Lumbar segmental rigidity: can its identification with facet injections and stretching exercises be useful?

OBJECTIVES: To describe a method for observing lumbar segmental rigidity and to show how motion measurements and pain/disability questionnaires can be used to evaluate outcomes of combined facet injections and stretching exercises. DESIGN: Preliminary 2-part study: (1) presentation of a technique for, identifying lumbar segmental rigidity based on physical observation of the spine's lateral bending; and (2) repeated measures of motion and pain/disability self-report in a chronic lumbar spinal disorder cohort, performed before and after treatment with combined facet injections and stretching exercises. SETTING: An outpatient tertiary rehabilitation facility providing interdisciplinary functional restoration for chronic disabling work-related spinal disorders. PATIENTS: Chronically disabled patients with lumbar spinal disorder (n = 39; mean age, 41yr; 82% male) with segmental rigidity at 1 or more levels on physical examination. Subjects averaged 20 months of disability, and 51% had preinjection spine surgery (average, 1.7 procedures involving up to 3 spinal segments). Thirty-nine percent of the cohort had a fusion at levels 1 or 2. INTERVENTIONS: Bilateral facet injections were administered under fluoroscopy to all patients, and 2 or 3 levels were performed in 93% of cases (range, levels 1-4). Patients were instructed in an unsupervised stretching program and were reassessed 2 to 4 weeks later. After an intensive supervised resistance exercise training program as part of interdisciplinary functional restoration, a third set of motion, pain, and disability measures were collected. MAIN OUTCOME MEASURES: Changes in true lumbar sagittal and coronal motion (T12-S1), measured with inclinometers, and pain/disability self-report were compared statistically. RESULTS: Patients' mobility improved significantly (p < .01-.0001) across all 4 motions. A large majority (71%-97%) of individuals improved on motion. According to self-reports made over the postinjection period, most patients improved their disability (83%) and pain intensity (63%) ratings. CONCLUSIONS: A simple physical examination technique for assessing lumbar spine segmental rigidity was used in this preliminary study to select patients and levels for combined facet injection and stretching exercise, with resultant improvements in mobility and self-reported pain/disability that may extend beyond the pharmacologic duration of the corticosteroid. The efficacy of either the facet injection or stretching components alone in achieving objective mobility improvements cannot be determined from the present study, but warrants future investigation.     

Emergency Nurses’ Guide to Neonatal Lumbar Punctures

A neonatal lumbar puncture can present many challenges for emergency nurses that may not be seen with older children or adults. It is imperative that emergency nurses have the knowledge and training related to the procedure to ensure a positive process for the neonate, involved family and health care team members, as well as the overall outcomes of the procedure. This paper provides a practical guide to the essential knowledge for a neonatal lumbar puncture in the emergency department. The main points conveyed in this paper include considerations such as indications for a neonatal lumbar puncture, how to prepare for the procedure, how to position the neonate, possible complications, and caregiver support.     

A Minimally Invasive Treatment for Lumbar Disc Herniation: DiscoGel? Chemonucleolysis in Patients Unresponsive to Chemonucleolysis with Oxygen-Ozone

A multitude of therapies is available to treat disc herniation, ranging from conservative methods (medication and physical therapy) to minimally invasive (percutaneous) treatments and surgery. O?-O? chemonucleolysis (O?-O? therapy) is one of the minimally invasive treatments with the best cost/benefit ratio and lowest complication rate. Another substance recently made available exploiting the chemical properties of pure ethanol is DiscoGel?, a radiopaque gelified ethanol more viscous than absolute alcohol 8,9. The present study aimed to assess the therapeutic outcome of DiscoGel? chemonucleolysis in patients with lumbar disc herniation unresponsive to O?-O? therapy. Thirty-two patients aged between 20 and 79 years were treated by DiscoGel? chemonucleolysis between December 2008 and January 2010. The treatment was successful (improvement in pain) in 24 out of 32 patients. DiscoGel? is safe and easy to handle and there were no complications related to product diffusivity outside the treatment site. The therapeutic success rate of DiscoGel? chemonucleolysis in patients unresponsive to O?-O? therapy was satisfactory. Among other methods used to treat lumbar disc herniation, DiscoGel? chemonucleolysis can be deemed an intermediate procedure bridging conservative medical treatments and surgery.     

Can Physiotherapists Locate Lumbar Spinal Levels by Palpation?

Summary

The ability to identify spinal levels by palpation is a basic skill and a pre-requisite of more complex palpatory tasks of spinal assessment. This study investigated the reliability of palpating lumbar spinal levels, taking into account the dimensions of the lumbar spinous processes. For intra-therapist reliability, three therapists palpated five normal subjects five times; and for intertherapist reliability, 14 physiotherapists palpated five normal subjects once each. The skin overlying the required spinal level was marked with an ultraviolet pen and those marks were transcribed on to clear plastic sheets for analysis. There was only fair agreement between the physiotherapists (kappa = 0.28) and the overall average distance between marks was greater than the height of any lumbar spinous process, indicating that the therapists were often palpating different levels. There was substantial (kappa = 0.61, 0.70) to almost perfect agreement (kappa = 0.90) within therapists. Although the study provided support for the ability of therapists to re-palpate the same spinal level within a session, the lack of inter-therapist reliability suggests that further research into the reliability of spinal palpation is required if it is to remain an important component of spinal therapy.     

Lumbar disc replacement surgery—successes and obstacles to widespread adoption

Purpose of review

Lumbar disc replacement has been a surgical alternative to fusion surgery for the treatment of lumbar degenerative disc disease (DDD) for many years. Despite enthusiasm after the approval of the first devices, implantation rates have remained low, especially in the USA. The goal of this review is to provide a general overview of lumbar disc replacement in order to comprehend the successes and obstacles to widespread adoption.

Recent findings

Although a large amount of evidence-based data including satisfactory long-term results is available, implantation rates in the USA have not increased in the last decade. Possible explanations for this include strict indications for use, challenging surgical techniques, lack of device selection, fear of late complications or revision surgeries, and reimbursement issues.

Summary

Recent publications can address some of the past concerns, but there still remain obstacles to widespread adoption. Upcoming data on long-term outcome, implant durability and possible very late complications will determine the future of lumbar disc replacement surgery.

     

Pain Management Practices for Lumbar Punctures: Are We Consistent?

In most pediatric oncology centers across Canada, it is now standard practice for children to be sedated for lumbar punctures (LPs). Although the use of sedation for LPs is well established in the pediatric oncology population, its use in other hospital units is not well documented. A patient record audit was completed to understand the types of pain management strategies used for LPs performed throughout a pediatric hospital. Fifty-nine patients aged between 3 days and 17 years underwent a total of 67 LPs. Pain management strategies varied among the different patient service units. Oncology patients were consistently sedated for an LP, whereas patients in the emergency department were less likely to be given any type of sedation. Recommendations are aimed at providing consistent best practice pain management for LPs throughout the hospital.     

Lumbar spinal stenosis patients are satisfied with short-term results of surgery – younger age,symptom severity,disability and depression decrease satisfaction

Purpose. To study the lumbar spinal stenosis (LSS) patients' (n = 98) satisfaction with surgery outcome and associated factors at three months post-operative stage.

Method. LSS-related physical functioning and pain were assessed with Oswestry disability index, Stucki questionnaire, Visual Analogue Scale and pain drawings. Depression was assessed with 21-item Beck Depression Inventory. Psychological well-being was assessed with the Life satisfaction scale, Toronto Alexithymia Scale and Sense of Coherence Scale. All questionnaires were administered before and 3 months after surgical treatment of LSS. Satisfaction with surgery outcome was assessed with a separate scale.

Results. Considerable improvement was evident in all the functional and pain-related variables. Two-thirds (66%) of the patients were at least clearly satisfied with the surgery outcome. Younger age, symptom severity, disability and depression were independently associated with dissatisfaction with surgery outcome.

Conclusion. The lack of physical, functional and emotional well-being is associated with the patients' dissatisfaction with the surgery outcome. Patient satisfaction is a valid outcome to be measured in LSS patients undergoing surgery. It is recommended that patients should be provided with realistic pre-operative patient information and that depression be assessed pre-operatively.     

Analysis of Gene Expression Pattern of Lumbar Intervertebral Disc Degeneration in Human

Intervertebraldiscdegenerationisthemainreasonofthe outbreakofvertebralcolumndegeneration.Theexpertsdomes ticandoverseahavestudiedthisdiseasefromtheanglesofanat omy,biochemistry,molecularbiologyandsoon.Butthedetails oftheintervertebraldiscdegenerationmechanismhavenotbeen explained.Inthisstudy,weadopt4096cDNAmicroarraysof humangenes,settingthedegeneratedintervertebraldiscfrom theclinicalsurgeryastheobjectstostudythecDNAmicroarray ofhumandegeneratedintervertebraldisc,andtosettlethefoun dationfo…     

Symptomatic Magnetic Resonance Imaging–Confirmed Lumbar Disk Herniation Patients: A Comparative Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either High-Velocity,Low-Amplitude Spinal Manipulative Therapy or Imaging-Guided Lumbar Nerve Root Injections

ObjectivesThe purpose of this study was to compare self-reported pain and “improvement” of patients with symptomatic, magnetic resonance imaging–confirmed, lumbar disk herniations treated with either high-velocity, low-amplitude spinal manipulative therapy (SMT) or nerve root injections (NRI).MethodsThis prospective cohort comparative effectiveness study included 102 age- and sex-matched patients treated with either NRI or SMT. Numerical rating scale (NRS) pain data were collected before treatment. One month after treatment, current NRS pain levels and overall improvement assessed using the Patient Global Impression of Change scale were recorded. The proportion of patients, “improved” or “worse,” was calculated for each treatment. Comparison of pretreatment and 1-month NRS scores used the paired t test. Numerical rating scale and NRS change scores for the 2 groups were compared using the unpaired t test. The groups were also compared for “improvement” using the χ² test. Odds ratios with 95% confidence intervals were calculated. Average direct procedure costs for each treatment were calculated.ResultsNo significant differences for self-reported pain or improvement were found between the 2 groups. “Improvement” was reported in 76.5% of SMT patients and in 62.7% of the NRI group. Both groups reported significantly reduced NRS scores at 1 month (P = .0001). Average cost for treatment with SMT was Swiss Francs 533.77 (US $558.75) and Swiss Francs 697 (US $729.61) for NRI.ConclusionsMost SMT and NRI patients with radicular low back pain and magnetic resonance imaging–confirmed disk herniation matching symptomatic presentation reported significant and clinically relevant reduction in self-reported pain level and increased global perception of improvement. There were no significant differences in outcomes between NRI and SMT. When considering direct procedure costs, the average cost of SMT was slightly less expensive.     

Which Neuromuscular Attributes Are Associated With Changes in Mobility Among Community-Dwelling Older Adults With Symptomatic Lumbar Spinal Stenosis?

Objectives

To identify neuromuscular attributes associated with mobility and changes in mobility over 2 years of follow-up among patients with and without symptomatic lumbar spinal stenosis (SLSS).

Lebanese parents’ experiences with a child with cancer

BackgroundThe impact of childhood cancer on the family has been studied in different cultures and continues to be an object of study and concern, In Lebanon, a country of 4 million people 282 new pediatric cases of cancer age <20 years diagnosed in 2004 were reported in 2008.ObjectivesThe purpose of this study was to explore the experiences of Lebanese families living with a child with cancer.MethodThe study followed purposeful sampling in which 12 parents (mother or father) of a child with cancer were interviewed. Data were analyzed following the hermeneutical process as described by Diekelmann and Ironsides (1998).ResultsA constitutive pattern “It is a continuous battle” and five themes emerged from the data analysis. Living with the shock of the diagnosis; Alterations in the quality of the family’s life; Living with added burdens; Disease impact on the family and sibling dynamics; Living with uncertainty represent the major themes that emerged from the participants’ experiences while living with a child with cancer.ConclusionThe study contributes to the knowledge that would help health care professionals understand the experiences and challenges that are faced by Lebanese families living with a child with cancer. This awareness would serve as a basis for health care professionals in general and nurses in particular to understand parents’ experiences, and offer support, elicit communication of feelings, and examine possibilities for forming a partnership during the challenging course of the child’s illness. Supported parents are more likely to provide more effective care to their child with cancer.     

Side-shifting hemicrania continua with aura (migraine with aura with autonomic symptoms responsive to indomethacin?)

Atypical features of hemicrania continua (HC), including both visual aura and side shifting, have been reported previously. However, auras and variable unilaterality have never been reported together in HC. We report two patients with side-shifting HC with aura. These patients' symptoms are unilateral headaches, visual aura, autonomic features, throbbing pain, nausea and photo/phonophobia. One could speculate that the unilaterality and/or the autonomic symptom modules are indomethacin responsive. The patients can also be classified as chronic migraine with aura, with autonomic symptoms, responsive to indomethacin. Neither migraine subtype nor side-shifting HC with aura is included in the current International Headache Society (IHS) classification, so these patients are not classifiable. Side-shifting HC with aura implies the need to revisit the traditional IHS categorization of headaches into unique diagnostic groups. The modular headache theory may be a tool for the understanding of these rare and complex cases.