The  Pittsburgh knee rules  are medical rules created to ascertain whether a  knee injury  requires the use of an  X-ray  to assess a  fracture .


Blunt trauma  or a fall as mechanism of injury and either of the following:


If the patient satisfies the above criteria, they should receive an X-ray to assess for a possible fracture.


The sensitivity of using the Pittsburgh knee rules is 99% with a specificity of 60%. That means the use of the above rules has a  false negative  result of 1% and a  false positive  result of 40%. [ 1 ]


From a medical point of view, the false positive result is less important as if the patient is positive, they should receive an X-ray to assess for a possible fracture, which has a much higher specificity. However, from a practical point of view, false positives that lead to negative X-ray tests were the very thing that the knee rules are trying to address. Nonetheless, the Pittsburgh knee rules offer fewer false positives than do the  Ottawa knee rules , though the Ottawa knee rules are more commonly used. [ 2 ]  The Ottawa knee rules count even a  limping  step as a step. Pittsburgh counts only a complete heel/toe plant as a step. This key difference likely accounts for the difference in specificity.


The use of the Pittsburgh knee rules reduces the use of knee  radiographs  by 52%. [ 3 ]


The  Revised Trauma Score  ( RTS ) is a physiologic scoring system based on the initial  vital signs  of a patient. [ 1 ]  A lower score indicates a higher severity of injury. [ 2 ]


The Revised Trauma Score is made up of three categories:  Glasgow Coma Scale ,  systolic  blood pressure, and respiratory rate. The score range is 0–12.  In  START   triage , a patient with an RTS score of 12 is labeled delayed, 11 is urgent, and 3–10 is immediate. Those who have an RTS below 3 are declared dead and should not receive certain care because they are highly unlikely to survive without a significant amount of resources. [ citation needed ]


The score is as follows: [ 3 ]


These three scores (Glasgow Coma Scale, Systolic Blood Pressure, Respiratory Rate) are then used to take the weighted sum by RTS = 0.9368 GCSP + 0.7326 SBPP + 0.2908 RRP Values for the RTS are in the range 0 to 7.8408. The RTS is heavily weighted towards the Glasgow Coma Scale to compensate for major head injury without multisystem injury or major physiological changes. A threshold of RTS < 4 has been proposed to identify those patients who should be treated in a trauma centre, although this value may be somewhat low.


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Acromioplasty  is an  arthroscopic  surgical procedure involving the  acromion , a bony process of the  shoulder blade .


Generally, it implies removal of a small piece of the surface of the acromion that is in contact with a tendon of the  rotator cuff  causing, by friction, damage to the tendon.


The procedure has been used to treat  rotator cuff tears  and  impingement syndrome , [ 1 ] [ 2 ]  although its benefits have been debated. [ 3 ] [ 4 ]


Arthroscopy: The Journal of Arthroscopic and Related Surgery  is a  peer-reviewed   medical journal  that was established in 1985 and covers research on the clinical practice of  arthroscopic  and  minimally invasive surgery , a subspecialty of  orthopedic surgery . It is the official journal of the  Arthroscopy Association of North America . The initiative in establishing the journal was taken by Imran sheikh and the first  editor-in-chief  was S. Ward Casscells, who was succeeded in 1992 by Gary G. Poehling. In 2014 James H. Lubowitz succeeded the retiring Dr. Poehling. [ 1 ] [ 2 ]   Arthroscopy Techniques  is an  open access  online companion journal publishing peer-reviewed techniques videos.


The journal is abstracted and indexed by  MEDLINE ,  Web of Science , and  Scopus .


Blumensaat's line  is a line which corresponds to the roof of the  intercondylar fossa of femur  as seen on a  lateral   radiograph  of the  knee joint . [ 1 ]  The angle at which this line appears on the radiograph can be used to determine the position of the patella or diagnose an ACL injury. [ 2 ]


On a normal radiograph, the line intersects the  inferior  pole of the  patella , and so can be useful in diagnosing a broken femur as well as a  patellar tendon rupture .


It also helps to define "Schottle point" intra-operatively for reconstruction of MPFL(Medial patello-femoral ligament.) [ 3 ]


It may also be used to describe the course of an ACL graft.


A  bone cutter  is a  surgical instrument  used to cut or remove  bones . [ 1 ] [ 2 ]  In addition to surgery, they are also used in  forensics  and  dismemberment .


Types of medical bone cutters include:


In medicine,  Clarke's test  (also known as the  Osmond-Clarke test  or  patellar grind test ) is a component of  knee examination  which may be used to test for  patellofemoral pain syndrome ,  chondromalacia patellae , patellofemoral  arthritis , or anterior knee pain. It is not a standard part of the knee examination but is used to diagnose anterior knee pain where the history indicates this as the likely pathology. The patient is asked to actively contract the  quadriceps  muscle while the examiner's hand exerts pressure on the  superior  pole of the  patella , so trying to prevent the  proximal  movement of the patella. While it can produce some discomfort even in normal people, the reproduction of the symptoms suggest pain of patellofemoral origin. [ 1 ]


Evidence for the validity of Clarke's test is limited and some sources claim the test is not clinically useful, [ 2 ] [ 3 ]  though it remains prevalent in clinical practice.


The  Codman triangle  (previously referred to as  Codman's triangle ) is the triangular area of new  subperiosteal  bone that is created when a lesion, often a  tumor , raises the  periosteum  away from the bone. [ 1 ]   A Codman triangle is not actually a full triangle.  Instead, it is often a pseudotriangle on  radiographic  findings, with  ossification  on the original bone and one additional side of the triangle, which forms a two sided triangle with one open side.  This two sided appearance is generated due to a tumor (or growth) that is growing at a rate which is faster than the periosteum can grow or expand, so instead of  dimpling , the periosteum tears away and provides ossification on the second edge of the triangle. [ 2 ]  The advancing tumour displaces the periosteum away from the bone medulla. The displaced and now lateral periosteum attempts to regenerate underlying bone. This describes a periosteal reaction. [ citation needed ]


The main causes for this sign are  osteosarcoma ,  Ewing's sarcoma ,  eumycetoma , and a  subperiosteal abscess . [ 3 ] [ 4 ]


Darrach's procedure  or  distal ulna resection  is a surgical technique for the surgical removal of the  head of ulna . It is performed in cases of  radial – ulnar  joint pain and instability. [ 1 ]  The styloid process and muscular attachments are left intact. [ 2 ]  Weakness and instability can develop after the procedure. It is most appropriate for elderly patients with low physical demands. [ 3 ]


The  Denis Browne bar , also known as the  Denis Browne splint  or  foot abduction orthosis , is a medical device used in the treatment of  club foot . The device is named after  Sir Denis Browne  (1892-1967), an Australian-born surgeon at  Great Ormond Street Hospital  in London who was considered the father of  pediatric surgery  in the United Kingdom. [ 1 ]  Browne first described the device in 1934. [ 2 ]  The bar may be used as part of the  Ponseti method , a series of nonsurgical techniques to address club foot. [ citation needed ]


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The  Denis classification  is a system of categorizing  sacral  fractures. [ 1 ]


Dynamic hip screw (DHS)  or  Sliding Screw Fixation  is a type of  orthopaedic  implant designed for fixation of certain types of  hip fractures  which allows controlled dynamic sliding of the  femoral head  component along the construct. [ citation needed ]  It is the most commonly used implant for  extracapsular fractures  of the hip, [ 1 ]  which are common in older  osteoporotic  patients. There are 3 components of a dynamic hip screw, including a lag screw (inserted into the neck of the femur), a sideplate and several cortical screws (fixated into the proximal femoral shaft). The idea behind the dynamic compression is that the femoral head component is allowed to move along one plane; since bone responds to dynamic stresses, the native femur may undergo primary healing: cells join along boundaries, resulting in a robust joint requiring no remodeling.


Elbow fractures  are any broken bone in or near the  elbow joint  and include  olecranon fractures ,  supracondylar humerus fractures  and  radial head fractures . [ 1 ]  The elbow joint is formed by three different bones: the  ulna ,  radius , and  humerus  that permit the joint to move like a hinge and allow a person to straighten and bend their arm and these bones are connected by tendons, ligaments, and muscle to form the joint. [ 2 ]


The  terrible triad of the elbow  (not to be confused with the  terrible triad  of the knee) is a combination of: [ 3 ]


The  terrible triad of the elbow  is confers joint instability and a major risk of developing  osteoarthritis . [ 3 ]


The  Evans–Jensen classification  is a system of categorizing  intertrochanteric   hip fractures  based on the  fracture  pattern of the proximal  femur .


Fairbank's changes  describe the radiological changes observed on an  AP   radiograph  of the  knee  after  meniscectomy . [ 1 ]


Fairbank identified significant changes including squaring of the  femoral condyles , peak eminences, ridging, and  joint space  narrowing. [ 2 ] [ 3 ]


Femoral head fractures  are very rare  fractures  of the upper end ( femoral head ) of the thigh bone ( femur ). They are a very rare kind of  hip fracture  that may be the result of a fall like most hip fractures but are more commonly caused by more violent incidents such as traffic accidents They are categorized according to the Pipkin classification based on the following  bone fracture  patterns: [ 1 ]


Fixation  in  orthopedics  is the process by which an injury is rendered immobile. [ 1 ]  This may be accomplished by  internal fixation , using  intramedullary rod ,  Kirschner wire  or  dynamic compression plate ; or by  external fixation , using a  spanning external fixator ,  Taylor Spatial Frame  or  Ilizarov apparatus . [ citation needed ]


A  foot deformity  is a disorder of the foot that can be congenital or acquired.


Such deformities can include  hammer toe ,  club foot ,  flat feet ,  pes cavus , etc.


The  Galeazzi test , also known as the Allis sign, is used to assess for  hip dislocation , primarily in order to test for  developmental dysplasia of the hip . It is performed by flexing an  infant's  knees when they are  lying down  so that the feet touch the surface and the  ankles  touch the  buttocks . If the knees are not level then the test is positive, indicating a potential  congenital  hip malformation. [ 1 ]


Gilula's lines  are three arcs drawn on an  AP   radiograph  of the  wrist  used to assess the alignment of the  carpal bones . [ 1 ]


There should be no step-off in the contour of the lines when drawn on a normal wrist.


The  Gosselin fracture  is a V-shaped  fracture  of the  distal   tibia  which extends into the  ankle  joint and fractures the tibial  plafond  into anterior and posterior fragments. [ 1 ]


The fracture was described by  Leon Athanese Gosselin , chief of surgery at the  Hôpital de la Charité  in Paris. [ 2 ]


A  hand deformity  is a  disorder  of the hand that can be  congenital  or acquired. An example is  Madelung's deformity .


The  Hawkins–Kennedy Test  is a test used in the evaluation of orthopedic shoulder injury.  It was first described in the 1980s by Canadians  R. Hawkins  and J. Kennedy, and a positive test is most likely indicative of damage to the  tendon  of the  supraspinatus muscle . [ 1 ] [ 2 ]


A positive Hawkins–Kennedy test is indicative of an impingement of all structures that are located between the  greater tubercle  of the  humerus  and the  coracohumeral ligament . The impinged structures include the  supraspinatus  muscle,  teres minor muscle , and the  infraspinatus muscle . The Hawkins–Kennedy test is considered to be a highly  sensitive  test (79%) [ 3 ]  and thus a positive Hawkins–Kennedy test suggests that injury is likely.


The patient is examined while sitting, with their  shoulder  flexed to 90° and their  elbow  flexed to 90°.  The examiner grasps and supports proximal to both, the patient's  wrist  and elbow, to ensure maximal relaxation, then quickly rotates the patient's arm  internally . [ 4 ] [ 5 ]   Pain located below the  acromioclavicular joint  with  internal rotation  is considered a positive test result. [ 6 ] [ 7 ]


The  Herbert screw  (invented by  Timothy Herbert ) is a variable pitch  cannulated  screw typically made from  titanium  for its biocompatible properties as the screw is normally intended to remain in the patient indefinitely. It became generally available in 1978. [ 1 ] [ 2 ]  It is one of the earliest designs of headless compression screws which are used to achieve interfragmentary compression through its differential pitch between the threads at each end of the screw (distance between adjacent threads of screw).


It is used in  scaphoid ,  capitellum ,  radial head  and in osteochondral fractures. Other uses include osteochondritis dissecans & small joint arthrodesis. [ 3 ]


Hilgenreiner's line  is a horizontal line drawn on an  AP   radiograph  of the  pelvis  running between the inferior aspects of both  triradiate cartilages  of the  acetabulums . [ 1 ]   It is named for  Heinrich Hilgenreiner . [ citation needed ]


Used in conjunction with  Perkin's line  or the  acetabular angle , Hilgenreiner's line is useful in the diagnosis of  developmental dysplasia of the hip .


A  hip spica cast  is a sort of  orthopedic cast  used to immobilize the  hip  or  thigh . It is used to facilitate healing of injured  hip joints  or of  fractured   femora .


A  hip spica  includes the trunk of the body and one or both legs. A hip spica which covers only one leg to the ankle or foot may be referred to as a single hip spica, while one which covers both legs is called a double hip spica. A one-and-a-half hip spica encases one leg to the ankle or foot and the other to just above the knee. The extent to which the hip spica covers the trunk depends greatly on the injury and the surgeon; the spica may extend only to the navel, allowing mobility of the spine and the possibility of walking with the aid of crutches, or may extend to the rib cage or even to the armpits in some rare cases. Hip spicas were formerly common in reducing femoral fractures. Spica casts are used for treating  hip dysplasia  (developmental dislocation of hip). [ 1 ] [ 2 ]


Spica casts are typically made using a soft padded lining, which tightly wrapped around the leg and hip joint. It is then wrapped in either a fiberglass or plaster cast. Fiberglass is generally preferred, as it is stronger than plaster and significantly lighter. It also dries faster than plaster casts. [ citation needed ]


In some cases, a hip spica may only extend down one or more legs to above the knee. Such casts, called pantaloon casts, are occasionally seen to immobilize an injured lumbar spine or pelvis, in which case the trunk portion of the cast usually extends to the armpits. [ citation needed ]


Some spica casts also include a cross bar attached the legs near the knee or calf to add additional stability. Spica casts have a large opening in the front and back to allow the wearer to use the toilet. For babies, the opening is large enough to tuck a diaper on the inside, and then an additional diaper is worn over the cast to keep the inside diaper in place. Many casts also include a Gore-Tex lining, which is similar to the texture of a thin raincoat. It provides waterproofing on the inside of the cast and allows the inside to be wiped down with wipes or water as needed. [ citation needed ]


A  Hoffa fracture  is an  intra-articular  supracondylar distal  femoral  fracture, characterized by a  fracture  in the  coronal plane . [ 1 ]


It is named for  Albert Hoffa . [ 1 ]


The  Hubscher maneuver  (or  Jack's test ) is a method of evaluating the flexibility of a  pes planus  or  flat foot  type. The test is performed with the patient  weight bearing , with the foot flat on the ground, while the clinician dorsiflexes the  hallux  and watches for an increasing concavity of the Arches of the foot.  A positive result (arch formation) results from the flatfoot being flexible. A negative result (lack of arch formation) results from the flatfoot being rigid. In a Jack's test, the patient raises the rearfoot off the ground, thus passively dorsiflexing the hallux in Closed Kinetic Chain. This will result in an increase of the arch height in cases of Dynamic (Flexible) Flat Foot.  If the deformity is a Static (rigid) Flat foot, the height of the arch will be unaffected by raising up the heel on the forefoot.


It is also one method of diagnosing functional hallux limitus. Recent investigations into its reliability have questioned its ability to predict range of motion at the 1st MTP during Gait.


The  Lauge-Hansen classification  is a system of categorizing  ankle fractures  based on the foot position and the force applied. [ 1 ]


In  orthopedic surgery , the  lunotriquetral shear test  or  lunotriquetral shear maneuver  involves stabilizing the  lunate  between thumb and index finger of one hand and the  triquetrum  between the thumb and index finger of the other. The  pisiform  and triquetrum are pushed in a  palmar  to  dorsal  direction. Discomfort in this area suggests the possibility of injury to the lunotriquetral interosseous ligament. [ 1 ]


A  Malgaigne fracture  is vertical  pelvic fracture  with bilateral  sacroiliac  dislocation and fracture of the  pubic rami .


It is named for  Joseph-François Malgaigne .


Mulder's sign  is a physical exam finding associated with  Morton's neuroma , which may be elicited while the patient is in the  supine  position on the examination table.  The pain of the neuroma, as well as a click, can be produced by squeezing the two metatarsal heads together with one hand, while concomitantly putting pressure on the interdigital space with the other hand.  With this technique, the pain of the Morton's neuroma will be localized strictly to the  plantar  surface of the involved interspace, with  paresthesias  radiating into the affected toes.


It is named after the Dutch surgeon and  podiatrist , Jacob D. Mulder (1901–1965). [ 1 ] [ 2 ] [ 3 ]


The  Mumford procedure , also known as distal clavicle excision or distal clavicle resection, is an orthopedic procedure performed to ameliorate shoulder pain and discomfort by excising the distal (lateral) end  of the  clavicle . Those suffering from  osteoarthritis  in the  acromioclavicular joint  can opt for this procedure when non-surgical alternatives (e.g.,  cortisone  injection) are unsuccessful. [ 1 ]  The surgery can be performed through an open or  arthroscopic  procedure. A regimen of physical therapy following surgery is prescribed and most patients experience full recovery within 8 to 10 weeks post-surgery. [ 1 ]  The procedure was created by, and named for, orthopedic surgeon  Eugene Bishop Mumford  in 1941. [ 2 ] [ 3 ]


This  surgery  article is a  stub . You can help Wikipedia by  expanding it .


Osteitis  is  inflammation  of  bone . More specifically, it can refer to one of the following conditions:


Osteochondritis  is a painful type of  osteochondrosis  where the  cartilage  or  bone  in a  joint  is  inflamed . [ 1 ]


It often refers to  osteochondritis dissecans  (OCD). The term  dissecans  refers to the "creation of a flap of cartilage that further dissects away from its underlying subchondral attachments (dissecans)". [ 2 ]


The other recognized types of osteochondritis are  osteochondritis deformans juvenilis  (osteochondritis of the  capitular head  of the  epiphysis  of the  femur ) [ 1 ]  and  osteochondritis deformans juvenilis dorsi  (osteochondrosis of the  spinal vertebrae , also known as Scheuermann's disease). [ 1 ] [ 3 ]


Osteochondritis, and especially osteochondritis dissecans, can manifest in animals as a primary cause of  elbow dysplasia , a  chronic  condition in some dog breeds. [ 4 ]


In February 2021, the U.S.  Food and Drug Administration  (FDA) approved the  Patient Specific Talus Spacer   3D-printed   talus   implant  for humanitarian use. [ 1 ]  The Patient Specific Talus Spacer is the first in the world and first of its kind implant to replace the talus; the bone in the  ankle joint  that connects the  leg  and the  foot . The implant is used for the treatment of  avascular necrosis  (AVN) of the ankle joint, a serious and progressive condition that causes the death of  bone tissue  stemming from a lack of  blood supply  to the area. [ 1 ]  The implant provides a joint sparing alternative to other surgical interventions commonly used in late stage AVN that may disable motion of the ankle joint. [ 1 ]


The Patient Specific Talus Spacer is a 3D printed implant that can be used in talus replacement surgery. [ 1 ]  The talus spacer is made for each recipient individually modeled from  computed tomography  (CT) imaging and is fitted to a recipient's specific  anatomy . [ 1 ]  During the replacement surgery, the recipient's  talus bone  is removed and replaced with the implant, which is made from  cobalt chromium alloy . [ 1 ]  This procedure’s intention is to improve motion and reduce pain for AVN patients who would otherwise require  ankle arthrodesis  or  amputation  procedures. [ 2 ]


The FDA reviewed data for the Patient Specific Talus Spacer through the  humanitarian device exemption  (HDE) process. [ 1 ]  A  Humanitarian Use Device  (HUD) is a device that is intended to benefit people by treating or diagnosing a disease or condition that affects not more than 8,000 individuals in the U.S. per year. [ 1 ] [ 3 ]


Data supporting the safety and probable benefit of the Patient Specific Talus Spacer include results from 31 patients and 32 talus replacement surgeries (one patient had operations on both ankles) with the implant. [ 1 ]  At three years post-operation, the average reported pain decreased from "moderate to severe" prior to surgery to "mild" post-surgery, and average range of motion in the ankle joint also improved. [ 1 ]  These measures were assessed using standard subjective scoring systems for pain and functionality. [ 1 ]


By the three-year mark, out of 32 cases, there were three reported additional surgeries. [ 1 ]  The most common reported adverse events were pain and  scar tissue  at the  surgery site . [ 1 ]


The FDA granted the HDE approval of the Patient Specific Talus Spacer to Additive Orthopaedics, LLC. [ 1 ]


This article incorporates  public domain material  from the  United States Department of Health and Human Services


Pauwel's angle  is the angle between the line of a  fracture of the neck of the femur  and the horizontal as seen on an anterio-posterior  radiograph . [ 1 ]  Pauwel's angle is named after the  German   orthopedist   Friedrich Pauwels . [ 2 ]      Introduced in 1935, this system was the first biomechanical classification for femoral neck fractures, and is still in use. [ 3 ]


An increasing angle leads to a more unstable  fracture  and an increase in the  shear stress  at the fracture site. This shear leads to higher rates of nonunion.


Perkin's line  is a line drawn on an  AP   radiograph  of the  pelvis  perpendicular to  Hilgenreiner's line  at the  lateral aspects of the  triradiate cartilage  of the  acetabulum . [ 1 ] [ 2 ]


Used in conjunction with  Hilgenreiner's line , Perkin's line is useful in the diagnosis of  developmental dysplasia of the hip ; the upper femoral  epiphysis  should be in the inferomedial quadrant on a normal radiograph. Lateral displacement relative to Perkin's line is indicative of DDH.


The  Ruedi–Allgower classification  is a system of categorizing  pilon fractures  of the  distal   tibia . [ 1 ]


The  Seinsheimer classification  is a system of categorizing  subtrochanteric   hip fractures  based on the  fracture  pattern of the proximal  femoral  shaft. The classification was developed by  Frank Seinsheimer III  in 1978. In the published work, fifty-six patients were treated for subtrochanteric fractures, and their fractures were "classified according to the number of major fragments and the locations and shapes of the fracture lines." This system of classification was used to assess the correlation between type of fracture and success of treatment. [ 1 ]


A later study of 50 subtrochanteric fractures, which were assessed using the Seinsheimer classification, criticized the classification system for having poor  inter-rater reliability . They noted that "Earlier studies of pertrochanteric [sic] and femoral neck fractures show that the use of classification systems is often difficult, with low agreement (Frandsen et al. 1988, Andersen et al. 1990, Gehrchen et al. 1993). The results of these studies accord with the low level of interobserver agreement in our study. A total agreement of 26% or at the best 60% is not acceptable." [ 2 ]   A further study published in 2014 assessed four subtrochanteric fracture classification systems, including the Seinsheimer system, and concluded that "the four subtrochanteric classification systems which we assessed were not found to be sufficiently reproducible to be of any significant value in clinical practice." [ 3 ]


A  spiral fracture  (a.k.a.  torsion fracture ) is a  bone fracture  occurring when  torque  (a rotating force) is applied along the axis of a  bone . [ 1 ]  Spiral fractures often occur when the body is in motion while one extremity is planted. For example, a spiral fracture of the  tibia  (the shinbone) can occur in young children when they fall short on an extended leg while jumping. This occurrence is known as " toddler 's fracture". Spiral fractures are also recognized as being suspicious in very young children since to obtain a fracture of this sort requires forceful twisting or jerking of the limbs.  Child abuse  (physical abuse) and certain conditions such as  osteogenesis imperfecta  (OI) are considered  differentials  when identifying spiral or torsion fractures. [ 2 ]


Sulcoplasty  is an  orthopedic   surgical  procedure performed on a groove ( sulcus ) or indentation present on particular bones. In veterinary surgery it is often employed to remedy a displaced kneecap ( luxating patella ) by deepening the trochlear sulcus, the groove at the end of the  femur  on which the  patella  normally sits. [ 1 ]


A  tension band wire  is a form of orthopaedic  internal fixation [ 1 ]  method used to convert distraction forces into compression forces, promoting  bone healing . [ citation needed ]


The  Thompson and Epstein classification  is a system of categorizing  posterior   fracture/dislocations of the hip . [ 1 ] [ 2 ]


The  Thurstan Holland sign [ 1 ]  or fragment, also known as the  shiny corner sign , [ 2 ]  is the small  metaphyseal  triangular portion of bone carried with the  physis  in type II and IV  Salter–Harris fractures . The sign was named after the Liverpool pioneer in radiology,  Charles Thurstan Holland  (1863–1941). [ 3 ]


Trethowan's sign  is when  Klein's line  does not intersect the lateral part of the superior femoral epiphysis on an AP radiograph of the  pelvis . [ 1 ]


Trethowan's sign is indicative of a diagnosis of  slipped capital femoral epiphysis .


Waddell's triad  is a pattern of injury seen in pedestrian  children  who are struck by motor vehicles. [ 1 ]  The triad comprises:


The mechanism of injury is an initial impact causing injury to the femur on one side ( bumper  injury) and the torso on the same side ( fender  or  hood ), following which the child is thrown, striking the head on the ground or another object and sustaining injury to the opposite side of the head. [ 2 ]  In countries where cars drive on the right, pedestrians tend to be struck on the left, causing left femur fractures, injuries to the left chest or  spleen , and right sided head injuries. [ 3 ]


Although this injury pattern may not be common, [ 4 ]  it is used to emphasize the point that children involved in high energy impacts should not be assumed to have isolated injuries. [ 5 ]


Le Fort's fracture of the ankle  is a vertical  fracture  of the  antero - medial  part of the  distal   fibula  with  avulsion  of the  anterior tibiofibular ligament , [ 1 ]  opposite to a  Tillaux-Chaput avulsion fracture


The injury was described by  Léon Clément Le Fort  in 1886. [ 2 ]


Articular cartilage damage  in the knee may be found on its own but it will more often be found in conjunction with injuries to  ligaments  and  menisci . People with previous surgical interventions face more chances of articular cartilage damage due to altered mechanics of the  joint . Articular cartilage damage may also be found in the shoulder causing pain, discomfort and limited movement.
 Cartilage  structures and functions can be damaged. Such damage can result from a variety of causes, such as a bad fall or traumatic sport-accident, previous knee injuries or wear and tear over time. Immobilization for long periods can also result in cartilage damage. [ citation needed ]


Articular cartilage does not usually regenerate (the process of repair by formation of the same type of tissue) after injury or disease leading to loss of tissue and formation of a defect. This fact was first described by William Hunter in 1743. [ 1 ]  Several surgical techniques have been developed in the effort to  repair  articular cartilage defects.


Articular cartilage has a very limited capacity for self repair. Small damage does not repair itself and can often get worse over time. As cartilage is aneural and avascular (lack of nerve and blood supply, respectively), shallow damage often does not trigger pain. [ citation needed ]


When the damage increases and the chondral defect reaches the  subchondral bone , the blood supply in the bone starts a healing process in the defect. Scar tissue made up of a type of cartilage called  fibrocartilage  is then formed. Although fibrocartilage is able to fill in articular cartilage defects, its structure is significantly different from that of hyaline cartilage; it is much denser and it doesn't withstand the demands of everyday activities as much as hyaline cartilage. It is therefore at a higher risk of breaking down. [ 2 ]


Wang  et al.  (2006) found that small articular cartilage defects can progress to  osteoarthritis  over time if left untreated. [ 3 ]  An articular cartilage defect that initially may be small still has the potential to have a physical and chemical "domino effect" on the surrounding "normal" articular cartilage. [ 2 ]


Pitkin  et al.  (2014) discovered a potential etiology for articular cartilage damage. When the interarticular transmission of pressures is interrupted so that cartilage cannot distribute its pressure load to adjacent joints, it bears exceptionally high loads, which in time lead to degradation. [ 4 ]


No non-invasive tests are currently able to diagnose articular cartilage damage. Additionally, symptoms vary considerably from person to person. Or as Dr. Karen Hambly stated:


You may or may not have pain and you could have no, or limited, swelling. Yes you may experience locking if a piece of articular cartilage has broken off and is a loose body in the joint or you may experience catching or giving way. You are likely to have some muscle wasting and difficulty in activities such as going up and down stairs, walking or running but then people with any moderate knee injury are likely to as well. This is why articular cartilage damage is the 'Cinderella' of knee problems. It tends to be diagnosed only after other structures have been ruled out – well if it isn't your meniscus or ligaments, what else could it be, perhaps we should look at the articular cartilage?


MRI -scans are becoming more valuable in the analysis of articular cartilage but their use is still expensive and time-consuming.  X-rays  show only bone injuries and are therefore not very helpful in diagnosing cartilage damage, especially not in early stages. The best tool for diagnosing articular damage is the use of  arthroscopy . [ citation needed ]


The International Cartilage Repair Society has set up an arthroscopic grading system by which cartilage defects can be ranked:


Doctors will often also measure the size of each defect. Defects smaller than 2 cm 2 , for example, are considered to be small. It is also important to remember that although the amount of damage is an important factor, the location of the defect(s) can also influence the symptoms you are getting in terms of pain and function and their repair options available. [ 2 ]


In contrast to popular perception, pain is not a good indicator for determining the extent of articular cartilage damage. One person can have severe pain with a single small defect while another person can have very little pain with several large full thickness defects. [ 2 ]


Since articular cartilage does not have a blood supply and chondrocytes (cells in articular cartilage) have limited mobility, the articular cartilage has very limited ability to heal itself. If left untreated, the cartilage lesions will gradually worsen and the grade of the lesion or defect will increase. [ 5 ]


Though articular cartilage damage is not life-threatening, it does strongly affect one's quality of life. Articular cartilage damage is often the cause of severe pain, knee swelling, substantial reduction in mobility and severe restrictions to one's activities. Over the last decades, however, research has focused on  regenerating damaged joints .


These regenerative procedures are believed to delay  osteoarthritis  of injuries on the articular cartilage of the knee, by slowing down the degeneration of the joint compared to untreated damage. [ 2 ]  According to Mithoefer  et al.  (2006), these  articular cartilage repair  procedures offer the best results when the intervention takes place in the early stages of the cartilage damage. [ 6 ]


Back strain  is the injury occurring to muscles or  tendons . Due to back strain, the tendons and muscles supporting the spine are twisted or pulled. Chronic back strain occurs because of the sustained trauma and wearing out of the back muscles. [ 1 ]  Acute back strain can occur following a single instance of over stressing of back muscles, as in lifting a heavy object. Chronic back strain is more common than the acute type.


To avoid back strain it is important to bend the knees whenever you lift a heavy object – see  partial squats . [ 2 ]


The pain over the back is localized and does not radiate into the leg. It occurs suddenly and may be accompanied by muscle spasms. The pain is dull, aching type and decreases on rest. It may be aggravated with activity. [ 3 ]


Back strain is treated using analgesics such as ibuprofen, rest and use of  ice packs . The patient can resume activities 24–48 hours after pain and swelling is reduced. It is not recommended to have prolonged immobilization or bed rest. If the pain does not subside in two weeks, additional treatment may be required.
Prevention of back strain is possible by adopting proper body mechanics while sitting, standing and lifting. [ 4 ]


A  Bankart lesion  is a type of shoulder  injury  that occurs following a  dislocated shoulder . [ 3 ]  It is an  injury  of the  anterior  ( inferior )  glenoid labrum  of the shoulder. [ 4 ]  When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it. It is an indication for  surgery  and often accompanied by a  Hill-Sachs lesion , damage to the posterior  humeral  head. [ 5 ]


A bony Bankart is a Bankart lesion that includes a  fracture  of the anterior-inferior  glenoid cavity  of the  scapula bone . [ 6 ]


The Bankart lesion is named after English orthopedic surgeon  Arthur Sydney Blundell Bankart  (1879–1951). [ 7 ]


Bankart lesions are characterized by recurrent shoulder instability and widespread shoulder discomfort. Some individuals may experience catching, locking, or popping feelings in their shoulders. The majority of Bankart lesion patients have primary or recurrent anterior shoulder dislocation. [ 1 ]


The diagnosis is usually initially made by a combination of physical exam and  medical imaging , where the latter may be  projectional radiography  (in cases of bony Bankart) and/or  MRI  of the shoulder. The presence of intra-articular contrast allows for better evaluation of the  glenoid labrum . [ 8 ]  Type V  SLAP tears  extends into the Bankart defect. [ 9 ]


Arthroscopic repair of Bankart injuries have good success rates, though nearly one-third of patients require further surgery for continued instability after the initial procedure in a study of young adults, with higher re-operation rates in those less than 20 years of age. [ 10 ]  Options for repair include an  arthroscopic  technique or a more invasive open  Latarjet procedure , [ 11 ]  with the open technique tending to have a lower incidence of recurrent dislocation, but also a reduced range of motion following surgery. [ 12 ]


Blount's disease  (or  Blount disease ) is a growth disorder of the  tibia  (shin bone) which causes the lower leg to angle inward, resembling a  bowleg . [ 2 ]  It is also known as "tibia vara". [ 3 ] [ 2 ]


Blount disease is a growth disorder of the  shin bone  which causes the lower leg to angle inward, resembling a  bowleg . It can present in boys under 4-years in both legs, or in adolescents usually on one side. Causes are thought to be genetic and environmental, like obesity, African-American lineage, and early walkers. [ 4 ]


Lower extremity deformities in  rickets  can closely mimic those produced by Blount's disease. To differentiate between rickets and Blount's disease it is important to correlate the clinical picture with laboratory findings such as calcium, phosphorus and  alkaline phosphatase . Besides the X-ray appearance. Bone deformities in rickets have a reasonable likelihood to correct over time, while this is not the case with Blount's disease. [ citation needed ]   Nevertheless, both disorders may need surgical intervention in the form of bone osteotomy or more commonly guided growth surgery. [ 5 ]   Osteochondrodysplasias  or genetic bone diseases can cause lower extremity deformities similar to Blount's disease. The clinical appearance and the characteristic radiographic are important to confirm the diagnosis. [ 6 ] [ 7 ]


Children who develop severe bowing before the age of 3 may be treated with  knee ankle foot orthoses . [ 9 ]  However, bracing may fail, or bowing may not be detected until the child is older. Bracing should be started by 3 years of age. In some cases, surgery may be performed. [ 10 ] [ 2 ] [ 11 ] [ 8 ]


Blount disease is one of the 8 severe comorbidities of  severe obesity  (BMI >35), which are an indication for  bariatric surgery  in children per a 2019 policy statement of the  American Academy of Pediatrics .
The other severe comorbidities are: obstructive sleep apnea (Apnea-Hypopnea Index > .5), Type2 Diabetes mellitus, idiopathic intracranial hypertension (IIH), nonalcoholic steatohepatitis,  SCFE ,  GERD , and hypertension. [ 12 ]


Blount disease is named after  Walter Putnam Blount  (1900–1992), an American pediatric orthopedic surgeon, who described it in 1937. [ 13 ] [ 14 ]  It has also been known as Mau-Nilsonne syndrome, after C. Mau and H. Nilsonne, who published early case reports of the condition. [ 15 ] [ 16 ]  it is today considered an acquired disease of the proximal tibial metaphysis rather than an epiphyseal dysplasia or osteochondrosis. [ 11 ]


Calcific tendinitis  is a common condition where deposits of  calcium phosphate  form in a tendon, sometimes causing pain at the affected site. Deposits can occur in several places in the body, but are by far most common in the  rotator cuff  of the shoulder. Around 80% of those with deposits experience symptoms, typically chronic pain during certain shoulder movements, or sharp acute pain that worsens at night. Calcific tendinitis is typically diagnosed by  physical exam  and  X-ray imaging . The disease often resolves completely on its own, but is typically treated with  non-steroidal anti-inflammatory drugs  to relieve pain, rest and  physical therapy  to promote healing, and in some cases various procedures to breakdown and/or remove the calcium deposits.


Adults aged 30–50 are most commonly affected by calcific tendinitis. It is twice as common in women as men, and is not associated with exercise. Calcifications in the rotator cuff were first described by  Ernest Codman  in 1934. The name, "calcifying tendinitis" was coined by  Henry Plenk  in 1952.


Up to 20% of those with calcification in the tendons have no symptoms because it is an integral part of the tendinopathy. [ 1 ]  For those with symptoms, the symptoms vary based on the phase of the disease. In the initial "formative phase" when the calcium deposits are being formed, people rarely experience any symptoms. [ 1 ]  Those that do have symptoms tend to have intermittent shoulder pain, particularly during forward shoulder flexion (i.e. lifting the arm in front of the body). [ 1 ]  In the "resorptive phase" when the calcium deposit is breaking down, many experience severe acute pain that worsens at night. [ 1 ]  Those affected tend to hold the shoulder rotated inwards to alleviate pain, and have difficulty lying on the affected shoulder. [ 1 ]  Some people experience heat and redness at the affected shoulder, as well as a limited range of motion. [ 1 ]


The pathophysiology of tendinopathy is mucoid degeneration, part of which is chondroid metaplasia of the fibroblasts.  Chondroid metaplasia means the fibroblasts are acting like cartilage cells (chondrocytes). Fibroblasts that are acting like chondrocytes can deposit calcium into the soft tissues as they do in bone.  Calcification in the tendons is a common component of tendinopathy.


The calcification consists of  tendinitis is caused by deposits of  calcium phosphate  crystals in the tendon. [ 1 ]  These deposits are common in rotator cuff tendinopathy and are most frequently found in the  supraspinatus tendon  (63% of the time), and less frequently in the  infraspinatus tendon  (7%),  subacromial bursa  (7%),  subscapularis tendon  (3%), or in both the supraspinatus and subscapularis tendons at the same time (20%). [ 1 ]


The development of calcific tendinitis is often divided into three stages. First, in the "precalcific stage", something causes tendon cells to transform into other cells that can act as sites for calcium deposition. [ 2 ]  This is followed by the two-part "calcific stage"; first calcium is deposited (the formative phase), then the body begins to break down the calcium deposit (the resorptive phase). [ 2 ]  Finally, in the "postcalcific stage" the calcium deposits are replaced with  new tissue  and the tendon completely heals. [ 2 ]


Calcific tendinitis is typically diagnosed by  physical examination  and  X-ray  imaging. [ 1 ]  During the formative phase, X-ray images typically reveal calcium deposits with uniform density and a clear margin. [ 1 ]  In the more painful resorptive phase, deposits instead appear cloudy and with unclear margins. [ 1 ]  By  arthroscopy , formative stage deposits appear crystalline and chalk-like, while resorptive stage deposits appear smooth resembling toothpaste. [ 1 ]   Ultrasound  is also used to locate and assess calcium deposits. In the formative stage, deposits are  hyperechoic  and arc-shaped; in the resorptive stage deposits are less  echogenic  and appear fragmented. [ 1 ] [ 3 ]


The first line of treatment for calcific tendinitis is typically  nonsteroidal anti-inflammatory drugs  to relieve pain, rest for the affected joint, and sometimes physical therapy to avoid joint stiffness. [ 3 ] [ 1 ]  For those with severe pain direct injections of steroids to the affected site are often effective for pain relief, [ 1 ]  but may interfere with reabsorption of the calcium deposit. [ 3 ]  For those whose pain doesn't improve with medication and rest, the deposit can be dissolved and removed with techniques called "ultrasound-guided needling", "barbotage", and "US-PICT" (for "ultrasound percutaneous injection in calcific tenditis"). In each, ultrasound is used to locate the deposit and guide a needle to the affected site. There  saline  and  lidocaine  are injected to dissolve the deposit, then removed to wash it away. [ 1 ] [ 3 ] [ 2 ]  Another common treatment is  extracorporeal shockwave therapy , where pulses of sound are used to break up the deposit and promote healing. [ 1 ]  There is little standardization of energy levels, duration, and time interval of treatment; though most studies report positive outcomes with low- to medium-energy waves (below 0.28  mJ /mm 2 ). [ 3 ]


Surgery is only recommended once 6 months of conservative, non-operative treatment has failed to reduce symptoms. Surgery is arthroscopic and involves calcification removal with or without acromioplasty of the shoulder. [ 4 ]  Additionally, debate remains over whether a complete removal of the deposits is necessary, or if equal pain relief can be obtained from a partial removal of calcium deposits. [ 5 ]


Removing the deposits either with open shoulder surgery or arthroscopic surgery are both difficult operations, but with high success rates (around 90%). About 10% require re-operation.  If the deposit is large, then frequently the patient will require a rotator cuff repair to fix the defect left in the tendon when the deposit is removed or to reattach the tendon to the bone if the deposit was at the tendon insertion into the bone.


Nearly all people with calcific tendinitis recover completely with time or treatment. [ 6 ]  Treatment helps alleviate pain, but long-term follow-up studies have shown that people recover with or without treatment. [ 6 ]


Calcific tendinitis typically occurs in adults aged 30 to 50, and is rare in those older than 70. It is twice as common in women as men. [ 1 ]


Risk factors that increase the chance of developing calcific tendinitis include; hormonal disorders, like diabetes and  hypothyroidism , autoimmune disorders, like  rheumatoid arthritis , and metabolic disorders that also cause kidney stones, gallstones, and  gout . Occupations that consist of repetitive overhead lifting, such as athletes or construction workers, do not seem to significantly increase the likelihood of developing calcific tendinitis. [ 5 ]


Calcifications in the  rotator cuff  tendon were first described by  Ernest Codman  in his 1934 book  The Shoulder . [ 3 ]  In 1952, in his study on x-ray therapy for people with such calcifications,  Henry Plenk  coined the term "calcifying tendinitis". [ 3 ] [ 7 ]


Clay-shoveler's fracture  is a stable  fracture  through the  spinous process  of a  vertebra  occurring at any of the lower cervical or upper thoracic vertebrae, classically at  C6  or  C7 . [ 1 ]  In Australia in the 1930s, men digging deep ditches tossed clay 10 to 15 feet above their heads using long handled shovels. [ 2 ]   Instead of separating, the sticky clay would sometimes stick to the shovel. At the top of the arc of motion, with the arms extended, the worker may hear a pop and feel a sudden pain between the shoulder blades, unable to continue working. [ 3 ] [ 4 ]


Dactylitis  or  sausage digit  is inflammation of an entire digit (a finger or toe), [ 1 ]  and can be painful.


The word  dactyl  comes from the  Greek  word  daktylos  'finger'. As a medical term, it refers to both the fingers and the toes.


Dactylitis can occur in  seronegative arthropathies , such as  psoriatic arthritis  and  ankylosing spondylitis , and in  sickle-cell disease  as result of a vasoocclusive crisis with bone infarcts, and in infectious conditions including  tuberculosis ,  syphilis , and  leprosy . In  reactive arthritis , sausage fingers occur due to synovitis. [ 2 ]  Dactylitis may also be seen with  sarcoidosis .


In sickle-cell disease it typically occurs after 6 months of age (as in infants protective  fetal hemoglobin , HbF, is replaced with adult hemoglobin and the disease manifests) and is often the first clinical presentation of the disorder. [ 3 ]


In  neurology ,  diastematomyelia  (occasionally  diastomyelia ) is a  congenital disorder  in which a part of the  spinal cord  is split, usually at the level of the upper lumbar  vertebra  in the  longitudinal  ( sagittal ) direction. Females are affected much more commonly than males. This condition occurs in the presence of an  osseous ,  cartilaginous  or  fibrous   septum  in the central portion of the  spinal canal  which then produces a complete or incomplete sagittal division of the spinal cord into two hemicords. When the split does not reunite distally to the spur, the condition is referred to as  diplomyelia , which is true duplication of the spinal cord. [ 1 ] [ additional citation(s) needed ]


The signs and symptoms of diastematomyelia may appear at any time of life, although the  diagnosis  is usually made in childhood.  Cutaneous  lesions (or stigmata), such as a hairy patch,  dimple ,  Hemangioma ,  subcutaneous  mass,  Lipoma  or  Teratoma  over the affected area of the spine is found in more than half of cases. Neurological symptoms are nonspecific, indistinguishable from other causes of  cord tethering . The symptoms are caused by tissue attachments that limit the movement of the spinal cord within the spinal column.  These attachments cause an abnormal stretching of the spinal cord. [ citation needed ]


The course of the disorder is progressive.  In children, symptoms may include the " stigmata " mentioned above and/or foot and spinal  deformities ; weakness in the legs;  low back pain ;  scoliosis ; and  incontinence .  In adulthood, the signs and symptoms often include progressive sensory and motor problems and loss of bowel and bladder control.  This delayed presentation of symptoms is related to the degree of strain placed on the spinal cord over time.
 Tethered spinal cord syndrome  appears to be the result of improper growth of the neural tube during fetal development, and is closely linked to  spina bifida .


Tethering may also develop after spinal cord injury and scar tissue can block the flow of fluids around the spinal cord.  Fluid pressure may cause  cysts  to form in the spinal cord, a condition called  syringomyelia .  This can lead to additional loss of movement, feeling or the onset of pain or  autonomic  symptoms.


Cervical diastematomyelia can become symptomatic as a result of  acute trauma , and can cause major neurological deficits, like hemiparesis, to result from otherwise mild trauma. [ 2 ]


The following definitions may help to understand some of the related entities: [ citation needed ]


Diastematomyelia is a " dysraphic state " of unknown embryonic origin, but is probably initiated by an  accessory neurenteric canal  (an additional embryonic spinal canal.) This condition may be an isolated phenomenon or may be associated with other segmental anomalies of the  vertebral bodies  such as  spina bifida ,  kyphoscoliosis ,  butterfly vertebra ,  hemivertebra  and  block vertebrae  which are observed in most of the cases.  Scoliosis  is identified in more than half of these patients. In most of the symptomatic patients, the spinal cord is split into halves by a bony spicule or  fibrous  band, each half being surrounded by a  dural  sac. Other conditions, such as  intramedullary tumors ,  tethered cord ,  dermoids ,  lipoma ,  syringomyelia ,  hydromyelia  and  Arnold–Chiari malformations  have been described in medical literature, but they are exceptionally rare. [ citation needed ]


Diastematomyelia usually occurs between 9th  thoracic  and 1st  sacral  levels of the  spinal column  with most being at the level of the upper  lumbar vertebra .  Cervical  diastematomyelia is a very rare entity. The extent (or length of spinal cord involved) varies from one affected individual to another. In approximately 60% of patients with diastematomyelia, the two hemicords, each covered by an intact layer of  pia   arachnoid , travel through a single  subarachnoid space  surrounded by a single dural sac. Each hemicord has its own  anterior spinal artery . This form of diastematomyelia is not accompanied by any bony spur or fibrous band and is rarely symptomatic unless hydromyelia or tethering is present. The other 40% of patients have a bony spur or a fibrous band that passes through the two hemicords. In these cases, the  dura  and arachnoid are split into two separate dural and arachnoidal sacs, each surrounding the corresponding hemicord which are not necessarily symmetric. Each hemicord contains a central canal, one  dorsal horn  (giving rise to a  dorsal nerve root ), and one  ventral horn  (giving rise to a  ventral nerve root .) One study showed the bony spur typically situated at the most inferior aspect of the dural cleft. They advised that if the imaging appears to show otherwise, a second spur (present in about 5% of patients with diastematomyelia) is likely to be present.The  conus medullaris  is situated below the L2 level in more than 75% of these diastematomyelia patients. Thickening of the  filum terminale  is seen in over half of the cases. While the level of the cleft is variable, it is most commonly found in the lumbar region. The two hemicords usually reunite caudally to the cleft. Occasionally, however, the cleft will extend unusually low and the cord will end with two separate coni medullarae and two fila terminale ("Diplomyelia").


Adult presentation in diastematomyelia is unusual. With modern imaging techniques, various types of spinal  dysraphism  are being diagnosed in adults with increasing frequency. The commonest location of the lesion is at first to third lumbar vertebrae. Lumbosacral adult diastematomyelia is even rarer. Bony malformations and dysplasias are generally recognized on plain  x-rays .  MRI  scanning is often the first choice of screening and diagnosis. MRI generally give adequate analysis of the spinal cord deformities although it has some limitations in giving detailed bone anatomy. Combined myelographic and post-myelographic  CT  scan is the most effective diagnostic tool in demonstrating the detailed bone, intradural and extradural pathological anatomy of the affected and adjacent spinal canal levels and of the bony spur.


Prenatal ultrasound  diagnosis of this anomaly is usually possible in the early to mid third-trimester. An extra posterior echogenic focus between the fetal  spinal laminae  is seen with splaying of the posterior elements, thus allowing for early surgical intervention and have a favorable prognosis. Prenate ultrasound could also detect whether the diastematomyelia is isolated, with the skin intact or association with any serious neural tube defects. Progressive neurological lesions may result from the "tethering cord syndrome" (fixation of the spinal cord) by the diastematomyelia phenomenon or any of the associated disorders such as  myelodysplasia ,  dysraphia  of the spinal cord.


Surgical intervention is warranted in patients who present with new onset neurological signs and symptoms or have a history of progressive neurological manifestations that can be related to this abnormality. The surgical procedure required for the effective treatment of diastematomyelia includes  decompression (surgery)  of neural elements and removal of bony spur. This may be accomplished with or without resection and repair of the duplicated dural sacs. Resection and repair of the duplicated dural sacs is preferred since the dural abnormality may partly contribute to the "tethering" process responsible for the symptoms of this condition.


Post-myelographic CT scanning provides individualized detailed maps that enable surgical treatment of cervical diastematomyelia, first performed in 1983. [ 2 ] [ 3 ]


Asymptomatic patients do not require surgical treatment. These patients should have regular neurological examinations since it is known that the condition can deteriorate. If any progression is identified, then a resection should be performed.


Failed Back Syndrome  ( abbreviated  as  FBS )  is a  condition  characterized by  chronic pain  following  back surgeries . [ 1 ] [ 2 ]  The term "post-laminectomy syndrome" is sometimes used by doctors to indicate the same condition as failed back syndrome. [ 3 ]  Many factors can contribute to the onset or development of FBS, including residual or recurrent  spinal disc herniation , persistent  post-operative  pressure on a  spinal nerve , altered joint mobility,  joint hypermobility  with instability, scar tissue ( fibrosis ),  depression ,  anxiety ,  sleeplessness ,  spinal  muscular  deconditioning  and  Cutibacterium acnes  infection. [ 4 ]   An individual may be predisposed to the development of FBS due to  systemic disorders  such as  diabetes ,  autoimmune disease  and  peripheral blood vessels (vascular) disease .


Common symptoms of Failed Back Surgery Syndrome (FBS) include diffuse, dull, and aching pain in the back or legs, often accompanied by abnormal sensations such as sharp, pricking, or stabbing pain in the extremities. [ 5 ]  Patients may also experience pain at a different level from the location originally treated, along with an inability to fully recuperate and restricted mobility. Sharp, stabbing pain in the back, numbness, back spasms, or pain radiating from the lower back into the legs are frequently reported. In addition to physical discomfort, FBS can lead to psychological symptoms such as anxiety, depression, and  insomnia . Some individuals may develop a dependence on pain medication due to  chronic pain . [ 6 ]


The number of  spinal surgeries  varies around the world. The  United States  and the  Netherlands  report the highest number of spinal surgeries, while the  United Kingdom  and  Sweden  report the fewest. Recently, there have been calls for more aggressive surgical treatment in  Europe . Success rates of spinal surgery vary for many reasons. [ 7 ] [ 8 ] [ 9 ]


Patients who have undergone one or more operations on the  lumbar spine  and continue to experience pain afterwards can be divided into two groups.


In 1992, Turner  et al.  published a survey of 74 journal articles which reported the results after decompression for  spinal stenosis .  Good to excellent results were on average reported by 64% of the patients.  There was, however, a wide variation in outcomes reported.  There was a better result in patients who had a degenerative  spondylolisthesis . [ 13 ]  A similarly designed study by Mardjekto et al. found that a concomitant spinal  arthrodesis  (fusion) had a greater success rate. [ 14 ]  Herron and Trippi evaluated 24 patients, all with degenerative  spondylolisthesis  treated with  laminectomy  alone.  At follow-up varying between 18 and 71 months after surgery, 20 out of the 24 patients reported a good result. [ 15 ]   Epstein  reported on 290 patients treated over a 25-year period.  Excellent results were obtained in 69% and good results in 13%. [ 16 ]   These optimistic reports do not correlate with "return to competitive employment" rates, which for the most part are dismal in most spinal surgery series. [ citation needed ]


In the past two decades there has been a dramatic increase in  fusion surgery  in the U.S.: in 2001 over 122,000 lumbar fusions were performed, a 22% increase from 1990 in fusions per 100,000 population, increasing to an estimate of 250,000 in 2003, and 500,000 in 2006. [ 17 ] [ 18 ] [ 19 ]  In 2003, the national bill for the hardware for fusion alone was estimated to have soared to $2.5 billion a year. [ 18 ] [ 20 ]
For patients with continued  pain after surgery  which is not due to the above complications or conditions,  interventional pain physicians  speak of the need to identify the "pain generator" i.e. the anatomical structure responsible for the patient's pain. To be effective, the surgeon must operate on the correct  anatomic structure , but is often not possible to determine the source of the pain. [ 21 ] [ 22 ]  The reason for this is that many patients with  chronic pain  often have disc bulges at multiple spinal levels and the physical examination and imaging studies are unable to pinpoint the source of pain. [ 21 ]  In addition,  spinal fusion  itself, particularly if more than one spinal level is operated on, may result in "adjacent segment degeneration". [ 23 ]   This is thought to occur because the fused segments may result in increased  torsional  and  stress forces  being transmitted to the  intervertebral discs  located above and below the fused  vertebrae . [ 23 ]  This pathology is one reason behind the development of artificial discs as a possible alternative to fusion surgery.  But fusion surgeons argue that  spinal fusion  is more time-tested, and artificial discs contain metal hardware that is unlikely to last as long as biological material without shattering and leaving metal fragments in the spinal canal. These represent different  schools of thought . (See discussion on disc replacement infra.) [ citation needed ]


Another highly relevant consideration is the increasing recognition of the importance of " chemical radiculitis " in the generation of  back pain . [ 24 ]   A primary focus of surgery is to remove "pressure" or reduce mechanical compression on a  neural  element: either the  spinal cord , or a  nerve root . But it is increasingly recognized that  back pain , rather than being solely due to compression, may instead entirely be due to chemical  inflammation of the nerve root.   It has been known for several decades that disc herniations result in a massive inflammation of the associated nerve root. [ 24 ] [ 25 ] [ 26 ] [ 27 ]  In the past five years increasing evidence has pointed to a specific inflammatory mediator of this pain. [ 28 ] [ 29 ]   This inflammatory molecule, called  tumor necrosis factor-alpha  (TNF), is released not only by the herniated or protruding disc, but also in cases of disc tear (annular tear), by facet joints, and in  spinal stenosis . [ 24 ] [ 30 ] [ 31 ] [ 32 ]  In addition to causing pain and inflammation, TNF may also contribute to  disc degeneration . [ 33 ]  If the cause of the pain is not compression, but rather is inflammation mediated by TNF, then this may well explain why surgery might not relieve the pain, and might even exacerbate it, resulting in FBS.


A 2005 review by Cohen concluded, 'The SI joint is a real yet underappreciated pain generator in an estimated 15% to 25% of patients with axial LBP'. [ 34 ]  Studies by Ha, et al., show that the incidence of SI joint degeneration in post-lumbar fusion surgery is 75% at 5 years post-surgery, based on imaging. [ 35 ]  Studies by DePalma and Liliang, et al., demonstrate that 40–61% of post-lumbar fusion patients were symptomatic for  SI joint dysfunction  based on diagnostic blocks. [ 36 ] [ 37 ]


Recent studies have shown that  cigarette smokers  will routinely fail all spinal surgery, if the goal of that surgery is the decrease of pain and impairment.  Many surgeons consider smoking to be an absolute  contraindication  to spinal surgery.   Nicotine  appears to interfere with bone metabolism through induced  calcitonin  resistance and decreased  osteoblastic  function.  It may also restrict small blood vessel diameter leading to increased scar formation. [ 38 ] [ 39 ] [ 40 ] [ 41 ] [ 42 ] [ 43 ] [ 44 ] [ excessive citations ]


There is an association between  cigarette smoking ,  back pain  and  chronic pain syndromes  of all types. [ 45 ] [ 46 ] [ 39 ] [ 47 ] [ 48 ]


In a report of 426 spinal surgery patients in  Denmark , smoking was shown to have a negative effect on fusion and overall patient satisfaction, but no measurable influence on the functional outcome. [ 49 ]


There is a validation of the hypothetical assumption that postoperative  smoking cessation  helps to reverse the impact of cigarette smoking on outcome after spinal fusion.  If patients cease cigarette smoking in the immediate post operative period, there is a positive impact on success. [ 50 ]


Regular  smoking in adolescence  was associated with low back pain in  young adults . Pack-years of smoking showed an exposure-response relationship among girls. [ 51 ]


A recent study suggested that cigarette smoking adversely affects serum  hydrocodone  levels. Prescribing physicians should be aware that in some cigarette smokers, serum hydrocodone levels might not be detectable. [ 52 ]


In a study from Denmark reviewing many reports in the literature, it was concluded that smoking should be considered a weak risk indicator and not a cause of low back pain. In a multitude of  epidemiologic  studies, an association between smoking and low back pain has been reported, but variations in approach and study results make this literature difficult to reconcile. [ 53 ]  In a massive study of 3482 patients undergoing lumbar spine surgery from the National Spine Network, co-morbidities of (1) smoking, (2) compensation, (3) self reported poor overall health and (4) pre-existing psychological factors were predictive in a high risk of failure. Followup was carried out at 3 months and one year after surgery. Pre-operative depressive disorders tended not to do well. [ 54 ]


Smoking has been shown to increase the incidence of post operative infection as well as decrease fusion rates. One study showed 90% of post operative infections occurred in smokers, as well as  myonecrosis  (muscle destruction) around the  wound . [ 55 ] [ 56 ]


Before the advent of CT scanning, the pathology in failed back syndrome was difficult to understand.  Computerized tomography  in conjunction with  metrizamide   myelography  in the late 1960s and 1970s allowed direct observation of the mechanisms involved in post operative failures. Six distinct pathological conditions were identified: [ citation needed ]


Removal of a disc at one level can lead to  disc herniation  at a different level at a later time.  Even the most complete  surgical excision  of the disc still leaves 30–40% of the disc, which cannot be safely removed. This retained disc can re-herniate sometime after surgery. Virtually every major structure in the abdomen and the posterior  retroperitoneal space  has been injured, at some point, by removing discs using posterior  laminectomy / discectomy  surgical procedures. The most prominent of these is a laceration of the  left internal iliac vein , which lies in close proximity to the anterior portion of the disc. [ 57 ] [ 58 ]  In some studies, recurrent pain in the same radicular pattern or a different pattern can be as high as 50% after disc surgery. [ 59 ] [ 60 ]    Many observers have noted that the most common cause of a failed back syndrome (FBS) is caused from recurrent disc herniation at the same level originally operated. A rapid removal in a second surgery can be curative. The clinical picture of a recurrent disc herniation usually involves a significant pain-free interval.  However, physical findings may be lacking, and a good history is necessary. [ 61 ] [ 62 ] [ 63 ] [ 64 ]  The time period for the emergence of new symptoms can be short or long.  Diagnostic signs  such as the  straight leg raise  test may be negative even if real  pathology  is present. [ 60 ] [ 65 ]  The presence of a  positive myelogram  may represent a new disc herniation, but can also be indicative of a post operative scarring situation simply mimicking a new disc. Newer  MRI  imaging techniques have clarified this dilemma somewhat. [ 61 ] [ 62 ] [ 66 ] [ 67 ] [ 68 ]  Conversely, a recurrent disc can be difficult to detect in the presence of post op scarring.  Myelography  is inadequate to completely evaluate the patient for recurrent disc disease, and  CT  or MRI scanning is necessary.  Measurement of  tissue density  can be helpful. [ 11 ] [ 66 ] [ 69 ] [ 70 ] [ 71 ]


Even though the complications of  laminectomy  for disc herniation can be significant, a recent series of studies involving thousands of patients published under auspices of  Dartmouth Medical School  concluded at four-year follow-up that those who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients in all primary and secondary outcomes except work status. [ 72 ]


Spinal stenosis  can be a late complication after  laminectomy  for disc herniation or when surgery was performed for the primary pathological condition of  spinal stenosis . [ 11 ] [ 73 ] [ 74 ]  In the Maine Study, among patients with  lumbar spinal stenosis  completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or non-surgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. [ 75 ]


A large study of  spinal stenosis  from Finland found the  prognostic factors  for ability to work after surgery were ability to work before surgery, age under 50 years, and no prior back surgery. The very long-term outcome (mean follow-up time of 12.4 years) was excellent-to-good in 68% of patients (59% women and 73% men). Furthermore, in the longitudinal follow-up, the result improved between 1985  and 1991. No special complications were manifested during this very long-term follow-up time. The patients with total or subtotal block in preoperative  myelography  achieved the best result.  Furthermore, patients with block stenosis improved their result significantly in the longitudinal follow-up. The postoperative stenosis seen in  computed tomography  (CT)  scans  was observed in 65% of 90 patients, and it was severe in 23 patients (25%). However, this successful or unsuccessful  surgical decompression  did not correlate with patients' subjective  disability , walking capacity or  severity of pain . Previous back surgery had a strong worsening effect on surgical results. This effect was very clear in patients with total block in the preoperative  myelography . The surgical result of a patient with previous back surgery was similar to that of a patient without previous back surgery when the time interval between the last two operations was more than 18 months. [ 76 ]


Post-operative MRI findings of  stenosis  are probably of limited value compared to symptoms experienced by patients. Patients' perception of improvement had a much stronger correlation with long-term surgical outcome than structural findings seen on post-operation  magnetic resonance imaging . Degenerative findings had a greater effect on patients' walking capacity than stenotic findings. [ 77 ] [ 78 ]


Postoperative radiologic stenosis was very common in patients operated on for  lumbar spinal stenosis , but this did not correlate with  clinical outcome . The clinician must be cautious when reconciling clinical symptoms and signs with postoperative  computed tomography  findings in patients operated on for lumbar spinal stenosis. [ 79 ]


A study from  Georgetown University  reported on one-hundred patients who had undergone  decompressive surgery  for lumbar stenosis between 1980 and 1985.  Four patients with post-fusion stenosis were included. A 5-year follow-up period was achieved in 88 patients. The mean age was 67 years, and 80% were over 60 years of age. There was a high incidence of coexisting medical diseases, but the principal disability was lumbar stenosis with neurological involvement.  Initially there was a high incidence of success, but recurrence of neurological involvement and persistence of low-back pain led to an increasing number of failures. By 5 years this number had reached 27% of the available population pool, suggesting that the failure rate could reach 50% within the projected  life expectancies  of most patients. Of the 26 failures, 16 were secondary to renewed neurological involvement, which occurred at new levels of stenosis in eight and recurrence of stenosis at operative levels in eight. Reoperation was successful in 12 of these 16 patients, but two required a third operation. The incidence of  spondylolisthesis  at 5 years was higher in the surgical failures (12 of 26 patients) than in the surgical successes (16 of 64). Spondylolisthetic  stenosis  tended to recur within a few years following decompression.  Because of  age and associated illnesses , fusion may be difficult to achieve in this group. [ 80 ]


A small minority of lumbar surgical patients will develop a post operative infection. In most cases, this is a bad complication and does not bode well for eventual improvement or future employability.  Reports from the surgical literature indicate an infection rate anywhere from 0% to almost 12%. [ 81 ] [ 82 ] [ 83 ] [ 84 ] [ 85 ] [ 86 ] [ 87 ] [ 88 ] [ 89 ] [ 90 ] [ 91 ] [ 92 ] [ 93 ] [ 94 ] [ 95 ] [ 96 ] [ excessive citations ]  The  incidence of infection  tends to increase as the complexity of the procedure and operating time increase.  Usage of  metal implants  (instrumentation) tends to increase the risk of infection.  Factors associated with an increased infection include  diabetes mellitus ,  obesity ,  malnutrition ,  smoking , previous infection,  rheumatoid arthritis , and  immunodeficiency . [ 97 ] [ 98 ] [ 99 ] [ 100 ] [ 101 ] [ 102 ] [ excessive citations ]  Previous wound infection should be considered as a contraindication to any further spinal surgery, since the likelihood of improving such patients with more surgery is small. [ 103 ] [ 104 ] [ 105 ] [ 106 ] [ 107 ] [ 108 ]   Antimicrobial prophylaxis  reduces the rate of surgical site infection in lumbar spine surgery, but a great deal of variation exists regarding its use. In a Japanese study, utilizing the  Centers for Disease Control  recommendations for antibiotic prophylaxis, an overall rate of 0.7% infection was noted, with a single dose antibiotic group having 0.4% infection rate and multiple dosage antibiotic infection rate of 0.8%. The authors had previously used  prophylactic antibiotics  for 5 to 7 postoperative days. Based on the  Centers for Disease Control and Prevention  (CDC) guideline, their antibiotic prophylaxis was changed to the day of surgery only. It was concluded there was no statistical difference in the rate of infection between the two different antibiotic protocols. Based on the  CDC  guideline, a single dose of prophylactic antibiotic was proven to be efficacious for the prevention of infection in  lumbar spine  surgeries. [ 109 ]


Epidural scarring following a  laminectomy  for disc excision is a common feature when re-operating for recurrent  sciatica  or  radiculopathy . [ 61 ]  When the scarring is associated with a  disc herniation  and/or recurrent  spinal stenosis , it is relatively common, occurring in more than 60% of cases. For a time, it was theorized that placing a  fat graft  over the dural could prevent post operative scarring.  However, initial enthusiasm has waned in recent years. [ 110 ] [ 111 ] [ 112 ] [ 113 ] [ 114 ]  In an extensive  laminectomy  involving 2 or more  vertebra , post operative scarring is the norm.  It is most often seen around the  L5  and  S1 nerve roots . [ 115 ] [ 116 ] [ 117 ]


Fibrous scarring can also be a complication within the  subarachnoid  space.  It is notoriously difficult to detect and evaluate.  Prior to the development of  magnetic resonance imaging , the only way to ascertain the presence of  arachnoiditis  was by opening the  dura . In the days of  CT  scanning and  Pantopaque  and later,  Metrizamide   myelography , the presence of  arachnoiditis  could be speculated based on  radiographic  findings.  Often,  myelography  prior to the introduction of  Metrizamide  was the cause of  arachnoiditis .   It can also be caused by the long term pressure brought about with either a severe  disc herniation  or  spinal stenosis . [ 62 ] [ 61 ] [ 118 ] [ 119 ] [ 64 ]   The presence of both  epidural scarring  and  arachnoiditis  in the same patient are probably quite common.  Arachnoiditis  is a broad term denoting  inflammation of the meninges  and  subarachnoid  space. A variety of causes exist, including infectious,  inflammatory , and  neoplastic  processes. Infectious causes include  bacterial ,  viral ,  fungal , and  parasitic   agents .  Noninfectious inflammatory processes  include surgery, intrathecal hemorrhage, and the administration of  intrathecal  (inside the  dural canal ) agents such as myelographic contrast media,  anesthetics  (e.g.  chloroprocaine ), and  steroids  (e.g. Depo-Medrol, Kenalog). Lately iatrogenic arachnoiditis has been attributed to misplaced  Epidural Steroid Injection therapy  when accidentally administered intrathecally. The preservatives and suspension agents found in all steroid injectates, which aren't indicated for epidural administration by the  U.S. Food & Drug Administration  (FDA) due to reports of severe adverse events including  arachnoiditis ,  paralysis  and  death , have now been directly linked to the onset of the disease following the initial stage of  chemical meningitis . [ 120 ] [ 121 ] [ 122 ] [ 123 ]
 Neoplasia  includes the  hematogenous spread  of  systemic tumors , such as  breast  and  lung carcinoma ,  melanoma , and  non-Hodgkin lymphoma . Neoplasia also includes direct seeding of the  cerebrospinal fluid  (CSF) from primary central nervous system (CNS) tumors such as  glioblastoma multiforme ,  medulloblastoma ,  ependymoma , and  choroid plexus carcinoma . Strictly speaking, the most common cause of  arachnoiditis  in failed back syndrome is not infectious or from cancer.  It is due to non-specific scarring secondary to the surgery or the underlying pathology. [ 124 ] [ 125 ] [ 126 ] [ 127 ] [ 128 ] [ 129 ] [ 130 ] [ 131 ]


Laceration  of a  nerve root , or damage from  cautery  or  traction  can lead to  chronic pain , however this can be difficult to determine. Chronic compression of the nerve root by a persistent agent such as  disc , bone ( osteophyte ) or  scarring  can also permanently damage the nerve root.  Epidural scarring  caused by the initial  pathology  or occurring after the surgery can also contribute to  nerve damage .  In one study of failed back patients, the presence of pathology was noted to be at the same site as the level of surgery performed in 57% of cases. The remaining cases developed pathology at a different level, or on the opposite side, but at the same level as the surgery was performed. In theory, all failed back patients have some sort of nerve injury or damage which leads to a  persistence of symptoms  after a reasonable  healing time . [ 59 ] [ 60 ] [ 132 ]


Failed back syndrome (FBS) is a well-recognized complication of surgery of the lumbar spine. It can result in chronic pain and disability, often with disastrous emotional and financial consequences to the patient. Many patients have traditionally been classified as "spinal cripples" and are consigned to a life of long-term narcotic treatment with little chance of recovery.  Despite extensive work in recent years, FBS remains a challenging and costly disorder. [ 133 ]


The treatments of post-laminectomy syndrome include  physical therapy ,  microcurrent electrical neuromuscular stimulator , [ 134 ]  minor nerve blocks,  transcutaneous electrical nerve stimulation  (TENS),  behavioral medicine ,  non-steroidal anti-inflammatory  (NSAID) medications,  membrane stabilizers ,  antidepressants ,  spinal cord stimulation , and  intrathecal   morphine   pump . Use of  epidural steroid injections  may be minimally helpful in some cases. The targeted  anatomic  use of a potent anti-inflammatory  anti-TNF   therapeutics  is being investigated.


A study of chronic pain patients from the  University of Wisconsin  found that  methadone  is most widely known for its use in the treatment of  opioid  dependence, but  methadone  also provides effective  analgesia .  Patients who experience inadequate pain relief or intolerable side effects with other opioids or who suffer from neuropathic pain may benefit from a transition to methadone as their  analgesic  agent. Adverse effects, particularly respiratory depression and death, make a fundamental knowledge of  methadone 's pharmacological properties essential to the provider considering  methadone  as  analgesic  therapy for a patient with chronic pain. [ 135 ]


Patients who have  sciatic  pain (pain in the back, radiating down the buttock to the leg) and clear clinical findings of an identifiable  radicular  nerve loss caused by a herniated disc will have a better post operative course than those who simply have low back pain. If a specific disc herniation causing pressure on a nerve root cannot be identified, the results of surgery are likely to be disappointing. Patients involved in worker's compensation, tort litigation or other compensation systems tend to fare more poorly after surgery. Surgery for spinal stenosis usually has a good outcome, if the surgery is done in an extensive manner, and done within the first year or so of the appearance of symptoms. [ 11 ] [ 60 ] [ 136 ] [ 137 ] [ 138 ]


Oaklander and North define the Failed Back Syndrome as a chronic pain patient after one or more surgical procedure to the spine.  They delineated these characteristics of the relation between the patient and the surgeon:


In the absence of a financial source for disability or worker's compensation, other psychological features may limit the ability of the patient to recover from surgery.  Some patients are simply unfortunate, and fall into the category of "chronic pain" despite their desire to recover and the best efforts of the physicians involved in their care. [ 140 ] [ 141 ] [ 142 ] [ 143 ] [ 144 ] [ 145 ] [ 146 ] [ 147 ] [ 148 ] [ 149 ] [ 150 ]  Even less invasive forms of surgery are not uniformly successful; approximately 30,000-40,000  laminectomy  patients obtain either no relief of symptomatology or a recurrence of symptoms. [ 151 ]  Another less invasive form of spinal surgery, percutaneous disc surgery, has reported revision rates as high as 65%. [ 152 ]  It is no surprise, therefore, that FBS is a significant medical concern which merits further research and attention by the medical and surgical communities. [ 21 ] [ 22 ]


Lumbar  total disc replacement was originally designed to be an alternative to lumbar  arthrodesis  (fusion). The procedure was met with great excitement and heightened expectations both in the United States and Europe. In late 2004, the first lumbar total disc replacement received approval from the  U.S. Food and Drug Administration  (FDA). More experience existed in Europe.  Since then, the initial excitement has given way to skepticism and concern. [ 153 ] [ 154 ] [ 155 ] [ 156 ] [ 157 ] [ 158 ] [ 159 ]  Various failure rates and strategies for revision of total disc replacement have been reported. [ 160 ]


The role of artificial or total disc replacement in the treatment of spinal disorders remains ill-defined and unclear. [ 161 ]  Evaluation of any new technique is difficult or impossible because physician experience may be minimal or lacking.  Patient expectations may be distorted. [ 162 ] [ 163 ]  It has been difficult to establish clear cut indications for artificial disc replacement.  It may not be a replacement procedure or alternative to fusion, since recent studies have shown that 100% of fusion patients had one or more contraindications to disc replacement. [ 164 ] [ 165 ] [ 166 ]    The role of disc replacement must come from new indications not defined in today's literature or a relaxation of current contraindications. [ 161 ]


A study by Regan found the result of replacement was the same at L4-5 and L5-S1 with the CHARITE disc.  However, the ProDisc II had more favorable results at L4-5 compared with L5-S1. [ 167 ] [ 168 ]


A younger age was predictive of a better outcome in several studies. [ 158 ] [ 169 ] [ 170 ]  In others it has been found to be a negative predictor or of no predictive value. [ 171 ] [ 172 ] [ 173 ] [ 174 ] [ 175 ]  Older patients may have more complications. [ 174 ]


Prior spinal surgery has mixed effects on disc replacement.  It has been reported to be negative in several studies. [ 171 ] [ 176 ] [ 177 ] [ 178 ] [ 175 ] [ 179 ]  It has been reported to have  no effect in other studies. [ 180 ] [ 169 ] [ 173 ] [ 178 ] [ 181 ] [ 158 ]  Many studies are simply inconclusive. [ 171 ]  Existing evidence does not allow drawing definite conclusions about the status of disc replacement at present. [ 161 ]


Many failed back patients are significantly impaired by chronic pain in the back and legs. Many of these will be treated with some form of electrical stimulation. This can be either a  transcutaneous electrical nerve stimulation  device placed on the skin over the back or a nerve stimulator implanted into the back  with electrical probes which directly touch the spinal cord. Also, some chronic pain patients utilize  fentanyl  or narcotic patches.  These patients are generally severely impaired and it is unrealistic to conclude that application of  neurostimulation  will reduce that impairment. For example, it is doubtful that  neurostimulation  will improve the patient enough to return to competitive employment.  Neurostimulation  is  palliative . TENS units work by blocking  neurotransmission  as described by the pain theory of Melzack and Wall. [ 182 ]  Success rates for implanted  neurostimulation  has been reported to be 25% to 55%. Success is defined as a relative decrease in pain. [ 183 ]


Limited case series have shown improvement for patients with failed back surgery who were managed with  chiropractic care . [ 184 ] [ 185 ] [ 186 ]


Smaller procedures that do not remove  bone  (such as Endoscopic Transforaminal Lumbar Discectomy and Reconfiguration) do not cause post  laminectomy / laminotomy  syndrome. [ 187 ]


Under rules promulgated by Titles II and XVI of the United States  Social Security Act , chronic  radiculopathy ,  arachnoiditis  and spinal stenosis are recognized as disabling conditions under Listing 1.04 A ( radiculopathy ), 1.04 B ( arachnoiditis ) and 1.04 C ( spinal stenosis ). [ 188 ]


In a groundbreaking  Canadian  study, Waddell  et al.  reported on the value of repeat surgery and the return to work in worker's compensation cases. They concluded that workers who undergo spinal surgery take longer to return to their jobs. Once two spinal surgeries are performed, few if any ever return to gainful employment of any kind. After two spinal surgeries, most people in the worker's comp system will not be made better by more surgery. Most will be worse after a third surgery. [ 189 ]


Episodes of back pain associated with on the job injuries in the worker's compensation setting are usually of short duration. About 10% of such episodes will not be simple, and will degenerate into chronic and disabling back pain conditions, even if surgery is not performed. [ 190 ] [ 191 ]


It has been hypothesized that  job dissatisfaction  and individual perception of physical demands are associated with an increased time of recovery or an increased risk of no recovery at all. [ 192 ]  Individual psychological and social work factors, as well as worker-employer relations are also likely to be associated with time and rates of recovery. [ 193 ] [ 194 ] [ 195 ]


A Finnish study of return to work in patients with  spinal stenosis  treated by surgery found that:


In fact, women's and men's working capacity do not differ after  lumbar spinal stenosis  operation. If the aim is to maximize working capacity, then, when a lumbar spinal stenosis operation is indicated, it should be performed without delay. In lumbar spinal stenosis patients who are older than 50 years old and on sick leave, it is unrealistic to expect that they will return to work. Therefore, after such an extensive surgical procedure, re-education of patients for lighter jobs could improve the chances of these patients returning to work. [ 196 ]


In a related  Finnish  study, a total of 439 patients operated on for lumbar spinal stenosis during the period 1974–1987 was re-examined and evaluated for working and functional capacity approximately 4 years after the  decompressive surgery . The ability to work before or after the operation and a history of no prior back surgery were variables predictive of a good outcome. Before the operation 86 patients were working, 223 patients were on sick leave, and 130 patients were retired. After the operation 52 of the employed patients and 70 of the unemployed patients returned to work. None of the retired patients returned to work. Ability to work preoperatively, age under 50 years at the time of operation and the absence of prior back surgery predicted a postoperative ability to work. [ 197 ]


A report from Belgium noted that patients reportedly return to work an average of 12 to 16 weeks after surgery for lumbar disc herniation. However, there are studies that lend credence to the value of an earlier stimulation for return to work and performance of normal activities after a limited  discectomy . At follow-up assessment, it was found that no patient had changed employment because of back or leg pain. The sooner the recommendation is made to return to work and perform normal activities, the more likely the patient is to comply. Patients with ongoing disabling back conditions have a low priority for return to work. The probability of return to work decreases as time off work increases.   This is especially true in Belgium, where 20% of individuals did not resume work activities after surgery for a disc herniation of the lumbar spine. [ citation needed ]


In Belgium, the medical advisers of sickness funds have an important role legally in the assessment of working capacity and medical rehabilitation measures for employees whose fitness for work is jeopardized or diminished for health reasons. The measures are laid down in the sickness and invalidity legislation. They are in accordance with the principle of preventing long-term disability. It is apparent from the authors' experience that these measures are not adapted consistently in medical practice. Most of the medical advisers are focusing purely on evaluation of corporal damage, leaving little or no time for rehabilitation efforts. In many other countries, the evaluation of work capacity is done by social security doctors with a comparable task. [ 198 ]


In a comprehensive set of studies carried out by the  University of Washington School of Medicine , it was determined that the outcome of lumbar fusion performed on injured workers was worse than reported in most published case series.  They found 68% of lumbar fusion patients still unable to return to work two years after surgery.  This was in stark contrast to reports of 68% post-op satisfaction in many series. [ 199 ] [ 142 ]  In a follow-up study it was found that the use of intervertebral fusion devices rose rapidly after their introduction in 1996.  This increase in metal usage was associated with a greater risk of complication  without improving disability or re-operation rates. [ 200 ] [ 201 ] [ 202 ] [ 203 ]


The identification of  tumor necrosis factor-alpha  (TNF) as a central cause of inflammatory spinal pain now suggests the possibility of an entirely new approach to selected patients with FBS.  Specific and potent inhibitors of TNF became available in the U.S. in 1998, and were demonstrated to be potentially effective for treating  sciatica  in experimental models beginning in 2001. [ 204 ] [ 205 ] [ 206 ]  Targeted anatomic administration of one of these anti-TNF agents,  etanercept , a patented treatment method, [ 207 ]  has been suggested in published pilot studies to be effective for treating selected patients with chronic disc-related pain and FBS. [ 208 ] [ 209 ]  The scientific basis for pain relief in these patients is supported by the many current review articles. [ 210 ] [ 211 ]  In the future new imaging methods may allow non-invasive identification of sites of neuronal inflammation, thereby enabling more accurate localization of the "pain generators" responsible for symptom production. These treatments are still experimental. [ citation needed ]


If chronic pain in FBS has a chemical component producing inflammatory pain, then prior to additional surgery it may make sense to use an anti-inflammatory approach. Often this is first attempted with non-steroidal anti-inflammatory medications, but the long-term use of  Non-steroidal anti-inflammatory drugs  (NSAIDS) for patients with persistent back pain is complicated by their possible cardiovascular and gastrointestinal toxicity; and NSAIDs have limited value to intervene in TNF-mediated processes. [ 22 ]  An alternative often employed is the injection of cortisone into the spine adjacent to the suspected pain generator, a technique known as "epidural steroid injection". [ 212 ]  Although this technique began more than a decade ago for FBS, the efficacy of epidural steroid injections is now generally thought to be limited to short term pain relief in selected patients only. [ 213 ]  In addition, epidural steroid injections, in certain settings, may result in serious complications. [ 214 ]  Fortunately there are now emerging new methods that directly target TNF. [ 208 ]  These TNF-targeted methods represent a highly promising new approach for patients with chronic severe spinal pain, such as those with FBS. [ 208 ]  Ancillary approaches, such as rehabilitation,  physical therapy ,  anti-depressants , and, in particular, graduated exercise programs, may all be useful adjuncts to anti-inflammatory approaches. [ 22 ]  In addition, more invasive modalities, such as spinal cord stimulation, may offer relief for certain patients with FBS, but these modalities, although often referred to as "minimally invasive", require additional surgery, and have complications of their own. [ 215 ] [ 216 ]


A report from  Spain  noted that the investigation and development of new techniques for instrumented  surgery  of the  spine  is not free from  conflicts of interest . The influence of financial forces in the development of new technologies and its immediate application to spine surgery, shows the relationship between the published results and the industry support. Authors who have developed and defended fusion techniques have also published new articles praising new spinal technologies. The author calls spinal surgery the  "American Stock and Exchange" and "the bubble of spine surgery". The scientific literature doesn't show clear evidence in the cost-benefit  studies  of most instrumented surgical interventions of the spine compared with the conservative treatments. It has not been yet demonstrated that fusion surgery and disc replacement are better options than the conservative treatment. It's necessary to point out that at present " there are relationships between the industry and back pain, and there is also an industry of the back pain ".


Nonetheless, the "market of the spine surgery" is growing because patients are demanding solutions for their back problems. The tide of scientific evidence seems to go against the spinal fusions in the degenerative disc disease,  discogenic pain  and in specific back pain. After decades of advances in this field, the results of spinal fusions are mediocre. New epidemiological studies show that " spinal fusion must be accepted as a non proved or experimental method for the treatment of back pain ". The surgical literature on  spinal fusion  published in the last 20 years establishes that instrumentation seems to slightly increase the fusion rate and that instrumentation doesn't improve the clinical results in general. We still are in need of randomized studies to compare the surgical results with the natural history of the disease, the placebo effect, or conservative treatment. The European Guidelines for lumbar chronic pain management show  "strong evidence" indicating that complex and demanding spine surgery where different instrumentation is used, is not more effective than a simple, safer and cheaper  posterolateral  fusion without instrumentation. Recently, the literature published in this field is sending a message to use "minimally invasive techniques"; – the abandonment of transpedicular fusions. Surgery in general, and usage of metal fixation should be discarded in most cases. [ 217 ]


In  Sweden , the national registry of lumbar spine surgery reported in the year 2000 that 15% of patients with spinal stenosis surgery underwent a concomitant fusion. [ 218 ]  Despite the traditionally conservative approach to spinal surgery in Sweden, there have been calls from that country for a more aggressive approach to lumbar procedures in recent years. [ citation needed ]