An Evaluation of the Effectiveness of Hyaluronidase in the Selective Nerve Root Block of Radiculopathy: A Double Blind, Controlled Clinical Trial

고상봉,Alexander R. Vaccaro,장호진,신동영 대한척추외과학회 2015 Asian Spine Journal Vol.9 No.1

Study Design: Prospective, double-blind, randomized controlled trial. Purpose: To determine the ability of hyaluronidase to provide longer lasting pain relief and functional improvement in patients with lumbar radiculopathy. Overview of Literature: Selective nerve root block (SNRB) is a good treatment option in lumbar radiculopathy. We studied the effectiveness of hyaluronidase when added to the traditional SNRB regimen. Methods: A sample size of 126 patients per group was necessary. A sample of 252 patients who underwent an injection procedure with or without hyaluronidase due to radiculopathy was included in this study. The patients were randomly divided into two groups: the control (C) group and the hyaluronidase (H) group. After SNRB due to radiculopathy, the visual analog scale (VAS) was compared at 2, 4, 6, 8, and 12 weeks between the two groups, and the Oswestry disability index (ODI) was compared at 12 weeks between the two groups. Results: Both groups seemed to have general improvement in VAS, but in C group, the VAS was higher than the H group 2 and 4 weeks after the surgery, and the difference in time-group change between 2 groups was statistically significant (p <0.05). ODI improved in both groups, and the difference in time-group change between 2 groups was not statistically significant (p >0.05). Conclusions: The rebound pain (the re-occurrence of pain within 2–4 weeks after injection) that occurs within 2–4 weeks after the injection of the routine regimen can be reduced when hyaluronidase is added to the routine SNRB regimen.

The Prevalence of Lumbar Spine Facet Joint Osteoarthritis and Its Association with Low Back Pain in Selected Korean Populations

Sangbong Ko,Alexander R. Vaccaro,Sangwook Lee,Jaekun Lee,Hojin Chang 대한정형외과학회 2014 Clinics in Orthopedic Surgery Vol.6 No.4

Background: This study was to evaluate the association of lumbar spine facet joint osteoarthritis (LSFJOA) identified by multi-detector computed tomography (MDCT) with age and low back pain (LBP) in an adult community-based population in Korea. Methods: A sample of 472 participants (age range, 20 to 84 years) who underwent MDCT imaging for abdominal or urological lesions, not for chief complaints of LBP, were included in this study. LSFJOA based on MDCT findings was characterized using four grades of osteoarthritis of the facet joints. The prevalence of LSFJOA according to age group (below 40 years, 40–49 years, 50–59 years, 60–69 years, and above 70 years), gender, and spinal level was analyzed using chi-square tests and the association between LBP and LSFJOA adjusting for age, gender, and spine level was analyzed using multiple binary logistic regression test. Results: Eighty-three study subjects (17.58%) had LSFJOA (grade ≥ 2). The prevalence of LSFJOA was not associated with gender (p = 0.092). The prevalence of LSFJOA increased with age (p = 0.015). The highest prevalence of LSFJOA was observed at L4–5 in men (p = 0.001) and at L5–S1 in women (p = 0.003), and at L5–S1 in the overall population (p = 0.000). LSFJOA was not associated with LBP in men (p = 0.093) but was associated with LBP in women (p = 0.003), especially at L3–4 (p = 0.018) and L5–S1 (p = 0.026). Conclusions: The prevalence of LSFJOA based on the computed tomography imaging was 17.58% in the adult community Korean population. The prevalence of LSFJOA increased with age, and the highest prevalence was noted at L5–S1. LSFJOA was not associated with LBP at any spinal level and age except at L3–4 and L5–S1 in women.

The Role of Exercise in the Alleviation of Neuropathic Pain Following Traumatic Spinal Cord Injuries: A Systematic Review and Meta-analysis

Amirmohammad Toloui,Hamzah Adel Ramawad,Pantea Gharin,Alexander R. Vaccaro,Hamed Zarei,Mostafa Hosseini,Mahmoud Yousefifard,Vafa Rahimi-Movaghar 대한척추신경외과학회 2023 Neurospine Vol.20 No.3

Objective: The objective of this systematic review and meta-analysis was to assess the efficacy of exercise in neuropathic pain following traumatic spinal cord injuries. Methods: The search was conducted in MEDLINE, Embase, Scopus, and Web of Science by the end of 2022. Two independent researchers included the articles based on the inclusion and exclusion criteria. A standardized mean difference was calculated for each data and they were pooled to calculate an overall effect size. To assess the heterogeneity between studies, I2 and chi-square tests were utilized. In the case of heterogeneity, meta-regression was performed to identify the potential source. Results: Fifteen preclinical studies were included. Meta-analysis demonstrated that exercise significantly improves mechanical allodynia (standardized mean difference [SMD], -1.59; 95% confidence interval [CI], -2.16 to -1.02; p < 0.001; I2 = 90.37%), thermal hyperalgesia (SMD, 1.95; 95% CI, 0.96–2.94; p < 0.001), and cold allodynia (SMD, -2.92; 95% CI, -4.4 to -1.43; p < 0.001). The improvement in mechanical allodynia is significantly more in animals with a compression model of SCI (meta-regression coefficient, -1.33; 95% CI, -1.84 to -0.57; p < 0.001) and in mild SCI (p < 0.001). Additionally, the improvement was more prominent if the training was started 7 to 8 days postinjury (coefficient, -2.54; 95% CI, -3.85 to -1.23; p < 0.001) and was continued every day (coefficient, -1.99; 95% CI, -3.07 to -0.9; p < 0.001). Likewise, voluntary exercise demonstrated a significantly more effect size (coefficient, -1.45; 95% CI, -2.67 to -0.23; p = 0.02). Conclusion: Exercise is effective in the amelioration of neuropathic pain. This effect in mechanical allodynia is more prominent if voluntary, continuous training is initiated in the subacute phase of mild SCI.

Correlation of Early Outcomes and Intradiscal Interleukin-6 Expression in Lumbar Fusion Patients

John D. Koerner,Dessislava Z. Markova,Greg D. Schroeder,Christopher L. Antonacci,Joseph Mendelis,Alexander R. Vaccaro,D. Greg Anderson,Chris K. Kepler 대한척추신경외과학회 2020 Neurospine Vol.17 No.1

Objective: To determine if there is correlation between intradiscal levels of interleukin-6 (IL-6) and early outcome measures in patients undergoing lumbar fusion for painful disc degeneration. Methods: Intervertebral disc tissue was separated into annulus fibrosus/nucleus pulposus and cultured separately in vitro in serum-free medium (Opti-MEM). Conditioned media was collected after 48 hours. The concentration of IL-6 was quantified using enzyme-linked immunosorbent assay. Pearson correlation coefficients quantified relationships between IL-6 levels and pre- and postoperative visual analogue scale (VAS) back pain and Oswestry Disability Index (ODI), as well as change in VAS/ODI. Results: Sixteen discs were harvested from 9 patients undergoing anterior lumbar interbody fusion (mean age, 47.4 years; range, 21–70 years). Mean preoperative and 6-month postoperative VAS were 8.1 and 3.7, respectively. Mean preoperative and postoperative ODI were 56.2 and 25.6, respectively. There were significant positive correlations between IL-6 expression and postoperative VAS (ρ=0.38, p=0.048) and ODI (ρ=0.44, p=0.02). No significant correlations were found between intradiscal IL-6 expression and preoperative VAS (ρ=-0.12, p=0.54). Trends were seen associating IL-6 expression and change in VAS/ODI (ρ=-0.35 p=0.067; ρ=-0.34, p=0.08, respectively). A trend associated IL-6 and preoperative ODI (ρ=0.36, p=0.063). Conclusion: The direct association between IL-6 expression and VAS/ODI suggests patients with elevated intradiscal cytokine expression may have worse early outcomes than those with lower expression of IL-6 after surgery for symptomatic disc degeneration.

Significance of Facet Fluid Index in Anterior Cervical Degenerative Spondylolisthesis

Lee Yunsoo,Heard Jeremy C.,Lambrechts Mark J.,Kern Nathaniel,Wiafe Bright,Goodman Perry,Mangan John J.,Canseco Jose A.,Kurd Mark F.,Kaye Ian D.,Hilibrand Alan S.,Vaccaro Alexander R.,Kepler Christophe 대한척추외과학회 2024 Asian Spine Journal Vol.18 No.1

Study Design: Retrospective cohort study.Purpose: To correlate cervical facet fluid characteristics to radiographic spondylolisthesis, determine if facet fluid is associated with instability in cervical degenerative spondylolisthesis, and examine whether vertebral levels with certain facet fluid characteristics and spondylolisthesis are more likely to be operated on.Overview of Literature: The relationship between facet fluid and lumbar spondylolisthesis is well-documented; however, there is a paucity of literature investigating facet fluid in degenerative cervical spondylolisthesis.Methods: Patients diagnosed with cervical degenerative spondylolisthesis were identified from a hospital’s medical records. Demographic and surgical characteristics were collected through a structured query language search and manual chart review. Radiographic measurements were made on preoperative MRIs for all vertebral levels diagnosed with spondylolisthesis and adjacent undiagnosed levels between C3 and C6. The facet fluid index was calculated by dividing the facet fluid measurement by the width of the facet. Bivariate analysis was conducted to compare facet characteristics based on radiographic spondylolisthesis and spondylolisthesis stability.Results: We included 154 patients, for whom 149 levels were classified as having spondylolisthesis and 206 levels did not. The average facet fluid index was significantly higher in patients with spondylolisthesis (0.26±0.07 vs. 0.23±0.08, p <0.001). In addition, both fluid width and facet width were significantly larger in patients with spondylolisthesis (p <0.001 each). Cervical levels in the fusion construct demonstrated a greater facet fluid index and were more likely to have unstable spondylolisthesis than stable spondylolisthesis (p <0.001 each).Conclusions: Facet fluid index is associated with cervical spondylolisthesis and an increased facet size and fluid width are associated with unstable spondylolisthesis. While cervical spondylolisthesis continues to be an inconclusive finding, vertebral levels with spondylolisthesis, especially the unstable ones, were more likely to be included in the fusion procedure than those without spondylolisthesis.

Inhibition of Neurogenic Inflammatory Pathways Associated with the Reduction in Discogenic Back Pain

Canseco Jose A.,Levy Hannah A.,Karamian Brian Abedi,Blaber Olivia,Chang Michael,Patel Neil,Curran John,Hilibrand Alan S.,Schroeder Gregory D.,Vaccaro Alexander R.,Markova Dessislava Z.,Surrey David E. 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.6

Study Design: Retrospective cohort study.Purpose: This study aimed to determine whether the initiation of anti-calcitonin gene-related peptide (CGRP inhibitor) medication therapy for migraines was also associated with improvements in back/neck pain, mobility, and function in a patient population with comorbid degenerative spinal disease and migraine.Overview of Literature: CGRP upregulates pro-inflammatory cytokines such as tumor necrosis factor-α, interleukin-6, brain-derived neurotrophic factor, and nerve growth factor in spinal spondylotic disease, which results in disc degeneration and sensitization of nociceptive neurons. Although CGRP inhibitors can quell neurogenic inflammation in migraines, their off-site efficacy as a therapeutic target for discogenic back/neck pain conditions remains unknown.Methods: All adult patients diagnosed with spinal spondylosis and migraine treated with CGRP inhibitors at a single academic institution between 2017 and 2020 were retrospectively identified. Patient demographic and medical data, follow-up duration, migraine severity and frequency, spinal pain, functional status, and mobility before and after the administration of CGRP inhibitors were collected. Paired univariate analysis was conducted to determine significant changes in spinal pain, headache severity, and headache frequency before and after the administration of CGRP inhibitors. The correlation between changes in the spinal pain score and functional or mobility improvement was assessed with Spearman’s rho.Results: In total, 56 patients were included. The mean follow-up time after the administration of CGRP inhibitors was 123 days for spinal pain visits and 129 days for migraine visits. Back/neck pain decreased significantly (<i>p</i> <0.001) from 6.30 to 4.36 after starting CGRP inhibitor therapy for migraine control. As recorded in the spine follow-up notes, 25% of patients experienced a functional improvement in the activities of daily living, and 17.5% experienced mobility improvement while taking CGRP inhibitors. Change in back/ neck pain moderately correlated (ρ=−0.430) with functional improvement but was not correlated with mobility improvement (ρ=−0.052).Conclusions: Patients taking CGRP inhibitors for chronic migraines with comorbid degenerative spinal conditions experienced significant off-target reduction of back/neck pain.