Post-Laminectomy Pain
[…] the implementation of International Classification of Disease (ICD-11) on January 1st, 2022, this diagnosis was changed to “chronic pain after spinal surgery (CPSS)”. However, the ICD-11 has yet to be widely adopted. The terms “post-laminectomy pain” and “FBSS” will be used throughout this document for continuity and to improve search engine optimization for this topic, but readers should be aware of the new terminology for future reference. The term “persistent spinal pain syndrome (PSPS)” with two subtypes (T1 – no spine surgery performed and T2 – post-spine surgery) has also been proposed to address some ambiguity with CPSS but has not yet been added to the ICD-11.1,2 Post-laminectomy pain is defined by the IASP as “lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location”.3 There may be many causes for this chronic pain creating a complex pathophysiology. Predictive risk factors include preoperative (patient) factors, intraoperative factors, and postoperative factors.4,5,6,7,8 Preoperative: this can be divided into patient-specific and surgery-specific factors. Depression, anxiety, hypochondriasis, obesity, smoking, worker’s compensation or ongoing litigation, and radiographic findings such as disc herniation, stenosis, and fibrosis increase the risk of FBSS.9,10 Psychosocial factors are strongly linked to developing disability from low back pain (LBP).11 However, this does not exclude an organic problem, and these factors should be optimized before the surgery.12 Earlier surgery in patients with poor psychometrics and lumbar disc disease may actually improve pain outcome, as prolonged pain and distress can reduce the efficacy of the surgery.13 Selecting an inappropriate patient for surgical treatment (e.g., isolated axial back pain for microdiscectomy or multiple revision surgeries) or an inappropriate surgical approach (e.g., inadequate decompression) can increase the risk of developing FBSS.6 Patients with previous back surgeries have a lower chance of pain relief following surgery and a higher chance of developing FBSS.8 Surgical: operating at the wrong vertebral level or operating at a single vertebral level when the pain generators are multiple levels can lead to poor pain relief.6,8 Lumbarization of the sacral vertebra or sacralization of the lumbar vertebra can lead to operating at the incorrect level. Poor surgical technique is also significant factor in the development of FBSS, especially if there is inadequate decompression at the lateral recess or neural foramina.14,15 Conversely, spine instability may occur if > 33% of the bilateral articular or 100% unilateral articular surfaces are removed.14 Minimally invasive techniques with limited exposure can increase […]
Acromioclavicular Joint Disorders
[…] require repetitive overhead lifting have a higher prevalence of AC joint arthritis.13 It is also more common in patients with spinal cord injury, with a prevalence of 50-71%.14 Social role and social support system Impairment in ADLs are common with AC joint […]
Syringomyelia
[…] malformations; however, idiopathic and rare familial cases are described2. Acquired syringomyelia, also known as primary spinal syringomyelia, can be secondary to spinal cord injury, arachnoiditis, inflammatory or infectious conditions, or neoplasms. Other terms used to describe syringomyelia include communicating or non-communicating syringomyelia. Communicating […]
Vascular Malformations of the Brain and Spine in Children
[…] to accommodate for resultant persistent functional impairments. Social Acute neurologic sequala with resultant functional impairment from an acquired brain or spinal cord injury requires good family and social support. As the child transitions back into the home, school and community, proper accommodations and assistance may be required for mobility and activities of daily living. Support, counseling, education, and developmental guidance is needed for family and other caregivers. Resources for opportunities to be creative and social for children of all ages, including infants and teens, is beneficial. Professional There is often a delay in diagnosis due to the low overall incidence, thus heightened clinical suspicion is necessary for prompt diagnosis. In the initial phase, when emergent symptoms are being controlled and addressed, there may be a delay in definitive treatment of the AVM. This may pose as a stressful time for patients and families with concerns about the risk of recurrence of emergent symptoms. Rehabilitation Management and Treatments Current treatment guidelines Treatment may be conservative or interventional depending on lesion features, clinical presentation and patient specific factors.25 Treatment options include endovascular embolization via catheter delivery of liquid embolics or coils, microsurgical resection, and stereotactic radiosurgery (e.g., Gamma knife). Embolization alone rarely represents a curative treatment. However, a reduction in the size of the nidus or AVM flow may enable the performance of stereotactic radiosurgery or facilitate surgical removal. The risk of all treatment modalities should be weighed against the natural history risks of AVMs. The Spetzler-Martin (SM) grading scale is utilized as a decision tool to estimate the risk of surgical resection by evaluating the AVM size, pattern of venous drainage and eloquence of brain location, with higher grades of 4 and 5 being associated with greater surgical morbidity and mortality.1,16,26 Generally, AVMs with high grades are managed with conservative management due to rupture risk and worse prognosis with operative treatment including partial resection.15,25,27 Further, there is evidence that medical management alone of unruptured AVMs of the brain is superior to interventional therapy or medical plus interventional therapy at 5 year follow up.27 At different disease stages Acute: Observation, medical management and emergent surgical intervention may be warranted based on AVM characteristics and clinical presentation. With acute hemorrhagic presentation, prompt life saving measures to prevent further neurologic compromise are essential. Definitive treatment may be delayed to allow for characterization, healing, or adjuvant therapy as part of a staged treatment plan due to the size, location and complexity of the lesion.16 However, despite variances in clinical courses, treatment outcomes, and complications, pediatric patients with AVMs who underwent acute inpatient rehabilitation saw improvement in their WeeFIM scores upon discharge.28 Subacute: Depending on the location and type of vascular malformation, subsequent monitoring of the lesion with symptom presentation and imaging studies is done. This will guide further need for surgical intervention with a goal of lesion obliteration and prevention of re-bleeding and further neurologic sequela. In some asymptomatic AVMs that are incidentally found, clinical observation with monitoring is appropriate.16 Chronic/stable: Long term follow-up is necessary due to risk of recurrence and re-rupture. There are currently no established guidelines for length of monitoring. New or evolving symptoms warrant additional imaging/workup to ensure stability of the vascular lesion. Neurologic deficits may improve or persist indefinitely.16 Rehabilitation strategies apply as with any other cause of acquired brain or spinal cord injury. (Please see rehabilitation care for pediatric stroke and spinal cord injury). Coordination of care To date, no definitive guidelines exist for the management of brain and spinal AVMs. Multispecialty interdisciplinary care is vital given the complex nature and course of AVMs with the risks of intervention balanced against the natural course of each individualized treatment strategy.29 This pertains to both medical/surgical management of the vascular lesion as well as in the rehabilitation management of acquired brain and spinal cord injury. Patient and family education Patient and family education as to the diagnosis and possible treatment options, with a good understanding of its risk and benefits, as well as the need for subsequent follow-up and rehabilitation cannot be over-emphasized. With the high rate of persistent neurological deficits, it is important to be able to counsel families on the likelihood of long-term deficits following AVM surgeries. These neurological deficits can be predicted using preoperative deficits, lesions of the eloquent cortex, and AVMs > 3 cm.30 Measurement of treatment outcomes Treatment must prevent recurrence that can worsen clinical status. Outcome measures are mainly based […]
Lumbar Radiculopathy
Disease/ Disorder Definition Lumbar radiculopathy refers to any pathologic condition affecting the lumbar nerve roots. In practical terms, radiculopathy is spinal nerve-related symptoms such as pain, with variable presence of paresthesias, weakness, reflex changes, and secondary interference of normal activities. […]
Knee Neuropathies
[…] of freeze-killed nerve grafts. Neuropathology and Applied Neurobiology, 16(5), 411-421. Chu, T., & Wu, W. (2009). Neurotrophic factor treatment after spinal root avulsion injury. Cent Nerv Syst Agents Med Chem, 9(1), 40-55. Thanos, P., Okajima, S., Tiangco, D., & Terzis, […]
Upper Extremity Proximal Mononeuropathies
[…] compromised can lead to the shoulder girdle and upper extremity pain, weakness, and loss of function. These nerves include the Spinal accessory, long thoracic, upper/lower subscapular nerves axillary, suprascapular, and musculocutaneous, nerves. Etiology All are vulnerable to injury from blunt […]
Cervical Radiculopathy
[…] in relieving chronic intractable pain of cervical origin.23 The potential risks associated with this route of injection include epidural hematoma, spinal cord injury, dural puncture, and headache. Stojanovic et al. evaluated 38 epidurograms of interlaminar epidural steroid injection and noted that the […]
Intrathecal Pump Management
[…] as first-line intrathecal therapies for chronic intractable pain (benign or malignant). Baclofen is indicated for chronic spasticity of spinal (traumatic spinal cord injury and multiple sclerosis) or cerebral (acquired brain injury, cerebral palsy and stroke) origin. For spasticity of spinal origin, each […]
Pediatric Neuromuscular Scoliosis
[…] Neurologic exam should include assessment of muscle tone, reflexes, balance, gait, walking capacity, motor strength, and sensory exam (especially in spinal cord injury patients). Musculoskeletal exam should include joint range of motion (paying careful attention to the hip and pelvic positioning), shoulder […]