Short-term outcome in lumbar spine surgery

Summary A prospective survey of the outcome of lumbar surgery was carried out under conditions where all intervention was according to routine procedures. Of a consecutive series of patients 132 cases (92%) could be evaluated. The aim was to investigate possible predictive factors among self-reported data and clinical data readily available under routine circumstances. Follow-up was for six months post-operatively. Surgical findings were: herniated disc (62%), ostechondrosis (21%), other pathology (7%), and negative findings (10%). Unsatisfactory outcome was either relapse, operation before follow-up (9%) or persisting pain (30%). The surgical finding of a disc herniation predicted a significantly better outcome than any other finding. Cases previously operated upon (20%) fared equal with those operated upon for the first time irrespective of surgical findings.Self-reported weighting of preoperative pain and its location showed that predominant sciatica was significantly associated with the finding of a disc herniation, but also with satisfactory outcome irrespective of the operative finding. Factors without predictive value included sex, age, number of prior back surgeries, duration and impact of symptoms, and clinical findings. The social consequences were associated with the duration of low back disease.     

化学性神经根炎

目的研究分析疼痛椎间盘的纤维环破裂与患者下肢放射痛的关系,进而探讨是否存在化学性神经根炎这一临床病理现象.方法临床收集42例单节段椎间盘源性下腰痛伴单侧或双侧下肢放射痛患者,男27例,女15例;年龄19～52岁,平均34.9岁;症状持续至少6个月,平均3年4个月.通过椎间盘造影和其后的CT扫描,分析纤维环撕裂方向与下肢放射痛侧别的关系;行肌电图和运动神经传导速度检查,分析有无神经根损伤,以及其与下肢放射痛的关系.结果腰椎间盘造影时,所有患者显示单水平纤维环破裂且呈现一致性疼痛复制反应,纤维环撕裂方向与下肢放射痛的侧别有显著的正相关性.42例肌电图检查提示神经根损害者32例（76%）.23例单侧下肢放射痛者中17例（74%）存在神经根损害,均为同侧;19例双侧下肢放射痛者中有15例（79%）存在神经根损害.症状侧腓总神经和胫神经运动传导速度较正常侧减慢,差异有统计学意义.结论疼痛椎间盘产生的炎性化学物质通过纤维环全层撕裂漏出并作用于相邻神经根引起神经根损害,可能是化学性神经根炎产生的基本病理生理学机制.     

Failed less invasive lumbar spine surgery as a predictor of subsequent fusion outcomes

Purpose

It is not uncommon for patients to undergo less invasive spine surgery (LISS) prior to succumbing to lumbar fusion; however, the effect of failed LISS on subsequent fusion outcomes is relatively unknown. The aim of this study was to test the hypothesis that patients who suffered failed LISS would afford inferior subsequent fusion outcomes when compared to patients who did not have prior LISS.

Methods

After IRB approval, registry from a spine surgeon was queried for consecutive patients who underwent fusion for intractable low back pain. The 47 qualifying patients were enrolled and split into two groups based upon a history for prior LISS: a prior surgery group (PSG) and a non-prior surgery group (nPSG).

Results

Typical postoperative outcome questionnaires, which were available in 80.9 % of the patients (38/47) at an average time point of 40.4 months (range, 13.5–66.1 months), were comparatively analysed and failed to demonstrate significant difference between the groups, e.g. PSG v. nPSG: ODI—14.6 ± 10.9 vs. 17.2 ± 19.4 (P = 0.60); SF12-PCS—10.9 ± 11.0 vs. 8.7 ± 12.4 (p = 0.59); bNRS—3.0 (range −2–7) vs. 2.0 (range −3–8) (p = 0.91). Patient satisfaction, return to work rates, peri-operative complications, success of fusion and rate of revision surgery were also not different.

Conclusions

Although limited by size and retrospective design, the results of this rare investigation suggest that patients who experience a failed LISS prior to undergoing fusion will not suffer inferior fusion outcomes when compared to patients who did not undergo prior LISS.     

Return to work following surgery for lumbar radiculopathy: a systematic review

Background Context

Informing patients about postoperative return to work (RTW) expectations is of utmost importance because of the influence of realistic expectations on RTW outcomes.

A predictive model for outcome after conservative decompression surgery for lumbar spinal stenosis

This study was designed to develop predictive models for surgical outcome based on information available prior to lumbar stenosis surgery. Forty patients underwent decompressive laminarthrectomy. Preop and 1-year postop evaluation included Waddells nonorganic signs, CT scan, Waddell disability index, Oswestry low back pain disability questionnaire, low back outcome score (LBOS), visual analog scale (VAS) for pain intensity, and trunk strength testing. Statistical comparisons of data used adjusted error rates within families of predictors. Mathematical models were developed to predict outcome success using stepwise logistic regression and decision-tree methodologies (chi-squared automatic interaction detection, or CHAID). Successful outcome was defined as improvement in at least three of four criteria: VAS, LBOS, and reductions in claudication and leg pain. Exact logistic regression analysis resulted in a three-predictor model. This model was more accurate in predicting unsuccessful outcome (negative predictive value 75.0%) than in successful outcome (positive predictive value 69.6%). A CHAID model correctly classified 90.1% of successful outcomes (positive predictive value 85.7%, negative predictive value 100%). The use of conservative surgical decompression for lumbar stenosis can be recommended, as it demonstrated a success rate similar to that of more invasive techniques. Given its physiologic and biomechanical advantages, it can be recommended as the surgical method of choice in this indication. Underlying subclinical vascular factors may be involved in the complaints of spinal stenosis patients. Those factors should be investigated more thoroughly, as they may account for some of the failures of surgical relief. The CHAID decision tree appears to be a novel and useful tool for predicting the results of spinal stenosis surgery     

EMG analysis of lumbar paraspinal muscles as a predictor of the risk of low-back pain

Studies of EMG power spectra have established associations between low-back pain (LBP) and median frequency (MF). This 2-year prospective study investigates the association of LBP with EMG variables over time. 120 health care workers underwent paraspinal EMG measurements and assessment of back pain disability. The EMG recordings were performed under isometric trunk extension at 2/3 maximum voluntary contraction and acquired from erector spinae muscles at the level of L4/L5. 108 (90%) subjects were reviewed at a minimum 2-year follow up. 16 out of 93 subjects with no history of chronic low-back pain became worse as measured by time off work, disability, reported pain and self-assessment rating. The value of the EMG variable half-width at inception demonstrated significant association with changes in subject’s outcome measure and their own assessment of their LBP at follow up (p < 0.05). Based on self-assessment data, subjects with no history of chronic LBP with half-width of greater than 56 Hz were at threefold greater risk of developing back pain compared with the remainder of the population (p = 0.045). The value of the initial median frequency (IMF) and MF slope at inception were also associated with the subjects’ own assessment of LBP at follow up. Subjects with an IMF greater than 49 Hz were at 5.8-fold greater risk of developing back pain compared with the remainder of the population (p = 0.014). EMG variables recorded from lumbar paraspinal muscles can identify a sub group of subjects at increased risk of developing low-back pain in the future.     

以腰腿痛为主要症状的恶性肿瘤26例

腰腿痛是骨科常见病,骨科医生常想到腰椎间盘突出症,对老年患者考虑骨质疏松症,我们近9年中见到26例以腰腿痛为主要症状的恶性肿瘤,报告如下。1临床资料本组26例中,男性17例,女性9例;年龄48～90岁,平均69.7岁。转移性骨肿瘤22例,多发性骨髓瘤4例。骨肿瘤中男性12例,女性10例;年     

Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography

The vertebral end-plate has been identified as a possible source of discogenic low back pain. MRI demonstrates end-plate (Modic) changes in 20–50% of patients with low back pain. The aim of this study was to investigate the association between Modic changes on MRI and discogenic back pain on lumbar discography. The MRI studies and discograms of 58 patients with a clinical diagnosis of discogenic back pain were reviewed and the presence of a Modic change was correlated with pain reproduction at 152 disc levels. Twenty-three discs with adjacent Modic changes were injected, 21 of which were associated with pain reproduction. However, pain was also reproduced at 69 levels where no Modic change was seen. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for a Modic change as a marker of a painful disc were 23.3%, 96.8%, 91.3% and 46.5% respectively. Modic changes, therefore, appear to be a relatively specific but insensitive sign of a painful lumbar disc in patients with discogenic low back pain. Received: 24 October 1997 Revised: 11 March 1998 Accepted: 21 April 1998     

Use of the subcutaneous lumbar spine (SLS) index as a predictor for surgical complications in lumbar spine surgery

Background context

Lumbar spine surgeries require adequate exposure to visualize key structures and limited exposure can make surgery more technically difficult, thus increasing the potential for complications. Body mass index and body mass distribution have been shown to be associated with worse surgical outcomes.

A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with mechanical lumbar traction

The objective of the study was to develop a clinical prediction rule for identifying patients with low back pain, who improved with mechanical lumbar traction. A prospective, cohort study was conducted in a physiotherapy clinic at a local hospital. Patients with low back pain, referred to physiotherapy were included in the study. The intervention was a standardized mechanical lumbar traction program, which comprised three sessions provided within 9 days. Patient demographic information, standard physical examination, numeric pain scale, fear-avoidance beliefs questionnaire and Oswestry low back pain disability index (pre- and post-intervention) were recorded. A total of 129 patients participated in the study and 25 had positive response to the mechanical lumbar traction. A clinical prediction rule with four variables (non-involvement of manual work, low level fear-avoidance beliefs, no neurological deficit and age above 30 years) was identified. The presence of all four variables (positive likelihood ratio = 9.36) increased the probability of response rate with mechanical lumbar traction from 19.4 to 69.2%. It appears that patients with low back pain who were likely to respond to mechanical lumbar traction may be identified.     

Movement coordination of the lumbar spine and hip during a picking up activity in low back pain subjects

The effect of low back pain, with or without nerve root signs, on the joint coordination and kinematics of the lumbar spine and hips during everyday activities, such as picking up an object from the floor, are largely unknown. An experimental study was designed to compare lumbar spine and hip joint kinematics and coordination in subjects with and without sub-acute low back pain, while picking up an object in a sitting position. A three-dimensional real-time electromagnetic tracking device was used to measure movements of the lumbar spine and hips. Sixty participants with subacute low back pain, with or without straight leg raise signs, and twenty healthy asymptomatic participants were recruited. The ranges of motions of lumbar spine and hips were determined. Movement coordination between the two regions was examined by cross-correlation. Results showed that mobility was significantly reduced in subjects with back pain, who compensated for limited motion through various strategies. The contribution of the lumbar spine relative to that of the hip was, however, found to be similar in all groups. The lumbar spine–hip joint coordination was substantially altered in subjects with back pain, in particular, those with a positive straight leg raise sign. We conclude that changes in the lumbar and hip kinematics were related to back pain and limitation in straight leg raise. Lumbar–hip coordination was mainly affected by the presence of positive straight leg raise sign when picking up an object in a sitting position.     

Extradural inflammation associated with annular tears: demonstration with gadolinium-enhanced lumbar spine MRI

Annular tears are manifest on MRI as the high-intensity zone (HIZ) or as annular enhancement. Patients with annular tears may experience low back pain with radiation into the lower limb in the absence of nerve root compression. Inflammation of nerve roots from leak of degenerative nuclear material through full-thickness annular tears is a proposed mechanism for such leg pain. The aim of this study is to illustrate the appearance of extradural enhancement adjacent to annular tears in patients being investigated for low back pain with radiation into the lower limb(s). Sagittal T1- and T2-weighted spin echo and axial T1-weighted spin echo sequences were obtained in eight patients being investigated for low back and leg pain. In all patients, the T1-weighted sequences were repeated following intravenous gadopentetate dimeglumine (Gd-DTPA). Annular tears were identified at 12 sites in eight patients. Extradural inflammation appeared as a region of intermediate signal intensity replacing the fat between the posterior disc margin and the theca, which enhanced following Gd-DTPA. The inflammatory change was always associated with an annular tear, and in four cases directly involved the nerve root. Enhancement of the nerve root was seen in two cases. The findings may be relevant in the diagnosis of chemical radiculopathy secondary to inflammation at the site of an annular leak from a degenerating disc. Received: 29 June 1998 Revised: 30 September 1998 Accepted: 19 October 1998     

A longitudinal study for incidence of low back pain and radiological changes of lumbar spine in asymptomatic Japanese military young adults

Introduction

The relation between radiological abnormalities on lumbar spine and low back pain (LBP) has been debated, presumably because of potential biases related to heterogeneity in selection of the subjects, radiological abnormalities at entry, or its cross-sectional observation in nature. Therefore, the aim of this study of a selected population of asymptomatic Japanese Self Defense Forces (JSDF) young adults male with normal lumbar radiographs was to investigate the incidence of newly developed lumbar degenerative changes at middle age and to study their association to LBP.

Subjects and methods

In 1990, 84 JSDF male military servicemen aged 18 years, without a history of LBP and radiological abnormal findings, were enrolled. After 20 years, 84 subjects were underwent repeated X-ray and completed questionnaires on current LBP and lifestyle factors.

Results

The prevalence of LBP was demonstrated 59 %, with 85 % of them showing mild pain. Analysis of lumbar radiographs revealed that 48 % had normal findings and 52 % had degenerative changes. The association between LBP and life style factors was not demonstrated. Lumbar spine in subjects with LBP was more degenerated than in those without. Although disc space narrowing and LBP did not achieve a statistical significance, a significant correlation existed between vertebral osteophyte and LBP in univariate and multivariate analysis (OR 3.0; 95 % CI 1.227–7.333).

Discussion and conclusions

This longitudinal study demonstrated the significant association between vertebral osteophyte and incidence of mild LBP in initially asymptomatic and radiologically normal subjects. These data provide the additional information concerning the pathology of LBP, but further study is needed to clarify the clinical relevance.     

Evaluation of a Dallas Pain Questionnaire classification in relation to outcome in lumbar spinal fusion

Several studies have suggested that psychosocial distress is an important predictor of negative outcome in lumbar spine surgery. Ozguler et al. [Spine 27:1783–1789, 2002, 18] described a classification tool for low back pain patients using the Dallas Pain Questionnaire (DPQ) which included a measure of distress. We wanted to evaluate the ability of this classification tool to predict the outcome in spinal fusion patients. Five hundred and sixty-six patients (239 men, 327 women; mean age 46, range 18–81) operated between 1992 and 2002, with a complete DPQ preoperatively and after a minimum of 1-year follow-up, were included. They were classified preoperatively and at follow-up into four groups: group 1 (slight disability), group 2 (intermediate disability), group 3 (major disability) and group 4 (major disability and emotional distress). Using logistic regression, seven predictor variables were investigated: age (−39 years/40–59 years/60+ years), Gender (male/female), Indication (spondylolisthesis/primary degeneration/secondary degeneration), Work status (working/without work or on sick leave/retired or pensioned), Duration of pain (less than 1 year/1–2 years/more than 2 years), Presence of radiating pain (yes/no) and disability/distress [intermediate disability (group 1–2)/major disability (group 3)/major disability and distress (group 4)]. The outcome variable was disability at follow-up (low = group1 + 2/high = group 3 + 4). Preoperative classification was group 1, 1%; group 2, 14%; group 3, 37%; group 4, 48%. Variables found to predict high disability at follow-up were secondary degeneration Odds Ratio (OR) 1.61 (P=0.020), being retired/pensioned OR 3.48 (P<0.0005), age between 40–59 years OR 1.68 (P=0.011), belonging to group 3 OR 2.69 (P=0.003) or belonging to group 4 OR 5.53 (P<0.0005). The classification based on the DPQ were able to identify lumbar spinal fusion patients with a considerable amount of psychological distress in their symptomatology. Furthermore, the presence of distress, as determined by this classification, was a highly significant risk factor for inferior outcome.     

The lumbar spine and low back pain in golf: a literature review of swing biomechanics and injury prevention

BACKGROUND CONTEXT: The golf swing imparts significant stress on the lumbar spine. Not surprisingly, low back pain (LBP) is one of the most common musculoskeletal complaints among golfers. PURPOSE: This article provides a review of lumbar spine forces during the golf swing and other research available on swing biomechanics and muscle activity during trunk rotation. STUDY DESIGN: The role of "modern" and "classic" swing styles in golf-associated LBP, as well as LBP causation theories, treatment, and prevention strategies, are reviewed. METHODS: A PubMed literature search was performed using various permutations of the following keywords: lumbar, spine, low, back, therapy, pain, prevention, injuries, golf, swing, trunk, rotation, and biomechanics. Articles were screened and selected for relevance to injuries in golf, swing mechanics, and biomechanics of the trunk and lumbar spine. Articles addressing treatment of LBP with discussions on trunk rotation or golf were also selected. Primary references were included from the initial selection of articles where appropriate. General web searches were performed to identify articles for background information on the sport of golf and postsurgical return to play. RESULTS: Prospective, randomized studies have shown that focus on the transversus abdominus (TA) and multifidi (MF) muscles is a necessary part of physical therapy for LBP. Some studies also suggest that the coaching of a "classic" golf swing and increasing trunk flexibility may provide additional benefit. CONCLUSIONS: There is a notable lack of studies separating the effects of swing modification from physical rehabilitation, and controlled trials are necessary to identify the true effectiveness of specific swing modifications for reducing LBP in golf. Although the establishment of a commonly used regimen to address all golf-associated LBP would be ideal, it may be more practical to apply basic principles mentioned in this article to the tailoring of a unique regimen for the patient. Guidelines for returning to golf after spine surgery are also discussed.     

Yoga and disc degenerative disease in cervical and lumbar spine: an MR imaging-based case control study

The objective of the current study was to find out whether yoga practice was beneficial to the spine by comparing degenerative disc disease in the spines of long-time yoga practitioners and non-yoga practicing controls, using an objective measurement tool, magnetic resonance imaging. This matched case–control study comprised 18 yoga instructors with teaching experience of more than 10 years and 18 non-yoga practicing asymptomatic individuals randomly selected from a health checkup database. A validated grading scale was used to grade the condition of cervical and lumbar discs seen in magnetic resonance imaging of the spine, and the resulting data analyzed statistically. The mean number of years of yoga practice for the yoga group was 12.9 ± 7.5. The overall (cervical + lumbar) disc scores of the yoga group were significantly lower (indicating less degenerative disc disease) than those of the control group (P < 0.001). The scores for the cervical vertebral discs of the yoga group were also significantly lower than those of the control group (P < 0.001), while the lower scores for the yoga group in the lumbar group approached, but did not reach, statistical significance (P = 0.055). The scores for individual discs of yoga practitioners showed significantly less degenerative disease at three disc levels, C3/C4, L2/L3 and L3/L4 (P < 0.05). Magnetic resonance imaging showed that the group of long-term practitioners of yoga studied had significantly less degenerative disc disease than a matched control group.     

Total disc replacement surgery for symptomatic degenerative lumbar disc disease: a systematic review of the literature

The objective of this study is to evaluate the effectiveness and safety of total disc replacement surgery compared with spinal fusion in patients with symptomatic lumbar disc degeneration. Low back pain (LBP), a major health problem in Western countries, can be caused by a variety of pathologies, one of which is degenerative disc disease (DDD). When conservative treatment fails, surgery might be considered. For a long time, lumbar fusion has been the “gold standard” of surgical treatment for DDD. Total disc replacement (TDR) has increased in popularity as an alternative for lumbar fusion. A comprehensive systematic literature search was performed up to October 2008. Two reviewers independently checked all retrieved titles and abstracts, and relevant full text articles for inclusion. Two reviewers independently assessed the risk of bias of included studies and extracted relevant data and outcomes. Three randomized controlled trials and 16 prospective cohort studies were identified. In all three trials, the total disc replacement was compared with lumbar fusion techniques. The Charité trial (designed as a non-inferiority trail) was considered to have a low risk of bias for the 2-year follow up, but a high risk of bias for the 5-year follow up. The Charité artificial disc was non-inferior to the BAK^® Interbody Fusion System on a composite outcome of “clinical success” (57.1 vs. 46.5%, for the 2-year follow up; 57.8 vs. 51.2% for the 5-year follow up). There were no statistically significant differences in mean pain and physical function scores. The Prodisc artificial disc (also designed as a non-inferiority trail) was found to be statistically significant more effective when compared with the lumbar circumferential fusion on the composite outcome of “clinical success” (53.4 vs. 40.8%), but the risk of bias of this study was high. Moreover, there were no statistically significant differences in mean pain and physical function scores. The Flexicore trial, with a high risk of bias, found no clinical relevant differences on pain and physical function when compared with circumferential spinal fusion at 2-year follow up. Because these are preliminary results, in addition to the high risk of bias, no conclusions can be drawn based on this study. In general, these results suggest that no clinical relevant differences between the total disc replacement and fusion techniques. The overall success rates in both treatment groups were small. Complications related to the surgical approach ranged from 2.1 to 18.7%, prosthesis related complications from 2.0 to 39.3%, treatment related complications from 1.9 to 62.0% and general complications from 1.0 to 14.0%. Reoperation at the index level was reported in 1.0 to 28.6% of the patients. In the three trials published, overall complication rates ranged from 7.3 to 29.1% in the TDR group and from 6.3 to 50.2% in the fusion group. The overall reoperation rate at index-level ranged from 3.7 to 11.4% in the TDR group and from 5.4 to 26.1% in the fusion group. In conclusion, there is low quality evidence that the Charité is non-inferior to the BAK cage at the 2-year follow up on the primary outcome measures. For the 5-year follow up, the same conclusion is supported only by very low quality evidence. For the ProDisc, there is very low quality evidence for contradictory results on the primary outcome measures when compared with anterior lumbar circumferential fusion. High quality randomized controlled trials with relevant control group and long-term follow-up is needed to evaluate the effectiveness and safety of TDR.     

Type 1 Modic changes was a significant risk factor for 1-year outcome in sick-listed low back pain patients: a nested cohort study using magnetic resonance imaging of the lumbar spine

Background contextIt is not clear whether Modic changes (MC) is associated with low back pain (LBP) outcome.PurposeTo study associations between baseline degenerative manifestations and outcome in sick-listed LBP patients.Study designProspective nested cohort study based on a randomized controlled trial.Patient sampleOut of 325 sick-listed LBP patients, 141 were consecutively examined by magnetic resonance imaging (MRI) and included and 140 completed the study.Outcome measuresDegenerative manifestations of the lumbar spine were quantified; associations were studied in relation to the three primary outcomes: change of back+leg pain, change of function as measured by Roland-Morris questionnaire, and 1-year unsuccessful return to work (U-RTW).MethodsBy using a previously validated MRI protocol, a specialist in radiology, who had no access to clinical data, described the images. Associations were studied by linear and logistic regression with adjustment for previously identified prognostic factors for 1-year pain and function and for U-RTW.ResultsClinically, 43% of the patients had radiculopathy. Degenerative changes were prevalent with altered disc contours in 84%, high-intensity zones in 70%, and nerve root touch or impingement in 63% of the patients. MC was identified in 60% of the patients, 18% with Type 1 changes and 42% with Type 2 changes, Type 1 including both Type 1 and Type 1 in combination with Type 2. Patients with Type 1 changes reported more back pain and did not improve in pain or disability. They increased to include 30% of the patients with U-RTW at 1 year. Patients with Type 2 changes did not differ significantly from patients without MC but differed significantly from patients with Type 1 changes in all three outcomes. Other degenerative manifestations were not significantly associated with any of the three outcomes.ConclusionsThe only degenerative manifestation negatively associated with outcome was Type 1 MC that affected 18% of the cohort at baseline and implied an increased risk for no improvement in pain and function and for U-RTW, even after adjustment for other prognostic factors.     

Duration of symptoms as a predictor of outcome after lumbar disc surgery

Summary Retrospectively 93 consecutive patients operated on for lumbar disc herniation were studied in order to evaluate the prognostic value of symptoms (lumbar pain and sciatica) and sick-leave. Surgical results were evaluated 1–3 years postoperatively by a questionaire. The duration of the present attack of sciatica and sick-leave prior to surgery was significantly longer in the group with unsatisfactory outcome compared to the group with satisfactory outcome. Patients with duration of the present attack of sciatica of less than 6 months had a significantly better result concerning outcome compared to patients with duration of 6–12 months and more than 12 months.Patients who returned to the same type of work had a pre-operatively statistically significant shorter duration of present sick-leave, compared to the patients who had changed the type of work and the patients who did not return to work.The patients with duration of their present sick-leave of less than 6 months had a significantly higher percentage of returning to the same type of work compared to patients with duration of their present sick-leave of 6–12 months and more than 12 months.We conclude that the duration of sciatica and sick-leave before the operation has value as predictive factors concerning the over-all result after surgery for lumbar disc herniation.