Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.

BACKGROUND: The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care. AIM: To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs). DESIGN OF STUDY: Group randomised controlled trial, using the health centre as the unit of randomisation. SETTING: Primary care teams in north-west England. METHOD: Twenty-four health centres were randomly allocated to an intervention or control arm. Practices in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain, as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms. RESULTS: Twenty-four centres were randomised. Two thousand, one hundred and eighty-seven eligible patients presented with acute low back pain during the study period: 1049 in the intervention group and 1138 in the control group. There were no significant differences between study groups in the proportion of patients who were referred for X-ray, issued with a sickness certificate, prescribed opioids or muscle relaxants, or who were referred to secondary care, but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit (difference in proportion = 12.2%, 95% confidence interval [CI] = 2.8% to 21.6%). CONCLUSION: The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs. An increase in referral to physiotherapy or educational programmes followed the provision of a triage service.     

Primary care referrals for lumbar spine radiography: diagnostic yield and clinical guidelines.

BACKGROUND: Primary care requests for radiographs of the lumbar spine have come under increasing scrutiny. Guidelines aiming to reduce unnecessary radiographs by limiting referrals to patients at high risk of serious disease have been widely distributed. Trial evidence suggests that guidelines can reduce radiography referrals. It is not clear whether this reduction has been achieved in routine practice. AIM: This study, using routine data, was conducted to measure trends in pnmary care referrals for lumbar spine radiography at two hospitals between 1994 and 1999. DESIGN OF STUDY: Analysis of primary care requests for lumbar spine radiography from computerised records. SETTING: Addenbrooke's Hospital, Cambridge (1 July 1994 to 30 June 1999), and Ipswich General Hospital (1 July 1995 to 30 June 1999), United Kingdom. METHOD: All primary care requests for lumbar radiography were identified electronically from computerised information systems. A random sample of 2100 radiography reports were classified according to clinical importance. These classifications were used to examine whether the proportion of radiographs demonstrating potentially more serious findings had increased between 1994 and 1999. RESULTS: There was no evidence that primary care referrals for radiography of the lumbar spine had decreased between 1994 and 1999 at either hospital. General practitioners did not progressively refer more high-risk patients for lumbar radiography. Only a small proportion of patients had important radiographic findings that might warrant specialist referral or specific therapy. CONCLUSION: The implementation of diagnostic guidelines offers much to the NHS. However in these two hospitals, the reduction in radiograph utilisation evident in trials was not achieved. Guideline development is a resource intensive process; distribution must be supported by more effective implementation strategies.     

Screening of lower back pain, low back pain clinic. The clinical experience

Acute low back pain is a common complaint with high prevalence in society. Orthopaedic and specialist spinal services may be overwhelmed by large numbers of patients with low back pain who do not require investigation or surgical intervention. This phenomenon has led to the establishment of back pain screening clinics as a system of triage for those with acute low back pain. In March 2001, a back pain screening clinic was established in the Adelaide and Meath Hospitals incorporating the National Children's hospital. Six hundred and sixty-five patients were seen in the first year of this clinic. Of these, only ninety-six required referral to the orthopaedic spinal clinic. Just twenty-nine of these patients required surgical intervention. The introduction of this service resulted in a reduction in the waiting periods for the specialised spine clinic. We conclude that back pain screening clinics result in a clinical and economical improvement in the care of those suffering from acute low back pain. This is achieved by the systematic and efficient assessment, treatment and referral of patients afflicted with acute low back pain.     

Frequency and costs of diagnostic imaging in office practice--a comparison of self-referring and radiologist-referring physicians

BACKGROUND. To assess possible differences in physicians' practices with respect to diagnostic imaging, we compared the frequency and costs of imaging examinations as performed by primary physicians who used imaging equipment in their offices (self-referring) and as ordered by physicians who always referred patients to radiologists (radiologist-referring). METHODS. Using a large, private insurance-claims data base, we analyzed 65,517 episodes of outpatient care by 6419 physicians for acute upper respiratory symptoms, pregnancy, low back pain, or (in men) difficulty urinating. The respective imaging procedures studied were chest radiography, obstetrical ultrasonography, radiography of the lumbar spine, and excretory urography, cystography, or ultrasonography. RESULTS. For all four clinical presentations, the self-referring physicians obtained imaging examinations 4.0 to 4.5 times more often than the radiologist-referring physicians (P less than 0.0001 for all four). For chest radiography, obstetrical ultrasonography, and lumbar spine radiography, the self-referring physicians charged significantly more than the radiologists for imaging examinations of similar complexity (P less than 0.0001 for all three). The combination of more frequent imaging and higher charges resulted in mean imaging charges per episode of care that were 4.4 to 7.5 times higher for the self-referring physicians (P less than 0.0001). These results were confirmed in a separate analysis that controlled for the specialty of the physician. CONCLUSIONS. Physicians who do not refer their patients to radiologists for medical imaging use imaging examinations more frequently than do physicians who refer their patients to radiologists, and the charges are usually higher when the imaging is done by the self-referring physician. From our results it is not possible to determine which group of physicians uses imaging more appropriately.     

Activity Increase Despite Arthritis (A?DA): phase II randomised controlled trial of an active management booklet for hip and knee osteoarthritis in primary care

Background

The Hip & Knee Book: Helping you cope with osteoarthritis was developed to change disadvantageous beliefs and encourage physical activity in people with hip or knee osteoarthritis.

Aim

To assess the feasibility of conducting a definitive randomised controlled trial (RCT) of this evidence-based booklet in people with hip or knee osteoarthritis.

Design

Phase II feasibility randomised controlled trial (RCT).

Method

Computerised searches of patients'' record databases identified people with osteoarthritis of the hip or knee, who were invited to participate in the RCT comparing the new booklet with a control booklet. Outcomes were measured at baseline, 1 month, and 3 months, and included: beliefs about hip and knee pain, exercise, and fear avoidance; level of physical activity; and health service use.

Results

The trial methods were feasible in terms of recruitment, randomisation, and follow-up, but most participants recruited had longstanding established symptoms. After one and 3 months, there was a small relative improvement in illness, exercise, and fear-avoidance beliefs and physical activity level in The Hip & Knee Book group (n = 59) compared with the control group (n = 60), which provides some proof of principle for using these outcomes in future trials.

Conclusion

This feasibility study provided proof of principle for testing The Hip & Knee Book in a larger definitive RCT.     

汽车驾驶员腰椎保护带的振动防护效应测试及其生物力学作用分析

通过对汽车驾驶员腰部振动的测试 ,了解腰椎保护带对振动的防护效应并对其生物力学作用进行分析。以日本产五十铃八吨载重卡车 (TDG72 )为测试车型。在装载六吨货物以三种不同车速 (10、30、6 0 km/ h)行进在柏油公路时 ,分别在佩带和不佩带腰椎保护带的情况下 ,对驾驶员腰椎部位垂直振动和水平纵向振动进行实时测量 (传感器安置于裤腰带和保护带的背外侧 )。结果显示 :1驾驶员腰部振动频率多为 10 Hz以下 ,属低频振动 ;2垂直振动大于水平纵向振动 ;3系腰椎保护带时的振动测量值大于不系腰椎保护带的测量值。由于腰椎保护带改变了脊柱的生物力学和振动特性 ,从而起到了保护腰椎的作用。我们认为它是防治汽车驾驶员腰痛的良好方法之一。     

Analysis of Efficacy Differences between Caudal and Lumbar Interlaminar Epidural Injections in Chronic Lumbar Axial Discogenic Pain: Local Anesthetic Alone vs. Local Combined with Steroids

Study Design: Comparative assessment of randomized controlled trials of caudal and lumbar interlaminar epidural injections in chronic lumbar discogenic pain.Objective: To assess the comparative efficacy of caudal and lumbar interlaminar approaches of epidural injections in managing axial or discogenic low back pain.Summary of Background Data: Epidural injections are commonly performed utilizing either a caudal or lumbar interlaminar approach to treat chronic lumbar axial or discogenic pain, which is pain exclusive of that associated with a herniated intervertebral disc, or that is due to degeneration of the zygapophyseal joints, or due to dysfunction of the sacroiliac joints, respectively. The literature on the efficacy of epidural injections in managing chronic axial lumbar pain of presumed discogenic origin is limited.Methods: The present analysis is based on 2 randomized controlled trials of chronic axial low back pain not caused by disc herniation, radiculitis, or facet joint pain, utilizing either a caudal or lumbar interlaminar approach, with a total of 240 patients studied, and a 24-month follow-up. Patients were assigned to receive either local anesthetic only or local anesthetic with a steroid in each 60 patient group.Results: The primary outcome measure was significant improvement, defined as pain relief and functional status improvement of at least 50% from baseline, which was reported at 24-month follow-ups in 72% who received local anesthetic only with a lumbar interlaminar approach and 54% who received local anesthetic only with a caudal approach. In patients receiving local anesthetic with a steroid, the response rate was 67% for those who had a lumbar interlaminar approach and 68% for those who had a caudal approach at 12 months. The response was significantly better in the lumbar interlaminar group who received local anesthetic only, 77% versus 56% at 12 months and 72% versus 54% at 24 months.Conclusion: This assessment shows that in patients with axial or discogenic pain in the lumbar spine after excluding facet joint and SI Joint pain, epidural injections of local anesthetic by the caudal or lumbar interlaminar approach may be effective in managing chronic low back pain with a potential superiority for a lumbar interlaminar approach over a caudal approach.     

Role of the sinu-vertebral nerve in low back pain and anatomical basis of therapeutic implications

Low back pain is frequent and results in major disability for patients. This anatomical study was done to understand mechanisms involved in that pain. Two kinds of innervation are present in the lumbar spine: one depends on the somatic nervous system and the other on the sympathetic nervous system. The sympathetic nerves are the sinu-vertebral nerves and the rami communicantes which innervate the intervertebral disc, the ventral surface of the dura mater, the longitudinal dorsal ligament and the longitudinal ventral ligament. The sinu-vertebral nerve was described first by Luschka in 1850. This nerve is implicated in diffuse low back pain because of its pathway and its sympathetic component. This nerve cannot directly reach a somatic element at each level of the lumbar spine, so must first reach the L2 spinal ganglion. Thus, there is a "hole" in the somatic innervation between L3 and L5 because the dorsal nerves do not reach the skin at these levels. The pain therefore takes another route through the sympathetic system. Discogenic pain is mediated by the sinu-vertebral nerves, and through the rami communicantes reaches the L2 spinal ganglion. Anatomical and clinical features reinforce this hypothesis.     

Jogging Kinematics After Lumbar Paraspinal Muscle Fatigue

Context:

Isolated lumbar paraspinal muscle fatigue causes lower extremity and postural control deficits.

Objective:

To describe the change in body position during gait after fatiguing lumbar extension exercises in persons with recurrent episodes of low back pain compared with healthy controls.

Design:

Case-control study.

Setting:

Motion analysis laboratory.

Patients or Other Participants:

Twenty-five recreationally active participants with a history of recurrent episodes of low back pain, matched by sex, height, and mass with 25 healthy controls.

Intervention(s):

We measured 3-dimensional lower extremity and trunk kinematics before and after fatiguing isometric lumbar paraspinal exercise.

Main Outcome Measure(s):

Measurements were taken while participants jogged on a custom-built treadmill surrounded by a 10-camera motion analysis system.

Results:

Group-by-time interactions were observed for lumbar lordosis and trunk angles (P < .05). A reduced lumbar spine extension angle was noted, reflecting a loss of lordosis and an increase in trunk flexion angle, indicating increased forward trunk lean, in healthy controls after fatiguing lumbar extension exercise. In contrast, persons with a history of recurrent low back pain exhibited a slight increase in spine extension, indicating a slightly more lordotic position of the lumbar spine, and a decrease in trunk flexion angles after fatiguing exercise. Regardless of group, participants experienced, on average, greater peak hip extension after lumbar paraspinal fatigue.

Conclusions:

Small differences in response may represent a necessary adaptation used by persons with recurrent low back pain to preserve gait function by stabilizing the spine and preventing inappropriate trunk and lumbar spine positioning.     

Wallis 棘突间动态稳定系统治疗腰椎管狭窄症的临床疗效观察

目的　探讨Wallis棘突间动态稳定系统(简称Wallis系统)治疗腰椎管狭窄症的临床疗效。  方法 　2010年10月～2012年5月,应用Wallis系统治疗腰椎管狭窄症27例。观察手术时间、出血量、术后住院时间、术后并发症,比较术前、术后1周、术后3个月、1年随访时下腰痛JOA评分、腰腿痛VAS 评分、Oswestry 功能障碍指数情况( ODI)及X 线片上手术节段椎间隙高度( intervertebral disc height,IDH)变化。  结果　平均手术时间70 min,术中出血量100 ml,术后住院时间4 d,术后未发现假体移位、棘突骨折等并发症。所有患者术后症状明显改善,术后1周、3 个月及1年随访时下腰痛JOA评分、腰腿痛VAS 评分、Oswestry 功能障碍指数情况( ODI)与术前比较均有统计学差异（P<0.01）。术后1周随访时手术节段椎间隙与术前相比有统计学差异（P<0.01）,术后3个月及1年随访时手术节段椎间隙与术前相比无统计学差异（P>0.05）。  结论　Wallis系统治疗腰椎管狭窄症,创伤小、恢复快,临床效果满意,为腰椎管狭窄疾病的手术治疗提供了一种新的选择。     

“腰三针”干预腰多裂肌损伤大鼠多种氧化应激因子的表达

文题释义：多裂肌：是椎旁肌群中的重要肌肉之一,对脊柱稳定性的维持有重要作用。在腰椎后路手术过程中,多裂肌也是最容易被损伤的肌肉之一。 腰三针：由肾俞穴、大肠俞穴和委中穴组成,是临床治疗腰椎间盘突出症、椎管狭窄、腰肌劳损等腰部相关疾病的重要穴位。 氧化应激：是指机体氧化与抗氧化失衡,活性氧自由基生成与堆积过多,伴或不伴抗氧化能力下降引起的细胞化学损害及功能障碍。氧化应激和炎症反应可相互作用发生,氧化应激可诱发炎症,炎症亦可加重氧化应激。 背景：腰椎后路手术是目前临床进行诸多手术如椎间盘切除、椎管减压等的主要手术入路,但有10%-40%的腰椎后路手术患者在术后不久可再次出现腰背部疼痛及相关功能障碍,这与手术过程中对椎旁肌如多裂肌的过度牵拉或钝性损伤有关。 目的：观察腰三针对大鼠腰多裂肌损伤后氧化应激因子丙二醛、活性氧、超氧化物歧化酶、谷胱甘肽过氧化物酶及磷酸化蛋白激酶B表达的影响。方法：将24只雄性SD大鼠随机分为3组,每组8只。模型组、腰三针组分别采用0.5%布比卡因盐酸盐肌内注射复制大鼠腰多裂肌损伤模型;对照组予生理盐水肌内注射。对照组与模型组造模后不进行针刺干预,腰三针组造模后给予针刺靳三针之“腰三针”,即大肠俞、肾俞、委中,针刺后连接电针,波形选用疏密波,电针频率采用2 Hz/10 Hz,电流强度选择1 mA,持续干预20 min,每天干预1次,共干预7 d。电针干预7 d后,通过苏木精-伊红染色观察损伤部位多裂肌形态学变化,采用试剂盒检测各组大鼠多裂肌中丙二醛、活性氧、超氧化物歧化酶、谷胱甘肽过氧化物酶的表达;采用Western-blot法检测多裂肌中磷酸化蛋白激酶B蛋白的表达。实验经广东省第二中医院实验动物伦理委员会批准,伦理批准号：048617。结果与结论：①苏木精-伊红染色显示,干预7 d后,模型组可见肌纤维损伤明显,但已出现部分修复,但炎性细胞数量仍较多;腰三针组可出现较多新生的肌纤维,炎性细胞明显减少;②腰三针组肌纤维横截面积明显优于模型组(P < 0.01);③干预后,模型组丙二醛、活性氧表达量明显高于对照组(P < 0.01);腰三针组丙二醛、活性氧表达明显低于模型组(P < 0.01),超氧化物歧化酶、谷胱甘肽过氧化物酶表达高于模型组(P < 0.01或P < 0.05);腰三针组磷酸化蛋白激酶B蛋白表达明显高于模型组(P < 0.01);④结果说明,腰三针干预可显著降低多裂肌损伤后氧化应激水平,可能与提高磷酸化蛋白激酶B的表达有关。 ORCID: 0000-0003-3561-0602(白振军) 中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程     

The Short-Term Effects of Joint Mobilizations on Acute Mechanical Low Back Dysfunction in Collegiate Athletes

Context: Although a variety of theories and studies have been cited to support the use of joint mobilization in the spine as an integral part of the treatment and rehabilitation process, information about the short-term effects of joint mobilization on acute low back injury with respect to patient pain and strength changes has been limited.Objective: To examine the short-term effects of grade 1 and 2 posteroanterior joint mobilizations at the lumbar spine on subject pain and muscle force after an episode of acute, mechanical low back pain.Design: Group (2) by time (2 or 3).Setting: Athletic training clinic.Patients or Other Participants: Male collegiate athletes (n = 19) with mechanical low back pain as assessed through a standardized evaluation were randomly assigned to a control (n = 10) or experimental (n = 9) group.Intervention(s): All subjects underwent a standardized treatment protocol of cryotherapy and stretching during data collection. Subjects completed the McGill Pain Questionnaire and a visual analog scale (the latter to assess pain levels during range-of-motion activities) and, using a handheld dynamometer, performed 3 maximum voluntary isometric contractions to determine muscle force. Grade 1 and 2 joint mobilizations were administered to the experimental group, whereas the control group was placed in a prone position of comfort for the time it took to perform the joint mobilizations.Main Outcome Measure(s): Baseline, immediate posttreatment, and 24-hour posttreatment measurements of pain and muscle force were taken.Results: Compared with the control group, the experimental group demonstrated significant decreases in the sensory subscale scores of the McGill Pain Questionnaire and in pain during lumbar extension and a significant increase in force production.Conclusions: Grade 1 and 2 joint mobilizations reduced subjects' pain and increased force production in the short-term stages of mechanical low back pain.     

Evaluation of Lumbar Facet Joint Nerve Blocks in Managing Chronic Low Back Pain: A Randomized,Double-Blind,Controlled Trial with a 2-Year Follow-Up

Study Design: A randomized, double-blind, controlled trial.Objective: To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks with or without steroids in managing chronic low back pain of facet joint origin.Summary of Background Data: Lumbar facet joints have been shown as the source of chronic pain in 21% to 41% of low back patients with an average prevalence of 31% utilizing controlled comparative local anesthetic blocks. Intraarticular injections, medial branch blocks, and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin.Methods: The study included 120 patients with 60 patients in each group with local anesthetic alone or local anesthetic and steroids. The inclusion criteria was based upon a positive response to diagnostic controlled, comparative local anesthetic lumbar facet joint blocks.Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months.Results: Significant improvement with significant pain relief of ≥ 50% and functional improvement of ≥ 40% were observed in 85% in Group 1, and 90% in Group II, at 2-year follow-up.The patients in the study experienced significant pain relief for 82 to 84 weeks of 104 weeks, requiring approximately 5 to 6 treatments with an average relief of 19 weeks per episode of treatment.Conclusions: Therapeutic lumbar facet joint nerve blocks, with or without steroids, may provide a management option for chronic function-limiting low back pain of facet joint origin.     

Posterior lumbar interbody fusion via a unilateral approach

This study sought to determine the outcomes of posterior lumbar interbody fusion (PLIF), via a unilateral approach, in selected patients who presented with unilateral leg pain and segmental instability of the lumbar spine. Patients with a single level of a herniated disc disease in the lumbar spine, unilateral leg pain, chronic disabling lower back pain (LBP), and a failed conservative treatment, were considered for the procedure. A total of 41 patients underwent a single-level PLIF using two PEEK (Poly-Ether-Ether-Ketone) cages filled with iliac bone, via a unilateral approach. The patients comprised 21 women and 20 men with a mean age of 41 years (range: 22 to 63 years). Two cages were inserted using a unilateral medial facetectomy and a partial hemilaminectomy. At follow-up, the outcomes were assessed using the Prolo Scale. The success of the fusion was determined by dynamic lumbar radiography and/or computerized tomography scanning. All the patients safely underwent surgery without severe complications. During a mean follow-up period of 26 months, 1 patient underwent percutaneous pedicle screw fixation due to persistent LBP. A posterior displacement of the cage was found in one patient. At the last follow up, 90% of the patients demonstrated satisfactory results. An osseous fusion was present in 85% of the patients. A PLIF, via a unilateral approach, enables a solid union with satisfactory clinical results. This preserves part of the posterior elements of the lumbar spine in selected patients with single level instability and unilateral leg pain.     

腰椎椎弓根应力性骨折：1例报道及文献复习

目的　探讨腰椎椎弓根应力性骨折诊断和治疗特点。  方法　回顾分析1例腰椎椎弓根应力性骨折。男性,36岁,柔道运动爱好者,一次柔道练习时感腰痛和腰部活动受限,无神经根刺激症,X线平片未见明显椎弓根骨折,经CT诊断为第五腰椎右侧椎弓根不全性应力性骨折,ODI评分为46%,采取佩戴脊柱支具保守治疗。  结果　6个月后椎弓根骨折愈合,腰痛消失,恢复脊柱正常功能,ODI评分恢复至4%。随访至24个月,患者ODI评分无改变。  结论　腰椎椎弓根应力性骨折发生于脊柱活动量大和重复性多的年轻人,主要外力是扭转力。对于无神经根刺激症的腰椎椎弓根不全性应力性骨折,佩戴脊柱支具保守治疗,效果良好。     

Role of the sinu-vertebral nerve in low back pain and anatomical basis of therapeutic implications

Low back pain is frequent and results in major disability for patients. This anatomical study was done to understand mechanisms involved in that pain. Two kinds of innervation are present in the lumbar spine: one depends on the somatic nervous system and the other on the sympathetic nervous system. The sympathetic nerves are the sinu-vertebral nerves and the rami communicantes which innervate the intervertebral disc, the ventral surface of the dura mater, the longitudinal dorsal ligament and the longitudinal ventral ligament. The sinu-vertebral nerve was described first by Luschka in 1850. This nerve is implicated in diffuse low back pain because of its pathway and its sympathetic component. This nerve cannot directly reach a somatic element at each level of the lumbar spine, so must first reach the L2 spinal ganglion. Thus, there is a "hole" in the somatic innervation between L3 and L5 because the dorsal nerves do not reach the skin at these levels. The pain therefore takes another route through the sympathetic system. Discogenic pain is mediated by the sinu-vertebral nerves, and through the rami communicantes reaches the L2 spinal ganglion. Anatomical and clinical features reinforce this hypothesis. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer Link server at http://dx.doi.org/10.1007/s00276-002-0084-8.     

Outcome of general practitioner referrals to specialist outpatient clinics for back pain.

In 1983-84 general practitioners in the Oxford region kept records of their referrals to outpatient clinics over a period of six months. Five years later in 1988-89 the general practice notes of 182 patients referred for back pain were studied to determine the outcomes of their referral. The actions initiated in the outpatient clinics were compared with the general practitioners' main reason for referral recorded at the time of referral. Of the 182 patients 136 (74.7%) received specialist treatment following the outpatient referral despite the fact that general practitioners had given treatment as the main reason for referral in only 28.6% of cases. Patients' mean consultation rate for back pain declined from 4.2 consultations per annum to 0.9 (P less than 0.001) over the five year period, but there was a small but significant increase in consultations for other problems. Five years after the referral 33.3% of patients were still consulting their general practitioner for back pain. The referral system for patients with chronic back pain could be rationalized to reduce the need for re-referrals and multiple follow-up outpatient consultations. There is a need to improve communications between general practitioners, specialists and patients about the purpose of referral, the likely effects of treatment and the scope for prevention. A survey of the outcome of referrals for common conditions, such as back pain, is a useful first step in the development of referral guidelines.     

Clinical incidence of sacroiliac joint arthritis and pain after sacropelvic fixation for spinal deformity

Purpose

Sacroiliac fixation using iliac screws for highly unstable lumbar spine has been reported with an improved fusion rate and clinical results. On the other hand, there is a potential for clinical problems related to iliac fixation, including late sacroiliac joint arthritis and pain.

Materials and Methods

Twenty patients were evaluated. Degenerative scoliosis was diagnosed in 7 patients, failed back syndrome in 6 patients, destructive spondyloarthropathy in 4 patients, and Charcot spine in 3 patients. All patients underwent posterolateral fusion surgery incorporating lumbar, S1 and iliac screws. We evaluated the pain scores, bone union, and degeneration of sacroiliac joints by X-ray imaging and computed tomography before and 3 years after surgery. For evaluation of low back and buttock pain from sacroiliac joints 3 years after surgery, lidocaine was administered in order to examine pain relief thereafter.

Results

Pain scores significantly improved after surgery. All patients showed bone union at final follow-up. Degeneration of sacroiliac joints was not seen in the 20 patients 3 years after surgery. Patients showed slight low back and buttock pain 3 years after surgery. However, not all patients showed relief of the low back and buttock pain after injection of lidocaine into the sacroiliac joint, indicating that their pain did not originate from sacroiliac joints.

Conclusion

The fusion rate and clinical results were excellent. Also, degeneration and pain from sacroiliac joints were not seen within 3 years after surgery. We recommend sacroiliac fixation using iliac screws for highly unstable lumbar spine.     

Understanding quality of life in patients with colorectal cancer: comparison of data from a randomised controlled trial,a population based cohort study and the norm reference population

Background and aims:Quality of life (QoL) is an important outcome measure in clinical studies. However, there is little experience with the interpretation of QoL results. Methods:To guide interpretation of QoL results from a randomised controlled trial (RCT) targeting the effectiveness of the immune modulator G-CSF on postoperative recovery in high risk (ASA III/IV) colorectal cancer patients, we compared RCT data with data from a population based cohort study and norm reference data. QoL was assessed using the European Organisation for the Research and Treatment of Cancer (EORTC) QLQ-C30 and CR38 questionnaires. QoL results were analysed on discharge from hospital and six months postoperatively. Results:Colorectal cancer patients (both from the RCT and the cohort study) showed the greatest differences in QoL scores compared to norm reference data at discharge from hospital. Six months postoperatively, global quality of life and pain approximated norm reference values indicating optimal recovery. However, deficits still appeared in scores for role functioning, physical functioning, social functioning and fatigue. The best improvements (discharge from hospital to six months postoperatively) were seen with respect to physical functioning, fatigue and pain. Conclusions:For further analysis of RCT data, physical functioning and fatigue scores may be more sensitive than global quality of life to detect differences in treatment effects.