Raffaele Borghi

Central sensitization in chronic low back pain: A narrative review

Low back pain is one of the four most common disorders in all regions, and the greatest contributor to disability worldwide, adding 10.7% of total years lost due to this health state. The etiology of chronic low back pain is, in most of the cases (up to 85%), unknown or nonspecific, while the specific causes (specific spinal pathology and neuropathic/radicular disorders) are uncommon. Central sensitization has been recently recognized as a potential pathophysiological mechanism underlying a group of chronic pain conditions, and may be a contributory factor for a sub-group of patients with chronic low back pain. The purposes of this narrative review are twofold. First, to describe central sensitization and its symptoms and signs in patients with chronic pain disorders in order to allow its recognition in patients with nonspecific low back pain. Second, to provide general treatment principles of chronic low back pain with particular emphasis on pharmacotherapy targeting central sensitization.

Pedicle screw insertion techniques: an update and review of the literature.

Pedicle screw construct have become one of the most practiced procedure in spinal surgery. Despite commonly used, questions remain about their safety especially for the thoracic spine and in deformity where difficulty in positioning can lead to pedicle breach and adjacent structures injury. Misplacement rates have been reported to be from 5 to 41% in the lumbar spine and from 3 to 55% in the thoracic spine. Hence, various procedures have been described in order to improve pedicle screw insertion accuracy. Aim of this study is to evaluate current concepts on pedicle screws placement techniques to better understand recent attitude and clarify some doubts when selecting the most proper method.

Can neural blocks prevent phantom limb pain

Phantom limb syndrome (PLS) is a syndrome including stump pain, phantom limb pain and not-painful phantom sensations, which involves a large part of amputee patients and often has devastating effects on their quality of life. The efficacy of standard therapies is very poor. Nerve blocks have been investigated for the treatment and prevention of PLS. Epidural and peripheral blocks limited to the first three postamputation days can only reduce acute pain but cannot prevent the later development of PLS. Recent studies have shown that ambulatory prolonged peripheral nerve block (up to 30 days postamputation) may represent a new possible option to treat phantom pain and prevent the development of PLS and chronic pain.

Surgical treatment of hallux valgus associated with flexible flatfoot during growing age

PurposeDuring growth, hallux valgus could present associated with flatfoot. Considering the current disagreement about correction of hallux valgus during growth and the lack of reports about simultaneous correction of hallux valgus associated with flexible flatfoot, we present simultaneous treatment of both deformities during growth combining subtalar arthroeresis and SERI first metatarsal osteotomy, reporting results at an average five-year follow-up.MethodsThirty-two children (64 feet, age range 8–12 years) affected by hallux valgus associated with flexible flatfoot underwent surgical treatment combining SERI first metatarsal osteotomy and subtalar arthroereisis with bioabsorbable endorthotic implant. Clinical evaluation was summarized with AOFAS score, and standard standing radiographs were performed.ResultsAOFAS score ranged from 86 ± 2 to 98 ± 2 (hindfoot) and from 80 ± 4 to 98 ± 2 (forefoot). HVA ranged from 21° ± 2 to 5° ± 2, IMA from 14° ± 2 to 7° ± 2, DMAA from 18° ± 2 to 2° ± 2, and Meary’s angle from 162° ± 11 to 175° ± 4. Complications included one case of delayed wound healing, inflammatory skin reaction around the outlet of the percutaneous Kirschner wire in two cases, displacement of the endorthotic implant in one case, and a second surgery to replace the implant.ConclusionsSERI osteotomy and subtalar arthroereisis resulted in an effective, technically simple and easily combined approach, with a high rate of good results and low rate of complications at mid-term follow-up. These techniques performed simultaneously represent a viable option in case of hallux valgus associated with flexible flatfoot during growth. Nevertheless, considering the limitations of this study, we believe that a larger case series and a longer follow-up should be desirable.

Preservation of hamstring tibial insertion in anterior cruciate ligament reconstruction: a review of the current literature

Abstract Hamstring graft (HG) used in anterior cruciate ligament (ACL) reconstruction undergoes a biological modification process called “ligamentization” in the early postoperative period that proceeds through three different phases: an early graft-healing phase with central graft necrosis, a phase of proliferation, and finally, a ligamentization phase toward the properties of the intact ACL. The fastening of this process could result in more aggressive rehabilitation protocols as well as faster sport resumption. A recent literature supports the preservation of HG tibial attachment in order to enhance “ligamentization” process. Aim of this literature review is to describe all the techniques described that spare HG tibial insertion and the obtained results in order to evaluate evidence that would substantiate the maintenance of HG tibial insertion in ACL reconstruction. A search was performed using the following keywords “ACL reconstruction” in combination with “hamstrings,” “hamstrings insertion,” “tibial insertion,” “ligamentization,” and “over the top”; 18 articles were found to be relevant. Among these, eight randomized clinical trials (RCTs) were found. The RCT analyzed presented a high number of biases regarding the analyzed topic, thus making impossible to draw definitive evidences to validate HG tibial insertion sparing in ACL reconstruction. Despite the satisfactory results in many clinical series and the promising results in anatomic and animal studies, well-designed prospective clinical trials with large cohort of patients associated with MRI evaluation are mandatory to assess the beneficial effects of HG attachment preservation in ACL reconstruction.

Surgical tricks for open lumbar discectomy.

Herniated disc syndrome in the lumbar spine is the consequence of the conflict between a spinal root or cauda equina and a fragment of nucleus pulposus migrated through the annulus fibrosus. Patients usually complain of pain or paraesthesia travelling down to the lower extremity in the corresponding dermatome. In the majority of cases symptoms and radiographic signs regress with conservative measures [1]. However, many patients experience persistent symptoms or severe rapid pain progression with sensitive and motor deficits due to the rapid compression of one or more spinal roots. Lumbar discectomy is usually indicated after 6–12 weeks of conservative treatment if pain remains intractable or in case of severe sensitive or motor deficits [2, 3].

Treatment of recent onset low back pain with periradicular injections of meloxicam: a randomized, double blind, placebo controlled cross-over study

BACKGROUND Low back pain (LBP) is a common and costly illness. This randomized, double-blind, placebo-controlled, cross-over study tested the hypothesis that periradicular injections of meloxicam would reduce LBP and improve physical activity compared to a saline injection at 3 months follow-up. METHODS After IRB approval, 80 consenting patients suffering LBP of <6 months duration were randomly assigned to the control (C-group, N.=40, receiving 10 mL of saline) or the meloxicam (M-group, N.=40, receiving 10 mg in 10 mL saline). If the pain Numeric Rating Score (NRS) at 24 hours remained >50% of the pretreatment score, the patient was crossed-over to the other group. A successful treatment was NRS<3 at 3 months follow-up. Secondary outcome measures which were assessed included work-absence, physical-assistance, physical-activities limitations and pain-related insomnia. RESULTS The baseline NRS was 9.3 (95% CI: 8.9-9.7) in the C-group and 9.2 (95% CI: 8.8-9.6) in the M-group. At the 24 hours follow-up after the initial treatment, the mean NRS was 6.3 (95% CI: 5.4-7.2) in the C-group vs. 3.5 (95% CI: 2.6-4.4) in the M-group (P<0.05). The number of cross-over cases was significantly higher in the C-group (N.=31, 77.5% vs. N.=5, 12.5%, P<0.001). At the 3 months follow-up, 66 patients (35+31) were allocated in the M-group and 54 (82%) reported NRS Score <3, while only 14 (9+5) patients remained in the C-group and eight patients had NRS<3. CONCLUSIONS Periradicular injection of meloxicam is an effective analgesic treatment for acute/subacute LBP. This novel use of meloxicam also leads to an improvement in the level of physical activity at the 3-month follow-up.

Outcomes of total hip replacement in limbs affected by poliomyelitis

Introduction The outcomes of total hip replacement in patients suffering from residual poliomyelitis are poorly covered in the literature. In this retrospective study we posed the question of whether total hip replacement performed for degenerative hip diseases in limbs with residual poliomyelitis could determine satisfactory mid-term clinical and radiographic results, with a reasonable complication rate. Methods A retrospective study was carried out to assess the results of 14 total hip replacements performed on 14 patients with residual poliomyelitis on the involved limb from June 1999 to September 2011. Average age at the time of surgery was 51 years (range 26-66 years). Mean duration of follow-up was 92 months (range 52-156 months). Surgery was performed through a direct lateral approach on all hips. All but one were cementless implants. Results 2 implants failed, 1 due to traumatic acetabular fracture 6 days after surgery, and 1 due to aseptic cup loosening 13 years after surgery. Surgery was uneventful in all patients except 1 (7%), who experienced a transient sensory sciatic nerve palsy. At the latest follow up Harris Hip Score was 83.3 (range 72-91) with a marked improvement when compared to preoperative score (average 52, range 32-78). No dislocations had occurred. Conclusions Total hip replacement can be considered a feasible option for hip osteoarthritis in patients with limbs affected by residual poliomyelitis. Longer follow-up studies are needed to assess the effectiveness of unconstrained total hip replacement in polio patients.

Transforaminal lumbar interbody fusion.

L2–L3–L4 posterolateral arthrodesis associated with asymmetric right transforaminal interbody fusion at L3–L4 intervertebral space was planned. The patient was placed on a suitable spine frame in prone position with the hips in neutral extension, in order to maintain lumbar lordosis. A proper positioning allows the abdomen to hang free to reduce abdominal pressure, which leads to diminished venous engorgement and intraoperative bleeding. A standard midline approach was performed from L1 to L5. The supraspinous and interspinous ligaments were carefully left intact. Once the posterior processes were carefully exposed, the articular processes of L2, L3 and L4 joints were detected. Joint capsule of L2–L3 preserved intact in order to avoid proximal junction kyphosis. In order to find the entry point for pedicle screw we usually place a forceps over the transverse process to identify the proximal and distal margins of the pedicle. The cortex on the entry point is opened with an awl where the articular joint reaches the transverse process. Pedicles were gently drilled with a 2.7 mm drill bit. This technique provides a very fine hole during the pedicle penetration, which can be corrected simply in case of incorrect trajectory creation. The integrity of the walls of the pedicles was checked. 2 mm K-wires were inserted in each pedicle. Fluoroscopy

Single level anterior cervical discectomy and interbody fusion

Degenerative disorder of cervical intervertebral disc is a common cause of neck and upper limb pain. There are several reported surgical techniques available for decompression and stabilization of the interested segment in order to treat the degenerative disorder of cervical disc [1]. Anterior cervical discectomy and interbody fusion (ACDIF) for a single level can be performed in different ways to provide good stability and restoring sagittal segmental alignment [2]; however, the rationale for the choice between different techniques remains unclear [1, 3]. The aim of this video case presentation is to show the surgical technique of ACDIF using stand-alone polyetheretherketone (PEEK) cage.