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 261,466 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The challenge of failed back surgery is in the decision of when to operate and how to do it competently. Specific neuroanatomic indications as a basis for surgical treatment should reduce surgical failures. One source of failure is a "battered root" and the arachnoiditis which may follow limited or inadequate interlaminar exposure. Even with adequate interlaminar exposure, hemostasis may be difficult if preoperative positioning of the patient to diminish intra-abdominal pressure has not been performed. Bleeding can obscure the operative field and the surgeon's ability to visualize and deal with the problem at hand. A less common cause of failure is segmental instability. This may be pre-existing and related to facet tropism. It may also be a consequence of surgical removal of posterior vertebral elements, thus creating a loss of stability with or without a discernable change in vertebral alignment. The surgeon should try to: avoid becoming enmeshed in the psychodynamic problems of patients. He should use specific diagnostic tests, e.g., nerve blocks or facet injections, in an effort to localize specific sources of pain; recognize that prognosis is adversely affected by additional surgery; and avoid "exploratory" operations. Furthermore, neurolysis without spatial decompression, bony or otherwise, is eventually futile. All patients with failed back surgery have a psychodynamic component to their pain. This article will have achieved its purpose if it promotes recognition that a small percentage of patients with failed back surgery can be helped. These are individuals in whom specific diagnostic tests or clinical acumen uncover a surgically correctable lesion, be it compressive or radiculopathy or segmental instability. In such instances an adverse psychologic profile need not necessarily be a deterrent to surgical treatment.
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PMID:Failed lumbar disc surgery: cause, assessment, treatment. 706 9

The long-term effect of sacral rhizotomy in 24 patients with coccygodynia was evaluated. Prior to section of both the S-4 and S-5 roots all patients had coccygeal pain and tenderness which had not responded to severe conservative and surgical therapeutic measures. In 8 patients the coccalgia (S-4 S-5 pain) was associated with unilateral pain in the S-3 area, in another 8 patients it was associated with disabling lumbago and in the remaining group of 8 patients coccalgia occurred without pain in neighbouring areas. Only 6 patients responded well to sacral rhizotomy. All these patients belonged to the final group of 8 patients with pain distribution limited to the S-4 S-5 area. Serious complications occurred after 6 of the 24 rhizotomies. Five of these patients belonged to the two groups who besides coccalgia also had disabling lumbago or signs of rhizopathy about the S-4 level. A restrictive attitude to sacral rhizotomy in coccalgia is recommended especially when it is associated with pain in neighbouring areas and also if there is any reason to believe that there are factors present predisposing to the development of arachnoiditis.
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PMID:Sacral rhizotomy in cases of ano-coccygeal pain. A follow-up of 24 cases. 724 96

Are spinal schwannomas as benign as we think? To what extent do patients recover? Are patients prone to develop late complications such as cystic myelopathy or symptomatic spinal deformity? Is their life expectancy compromised? In an effort to answer these questions, the authors analyzed the long-term outcome for 187 patients from one neurosurgical department with surgically treated spinal schwannoma. Median follow-up period was 12.9 years (2454 patient years). One-fifth of the patients considered themselves free of symptoms at follow-up examination. The most common late complaint was local pain (46%), followed by radiating pain (43%), paraparesis (31%), radicular deficit (28%), sensory deficit due to a spinal cord lesion (27%), and difficulty voiding (19%). Late complications occurred in 21% of the patient population, including cystic myelopathy (2%), spinal arachnoiditis (6%), spinal deformity (6%), and troublesome pain (7%). Life expectancy of the patients corresponded to that of the general population.
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PMID:Long-term outcome after removal of spinal schwannoma: a clinicopathological study of 187 cases. 767 10

A 30-year-old female experienced a sudden sharp pain radiating down to the left leg from the lower back at epidural intubation for anesthesia at childbirth. She continued to complain of pain in the left leg afterwards. Magnetic resonance images demonstrated a conglomeration of adherent nerve roots due to lumbar adhesive arachnoiditis. Microsurgical dissection of adherent nerve roots was performed. Her symptoms disappeared after surgery, but soon recurred, being less severe and responsive to anti-inflammatory agents. Lumbar adhesive arachnoiditis should be considered for differential diagnosis in patients presenting with back and leg pain syndrome.
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PMID:Lumbar adhesive arachnoiditis following attempted epidural anesthesia--case report. 775 9

Chronic adhesive arachnoiditis is cited as an important cause of recurrent pain and disability after extradural lumbar disc surgery. Myelography using oil-based or ionic water-soluble contrast media was a major contributing factor, and it was not possible to distinguish the prevalence of arachnoiditis probably due to surgery alone. Today it should be possible to make this distinction, which was the purpose of this study. Using high-resolution MRI in 129 patients symptomatic at least 1 year after surgery, a prevalence of arachnoiditis of 20% was found, which dropped to 3% when patients who had undergone oil-based myelography were excluded. Arachnoiditis was diffuse in 88% and focal in 12%. When oil-based media were involved it was focal in 13%, and when not, in one of three cases. It was concluded that arachnoiditis does occur after extradural lumbar disc surgery independently of the use of some myelographic contrast media, and that it may be diffuse or confined only to the operated level. Its prevalence was estimated at 4.6%, four cases focal and two cases diffuse. The causes and clinical significance can only be the subject of speculation.
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PMID:Postoperative arachnoiditis diagnosed by high resolution fast spin-echo MRI of the lumbar spine. 776 Oct 1

We describe 3 patients, who exhibited neurological symptoms after single dose epidural anaesthesia. In patient 1 an unrecognized spinal arteriovenous fistula (AVF) caused paraparesis following epidural block. The dilated veins draining an AVF are space-occupying structures and the injection of the anaesthetic solution may have precipitated latent ischaemic hypoxia of the spinal cord due to raised venous pressure. In patient 2, epidural block was followed by postoperative permanent saddle pain and hypoaesthesia. The injection of the anaesthetic in a narrow spinal canal with multiple discal protrusions and restriction of interlaminar foramina may have acutely produced mechanical compression of the spinal cord or roots. Patient 3 exhibited post-epidural block spinal arachnoiditis. Although the few reported cases of this syndrome exhibit severe neurological damage, our patient presented with scarse symptoms. Our cases point out the importance of accurate neurological history and examination of candidates for epidural anaesthesia and of accurate anaesthetic history for neurological patients.
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PMID:Neurologic symptoms after epidural anaesthesia. Report of three cases. 783 88

We have performed single-neuron recording and microstimulation in the region of the thalamic principal sensory nucleus (ventrocaudal nucleus, Vc) prior to implantation of a deep brain-stimulating electrode in a patient with pain secondary to arachnoiditis and with a past history of unstable angina. Cells located in the 16 mm lateral plane had cutaneous receptive fields on the chest wall. At and posterior to the location of these cells stimulation coincided precisely with the sensation of angina (stimulation-associated angina). The description of stimulation-associated angina was measured using a questionnaire and was identical to the patient's usual angina except that it began and terminated suddenly. Stimulation-associated angina was coincident with a tingling sensation in the leg. Clinical, hemodynamic, electrophysiologic and biochemical measures of cardiac function showed no evidence of myocardial strain or injury related to stimulation-associated angina. Since cells in the region of the principle sensory nucleus of thalamus respond to cardiac injury in animals, the present results suggest that this region mediates the sensation of angina.
Pain 1994 Oct
PMID:The sensation of angina can be evoked by stimulation of the human thalamus. 785 92

The persistence of lumbar and nerve root pain after nerve root decompression surgery may be attributed to one of five causes; 1) progression of the spondylotic disease in the presence of peridural fibrosis; 2) recurrence of disc herniation or new hernia; 3) stenosis of the spinal or nerve root canal; 4) arachnoiditis; 5) vertebral instability. In most patients with peridural fibrosis and worsening of spondylotic lesions regression of nerve root symptoms was obtained after several months of conservative treatment, which continues to constitute essential treatment for most patients with recurrence of lumbar symptoms. The authors report the results obtained with the surgical treatment of 95 patients performed between 1981 and 1991 and divided into the categories listed above. Of these patients, 70 were submitted to further decompression surgery while 25 were submitted to posterolateral vertebral fusion. Reintervention obtained useful results in 83% of the cases where there had been recurrence of disc herniation; nerve root release obtained positive results in 100% of the cases where there was stenosis. Results obtained after wide decompression were poor in all of the cases with arachnoiditis; in these patients conservative treatment with T.E.N.S. can obtain a fair amount of control over pain. Positive results were obtained in 84% of the 25 patients submitted to posterolateral fusion for the treatment of vertebral instability, with fusion obtained in 96% of the cases. Surgical treatment is indicated for psychotic, neurotic patients or those with insurance-related motivations only when the organic cause of the symptoms is clearly evident.
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PMID:Failed back syndrome: a study on 95 patients submitted to reintervention after lumbar nerve root decompression for the treatment of spondylotic lesions. 807 69

The use of intraspinal therapy for the management of intractable pain from nonmalignant causes has not been widely discussed. An implantable, externally programmable infusion pump was used for intraspinal delivery of morphine sulfate to 15 patients with intractable pain from reflex sympathetic dystrophy, arachnoiditis after spinal surgery, or an unknown cause. Dosage patterns were individualized. At follow-up ranging from 2 to 44 months, pain relief was reported as excellent by 8 patients, good by 3, and fair by 4. Six patients have returned to work. Two patients chose to terminate therapy. Few complications occurred, but most patients needed increasingly larger doses over time to maintain pain relief. Intraspinal infusion of morphine sulfate by use of an implanted, externally programmable pump is safe and effective in selected patients with intractable pain of nonmalignant origin.
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PMID:Intraspinal delivery of opiates by an implantable, programmable pump in patients with chronic, intractable pain of nonmalignant origin. 807 18

Epidural analgesia (EA) is the best technique to obtain pain relief during labour. But the needle, the catheter and the local anaesthetics (LA) are 3 reasons to cause maternal complications. In France we do not know the exact number of EA performed every year and it is very difficult to appreciate the incidence of maternal complications. Therefore, it is necessary to know it and try to reduce the incidence of some of them. Maternal complications after EA are classically: 1. caused by catheter or needle: massive subarachnoid injection, toxic intravenous injection with convulsions and/or cardiac arrest; 2. secondary to infectious problems: meningitis or epidural abscess; 3. due to LA with the very rare anaphylactoid reactions; 4. due to prolonged neurologic complications with epidural and subdural haematomas, subarachnoid cysts or arachnoiditis. These complications are rare: 1/4,700 in the largest series of literature, involving more than 500,000 EA. In France, we tried to quantify maternal complications among nearly 300,000 EA performed over a period of 5 years. The overall incidence of serious complications was 1/4,005 EA. The most frequent are accidental dural puncture (1/156), massive subarachnoid injections (1/8,010) and convulsions (1/9,011). The incidence of these 3 complications must be reduced by better training, material or attention during bolus injection of LA.
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PMID:[Epidemiology of complications of obstetrical epidural analgesia]. 808 39


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