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BACKGROUND: Low-level laser therapy (LLLT) is commonly used in medical applications, but scientific studies of its efficacy and the mechanism by which it causes loss of fat from fat cells for body contouring are lacking. This study examined the effectiveness and mechanism by which 635­680 nm LLLT acts as a non-invasive body contouring intervention method. METHODS: Forty healthy men and women ages 18­65 years with a BMI <30 kg/m2 were randomized 1:1 to laser or control treatment. Subject's waistlines were treated 30 min twice a week for 4 weeks. Standardized waist circumference measurements and photographs were taken before and after treatments 1, 3, and 8. Subjects were asked not to change their diet or exercise habits. In vitro assays were conducted to determine cell lysis, glycerol, and triglyceride release. RESULTS: Data were analyzed for those with body weight fluctuations within 1.5 kg during 4 weeks of the study. Each treatment gave a 0.4­0.5 cm loss in waist girth.Cumulative girth loss after 4 weeks was −2.15 cm (−0.78 ± 2.82 vs. 1.35 ± 2.64 cm for the control group,p < 0.05). A blinded evaluation of standardized pictures showed statistically significant cosmetic improvement after 4 weeks of laser treatment. In vitro studies suggested that laser treatment increases fat loss from adipocytes by release of triglycerides, without inducing lipolysis or cell lysis. CONCLUSIONS: LLLT achieved safe and significant girth loss sustained over repeated treatments and cumulative over 4 weeks of eight treatments. The girth loss from the waist gave clinically and statistically significant cosmetic improvement.

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Progressive nature of the myelopathy seen in patients with dural arteriovenous fistulas call for timely diagnosis and surgical intervention to alleviate symptoms of neurologic dysfunction. We present a case report of a 51-year-old male presented with progressive sensory and motor deficits, along with gait instability associated with urinary incontinence for a period of one year. MRI of the spine demonstrated a thoracic spinal dural arteriovenous fistula. Spinal angiography showed at T7 on the left a common origin of the artery of adamkiewicz, a posterior spinal artery and the spinal dural arteriovenous fistula. The fistula was surgically treated and the patient made an almost complete recovery. To the author's knowledge, this is the first time that this common origin, of the three vessels, is described in the literature.

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UNLABELLED: The association of low back pain with physical workload in seated workstation related jobs has been debated and remains controversial. Clinical studies eliciting the natural history of the disease in this emerging population are insufficient to make definitive conclusions. We report four consecutive cases of patients suffering from low back pain presenting to a tertiary spine clinic with severe non-specific low back pain. Two patients as age-matched controls with persistent low back pain were followed for 6 months after receiving conventional treatment. In comparison, two test patients received parallel conventional treatment along with orthopaedic full spinal supports as an additional treatment modality. Outcomes analysed demonstrate the efficacy of orthopaedic full spinal supports for treating low back pain. TRIAL REGISTRATION NUMBER: NCT00553540.

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OBJECTIVE: The aim of the study was to identify patient factors that correlate with a strong response to opioid pain medications in low back pain patients. DESIGN: Prospective analysis. SETTING: Tertiary Institutional Spine Care Center. PATIENTS, PARTICIPANTS: All patients visiting a tertiary referral spine center with primary diagnosis of low back pain (n = 486) and minimum duration of 6 months. INTERVENTIONS: Opioid medication. MAIN OUTCOME MEASURES: Analysis factors included visual analog pain scale (VAS), symptom relief scores, and results on 36-item Short Form Health Survey (SF-36). A longitudinal descriptive analysis and a multivariable logistic regression were performed on the results of the VAS and SF-36 scores. RESULTS: The average age of opioid and nonopioid treated patients was 62 years versus 64 years, (p = 0.13) and gender distributions at 53 percent versus 50 percent female (p = 0.43). SF-36 scores were statistically significant and associated with the opioid categorization. For every unit increase in symptom relief score, the likelihood of opioid use is doubled (OR = 2.1, 95 percent CI = 1.5-2.8, p < 0.001); and increased by 25 percent with each 10-point decrease in the social functioning quality of life score (OR = 0.98, 95 percent CI = 0.96-0.99, p = 0.006). CONCLUSIONS: Social quality of life and symptom relief measurements comprise the optimal set of independent factors that correlate most strongly with a response to opioid use in low back pain patients.

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Pain is a complex phenomenon lacking a well-defined paradigm for diagnosis and management across medical disciplines. This is due in part to inconsistencies in the assessment of pain as well as in the measurement of related social and psychological states. Efforts to evaluate and measure pain through objective tests have been hindered by challenges such as methodological differences in data acquisition, and the lack of common, universally accepted information systems. Physicians and hospital administrators have expressed mixed reactions to the costs that inevitably accompany advances in medical technology. Nonetheless, computer systems are currently being developed for use in the quantitative assessment and management of pain, which can advance our understanding of the public health impact of pain, improve the care individual patients receive, and educate providers. The description of an interdisciplinary, integrated, health survey system illustrates the approach and highlights the advantages of using information technology in pain evaluation and management.

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Human intervertebral disc undergoes multifactorial biochemical and morphologic degenerative changes during the process of aging. The frequency of degeneration, especially lumbar degeneration increases sharply with age and is regarded as a major cause of discogenic low back pain. Since degenerative discs are often asymptomatic, the pathobiology of discogenic back pain remains unclear. Degenerated discs spontaneously produce increased amounts of inflammatory mediators suggesting their role in the degenerative process of the intervertebral disc. However, the relationship between aging, degenerative processes, and actual illness is far from clear. Basic science research has demonstrated that the intervertebral disc is an avascular tissue element occupied by inadequately characterized cells in an extensive extracellular matrix. While the annulus fibrosus is predominantly collagenous, the matrix of the central nucleus pulposus is rich in proteoglycans. With aging, the substance of proteoglycans significantly decreases which is believed to be a critical factor in intervertebral disc degeneration. A variety of inflammatory mediators have been implicated in the degeneration of the intervertebral disc including nitric oxide (NO), interleukins, matrix metalloproteinases (MMP), prostaglandin E2 (PGE2), tumor necrosis factor alpha (TNF-alpha) and a group of cytokines. MMPs, PGE2, and a variety of cytokines have been already been shown to play a role in the degradation of articular cartilage. Nitric oxide is a novel mediator that is drawn into much attention recently for its role in disc abnormalities. Elevated nitric oxide production derived from NO synthase activity has been manifested in cerebrospinal fluid in patients with degenerative lumbar disease. However, the regulatory mechanism of NO and its relationship to the clinical manifestations are unclear. The biochemical events that occur with the 'aging spine' and in particular, the role of inflammatory mediators in intervertebral disc degeneration have not been studied assertively. Correspondingly, the association between degeneration of the intervertebral disc and the nociceptive mechanism of back pain is also not fully elucidated. However, there is high incidence of degenerated disc disorders manifested as back and neck pain and are among the most commonly encountered complaints in elderly population. It is hypothesized that the degenerative cascade ultimately leads to extensive structural defects and loss of normal motion segment function and configuration.

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OBJECTIVE: Surgical strategies for the decompression of lumbar spinal stenosis have evolved to include minimally invasive techniques providing for adequate and safe decompression while reducing perioperative morbidity. Retrospective case series analysis of 220 consecutive patients with lumbar spinal stenosis who underwent microscopic or microendoscopic minimally invasive decompression was performed. The objective was to evaluate the risks associated with performing a minimally invasive decompression for spinal stenosis in a large group of patients. METHODS: Two hundred twenty patients with symptomatic neurogenic claudication from lumbar spinal stenosis failing nonoperative treatment received a minimally invasive decompression surgery. Intraoperative data, postoperative data through hospital discharge, and clinical follow-up were analyzed. RESULTS: The average age was 74.2 years (range 49-98 years). There were 379 spinal levels decompressed in 220 patients. Sixty-nine patients (31.4%) had a grade 1 degenerative spondylolisthesis. One hundred sixty-eight patients (76%) received spinal anesthesia, and 52 received general anesthesia. Eighty-seven patients (40%) had a preoperative American Society of Anesthesiologists score of 3 or 4. Average operative blood loss was 92 mL. There were 17 intraoperative durotomies (4.5% rate). The average length of stay before discharge was 1.2 days. Ten patients went to inpatient rehabilitation at discharge. One hundred ninety-four patients (88.2%) were discharged within 24 hours. There were five readmissions within the first month after discharge, four of those for medical complications. There were 24 minor complications and 14 major complications. Forty-two patients (19%) took no oral or parenteral narcotic pain medications in the postanesthesia to discharge period. CONCLUSION: Minimally invasive decompression strategies for spinal stenosis seem consistently to result in short hospital lengths of stay, minimal requirements for narcotic pain medications, and a low rate of readmission and complications.

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Pedicle screw (PS) instrumentation provides an exceptionally rigid construct to promote fusion in cases of spinal trauma and degenerative disease. Although the safety of traditional open techniques for PS placement has been well documented, there are no large series in the literature in which the safety of percutaneously placed PSs has been examined. Because the advantages of minimally invasive spine surgery are becoming more widely recognized, especially in regard to the lessening of morbidity caused by pain and blood loss, there will be a greater demand for spine surgeons to place PSs percutaneously. During a 2-year period, the authors placed 287 PSs percutaneously with the aid of intraoperative fluoroscopy. Only one of these screws was later found to have breached the spinal canal, yielding a breach rate of 0.35% for percutaneously placed PSs (one of 287).

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OBJECT: The authors have developed a novel technique for percutaneous fusion in which standard microendoscopic discectomy is modified. Based on data obtained in their cadaveric studies they considered that this minimally invasive interbody fusion could be safely implemented clinically. The authors describe their initial experience with a microendoscopic transforaminal lumbar interbody fusion (METLIF) technique, with regard to safety in the placement of percutaneous instrumentation, perioperative morbidity, and early postoperative results. METHODS: The METLIF procedure was performed unilaterally in 20 patients with single-level lumbar spondylolisthesis or pure mechanical back pain with endoscopic assistance, hemilaminectomy, unilateral facetectomy, and microdiscectomy. Two interbody grafts were placed via the lateral exposure of the disc space. Bilateral percutaneous pedicle screws were then inserted. Compared with patients who had undergone single-level posterior LIF at the same institutions, intraoperative blood loss, hospital length of stay (LOS), and postoperative narcotic agent use were significantly lower in the METLIF group. The mean LOS for the percutaneous fusion group was 3.4 days (5.1 days in those who underwent PLIF; p < 0.02). There have been no procedure-related complications in this series to date. CONCLUSIONS: The METLIF technique provided an option for percutaneous interbody fusion similar to that in open surgery while minimizing destruction to adjacent tissues. This technique was safe and exhibited a trend toward decreased intraoperative blood loss, postoperative pain, total narcotic use, and the risk of transfusion.

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STUDY DESIGN: Feasibility analysis of percutaneous posterolateral thoracic microendoscopic discectomy in a human cadaver model. OBJECTIVE: To describe a new, minimally invasive, posterolateral approach to the thoracic spine for the treatment of disc herniations. SUMMARY OF BACKGROUND: Thoracoscopic discectomy offers surgeons direct ventral access to thoracic disc herniations but requires entry into the chest. Many surgeons favor a posterolateral approach to the thoracic spine, thereby avoiding morbidity associated with entry into the thoracic cavity. By adapting minimal access surgical techniques to the thoracic spine, effective treatment of thoracic disc herniations should be possible and may help expedite recovery. METHODS: Two cadaveric human torsos were used. Using simple adaptations of our standard lumbar microendoscopic discectomy technique, endoscopic discectomies were performed throughout the mid and lower thoracic spine. Operative time was recorded. The extent of the discectomy as well as the extent of bony removal was evaluated using computed tomography myelography. RESULTS: Nine discectomies were performed in two cadaveric specimens, from T5-T6-T9-T10. Operative times ranged from 46 to 77 minutes (mean 60 minutes). The procedure required removing 3.4 mm (+/-1.9 mm) of the ipsilateral facet, which amounted to 35.4% (+/-17.5%) of the facet complex. Canal decompression averaged 73.5% (+/-7.9%). CONCLUSIONS: Thoracic microendoscopic discectomy allows for a posterolateral approach to thoracic disc herniation without entry into the chest cavity that consistently gives access to the majority of the canal while requiring only a minimal amount of bone removal. This technique provides an approach angle similar to that obtained with other posterolateral discectomy techniques while limiting the morbidity associated with exposure.

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STUDY DESIGN: Double-blind, randomized, placebo-controlled study to assess the effectiveness of calcitonin nasal spray on symptoms and function in patients with lumbar canal stenosis. OBJECTIVE: To compare effectiveness of calcitonin administered by nasal spray with placebo in patients with clinically symptomatic lumbar canal stenosis. SUMMARY OF BACKGROUND DATA: Lumbar canal stenosis is the most common reason for spine surgery in individuals over 65 years of age. Nonoperative approaches have been not well studied and limited primarily to physical therapy exercises. Several small trials in the past have suggested that subcutaneous and intramuscular calcitonin is an effective nonsurgical option in treating the symptoms of spinal stenosis patients. Only three trials were randomized and placebo-controlled. METHODS: Fifty-five patients with clinical lumbar canal stenosis (pseudoclaudication), confirmatory MR imaging, and pain intensity index (VAS) of > or =6 were randomized to either placebo or intranasal calcitonin daily for 6 weeks, followed by an open label 6-week extension, during which all patients received active drug. Outcome parameters performed at baseline, 6 weeks, and 12 weeks, included pain intensity index, walking time and distance to pain, SF-36, and Oswestry disability index. RESULTS: Thirty-six patients received calcitonin, and 19 placebo. Eight (14.54%) calcitonin and 4 (7.27%) placebo patients withdrew from the study. The mean baseline pain score for calcitonin group was 7.8 and 7.5 for placebo. Comparisons at week 6 showed no statistically significant difference in the change in pain intensity (VAS) between calcitonin group (-2.9) and placebo (-2.4) (P = 0.4382) from baseline. There was no significant difference in walking time to pain (calcitonin -10.0 seconds; placebo +32.2 seconds; P = 0.5136). Walking distance to pain showed a mean improvement of +91.4 ft in the calcitonin group and +254.7 ft in the placebo group (P = 0.4948). No significant difference was observed in the SF-36 score between the treatment groups. Using a threshold of at least 50% reduction in pain from baseline to 6 weeks, 12 of 29 (41.37%) of calcitonin patients were considered responders versus 7 of 18 (38.88%) of placebo patients (P = 0.4238) CONCLUSIONS: In this first ever largest randomized placebo-controlled parallel group trial of nasal calcitonin in spinal stenosis, nasal calcitonin was not superior to placebo in treating the symptoms of spinal stenosis at 6 weeks. Based on this study, nasal calcitonin does not appear to have a role in nonoperative treatment of lumbar canal stenosis.

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Changing health care regulations and funding have led healthcare providers to develop new ways of providing care for patients who have back pain, while consuming fewer hospital resources. As no consensus exists for a transcendent model of preoperative and postoperative assessment and care, clinicians must define their objectives clearly for effective patient care. These include, but are not limited to, acquiring pertinent medical information, consultations, and laboratory testing necessary to assess perioperative risk; optimizing the patient's condition and developing an appropriate perioperative care plan; and educating the patient about intraoperative care and postoperative management to reduce preoperative anxiety. Clinical circumstances and specific tests for patients who have back pain meet the criteria for good screening opportunities and should be used effectively for pre- and postoperative care.

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New drugs to treat osteoporosis, along with two new minimally invasive surgical procedures, are important options for preventing vertebral compression fractures and treating severe back pain and disability. However, the mainstay treatments remain cautious use of analgesics, limited bed rest, and physical rehabilitation.

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