Abstract
Introduction: Current diagnostic labels used to dictate the prescription of treatment have been derived from studies of cadavers and surgery performed upon the unconscious patient.
Methods: In 800 patients, feedback during aware state surgery was independently recorded . Pain sources were detected by spinal probing and verified by endoscopy in the extra foraminal, epidural, foraminal and intradiscal zones.
Results: The nerve was found variously painfully tethered to the ascending facet joint, the superior foraminal ligament, superior notch osteophytes, shoulder osteophytes and directly tethered to the disc. In addition, the disc pad, posterior longitudinal ligament and tissues on the dorsum of the vertebra were found to be individually sensitive. These sources produced both local and referred pain.
In two thirds of patients with back pain, the disc itself was quiescent to both external and internal manipulation. In a third of patients, the inflamed nerve produced atypical peripheral radicular symptoms on direct probing.
Discussion: These unrecognised pain sites and the atypical peripheral symptoms they produce may lead to atypical presentations and mal-targeted interventions. Their persistence may account for failures following conventional surgery.
Endoscopy offers an intriguing method of localising and understanding the pathology that underlies diagnostic labels such as failed back syndrome, failed back surgery syndrome, instability and lateral recess stenosis. It is suggested that future surgery be based upon the findings of spinal probing with endoscopic verification.
Dynamic retrolisthesis and olisthesis aggravates inflammation in these foraminal sites.
The abstracts were prepared by Dr P Dolan. Correspondence should be addressed to him at the British Orthopaedic Association, Royal College of Surgeons, 35-43 Lincoln’s Inn Fields, London WC2A 3PN.
