THE HONG KONG MINIMALLY INVASIVE BRAIN & SPINE NEUROSURGERY CENTRE

 
NEUROSURGERY is a highly specialized surgical subspecialty that involves i) medical treatments ii) physical treatments iii) interventional or endovascular procedures and iv) minimally invasive microsurgeries for treating a very wide spectrum of clinical conditions and diseases that happen at our BRAIN and SPINE. Among all, treating STROKE and PAIN are the basics of Neurosurgery daily practices.

In the other words, NEUROSURGEONs, with their knowledges and trainings, together with their sophisticated micro-instruments, utilize their operative skills under the microscope, they treat wide spectrum of clinical conditions and diseases that happen along human nervous systems and its surrounding tissues; skull, spinal column, vessels and related tissues.

The followings are the summary of the common routines in Neurosurgical Practices:

  1. Head trauma and brain injury

  2. Brain tumors and Pituitary tumors:

  3. Stroke: both Ischemic and Hemorrhagic strokes

    1. Stroke Risk Assessment and Stroke Screening

    2. Stroke Prevention:

    3. Stroke Acute Treatment within Golden-Hours;

  4. Neuropathic Pain Treatments and Functional Neurosurgery:

    1. Trigeminal neuralgia
    2. Glossopharyngeal neuralgia
    3. Hemifacial spasm

    Microvascular Decompression (MVD)

  5. Spine:

    1. Spinal Tumor

    2. Spinal Trauma:
       with or without spinal fracture, spinal cord or nerves injury.

      1. Minimally invasive decompression +/- fixation spinal surgery for spine stabilization.

    3. Spinal Herniated Disc:

      with numbness, pain, weakness at arms or legs, sciatica pain at legs.

      1. Spinal injection and radiofrequency treatments for discogenic back pain or sciatica pain at legs.
      2. Microdiscectomy for freeing the impinged nerves
      3. Mini-decompressive Laminectomy for freeing the impinged spinal cord or nerves.

    4. Spinal Stenosis at neck or lower back:

      with spinal cord or cauda equina nerves compressions, causing pain, numbness, weakness at arms or legs, disturbed gait, disturbed urinary habit and bowel habits, disturbed sexual function.

    5. Degenerative Spine Disease:

      with back pain, nerves compressions, spinal instability or scoliosis: 

      Minimally Invasive Spine Fusion Surgery under Microscope:
      1. Transforaminal Lumbar Interbody Fusion (TLIF)
      2. ObliquLumbar Interbody Fusione (OLIF)

Among all Neurosurgeries, minimally invasive spine surgery (MIS Spine Surgery) are the microsurgeries that Neurosurgeons most commonly perform among their routines. 

For all spine surgeries, Neurosurgeons apply their knowledges of nervous system and spinal column, and also their microsurgical skills and techniques, together with their micro-instruments of brain surgeries. Sometimes, Neurosurgeons may also add the technique of Continuous Intra-Operative Neural Monitoring (IOM) to monitor the nerve signal transmission function along brain, spinal cord and nerves during surgery, so as to assure patients’ good neurological outcome in spine surgeries. 

Seeking Second Medical Opinion

With the ever-advancing Medical Technology, seeking a second medical opinion is now the standard practice for all kinds of medical diagnoses. Getting a second medical opinion from another Medical Expert is a decision-support tool for ratification or modification of the medical suggestions from other doctors.

Second medical opinion may have critical impacts on the disease outcome by influencing the followings, namely 5Cs:

Head injury

Brain tumors can be subdivided into non-cancerous benign tumor and malignant cancerous tumor. If a tumor is originated within brain compartment ......

Spine Surgery
Spine Surgery

Tumors can develop in the vertebrae, nerves, and other tissue throughout your spine. Some spine tumors, such as astrocytomas, occur more commonly in children and adolescents......

Stroke Prevention

Given the disease burden of strokes, prevention is an important public health concern. As stroke neurosurgeons, we do not want to treat stroke unless we are forced to do so for acute stroke ......

brain tumor treatment Hong Kong

Brain tumors grow and compress normal brain tissue. Both benign and malignant tumors can cause swelling of the brain and raised intracranial pressure. Headache, dizziness....

THE HONG KONG MINIMALLY INVASIVE BRAIN & SPINE NEUROSURGERY CENTRE

 
NEUROSURGERY is a highly specialized surgical subspecialty that involves i) medical treatments ii) physical treatments iii) interventional or endovascular procedures and iv) minimally invasive microsurgeries for treating a very wide spectrum of clinical conditions and diseases that happen at our BRAIN and SPINE. Among all, treating STROKE and PAIN are the basics of Neurosurgery daily practices.

In the other words, NEUROSURGEONs, with their knowledges and trainings, together with their sophisticated micro-instruments, utilize their operative skills under the microscope, they treat wide spectrum of clinical conditions and diseases that happen along human nervous systems and its surrounding tissues; skull, spinal column, vessels and related tissues.

The followings are the summary of the common routines in Neurosurgical Practices:

  1. Head trauma and brain injury

  2. Brain tumors and Pituitary tumors:

  3. Stroke: both Ischemic and Hemorrhagic strokes

    1. Stroke Risk Assessment and Stroke Screening

    2. Stroke Prevention:

    3. Stroke Acute Treatment within Golden-Hours;

  4. Neuropathic Pain Treatments and Functional Neurosurgery:

    1. Trigeminal neuralgia
    2. Glossopharyngeal neuralgia
    3. Hemifacial spasm

    Microvascular Decompression (MVD)

  5. Spine:

    1. Spinal Tumor

    2. Spinal Trauma:
       with or without spinal fracture, spinal cord or nerves injury.

      1. Minimally invasive decompression +/- fixation spinal surgery for spine stabilization.

    3. Spinal Herniated Disc:

      with numbness, pain, weakness at arms or legs, sciatica pain at legs.

      1. Spinal injection and radiofrequency treatments for discogenic back pain or sciatica pain at legs.
      2. Microdiscectomy for freeing the impinged nerves
      3. Mini-decompressive Laminectomy for freeing the impinged spinal cord or nerves.

    4. Spinal Stenosis at neck or lower back:

      with spinal cord or cauda equina nerves compressions, causing pain, numbness, weakness at arms or legs, disturbed gait, disturbed urinary habit and bowel habits, disturbed sexual function.

    5. Degenerative Spine Disease:

      with back pain, nerves compressions, spinal instability or scoliosis: 

      Minimally Invasive Spine Fusion Surgery under Microscope:
      1. Transforaminal Lumbar Interbody Fusion (TLIF)
      2. ObliquLumbar Interbody Fusione (OLIF)

Among all Neurosurgeries, minimally invasive spine surgery (MIS Spine Surgery) are the microsurgeries that Neurosurgeons most commonly perform among their routines. 

For all spine surgeries, Neurosurgeons apply their knowledges of nervous system and spinal column, and also their microsurgical skills and techniques, together with their micro-instruments of brain surgeries. Sometimes, Neurosurgeons may also add the technique of Continuous Intra-Operative Neural Monitoring (IOM) to monitor the nerve signal transmission function along brain, spinal cord and nerves during surgery, so as to assure patients’ good neurological outcome in spine surgeries. 

Lumbar Spinal Stenosis FAQs
 
 
What is Lumbar Spinal Stenosis?
The lumbar spine is the low back. Spinal stenosis is a narrowing of the spinal canal, which contains the spinal cord and nerves (Fig. 1). This narrowing can put pressure on the spinal cord or on the nerves that branch out from  the compressed areas.
 
Fig. 1.
Anatomy of the spine showing the spinal canal and the facet joints and disks.
 
Lumbar spinal stenosis most commonly causes cramping, pain or pins & needles in one’s legs; but it can also cause: back pain; loss of sensation in the legs; and sometimes problems with bladder or bowel function.
 
What are the Symptoms of Lumbar Spinal Stenosis?
Spinal narrowing doesn’t always cause problems. But if the narrowed areas compress the spinal cord or spinal nerves, one is likely to develop symptoms. These often start gradually and grow worse over time. [1]
 
The most common spinal stenosis symptoms include:

Pain or cramping in the legs. Compressed nerves in the lumbar spine can lead to pain or cramping in the legs when one stands for long periods of time or walks. The discomfort usually eases on bending forward or sitting down, but it persists one continues to stand upright. Pain in the legs on walking is known as ‘claudication’ after the Roman Emperor Claudius, who had a limp. The form of claudication caused by lumbar spinal stenosis is called neurogenic claudication, because it caused by a problem with the nerves. Another type of claudication, vascular claudication, occurs when there is a narrowing or blockage in the arteries in the legs. Although both types of claudication cause similar symptoms, they differ in two important ways: vascular claudication usually becomes worse when one walks uphill and improves when one stands still. Neurogenic claudication is usually worse when going downhill and gets better when leaning forward or sitting down, because flexing the spine (bending forward) usually reduces the compression.
 
Radiating back and hip pain. Nerve compression can cause pain that starts in the hip or buttocks and extends down the back of the leg. The pain is worse when sitting and generally affects only one side (Fig. 2). Often this is referred to as ‘sciatica’ as the pain is largely in the distribution.
 
Fig. 2. Fig. 3.
Typical location of pain in sciatica. Anatomical classification of lumbar spinal stenosis.
 
 
Loss of bowel or bladder function (cauda equina syndrome). In severe cases, nerves to ones bladder or bowels may be affected, leading to partial or complete urinary or faecal incontinence.
 
If you experience these problems, seek medical care right away.
 
Are there different types of lumbar spinal stenosis?
Primary spinal stenosis, which is relatively uncommon, is present at birth.
 
Acquired spinal stenosis, which is the type that most people have, develops later in life. It’s usually a result of degenerative changes in the spine that occur with aging.
 
Anatomically, we can classify it into Central, Lateral, Foraminal, and Extraforaminal stenosis – this is relevant to treatment (Fig. 3). [1]
 
How serious is lumbar spinal stenosis?
Usually lumbar spinal stenosis only causes discomfort in the legs on walking, and it usually recovers completely with treatment, however, it can sometimes cause more severe problems, especially if treatment is delayed.
 
Permanent sensation loss. Lumbar spinal stenosis may cause a loss of feeling in one’s feet or legs. As a result, cuts or wounds may become seriously infected because one is not aware of them.
 
Loss of bowel or bladder function (Cauda equina syndrome). This complication is rather poor in prognosis. The recovery of the neurological deficit is unpredictable even after prompt surgical treatment.
 
Muscle wasting may be permanent, even after the pressure is relieved.
 
What is the cause of lumbar spinal stenosis?
Lumbar spine degeneration is the most common cause.

Facet joint arthritis is osteoarthritis that affects the facet joints at the back of the spine. With time, the cartilage begins to deteriorate and its smooth surface becomes rough. If it wears down completely, bone may rub painfully on bone. In an attempt to repair the damage, the body may produce bony growths called ‘osteophytes’ or ‘bone spurs’. When these form on the facet joints in the spine, they narrow the spinal canal.
 
Herniated discs. These are also known as ‘slipped discs’. Herniated discs may occur on their own, or be one of the causes of spine stenosis. By the age of 30, the intervertebral discs may start to show signs of deterioration. They begin to lose their water content, becoming flatter and more brittle. Eventually, the tough, fibrous outer covering of the disk may develop tiny tears, causing the jelly-like substance in the disc’s centre to seep out (herniation or rupture). The herniated disc presses.
 
Ligamentum flavum hypertrophy. Ligaments in the back can undergo degenerative changes, becoming stiff and thick. The usual culprit in lumbar spinal stenosis is the ligamentum flavum (‘yellow ligament’) which runs inside the spinal canal. The thickening may press on the nerves, and the stiffening prevents the spine from moving properly.
 
Other Causes
There are other causes, such as spinal tumors, injury, Paget’s disease of bone, achondroplasia and others, but they are relatively uncommon and beyond the scope of this article.
 
What are the risk factors for lumbar spinal stenosis?
Age is the main risk factor for spinal stenosis. The risk of developing spinal stenosis increases after age 50. Other risk factors are a history of injury to the back, congenital stenosis, sports with overuse of the back muscles, and metabolic bone disease.
 
When should I seek medical advice?
Many people may ignore the early symptoms of spinal stenosis, believing that the pain and stiffness they experience are a normal part of aging. If pain, stiffness, numbness or weakness of the legs is troubling, it is appropriate to discuss the problem with a spine specialist. The rare complication of cauda equina syndrome warrants emergency surgical treatment.
 
How is lumbar spinal stenosis diagnosed?
History: The typical story is of pain in the legs with or without back pain.
 
Examination: Usually the back is stiff, but there are few other physical findings.
 
X-ray Lumbar Spine including views in flexion and extension. X-rays often show degenerative changes. They help to rule out problems that cause similar symptoms, including fractures, bone tumours, metabolic diseases etc. Flexion and extension views show if the spine is moving abnormally.
 
Magnetic Resonance Imaging (MRI). MRI uses a combination of magnetism and radio waves to produce three dimensional images. MRI is extremely useful for assessing the spine as it shows the nerves and other soft tissues as well as the bones. MRI produces cross-sectional images in three planes, allowing doctors to get a clear understanding of the anatomy. hong kong spine and pain centre has a special weight bearing MRI scanner which takes images with the individual standing up – this can be helpful, as lumbar spinal stenosis symptoms are usually only present when one is standing (Fig. 4). [2]
 
 
Fig.4. The special weight bearing MRI scanner takes images with the individual’s positions
A. Upright B. Tilting C. Supine
 
 
Injection tests. Although the MRI produces beautiful pictures of the anatomy, it does not show ‘pain’. If one has back pain it is sometimes necessary to inject local anaesthetic into various places in the back to work out what is causing the pain.
 
What is the treatment?
Most patients are recommended non-operative treatment for at least 6 weeks. Surgical treatment will be advised if the patient is not responding well.
 
Physical therapy. Working with a therapist can build up the back muscle strength and endurance and improve the flexibility and stability of the spine. [3]
 
Rest or restricted activity. Moderate rest followed by a gradual return to activity may improve symptoms. Walking is usually the best exercise, especially for people with neurogenic claudication, but biking also is helpful because it keeps ones back in a flexed position, which reduces nerve compression.
 
A back brace or corset. This helps provide support and may especially benefit people who have weak abdominal muscles or degeneration in more than one area of the spine.
 
Paracetamol. Paracetamol/Acetaminophen (Panadol, Tylenol) is a mild analgesic, but has a synergy with other drugs. It is very safe when taken in the correct dosage, even in the long-term. If one is able to control ones pain with paracetamol it is probably not necessary to consider more aggressive treatment.
 
Non-Steroidal Anti-Inflammatory Drugs. These reduce inflammation and pain, but have the side effects of stomach ulcers and kidney damage. They include over-the-counter medications, such as aspirin, ibuprofen (Advil, Motrin, Nurofen, etc) and prescription medicines which are generally stronger.
 
The new ‘COX2 selective inhibitors’ such as celecoxib (Celebrex) and etoricoxib (Arcoxia) have all the advantages but few of the side effects of the older ‘non-selective’ drugs, and are very safe, even in long-term usage – though not quite as safe as paracetmol.
 
Narcotic Analgesics. A number of painkillers are based on morphine. Commonly used ones include: codeine; tramadol; dextropropoxyphene, oxycodone (Oxycontin, mixed with paracetamol as Percocet), Hydocodone (mixed with paracetamol as Vicodin). They are effective painkillers, but they often make one feel ‘woozy’ and one becomes tolerant to them in time, so they become less effective. They are best not used in the long-term.
 
Antidepressant and Antiepileptic Drugs. Amitriptyline, gabapentin (Neurontin) and pregabalin (Lyrica) are very helpful for neuropathic pain. The common side effect is drowsiness (which can be helpful if the drugs are taken at night), but they can sometimes cause liver damage. [4]
 
Muscle relaxants. Baclofen and diazepam (Valium) are very helpful for back muscle spasm. They relax the muscles and have the synergistic effect with physiotherapy treatment. The major side effects are muscle weakness and drowsiness.
 
Chondroitin sulfate and glucosamine. These non-prescription food supplements, used either alone or in combination, reduce the pain of osteoarthritis, but not of nerve compression – so they may help back pain from facet joint arthritis, but they are unlikely to help leg problems. They are completely safe.
 
Epidural steroid injections. Steroids suppress inflammation and can be especially helpful in treating pain that radiates down the back of the leg. A single dose may provide significant relief. But because corticosteroids can cause a number of significant side effects, the number of injections one can receive is limited, usually to no more than three in one year. [5]
 
What are the surgical treatments?
The goal of surgery is to relieve pressure on the spinal cord or nerves and to maintain the integrity and strength of the spine. This can be accomplished in several ways, depending on the cause of the problem. Broadly speaking, we can divide the surgical procedures into:
  1. posterior decompression alone
  2. posterior decompression with dynamic stabilisation
  3. posterior decompression with instrumented spinal fusion
Decompressive laminectomy
Indications: Decompressive laminectomy is for those with lumbar spinal stenosis with neurogenic claudication and/or sciatica pain but not back pain or a radiologically unstable spine.
 
Technique: This is the classic surgery for the lumbar spinal stenosis. By removing the entire lamina (the bone covering the back of the spinal canal), the nerves are decompressed. In conventional surgery, the surgeon makes a single incision in the back (Fig. 5). However, some surgeons do this procedure by a minimally invasive technique by using multiple small incisions. Although this takes longer, the patient usually has less pain and a faster rehabilitation.
 
Risks: Complications are uncommon with modern techniques, but include infection, dural tear, nerve root injury, significant bleeding, deep vein thrombosis, paralytic ileus and neurological deterioration.
 
Results: Most people do extremely well with excellent relief of symptoms, but laminectomy does significantly alter the normal anatomy, potentially destabilising the spine. About 20-30% of the patients will need another surgery 5 years after laminectomy because of back pain, instability or recurrence of symptoms. At this stage, most of them will need a revision decompression and instrumented posterior spinal fusion (Fig. 6).
 
 
Fig. 5. Fig. 6.
Conventional incision for laminectomy. The muscles are retracted and the laminae are displayed. Laminectomy and instrumented posterior fusion. The laminae have been removed to decompress the nerves. Three pairs of metal screws have been placed to hold the bone and bone graft has been placed to cause the two spinal segments to fuse together permanently.

 
 
Laminotomy
Indications: Decompressive laminotomy is for those with lumbar spinal stenosis with neurogenic claudication and/or sciatica pain but not back pain or a radiologically unstable spine. It is mainly indicated for spinal canal narrowing at the central and lateral recess. Only a small amount of tissue is removed (Fig. 7). The advantage is that one can preserve more the normal anatomy of the spine for the muscles to reattach.  Theoretically laminotomy does not affect the stability of the spine as much as a laminectomy and with less chance of requiring a later fusion operation. This procedure can always be performed minimally invasively. [6]
 
 
Fig. 7. Laminotomy
The shaded red circle shows the small area of the bone of the lamina and ligamentum flavum which is removed. The procedure can be performed minimally invasively – the black circle represents a tube through which special instruments are passed, thus requiring only a tiny incision.
 
 
Technique: The surgeon removes only part of the lamina, bone spurs from the facet joint and thickened ligaments compressing on the dura or nerve roots. Risks: The risks are the same as for laminectomy.
 
Results: Most people do extremely well with excellent relief of symptoms.
 
Interspinous Process Distraction Devices
Indications: In milder to moderate cases of lumbar spinal stenosis, one may have spinal claudication with or without radiculopathy. If one’s symptoms are dynamic – in other words there is relief with bending forward - it is a good indication for insertion of an interspinous process distraction device (IPDD) (Fig. 8). The IPDD ‘jacks’ up the spine creating more space for the nerves.
 
 
Fig. 8.
An interspinous process distraction device sitting between the spinous processes at the back of the spine.

 
Technique: This minimally invasive procedure performed via very small incisions. Sometimes laminotomies (see above) is performed at the same time. Usually one can get out of bed on the same day of the procedure.
 
Risks: Complications are uncommon with IPDD, because the device does not enter the spinal canal, but include infection, deep vein thrombosis, paralytic ileus and neurological deterioration. If laminotomy is performed at the same time, complications are the same as for laminectomy.
 
Results: Although IPDD is very new, results are encouraging so far. For moderate lumbar spinal stenosis, wide laminotomies and partial facetectomy is often performed in order to ensure adequate decompression. However, this may destabilise the spine in a way similar to conventional laminectomy. We believe that interspinous process distraction devices may stabilise the spine without the need for later fusion. [7, 8]

Posterior Instrumented Spinal Fusion
Indications: Severe lumbar spinal stenosis requiring extensive decompression; coexisting instability; severe deformity; associated back pain. Before the surgery, one may need discography and nerve root block to identify the origin of the symptoms. There is evidence showing that injection tests can provide useful advance indications of the likely success of the surgery.
 
Technique: The surgeon aims to realign the spine to a normal position, stabilise the spine to protect the nerves, and to treat the back pain. This procedure is composed of two parts. The first part is posterior decompression and the second part is spinal fusion with pedicle screws and bone grafting.
 
Mini-open or percutaneous Transforaminal Lumbar Interbody Fusion (TLIF) (Fig. 9) can be performed in the majority of the cases. The advantage is less bleeding, less wound pain, and faster rehabilitation than a conventional open spinal decompression and fusion. Normally, one would need to stay on bed for 2-3 days and be home within a week. Usually one is fully recovered and able to expected to resume full activity and sports at 6 - 9 months (the time for the bone to fuse).
 
 
Fig. 9. TLIF
The intervertebral disc has been replaced with a metal spacer and pairs of screws have been joined by  robs to hold the bones without movement. Bone graft (not shown) is placed to cause the two spinal segments to fuse together permanently.
 
 
Risks: The risks of surgery are the same as for laminectomy with the addition of implant malposition, failure of fusion, and accelerated disc degeneration at the adjacent segments. [9]
 
Can we prevent the development of lumbar spinal stenosis?
We can’t always prevent age-related changes in our backs, but the following steps can help keep our spine and joints as healthy as possible:
 
Exercise regularly. This helps maintain strength and flexibility in our spine, joints and ligaments. For the best results, combine aerobic activities such as walking and biking with weight training and stretching. Toning and stretching before exercise can help reduce wear and tear on the back. It also reduces the risk of injury by warming up muscles and increasing flexibility. Strength training can make the arms, legs and abdominal muscles stronger, which takes stress off the back. Start out exercise gradually and increase the duration and intensity of the workout
as we become stronger. Aim for at least 30 minutes of moderate exercise on most days.

Use good body mechanics. Being conscious of how we sit, stand, lift heavy objects and even how we sleep can go a long way toward keeping our back healthy.
 
Choose a seat that supports the lower back to minimise stress. If necessary, place a pillow or a rolled towel in the small of the back to maintain its normal curve.
 
When you drive, adjust the seat to keep both knees and hips level, and move the seat forward to avoid overreaching for the pedals.
 
Before lift something heavy, decide where to place it and how to get there. Pushing is safer than pulling. Always bend the knees so that both arms are level with the object. Avoid lifting overhead.
 
For the best sleep posture, choose a firm mattress. Use pillows for support, but don’t use one that forces your neck up at a severe angle.
 
Maintain a healthy weight. Extra weight puts additional stress on our bones and joints.
 
 
References:
  1. Lumbar spinal stenosis and nerve root 1. entrapment syndromes. Definition and classification. Arnoldi CC. Brodsky AE. Cauchoix J. Crock HV. Dommisse GF. Edgar MA. Gargano FP. Jacobson RE. Kirkaldy-Willis WH. Kurihara A. Langenskiold A. Macnab I. McIvor GW. Newman PH. Paine KW. Russin LA. Sheldon J. Tile M. Urist MR. Wilson WE. Wiltse LL. Clinical Orthopaedics & Related Research. (115):4-5, 1976 Mar-Apr.
  2. Surgical Results in Hidden Lumbar Spinal Stenosis Detected by Axial Loaded Computed Tomography and Magnetic Resonance Imaging – An Outcome Study. Jan Willen, Per J. Wessberg, Barbro Danielsson; Spine 2008; Vol 33, No.4, p E109-115.
  3. Effectiveness of Physical Therapy and Epidural Steroid Injections in Lumbar Spinal Stenosis Zarife Koc, Suheda Ozcakir, Koncuy Sivrioglu et al; Spine 2009, Vol 34, No 10, p985-989.
  4. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Yaksi A. Ozgonenel L. Ozgonenel B. Spine. 32(9):939-42, 2007 Apr 20.
  5. Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study. Botwin KP. Gruber RD. Bouchlas CG. Torres-Ramos FM. Sanelli JT. Freeman ED. Slaten WK. Rao S. American Journal of Physical Medicine & Rehabilitation. 81(12):898-905, 2002 Dec.
  6. Minimally Invasive Lumbar Spinal Decompression in the Elderly: Outcomes of 50 Patients Aged 75 years and Older; David S. Rosen, John E. O’Toole, Kurt M. Eichholz et al, Neurosurgery March 2007, Vol 60, No 3. p503-510.
  7. A prospective randomized multi-center study for the treatment of lumbar spinal stenosis with the X STOP interspinous implant: 1-year results. Zucherman JF. Hsu KY. Hartjen CA. Mehalic TF. Implicito DA. Martin MJ. Johnson DR 2nd. Skidmore GA. Vessa PP. Dwyer JW. Puccio S. Cauthen JC. Ozuna RM. European Spine Journal. 13(1):22-31, 2004 Feb.
  8. Minimally invasive spine technology and minimally invasive spine surgery: a historical review. Oppenheimer JH. DeCastro I. McDonnell DE. Neurosurgical Focus. 27(3):E9, 2009 Sep.
  9. Efficacy of surgery and type of fusion in patients with degenerative lumbar spinal stenosis. Gu Y. Chen L. Yang HL. Chen XQ. Dong RB. Han GS. Tang TS. Zhang ZM. Journal of Clinical Neuroscience. 16(10):1291-5, 2009 Oct.

 

Because the signs of stroke are traceable, if symptoms are identified through risk screening, suitable treatments can be received to reduce the risk of a stroke.

HKBSSP offers the following prevention treatments:

Medical Therapy: Drug for blood pressure control & cholesterolaemia, glucose control for diabetes, anticoagulant for atrial fibrillation, and antiplatelet for previous stroke patients.
Prevention 

Prophylactic Neurosurgery Percutaneous Cerebral Intervention (Neuro-PCI) revascularisation: this minimally invasive procedure not only can treat acute strokes effectively, it can also treat structural abnormalities such as cervical arteries stenosis, intracranial vascular anomaly, intracranial vascular stenosis, and cerebral aneurysm or arteriovenous malformation, to minimise the risk of a stroke.

Sacroiliac Joint Pain FAQs
 
 
 
Sacroiliac (SI) joint pain is a challenging condition affecting 15% to 25% of patients with axial low back pain, for which there is no standard long-term treatment. Recent studies have demonstrated that historical and physical examination findings and radiological imaging are insufficient to diagnose SI joint pain. The most commonly used method to diagnose the SI joint as a pain generator is with smallvolume local anesthetic blocks. In the article, I will try to explain the diagnostic methods and available treatments in detail.
 
Structure and Function of the SI joint
The sacroiliac joint is the largest axial joint in the body, with an average surface area of 17.5 cm2 [1]. There is wide variability in the adult SI joint [2, 3]. The SI joint is most often characterised as a large, auricularshaped, diarthrodial synovial joint. It has no joint capsule at the posterior and is covered by an extensive ligamentous structure, functioning as a connecting band between the sacrum and ilia. The ligaments are serving a static stabiliser to the joint. (Fig. 1) In addition, the SI joint is also supported by a network of muscles (gluteus maximus, piriformis and biceps femoris) that help to stabilise the pelvic bones.
 
 
 
Fig 1. Posterior ligamentous structures stabilizing sacroiliac joint.
 
 
Normal Aging of SI joint
Age-related changes in the SI joint begin in puberty and continue throughout life. Degenerative x-ray changes are usually found by the third and fourth decades. In the sixth decade, motion at the joint may become markedly restricted as the capsule becomes increasingly rigid.
 
Nerve supply to SI joint
The innervation of the SI joint remains a subject of much debate. Some authors have suggested that the anterior SI joint is devoid of nervous tissue [4, 5]. However, it is commonly believed that the lateral branches of the L5-S3 dorsal rami are responsible for the major nerve supply to the posterior SI joint [1].
 
Prevalence
Bernard and Kirkaldy-Willis, who performed the largest prevalence study, found that 22.5% of patients presenting with low back pain were suffering from SI joint pain [6]. By using criteria based on International Spinal Injection Society guidelines [7], the prevalence of SI joint pain in carefully screened LBP patients appears to be 15%–25% [8].
 
Causes of SI joint pain
Can be divided into intra-articular and extra-articular causes.
 
Intra-articular causes - arthritis and infection
Extra-articular causes - enthesopathy, fractures, ligamentous injury, and myofascial pain.
 
The mechanism of SI joint injury has is a combination of axial loading and abrupt rotation. This injury can lead to capsular or synovial disruption, capsular and ligamentous tension, hypomobility or hypermobility, extraneous compression or shearing forces, abnormal joint mechanics, microfractures or macrofractures, chondromalacia, soft tissue injury, and inflammation [9].
 
Factors affecting SI joint pain
Risk factors that operate by increasing the stress borne by the SI joints include:
1. pregnancy
2. true and apparent leg length discrepancy
3. gait abnormalities
4. prolonged vigorous exercise
5. scoliosis, and spinal fusion to the sacrum
 
Diagnosis and Presentation
History and Physical Examination
One of the most challenging aspects of treating SI joint pain is the complexity of diagnosis. Questions will be asked to differentiate the other pathologies such lumbar disc disease, nerve root compression, facet joint pain, primary or secondary myofascial syndromes, and symptoms from nonspinal structures all may mimic sacro-iliac joint pain. Inflammatory disorders of the sacroiliac joint, including ankylosing spondylitis and Reiter’s syndrome, often are diagnosed clinically.

Physical examination should include a thorough neurologic examination with evaluation of straight leg raising and assessment of pain and motion loss throughout the lower thoracic and lumbar spine. The hip joint should be tested and palpated for focal zones of soft-tissue or osseous pain in the lumbosacral pelvic region. The patient should point to the area of maximal pain, and its location should be noted. Focal areas of tenderness along the sacroiliac joint line and in the sacral sulcus is a typical sign.

In the literature, there are plenty of physical signs or tests for detecting SI joint pain. Patrick’s test (Fig. 2) and Gaenslen’s test (Fig. 3) are the 2 commonest physical examination [10].The reliability of provocative SI joint manouevres and alignment/mobility tests are not well validated.
 
         
         
 

Fig 2. Patrick’s test to put stress on Sacroiliac joints by external rotating the hip.

 

Fig 3. Gaenslen’s test to stress the sacroiliac joint by full flexion of hip joints.

 
 
 
Radiological Studies
Plain radiographs for confirmation of the pathology of the SI joint pain are very disappointing. MRI and CT scan can produce a better image of the architecture of the joint. They are reportedly 57.5% sensitive and 69% specific in diagnosing SI joint pain [11]. Radionuclide bone scanning in the identification of SI joint pain has sensitivity of 46% [12].
 
Pain Referral Patterns (Fig 4)
  • Sensory changes are localised to the medial buttock inferior to the posterior superior iliac spine, the superior aspect of the greater trochanter and the upper thigh.
  • Pain referral patterns for SI joint pain are buttock (94%), lower lumbar region (72%), calf (28%), groin area (14%), and foot pain (12%). Radiating pain to upper lumbar region (6%), and abdomen is rare (2-6%) [13-15].
   
 
 
 
  Fig 4. Pattern of radiation of of SI joint pain to the limbs.  
 
 
 
        Fig 5. X-ray anterior-posterior view of sacroiliac joint injection.
   
 
 
 
 

Fig 6. Sacroiliac joint belt for external support of sacroiliac joint instability.

 

 

 

 

Diagnostic Blocks (Fig 5)
Diagnostic block is the most reliable method to diagnose SI joint pain. The current standard is x-ray guided injection. Sometimes, CT guidance is necessary because of technical difficulty. Failure rate is around 5% with fluoroscopically guided SI joint injections [16,17].
 
Limitation of diagnostic block include the placebo effect, convergence and referred pain, neuroplasticity and central sensitisation, expectation bias, unintentional sympathetic blockade, systemic absorption of local anaesthetic, and psychosocial issues [18].

  
Treatment
The treatment of SI joint pain is well established. In general, the treatments can be divided into 2 categories:
1. directed at correcting the underlining pathology
2. aimed at alleviating symptoms
 
Conservative Management
The non-interventional management of SI joint pain should ideally address the underlining pathology. Correct underlying factors such as leg length discrepancy. Physical therapy and osteopathic or chiropractic manipulation can reduce pain and improve mobility [19]. Ankylosing spondylitis (AS) and other sero-negative spondyloarthropathy shoulder be treated with immunosuppressant medicines by a rheumatology specialist. Nonsurgical stabilisation programmes such as application of pelvic belts (Fig 6.) and exercise-induced pelvic stabilisation programs are effective in many cases [20, 21].
 
Hyaluronic acid injection
A viscosupplement to the joint. By injecting this substance, the joint may have a chance to recover. The initial results results are promising but the counterpart studies in the knee joints have shown weak evidence in providing a good long term pain relief. In addition, degenerative SI joint disease accounts for only a small percentage of patients [22]. Therefore, it is not a commonly used method.
 
Proliferative therapy (a.k.a. “prolotherapy”)
It has been advocated as a treatment for nonspecific low back pain and SI joint pain. The rationale behind the use of “prolotherapy” is that the ligaments and other soft tissue structures are of primary importance in the development of low back pain. Thus, the injection of a drug promoting fibroblast hyperplasia should theoretically increase the strength and reduce sensitisation of these structures. In the literature, there is no evidence showing that the prolotherapy can generate a long term success in reducing the pain [23].
 
Steroid injections
Injections with steroid and local anaesthetics often serve the dual function of being therapeutic and aiding in diagnosis. X-ray guided SI joint injections provide good to excellent pain relief lasting from 6 months to 1 year [24,25].
 
Radiofrequency Denervation Procedures
Radiofrequency (RF) denervation procedures provide prolonged pain relief to patients suffering SI joint pain. The technique is used to denervate the pain fibre supplying the SI joint by creating lesions around the joint. It is minimally invasive procedure done under local anaesthesia. It is usually day surgery. 2-3 puncture holes are made on each side of one SI joint. The surgical risk is negligible. During the RF treatment, a small amount of steroid is given to neutralise the irritation of the RF effect. The treated area will be sore for 1-2 weeks but after that the pain is significantly reduced. The success rate is 70% [26-28].
     
 

 
     
 
Fig 7. Radiofrequency denervation system.
 

 

Surgical fusion of SI joint
The primary indication for SI joint fusion is joint instability or fractures or advanced degeneration. Sacroiliac joint fusion can be done percutaneously by using X-ray or navigation guidance (Fig 7 and 8). The long-term success rate for SI joint fusion is 70% [29].

     
   
     
 
Fig 8. Anteroposterior radiograph after sacroiliac joint arthrodesis by anterior approach. Ipsilateral iliac crest bone graft was used, followed by transiliosacral compression screw fixation.
 
     
   
     
 
Fig 9. Implants for SI joint fusion.
 
 
Conclusions
The SI joint is a real, yet under-appreciated pain generator in about 15% to 25% of patients with axial low back pain. Whereas historical and physical examination findings have been previously advocated as useful tools in identifying patients with SI joint pain, more recent studies have demonstrated they have limited diagnostic value. Owing to the complexity of the joint, the mechanisms of SI pain are numerous and ill-defined. If there is no secondary causes (e.g. leg length problem or inflammatory arthritis), local anaesthetic with steroid injection under X-ray guidiance is an effective way to confirm the pain origin and at the same time treat the pain. The effect can last for 6 months or longer. One promising area in the treatment of SI joint pain is RF denervation, although there are limited clinical studies. Surgical fusion of SI joint is rarely needed unless there is an obvious instability or advanced arthritis.


References

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