we report the results of the full randomized trial, including the 3-month and 6-month between-arm comparisons, 12-month treatment arm results, and 6-month outcomes of BVN ablation in the former SC arm. Methods Prospective, open label, 1:1 randomized controlled trial of BVN ablation versus SC in 23 US sites with follow-up at 6 weeks, 3, 6, 9, and 12 months. SC patients were re-baselined and followed up for 6 months post BVN ablation. The primary endpoint was the between-arm comparison of mean Oswestry Disability Index (ODI) change from baseline. Secondary endpoints were Visual Analog Scale (VAS), Short Form (SF-36), EuroQual Group 5 Dimension 5-Level Quality of Life (EQ-5D-5L), responder rates, and rates of continued opioid use. Results 140 were randomized. Results from BVN ablation (n=66) were superior to SC (n=74) at 3 months for the primary endpoint (mean ODI reduction, difference between arms of −20.3 (CI −25.9 to −14.7 points; p<0.001)), VAS pain improvement (difference of −2.5 cm between arms (CI −3.37 to −1.64, p<0.001)) and quality of life outcomes. At 12 months, basivertebral ablation demonstrated a 25.7±18.5 point reduction in mean ODI (p<0.001), and a 3.8±2.7 cm VAS reduction (p<0.001) from baseline, with 64% demonstrating ≥50% reduction and 29% pain free. Similarly, the former SC patients who elected BVN ablation (92%) demonstrated a 25.9±15.5 point mean ODI reduction (p<0.001) from baseline. The proportion of opioid use did not change in either group (p=0.56). Discussion/Conclusion BVN ablation demonstrates significant improvements in pain and function over SC, with treatment results sustained through 12 months in patients with chronic low back pain of vertebrogenic origin.
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Affiliation(s)
- Matthew Smuck
- Physical Medicine & Rehabilitation Division, Stanford University, Redwood City, California, USA
| | - Jad Khalil
- Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Kevin Barrette
- Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Joshua Adam Hirsch
- Department of Neurointerventional Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Scott Kreiner
- Neurophysiatry, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Theodore Koreckij
- Orthopaedic Surgery Spine, St Luke's Hospital, Kansas, Missouri, USA
| | - Steven Garfin
- Orthopaedic Surgery, University of California San Diego, La Jolla, California, USA
| | - Nagy Mekhail
- Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
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Can neural signals override cellular decisions in the presence of DNA damage? DNA Repair (Amst) 2021; 103:103127. [PMID: 33990031 DOI: 10.1016/j.dnarep.2021.103127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/23/2022]
Abstract
Cells within an organism are in constant crosstalk with their surrounding environment. Short and long-range signals influence cellular behavior associated with division, differentiation, and death. This crosstalk among cells underlies tissue renewal to guarantee faithful replacement of old or damaged cells over many years. Renewing tissues also offer recurrent opportunities for DNA damage and cellular transformation that tend to occur with aging. Most cells with extensive DNA damage have limited options such as halting cell cycle to repair DNA, undergo senescence, or programmed cell death. However, in some cases cells carrying toxic forms of DNA damage survive and proliferate. The underlying factors driving survival and proliferation of cells with DNA damage remain unknown. Here we discuss potential roles the nervous system may play in influencing the fate of cells with DNA damage. We present a brief survey highlighting the implications the nervous system has in regeneration, regulation of stem cells, modulation of the immune system, and its contribution to cancer progression. Finally, we propose the use of planarian flatworms as a convenient model organism to molecularly dissect the influence of neural signals over cellular fate regulation in the presence of DNA damage.
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Michalik AJ, Patel RK. Evaluation of transforaminal epidural steroid injections for discogenic axial lumbosacral back pain utilizing PROMIS as an outcome measure. Spine J 2021; 21:202-211. [PMID: 33091610 DOI: 10.1016/j.spinee.2020.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/17/2020] [Accepted: 10/14/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Discogenic lumbosacral back pain continues to present a challenging clinical entity with limited, controversial therapeutic options. No study to date has evaluated the efficacy of fluoroscopically guided transforaminal epidural steroid injections (TFESI) in a homogenous patient population with axial lumbosacral back pain from discogenic pathology utilizing strict, explicitly clinical and radiographic criteria. Additionally, there is a paucity of published data utilizing Patient Reported Outcome Measurement Information System (PROMIS) scores as an outcome measure for interventional spine procedures. PURPOSE Evaluate the therapeutic effect of TFESIs in a specific subset of patients with discogenic axial lumbosacral back pain. Investigate PROMIS as an outcome measure for interventional spine procedures targeting focal degenerative spinal pathology. STUDY DESIGN/SETTING Retrospective review of patients presenting to a multidisciplinary, tertiary academic spine center. PATIENT SAMPLE Three thousand eight hundred eighty-one patients were screened for inclusion. A total of 26 patients with discogenic axial low back, based on strict clinical and radiographic criteria, underwent TFESIs. All patients had axial low back pain without radicular pain, ≥3 clinical features of discogenic pain, corroborative radiographic features of active discogenic pathology on lumbar spine magnetic resonance imaging without confounding spinal pathology. OUTCOME MEASURES PROMIS Pain Interference (PI) v1.1, PROMIS Physical Function (PF) v1.2/v2.0, and PROMIS Depression (D) v1.0 outcome scores were collected at baseline and postprocedure follow-up. METHODS Query of an institutional, patient reported outcome database and subsequent retrospective review of electronic medical records was performed. Statistical analysis comparing baseline and postprocedural PROMIS outcome scores and correlation between these instruments was performed. Additionally, an exploratory investigation of minimal clinically important difference achievement rates was performed. RESULTS Analysis determined a statistically significant improvement in PROMIS PI (p=.017, 95% CI=-8.02 to -1.82) and PROMIS PF (p=.003, 95% CI=0.91-8.72) scores after treatment with TFESIs. At post treatment time points, TFESI had medium effect size on pain (d=0.55) and function (d=0.59). Change in PROMIS D scores (p=.488, 95% CI -1.74-3.54; d=.08) did not demonstrate statistical significance. Pearson correlation demonstrated a moderate negative correlation (r=-0.544, p=.004) between PROMIS PF with PROMIS PI. Correlation between PROMIS PF (r=-0.239, p=.24) and PROMIS PI (r=0.198, p=.33) with PROMIS D was not significant. Fourteen (53.8%) and 9 (34.6%) subjects achieved minimum clinically important difference (MCID) for PROMIS PI and PROMIS PF, respectively. Nine subjects (34.6%) achieved MCID for PROMIS D despite not otherwise reaching statistical significance otherwise. CONCLUSIONS Utilizing PROMIS as an outcome measure, discogenic axial lumbosacral back pain patients appear to benefit from TFESI in terms of pain and physical function. This study contributes to the growing body of literature utilizing PROMIS scores in patients with clinical sequelae of degenerative spinal pathology; however, prospective studies are needed.
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Affiliation(s)
- Adam J Michalik
- University of Utah School of Medicine, Division of Physical Medicine and Rehabilitation, Salt Lake City, UT, USA.
| | - Rajeev K Patel
- University of Rochester Medical Center, Department of Physical Medicine and Rehabilitation, Rochester, NY, USA
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Basivertebral Nerve Ablation for the Treatment of Vertebrogenic Pain. Pain Ther 2020; 10:39-53. [PMID: 33128702 PMCID: PMC8119576 DOI: 10.1007/s40122-020-00211-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/08/2020] [Indexed: 12/19/2022] Open
Abstract
Chronic low back pain affects a significant portion of patients worldwide and is a major contributor to patient disability; however, it is a difficult problem to diagnose and treat. The prevailing model of chronic low back pain has presumed to follow a discogenic model, but recent studies have shown a vertebrogenic model that involves the basivertebral nerve (BVN). Radiofrequency ablation of the BVN has emerged as a possible nonsurgical therapy for vertebrogenic low back pain. The objective of this manuscript is to provide a comprehensive review of vertebrogenic pain diagnosis and our current understanding of BVN ablation as treatment.
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Intra-osseous basivertebral nerve radiofrequency ablation (BVA) for the treatment of vertebrogenic chronic low back pain. Neuroradiology 2020; 63:809-815. [PMID: 33051706 DOI: 10.1007/s00234-020-02577-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
STUDY DESIGN Prospective experimental uncontrolled trial. BACKGROUND Vertebrogenic pain is a frequently underestimated cause of chronic low back pain (LBP). Vertebral endplate degeneration, characterized by cortical bone damage and subchondral bone inflammatory reaction, is a significant source of LBP, the responsible of the pain transmission being the Basivertebral Nerve (BVN). Radiofrequency ablation of the BVN (BVA) leads to thermal injury of nerve tissue and interruption of the of chronic vertebrogenic pain transmission. PURPOSE The aim of this study is to evaluate the effectiveness, in terms of pain and disability reduction, of percutaneous (BVA) in treating patients affected by vertebrogenic chronic LBP. Moreover, as a secondary endpoint, the purpose is to assess the feasibility and safety of a percutaneous CT-guided technique. METHODS We performed percutaneous CT-guided BVN ablation in 56 consecutive patients presenting with vertebrogenic chronic LBP in local anesthesia using an articulating bipolar radiofrequency electrode (STAR™ Tumor Ablation System Merit). A 1-month follow-up MRI was performed to evaluate the ablation area in order to assess the target success of the procedure. A 3-month follow-up CT study was performed to evaluate bone mineral density in order to exclude structural bone abnormalities that might have been induced by the treatment. Pre- and post-procedure pain and disability levels were measured using the visual analogue scale (VAS) and Oswestry Disability Index (ODI). A 2-cm improvement threshold was set as clinical success for the VAS score and a 10-point improvement threshold was set as clinical success for the ODI score. RESULTS At 3- and 12-month follow-up, VAS and ODI scores decreased significantly compared to baseline. Clinical success was reached in 54/56 patients (96.5%) for pain and 54/56 patients (96.5%) for disability, exceeding significantly the MCID. CT-assisted targeting of the ablation zone was determined successful in 100% of patients. Mean operative time was 32 min. No immediate or delayed complications were detected. CONCLUSIONS Percutaneous CT-guided intra-osseous BVA seems to be a safe, fast, and powerful technique for pain relief in patients with vertebrogenic chronic LBP, when the selection of patients is based on a multidisciplinary approach including both conventional Diagnostic Radiology and Nuclear Medicine imaging.
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Macadaeg K, Truumees E, Boody B, Pena E, Arbuckle J, Gentile J, Funk R, Singh D, Vinayek S. A prospective, single arm study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. ACTA ACUST UNITED AC 2020; 3:100030. [PMID: 35141598 PMCID: PMC8819913 DOI: 10.1016/j.xnsj.2020.100030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/29/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022]
Abstract
Background The basivertebral nerve (BVN) has been a recently discovered target as a potential source for vertebrogenic chronic low back pain (CLBP). Prior randomized controlled trials have demonstrated safety and efficacy of BVN ablation for vertebrogenic CLBP, but minimal data exists regarding BVN ablation’s clinical effectiveness with broader application outside of strict trial inclusion criteria. Methods Prospective, single arm, open label effectiveness trial of 48 patients from community spine and pain practices treated with BVN ablation. Inclusion criteria required more than 6 months of CLBP and type 1 or 2 Modic changes on MRI to be enrolled. Patients were followed post procedure for 12 months using ODI, VAS, EQ-5D-5L and SF-36 patient reported outcome metrics.Results: 47 patients successfully received BVN ablation and 45 patients completed 12 months of follow up. Mean reduction in ODI at 12 months was 32.31 +/- 14.07 (p<0.001) with 88.89% (40/45) patients reporting a ≥15 point ODI decrease at 12 months. Mean VAS pain score decrease was 4.31+/-2.51 at 12 months (p<0.001) and more than 69% reported a 50% reduction in VAS pain scale. Similarly, SF-36 and EQ-5D-5L scores improved 26.27+/-17.19 and 0.22+/-0.15 (each p<0.001). Conclusions This data supports the clinical effectiveness of BVN ablation in the community practice setting, with similar 12 month improvements in patient reported outcomes as seen in previously published randomized control trials.
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Affiliation(s)
- K. Macadaeg
- Indiana Spine Group, 13225N Meridian St, Carmel, IN 46032, United States
| | - E. Truumees
- Professor of Orthopedics and Neurosurgery, University of Texas, Dell Medical School, Ascension Texas Spine and Scoliosis Center, Austin, TX, United States
| | - B. Boody
- Indiana Spine Group, 13225N Meridian St, Carmel, IN 46032, United States
- Corresponding author.
| | - E. Pena
- Ascension Texas Spine and Scoliosis Center, Austin, TX, United States
| | - J. Arbuckle
- Indiana Spine Group, 13225N Meridian St, Carmel, IN 46032, United States
| | - J. Gentile
- Indiana Spine Group, 13225N Meridian St, Carmel, IN 46032, United States
| | - R. Funk
- Indiana Spine Group, 13225N Meridian St, Carmel, IN 46032, United States
| | - D. Singh
- Ascension Texas Spine and Scoliosis Center, Austin, TX, United States
| | - S. Vinayek
- Indiana Spine Group, 13225N Meridian St, Carmel, IN 46032, United States
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Markman JD, Rhyne AL, Sasso RC, Patel AA, Hsu WK, Fischgrund JS, Edidin AA, Vajkoczy P. Association Between Opioid Use and Patient-Reported Outcomes in a Randomized Trial Evaluating Basivertebral Nerve Ablation for the Relief of Chronic Low Back Pain. Neurosurgery 2020; 86:343-347. [PMID: 31034561 DOI: 10.1093/neuros/nyz093] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic low back pain (CLBP) is a primary indication for opioid therapy. OBJECTIVE To evaluate the hypothesis that CLBP patients reporting reduced opioid use have superior functional outcomes following basivertebral nerve (BVN) radiofrequency ablation. METHODS This post hoc analysis from a sham-controlled trial examined short-acting opioid use from baseline through 1 yr. Opioid use was stratified into 3 groups by two blinded external reviewers. Two-sample t-tests were used to compare Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) measurements between those patients who increased or decreased their opioid usage compared to baseline. RESULTS Actively treated patients with decreased opioid use at 12 mo had a mean ODI improvement of 24.9 ± 16.0 (n = 27) compared to 7.3 ± 9.8 (n = 18) for patients reporting increased opioid use (P < .001). In the sham arm, the improvements in ODI were 17.4 ± 16.1 (n = 19) and 1.2 ± 14.3 (n = 5; P = .053) for the patients reporting decreased vs increased opioid usage, respectively. Actively treated patients reporting decreased opioid use had a mean improvement in VAS of 3.3 ± 2.5 (n = 27) compared to 0.6 ± 1.8 (n = 18) for patients reporting increased opioid use (P < .001). In the sham arm, the improvements in VAS were 2.5 ± 2.6 (n = 19) and 1.4 ± 1.9 (n = 5; P = .374) for patients reporting decreased vs increased opioid use, respectively. CONCLUSION Subjects undergoing BVN ablation who decreased opioid use had greater improvement in ODI and VAS scores compared with those reporting increased opioid usage. There is an association between functional benefit from BVN ablation and reduced opioid use.
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Affiliation(s)
- John D Markman
- Translational Pain Research Program Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Rick C Sasso
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alpesh A Patel
- Department of Orthopaedic Surgery and Department of Neurosurgery, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Wellington K Hsu
- Department of Orthopaedic Surgery and Department of Neurosurgery, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey S Fischgrund
- Department of Orthopedic Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | | | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin, Berlin, Germany
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Fischgrund JS, Rhyne A, Macadaeg K, Moore G, Kamrava E, Yeung C, Truumees E, Schaufele M, Yuan P, DePalma M, Anderson DG, Buxton D, Reynolds J, Sikorsky M. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham-controlled multi-center study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1925-1934. [DOI: 10.1007/s00586-020-06448-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/21/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
Abstract
Background
Damaged or degenerated vertebral endplates are a significant cause of vertebrogenic chronic low back pain (CLBP). Modic changes are one objective MRI biomarker for these patients. Prior data from the treatment arm of a sham-controlled, RCT showed maintenance of clinical improvements at 2 years following ablation of the basivertebral nerve (BVN). This study reports 5-year clinical outcomes.
Methods
In total, 117 US patients were treated successfully with BVN ablation. Patient-reported outcomes of ODI, VAS, postablation treatments, and patient satisfaction were collected at a minimum of 5-years following BVN ablation. Primary outcome was mean change in ODI. Comparisons between the postablation and baseline values were made using an analysis of covariance with alpha 0.05.
Results
Of the 117 US treated patients 100 (85%) were available for review with a mean follow-up of 6.4 years (5.4–7.8 years). Mean ODI score improved from 42.81 to 16.86 at 5-year follow-up, a reduction of 25.95 points (p < 0.001). Mean reduction in VAS pain score was 4.38 points (baseline of 6.74, p < 0.001). In total, 66% of patients reported a > 50% reduction in pain, 47% reported a > 75% reduction in pain, and 34% of patients reported complete pain resolution. Composite responder rate using thresholds of ≥ 15-point ODI and ≥ 2-point VAS for function and pain at 5 years was 75%.
Conclusion
CLBP patients treated with BVN ablation exhibit sustained clinical improvements in function and pain with high responder rates at a mean of 6.4 years following treatment. BVN ablation is a durable, minimally invasive treatment for vertebrogenic CLBP.
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Kim HS, Wu PH, Jang IT. Lumbar Degenerative Disease Part 1: Anatomy and Pathophysiology of Intervertebral Discogenic Pain and Radiofrequency Ablation of Basivertebral and Sinuvertebral Nerve Treatment for Chronic Discogenic Back Pain: A Prospective Case Series and Review of Literature. Int J Mol Sci 2020; 21:ijms21041483. [PMID: 32098249 PMCID: PMC7073116 DOI: 10.3390/ijms21041483] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 01/17/2023] Open
Abstract
Degenerative disc disease is a leading cause of chronic back pain in the aging population in the world. Sinuvertebral nerve and basivertebral nerve are postulated to be associated with the pain pathway as a result of neurotization. Our goal is to perform a prospective study using radiofrequency ablation on sinuvertebral nerve and basivertebral nerve; evaluating its short and long term effect on pain score, disability score and patients’ outcome. A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain. 30 patients with 38 levels of intervertebral disc presented with discogenic back pain with bulging degenerative intervertebral disc or spinal stenosis underwent Uniportal Full Endoscopic Radiofrequency Ablation application through either Transforaminal or Interlaminar Endoscopic Approaches. Their preoperative characteristics are recorded and prospective data was collected for Visualized Analogue Scale, Oswestry Disability Index and MacNab Criteria for pain were evaluated. There was statistically significant Visual Analogue Scale improvement from preoperative state at post-operative 1wk, 6 months and final follow up were 4.4 ± 1.0, 5.5 ± 1.2 and 5.7 ± 1.3, respectively, p < 0.0001. Oswestery Disability Index improvement from preoperative state at 1week, 6 months and final follow up were 45.8 ± 8.7, 50.4 ± 8.2 and 52.7 ± 10.3, p < 0.0001. MacNab criteria showed excellent outcomes in 17 cases, good outcomes in 11 cases and fair outcomes in 2 cases Sinuvertebral Nerve and Basivertebral Nerve Radiofrequency Ablation is effective in improving the patients’ pain, disability status and patient outcome in our study.
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Affiliation(s)
- Hyeun Sung Kim
- Nanoori Gangnam Hospital, Seoul, Spine Surgery, Seoul 06048, Korea; (P.H.W.); (I.-T.J.)
- Correspondence: ; Tel.: +82-2-6003-9767; Fax.: +82-2-3445-9755
| | - Pang Hung Wu
- Nanoori Gangnam Hospital, Seoul, Spine Surgery, Seoul 06048, Korea; (P.H.W.); (I.-T.J.)
- National University Health Systems, Juronghealth Campus, Orthopaedic Surgery, Singapore 609606, Singapore
| | - Il-Tae Jang
- Nanoori Gangnam Hospital, Seoul, Spine Surgery, Seoul 06048, Korea; (P.H.W.); (I.-T.J.)
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Wong DA. Basivertebral nerve ablation: does the path followed suggest this technology is ready for adoption into clinical practice?: COMMENTARY ON: Khalil J et al. A prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. SpineJ. 2019;10:1620-1632. DOI: https://doi.org/10.1016/j.spinee.2019.05.598. Spine J 2020; 20:154-155. [PMID: 32000959 DOI: 10.1016/j.spinee.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/04/2019] [Accepted: 10/07/2019] [Indexed: 02/03/2023]
Affiliation(s)
- David A Wong
- Presbyterian St. Luke's Medical Center Denver, Advanced Center for Spinal Microsurgery, 1719 East 19th Ave, Denver, CO 80218, USA.
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Khalil JG, Smuck M, Koreckij T, Keel J, Beall D, Goodman B, Kalapos P, Nguyen D, Garfin S. A prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J 2019; 19:1620-1632. [PMID: 31229663 DOI: 10.1016/j.spinee.2019.05.598] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/24/2019] [Accepted: 05/29/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Current literature suggests that degenerated or damaged vertebral endplates are a significant cause of chronic low back pain (LBP) that is not adequately addressed by standard care. Prior 2-year data from the treatment arm of a sham-controlled randomized controlled trial (RCT) showed maintenance of clinical improvements at 2 years following radiofrequency (RF) ablation of the basivertebral nerve (BVN). PURPOSE The purpose of this RCT was to compare the effectiveness of intraosseous RF ablation of the BVN to standard care for the treatment of chronic LBP in a specific subgroup of patients suspected to have vertebrogenic related symptomatology. STUDY DESIGN/SETTING A prospective, parallel, open label RCT was conducted at 20 U.S. sites. PATIENT SAMPLE A total of 140 patients with chronic LBP of at least 6 months duration, with Modic Type 1 or 2 vertebral endplate changes between L3 and S1, were randomized 1:1 to undergo either RF ablation of the BVN or continue standard care. OUTCOME MEASURES Oswestry Disability Index (ODI) was collected at baseline, 3, 6, 9, and 12-months postprocedure. Secondary outcome measures included a 10-point Visual Analog Scale (VAS) for LBP, ODI and VAS responder rates, SF-36, and EQ-5D-5L. The primary endpoint was a between-arm comparison of the mean change in ODI from baseline to 3 months post-treatment. METHODS Patients were randomized 1:1 to receive RF ablation or to continue standard care. Self-reported patient outcomes were collected using validated questionnaires at each study visit. An interim analysis to assess for superiority was prespecified and overseen by an independent data management committee when a minimum of 60% of patients had completed their 3-month primary endpoint visit. RESULTS The interim analysis showed clear statistical superiority (p<.001) for all primary and secondary patient-reported outcome measures in the RF ablation arm compared with the standard care arm. This resulted in a data management committee recommendation to halt enrollment in the study and offer early cross-over to the control arm. These results are comprised of the outcomes of the 104 patients included in the intent-to-treat analysis of the 3-month primary endpoint, which included 51 patients in the RF ablation arm and 53 patients in the standard care arm. Baseline ODI was 46.1, VAS was 6.67, and mean age was 50 years. The percentage of patients with LBP symptoms ≥5 years was 67.3%. Comparing the RF ablation arm to the standard care arm, the mean changes in ODI at 3 months were -25.3 points versus -4.4 points, respectively, resulting in an adjusted difference of 20.9 points (p<.001). Mean changes in VAS were -3.46 versus -1.02, respectively, an adjusted difference of 2.44 cm (p<.001). In the RF ablation arm, 74.5% of patients achieved a ≥10-point improvement in ODI, compared with 32.7% in the standard care arm (p<0.001). CONCLUSIONS Minimally invasive RF ablation of the BVN led to significant improvement of pain and function at 3-months in patients with chronic vertebrogenic related LBP.
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Affiliation(s)
- Jad G Khalil
- William Beaumont Hospital, Department of Orthopaedic Surgery, 3811 West 13 Mile Rd, Royal Oak, MI 48073, USA.
| | - Matthew Smuck
- Stanford Orthopedic Surgery, 450 Broadway St, Pavillion C, Redwood City, CA 94063, USA
| | - Theodore Koreckij
- Saint Luke's Hospital, Medical Plaza Bldg 1, Ste. 610, 4320 Wornall Rd, Kansas City, MO 64111, USA
| | - John Keel
- Emory Orthopedics/Spine Center, 59 Executive Park South NE, Atlanta, GA 30329, USA
| | - Douglas Beall
- Clinical Investigations, LLC, 1800 S. Renaissance Blvd, Ste 110, Edmond, OK 73013, USA
| | - Bradly Goodman
- Alabama Clinical Therapeutics, LLC, 52 Medical Park East Drive, Suite 203, Birmingham, Alabama 35235, USA
| | - Paul Kalapos
- Penn State Hershey Medical Center, 500 University Drive, H066, Hershey, PA 17033, USA
| | - Dan Nguyen
- Oklahoma Spine Hospital, 14100 Parkway Commons Drive, Ste 103, Oklahoma City, OK 73134, USA
| | - Steven Garfin
- University of California San Diego, 9500 Gilman Drive, #0602, La Jolla, CA 92093-0602, USA
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Truumees E, Macadaeg K, Pena E, Arbuckle J, Gentile J, Funk R, Singh D, Vinayek S. A prospective, open-label, single-arm, multi-center study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1594-1602. [DOI: 10.1007/s00586-019-05995-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/28/2019] [Accepted: 05/01/2019] [Indexed: 12/21/2022]
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Fischgrund JS, Rhyne A, Franke J, Sasso R, Kitchel S, Bae H, Yeung C, Truumees E, Schaufele M, Yuan P, Vajkoczy P, Depalma M, Anderson DG, Thibodeau L, Meyer B. Intraosseous Basivertebral Nerve Ablation for the Treatment of Chronic Low Back Pain: 2-Year Results From a Prospective Randomized Double-Blind Sham-Controlled Multicenter Study. Int J Spine Surg 2019; 13:110-119. [PMID: 31131209 DOI: 10.14444/6015] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The purpose of the present study is to report the 2-year clinical outcomes for chronic low back pain (CLBP) patients treated with radiofrequency (RF) ablation of the basivertebral nerve (BVN) in a randomized controlled trial that previously reported 1-year follow up. Methods A total of 147 patients were treated with RF ablation of the BVN in a randomized controlled trial designed to demonstrate safety and efficacy as part of a Food and Drug Administration-Investigational Device Exemption trial. Evaluations, including patient self-assessments, physical and neurological examinations, and safety assessments, were performed at 2 and 6 weeks, and 3, 6, 12, 18, and 24 months postoperatively. Participants randomized to the sham control arm were allowed to cross to RF ablation at 12 months. Due to a high rate of crossover, RF ablation treated participants acted as their own control in a comparison to baseline for the 24-month outcomes. Results Clinical improvements in the Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and the Medical Outcomes Trust Short-Form Health Survey Physical Component Summary were statistically significant compared to baseline at all follow-up time points through 2 years. The mean percent improvements in ODI and VAS compared to baseline at 2 years were 53.7 and 52.9%, respectively. Responder rates for ODI and VAS were also maintained through 2 years with patients showing clinically meaningful improvements in both: ODI ≥ 10-point improvement in 76.4% of patients and ODI ≥ 20-point improvement in 57.5%; VAS ≥ 1.5 cm improvement in 70.2% of patients. Conclusions Patients treated with RF ablation of the BVN for CLBP exhibited sustained clinical benefits in ODI and VAS and maintained high responder rates at 2 years following treatment. Basivertebral nerve ablation appears to be a durable, minimally invasive treatment for the relief of CLBP.
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Affiliation(s)
- Jeffrey S Fischgrund
- Department of Orthopedic Surgery, Oakland University, William Beaumont School of Medicine, Royal Oak, Michigan
| | - Alfred Rhyne
- OrthoCarolina Spine Center, Charlotte, North Carolina
| | - Jörg Franke
- Department of Orthopedics-Spine and Pediatric Orthopedics, Klinikum Magdeburg gGmbH, Magdeburg, Germany
| | - Rick Sasso
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Hyun Bae
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | | | - Eeric Truumees
- Seton Brain & Spine Institute, Department of Surgery, Dell Medical School, Seton Spine & Scoliosis Center, Austin, Texas
| | | | - Philip Yuan
- Department of Surgery, Long Beach Memorial Medical Center, Long Beach, California
| | - Peter Vajkoczy
- Department of Neurosugery, Charité Universitätsmedizin, Berlin Campus, Virchow Medical Center, Berlin, Germany
| | | | - David G Anderson
- Department of Orthopaedic and Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Bernhard Meyer
- Direktor der Neurochirurgische Klinik und Poliklinik, Technischen Universität München, Klinikum rechts der Isar, Munich, Germany
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Capoor MN, Ruzicka F, Sandhu G, Rollason J, Mavrommatis K, Ahmed FS, Schmitz JE, Raz A, Brüggemann H, Lambert PA, Fischetti VA, Slaby O. Importance of Propionibacterium acnes hemolytic activity in human intervertebral discs: A microbiological study. PLoS One 2018; 13:e0208144. [PMID: 30496247 PMCID: PMC6264842 DOI: 10.1371/journal.pone.0208144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 11/11/2018] [Indexed: 11/18/2022] Open
Abstract
Most patients with chronic lower back pain (CLBP) exhibit degenerative disc disease. Disc specimens obtained during initial therapeutic discectomies are often infected/colonized with Propionibacterium acnes, a Gram-positive commensal of the human skin. Although pain associated with infection is typically ascribed to the body's inflammatory response, the Gram-positive bacterium Staphylococcus aureus was recently observed to directly activate nociceptors by secreting pore-forming α-hemolysins that disrupt neuronal cell membranes. The hemolytic activity of P. acnes in cultured disc specimens obtained during routine therapeutic discectomies was assessed through incubation on sheep-blood agar. The β-hemolysis pattern displayed by P. acnes on sheep-blood agar was variable and phylogroup-dependent. Their molecular phylogroups were correlated with their hemolytic patterns. Our findings raise the possibility that pore-forming proteins contribute to the pathogenesis and/or symptomology of chronic P. acnes disc infections and CLBP, at least in a subset of cases.
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Affiliation(s)
- Manu N. Capoor
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, New York, New York, United States of America
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Filip Ruzicka
- Department of Microbiology, Faculty of Medicine, Masaryk University, St. Anne's University Hospital, Brno, Czech Republic
| | - Gurpreet Sandhu
- Faculty of Health and Life Sciences, School of Life Sciences, Coventry University, Coventry, United Kingdom
| | - Jess Rollason
- Faculty of Health and Life Sciences, School of Life Sciences, Coventry University, Coventry, United Kingdom
| | - Konstantinos Mavrommatis
- Celgene Corporation, Information Knowledge and Utilization, San Francisco, California, United States of America
| | - Fahad S. Ahmed
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Jonathan E. Schmitz
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Assaf Raz
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, New York, New York, United States of America
| | | | - Peter A. Lambert
- The School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham, United Kingdom
| | - Vincent A. Fischetti
- Laboratory of Bacterial Pathogenesis and Immunology, Rockefeller University, New York, New York, United States of America
| | - Ondrej Slaby
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
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Transforaminal Epiduroscopic Basivertebral Nerve Laser Ablation for Chronic Low Back Pain Associated with Modic Changes: A Preliminary Open-Label Study. Pain Res Manag 2018; 2018:6857983. [PMID: 30186540 PMCID: PMC6112211 DOI: 10.1155/2018/6857983] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/04/2018] [Accepted: 07/24/2018] [Indexed: 11/28/2022]
Abstract
Background Chronic low back pain (CLBP) arising from degenerative disc disease continues to be a challenging clinical and diagnostic problem whether treated with nonsurgical, pain intervention, or motion-preserving stabilization and arthrodesis. Methods Fourteen patients with CLBP, greater than 6 months, unresponsive to at least 4 months of conservative care were enrolled. All patients were treated successfully following screening using MRI findings of Modic type I or II changes and positive confirmatory provocative discography to determine the affected levels. All patients underwent ablation of the basivertebral nerve (BVN) using 1414 nm Nd:YAG laser-assisted energy guided in a transforaminal epiduroscopic approach. Macnab's criteria and visual analog scale (VAS) score were collected retrospectively at each follow-up interval. Results The mean age was 46 ± 9.95 years. The mean symptoms duration was 21.21 ± 21.87 months. The mean follow-up was 15.3 ± 2.67 months. The preoperative VAS score of 7.79 ± 0.97 changed to 1.92 ± 1.38, postoperatively (P < 0.01). As per Macnab's criteria, seven patients (50%) had excellent, six patients (42.85%) had good, and one patient (7.14%) had fair outcomes. Conclusion The transforaminal epiduroscopic basivertebral nerve laser ablation (TEBLA) appears to be a promising option in carefully selected patients with CLBP associated with the Modic changes.
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Fischgrund JS, Rhyne A, Franke J, Sasso R, Kitchel S, Bae H, Yeung C, Truumees E, Schaufele M, Yuan P, Vajkoczy P, DePalma M, Anderson DG, Thibodeau L, Meyer B. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: a prospective randomized double-blind sham-controlled multi-center study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1146-1156. [PMID: 29423885 DOI: 10.1007/s00586-018-5496-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/11/2018] [Accepted: 01/24/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of radiofrequency (RF) ablation of the basivertebral nerve (BVN) for the treatment of chronic low back pain (CLBP) in a Food and Drug Administration approved Investigational Device Exemption trial. The BVN has been shown to innervate endplate nociceptors which are thought to be a source of CLBP. METHODS A total of 225 patients diagnosed with CLBP were randomized to either a sham (78 patients) or treatment (147 patients) intervention. The mean age within the study was 47 years (range 25-69) and the mean baseline ODI was 42. All patients had Type I or Type II Modic changes of the treated vertebral bodies. Patients were evaluated preoperatively, and at 2 weeks, 6 weeks and 3, 6 and 12 months postoperatively. The primary endpoint was the comparative change in ODI from baseline to 3 months. RESULTS At 3 months, the average ODI in the treatment arm decreased 20.5 points, as compared to a 15.2 point decrease in the sham arm (p = 0.019, per-protocol population). A responder analysis based on ODI decrease ≥ 10 points showed that 75.6% of patients in the treatment arm as compared to 55.3% in the sham control arm exhibited a clinically meaningful improvement at 3 months. CONCLUSION Patients treated with RF ablation of the BVN for CLBP exhibited significantly greater improvement in ODI at 3 months and a higher responder rate than sham treated controls. BVN ablation represents a potential minimally invasive treatment for the relief of chronic low back pain. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Jeffrey S Fischgrund
- Department of Orthopedic Surgery, Oakland University William Beaumont School of Medicine, 3535 West 13 Mile Road, Suite 744, Royal Oak, MI, 48073, USA.
| | - A Rhyne
- Ortho Carolina Spine Center, Charlotte, USA
| | - J Franke
- Department of Orthopedics-Spine and Pediatric Orthopedics, Klinikum Magdeburg GmbH, Magdeburg, Germany
| | - R Sasso
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, USA
| | | | - H Bae
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, USA
| | - C Yeung
- Desert Institute for Spine Care, Phoenix, USA
| | - E Truumees
- Seton Spine and Scoliosis Center, Seton Medical Center, Brackenridge University Hospital, Austin, USA
| | - M Schaufele
- Pain Solutions Treatment Centers, Marietta, USA
| | - P Yuan
- Long Beach Memorial Medical Center, Long Beach, USA
| | - P Vajkoczy
- Department of Neurosurgery, Charité-Universitaetsmedizin Berlin, Campus Virchow Medical Center, Berlin, Germany
| | - M DePalma
- Virginia iSpine Physicians, Richmond, USA
| | - D G Anderson
- Departments of Orthopaedic and Neurological Surgery, Thomas Jefferson University, Philadelphia, USA
| | | | - B Meyer
- Direktor der Neurochirurgischen Klinik und Poliklinik, Klinikum Rechts der Isar, Munich, Germany
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Trabecular Microstructure and Damage Affect Cement Leakage From the Basivertebral Foramen During Vertebral Augmentation. Spine (Phila Pa 1976) 2017; 42:E939-E948. [PMID: 28098744 DOI: 10.1097/brs.0000000000002073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective study on cadaver specimens. OBJECTIVE To explore why cement leakage from basivertebral foramen (BF) easily occurs during vertebral augmentation procedures. SUMMARY OF BACKGROUND DATA Type B (through BF, basivertebral foramen) cement leakage is the most common type after vertebral augmentation, but the mechanism of this is still controversial. The contribution of vertebral trabecular bone orientation and trabecular damage during compression fracture to cement leakage is still unknown. METHODS In this study, 12 fresh-frozen human lumbar spines (T12-L5) were collected and divided into 24 three-segment units. Mechanical testing was performed to simulate a compression fracture. MicroCT were performed on all segments before and after mechanical testing, and trabecular microstructure of the superior, middle (containing BF), and inferior 1/3 of each vertebral body was analyzed. The diameter variation of intertrabecular space before and after compression fracture was used to quantify trabecular injury. After mechanical testing, vertebral augmentation, and imaging-based diagnosis were used to evaluate cement leakage. RESULTS Trabecular bone microstructural parameters in middle region (containing BF) were lower than those of the superior or inferior regions (P < 0.01). After compressive failure, 3D-reconstruction of the vertebral body by MicroCT demonstrated that intertrabecular distance in the middle region was markedly increased. Type B cement leakage was the most common type after vertebral augmentation, as found previously in Wang et al. (Spine J 2014;14: 1551-1558). CONCLUSION The presence of the BF and the relative sparsity of trabecular bone make the middle region of the vertebral body the mechanically weakest region. Trabecular bone in middle region suffered the most severe damage during compressive failure of the vertebral body, which resulted in the greatest intervertebral spacing, and subsequently the highest percentage of type B cement leakage. These data suggest specific mechanisms by which cement may leak from the BF, and the contribution of trabecular microstructure and trabecular injury. LEVEL OF EVIDENCE 4.
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Becker S, Hadjipavlou A, Heggeness MH. Ablation of the basivertebral nerve for treatment of back pain: a clinical study. Spine J 2017; 17:218-223. [PMID: 27592808 DOI: 10.1016/j.spinee.2016.08.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/24/2016] [Accepted: 08/29/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTENT Lumbar axial back pain arising from degenerative disc disease continues to be a challenging clinical problem whether treated with nonsurgical management, local injection, or motion segment stabilization and fusion. PURPOSE The purpose of this study was to determine the efficacy of intraosseous basivertebral nerve (BVN) ablation for the treatment of chronic lumbar back pain in a clinical setting. STUDY DESIGN Patients meeting predefined inclusion or exclusion criteria were enrolled in a study using radiofrequency energy to ablate the BVN within the vertebral bodies adjacent to the diagnosed level. Patients were evaluated at 6 weeks, and 3, 6, and 12 months postoperatively. PATIENT SAMPLE Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging finding of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years). OUTCOME MEASURES Self-reported outcome measures were collected prospectively at each follow-up interval. Measures included the Oswestry Disability Index (ODI), visual analogue scale score, and Medical Outcomes Trust 36-Item Short-Form Health Survey (SF-36). MATERIALS AND METHODS This is an industry-sponsored study to evaluate the effectiveness of intraosseous nerves in the treatment of chronic back pain. Consented and enrolled patients underwent ablation of the BVN using radiofrequency energy (INTRACEPT System, Relievant Medsystems, Inc, Redwood City, CA, USA) guided in a transpedicular or extrapedicular approach. Preoperative planning determined targeted ablation zone and safety zones. RESULTS Mean baseline ODI of the treated cohort was 52±13, decreasing to a mean of 23±21 at 3 months follow-up (p<.001). The statistically significant improvement in ODI observed at 3 months was maintained through the 12-month follow-up. The mean baseline visual analogue scale score decreased from 61±22 to 45±35 at 3 months follow-up (p<.05), and the mean baseline physical component summary increased from 34.5±6.5 to 41.7±12.4 at 3 months follow-up (p=.03). CONCLUSION Ablation of the BVN for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period.
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Affiliation(s)
- Stephan Becker
- Institute for Musculoskeletal Analysis, Research and Therapy & Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Medimpuls, Piaristengasse 2-4, 1080 Vienna, Austria
| | - Alexander Hadjipavlou
- University Hospital of Iraklion, Eleftherias Square 45, 71201 Heraklion, Crete, Greece
| | - Michael H Heggeness
- University of Kansas School of Medicine-Wichita, Office of Research, 1010 N Kansas, Wichita, KS 67214.
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Tubbs RS, Kirkpatrick CM, Fisahn C, Iwanaga J, Moisi MD, Hanscom DR, Chapman JR, Oskouian RJ. New Landmark for Localizing the Site of the Subdental Synchondrosis Remnant: Application to Discerning Pathology from Normal on Imaging. World Neurosurg 2016; 96:80-84. [PMID: 27591099 DOI: 10.1016/j.wneu.2016.08.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 08/22/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We hypothesized that the entry site of the basivertebral vein into the basivertebral foramen of C2 might localize the subdental synchondrosis between the odontoid process and body of C2, which may be helpful for odontoid fracture classification. METHODS Twenty-five dry adult C2 specimens underwent thin-cut computed tomography and were sectioned sagittally. The basivertebral foramen was then correlated to internal bony anatomy. Fifty magnetic resonance images were reviewed, and the location of the subdental synchondrosis was determined. RESULTS A basivertebral foramen was identified on the posterior surface of all dry C2 specimens. The openings were found at a distance of 30%-44% on an inferosuperior point along the vertical height of C2. For bony specimens with a subdental synchondrosis remnant (75%), entry of acupuncture needles into the basivertebral foramen was always directly at the level of the synchondrosis remnant. For magnetic resonance imaging (MRI), a subdental synchondrosis or its remnants were seen on all studies. The distance from the base of C2 to the subdental synchondrosis ranged from 9-13 mm. This equated to an inferosuperior point 32%-43% along the vertical height of C2. A strong correlation existed when comparing the location of the basivertebral foramen of bony specimens and the subdental synchondrosis location on MRI. CONCLUSIONS The basivertebral foramen is a consistently present anatomic reference point for the subdental synchondrosis even if the latter cannot be seen on conventional radiographic imaging. Our MRI data might also be useful in helping differentiate lesions affecting C2 from normal subdental cartilaginous remnants that can be encountered on imaging.
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Affiliation(s)
- R Shane Tubbs
- Seattle Science Foundation, Swedish Medical Center, Seattle, Washington, USA
| | | | - Christian Fisahn
- Seattle Science Foundation, Swedish Medical Center, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA.
| | - Joe Iwanaga
- Seattle Science Foundation, Swedish Medical Center, Seattle, Washington, USA
| | - Marc D Moisi
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - David R Hanscom
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Jens R Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Rod J Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
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Alves CJ, Neto E, Sousa DM, Leitão L, Vasconcelos DM, Ribeiro-Silva M, Alencastre IS, Lamghari M. Fracture pain-Traveling unknown pathways. Bone 2016; 85:107-14. [PMID: 26851411 DOI: 10.1016/j.bone.2016.01.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 12/14/2015] [Accepted: 01/08/2016] [Indexed: 12/15/2022]
Abstract
An increase of fracture incidence is expected for the next decades, mostly due to the undeniable increase of osteoporotic fractures, associated with the rapid population ageing. The rise in sports-related fractures affecting the young and active population also contributes to this increased fracture incidence, and further amplifies the economical burden of fractures. Fracture often results in severe pain, which is a primary symptom to be treated, not only to guarantee individual's wellbeing, but also because an efficient management of fracture pain is mandatory to ensure proper bone healing. Here, we review the available data on bone innervation and its response to fracture, and discuss putative mechanisms of fracture pain signaling. In addition, the common therapeutic approaches to treat fracture pain are discussed. Although there is still much to learn, research in fracture pain has allowed an initial insight into the mechanisms involved. During the inflammatory response to fracture, several mediators are released and will putatively activate and sensitize primary sensory neurons, in parallel, intense nerve sprouting that occurs in the fracture callus area is also suggested to be involved in pain signaling. The establishment of hyperalgesia and allodynia after fracture indicates the development of peripheral and central sensitization, still, the underlying mechanisms are largely unknown. A major concern during the treatment of fracture pain needs to be the preservation of proper bone healing. However, the most common therapeutic agents, NSAIDS and opiates, can cause significant side effects that include fracture repair impairment. The understanding of the mechanisms of fracture pain signaling will allow the development of mechanisms-based therapies to effectively and safely manage fracture pain.
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Affiliation(s)
- Cecília J Alves
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal; Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Rua Alfredo Allen, 208, 4150-180 Porto, Portugal
| | - Estrela Neto
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal; Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Rua Alfredo Allen, 208, 4150-180 Porto, Portugal; Faculdade de Medicina, Universidade do Porto (FMUP), Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Daniela M Sousa
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal; Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Rua Alfredo Allen, 208, 4150-180 Porto, Portugal
| | - Luís Leitão
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal; Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Rua Alfredo Allen, 208, 4150-180 Porto, Portugal; Instituto Ciências Biomédicas Abel Salazar (ICBAS), Universidade de Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal
| | - Daniel M Vasconcelos
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal; Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Rua Alfredo Allen, 208, 4150-180 Porto, Portugal; Instituto Ciências Biomédicas Abel Salazar (ICBAS), Universidade de Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal
| | - Manuel Ribeiro-Silva
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal; Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Rua Alfredo Allen, 208, 4150-180 Porto, Portugal; Faculdade de Medicina, Universidade do Porto (FMUP), Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal; Serviço de Ortopedia e Traumatologia, Centro Hospitalar São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Inês S Alencastre
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal; Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Rua Alfredo Allen, 208, 4150-180 Porto, Portugal
| | - Meriem Lamghari
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal; Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Rua Alfredo Allen, 208, 4150-180 Porto, Portugal; Instituto Ciências Biomédicas Abel Salazar (ICBAS), Universidade de Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal.
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Basivertebral foramen could be connected with intravertebral cleft: a potential risk factor of cement leakage in percutaneous kyphoplasty. Spine J 2014; 14:1551-8. [PMID: 24314766 DOI: 10.1016/j.spinee.2013.09.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 07/24/2013] [Accepted: 09/19/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND CONTEXT Among different types of cement leakage in percutaneous kyphoplasty (PKP) for osteoporotic vertebral body compression fractures, leaks into the spinal canal are considered to be the most common complication. One potential structure causing this type of cement leakage is the potential connection between the basivertebral foramen and the intravertebral cleft, which is revealed clearly on magnetic resonance (MR) images, but is often ignored in the literature. PURPOSE The purpose of this study is to assess the incidence rate of different types of cement leakage in PKP with or without intravertebral clefts and to determine whether the basivertebral foramen could be connected to the intravertebral cleft. STUDY DESIGN This study is a retrospective assessment of the presence of an intravertebral cleft in osteoporotic vertebral bodies and the different types of cement leakage after PKP on radiographs, computed tomographic (CT) scans, and MR images. PATIENT SAMPLE A total of 164 consecutive patients underwent PKP to treat 204 osteoporotic vertebral compression fractures. OUTCOME MEASURES Outcome measures include the occurrence of different types of cement leakage in the groups with an intravertebral cleft and without intravertebral clefts. METHODS A total of 204 vertebrae in 164 consecutive patients who underwent PKP to treat osteoporotic vertebral compression fractures were classified into two patterns based on preoperative radiographs, CT scans, and/or MR images of the treated levels: cleft pattern (with an intravertebral cleft in the vertebral body) and trabecular pattern (without intravertebral clefts). When an intravertebral cleft was identified, the investigators examined the basivertebral foramen and looked for a communication between the two structures on three-dimensional CT scans and MR images. On direct postoperative images, the patterns of cement leakage were classified as five types: type A, through a cortical defect into the paraspinal soft tissues; type B, through the basivertebral foramen; type C, via the needle channel; type D, through a cortical defect into the disc space; and type E, via the paravertebral vein. The association of the distribution of the cement leakage and the presence of an intravertebral cleft was analyzed retrospectively. Moreover, the association of type B leakage with the communication between the basivertebral foramen and the intravertebral cleft was also assessed. RESULTS The average interobserver kappa values for determining the type of cement leakage and the presence of intravertebral cleft were 0.916 (range, 0.792-1) and 0.935, respectively. In 41 of 204 vertebrae (19.9%), an intravertebral cleft was confirmed on preoperative images. A communication between the intravertebral cleft and the basivertebral foramen was seen in 10 vertebrae (24.4%). Cement leakage was 36.2% in the group with a trabecular pattern and 41.5% in the group with a cleft pattern (p>.05). Leaks through the basivertebral foramen (type B; N=30, 14.7%) and through cortical defects into the disc space (type D; N=14, 6.9%) were more common than other types. Twenty of 163 vertebrae with the trabecular pattern (12.3%) and 10 of 41 vertebrae with the cleft pattern (24.4%) were identified as type B leaks, which reached statistical significance (p<.05). There was no statistical difference between the trabecular pattern and the cleft pattern on other types of leaks. CONCLUSIONS Type B leaks are more common in vertebrae with an intravertebral cleft, which supports the presence of a connection between an intravertebral cleft and the basivertebral foramen. Thus, care must be taken when PKP is performed in these patients to avoid direct cement leakage into the spinal canal through the basivertebral foramen.
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Wang Q, Wang C, Fan S, Zhao F. Pathomechanism of intravertebral clefts in osteoporotic compression fractures of the spine: basivertebral foramen collapse might cause intravertebral avascular necrosis. Spine J 2014; 14:1090-1. [PMID: 24851741 DOI: 10.1016/j.spinee.2014.01.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 01/22/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Qiang Wang
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, No. 3 Qingchun Rd East, Hangzhou, Zhejiang 310016, People's Republic of China
| | - Chongyan Wang
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, No. 3 Qingchun Rd East, Hangzhou, Zhejiang 310016, People's Republic of China
| | - Shunwu Fan
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, No. 3 Qingchun Rd East, Hangzhou, Zhejiang 310016, People's Republic of China
| | - Fengdong Zhao
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, No. 3 Qingchun Rd East, Hangzhou, Zhejiang 310016, People's Republic of China
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Klassert TE, Patel SA, Rameshwar P. Tachykinins and Neurokinin Receptors in Bone Marrow Functions: Neural-Hematopoietic Link. ACTA ACUST UNITED AC 2010; 2010:51-61. [PMID: 20593004 DOI: 10.2147/jrlcr.s6509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
After many decades of neuropeptide research, advances in the field of tachykinins have considerably increased and shown their implications in several physiological processes. In this review we focus on the role of the tachykinins in the regulation of hematopoietic functions. Evidence has shown that neural control of this process is emerging as a significant category in hematopoietic modulation. In the context of this regulation, we discuss the existence of a complex network involving the neurokinin receptors, tachykinins and cytokines. This network is tightly regulated by each of its components.
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Affiliation(s)
- Tilman E Klassert
- Department of Medicine - Division of Hematology/Oncology, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA
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Buonocore M, Aloisi AM, Barbieri M, Gatti AM, Bonezzi C. Vertebral body innervation: Implications for pain. J Cell Physiol 2010; 222:488-91. [PMID: 20020509 DOI: 10.1002/jcp.21996] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Vertebral fractures often cause intractable pain. To define the involvement of vertebral body innervation in pain, we collected specimens from male and female patients during percutaneous kyphoplasty, a procedure used for reconstruction of the vertebral body. Specimens were taken from 31 patients (9 men and 22 women) suffering high-intensity pain before surgery. In total, 1,876 histological preparations were obtained and analysed. Immunohistochemical techniques were used to locate the nerves in the specimens. The nerve fibres were labelled by indirect immunofluorescence with the primary antibody directed against Protein Gene Product 9.5 (PGP 9.5), a pan-neuronal marker; another primary antibody directed against type IV collagen (Col IV) was used to identify vessels and to determine their relationship with vertebral nerve fibres. The mean percentage of samples in which it was possible to identify nerve fibres was 35% in men and 29% in women. The percentages varied depending on the spinal level considered and the sex of the subject, nerve fibres being mostly present around vessels (95%). In conclusion, there is scarce innervation of the vertebral bodies, with a clear prevalence of fibres located around vessels. It seems unlikely that this pattern of vertebral body innervation is involved in vertebral pain or in pain relief following kyphoplasty.
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Affiliation(s)
- Michelangelo Buonocore
- Unit of Clinical Neurophysiology & Neurodiagnostic Skin Biopsy, Fondazione Maugeri, Via Maugeri 10, 27100 Pavia, Italy.
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Immunohistochemical and histological study of human uncovertebral joints: a preliminary investigation. Spine (Phila Pa 1976) 2009; 34:1257-63. [PMID: 19455000 DOI: 10.1097/brs.0b013e31819b2b5d] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A descriptive cadaveric study. OBJECTIVE To investigate the anatomy and innervation of the uncovertebral joint to determine if it is synovial in nature and capable of generating pain. SUMMARY OF BACKGROUND DATA There is controversy with regard to the anatomic and histological makeup of the uncovertebral interface with some authors considering it a joint and others disc tissue. No research has investigated the presence of pain generating neurotransmitters within the uncovertebral cartilaginous and capsular tissue. METHODS Tissue from uncovertebral capsule and cartilage was harvested for each uncovertebral surface starting at the C2-C3 to the C6-C7 cervical segment. The tissue was placed in 4% paraformaldehyde fixative, then dehydrated and embedded in paraffin. Ten micron sections were cut through the tissue blocks and mounted on slides. The tissue was rehydrated and either stained with hematoxylin and eosin (H and E) or immunostained with antisera against protein gene product 9.5 (PGP 9.5), substance P (SP), neuropeptide Y (NPY), and calcitonin gene-related peptide (CGRP). RESULTS The sample consisted of 2 unembalmed fresh male human cadavers of a mean age of 83 years. Chondrocytes and synoviocytes were identified at the capsular tissue of each uncovertebral interface from C2-C3-C6-C7. Immunoreactivity for PGP 9.5, SP, CGRP, and NPY was observed at all uncovertebral interface levels in capsular tissue. CONCLUSION The presence of both synoviocytes and chondrocytes has been recorded in the present study, suggesting that the uncovertebral interface is synovial in nature. Immunoreactivity to PGP 9.5, SP, CGRP, and NPY indicates the presence of nerve fibers from both the somatic and autonomic nervous systems. These findings suggest that the uncovertebral joints are potential pain generators in the cervical spine.
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Abstract
STUDY DESIGN A descriptive study of the association between Schmorl nodes (SNs) and gender, ethnic origin, and age in a normal skeletal population. OBJECTIVES To gain reliable data on behavioral patterns of SNs in various human groups shedding light on its etiology. SUMMARY OF BACKGROUND DATA Opinions regarding SNs prevalence in human populations vary greatly (from 5% to 70%). This caveat greatly reduced our ability to recognize the etiology of the phenomenon and understand its clinical significance. METHODS Two hundred forty human skeleton vertebrae (T4-L5) from a normal adult population (divided by gender, ethnicity, and age) were examined for SNs. SNs were defined as depressions with sclerotic margins appearing on the vertebral body surface. RESULTS One hundred sixteen individuals (48.3%) of the 240 studied manifested SNs along their thoracolumbar spine. SNs are age independent and gender and ethnicity dependent, are significantly more common in males (54.2%) versus females (43%) and more common in European-Americans (60.3%) versus African-Americans (36.7%). CONCLUSION SNs are a common phenomenon in the normal adult populations with almost half of the individuals in our sample manifesting at least 1 vertebra with SN. Its demographic characteristics suggest that the phenomenon is not of occupational origin, promoting the notion of genetic background.
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Anselmetti GC, Manca A, Kanika K, Murphy K, Eminefendic H, Masala S, Regge D. Temperature measurement during polymerization of bone cement in percutaneous vertebroplasty: an in vivo study in humans. Cardiovasc Intervent Radiol 2009; 32:491-8. [PMID: 19280257 DOI: 10.1007/s00270-009-9509-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 12/26/2008] [Accepted: 01/06/2009] [Indexed: 12/30/2022]
Abstract
Aim of the study was to "in vivo" measure temperature, during percutaneous vertebroplasty (PV), within a vertebral body injected with different bone cements. According to the declaration of Helsinki, 22 women (60-80 years; mean, 75 years) with painful osteoporotic vertebral collapse underwent bilateral transpedicular PV on 22 lumbar vertebrae. Two 10-G vertebroplasty needles were introduced into the vertebra under digital fluoroscopy; a 16-G radiofrequency thermoablation needle (Starburst XL; RITA Medical System Inc., USA), carrying five thermocouples, was than coaxially inserted. Eleven different bone cements were injected and temperatures were measured every 30 s until temperatures dropped under 45 degrees C. After the thermocouple needle was withdrawn, bilateral PV was completed with cement injection through the vertebroplasty needle. Unpaired Student's t-tests, Kruskal-Wallis test, and Wilcoxon signed rank test were used to evaluate significant differences (p < 0.05) in peak temperatures, variations between cements, and clinical outcome. All procedures were completed without complications, achieving good clinical outcomes (p < 0.0001). Regarding average peak temperature, cements were divided into three groups: A (over 60 degrees C), B (from 50 degrees to 60 degrees C), and C (below 50 degrees C). Peak temperature in Group A (86.7 +/- 10.7 degrees C) was significantly higher (p = 0.0172) than that in Groups B (60.5 +/- 3.7 degrees C) and C (44.8 +/- 2.6 degrees C). The average of all thermocouples showed an extremely significant difference (p = 0.0002) between groups. None of the tested cements maintained a temperature >or=45 degrees C for more than 30 min. These data suggest that back-pain improvement is obtained not by thermal necrosis but by mechanical consolidation only. The relative necrotic thermal effect in vertebral metastases seems to confirm that analgesia must be considered the main intent of PV.
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Affiliation(s)
- Giovanni Carlo Anselmetti
- Interventional Radiology Unit, Institute for Cancer Research and Treatment (IRCC), Strada Provinciale 142, Km. 3,95, 10060, Candiolo, Turin, Italy.
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Okwueze MI, Cardwell NL, Wolfort SL, Nanney LB. Unexpected motor axons in the distal superficial radial and posterior interosseous nerves: a cadaver study. Clin Anat 2008; 20:790-4. [PMID: 17708562 DOI: 10.1002/ca.20527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The prevalence of motor variations in the nerves supplying muscles of the first web space was evaluated by a visual dissection and immunohistochemical analysis from 56 cadaver hands. By microscopic visualization, 30% of the superficial radial nerves (SRNs) sent branches into muscles of the first web space. Since these unexpected penetrating branches were expected to be sensory or proprioceptive, markers of sensory and motor axons were used for confirmation. Positive identifications of motor axons (as identified by positive immunostaining for choline acetyltransferase) were made in 30% of SRNs and in 28.5% of posterior interosseous nerves. Classical teachings that the SRNs and PINs are exclusively sensory have been brought into question. Our data are in agreement with the rare clinical finding that motor function occasionally persists following devastating injury to both the ulnar and median nerves. Anatomic prevalence for this variation appears much higher than previous descriptions have indicated.
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Affiliation(s)
- Martina I Okwueze
- Department of Plastic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-2631, USA
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