text:
|[ISRCTN 16558617] A randomized, controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain.
|Jump to Full Text
MedLine Citation:
|PMID: 16000173 Owner: NLM Status: PubMed-not-MEDLINE
|BACKGROUND: Postoperative epidural fibrosis may contribute to between 5% to 60% of the poor surgical outcomes following decompressive surgery. Correlations have been reported between epidural scarring and radicular pain, poor surgical outcomes, and a lack of any form of surgical treatment. The use of spinal endoscopic adhesiolysis in recent years in the management of chronic refractory low back and lower extremity pain has been described. METHODS: A prospective, randomized, double-blind trial was conducted to determine the outcome of spinal endoscopic adhesiolysis to reduce pain and improve function and psychological status in patients with chronic refractory low back and lower extremity pain. A total of 83 patients were evaluated, with 33 patients in Group I and 50 patients in Group II. Group I served as the control, with endoscopy into the sacral level without adhesiolysis, followed by injection of local anesthetic and steroid. Group II received spinal endoscopic adhesiolysis, followed by injection of local anesthetic and steroid. RESULTS: Among the 50 patients in the treatment group receiving spinal endoscopic adhesiolysis, significant improvement without adverse effects was shown in 80% at 3 months, 56% at 6 months, and 48% at 12 months. The control group showed improvement in 33% of the patients at one month and none thereafter. Based on the definition that less than 6 months of relief is considered short-term and longer than 6 months of relief is considered long-term, a significant number of patients obtained long-term relief with improvement in pain, functional status, and psychological status. CONCLUSION: Spinal endoscopic adhesiolysis with targeted delivery of local anesthetic and steroid is an effective treatment in a significant number of patients with chronic low back and lower extremity pain without major adverse effects.
|Laxmaiah Manchikanti; Mark V Boswell; Jose J Rivera; Vidya Sagar Pampati; Kim S Damron; Carla D McManus; Doris E Brandon; Sue R Wilson
Related Documents :
|3030063 - Surgical and conservative treatment of cervical spondylotic radiculopathy and myelopathy.
19674713 - A feasibility study assessing manual therapies to different regions of the spine for pa...
25423873 - Surgical repair of chronic patellar tendon rupture in total knee replacement with ipsil...
Publication Detail:
|Type: Journal Article Date: 2005-07-06
Journal Detail:
|Title: BMC anesthesiology Volume: 5 ISSN: 1471-2253 ISO Abbreviation: BMC Anesthesiol Publication Date: 2005 Jul
Date Detail:
|Created Date: 2005-08-18 Completed Date: 2005-10-07 Revised Date: 2010-09-20
Medline Journal Info:
|Nlm Unique ID: 100968535 Medline TA: BMC Anesthesiol Country: England
Other Details:
|Languages: eng Pagination: 10 Citation Subset: -
|Pain Management Center of Paducah, Paducah, Kentucky 42003, USA. firstname.lastname@example.com
Export Citation:
|APA/MLA Format Download EndNote Download BibTex
|MeSH Terms
|Full Text
Journal Information
Journal ID (nlm-ta): BMC Anesthesiol
Publisher: BioMed Central, London
Article Information
Copyright ? 2005 Manchikanti et al; licensee BioMed Central Ltd.
open-access: This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received Day: 8 Month: 11 Year: 2004
Accepted Day: 6 Month: 7 Year: 2005
collection publication date: Year: 2005
Electronic publication date: Day: 6 Month: 7 Year: 2005
Volume: 5First Page: 10 Last Page: 10
Publisher Id: 1471-2253-5-10
PubMed Id: 16000173
|A randomized, controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain [ISRCTN 16558617]
|Laxmaiah Manchikanti1
|Email: firstname.lastname@example.com
|Mark V Boswell2
|Email: email@example.com
|Jose J Rivera1
|Email: firstname.lastname@example.com
|Vidya Sagar Pampati1
|Email: email@example.com
|Kim S Damron1
|Email: email@example.com
|Carla D McManus1
|Email: firstname.lastname@example.com
|Doris E Brandon1
|Email: firstname.lastname@example.com
|Sue R Wilson1
|Email: firstname.lastname@example.com
1Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, Kentucky, 42003, USA
2Case University School of Medicine, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
Postoperative epidural fibrosis, the formation of dense scar tissue adjacent to the dura mater following surgical laminectomy, may play a role in up to 60% of the poor surgical outcomes following decompressive surgery [1-3]. A correlation between peridural scarring and radicular pain [4-7], and poor clinical outcomes [8,9] has been reported by some, while others [10-13] have questioned the role of epidural fibrosis as a causative factor. Increased complication rates have been reported with revision spine surgery with increased occurrence of dural tears, nerve root injury, and bleeding [14,15]. Phillips and Cunningham [16] reported that no form of surgical treatment or adhesion lysis procedure was safe or effective for post-lumbar laminectomy syndrome.
Epidural fibrosis results from the invasion of postoperative hematoma by dense fibrous tissue originating from the periosteum and within the deep surface of the paravertebral musculature [17,18]. Epidural fibrosis may extend into the neural canal and adhere to the dura mater and nerve roots, with mechanical tethering of nerve roots or dura by adhesions, which may in turn contribute to persistent back and leg pain following lumbar laminectomy. However, epidural fibrosis also may develop without surgical intervention, secondary to annular tear, hematoma, infection, or intrathecal contrast media [18-20]. Perineural fibrosis can render nerve roots hyperesthetic and hypersensitive to compression forces by interfering with cerebrospinal fluid-mediated nutrition [6] or by making the nerve susceptible to injury [7].
A moderate proportion of patients show improvement in pain and functional level with interventional pain management procedures, including fluoroscopically-directed epidural steroid injections and percutaneous adhesiolysis utilizing a special catheter [21,22]. In addition, initial clinical studies of spinal endoscopic adhesiolysis [23-29] and a preliminary report of a randomized controlled trial [30] showed improved clinical outcomes. However, a recent prospective, randomized, double-blind trial [31] comparing caudal epidural with targeted steroid placement on affected nerve roots during spinal endoscopy for chronic sciatica, concluded that targeted placement of steroid did not significantly reduce pain intensity and anxiety and depression compared with caudal epidural steroid injection.
Most studies utilized post lumbar laminectomy syndrome or epidural fibrosis as inclusion criteria, whereas one study [28] included patients with lumbar spinal stenosis, and another [31] exclusively studied patients without history of surgery. In addition, some studies [26,27,30] specifically described inclusion criteria as patients without long-term improvement following fluoroscopically directed epidural steroid injections and one-day percutaneous adhesiolysis. Consequently, these studies represent heterogenous populations. Even though retrospective evaluations [26,27] have shown the effectiveness of spinal endoscopic adhesiolysis in patients after lack of long-term effect following fluoroscopically-directed caudal epidural steroid injections and one-day percutaneous adhesiolysis, the effectiveness has not been demonstrated in controlled trials.
Spinal endoscopy also has been utilized for diagnostic purposes. Even though multiple authors have described various types of findings, including the identification of inflammation with an endoscope, neither the reliability nor the clinical utility of spinal endoscope as a diagnostic tool has been established [23-25,28,29]. Consequently, no attempt was made to evaluate the diagnostic utility of spinal endoscopy.
This randomized, double-blind, controlled trial of spinal endoscopic adhesiolysis and targeted delivery of steroids was designed to evaluate their effectiveness in patients with chronic low back and lower extremity pain who lacked significant response to fluoroscopically-directed epidural steroid injections and one-day percutaneous adhesiolysis with hypertonic saline neurolysis, as well as to other conservative modalities of treatment.
This study was designed to evaluate the effectiveness of spinal endoscopic adhesiolysis in chronic, refractory low back and lower extremity pain. The study was undertaken in an interventional pain management practice (a specialty referral center) in a private practice setting, in accordance with the guidelines for randomized controlled trials [32,33], and the quality checklists of systematic reviews [32,34-39]. The trial also was designed to meet criteria of a pragmatic or a practical clinical trial [30,40,41]. The protocol was approved by the Institutional Review Board of the Ambulatory Surgery Center where the study was conducted. The objective was to evaluate the effectiveness of spinal endoscopic adhesiolysis compared to caudal epidural steroid injection. The design consisted of a control group and an intervention group. Group I (control group) was treated with introduction of the spinal endoscope up to the S3 level, followed by injection of a local anesthetic and steroid. Group II (intervention group) was treated with appropriate spinal endoscopic adhesiolysis at L4, L5 or S1 level(s) unilaterally or bilaterally based on symptomatology, followed by a targeted injection of local anesthetic and steroid.
The majority of participants in this study were identified from existing patients of the interventional pain management practice. Eligible new patients were screened and identified as candidates for the program.
patients between 18 and 65 years of age with a history of chronic low back and lower extremity pain of at least two year's duration, without facet joint pain based on controlled comparative local anesthetic blocks, and without significant improvement with conservative treatment including fluoroscopically-directed epidural injections and one-day percutaneous adhesiolysis with hypertonic saline neurolysis, and willingness to participate in the clinical trial were enrolled.
Criteria for lack of significant response to caudal epidural steroid injections was pain relief (? 50%) for one week or less following a second epidural steroid injection, and relief of four weeks or less following a third epidural steroid injection or any of subsequent epidural steroid injections. Criteria for lack of response to one-day percutaneous adhesiolysis with hypertonic saline neurolysis was considered as lack of response to the first adhesiolysis procedure, less than two months of pain relief (? 50%) following the second or subsequent procedures.
patients with cauda equina syndrome, compressive radiculopathy, surgical intervention in the previous six months, opioid abuse and dependency evaluated by adherence monitoring, including random drug testing and opioid use of no greater than hydrocodone 100 mg per day, methadone 60 mg or morphine 100 mg or equivalent doses of other drugs; uncontrolled major depression or psychiatric disorders; uncontrolled or acute medical illnesses including severe cardiac, pulmonary, or other disorders; chronic conditions that could interfere with the interpretations of the outcome assessments such as severe hip or knee arthritis, neuropathy, or other disorders; pregnant or lactating women; history of adverse reaction to local anesthetic or steroids; inability to understand the informed consent and protocol; or inability to be positioned in the prone position during the procedure [30].
All patients were provided with the protocol and the informed consent document approved by the Institutional Review Board for this study. The informed consent document described the details of the trial.
The screening evaluation consisted of demographic data, medical/surgical history with co-existing diseases, radiographic investigations, physical examination, psychological evaluation with Pain Patient Profile (P-3?), Visual Analogue Scale (VAS) pain scores, work status, Oswestry Disability Index 2.0, and lumbar spine range of motion with ARCON ROM computerized dual inclinometer system, based on AMA "Guides to the Evaluation of Permanent Impairment" validity criterion utilizing three consecutive measurements with ? 5? or ? 10% of mean value.
All patients in both groups were provided identical preparation. All procedures were performed using fluoroscopy in an ambulatory surgery center in sterile operating rooms by one physician (LM).
The procedure included appropriate preparation with intravenous access, pre-procedure antibiotic administration, sterile preparation, and appropriate sedation with fentanyl and midazolam. Access to the epidural space was obtained with a RK? needle. An epidurogram was obtained which identified filling defects and/or epidural fibrosis. Adhesiolysis was carried out in the intervention group utilizing the myeloscope? spinal endoscopic video-guided catheter system and introducer system, with final positioning of the fiberoptic endoscope on the side and level of the defect and the source of pain with an additional injection of contrast to identify adhesiolysis, followed by targeted injection of local anesthetic and steroid.
Following initial epidurography in the control group, a 0.9 mm guidewire was inserted through the needle, which was advanced under fluoroscopic guidance to S3 level. Then, a 2-mm ? 17.8-cm dilator with catheter (sheath) was passed over the guidewire again up to S3. At that time, a 0.8-mm fiberoptic spinal endoscopic video-guided system was introduced into the catheter through the valve and was advanced until the tip was positioned at the distal end of the catheter through the valve, as determined by video and fluoroscopic images not to exceed S3. Following this, 10 mL of 1% lidocaine and 6 mg to 12 mg of betamethasone or 40 mg to 80 mg of methylprednisolone were injected through the epiduroscope. Following the completion of the procedure, the endoscope was removed and appropriate sterile Bioclusive dressing was applied.
In the intervention group, following initial epidurography, a 0.9-mm guidewire was inserted through the needle (occasionally facilitated by a small incision with a #11 straight blade), which was advanced under fluoroscopic guidance to the level of suspected pathology. Following this, a 2-mm ? 17.8-cm dilator with catheter (sheath) was passed over the guidewire. Once the catheter was advanced to the tip of the guidewire, the wire was removed. A 0.8-mm fiberoptic spinal endoscopic video-guided system was introduced into the catheter through the valve and advanced until the tip was positioned at the distal end of the catheter, as determined by video and fluoroscopic images. In conjunction with gentle irrigation using normal saline, the catheter and fiberoptic myeloscope were manipulated and rotated in multiple directions, with visualization of the nerve roots at various levels. Painful nerve root was confirmed by endoscopic manipulation, based on pre-procedural clinical and radiographic evaluation. Adhesiolysis and decompression were carried out by distension of the epidural space with normal saline and by mechanical means utilizing the fiberoptic endoscope. Adhesiolysis was confirmed by injection of non-ionic contrast material (Omnipaque 240?) and an epidurogram was performed on at least two occasions. The volume of sodium chloride solution utilized for irrigation was closely monitored. The protocol limited the total volume of contrast and sodium chloride solution not to exceed 100 mL. Adhesiolysis was limited to L4, L5 or S1 levels, either unilaterally or bilaterally. Following completion of the procedure, 4 mL to 8 mL of lidocaine 1%, preservative free, mixed with either 6 mg or 12 mg of betamethasone or 40 mg or 80 mg of methylprednisolone was injected after assuring that there was no evidence of subarachnoid leakage of contrast. The injection of betamethasone or methylprednisolone was based on its availability in the market. Methylprednisolone was utilized if betamethasone was not available. If pathology was identified at multiple levels, the procedure was carried out at those levels, and the injectate was given in divided doses. If there was a question of subarachnoid leakage of the contrast, a Racz catheter? was passed into the epidural space, and a mixture of local anesthetic was injected very slowly in incremental doses, followed by injection of the steroid if satisfactory follow-up was obtained without any subarachnoid blockade. Following the injection of local anesthetic and steroid, the scope was removed and appropriate sterile Bioclusive dressing was applied.
No specific co-interventions were offered. Baseline drug therapy was allowed to be continued with no changes being made towards increasing opioids until after the unblinding and/or documented failure of intervention. However, opioid decreases were implemented based on improvement in functional status and reduction in pain following the interventions. Self-directed exercises as tolerated were also prescribed.
Outcomes were assessed at 3-month, 6-month, and 12-month intervals post-treatment with the Visual Analogue Scale (VAS) pain scale, Oswestry Disability Index 2.0, work status, opioid intake, range of motion measurement by ARCON ROM computerized evaluation, and psychological evaluation by P-3. They were compared to baseline within both groups and with each other at various time intervals. Duration of relief was judged to be short-term, if relief was less than 6 months. If relief lasted for at least 6 months, it was considered long-term. Significant relief was defined as pain relief of 50% or greater.
VAS was measured on a 10 cm scale. P-3 psychological evaluation [42] and Oswestry Disability Index 2.0 [43] were assessed by administration of appropriate questionnaires. Range of motion was evaluated by a certified physical therapist, blinded to the type of treatment. Based on P-3, scores of 55 or higher were considered positive for a diagnosis of depression, whereas, scores of 56 or higher were considered to provide the diagnosis of anxiety or somatization.
Opioid intake was determined as none, mild, moderate, or heavy based on the dosage, frequency and schedule of the drug as follows: Considered as mild was an intake of Schedule IV opioids, i.e., propoxyphene napsylate, pentazocine hydrochloride, tramadol hydrochloride up to a maximum of four times, or hydrocodone less than 40 mg per day; considered moderate was an intake of Schedule III opioids, i.e., hydrocodone, up to 40 mg per day; and considered heavy was an intake of Schedule II opioids, i.e., oxycodone, morphine, meperidine, transdermal fentanyl, and methadone, in any dosage.
Employment and work status (employed, unemployed, housewife, disabled, and retired) were determined from the pre-treatment and post-treatment work status. Only employed and unemployed patients were considered to be eligible for employment, whereas disabled patients and retired patients were considered not employable. Patients in the "housewife" category were considered neither employable nor unemployable.
Randomization was 2:3 with two patients randomized to the control group (Group I), for every three patients randomized to the spinal endoscopic adhesiolysis group (Group II). Randomization was performed by the statistician using a computer-generated random allocation sequence in blocks of 15 patients.
The random allocation was concealed from the physician doing the procedure and personnel in the operating room until the intervention. Randomization was not revealed to the personnel in the recovery room or to the reviewing physician. After treatment, the patient was never in contact with anyone with knowledge to the randomization assignment, until after the unblinding was performed.
Unblinding was considered at a patient's request and/or treatment was considered a failure at 3 months or later. All other patients were unblinded at 12 months. Patients were also given an option to discontinue or to withdraw from the study for any and all reasons. They were considered withdrawn if follow-up was lost.
An intent-to-treat analysis was performed by including all subjects by carrying forward the last observation.
Demographic data were analyzed by means of the Student's t test and the chi-squared test. Fischer's exact test was used wherever the expected value was less than five. For analyzing Outcome measurement based on Visual Analogue Scale (VAS) Report and Oswestry Disability Index, range of motion (ROM), depression, anxiety and somatization scores, student's t test (parametric) and The Mann-Whitney U test (non-parametric) were used to test mean differences between groups. A paired t test and Wilcoxon signed-rank test were used to compare pre-and post-treatment results for individual patients. When results from both parametric and non-parametric tests were similar, P values from the parametric tests were reported in the tables and text. Results were considered statistically significant if the P value was less than 0.05.
The study was conducted from January 2002 through December 2003. As per the protocol, initial results were published in 2003; this preliminary report included a 6 month follow up with 16 patients in caudal epidural steroid injection group, and 23 patients in spinal endoscopy group [30]. To facilitate this publication, results of two patients in the control group and 12 patients in the intervention group were unblinded by the statistician for purposes of the evaluation and preliminary publication. This unblinding was not revealed to investigators, other staff, and the participants of the study. Consequently, 39 patients reported at 6 months were also included in the present report.
A diagram illustrating flow of the trial is depicted as Figure 1. In the control group, one patient was lost to follow-up after 3 months. In the intervention group, two patients withdrew from the study. One patient experienced no improvement, withdrew from the study, and underwent further surgical intervention. The second patient in the intervention group reported no significant relief and withdrew from the study and refused further follow-up. Intent to treat analysis was performed by using baseline or last follow-up data in both groups. All patients received only one treatment during the study period. Patients were considered withdrawn if they received any other interventional techniques. Last follow-up was utilized for analysis with 3-month data at 6 months and 12 months in 15 patients, and 6-month data at 12 months in two patients in the control group. In the intervention group, baseline data was utilized in two patients. In the intervention group, of the 11 patients unblinded at 3 months, five of them participated in outcomes assessment at 6 months and 12 months while six of them participated only at 6 months assessment. Thus, 3 month assessment results were utilized at 6 months and 12 months, whereas the results of 6 month assessments were utilized at 12 months in eight patients (six patients from 3 month unblinding and two patients from 6 month unblinding).
Table 1 illustrates the demographic characteristics. All the patients presented with back and lower extremity pain. Most patients had pain with unilateral symptoms, while bilateral symptoms were seen in 12% of the patients in each group.
In the control group, of the four patients (12%) with bilateral back and lower extremity pain, two patients received 12 mg of betamethasone and two patients received 80 mg of methylprednisolone. Of the remaining 29 patients, 16 patients received 6 mg of betamethasone and 13 patients received 40 mg of methylprednisolone. The volume of contrast was 8.6 ? 1.25 mL with a range of 8 to 12 mL (Table 2).
In the intervention group, adhesiolysis was performed bilaterally in six patients (12%). Adhesiolysis was performed at one level in two patients, at two levels in 47 patients, and at four levels in one patient. Unilateral adhesiolysis was performed in only one patient at L4 level. No bilateral adhesiolysis was performed at L4. Most commonly, adhesiolysis was performed at L5 and S1. The volume of sodium chloride solution injected was 55.0 ? 11.07 mL with a range of 35 to 70 mL. The volume of contrast was 11.2 ? 2.74 mL with volumes ranging from 8 to 16 mL. There were no cases of subarachnoid blockade identified prior to injection of local anesthetic and steroid. Thus, although it was available as part of the protocol, a Racz catheter was not used for any patient procedure in the study. Twelve milligrams of betamethasone in 8 mL of 1% lidocaine was injected in two patients and 80 mg of methylprednisolone in 8 mL of 1% lidocaine was injected in four patients, 6 mg of betamethasone in 4 mL of 1% lidocaine was injected in 28 patients, and 40 mg of methylprednisolone in 4 mL of 1% lidocaine was injected in 16 patients (Table 2).
A significant proportion of patients in the spinal endoscopic adhesiolysis group showed pain relief compared to the control group, as well as compared to the baseline findings (Fig 2).
Significant pain relief (? 50%) in months was calculated for both groups. Calculations for all patients showed that significant relief was seen for 0.7 ? 0.73 months in the control group, whereas, 7.6 ? 4.7 months of relief was noted for the intervention group. Significant pain relief was longer in the intervention group. Duration of significant relief (? 50%) (mean ? SD) was 9.3 ? 3.6 months in patients considered as successful (40 of 50).
In the control group, the proportion of patients with significant relief greater than 50% at 1 month was 33%, and at 3 months, 6 months, and 12 months was 0. By contrast, in the intervention group relief was 90% at 1 month, 80% at 3 months, 56% at 6 months, and 48% at 12 months (Fig. 3).
Functional outcome measurement was carried out based on Oswestry Disability Index 2.0. Significant improvements were seen in the intervention group compared to baseline in the same group, as well as compared to the control group (Fig. 4).
Analysis of range of motion evaluations showed significant improvements in the intervention group compared to the baseline, as well as the control group at intervals of 3 months, 6 months, and 12 months (Table 3).
Table 4 illustrates psychological outcomes of depression, anxiety, and somatization derived from P-3 scores. Significant improvement was noted in psychological parameters in the intervention group compared to the control group, as well as to baseline status in the treatment group.
Patients were evaluated for opioid intake, which was rated from none to significant as described in the methods section. Significant opioid intake was 40% in Group II at the end of 12 months, compared to 74% at baseline. For Group I, significant opioid usage was 55% at 12 months, compared to 61% at baseline.
Evaluation of employment status showed that in the intervention group employment increased to 32% at 12 months from 2% at baseline as compared to 6% at baseline and at 12 months in the control group. As illustrated in Table 5, almost all the patients deemed employable in the intervention group were employed at 12 months, in contrast to no change noted in the control group. In addition, in the intervention group, eight patients disabled at baseline were also employed at 12 months. There were no patients in this study with active workers' compensation injury cases or litigation.
The blinding was judged to be satisfactory. Following the treatment, and within one hour prior to discharge, patients were asked what treatment they believed they had received. Twenty-six of 33 patients in Group I and 42 of 50 patients in Group II believed they had received spinal endoscopy. Two patients in Group I and two patients in Group II were unable to theorize as to which procedure they may have received. The remaining patients guessed the wrong treatment. There was no significant difference among the groups as to whether they believed they had received the endoscopy or epidural steroid injection.
There was one case of subarachnoid block in Group II, identified after completion of the procedure and injection of local anesthetic and steroid. No adverse effects were noted in this patient. There were no other adverse events noted.
This randomized, double-blind, controlled evaluation demonstrated that following spinal endoscopic adhesiolysis a significant proportion of patients with chronic, refractory low back and lower extremity pain experienced significant pain relief (? 50%) at 3 months (80%), 6 months (56%), and at 12 months (48%), compared to the control group with only 33% of patients showing improvement at 1 month, and none thereafter. Associated improvements in VAS scores, Oswestry Disability Index, range of motion, and psychological status were also noted as compared to baseline measurements and results of the control group. These results are important in that the patients in this study represented a subset of patients who have not only failed multiple conservative modalities of management but also lacked significant, or long-term, response to fluoroscopically-directed epidural steroid injections and one-day percutaneous adhesiolysis.
Numerous studies have evaluated the effectiveness of spinal endoscopic adhesiolysis [24-29,31]; however, these studies utilized heterogenous inclusion criteria. Igarashi et al [29] evaluated patients with degenerative lumbar spinal stenosis. Manchikanti et al [26] evaluated only patients with a history of previous surgical intervention. In another study, Manchikanti et al [27] included patients who had not previously undergone surgery (a total of 16%). Dashfield et al [31] included only non-surgical patients. Geurts et al [24] reported results of spinal endoscopic adhesiolysis in 20 patients suffering with chronic low back pain. They reported > 50% reduction in pain in 40% of the patients at 3 months, and 35% at 6, 9, and 12 months. Richardson et al [25] reported results in 38 patients, with 19 of those patients identified with failed back surgery syndrome. They reported significant improvement based on Visual Analogue Scale and functional abilities. However, they have not reported data with regards to the proportion of patients with sustained relief at various time periods. Manchikanti et al [26,27] in two different studies, reported 75% relief at 3 months, 40% at 6 months, and 22% at 12 months in post-lumbar laminectomy patients; and, in a heterogenous group of patients including both post laminectomy and non-surgical patients, 52% of the patients at 3 months, 21% of the patients at 6 months, and 7% of the patients after 12 months. Igarashi et al [29] evaluated 58 patients with degenerative lumbar spinal stenosis, dividing them into two groups based on the presenting symptoms of either a monosegmental group (n = 34) or a multisegmental group (n = 24). They showed that relief of low back pain was observed up to 12 months after epiduroscopy in both groups, whereas relief of leg pain was evident up to 12 months after epiduroscopy in the monosegmental group, and up to 3 months after epiduroscopy in the multisegmental group. Dashfield et al [31] compared caudal epidural steroid injections with targeted steroid placement during spinal endoscopy for chronic sciatica in a prospective, randomized, double-blind trial. They randomized 60 patients with a 6-to 18-month history of sciatica to either a targeted epidural local anesthetic and steroid placement with a spinal endoscope, or caudal epidural local anesthetic and steroid placement. They defined sciatica as pain in the distribution of lumbar nerve root, accompanied by neurosensory and motor deficits, with or without back pain. They excluded patients with history of previous spinal surgery, coagulopathy, progressive motor neuron disorders or peripheral vascular disease, and patients receiving epidural corticosteroid injections within 3 months. No significant differences were found between the groups for any of the measures at any time. However, there were significant differences within both groups compared with pre-treatment values. The results of the present evaluation may not be compared to either the studies by Igarashi et al [29] or by Dashfield et al [31].
Igarashi et al [29] evaluated patients only with spinal stenosis. One-day percutaneous adhesiolysis also was shown to be effective in refractory spinal stenosis [44]. However, Igarashi et al [29] did not treat their patients with spinal stenosis with percutaneous adhesiolysis, which is considered as a safer and more effective procedure. The study by Dashfield et al [31] was performed in patients who were not expected to have epidural fibrosis and who had not been treated with either epidural steroid injections or with 1-day or 3-day percutaneous adhesiolysis. Consequently, there was no significant difference noted between caudal epidural steroid injections and targeted steroid placement with spinal endoscopy. In clinical practice in the United States, invasive intervention with spinal endoscopy as an initial treatment is not widely accepted.
The most common and worrisome complications of spinal endoscopy with adhesiolysis and injection of corticosteroids are related to dural puncture, spinal cord compression, intravascular injection, vascular injury, cerebral vascular or pulmonary embolus, infection, steroids, instrumentation with endoscope, and administration of high volumes of fluids potentially resulting in excessive epidural hydrostatic pressures, resulting in blindness, neurapraxia, numbness, intravascular injections, brain damage, and death [23-30,45-58]. Even though no major complications have been noted in this study, it is recommended that all precautions be undertaken, along with exhaustion of other modalities of treatments prior to embarking on spinal endoscopic adhesiolysis considering the safety and cost. The cost of the endoscope and the procedure are higher than either caudal epidural steroid injections or 1-day or 3-day percutaneous adhesiolysis procedure. The safety and effectiveness of 1-day and 3-day percutaneous adhesiolysis has been demonstrated [21,22].
The present evaluation utilized early unblinding in some patients, did not include a placebo group, and adapted a randomization ratio of 2:3 instead of 1:1. Considering the difficulties of recruiting patients to a double-blind trial, the authors considered the best way to recruit patients and give them a reasonable level of comfort was to offer additional treatment(s) if they failed the study, rather than allowing them to suffer for a year. Based on this allocation, the authors managed to include an acceptable number of patients. The control group for the study was not a true placebo group since interventions of caudal epidural steroid injections were used; nevertheless, the injections were ineffective in these patients. One of the objectives of the study was to demonstrate whether epidural steroid injections administered after adhesiolysis are effective as opposed to traditional or fluoroscopically-directed epidural steroid injections. In addition, this also served to provide a level of comfort to patients enrolled in the study since they knew they would receive some type of active treatment rather than a placebo. The authors believed that this type of randomization with a control group receiving standard treatment to be more effective and provide optimal results. A randomization process with a 2:3 ratio was selected to convince patients to enroll in the study, as they would have a higher chance of being included in a treatment group rather than a control group. The statistical validity was maintained throughout the study and an intent-to-treat analysis was incorporated in the study.
Trials of healthcare interventions are often described as either explanatory or pragmatic [40,41]. Explanatory trials generally measure efficacy ? the benefit a treatment produces under ideal conditions. Consequently, explanatory trials often use carefully-defined subjects in a well-controlled research setting. By contrast, pragmatic trials, also known as practical clinical trials, measure effectiveness ? benefit the treatment produces in routine clinical practice. Tunis et al [40] commented on the prevalence and significance of gaps in knowledge about clinical effectiveness of interventions and suboptimal evidence available to answer the critical questions. Most systematic reviews performed in interventional pain management include studies providing data not applicable to patients treated in typical practice settings. Consequently, limited quantity and quality of available scientific information impedes the efforts of public and private health insurers in developing evidence-based coverage policies for many new and existing technologies [59,60].
The substantial differences between explanatory and pragmatic trials illustrate a paradigm shift to clinical practice. Patient selection in an explanatory approach is based on the principles of homogenous population, primarily aiming to further scientific knowledge. However, in a pragmatic or practical clinical trial, the design reflects variations between patients that occur in real life clinical settings, and aims to inform choices between treatments. The authors consider this trial to be close to pragmatic or practical rather than explanatory. Even with appropriate randomization, the major focus of clinical research in the modern era of medicine, multiple other sources of bias may affect results. In this study, independent assessment was utilized. However, without a placebo treatment, in pragmatic approaches, the treatment response is the total difference between two treatments, including both treatment and associated placebo effects, as this will best reflect the likely clinical response in practice [22,30,58,61-65]. Practical clinical trials are expected to best address questions about the risks, benefits, and cost of an intervention as they would occur in routine clinical practice [41]. Thus, the most distinctive features of practical clinical trials are that they select patients from practices, either simulating actual practices or actual clinical practices. In addition, practical clinical trials often are designed to compare viable alternative clinical strategies. This study achieves both the distinctive features of practical clinical trials by selecting the population from an actual clinical practice and also by comparing viable alternative clinical strategies.
This procedure may be considered as a replacement for large bore catheter for percutaneous adhesiolysis, as we have not derived any diagnostic information. However, visualization of the scar tissue and freeing of the scar tissue from the nerve root may provide some additional benefit. The present day available catheters for percutaneous adhesiolysis are smaller bore. Consequently, spinal endoscopy with larger bore and improved flexibility appears to have a role. Percutaneous adhesiolysis has been shown to be an effective and safe procedure [21,22,45,46]. However this study went beyond percutaneous adhesiolysis and selected the patients after insufficient response after 1-day percutaneous adhesiolysis.
The issue remains for the patients who have had successful relief for 6 months or 12 months with regards to further treatment when pain returns and functional status deteriorates. Based on the present literature, with proper indications and precautions, the procedure may be repeated after approximately 6 months. In addition, the authors believe that even if patients have not responded previously to these procedures, if they have responded initially to spinal endoscopy, they may respond to 1-day or 3-day percutaneous adhesiolysis or even caudal epidural steroid injections. However, published data is not available at present to support this assumption and controlled trials are recommended to evaluate this postulate. Additional effect from spinal endoscopic adhesiolysis may be dependent on hydrostatic pressures created by the administration of sodium chloride solution which is not the case with lesser volume percutaneous adhesiolysis. However, percutaneous adhesiolysis also may be modified to accommodate this feature.
This controlled trial demonstrates that spinal endoscopic adhesiolysis reduces pain and improves functional and psychological status without adverse effects up to 12 months.
The author(s) declare that they have no competing interests.
LM conceived and designed the study, processed the data and wrote the manuscript.
MVB participated in the study's design and revised the manuscript.
JJR participated in its design and collected the clinical data.
VSP performed the statistical analysis.
KSD collected the clinical data.
CDM collected the clinical data.
DEB participated in the procedure.
SRW participated in the procedure.
All authors read and approved the final manuscript.
The pre-publication history for this paper can be accessed here:
|Alkalay RN,Kim DH,Urry DW,Xu J,Parker TM,Glazer PA. Prevention of postlaminectomy epidural fibrosis using bioelastic materialsSpine 2003;28:1659–1665. [pmid: 12897488] [doi: 10.1097/00007632-200308010-00006]
|Gil K,Frymoyer JW. Frymoyer JWThe management of treatment failure after decompressive surgery, The Adult Spine: Principles and Practice 1991New York: Lippincott-Raven Publishers; :849–870.
|Fritsch EW,Heisel J,Rupp S. The failed back surgery syndrome. Reasons, intraoperative findings, and long-term results: A report of 182 operative treatmentsSpine 1996;21:626–633. [pmid: 8852320] [doi: 10.1097/00007632-199603010-00017]
|Ross JS,Robertson JT,Frederickson RC,Petrie JL,Obuchowski N,Modic MT,deTribolet N. Association between peridural scar and recurrent radicular pain after lumbar discectomy: magnetic resonance evaluationNeurosurgery 1996;38:855–861. [pmid: 8692415] [doi: 10.1097/00006123-199604000-00053]
|Hoyland JA,Freemont AJ,Jayson MI. Intervertebral foramen venous obstruction. A cause of periradicular fibrosis?Spine 1989;14:558–568. [pmid: 2749370]
|Rydevik BL. The effects of compression on the physiology of nerve rootsJ Manipulative Physiol Ther 1992;15:62–66. [pmid: 1740654]
|Songer M,Ghosh L,Spencer D. Effects of sodium hyaluronate on peridural fibrosis after lumbar laminectomy and discectomySpine 1990;15:550–554. [pmid: 2402695]
|North RB,Campbell JN,James CS,Conover-Walker MK,Wang H,Piantadosi S,Rybock JD,Long DM. Failed back surgery syndrome: 5-year follow-up in 102 patients undergoing repeated operationNeurosurgery 1991;28:685–690. [pmid: 1831546] [doi: 10.1097/00006123-199105000-00008]
|Dullerud R,Graver V,Haakonsen M,Haaland AK,Loeb M,Magnaes B. Influence of fibrinolytic factors on scar formation after lumbar discectomy. A magnetic resonance imaging follow-up study with clinical correlation performed 7 years after surgerySpine 1998;23:1464–1469. [pmid: 9670398] [doi: 10.1097/00007632-199807010-00007]
|Pawl RP. Arachnoiditis and epidural fibrosis: The relationship to chronic painCurr Rev Pain 1998;2:93–99.
|Annertz M,J?nsson B,Stromquist B,Holtas S. No relationship between epidural fibrosis and sciatica in the lumbar postdiscectomy syndrome: A study with contrast-enhancement magnetic resonance imagery in symptomatic and asymptomatic patientsSpine 1995;20:449–453. [pmid: 7747228]
|Cervellini P,Curri D,Volpin L,Bernardi L,Pinna V,Benedetti A. Computed tomography of epidural fibrosis after discectomy. A comparison between symptomatic and asymptomatic patientsNeurosurgery 1988;6:710–713. [pmid: 3216968]
|Coskun E,Suzer T,Topuz O,Zencir M,Pakdemirli E,Tahta K. Relationships between epidural fibrosis, pain, disability, and psychological factors after lumbar disc surgeryEur Spine J 2000;9:218–223. [pmid: 10905440] [doi: 10.1007/s005860000144]
|Benoist M,Ficat C,Baraf P,Cauchoix J. Postoperative lumbar epiduro-arachnoiditis: Diagnosis and therapeutic aspectsSpine 1980;5:432–436. [pmid: 6450453]
|Cauchoix J,Ficat C,Girard B. Repeat surgery after disc excisionSpine 1978;3:256–259. [pmid: 152469]
|Phillips FM,Cunningham B. Managing chronic pain of spinal origin after lumbar surgerySpine 2002;27:2547–2553. [pmid: 12435991] [doi: 10.1097/00007632-200211150-00029]
|Larocca H,MacNab I. The laminectomy membraneJ Bone Joint Surg Br 1974;56B:545–550. [pmid: 4421702]
|McCarron RF,Wimpee MW,Hudkins PG,Laros GS. The inflammatory effects of nucleus pulposus: A possible element in the pathogenesis of low back painSpine 1987;12:760–764. [pmid: 2961088]
|Cooper RG,Freemont AJ,Hoyland JA,Jenkins JP,West CG,Illingworth KJ,Jayson MI. Herniated intervertebral disc-associated periradicular fibrosis and vascular abnormalities occur without inflammatory cell infiltrationSpine 1995;20:591–598. [pmid: 7604329]
|Parke WW,Watanabe R. Adhesions of the ventral lumbar dura. Adjunct source of discogenic pain?Spine 1990;15:300–303. [pmid: 2141188]
|Heavner JE,Racz GB,Raj P. Percutaneous epidural neuroplasty. Prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidaseReg Anesth Pain Med 1999;24:202–207. [pmid: 10338168] [doi: 10.1016/S1098-7339(99)90128-1]
|Manchikanti L,Rivera JJ,Pampati V,Damron KS,MCManus CD,Brandon DE,Wilson SR. One-day lumbar epidural adhesiolysis and hypertonic saline neurolysis in treatment of chronic low back pain: A randomized, double-blind trialPain Physician 2004;7:177–186. [pmid: 16868590]
|Manchikanti L,Singh V. Epidural lysis of adhesions and myeloscopyCurr Pain Headache Rep 2002;6:427–435. [pmid: 12413401]
|Geurts JW,Kallewaard JW,Richardson J,Groen GJ. Targeted methylprednisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica: A prospective, 1-year follow-up studyReg Anesth Pain Med 2002;27:343–352. [pmid: 12132057] [doi: 10.1053/rapm.2002.27175]
|Richardson J,McGurgan P,Cheema S,Prasad R,Gupta S. Spinal endoscopy in chronic low back pain with radiculopathy: A prospective case seriesAnaesthesia 2001;56:454–460. [pmid: 11350333] [doi: 10.1046/j.1365-2044.2001.01524-3.x]
|Manchikanti L,Pampati V,Bakhit CE,Pakanati RR. Non-endoscopic and endoscopic adhesiolysis in post lumbar laminectomy syndrome. A one-year outcome study and cost effective analysisPain Physician 1999;2:52–58. [pmid: 16906216]
|Manchikanti L. The value and safety of epidural endoscopic adhesiolysisAmer J Anesthesiol 2000;27:275–279.
|Krasuski P,Poniecka AW,Gal E,Wali A,Truong A,Hart AM. Epiduroscopy: Review of techniques and resultsPain Clinic 2001;13:71–76. [doi: 10.1163/15685690152385772]
|Igarashi T,Hirabayashi Y,Seo N,Saitoh K,Fukuda H,Suzuki H. Lysis of adhesions and epidural injection of steroid/local anesthetic during epiduroscopy potentially alleviate low back leg pain in elderly patients with lumbar spinal stenosisBr J Anesth 2004;93:181–187. [doi: 10.1093/bja/aeh201]
|Manchikanti L,Rivera J,Pampati VS,Damron KS,Beyer CD,Brandon DE,Wilson SR. Spinal endoscopic adhesiolysis in the management of chronic low back pain: A preliminary report of a randomized, double-blind trialPain Physician 2003;6:259–268. [pmid: 16880869]
|Dashfield AK,Taylor MB,Cleaver JS,Farrow D. Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double-blind trialBr J Anaesth 2005;94:514–519. [pmid: 15695544] [doi: 10.1093/bja/aei084]
|Systems to rate the strength of scientific evidenceEvidence Report/Technology Assessment No 47 University of North Carolina; Agency for Healthcare Research and Quality AHRQ Publication No 02-E016. 2002
|The Standards of Reporting Trials GroupA proposal for structured reporting of randomized controlled trialsJAMA 1994;272:1926–1931. [pmid: 7990245] [doi: 10.1001/jama.272.24.1926]
|van Tulder M,Furlan A,Bombardier C,Bouter L. Editorial Board of the Cochrane Collaboration Back Review Group. Updated method guidelines for systematic reviews in the Cochrane collaboration back review groupSpine 2003;28:1290–1299. [pmid: 12811274] [doi: 10.1097/00007632-200306150-00014]
|Nelemans PJ,deBie RA,deVet HCW. Injection therapy for subacute and chronic benign low back painSpine 2001;26:501–515. [pmid: 11242378] [doi: 10.1097/00007632-200103010-00014]
|Niemisto L,Kalso E,Malmivaara A,Seitsalo S,Hurri H,Cochrane Collaboration Back Review GroupRadiofrequency denervation for neck and back pain: a systematic review within the framework of the Cochrane collaboration back review groupSpine 2003;28:1877–1888. [pmid: 12923479] [doi: 10.1097/01.BRS.0000084682.02898.72]
|Koes BW,Bouter LM,van der Heijden GJMG. Methodological quality of randomized clinical trials on treatment efficacy in low back painSpine 1995;20:228–235. [pmid: 7716630]
|Koes BW,Scholten RJPM,Mens JMA,Bouter LM. Epidural steroid injections for low back pain and sciatica. An updated systematic review of randomized clinical trialsPain Digest 1999;9:241–247.
|van Tulder MW,Koes BW,Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: A systematic review of randomized controlled trials of the most common interventionsSpine 1997;22:2128–2156. [pmid: 9322325] [doi: 10.1097/00007632-199709150-00012]
|Tunis SR,Stryer DB,Clancy CM. Practical Clinical Trials. Increasing the value of clinical research for decision making in clinical and health policyJAMA 2003;290:1624–1632. [pmid: 14506122] [doi: 10.1001/jama.290.12.1624]
|Roland M,Torgerson DJ. What are pragmatic trials?BMJ 1998;316:285. [pmid: 9472515]
|Tollison CD,Langely JC. Pain Patient Profile (P-3?) Manual. 1995National Computer Systems, Minneapolis;
|Fairbank JC,Pynsent PB. The Oswestry Disability IndexSpine 2000;25:2940–2953. [pmid: 11074683] [doi: 10.1097/00007632-200011150-00017]
|Manchikanti L,Pampati VS,Rivera JJ,Fellows B,Beyer CD,Damron KS,Cash KA. Effectiveness of percutaneous adhesiolysis and hypertonic saline neurolysis in refractory spinal stenosisPain Physician 2001;4:366–373. [pmid: 16902683]
|Manchikanti L,Bakhit CE. Percutaneous lysis of epidural adhesionsPain Physician 2000;3:46–64. [pmid: 16906207]
|Viesca C,Racz G,Day M. Spinal techniques in pain management: lysis of adhesionsAnesthesiol Clin North Am 2003;21:745–766. [doi: 10.1016/S0889-8537(03)00088-9]
|Saberski L,Brull S. Spinal and epidural endoscopy: A historical reviewYale J Bio Med 1995;68:7–15. [pmid: 8748461]
|Bromage RP,Benumof JL. Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesiaReg Anesth Pain Med 1998;23:104–107. [pmid: 9552788] [doi: 10.1016/S1098-7339(98)90120-1]
|MacLean CA,Bachman DT. Documented arterial gas embolism after spinal epidural injectionAnn Emerg Med 2001;38:592–595. [pmid: 11679875] [doi: 10.1067/mem.2001.118008]
|Mateo E,Lopez-Alarcon MD,Moliner S,Calabuig E,Vivo M,De Andres J,Grau F. Epidural and subarachnoid pneumocephalus after epidural techniqueEur J Anesthesiol 1999;16:413–417. [doi: 10.1046/j.1365-2346.1999.00495.x]
|Katz JA,Lukin R,Bridenbaugh PO,Gunzenhauser L. Subdural intracranial air: An unusual cause of headache after epidural steroid injectionAnesthesiology 1991;74:615. [pmid: 1825771]
|Knight JW,Cordingley JJ,Palazzo MG. Epidural abscess following epidural steroid and local anesthetic injectionAnaesthesia 1997;52:576–578. [pmid: 9203886] [doi: 10.1111/j.1365-2044.1997.156-az0161.x]
|Tabandeh H. Intraocular hemorrhages associated with endoscopic spinal surgeryAm J Ophthalmol 2000;129:688–690. [pmid: 10844075] [doi: 10.1016/S0002-9394(99)00470-5]
|Kusher FH,Olson JC. Retinal hemorrhage as a consequence of epidural steroid injectionArch Opthalmol 1995;113:309–313.
|Purdy EP,Gurjit SA. Vision loss after lumbar epidural steroid injectionAnesth Analg 1998;86:119–122. [pmid: 9428864] [doi: 10.1097/00000539-199801000-00024]
|Sandberg DI,Lavyne MH. Symptomatic spinal epidural lipomatosis after local epidural corticosteroid injections: Case reportNeurosurgery 1999;45:162–165. [pmid: 10414580] [doi: 10.1097/00006123-199907000-00037]
|Manchikanti L. Role of neuraxial steroids in interventional pain managementPain Physician 2002;5:182–199. [pmid: 16902669]
|Manchikanti L,Staats PS,Singh V,Schultz DM,Vilims BD,Jasper JF,Kloth DS,Trescot AM,Hansen HC,Falasca TD,Racz GB,Deer T,Burton AW,Helm S,Lou L,Bakhit CE,Dunbar EE,Atluri SL,Calodney AK,Hassenbusch S,Feler CA. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal painPain Physician 2003;6:3–80. [pmid: 16878163]
|Garber AM. Evidence-based coverage policyHealth Aff (Milwood) 2001;20:62–82. [doi: 10.1377/hlthaff.20.5.62]
|Tunis R,Kang JL. Improvements in Medicare coverage of new technologyHealth Aff (Milwood) 2001;20:83–85. [doi: 10.1377/hlthaff.20.5.83]
|Manchikanti L,Manchikanti KN,Damron KS,Pampati VS. Effectiveness of cervical medial branch blocks in chronic neck pain: A prospective outcome studyPain Physician 2004;7:195–202. [pmid: 16868592]
|Manchikanti L,Pampati VS,Bakhit CE,Rivera JJ,Beyer CD,Damron KS,Barnhill RC. Effectiveness of lumbar facet joint nerve blocks in chronic low back pain: A randomized clinical trialPain Physician 2001;4:101–117. [pmid: 16906173]
|Manchikanti L,Cash KA,Moss TL,Rivera J,Pampati VS. Risk of whole body radiation exposure and protective measures in fluoroscopically guided interventional techniques: A prospective evaluationBMC Anesthesiol 2003;3:2. [pmid: 12904269] [doi: 10.1186/1471-2253-3-2]
|Manchikanti L,Pampati VS,Rivera JJ,Beyer CD,Damron KS,Barnhill RC. Caudal epidural injections with Sarapin or steroids in chronic low back painPain Physician 2001;4:322–335. [pmid: 16902678]
|Bogduk N,Karasek M. Two-year follow-up of a controlled trial of intradiscal electrothermal annuloplasty for chronic low back pain resulting from internal disc disruptionSpine J 2002;2:343–350. [pmid: 14589465] [doi: 10.1016/S1529-9430(02)00409-6]
Demographic characteristics
|Group I
|Group II
|Number of patients
|Age (Years)
|Mean ? SD
|47 ? 9.4
|50 ? 9.0
|54% (18)
|36% (18)
|46% (15)
|64% (32)
|Height (Inches)
|Mean ? SD
|66 ? 3.6
|66 ? 3.5
|Weight (Lbs)
|Mean ? SD
|181 ? 42.4
|174 ? 36.8
|Duration of pain (years)
|Mean ? SD
|12.4 ? 5.9
|11.8 ? 6.5
|Mode of onset of the pain
|39% (13)
|46% (23)
|61% (20)
|54% (27)
|Back and lower extremity pain
|100% (33)
|100% (50)
|Bilateral pain
|12% (4)
|12% (6)
|History of previous surgery
|73% (24)
|84% (42)
|Epidural fibrosis on MRI
|73% (24)
|84% (42)
|Disc herniation on MRI
|12% (4)
|10% (5)
Description of procedural characteristics
|Group I 33
|Group II 50
|?12 mg
|6% (2)
|4% (2)
|?6 mg
|48% (16)
|56% (28)
|55% (18)
|60% (30)
|?80 mg
|6% (2)
|8% (4)
|?40 mg
|39% (13)
|32% (16)
|45% (15)
|40% (20)
|Contrast in mL
|Mean ? SD
|8.6 ? 1.25
|11.2 ? 2.74
|8 ? 12
|8 ? 16
|Sodium chloride solution for irrigation in mL
|Mean ? SD
|55.0 ? 11.07
|35 ? 70
() indicates number of patients
Analysis of range of motion evaluation
|3 months
|6 months
|12 months
|Group I
|Group II
|Group I
|Group II
|Group I
|Group II
|Group I
|Group II
|Flexion (Normal 60?)
|Mean ? SD
|25.4 ? 10.0
|25.9 ? 11.4
|26.6 ? 10.3
|35.8*# ? 11.7
|25.8 ? 10.4
|36.7*# ? 13.7
|25.6 ? 10.3
|35.7*# ? 14.4
|Extension (Normal 25?)
|Mean ? SD
|9.7 ? 3.9
|9.0 ? 3.3
|10.9 ? 5.1
|14.7*# ? 5.3
|10.5 ? 5.1
|15.8*# ? 6.5
|10.9 ? 5.3
|16.3*# ? 7.0
|Lateral Flexion (Normal 25?)
|Mean ? SD
|8.1 ? 2.9
|8.4 ? 2.8
|7.9 ? 3.0
|14.0*# ? 5.3
|7.8 ? 3.0
|14.6*# ? 6.1
|7.7 ? 2.8
|15.1*# ? 6.8
* Indicates significant difference with Group I (P = 0.002)
# Indicates significant difference within the Group compared to baseline (P = 0.001)
Analysis of psychological status
|12 months
|Group I
|Group II
|Group I
|Group II
|Diagnosis (? 55)
|61% (20)
|68% (34)
|58% (19)
|Score Mean ? SD
|56.9 ? 8.8
|57.0 ? 9.9
|55.5 ? 10.6
|47.8*# ? 10.4
|Diagnosis (? 56)
|58% (19)
|62% (31)
|55% (18)
|Score Mean ? SD
|55.6 ? 10.6
|55.9 ? 11.9
|54.9 ? 9.9
|46.8*# ? 12.1
|Diagnosis (? 56)
|58% (19)
|74% (34)
|52% (17)
|30% (18)
|Score Mean ? SD
|55.4 ? 8.9
|56.6 ? 11.4
|55.9 ? 10.4
|47.8*# ? 12.3
* Indicates significant difference with Group I (P = < 0.05)
# Indicates significant difference with Baseline values within the Group (P = < 0.001)
Change in proportion of patients with employment status
|Employment Status
|Group I
|Group II
|At 12 months
|At 12 months
|2 (6%)
|2 (6%)
|1 (2%)
|16 (32%)*
|2 (6%)
|2 (6%)
|8 (16%)
|1 (2%)
|2 (6%)
|2 (6%)
|1 (2%)
|1 (2%)
|26 (79%)
|26 (79%)
|38 (76%)
|30 (60%)
|Over 65 (yrs)
|1 (3%)
|1 (3%)
|2 (4%)
|2 (4%)
*Indicates significant difference (P < 0.01)
Article Categories:
Previous Document: Further evidence for increased macrophage migration inhibitory factor expression in prostate cancer.
Next Document: Chiropractic as spine care: a model for the profession.


text: On Wed, 9 Jul 1997 13:31:46 -0400 (EDT) email@example.com (Brian Hechinger ) wrote: > > fsirand(8) is a program that randomizes the inode generation numbers on > > ffs file systems. > > and what exactly is the benefit of doing this?? To reduce the possibility of guessing a file generation number for purposes of spoofing an NFS file handle. Jason R. Thorpe firstname.lastname@example.com NASA Ames Research Center Home: 408.866.1912 NAS: M/S 258-6 Work: 415.604.0935 Moffett Field, CA 94035 Pager: 415.428.6939

subset: commoncrawl


text:
added link to it translation + minor fixes -
← Revision 4 as of 2012-12-31 20:11:14 → ⇥
add link to french translation
|Deletions are marked like this.
|Additions are marked like this.
|Line 3:
|Line 3:
|~-[[DebianWiki/EditorGuide#translation|Translation(s)]]: English - [[it/ImageMetaData|Italiano]] -~
|~-[[DebianWiki/EditorGuide#translation|Translation(s)]]: English - [[fr/ImageMetaData|Français]] - [[it/ImageMetaData|Italiano]] -~
Translation(s): English - Français - Italiano
Image MetaData
Working with image files (photos, etc.) often requires storing information about the files. There are already a number of storage formats to achieve this. There are also a number of packages working with these formats. The intention of this page is to document which programs work with each other. Please extend it if you have knowledge about a specific program.
You can find details about this format at Wikipedia's page on XMP. This format is embedded in a number of image formats. For image formats that do not support embedding the metadata, it can be stored in a file with extension "xmp" next to the image file.
Package info: geeqie
Supports two different internal plaintext formats in ~/.geeqie/metadata (old) and ~/.local/share/geeqie/metadata (new).
Supports reading and writing XMP.
Supports saving metadata in a .metadata directory next to the images.
When searching for keywords geeqie needs to traverse the filesystem tree, so searching can be slow.
Package info: f-spot
Stores metadata in a sqlite3 database located at ~/.config/f-spot/photos.db.
Package info: shotwell
Stores metadata in a sqlite3 database.
Package info: digikam
Supports XMP.


text:
Female Bradenton Escorts
See also:
Cape Coral
Fort Lauderdale
Miami Beach
Pompano Beach
Local and travelling female escorts from Bradenton are advertised in this category. We list adult personals of female Bradenton escorts here, to change escort gender and location use navigation links above. Bradenton escorts are welcome to place ads here. Bradenton hobbyists can choose from many independants, escort agencies and private entertainers working in Bradenton. Feel free to review and contact Bradenton escorts here!
No Matches Found - Try to Broaden Your Search Terms!
Local escorts from Bradenton city are listed here. Our site features various adult service and escort personals: Bradenton blonde escort personals, Bradenton brunette escort personals, Bradenton VIP escort service personals, Bradenton exotic escort service personals, Bradenton shemale escort personals, Bradenton models personals. We also list bachelor party girls and private entertainers in Bradenton, Bradenton GFE, fetish, BDSM & fantasy providers, as well as local Bradenton latin, asian and black adult entertainers.Boca Raton Escorts Boynton Beach Escorts Bradenton Escorts Brandon Escorts Cape Coral Escorts Clearwater Escorts Coral Springs Escorts Daytona Beach Escorts Englewood Escorts Fort Lauderdale Escorts Fort Myers Escorts Fort Walton Beach Escorts Gainesville Escorts Hialeah Escorts Hollywood Escorts Hudson Escorts Jacksonville Escorts Lake City Escorts Lake Worth Escorts Miami Escorts Miami Beach Escorts Miami Gardens Escorts Miramar Escorts Naples Escorts North Miami Beach Escorts Orlando Escorts Palm Bay Escorts Palm Beach Gardens Escorts Pembroke Pines Escorts Pompano Beach Escorts Port Orange Escorts Port Saint Lucie Escorts Riverview Escorts Saint Petersburg Escorts Sanford Escorts Sarasota Escorts Tallahassee Escorts Tampa Escorts West Palm Beach Escorts Winter Haven Escorts


text:
I love Freelancing. I love everything about freelancing. The best thing about freelancing? FREEDOM! My life is changed when I started freelancing and I love the changes!
Here's how freelancing has changed my life, so far:
Time Management
I think this is the most important aspect of all. I can manage time better when I get to control my own working hours. I get to do more every day!
Health Improvement
I used to get ill really often when I was working in retail, and it was terrible (who wants to get ill anyway?). I spent quite a fortune on medical expenses and I hated it. Now, my health has improved tremendously, physically and mentally. Truly loving my life!
Relationship Improvement
I hardly had any time to spend with my family when I was working in retail due to the long working hours but now I get to hang out with family and friends all the time. It is very important for me to spend time with my parents (after all, we are not getting any younger!).
Personal Growth
I have always wanted to study Psychology and I got the chance two years after I started freelancing. I am taking it slow and steady but I am definitely getting there! Apart from that, I have learned so much from mentors around the world such as Problogger. I truly enjoyed the experience and happy to gain more knowledge every day.
New Opportunities
Freelancing has opened many doors for me, and it never ceases to amaze me. It is a wonderful journey and I get to meet many new friends around the world.
Freelancing has much to offer to those who seek freedom and change of lifestyle. If you are considering a change of career, it is never too late to start freelancing.
The post How Freelancing Changed My Life appeared first on Writing Consultation.
This post first appeared on Writing Consultation, please read the originial post: here


text:
D273THCS Four-Wire Smoke/Heat Detector with Auxiliary Relay and Sounder. Four-wire smoke detector with a 135°F (57°C) heat sensor, an auxiliary relay, and a sounder.
This detector model is UL Listed and works with commercial fire protective signaling and household fire warning systems. Detects smoke particles produced during wood, paper, and fabric combustion. Sounders produce 85 dB at 10 ft (3 m). This detector model use an infrared (IR) LED light source and a silicon photodiode to measure light in a chamber. A fine screen covers the chamber to deter insects and reduce dust accumulation and nuisance alarms. During a fire, smoke particles reflect light onto the photodiode. When the photodiode measurements exceed the alarm threshold, the detector signals an alarm condition. After the alarm condition clears, interrupt power at the control panel to reset the detector. When a D132B Reversing Relay Module is used, the LED does not latch on alarm.
|D273 Series-Data Sheet (Size: 259.1 KB)
|D273 Series-Installation Instructions (Size: 415.3 KB)


text:
When we last left Boniface and Mercy, they had just agreed on a business deal. Mercy and the other members of her investment club would give Boniface $10,000 for the purpose of opening a new shop in a promising location near a new textile factory.
In return, Boniface would give the club a 10% ownership stake in his business, SmileSave Supermarkets. You can read Part 1 of the story here.
Let's see how the venture fared since then.
Growth Accelerates
Boniface wasted no time in deploying the injection of capital from the investment club. He hired builders and purchased cinder block, concrete, and corrugated iron the very next day. Within two months he had a tidy little road-side store.
The new location performed extremely well, just as Boniface had forecast. Customers filled the shop thanks to its fair prices and the variety of goods it had for sale. And, just like at the other SmileSave Supermarkets, Boniface's employees greeted every customer warmly as they entered the store.
A Disagreement Over Dividends
Soon, the day arrived for Boniface to deliver SmileSave's first quarterly financial report to the teachers' investment club. He was nervous as he put on his jacket and tie. He hoped that Mercy and the others would be pleased with their investment.
Boniface and the teachers gathered in an empty classroom after the students had been dismissed. He greeted them all warmly and proceeded to detail SmileSave's activities over the preceding three months. He told them its sales figures. Its expenses. Its assets. And its profits.
When Boniface announced that SmileSave had earned $4,000 during the quarter, Isaac, the science teacher jumped from his seat with glee.
"This is fantastic!" he exclaimed. "We will recoup our $10,000 investment in no time!"
Mercy, the math teacher, turned in her seat to face him, "But, Isaac, remember that we own just 10% of SmileSave. Boniface owns the other 90%. So, our portion of the earnings is $400 – not $4,000."
Isaac slowly sat back down in his chair. "Hmm… $400 for the investment club. And there are 10 of us who are members of the club. That means each of us receives just $40." The other teachers murmured.
"Not exactly," said Boniface nervously as he cleared his throat, "SmileSave must keep most of these profits in order to grow, so I am proposing a dividend of $1000 – not $4000."
The room fell into a stunned silence.
"But Boniface," said Grace, the English teacher, "That means each of us in the investment club will receive a dividend of just $10."
Boniface looked at the floor. Before he could respond, Mercy came to his rescue.
"Listen, everyone," she said, "We knew this was not a loan. This is an investment. If we demand that all profits be returned to us in the form of dividends, SmileSave will remain small. It's like having a flock of chickens and eating every egg that the hens lay. But if you allow some eggs to hatch, they will grow into roosters and hens, and your flock will grow."
The other teachers looked unconvinced.
"Let me explain how I intend to grow the business," said Boniface, "With the $3,000 of retained profits, I will begin to purchase materials to construct SmileSave Supermarket #5. I would also like to begin installing television in the shops, so that people can relax and watch English Premier league football or soap operas while eating fish and chips and drinking cold beverages."
There was silence in the room, as the teachers considered the plan.
"Hmm… I do like fish and chips," said Isaac as he rubbed his round belly.
"And I love to watch Manchester United," said Grace.
"All in favor of approving the dividend?" asked Mercy.
Every teacher raised a hand.
Building the Business
As the years passed, SmileSave grew and grew. Boniface built one new store per year. Then two. Then three. He hired more employees. He bought more trucks. He even constructed a refrigerated warehouse to store his goods.
And quarter after quarter, Boniface raised the shareholders' dividend in line with SmileSave's growing profitability. The investment club was delighted with the performance and there was rarely any more disagreement about the size of dividends.
As the business expanded, he realized he needed more good advisors like Mercy. So, Boniface formed a Board of Directors which included an accountant, a lawyer, a banker, and (of course) Mercy.
Going Public
Word of SmileSave spread throughout the region, and every week, it seemed, someone asked Boniface how they might invest in the business, too. Just like the teachers did years before.
Meanwhile, Isaac, the science teacher was nearing retirement age. He asked Boniface if it might be possible for him to sell his stake in SmileSave so that he and his wife could build a house closer to his grandchildren.
Boniface brought both of these questions to SmileSave's next Board of Directors meeting.
"We could simply arrange for Isaac to sell his stake to any new interested investors," said the lawyer.
The banker and accountant nodded their heads in agreement, but Mercy just sat in her chair, munching on Weetabix, and deep in thought.
"Boniface," she said suddenly, "are the shops selling a lot of fish and chips?"
"Indeed they are!" he replied. "It's actually becoming a problem, because people are standing, eating fish and chips in the store while watching soap operas. The shops become very crowded. Other customers bump into them while they try to shop. But how does this pertain to this meeting's agenda?"
Mercy looked around the table. "I think it is time for SmileSave to list on the stock exchange," she said.
"An IPO??" asked Boniface incredulously.
Ignoring him, Mercy turned to the accountant. "How much is SmileSave worth?" she inquired.
"Roughly $500,000," he replied.
"Good. I propose that we raise an additional $250,000 by offering shares of SmileSave to the stock market. We can use the additional funds to build fish and chips restaurants at each supermarket."
"That's an interesting idea," said the lawyer. "It will allow people to easily invest in the company while allowing investors like Isaac to sell their stake."
"Plus, the extra funds for investment in restaurants will help SmileSave grow even more quickly," said the banker.
"After the IPO, SmileSave will be worth $750,000," said the accountant, "We can specify that this be divided into 750,000 shares of $1.00 per piece."
"Will I still own a majority of the company?" asked Boniface cautiously.
"Yes," Mercy replied. "You presently own 90% of SmileSave, while the teachers' investment club owns 10%. To determine the value of your stake, just multiply $500,000 by 90%. That's $450,000."
"After the IPO, the shareholding structure will look like this," said the accountant.
- Boniface: 450,000 shares (60% of total)
- Teachers' Investment Club: 50,000 shares (7% of total)
- New public shareholders: 250,000 shares (33% of total)
- Total: 750,000 shares (100%)
Just as he did years before, Boniface rubbed his chin. "I like this proposal, Mercy. We have ourselves a deal."
And with that, the Board began preparations for listing on the stock market. At the Initial Public Offering (IPO), hundreds of new investors scrambled to secure shares (or stock) in the fast-growing business. Each of them now owned a little piece of each shop, truck, television, warehouse, and, most importantly profits.
And that is how SmileSave Supermarkets became a stock.
Now It's Your Turn
After reading the story of Boniface, what questions do you have about stocks and stock markets? Let us know in the comments!


text:
Hi I bought Excellence in writing from someone on the forum.
This purchase was for my sister who unfortunately did not use the program.
So now I would like to sell it, but I don't have 50 posts.
Any suggestions where I could do this?
Excellence in writing
Started by arcticsam , Aug 13 2010 09:57 AM
4 replies to this topic
Posted 13 August 2010 - 09:57 AM
Posted 13 August 2010 - 10:07 AM
You could try Vegsource, Ebay, HSLDA's Curriculum Market, or Homeschool Classifieds
Posted 13 August 2010 - 11:15 AM
I've been very happy with Homeschool Classifieds.
Posted 13 August 2010 - 12:26 PM
You can return any of the IEW programs for a full refund, just an FYI.
Posted 13 August 2010 - 12:49 PM
If you register on the IEWfamilies yahoo group, you will then receive information on their sister list for buying/selling used IEW products.


text:
Bonnie Lou Walters
Bonnie Lou (Phillips) Walters, 63, of West Liberty, Ohio, passed away at 11:40 a.m. on Thursday, June 7, 2012, at her residence.
She was born in Columbus, Ohio, on April 11, 1949, to the late Frank and Thelma Myers Phillips-Seimet.
On March 2, 1968, she married Jerry Wayne Walters and he survives along with two sons, Tracey (Rhonda) Walters of Convoy, Ohio, and Trent Walters of Columbus; a daughter, Trista (Keith) Hardwick of West Liberty, Ohio; nine grandchildren, Shelby, Chase, Marissa, Brooks and Lauren Walters, and Andrew, Sophia, Isabella and Owen Hardwick; nine siblings, Barry Phillips of Lima, Ohio; Tonda (John) Ricker of Fort Jennings, Ohio; Travis Phillips and Jeff (Miriam) Phillips, both of Mississippi; Todd Phillips of Las Vegas; Terry Phillips of Cloverdale, Ohio; Dorenda (Rob) Adams of Mississippi; Rhonda (David) Spiess of Ridgeville Corners, Ohio; and Lana (Robert) Addis of Antwerp, Ohio; three step-siblings, Doris (Richard) Birkmeier and Richard (Joni) Seimet, both of Ottawa, Ohio; and Carol (Dennis) Catrell of Fort Jennings, Ohio; and numerous nieces and nephews.
She was preceded in death by a brother and sister-in-law, Jay (Brenda) Phillips; a step-father, Lavern Seimet; and a step-sister, Marilyn Narthar.
Bonnie had formerly worked at Fleetwood Motor Homes in Decatur, Honda of America, and as a school bus driver for West Liberty-Salem Schools. She attended Christ Our King Church in Bellefontaine.
A funeral service will be conducted on Tuesday, June 12, at 11 a.m. at Christ Our King Church in Bellefontaine, with Pastor Robin Ricks and Norlin Ricks officiating.
The family will receive friends on Monday, June 11 from 2-4 and 6-8 p.m. at the church, and one hour prior to the funeral on Tuesday.
Burial will be in Fairview Cemetery in West Liberty.
Memorial contribution may be made in Bonnie's memory to Universal Home Health and Hospice Care.
Funeral arrangements are being handled by the Kauffman-Eichholtz Funeral Home in West Liberty.
Online condolences may be made at www.eichholtzfuneralhome.com.


text:
Workpiece Handling:Other Spray Washers Datasheets
Industrial Parts Washer Monorail
from International Thermal Systems LLC.
from International Thermal Systems LLC.
The Monorail Washer is a universal system serving a wide variety of OEM manufacturing applications. It is designed for mass production utilizing an overhead trolley monorail or power and free conveyor. Applications for a Monorail Washer include general parts cleaning and surface preparation for... [See More]
- Part Loading: Monorail; Conveyor
- Components: Wash Tank or Sump Tub
- Machine Type: Heated Cleaning Solution; (CompleteSystem)
- Source: Electric; Gas, Oil or Fuel (optional feature); Steam (optional feature); LPG, Natural Gas, Fuel Oil, Other Fuel Mixtures
Proceco Aircraft Wheel Washer -- Typhoon AWW
from Proceco Ltd.
from Proceco Ltd.
The Typhoon ®AWW aircraft wheel cleaning system is designed to clean up to 30 aircraft wheel hubs of any size in an 8-hour shift (1 wheel every 16 min.). This unique parts washer uses the latest aqueous cleaning technology complying with environmental regulations, to remove grease, rubber... [See More]
- Part Loading: Basket (optional feature); RotaryTable; FrontLoad; Indexing; Continuous Loading or Feed (optional feature); Auto Parts Loading; Conveyor (optional feature)
- Components: Brushes; Cabinet or Tunnel Enclosure; Heater; Pump; Wash Tank or Sump Tub; Filtration System or Oil Separator; Choice Of Options
- Machine Type: Aqueous Cleaning System; Heated Cleaning Solution; Carbon Removal; (Component) (optional feature); (CompleteSystem)
- Tank Capacity: 470


text:
Owners of a Horncastle coffee house are determined to help kick cancer into touch after revealing the heartache it has caused them.
Jonathan White and Chris Wilkinson, owners of the Market Place-based Old Stables, have organised an event as part of the 'World's Biggest Coffee Morning' to raise funds for Macmillan Cancer Support.
Mr White revealed they were determined to stage a successful event because of their recent experiences of cancer.
Mr White revealed a close friend and key member of their business 'team' had died from the disease earlier this year.
He confirmed one of their closest friends - a single parent - was also battling cancer.
And, he said his mother was the first female member of his immediate family to reach the age of 35 - because of cancer.
Mr White said: "Cancer is evil - an indiscriminate killer. No-one is safe.
"We have seen first hand the agony and the heartache it can cause.
"We wanted to do something about it.
"Macmillan - and all the other charities - do an absolutely fantastic job and we wanted to be part of it.
"The message has got to be - let's kick cancer in the ass."
Mr White said he and Mr Wilkinson were "heartbroken" when a friend and business associate lost her battle against cancer in March.
He added: "She was a graphic artist and was involved in the Old Stables from the start.
"She was very brave. She fought breast cancer and at one stage she thought she had beaten it.
"Then it came back and took her life."
He went on to reveal a close friend was battling cancer.
He added: "She is a single parent and again, she is fighting it. What's happened just shows no-one is safe - no-one is invincible."
*The coffee morning will be held at the Old Stables on September 26 from 10am-12 noon. There will be free cake and special boxes to make a donation.


text:
I feel bad for Rocco Baldelli and all of his injuries, but if he was healthy, it just wouldn't be fair. I think their inexperience will hold them back this year, but this team looks like it could be a force for years to come. I don't know about you, but I'm glad we're playing the old has-beens in the Bronx now.
Thursday, July 03, 2008
Can you believe it? The Rays!
The Rays??? Swept by the Rays!.No, folks these are not the Tampa Bay Devil Rays of old. As we just saw, they are very good, very very good. Some great young players, Evan Longoria, BJ Upton, Carl Crawford with a good blend of seasoned vets like Carlos Pena and Eric Hinske (remember him). And the pitching staff, Kazmir, Shields, Garza, and even Sonnanstine. They are loaded and given the youth could be trouble for years to come. The minor league prospects are among the best in baseball according to Baseball America with arms to rival our kids. Don't forget, they've traded away Elijah Dukes and Delmon Young (got Garza back), too. I don't know about you, but Evan Longoria looks better than Eva! I think even Tony Parker is jealous!
Labels: devil rays
1 comment:
- Adawg said...
Warren - it is hard to believe that the doormat of the AL East has finally picked itself up and is now giving the big boys - Boston and New York - a run for their money. As we discussed today on Twitter, I'm happy for the players but not feeling like the D-Rays fans really deserve this (they were a nonentity up until about 6 weeks ago). It will be interesting to see where things end up at the end of the season!
Aaron | @astrout
Subscribe to: Post Comments (Atom)


text:
|By Mark O'Neill
Article Rating:
|January 15, 2010 09:11 PM EST
I've written a "guest view" article for SD Times about the usage of API Keys in Web/Cloud APIs.
API keys seem like a simple way to manage access to a Web API, but if the authentication scheme is not secure then they are dangerously simple (or simply dangerous).
A key part of Cloud security is effective management of API key based authentication.
The article is here:
Read the original blog entry...
"Grape Up leverages Cloud Native technologies and helps companies build software using microservices, and work the DevOps agile way. We've been doing digital innovation for the last 12 years," explained Daniel Heckman, of Grape Up in this SYS-CON.tv interview at 21st Cloud Expo, held Oct 31 – Nov 2, 2017, at the Santa Clara Convention Center in Santa Clara, CA.
Mar. 10, 2018 06:00 AM EST Reads: 2,938
The general concepts of DevOps have played a central role advancing the modern software delivery industry. With the library of DevOps best practices, tips and guides expanding quickly, it can be difficult to track down the best and most accurate resources and information. In order to help the software development community, and to further our own learning, we reached out to leading industry analysts and asked them about an increasingly popular tenet of a DevOps transformation: collaboration.
Mar. 10, 2018 01:45 AM EST Reads: 5,119
"We are an integrator of carrier ethernet and bandwidth to get people to connect to the cloud, to the SaaS providers, and the IaaS providers all on ethernet," explained Paul Mako, CEO & CTO of Massive Networks, in this SYS-CON.tv interview at 21st Cloud Expo, held Oct 31 – Nov 2, 2017, at the Santa Clara Convention Center in Santa Clara, CA.
Mar. 10, 2018 01:00 AM EST Reads: 2,731
We call it DevOps but much of the time there's a lot more discussion about the needs and concerns of developers than there is about other groups. There's a focus on improved and less isolated developer workflows. There are many discussions around collaboration, continuous integration and delivery, issue tracking, source code control, code review, IDEs, and xPaaS – and all the tools that enable those things. Changes in developer practices may come up – such as developers taking ownership of code ...
Mar. 9, 2018 11:45 PM EST Reads: 7,373
"CA has been doing a lot of things in the area of DevOps. Now we have a complete set of tool sets in order to enable customers to go all the way from planning to development to testing down to release into the operations," explained Aruna Ravichandran, Vice President of Global Marketing and Strategy at CA Technologies, in this SYS-CON.tv interview at DevOps Summit at 21st Cloud Expo, held Oct 31 – Nov 2, 2017, at the Santa Clara Convention Center in Santa Clara, CA.
Mar. 9, 2018 01:30 PM EST Reads: 3,618
"NetApp's vision is how we help organizations manage data - delivering the right data in the right place, in the right time, to the people who need it, and doing it agnostic to what the platform is," explained Josh Atwell, Developer Advocate for NetApp, in this SYS-CON.tv interview at 20th Cloud Expo, held June 6-8, 2017, at the Javits Center in New York City, NY.
Mar. 9, 2018 11:00 AM EST Reads: 5,498
"Outscale was founded in 2010, is based in France, is a strategic partner to Dassault Systémes and has done quite a bit of work with divisions of Dassault," explained Jackie Funk, Digital Marketing exec at Outscale, in this SYS-CON.tv interview at 20th Cloud Expo, held June 6-8, 2017, at the Javits Center in New York City, NY.
Mar. 9, 2018 09:15 AM EST Reads: 5,253
"I focus on what we are calling CAST Highlight, which is our SaaS application portfolio analysis tool. It is an extremely lightweight tool that can integrate with pretty much any build process right now," explained Andrew Siegmund, Application Migration Specialist for CAST, in this SYS-CON.tv interview at 21st Cloud Expo, held Oct 31 – Nov 2, 2017, at the Santa Clara Convention Center in Santa Clara, CA.
Mar. 7, 2018 07:00 PM EST Reads: 4,057
Let's do a visualization exercise. Imagine it's December 31, 2018, and you're ringing in the New Year with your friends and family. You think back on everything that you accomplished in the last year: your company's revenue is through the roof thanks to the success of your product, and you were promoted to Lead Developer. 2019 is poised to be an even bigger year for your company because you have the tools and insight to scale as quickly as demand requires. You're a happy human, and it's not just...
Mar. 7, 2018 08:30 AM EST Reads: 3,326
The enterprise data storage marketplace is poised to become a battlefield. No longer the quiet backwater of cloud computing services, the focus of this global transition is now going from compute to storage. An overview of recent storage market history is needed to understand why this transition is important. Before 2007 and the birth of the cloud computing market we are witnessing today, the on-premise model hosted in large local data centers dominated enterprise storage. Key marketplace play...
Mar. 7, 2018 08:00 AM EST Reads: 3,025
How is DevOps going within your organization? If you need some help measuring just how well it is going, we have prepared a list of some key DevOps metrics to track. These metrics can help you understand how your team is doing over time. The word DevOps means different things to different people. Some say it a culture and every vendor in the industry claims that their tools help with DevOps. Depending on how you define DevOps, some of these metrics may matter more or less to you and your team.
Mar. 6, 2018 08:15 PM EST Reads: 3,567
Cavirin Systems has just announced C2, a SaaS offering designed to bring continuous security assessment and remediation to hybrid environments, containers, and data centers. Cavirin C2 is deployed within Amazon Web Services (AWS) and features a flexible licensing model for easy scalability and clear pay-as-you-go pricing. Although native to AWS, it also supports assessment and remediation of virtual or container instances within Microsoft Azure, Google Cloud Platform (GCP), or on-premise. By dr...
Mar. 6, 2018 01:00 PM EST Reads: 3,006
With continuous delivery (CD) almost always in the spotlight, continuous integration (CI) is often left out in the cold. Indeed, it's been in use for so long and so widely, we often take the model for granted. So what is CI and how can you make the most of it? This blog is intended to answer those questions. Before we step into examining CI, we need to look back. Software developers often work in small teams and modularity, and need to integrate their changes with the rest of the project code b...
Mar. 6, 2018 11:15 AM EST Reads: 2,985
Kubernetes is an open source system for automating deployment, scaling, and management of containerized applications. Kubernetes was originally built by Google, leveraging years of experience with managing container workloads, and is now a Cloud Native Compute Foundation (CNCF) project. Kubernetes has been widely adopted by the community, supported on all major public and private cloud providers, and is gaining rapid adoption in enterprises. However, Kubernetes may seem intimidating and complex ...
Mar. 5, 2018 08:00 PM EST Reads: 3,827
Is advanced scheduling in Kubernetes achievable?Yes, however, how do you properly accommodate every real-life scenario that a Kubernetes user might encounter? How do you leverage advanced scheduling techniques to shape and describe each scenario in easy-to-use rules and configurations? In his session at @DevOpsSummit at 21st Cloud Expo, Oleg Chunikhin, CTO at Kublr, answered these questions and demonstrated techniques for implementing advanced scheduling. For example, using spot instances and co...
Mar. 5, 2018 02:00 PM EST Reads: 3,607
DevOps is often described as a combination of technology and culture. Without both, DevOps isn't complete. However, applying the culture to outdated technology is a recipe for disaster; as response times grow and connections between teams are delayed by technology, the culture will die. A Nutanix Enterprise Cloud has many benefits that provide the needed base for a true DevOps paradigm. In their Day 3 Keynote at 20th Cloud Expo, Chris Brown, a Solutions Marketing Manager at Nutanix, and Mark Lav...
Mar. 5, 2018 01:00 PM EST Reads: 6,241
Enterprises are adopting Kubernetes to accelerate the development and the delivery of cloud-native applications. However, sharing a Kubernetes cluster between members of the same team can be challenging. And, sharing clusters across multiple teams is even harder. Kubernetes offers several constructs to help implement segmentation and isolation. However, these primitives can be complex to understand and apply. As a result, it's becoming common for enterprises to end up with several clusters. Thi...
Mar. 5, 2018 09:15 AM EST Reads: 3,406
Gone are the days when application development was the daunting task of the highly skilled developers backed with strong IT skills, low code application development has democratized app development and empowered a new generation of citizen developers. There was a time when app development was in the domain of people with complex coding and technical skills. We called these people by various names like programmers, coders, techies, and they usually worked in a world oblivious of the everyday pri...
Mar. 5, 2018 07:15 AM EST Reads: 2,887
"Cloud4U builds software services that help people build DevOps platforms for cloud-based software and using our platform people can draw a picture of the system, network, software," explained Kihyeon Kim, CEO and Head of R&D at Cloud4U, in this SYS-CON.tv interview at 21st Cloud Expo, held Oct 31 – Nov 2, 2017, at the Santa Clara Convention Center in Santa Clara, CA.
Mar. 5, 2018 05:30 AM EST Reads: 3,275
How often is an environment unavailable due to factors within your project's control? How often is an environment unavailable due to external factors? Is the software and hardware in the environment up to date with the target production systems? How often do you have to resort to manual workarounds due to an environment? These are all questions that you should ask yourself if testing environments are consistently unavailable and affected by outages. Here are three key metrics that you can tra...
Mar. 5, 2018 05:00 AM EST Reads: 2,123


text:
Men's Tennis: Top competition awaits team
Walker Carey | Wednesday, October 12, 2011
The Irish will return to action Thursday for the first time since Sept. 25 when they compete in the Midwest Singles/Doubles Championships at Ohio State.
Before the tournament, the top 56 players in the midwest are placed in the main draw. The final eight spots in the draw are determined through the qualifying round that will take place Thursday.
The Irish lead the field with nine players in the main draw, including seniors Niall Fitzgerald, Sam Keeton and Casey Watt.
The Irish also have three players who will be competing for the eight qualifying spots, junior Spencer Talmadge and freshmen Doug Barnard and Michael Fredericka.
Irish associate head coach Ryan Sachire said the tournament will feature tough competition, but he is confident the Irish will be able to compete at a high level.
"If I had to describe the level of competition in one word, it would be 'fierce'" Sachire said. "Ohio State has eight very good players in the main draw. Illinois, Michigan and Michigan State have several tough players in [the main draw]. It will definitely be a competitive weekend and that is exciting for everybody.
The Irish had success in the event last year when six Irish players advanced to the round of 16. Sachire does not believe that it is unfair to expect the same this year.
"I think we should have at least as many [in the round of 16] this year," Sachire said. "It does depend on the draws that some of our guys will get, but that many or more is definitely a realistic expectation."
Sachire said he is also excited with the progress his squad has made since they last competed.
"We have been able to accomplish a lot since we last played," Sachire said. "At first, we focused on reinforcing some fundamentals, such as utilizing our serves to set up our offense and some general volley work. The guys have done a great job making sure they have their technique down.
Over the past week, we have gone back to competing and thinking about how we are going to play [this weekend]. The break has been very beneficial to us."
Despite the staunch competition this weekend, the Irish hope to come away with a victory at the Midwest Singles/Doubles Championships in Columbus, starting Thursday.
Contact Walker Carey at [email protected]


text:
National Survey Measures Mason Student Engagement
Posted: February 22, 2007 at 1:00 am, Last Updated: November 30, -0001 at 12:00 am
By Beau Cribbs
Each year the National Survey of Student Engagement (NSSE) collects information from undergraduates at colleges and universities from around the country, including Mason. This is done to gauge how engaged specific student populations are in an assortment of educational and social activities.
In spring 2006, a random selection of about 3,600 first-year and senior Mason students were invited to participate in the survey. According to the NSSE report, these students were representative of Mason's diversity in terms of gender, race, age, enrollments status and grades. In all, 1,566 (or 43 percent) completed the online survey.
The information gathered reveals that the George Mason academic and social community continues to thrive, and that in many cases, Mason students are more confident in several areas of academic interest when compared to their peers surveyed at other colleges and universities.
The 2006 Benchmark Report released by the NSSE shows that student-faculty interaction at Mason has noticeably improved since the 2003 survey, so much so that Mason freshmen now score significantly higher on this benchmark than the majority of selected peers. As compared to the survey three years prior, "more Mason freshmen and seniors in 2006 have talked about their career plans with faculty and worked with faculty on activities other than course work," the report states.
Another observation of the Benchmark Report is that Mason students are busier than their peers, with more working part-time or full-time jobs either on or off campus. This percentage is higher than the proportion of working Mason students surveyed in the 2003 cohort.
Academically, more Mason students enjoy the advantage of collaborative learning than the majority of their peers. This includes having confidence in class presentations and in contributing to classroom discussions. Mason freshmen also have more reading and writing assignments than other surveyed college students.
In all, the survey results highlighted the Mason student population as willing to take on responsibility and eager to progress as academics.
To read the full report, see the Office of Institutional Assessment web site.


text: TVO Agenda on Makers November 13, 2009 / Cory Doctorow / News Here's last night's TVO Agenda interview on Makers — Steve Paikin and I had a fantastic talk. Share this post:TwitterFacebookTumblrPinterestGoogleStumbleUponEmail 3 Responses to "TVO Agenda on Makers" Christopher Kastensmidt November 13th, 2009 Great interview, Cory! Congrats! Marlon November 13th, 2009 That was awesome, I just subscribed to the Agenda vodcast. Jan Rubak November 16th, 2009 Two of my favourite people… great interview! Thank goodness for the intarwebs, allowing people like me in the cultural and intellectual wasteland of Alburrrdah to still get a steady dose of quality public television like TVO. (And many thanks to TVO for being progressive enough to make their material available like that.) I got a real kick out of the copyright blurb at the end of the video, where they adapted your bogus agreement conditions. :D Leave a Reply Name (required) Email (required) (will not be published) Website Your Comment Click here to cancel reply.


text:
Canada's Prime Minister got a peek at what many believe is the next big thing in gaming today as he toured Ubisoft's Montreal's headquarters.
Justin Trudeau tested out a virtual reality headset during his tour of the game studio on St-Laurent Boulevard.
This week, Ubisoft launched Far Cry Primal, the next installment in its critically acclaimed franchise, on the PlayStation 4 and Xbox One. The game was developed in Montreal.