The spine journal : official journal of the North American Spine Society
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Surgical treatment for lumbar degenerative disc disease (DDD) has been associated with highly variable results in terms of postoperative pain relief and functional improvement. Many experts believe that DDD should be considered a chronic pain disorder as opposed to a degenerative disease. Genetic variation of the catechol-O-methyltransferase (COMT) gene has been associated with variation in human pain sensitivity and response to analgesics in previous studies. ⋯ This is the first study to report an association between surgical treatment success in DDD patients and genetic variation in the putative pain sensitivity gene COMT. These findings require replication in other DDD populations but suggest that genetic testing for pain-relevant genetic markers such as COMT may provide useful clinical information in terms of predicting outcome after surgery for patients diagnosed with DDD.
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The X-STOP interspinous decompression device, as a treatment for neurogenic intermittent claudication (NIC) because of lumbar spinal stenosis (LSS), has been shown to be superior to nonoperative control treatment. Current Food and Drug Administration labeling limits X-STOP use to NIC patients with a maximum of 25° concomitant lumbar scoliosis. This value was arrived at arbitrarily by the device developers and is untested. ⋯ The outcome success rate for the X-STOP procedure to treat NIC is lower in patients with overall lumbar scoliosis more than 25° but is unaltered by segmental scoliosis at the affected level. Although patients and surgeons must be aware that the presence of more than 25° of scoliosis portends less favorable results with X-STOP implantation for NIC because of LSS, success in these patients is not precluded, and selection of treatment must be put into the context of individual patient risk and other treatment options.
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Case Reports
Cervicothoracic intraspinal pseudomeningocele with cord compression after a traumatic brachial plexus injury.
Pseudomeningoceles are noted within the neural foramen after avulsion plexus injuries. We present the case of a cervicothoracic epidural pseudomeningocele with spinal cord compression 18 years after a brachial plexus injury. ⋯ Pseudomeningoceles are common after brachial plexus avulsion injury and are usually stable, causing no symptoms, other than plexus neuropathies. We are unaware of previous reports of a patient with a traumatic brachial plexus avulsion who developed a large cervicothoracic, symptomatic, spinal, epidural, intracanalicular pseudomeningocele with cord compression 18 years after the initial injury. Patients with prior trauma and known plexus injuries with development of new neurological symptoms should be evaluated for the rare case of intradural pseudomeningoceles. Preoperative imaging with computed tomography myelography is important to isolate and definitively treat the fistulous connection.
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A balanced sagittal alignment of the spine has been shown to strongly correlate with less pain, less disability, and greater health status scores. To restore proper sagittal balance, one must assess the position of the occiput relative to the sacrum. The assessment of spinal balance preoperatively can be challenging, whereas predicting postoperative balance is even more difficult. ⋯ This analysis shows that many factors influence the overall sagittal balance of the patient, but it may be the position of the pelvis and lower spine that have a stronger influence than the position of the upper back and neck. Unfortunately, to our knowledge, there are no studies to date that have established a normal sagittal T1 tilt angle. However, our analysis has shown that when the T1 tilt was higher than 25°, all patients had at least 10 cm of positive sagittal imbalance. It also showed that patients with negative sagittal balance had mostly low T1 tilt values, usually below 13° of angulation. The T1 sagittal angle is a measurement that may be very useful in evaluating sagittal balance, as it was the measure that most strongly correlated with SVA(dens). It has its great utility where long films cannot be obtained. Patients whose T1 tilt falls outside the range 13° to 25° should be sent for full-column radiographs for a complete evaluation of their sagittal balance. On the other hand, a T1 tilt within the above range does not guarantee a normal sagittal balance, and further investigation should be performed at the surgeon's discretion.
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Dai F, Belfer I, Schwartz C, et al. Association of catechol-O-methyltransferase genetic variants with outcome in patients undergoing surgical treatment for lumbar degenerative disc disease. Spine J 2010:10:949-957 (in this issue).