Name: treating low back pain in failed back surgery patients with multicolumn-lead spinal cord stimulation
Uploaded: 2018-06-26T12:30:00.000+00:00
Duration: 4 min 42 s
Description: Watch this Scientific Journal Video about Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation at JoVE.com

The authors would like to thank Gabrielle Leyden for revising the final draft of this paper.

1. Patient Selection
<ol>
	<li>Make a diagnosis of FBSS20.</li>
	<li>Be sure that the FBSS patient meets all the inclusion criteria before being accepted for an SCS trial:
	<ol>
		<li>Chronic low back pain and/or radicular leg pain that were refractory to optimal medical therapy for a minimum of 6 months.</li>
		<li>Persistent pain despite 3 types of pharmacological treatments (paracetamol, non-steroidal anti-inflammatory drugs, opioids, antidepressant medications, anticonvulsant medications, etc.).</li>
		<li>Lemniscal pathways must remain at least partially intact (for paresthesia coverage of the painful area).</li>
	</ol>
	</li>
	<li>Rule out exclusion criteria for SCS in FBSS patients such as active infection, drug addiction or ongoing withdrawal, psychological contraindications, documented mechanical causes of low BP (discogenic pain, spondylolisthesis, spinal instability, and posterior joint osteoarthritis), and coagulopathy (due to risk of bleeding and epidural hematoma). Make sure that no coagulopathy is present by asking relevant questions, examining the patient and, if necessary, checking relevant blood tests for coagulopathy.</li>
</ol>
2. Neuromodulation Specialist
<ol>
	<li>If the FBSS patient meets the criteria for SCS, refer him to the neuromodulation specialist (NMS). 
	NOTE: The neuromodulation specialist in our team is a nurse. He is fully dedicated to pain and neuromodulation and is the coordinator of the pluridisciplinary team, which includes a psychologist, a physiotherapist, and a specialist pain nurse.</li>
	<li>Describe the anatomy of the pain pathways to the patient and explain the difference between nociceptive and neuropathic pain. Explain the sites of action of the different analgesic and co-analgesic medications. 
	NOTE: It is important that the patient understands the nature of neuropathic pain and can differentiate it from nociceptive pain. Once the patient has understood the physiology of their neuropathic pain, they are ready to learn about SCS.</li>
	<li>Explain to the patient the theoretical concept of SCS. The technique is believed to inhibit chronic pain by stimulating the large-diameter afferent nerve fibers in the spinal cord, in accordance with the gate control theory of pain.</li>
	<li>Measure the Visual Analog Scales (VAS) score21 for leg and back pain.</li>
	<li>Explain the objectives of the therapy:
	<ol>
		<li>Paresthesia coverage of the painful area of 50 to 70%.</li>
		<li>Reduction of pain (VAS score).</li>
		<li>Reduction in analgesic and co-analgesic medications.</li>
		<li>Improvement in the quality of sleep.</li>
		<li>Improvement in the quality of life.</li>
		<li>Improvement in the distance walked.</li>
	</ol>
	</li>
	<li>Explain the different components of an SCS device (epidural lead, internal pulse generator, and the extension cable connecting the lead to the IPG) and let the patient manipulate them to understand the system better.</li>
</ol>
3. Creation of the Health Insurance File by the NMS
<ol>
	<li>Describe in this file the characteristics of the patient&#39;s pain, quality of life, and quality of sleep, but also the patient&#39;s activities, walked distance, and analgesic and co-analgesic consumption. 
	NOTE: Under Belgian law, psychiatric evaluation is mandatory before any surgery to implant a foreign body. The psychiatrist has to rule out any psychiatric disorder and evaluate the patient&#39;s functional capacities in order to be able to accept and live with a foreign body.</li>
	<li>Attach the patient&#39;s medical record and the psychiatric evaluation to the Health Insurance File.</li>
</ol>
4. Implantation of the Multicolumn Lead
<ol>
	<li>Obtain the patient&#39;s informed consent after explaining the details of the surgical procedure, including the complications (infection 3&#8211;6%; serious neurological complications 0.54&#8211;1.71%; epidural hematoma 0.19&#8211;0.63%; spinal cord injury 0.022&#8211;0.067%; and cerebrospinal fluid leakage 0.05&#8211;0.001%)22. 
	NOTE: The long testing period required in Belgium is presumed to be the main reason for the higher infection rate (11%) observed in our institution, and we are currently trying to address this issue. This must be explained to the patient.</li>
	<li>In addition to the above risks, which are similar to those associated with other spinal procedures, explain the other risks normally associated with the use of an implant, such as allergic or immune system responses to the implanted materials; lead, extension, or neurostimulator erosion through the skin or migration; and formation of reactive tissue around the lead in the epidural space that can result in delayed spinal cord compression and paralysis, requiring surgical intervention. Time to onset can range from weeks to many years after implant. 
	NOTE: The neurological complication rates for percutaneous dorsal column stimulation leads are slightly higher (infection 3&#8211;6%; serious neurological complications 0&#8211;2.35%; epidural hematoma 0.75%; spinal cord injury 0.03&#8211;2.35%; and cerebrospinal fluid leakage 0.3%)22.</li>
	<li>If the patient doesn&#39;t have any contraindication, conduct an MRI to rule out any anomaly of the conus medullaris projection such as spinal dysraphism or other congenital spinal cord anomalies23.</li>
	<li>Perform antibiotic prophylaxis 30 min before incision using a single intravenous (IV) dose of Cefazolin, 50 mg/kg, with a maximum of 2 gm, through a 16 G needle placed in a peripheral route.</li>
	<li>With the patient under general anesthesia (use 0.1 &#181;g/kg Sunfentanil, 2 mg/kg Propolipid 1%, 0.3 mg/kg Ketamine Hydrochloride (see Table of Materials), and 0.3 mg/kg Rocuronium) and in the prone position, define the incision site between the spinous processes of T10 and T11 under fluoroscopic assistance.</li>
	<li>Infiltrate the incision site with 5 mL of a 20 mL solution of 0.5% Bupivacaine and 1:200,000 adrenaline (see Table of Materials).</li>
	<li>Incise until the thoracic aponeuroses are revealed.</li>
	<li>Dissect the paravertebral musculature on both sides of T10&#39;s supraspinous process and place the retractor.</li>
	<li>Resect the supraspinous and interspinous ligaments and dissect the lamina of T10 (5 mm on each side and 5 mm in the craniocaudal direction).</li>
	<li>Before inserting the lead, perform a partial laminectomy of T10 to create enough space to allow the insertion of the lead (no need to remove the entire lamina).</li>
	<li>Insert the phantom lead into the epidural space, while keeping the insertion of the flavum ligament on the upper part of the T11 lamina intact. 
	NOTE: This T11 lamina is used as a guide for the insertion of the lead into the epidural space.</li>
	<li>Place the lead as medially as possible under fluoroscopic guidance. The final lead&#39;s position is reached when placed midline in the projection of the bodies of T8&#8211;T9 under fluoroscopic control.</li>
	<li>Fix the lead to the interspinous ligament of T11 by doing a single interrupted stitch.</li>
	<li>Tunnel the extensions from your operative field to the lateral side of the back (often the right one) by using the tunneling tool provided by the company, and then connect them to the lead.</li>
	<li>Check fluoroscopically to be sure the lead has not moved and is still in the epidural space, midline, in the projection of T8&#8211;T9.</li>
	<li>Remove the retractor and make sure there is no bleeding.</li>
	<li>Suture the musculo-aponeurotic layer by means of simple interrupted stitches of braided synthetic absorbable suture material (see Table of Materials).</li>
	<li>Connect the two intrinsic external extensions to the two extrinsic external extensions. Tunnel them in the subcutaneous fat in such a way that they exit through the skin 15 cm laterally to the incision site. 
	NOTE: The choice of the side is discussed preoperatively with the patient and depends on the implantation location of the internal pulse generator.</li>
	<li>Wrap the intrinsic and extrinsic extensions and suture the subcutaneous layer by means of simple interrupted stitches of braided synthetic absorbable suture material (see Table of Materials).</li>
	<li>Make a dermic subcuticular suture using finer absorbable 3/0 suture material (see Table of Materials) and apply antiseptic and bandages. During this step, administer a single IV dose of 1g Paracetamol and 100 mg Tradonal.</li>
</ol>
5. Postoperative Trial
<ol>
	<li>When the lead is placed, connect it to an external stimulator for a period of four weeks. 
	NOTE: This long test period is required by the Belgian law as a condition to reimburse the implantation of the pulse generator during a second operation.</li>
	<li>Begin the programming sessions a few hours after surgery. The objective of the therapy is to cover the painful area by pleasant paresthesia.</li>
	<li>Connect the external neurostimulator to the extrinsic external lead extensions.</li>
	<li>Place the clinician programmer on the external neurostimulator. Turn the clinician programmer on and then turn the neurostimulation on. Start by setting the pulse width (PW) to 260 &#181;s, at a rate of 60 Hz.</li>
	<li>If LP was bilateral, perform a first screening using a guarded cathode (+-+), starting with the top-left tripolar longitudinal stimulation configuration (Figure 1), in order to identify the laterality of the lead (right/left).</li>
	<li>Perform a rapid scan of the left side with the four remaining left-side tripolar longitudinal stimulation configurations (Figure 2). An idea of the painful metameric level is determined during this unilateral screening. Thereafter, scan the right side following the same scheme (Figure 3).</li>
	<li>Finally, activate the stimulation configuration(s) allowing better paresthesia coverage of the painful leg area(s). 
	NOTE: If there is bilateral LP, two different stimulation configurations must be programmed to obtain optimal paresthesia coverage of the two painful areas.</li>
	<li>For back pain, test a transverse tripolar configuration at the top of the lead first, using the guarded cathode configuration (Figure 4). If this configuration gives insufficient paresthesia coverage, test a &#34;half flower-like pattern&#34; configuration of four anodes around a cathode (Figure 4). If this configuration does not provide sufficient paresthesia coverage and/or pain suppression again, use a tripolar longitudinal configuration in order to verify possible bilateral stimulation by one channel (Figure 4).</li>
	<li>Fine-tune back pain area coverage by increasing PW to 450 &#181;s. This makes it possible to enlarge the area of stimulation. Adjust the pulse rate between 40 and 60 Hz to obtain the most satisfying paresthesia coverage of the painful area. 
	NOTE: These settings are based on experience with this multicolumn surgical lead and may of course vary with a different device or stimulation strategy (high-intensity stimulation, for example). For more detailed instructions, please consult the Programmer Quick Guide24.</li>
	<li>Ensure close follow-up (at least once a week) of the patient during the trial phase (1 month in Belgium) to check appropriate wound healing and optimize paresthesia coverage by repeating Steps 5.7, 5.8 and 5.9. Use sterile technique bandage changes22. Educate the patient about the signs and symptoms of an emerging surgical site infection.</li>
	<li>At the end of the trial period, use sharp scissors to cut the external extension flush with the skin in order to reduce the risk of infection until the next surgical procedure.</li>
</ol>
6. Implantation of the Internal Pulse Generator
<ol>
	<li>If pain relief is higher than 50% at the end of the one-month trial period (Belgian reimbursement criteria), obtain the patient&#39;s informed consent and set a date for the IPG placement. Pain relief is assessed by using the VAS scale22. 
	NOTE: The patient decides on the site of the IPG placement after the advantages and drawbacks of the different locations are discussed with the NMS.</li>
	<li>Perform antibiotic prophylaxis 30 minutes before incision using a single intravenous dose of Cefazolin 50 mg/kg, with a maximum of 2 g, with a 16 G needle.</li>
	<li>With the patient under general anesthesia (same protocol as mentioned in Step 4.3), make a 7 cm-long and 2 cm-deep incision and create a pocket for the IPG in the subcutaneous fat of the abdominal wall or the external quadrant of a buttock, according to patients&#39; wishes (as discussed before surgery - Step 6.1).</li>
	<li>Excise the dorsal scar made for the lead implantation (Step 4.3), dissect the lead extensions from the surrounding tissues, and disconnect the lead from its external extrinsic extensions.</li>
	<li>Tunnel the intrinsic extension of the lead towards the implantation site of the IPG.</li>
	<li>Connect the lead&#39;s intrinsic extensions to its IPG.</li>
	<li>Suture the subcutaneous layer by simple interrupted stitches of 2/0 and 1/0 braided synthetic absorbable suture material.</li>
	<li>Make a dermal subcuticular suture using finer absorbable 3/0 suture material and apply antiseptic and bandages. During this step, administer a single IV dose of Paracetamol 1 gm and Tradonal 100 mg.</li>
</ol>
7. Postoperative Care and Follow-up Visits
<ol>
	<li>With the clinician programmer, set the programming parameters according to the ones that worked the best during the trial period (Step 5.7).</li>
	<li>Teach the patient how to use the programmer25. Explain again the different components of the neurostimulation system. Educate the patient to avoid activities requiring excessive twisting or stretching.</li>
	<li>Instruct the patient always to inform any healthcare personnel that they have an implanted neurostimulation system before any procedure is begun. Provide instructions about the warnings (CT-scan, defibrillation and cardioversion, electrocautery, lithotripsy, MRI, microwave ablation, and security screening devices) and precautions (bone growth stimulators, dental drills and ultrasonic probes, electrolysis, electromagnetic field devices, laser procedures, psychotherapeutic procedures, radiation therapy, and household items) for a neurostimulation system.</li>
	<li>Ensure close follow-up of the patient after the surgery to check for surgical site infection and appropriate paresthesia coverage.</li>
</ol>

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The authors have nothing to disclose.

Recent studies have demonstrated that SCS can reliably improve the different pain components of FBSS patients, improve their quality of life (e.g., quality of sleep and physical activity), and these benefits are sustained during a long-term follow-up3,17,18,19.
Depending on the localization of the pain, we use a different approach. When the patient has only ...

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Before FBSS can be established, other conditions, such as persistent nerve root compression, permanent nerve root injury as a consequence of the original compression or surgery, arachnoiditis, incorrect initial diagnoses, and documented mechanical causes for low back pain (such as spinal instability, posterior joint osteoarthritis, spondylolysthesis, and discogenic pain), should be excluded1,2,3. FBSS patients may have severe or disabling neuropathic pain, and the syndrome is worrisome since it is chronic and resistant to conventional treatment. Its incidence and prevalence are similar to those of rheumatoid arthritis4. It is thus a great burden for industrialized societies5.
Spinal cord stimulation (SCS) with dorsal epidural leads can be used to treat back pain (BP) and leg pain (LP) in FBSS patients, although the SCS pain relief mechanism has not been fully investigated. According to the gate control theory, which was first proposed by Ronald Melzack and Patrick Wall in 1965, the brain monitors the activity of a tiny neural network distributed along the dorsal horn of the spinal cord that is regulated by nociceptive but also non-nociceptive afferents6. These complex circuits in the superficial dorsal horn of the spinal cord are responsible for relieving pain in a specific location in the body when an intense tactile stimulus is applied to the same place7,8. However, several studies have shown that SCS is not only dependent on this theory. Several neurotransmitters (acetylcholine, gamma-aminobutyric acid, and serotonin) have been reported to have a role in the SCS mechanism9,10,11,12, as well as numerous brain areas13,14 and different spinal fibers15.
An SCS device includes an epidural lead, internal pulse generator (IPG), and an extension cable to connect the lead to the IPG. The stimulation settings are adjusted by an external remote control. Two types of electrode can be used, namely, percutaneous and surgical leads.
The efficacy of SCS in improving the radicular LP component of FBSS has already been demonstrated in previously published studies, including the EVIDENCE study16, and two new technologies have recently been shown to be effective for treating the BP component, which is known to be recalcitrant to SCS. The first one is high-frequency stimulation17. The second one is the use of surgical multicolumn lead3,18. The main disadvantages of the former technique are that their batteries need more frequent charging and that the programming optimization is challenged by longer &#34;wash-in&#34; times19. The latter technique is more invasive than the percutaneous high-frequency stimulation technique because it requires a small laminectomy, making peroperative paresthesia mapping under local anesthesia challenging, although possible3. Indeed, this procedure can be performed under local anesthesia supplemented by conscious sedation or spinal anesthesia3. In our institution, when targeting back pain in FBSS patients, we place such surgical leads through a small laminectomy at the 10th thoracic level with the patient under general anesthesia. The lasting efficacy of this method with such multicolumn leads for treating LP and BP in FBSS patients has been demonstrated by 3 year follow-up18. A detailed protocol of our method is given below.

<table><tbody><tr><td>16-20 GA needle</td><td>BD Insyte- W</td><td></td><td></td></tr><tr><td>NaCl 0.9% 1 L</td><td>Baxter</td><td>AKE1324</td><td></td></tr><tr><td>Iso-betadine Dermic (500mL)</td><td>MEDA</td><td>09461.16</td><td></td></tr><tr><td>Iso-betadine Soap (500mL)</td><td>MEDA</td><td>09462.10</td><td></td></tr><tr><td>Iso-betadine hydroalcoolic (125 mL)</td><td>MEDA</td><td>41534.1</td><td></td></tr><tr><td>Ziehm Vision R FD</td><td>Ziehm Imaging Inc.</td><td>CB05183</td><td></td></tr><tr><td>Marcain 0.5% + adrenaline 1/200.000 20 mL</td><td>Astrazenca</td><td>PA 970/46/2</td><td>0.5% Bupivacaine/1:200,000 adrenaline solution&amp;nbsp;</td></tr><tr><td>external Neurostimulator (eNs)&amp;nbsp;</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>37022</td><td></td></tr><tr><td>Trousse de colonne lombaire CHR Citadelle (Procedure pack)&amp;nbsp;</td><td>M&amp;ouml;lnlycke</td><td>97061425-01</td><td></td></tr><tr><td>OR Table</td><td>Maquet</td><td>1150.30D0</td><td></td></tr><tr><td>OR Lights</td><td>Trumpf</td><td>1929278</td><td></td></tr><tr><td>Specify SureScan MRI</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>977C165</td><td>Multicolumn lead</td></tr><tr><td>Primeadvanced surescan mri neurostimulator&amp;nbsp;</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>97702</td><td>Internal Pulse Generator</td></tr><tr><td>Monocryl 3/0</td><td>Ethicon</td><td>Y423</td><td></td></tr><tr><td>Polysorb 2/0</td><td>Covidien</td><td>GL123</td><td></td></tr><tr><td>Polysorb 1</td><td>Covidien</td><td>CL535</td><td></td></tr><tr><td>Polysorb 2</td><td>Covidien</td><td>CL055</td><td></td></tr><tr><td>Cutiplast Steril 20x10 cm</td><td>Smith&amp;amp;Nephew</td><td>66001475</td><td>Bandage</td></tr><tr><td>MyStim Programmer</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>97740</td><td></td></tr><tr><td>FixoCath</td><td>Pajunk</td><td>001151-37Z</td><td></td></tr><tr><td>N&#039;Vision Programmer&amp;nbsp;</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>8840</td><td></td></tr><tr><td>3M Tegaderm Film 10x12cm</td><td>3M Deutschland GmbH</td><td>1626W</td><td></td></tr><tr><td>Extension Kit</td><td>Medtronic Inc., MN, USA</td><td>37081-40</td><td></td></tr><tr><td>Paracetamol</td><td>Fresenius Kabi</td><td></td><td></td></tr><tr><td>Tradonal&amp;nbsp;</td><td>Meda Pharma</td><td></td><td></td></tr><tr><td>Sufentanil</td><td>Janssen- Cilag</td><td></td><td></td></tr><tr><td>Propolipid 1%</td><td>Fresenius Kabi</td><td></td><td></td></tr><tr><td>Ketalar (Ketamine Hydrochloride)</td><td>Pfizer</td><td></td><td></td></tr><tr><td>Rocuronium Bromide</td><td>Bbraun</td><td></td><td></td></tr><tr><td>Cefazolin</td><td>Milan</td><td></td><td></td></tr></tbody></table>

treating low back pain in failed back surgery patients with multicolumn-lead spinal cord stimulation

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Spinal cord stimulation with dorsal epidural leads can be used to treat back and leg pain in FBSS patients. This paper presents a detailed protocol for using spinal cord stimulation with surgical leads in FBSS patients. In our department, with the patient under general anesthesia, we place the lead in the epidural space by means of a small laminectomy at the 10th thoracic level. Placement of the lead is followed by a 1 month trial period with an externalized lead. If pain relief is greater than 50% at the end of this 1 month stimulation trial (required by Belgian reimbursement criteria), an internal pulse generator is then placed under the skin and connected to the lead in a second surgical procedure. We have demonstrated that using this technique in rigorously selected FBSS patients can significantly improve back pain, leg pain, patient activity, and quality of life for a sustained period of time.

A prospective, non-randomized, controlled study of 62 consecutive FBSS patients who were implanted with a multicolumn lead using this method in our center, CHR Citadelle, in Li&#232;ge, Belgium, was recently published in Neuromodulation18 . All patients had had previous spinal surgery, had been screened for possible secondary causes of their pain, and were refractory to optimal medical therapy. Multicolumn surgical leads were placed in all 62 patients in the projec...

Watch this Scientific Journal Video about Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation at JoVE.com

Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation

This paper presents a method that uses spinal cord stimulation with a multicolumn lead to treat neuropathic low back pain in failed back surgery patients.

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Spinal cord stimulation with dorsal epidural leads can be ...

treating-low-back-pain-failed-back-surgery-patients-with-multicolumn

Universidad San Sebastian

Research

JoVE Journal

Behavior

14.4K Views.  CHR Citadelle. This paper presents a method that uses spinal cord stimulation with a multicolumn lead to treat neuropathic low back pain in failed back surgery patients.

Video: Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation

Dorsal Column Steerability with Dual Parallel Leads using Dedicated Power Sources:  A Computational Model

In spinal cord stimulation (SCS), concordance of stimulation-induced paresthesia over painful body regions is a necessary condition for therapeutic efficacy. Since patient pain patterns can be unique, a common stimulation configuration is the placement of two leads in parallel in the dorsal epidural space. This construct provides flexibility in steering stimulation current mediolaterally over the dorsal column to achieve better pain-paresthesia overlap. Using a mathematical model with an accurate fiber diameter distribution, we studied the ability of dual parallel leads to steer stimulation between adjacent contacts on dual parallel leads using (1) a single source system, and (2) a multi-source system, with a dedicated current source for each contact. The volume conductor model of a low-thoracic spinal cord with epidurally-positioned dual parallel (2 mm separation) percutaneous leads was first created, and the electric field was calculated using ANSYS, a finite element modeling tool. The activating function for 10 um fibers was computed as the second difference of the extracellular potential along the nodes of Ranvier on the nerve fibers in the dorsal column. The volume of activation (VOA) and the central point of the VOA were computed using a predetermined threshold of the activating function. The model compared the field steering results with single source versus dedicated power source systems on dual 8-contact stimulation leads. The model predicted that the multi-source system can target more central points of stimulation on the dorsal column than a single source system (100 vs. 3) and the mean steering step for mediolateral steering is 0.02 mm for multi-source systems vs 1 mm for single source systems, a 50-fold improvement. The ability to center stimulation regions in the dorsal column with high resolution may allow for better optimization of paresthesia-pain overlap in patients.

Using a mathematical model of spinal cord stimulation, we found that a multi-source system with independent power sources for each contact can target more central points of stimulation on the dorsal column (100 vs 3) and has 50-fold more field steering resolution (0.02mm vs 1mm) than a single-source system.

In spinal cord stimulation (SCS), concordance of stimulation-induced paresthesia over painful body regions is a necessary condition for therapeutic ...

Medicine

Paradigms of Lower Extremity Electrical Stimulation Training After Spinal Cord Injury

Skeletal muscle atrophy, increased adiposity and reduced physical activity are key changes observed after spinal cord injury (SCI) and are associated with numerous cardiometabolic health consequences. These changes are likely to increase the risk of developing chronic secondary conditions and impact the quality of life in persons with SCI. Surface neuromuscular electrical stimulation evoked resistance training (NMES-RT) was developed as a strategy to attenuate the process of skeletal muscle atrophy, decrease ectopic adiposity, improve insulin sensitivity and enhance mitochondrial capacity. However, NMES-RT is limited to only a single muscle group. Involving multiple muscle groups of the lower extremities may maximize the health benefits of training. Functional electrical stimulation-lower extremity cycling (FES-LEC) allows for the activation of 6 muscle groups, which is likely to evoke greater metabolic and cardiovascular adaptation. Appropriate knowledge of the stimulation parameters is key to maximizing the outcomes of electrical stimulation training in persons with SCI. Adopting strategies for long-term use of NMES-RT and FES-LEC during rehabilitation may maintain the integrity of the musculoskeletal system, a pre-requisite for clinical trials aiming to restore walking after injury. The current manuscript presents a combined protocol using NMES-RT prior to FES-LEC. We hypothesize that muscles conditioned for 12 weeks prior to cycling will be capable of generating greater power, cycle against higher resistance and result in greater adaptation in persons with SCI.

Spinal cord injury is a traumatic medical condition that may result in elevated risks of chronic secondary metabolic disorders. Here, we presented a protocol using surface neuromuscular electrical stimulation-resistance training in conjunction with functional electrical stimulation-lower extremities cycling as a strategy to ameliorate several of these medical problems.

Skeletal muscle atrophy, increased adiposity and reduced physical activity are key changes observed after spinal cord injury (SCI) and are associated with ...

Experimental Strategies to Bridge Large Tissue Gaps in the Injured Spinal Cord after Acute and Chronic Lesion

After a spinal cord injury (SCI) a scar forms in the lesion core which hinders axonal regeneration. Bridging the site of injury after an insult to the spinal cord, tumor resections, or tissue defects resulting from traumatic accidents can aid in facilitating general tissue repair as well as regenerative growth of nerve fibers into and beyond the affected area. Two experimental treatment strategies are presented: (1) implantation of a novel microconnector device into an acutely and completely transected thoracic rat spinal cord to readapt severed spinal cord tissue stumps, and (2) polyethylene glycol filling of the SCI site in chronically lesioned rats after scar resection. The chronic spinal cord lesion in this model is a complete spinal cord transection which was inflicted 5 weeks before treatment. Both methods have recently achieved very promising outcomes and promoted axonal regrowth, beneficial cellular invasion and functional improvements in rodent models of spinal cord injury.
The mechanical microconnector system (mMS) is a multi-channel system composed of polymethylmethacrylate (PMMA) with an outlet tubing system to apply negative pressure to the mMS lumen thus pulling the spinal cord stumps into the honeycomb-structured holes. After its implantation into the 1 mm tissue gap the tissue is sucked into the device. Furthermore, the inner walls of the mMS are microstructured for better tissue adhesion.
In the case of the chronic spinal cord injury approach, spinal cord tissue - including the scar-filled lesion area - is resected over an area of 4 mm in length. After the microsurgical scar resection the resulting cavity is filled with polyethylene glycol (PEG 600) which was found to provide an excellent substratum for cellular invasion, revascularization, axonal regeneration and even compact remyelination in vivo.

Severe spinal cord injuries often result in tissue defects. Two possibilities are described to successfully bridge such gaps to promote tissue adaptation, regenerative responses and functional improvement in rats via implantation of a mechanical microconnector system after acute injury and five weeks after complete spinal cord transection.

After a spinal cord injury (SCI) a scar forms in the lesion core which hinders axonal regeneration. Bridging the site of injury after an insult to the ...

Neuroscience

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large implant size and optimal implant position. However, current methods for lateral interbody cage placement require either a two-staged procedure or a single lateral decubitus position that precludes surgeons from having either full access to the posterior spine for direct decompression or comfortable pedicle screw placement.
Herein is one institution's experience with 10 cases of a prone single-position approach for simultaneous access to the anterior and posterior lumbar spine. This allows both lateral lumbar interbody cage placement, direct posterior decompression, and pedicle screw placement, all in one position. Three-dimensional (3D) navigation is utilized for increased precision in both approaching the lateral spine and interbody cage placement. The traditional blind psoas muscle tubular dilation was also modified. Tubular retractors and lateral vertebral body retractor pins were used to minimize the risks to the lumbar plexus.

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large ...

Spinal Shortening Surgery for Lumbosacral Nerve Bowstring Disease: A Surgical Technique

Lumbosacral nerve bowstring disease (LNBD) is a syndrome of neurological symptoms caused by differences in the development speed of lumbosacral bone tissue and nerve tissue, which result in a longitudinal stretch of the slow-growing nerve tissue. LNBD is usually caused by congenital factors and accompanied by other lumbosacral diseases, such as lumbar spinal stenosis, lumbar spondylolisthesis, and iatrogenic factors. The main symptoms of LNBD are lower extremity neurological symptoms and fecal dysfunction. The conservative treatment of LNBD includes rest, functional exercise, and drug therapy, but it usually fails to achieve satisfactory clinical results. Few studies have reported on the surgical treatment of LNBD. In this study, we used posterior lumbar interbody fusion (PLIF) to shorten the spine (0.6-0.8mm/segment). This reduced the axial tension of the lumbosacral nerves and relieved the patient's neurological symptoms. We report on the case of a 45 year old male patient whose main symptoms were left lower extremity pain, decreased muscle strength, and hypoesthesia. The above symptoms were significantly relieved 6 months after surgery.

Lumbosacral nerve bowstring disease (LNBD) is a syndrome comprising a series of neurological symptoms caused by high axial tension of the lumbosacral nerve due to congenital, iatrogenic, and other factors. Here, we introduce a surgical technique for the treatment of LNBD through spinal shortening surgery.

Lumbosacral nerve bowstring disease (LNBD) is a syndrome of neurological symptoms caused by differences in the development speed of lumbosacral bone ...

Anterior Cervical Hybrid Decompression and Fusion Surgery to Treat Multilevel Cervical Spondylotic Myelopathy

Cervical spondylotic myelopathy (CSM) is a common disease resulting from intervertebral disc herniation, ossification of the posterior longitudinal ligament, and other pathological changes that cause spinal cord compression. CSM progresses insidiously with mild upper-limb numbness, which patients tend to ignore. As the condition worsens, the patients may experience a limp, limited fine motor activity, and eventually, a loss of daily activity. Conservative treatments, such as physical therapy and medication, are frequently ineffective for CSM. Once surgery is deemed to be required, decompression surgery is the best option. So far, both anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) have been commonly used to treat CSM. In addition, a type of hybrid procedure that combines ACDF with ACCF has been used to treat some CSM cases and achieved satisfying results. Thus, this study aims to introduce this hybrid surgical technique and advocate for it based on its patient success.

This paper describes a hybrid surgical technique that combines anterior cervical discectomy and fusion with anterior cervical corpectomy and fusion to treat patients with multilevel cervical spondylotic myelopathy.

Cervical spondylotic myelopathy (CSM) is a common disease resulting from intervertebral disc herniation, ossification of the posterior longitudinal ...

Effects of Manual Therapy on a Chronic Non-Specific Low Back Pain Murine Model

Manual Therapy for a Chronic Non-Specific Low Back Pain Rat Model

Chronic low back pain (CLBP) is a highly prevalent condition worldwide and a major cause of disability. The majority of patients with CLBP are diagnosed with chronic non-specific low back pain (CNLBP) due to an unknown pathological cause. Manual therapy (MT) is an integral aspect of traditional Chinese medicine and is recognized as Tuina in China. It involves techniques like bone-setting and muscle relaxation manipulation. Despite its clinical efficacy in treating CNLBP, the underlying mechanisms of MT remain unclear. In animal experiments aimed at investigating these mechanisms, one of the main challenges is achieving normative MT on CNLBP model rats. Improving the stability of finger strength is a key issue in MT. To address this technical limitation, a standardized procedure for MT on CNLBP model rats is presented in this study. This procedure significantly enhances the stability of MT with the hands and alleviates common problems associated with immobilizing rats during MT. The findings of this study are of reference value for future experimental investigations of MT.

This study proposes a standardized procedure for manual therapy on chronic low back pain model rats, which will be of reference value for future experimental research on manual therapy.

Chronic low back pain (CLBP) is a highly prevalent condition worldwide and a major cause of disability. The majority of patients with CLBP are diagnosed ...

A 3-Channel Endoscopic Technique for Lumbar Stenosis and Contralateral Herniation

The Third Channel-Assisted Unilateral Biportal Endoscopic Technique for Lumbar Spinal Stenosis Combined with Contralateral Disc Herniation

Unilateral biportal endoscopic (UBE) spine surgery is an emerging minimally invasive surgical (MIS) technique that has gained popularity for treating lumbar spinal stenosis, particularly in Eastern Asia. The traditional UBE technique, with two portals on one side, can achieve successful unilateral laminotomy for bilateral decompression (ULBD) and, therefore, demonstrates favorable clinical outcomes. However, in the case of lumbar spinal stenosis combined with contralateral disc herniation, it is very difficult to remove the contralateral disc herniation, especially the loose disc fragment within the deep disc. Here, a third channel of the traditional UBE technique was developed to do the discectomy within the ipsilateral endoscopic vision, with which the instruments can go vertically into the contralateral disc, allowing easy discectomy. This technique can not only achieve adequate decompression of the bilateral spinal canal but also effectively remove contralateral herniated disc fragments. This technique avoids performing another UBE procedure on the opposite side, which can potentially shorten the duration of the operation, minimize blood loss and tissue damage, and ensure sufficient neural decompression. This paper will introduce the indications and surgical operation procedures, as well as present a classical case report and follow-up data, to facilitate the application of the third channel-assisted UBE (T-UBE) technique for spine surgeons.

Author Spotlight: Unveiling the Potential of TUBE Technique in Spinal Surgery

Here, we present the third channel-assisted UBE technique, which allows for the vertical removal of herniated disc fragments. This technique can effectively address the limitations of traditional UBE techniques. This article will systematically elaborate on this procedure.

Unilateral biportal endoscopic (UBE) spine surgery is an emerging minimally invasive surgical (MIS) technique that has gained popularity for treating ...

Treating Lumbar Spinal Stenosis with a Minimally Invasive Spine Surgery

Percutaneous Endoscopic Unilateral-Approach Bilateral Decompression for Lumbar Spinal Stenosis

Lumbar spinal stenosis (LSS) involves the narrowing of the spinal canal due to degenerative changes in the vertebral joints, intervertebral discs, and ligaments. LSS encompasses central canal stenosis (CCS), lateral recess stenosis (LRS), and intervertebral foramen stenosis (IFS). The utilization of lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has gained popularity in the treatment of CCS and LRS. This popularity is attributed to the rapid development of endoscopic instruments and the progress of endoscopic philosophy.
In this technical report, a detailed introduction to the steps and key points of LE-ULBD is provided. Simultaneously, a retrospective review of 132 consecutive patients who underwent LE-ULBD for central canal and/or lateral recess stenosis was conducted. The outcomes after more than two years of follow-up were assessed using the visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores, and the modified MacNab criteria to evaluate surgical efficacy. All 132 patients underwent LE-ULBD successfully. Among them, 119 patients were rated as "excellent," while 13 patients were rated as "good" based on the modified MacNab criteria during the last follow-up. Incidental dural tears occurred in four cases, but there were no post-operative epidural hematomas or infections. The experience demonstrates that LE-ULBD is a less invasive, effective, and safe approach. It can be considered as an alternative option for treating patients with lumbar central canal stenosis and/or lateral recess stenosis.

Author Spotlight: Scope of LE-ULBD as a Safe, Effective, and Minimally Invasive Approach to Treat Lumbar Spinal Stenosis

The present protocol describes the steps and key points of lumbar endoscopic unilateral laminotomy for bilateral decompression for the treatment of degenerative lumbar spinal stenosis.

Lumbar spinal stenosis (LSS) involves the narrowing of the spinal canal due to degenerative changes in the vertebral joints, intervertebral discs, and ...

Technique of Sagittal Adjusting Screw System for Thoracolumbar Burst Fractures

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

Thoracolumbar (TL) burst fracture is one of the most common indications for minimally invasive percutaneous pedicle screw fixation. Although the indication for surgical treatment of neurologically intact TL fractures remains under debate, studies have demonstrated that posttraumatic malalignment may lead to a deterioration in the patient&#39;s quality of life. For burst fractures with malalignment or fragments in the spinal canal, a reduction technique using ligamentotaxis is commonly used to improve long-term outcomes.
The sagittal adjusting screw (SAS) system is a monoaxial screw system with a fixed head and concave sliding saddle that allows lordotic sliding of the rod in the sagittal plane after screw insertion. SAS also has a percutaneous option and has been used for TL spine fractures. Notably, the SAS only allows motion on the sagittal plane, allowing both secure fixation and angular reduction. The SAS has certain advantages over the conventional Schanz screw system or normal mono-/multiaxial pedicle screws for TL spine fracture treatment. In addition, specialized trauma reduction devices are available for the SAS system. In this video protocol, we discuss the indication for the SAS system in TL burst fracture and describe a technique of TL burst fracture reduction and fixation using the SAS system. Additionally, we describe our recent case series with radiological evaluation, including regional kyphotic angle and percent loss of anterior vertebral body height, to evaluate the newly introduced trauma reduction device.

The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.