Catastrophization,fear of movement,anxiety, and depression are associated with persistent,severe low back pain and disability

BACKGROUND CONTEXTPsychological characteristics are important in the development and progression of low back pain (LBP); however, their role in persistent, severe LBP is unclear.PURPOSETo investigate the relationship between catastrophization, depression, fear of movement, and anxiety and persistent, severe LBP, and disability.STUDY DESIGN/ SETTINGOne-year prospective cohort study.PATIENT SAMPLEParticipants were selected from the SpineData registry (Denmark), which enrolls individuals with LBP of 2 to 12 months duration without radiculopathy and without satisfactory response to primary intervention.OUTCOME MEASURESPsychological characteristics, including catastrophization, depression, fear of movement, and anxiety, were examined at baseline using a validated screening questionnaire. Current, typical, and worst pain in the past 2 weeks were assessed by 11-point numeric rating scales and an average pain score was calculated. Disability was measured using the 23-item Roland-Morris Disability Questionnaire.METHODSParticipants completed baseline questionnaires on initial presentation to the Spine Center (Middelfart, Denmark), and follow-up questionnaires were sent and returned electronically. Statistical analysis involved multivariable Poisson regression to investigate the association between psychological factors and the number of episodes of severe pain or disability. This study received no direct funding.RESULTSOf the 952 participants at baseline, 633 (63.4%) provided data 1 year later. Approximately half of the participants reported severe LBP (n=299, 47.2%, 95% confidence interval [CI] 43.3%–51.2%) or disability (n=315, 57.6%, 95% CI 53.3%–61.8%) at a minimum of one time point, and 14.9% (n=94, 95% CI 12.2%–17.9%) and 24.3% (n=133, 95% CI 20.8%–28.1%) experienced severe LBP or disability at two time points, respectively. Multivariable Poisson regression showed a relationship between catastrophization, depression, fear of movement, and anxiety and a greater number of time points with severe LBP and disability, after adjusting for age, gender, body mass index, and duration of symptoms. However, when all psychological factors were added to the regression model, only catastrophization and depression remained significantly associated.CONCLUSIONSThis study showed that persistent, severe LBP, and disability is common in a secondary care population with LBP and is associated with a variety of psychological risk factors, in particular catastrophization and depression, highlighting the importance of considering these factors in the design and evaluation of outcomes studies for LBP.     

Hip-spine relationship in total hip arthroplasty – Simplifying the concepts

Total hip arthroplasty (THA) has been described as the operation of the century. Despite significant advancement in the field of technology, hip instability remains second most common cause of revision hip surgery after infection. There is garning interest to identify role of hip-spine relationship in order to identify high-risk patients for instability after THA. Acetabular component position varies according to spinal alignment and mobility in order to decrease risk of impingement and instability. Preoperative work up includes standing pelvis anteroposterior radiograph and lateral spino-pelvic radiograph in standing and sitting position. The focus of this review is to develop an algorithm to address the spino-pelvic pathology and guide the treatment on the basis of sagittal movement of the spine-pelvis-hip complex and to minimise the rate of dislocation following THA.     

Three-dimensional morphological analysis of cervical foraminal stenosis using dynamic flexion-extension computed tomography images

BackgroundMorphological features of foraminal stenosis in cervical spondylotic radiculopathy and the adequate extent of facet resection in posterior cervical foraminotomy remain uncertain. Herein, we evaluated quantitatively foraminal widths in cervical spondylotic radiculopathy on dynamic flexion-extension computed tomography using a novel three-dimensional analysis method and determined the extent of facet resection in posterior cervical foraminotomy.MethodsSeventeen patients undergoing posterior cervical foraminotomy for cervical spondylotic radiculopathy were evaluated. A neuroforamen three-dimensional model was built from preoperative images of flexion-extension computed tomography myelography, and an ordinary cervical spine coordinate system and an original neuroforaminal coordinate system, were established. In the neuroforaminal coordinate system, minimum areas perpendicular to the long axis by the slices from inlet to outlet of neuroforamen and narrowest foraminal width in a slice of minimum area were measured. The location of the narrowest region from inlet of the foramen was calculated. Ratios of minimum and sufficient facet resection were obtained from the location of the narrowest region in the neuroforaminal coordinate system.ResultsThe narrowest foraminal widths (flexion/extension) in the cervical spine coordinate system and the neuroforaminal coordinate system were 2.9/2.3 and 2.6/1.9 mm, respectively. The mean values of the location of the narrowest region (flexion/extension) were 0.27/0.22 and 0.50/0.45 mm, respectively, and the narrowest region in the neuroforaminal coordinate system was located on the outer side than in the cervical spine coordinate system (p < 0.001). The ratios of minimum and sufficient facet resection were 23 ± 8% and 32 ± 9%, respectively.ConclusionsThe narrowest regions both in flexion and extension are located at the middle of the foramen based on the neuroforaminal coordinate system. Ordinary evaluation of axial computed tomography images likely underestimates the extent of facet resection, whereas certain extent of facet resection does not exceed 50% in cases with single-level cervical spondylotic radiculopathy.Study designA retrospective case control study.     

Novel technique to accurately measure femoral diameter using a Thomas splint

IntroductionDuring surgical management of femoral shaft fractures, difficulties arise when treating patients with narrow femoral diaphyseal canals, such as young patients and those with dysplastic femurs secondary to underlying pathology. Accurate pre-operative assessment of the femoral diaphyseal canal diameter would allow the surgeon to plan surgical technique and ensure appropriate equipment was available, such as narrow, unreamed or paediatric sized nails.TechniqueWhen secured to the patient both longitudinal rods of the main Thomas Splint component lie parallel with the femoral shaft and horizontal to the radiographic x-ray plate. The diameter of these rods are 13 mm (Adult and paediatric). Using the calibration tool, we calibrate the diameter of the Thomas Splint to 13 mm, accurately measuring any further detail on that radiograph, such as the diaphyseal canal diameter.ConclusionAccurate knowledge pre-operatively of radiographic measurements is highly valuable to the operating surgeon. This technique can accurately measure femoral canal diameter using the Thomas splint, negates the requirement for a calibration marker, is reproducible, easy to perform, and is indispensible when faced with a patient with a narrow femoral canal in a diaphyseal femoral fracture. (181 words)     

A modified deltoid splitting approach with axillary nerve bundle mobilization for proximal humeral fracture fixation

IntroductionThe deltopectoral and the deltoid splitting approach are commonly used for the treatment of proximal humeral fractures. While the deltopectoral approach requires massive soft tissue devascularization, the deltoid splitting approach needs an additional skipped incision to avoid axillary nerve injury. The purpose of this study was to describe a modified anterolateral deltoid splitting approach with axillary nerve bundle mobilization in the treatment of proximal humeral fractures and to assess its radiologic and clinical outcomes.Patients and methodsTwenty-two consecutive patients with proximal humeral fractures were treated with minimally invasive plate osteosynthesis by using a modified anterolateral deltoid splitting approach with axillary nerve bundle mobilization. The patients were divided into two groups: 10 patients of Neer type 2 or 3 fractures vs. 12 patients of Neer type 4 fractures. The mean age of the study population was 63.5 years (range: 30–80 years). Six patients had valgus impacted fractures, and nine had fractures with medial comminution.ResultsFracture union was achieved in all cases. The mean time to union was 8.6 weeks (range: 6–12 weeks). Major complications, such as avascular necrosis of the humeral head and varus collapse at the fracture site, were not observed. No patients had clinically detectable sensory deficits in the axillary nerve distribution or paralysis of the anterior deltoid muscle. The mean neck-shaft angle at the final follow-up was 136.9° (range, 115°–159°). The mean visual analog score for patient satisfaction was 9.1 (range, 6–10), and the mean Neer scores were 93.5 (range, 84–100). There were no significant differences between the two groups with respect to radiologic and clinical outcomes except Neer scores: 95.8 (range: 86–100) in Neer type 2 or 3 fractures and 91.7 (range: 84–99) in Neer type 4 fractures.ConclusionThe use of a modified anterolateral deltoid splitting approach with axillary nerve bundle mobilization in the treatment of proximal humeral fractures yielded excellent outcomes. This approach is a useful alternative to the deltopectoral or the deltoid splitting approaches in the treatment of proximal humeral fractures.     

Association between sagittal alignment and loads at the adjacent segment in the fused spine: a combined clinical and musculoskeletal modeling study of 205 patients with adult spinal deformity

Purpose

Sagittal malalignment is a risk factor for mechanical complications after surgery for adult spinal deformity (ASD). Spinal loads, modulated by sagittal alignment, may explain this relationship. The aims of this study were to investigate the relationships between: (1) postoperative changes in loads at the proximal segment and realignment, and (2) absolute postoperative loads and postoperative alignment measures.

Methods

A previously validated musculoskeletal model of the whole spine was applied to study a clinical sample of 205 patients with ASD. Based on clinical and radiographic data, pre-and postoperative patient-specific alignments were simulated to predict loads at the proximal segment adjacent to the spinal fusion.

Results

Weak-to-moderate associations were found between pre-to-postop changes in lumbar lordosis, LL (r =  − 0.23, r =  − 0.43; p < 0.001), global tilt, GT (r = 0.26, r = 0.38; p < 0.001) and the Global Alignment and Proportion score, GAP (r = 0.26, r = 0.37; p < 0.001), and changes in compressive and shear forces at the proximal segment. GAP score parameters, thoracic kyphosis measurements and the slope of upper instrumented vertebra were associated with changes in shear. In patients with T10-pelvis fusion, moderate-to-strong associations were found between postoperative sagittal alignment measures and compressive and shear loads, with GT showing the strongest correlations (r = 0.75, r = 0.73, p < 0.001).

Conclusions

Spinal loads were estimated for patient-specific full spinal alignment profiles in a large cohort of patients with ASD pre-and postoperatively. Loads on the proximal segments were greater in association with sagittal malalignment and malorientation of proximal vertebra. Future work should explore whether they provide a causative mechanism explaining the associated risk of proximal junction complications.

     

Age-adjusted alignment goals in adult spinal deformity surgery

Adult spinal deformity causes pain, disability, and alterations in the quality of life of patients. Sagittal alignment and spinopelvic parameters have been established to provide surgeons with correction goals based upon normative population values. Recently, much research has been done to optimize patient outcomes regarding these parameters and at the same time reduce complications such as proximal junction kyphosis. Recently, there has been growing interest in tailoring these alignment goals based on patient age, with an overall intention of achieving a less substantial correction in older patients compared to traditional alignment goals used for younger populations. This review paper will provide a framework of understanding how advanced age impacts the sagittal alignment of the spine, the evidence supporting age-adjusted alignment goals, and also shortcomings and areas for future investigation.     

A biomimetic artificial intervertebral disc system composed of a cubic three-dimensional fabric

Background contextIn the quest for clinically functional artificial intervertebral discs (AIDs), multidisciplinary technologies have been employed. Existing solid mobile AIDs essentially consist of the superposition of solid plates and core materials; however, it is thought that an ideal surgical AID technology has not yet been developed. To overcome the limitation of these existing AIDs, we developed a unique flexible AID disc system on the basis of our original biomimetic concept. The AID is composed of a cubic three-dimensional fabric (3DF) with a triaxial fiber alignment, which offers biomimetic long-term dynamic mechanical behavior along with durability.PurposeThis article substantiates the potential clinical use of the 3DF disc system that quite differs from existing ones.Study designWe designed the lumbar and cervical 3DF discs that improved the structural weaknesses caused by the collagenous fiber alignment of biological intervertebral disc. Bioresorbable hydroxyapatite particles were deposited on the surface layer of the 3DF disc to promote new bony ingrowth and to ensure secure binding at the interface of the contacting vertebral bodies. A stand-alone system was devised for surgical reliability in terms of both positioning and fixation, allowing tight press fitting with the vertebral bodies. Bioactive and bioresorbable pins were penetrated through the 3DF disc body and projected from the surface to allow ideal insertion and fixation to the disc space, preserving the precise position during dynamical movement. In vitro endurance of the 3DF disc was examined under long-term alternating stresses, and the in vivo animal tests were conducted in the intervertebral lumbar discs at L5–L6 excised from baboons and replaced with the lumbar 3DF disc.MethodsThe static mechanical endurance was assessed through a creep test. In vitro endurance of the 3DF disc under repetitive stresses including axial compressing, flexion-extension, torsional twisting, and lateral bending were applied to the 3DF disc for a long-term for up to 105 million stresses, which is roughly equivalent to exposure of natural biological movement for more than 50 years. In the animal test, eight baboons were euthanized 6 months postoperatively. To their extracted spines, six pure moments (flexion and extension, left and right lateral bending, and left and right torsion) were applied vertically to the superior end of the specimen and then values of range of motions (ROMs) were calculated. Histological analyses were conducted on 12 reticuloendothelial and systemic tissues.ResultsThe 3DF disc retained its biomimetic “J-shaped” stress-strain behavior without generating wear debris for up to 105 million stresses. A 130-N loading for the creep test decreased the height of 0.3 mm during 80 to 1,000 hours. In the biomechanical test, ROM values of axial rotation and flexion-extension showed no significant difference from the intact excluding that of lateral bending because the location of each pin to stand alone certainly controlled the bending behavior only. The histological analysis indicated no significant pathologic changes induced by the 3DF disc.ConclusionsThe 3DF disc system is clinically suitable for human disc replacement arthroplasty based on the findings of long-term durability with dynamic motion in vitro and effective animal tests in vivo. This system surely overcomes the limitations of existing solid AIDs, and the clinical potential of the biomimetic 3DF discs has been verified. This new biomaterial technology delivers most of the functions and characteristics required by a clinically available AID if applied correctly by surgeons.     

Paradoxical relationship in sensorimotor system: Knee joint position sense absolute error and joint stiffness measures

BackgroundRelationships between joint position sense and the sensorimotor characteristics such as joint stiffness, time to detect motion, and time to peak torque during a perturbation test have rarely been investigated due to methodological challenges. The purpose of this study was to compare joint position sense and the sensorimotor characteristics in healthy individuals.MethodsA total of 26 subjects were recruited and completed joint position sense and a perturbation test on isokinetic dynamometer. Joint position sense was assessed by comparison of the absolute angle difference between a reference and replicated position. During the perturbation test, the dynamometer moved the knee flexion angle from 70° to 30° (0° represents a full knee extension) at the velocity of 500° per second at random. Subjects were asked to react and pull back the leg as soon as they perceived the movement. Pearson or Spearman's correlation coefficients were used to assess these relationships (P < 0.05).FindingsLarger joint position sense absolute error values were significantly correlated with higher short-range at 50 milliseconds (r = 0.572, P = 0.002), at 100 milliseconds (ρ = 0.416, P = 0.035), and reactive joint stiffness (r = 0.395, P = 0.046).InterpretationThere was a paradoxical relationship between higher joint stiffness and worsened joint position sense. Potential reasons include sensory weighting within the sensorimotor system and thixotropic properties (after-effects of muscle eccentric contractions to increase stiffness and alter joint position sense).