Surgery for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline.

Spine. 2009 Apr 9; Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JDSTUDY DESIGN.: Systematic review. OBJECTIVE.: To systematically assess benefits and harms of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis. SUMMARY OF BACKGROUND DATA.: Although back surgery rates continue to increase, there is uncertainty or controversy about utility of back surgery for various conditions. METHODS.: Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of the above therapies. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. RESULTS.: For nonradicular low back pain with common degenerative changes, we found fair evidence that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard (nonintensive) nonsurgical therapy. Less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion. Clinical benefits of instrumented versus noninstrumented fusion are unclear. For radiculopathy with herniated lumbar disc, we found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. For symptomatic spinal stenosis with or without degenerative spondylolisthesis, we found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. For both conditions, patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up in some trials. Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease and that an interspinous spacer device is superior to nonsurgical therapy for 1- or 2-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge long-term benefits or harms. CONCLUSION.: Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.

A pyogenic discitis at c3-c4 with associated ventral epidural abscess involving c1-c4 after intradiscal oxygen-ozone chemonucleolysis: a case report.

Spine. 2009 Apr 15; 34(8): E298-304Bo W, Longyi C, Jian T, Guangfu H, Hailong F, Weidong L, Haibin TSTUDY DESIGN: A case report and clinical discussion. OBJECTIVE: To describe an unique case of purulent discitis at C3-C4 and an anterior C1-C4 epidural abscess secondary to oxygen-ozone therapy for the herniated cervical discs. SUMMARY OF BACKGROUND DATA: Previously reported complications secondary to ozone therapy are rarely documented. No cases of pyogenic discitis with associated epidural abscess after oxygen-ozone therapy have been reported to date. To our knowledge, this is the first such case reported in literature. METHODS: A 57-year-old female patient with nuchal stiffness was previously treated with ozone therapy at the discs of C3-C4, C4-C5, and C6-C7. Five days later, she presented with an attack of neck pain and fever followed by progressive quadriplegia with sudden onset of dyspnea and was referred to our hospital. On admission, physical examination revealed a temperature of 38.8 degrees C, evident neck tenderness, marked global weakness (grade 1-2/5 MRC) in bilateral upper-limb, and a modest global weakness in bilateral lower-limb (grade 4/5 MRC). Laboratory findings showed a significantly elevated WCC, ESR, and CRP. Blood culture was negative. Enhanced-MR imaging demonstrated a purulent discitis at C3-C4 and a ventral C1-C4 epidural abscess with homogenous enhancement indicative of a solid phlegmonous granulation tissue. RESULTS: We formulated a 3-stage treatment involving C1-C4 multilevel decompressive laminectomies, subtotal unilateral C3-C4 facetectomies, and tissue sampling for culture with application of a corset after surgery, followed by a delayed secondary posterior thorough drainage of epidural liquid pus using a suction-irrigation drainage, after the abscess had turned to a necrotic liquid abscess, on the basis of findings of enhanced-MR imaging, by 10-day duration of intravenously antibiotic therapy tailored to Streptococcus bovis isolated from infected tissue. Over the next few weeks, the patient made an excellent neurologic recovery. However, she did not consent to undergo further occipitocervical fusion until the follow-up MR imaging at 8 months demonstrated postlaminectomy kyphosis. After surgery, the patient remained clinically satisfactory in neurology without evidence of a recurrence of spinal infection. A slight improvement in the cervical spine curve was demonstrated in the follow-up radiograph at nearly 4-month postoccipitocervical fusion. CONCLUSION: This case report illustrates a rare but life-threatening complication of oxygen-ozone therapy for the cervical disc herniation. Infection is a common risk for any invasive spinal techniques involving puncture, so attention should be paid to the sterility during the procedures. A high index of suspicion along with reliance on enhanced-MRI is essential to diagnose the condition and institute appropriate treatment on an individual basis.