Correlation of pain, functional impairment, and health-related quality of life with radiological grading scales of lumbar degenerative disc disease

Pain Relief and Safety of Microwave Ablation Combined with Percutaneous Vertebroplasty for Vertebral Metastasis: A Pilot Study

BACKGROUND

 We investigate the pain relief and safety of microwave ablation (MWA) combined with percutaneous vertebroplasty (PVP) in the treatment of metastatic vertebral tumors.

METHODS

 This prospective pilot study enrolled patients with metastatic vertebral tumors treated between January 2018 and October 2019. The participants were randomized to the PVP and MWA + PVP groups. Clinical parameters, pain visual analog scale (VAS), analgesic use scores (AUS), and quality-of-life score (QLS) were compared between groups.

RESULTS

 Sixty-seven participants were enrolled (PVP: n = 35; MWA + PVP: n = 32). There were no differences in bone cement injection volume, extravasation, and X-ray exposure time between the two groups (p > 0.05), but treatment costs were higher for the MWA + PVP group (26,418 ± 194 vs. 15,606 ± 148 yuan; p < 0.05). There were no significant improvements in VAS from baseline to 24 hours, 72 hours, 7 days, 1 month, and 3 months in the two groups (p > 0.05); at 6 and 12 months after the operation, the improvement from baseline was significant in the two groups (p < 0.05). The VAS was lower at 6 months (2.7 ± 0.7 vs. 3.2 ± 0.7) and 12 months (3.5 ± 0.8 vs. 4.0 ± 0.7) in the MWA + PVP group (both p < 0.01 vs. PVP). The AUS and QLS were improved with PVP at 6 and 12 months (p < 0.05) and with MWA + PVP at 12 months (p < 0.05). The AUS was lower at 6 and 12 months in the MWA + PVP group (p < 0.05 vs. PVP).

CONCLUSION

 MWA combined with PVP might be a safe and effective palliative treatment for pain from metastatic vertebral tumors.

The Comparison between Herniated and Non-Herniated Disc Levels Regarding Intervertebral Disc Space Height and Disc Degeneration, A Magnetic Resonance Study

PURPOSE

The main purpose of this study was to evaluate the intervertebral disc height and intervertebral disc degeneration between the normal group and the group with disc herniation at the level of the L4-L5 intervertebral disc by MRI using the Pfirrmann grading system.

MATERIALS AND METHODS

385 patients were included in this study. MRI images were reevaluated and intervertebral disc heights were measured from the anterior, middle and posterior segments. Researchers divided disc pathologies into two groups. In the non-herniated group; normal or bulging ones; in the herniated group, they included those with protrusion or extrusion.

RESULTS

385 lumbar MRI examinations meeting the study criteria were included in study. There were 56.9% (219/385) females and 43.1% (166/385) males in the study. For the whole patients in the study group, the intervertebral disc height values at the L4-5 level were measured as 12.34 mm, 11.58 mm, and 7.60 mm in the anterior, middle, and posterior localizations, respectively.

CONCLUSIONS

At the L4-5 level, the height of the disc distances in the herniated group was lower than in the normal group. The Pfirrman score was found to be higher in the herniated group in terms of disc degeneration compared to the normal group.

Assessment of quality of life, pain level and disability outcomes after lumbar discectomy

This study aimed to assess the quality of life of 113 Caucasian patients with intervertebral disc (IVD) degeneration of the lumbosacral (L/S) spine who qualified for microdiscectomy during a 12-month period after surgery. Based on magnetic resonance imaging before the surgery, the degree of radiological advancement of the degenerative changes was determined according to the Pfirrmann grading scale from 1 to 5. To assess pain intensity, the Visual Analog Scale (VAS) was used; the Satisfaction with Life Scale (SWLS) was used to evaluate quality of life; and to assess the degree of ability, the Oswestry Low Back Pain Disability Questionnaire (ODI) was employed. The level of pain, assessed using the VAS, significantly changed in the months following the surgery, with the highest values noted before surgery and the lowest a year after. In turn, the results of the SWLS questionnaire revealed a significant increase in satisfaction with life in the subsequent stages of the study. The conducted correlation analysis revealed significant dependencies in terms of quality of life in regard to pain as well as degree of disability. The level of pain and degree of disability were closely related to the degree of radiological advancement of degenerative changes according to the Pfirrmann grading scale.

Evaluation of health related quality of life with the use of Oswestry disability index in degenerative discogenic low back pain

Background

Intervertebral disc degeneration (IVD) is a main underlying cause for low back pain (LBP). Oswestry Disability Index (ODI) is a valuable tool used to measure patient’s low back functional outcome. Our aim is to evaluate the relation between clinical assessment of LBP and health related quality of life with the use of ODI and magnetic resonance image (MRI) findings in patients with degenerative prolapsed IVD disease.

Result

There was a significant correlation between Pfirrmann grades and ODI (p < 0.0001) and with type of disc morphology mostly protrusion (p < 0.0001) but insignificant correlation with visual analogue scale (VAS) (p = 0.198) and most of the clinical parameters (p > 0.05). There was a significant correlation between ODI and VAS (p = 0.003). Higher Pfirrmann grades were found at lower lumbosacral levels L4-5 and L5-S1.

Conclusion

Higher Pfirrmann grades correlated with the increased ODI. No association was found between MRI grading in lumbosacral spine with pain intensity and most of the clinical parameters among persons with discogenic LBP. Chronic LBP is widely accepted to be a multifactorial disorder that could not be contained within a single lumbar compartment. Clinician should not depend on MRI findings only in the diagnosis. History from the patient and clinical examination is particularly important to reach the final diagnosis. ODI might be convenient in achieving patient’s confidence and decreasing unnecessary investigations.

Relationship between lumbar disc degeneration on MRI and low back pain: A cross-sectional community study

Purpose:

Although an association has been suggested between disc degeneration (DD) and low back pain (LBP), some DD is thought to be an age-related change unrelated to symptoms. Age-inappropriate DD, however, may be associated with LBP. The purpose of this study was to investigate whether there is a difference in LBP and LBP-related quality of life between age-appropriate and age-inappropriate DD, as assessed by magnetic resonance imaging (MRI).

Participants and methods:

In this cross-sectional study, degenerative change in the lumbar intervertebral discs of 382 subjects (age range, 27-82 years) was evaluated by MRI. Degenerative Disc Disease (DDD) scores were assigned using the Schneiderman classification, as the sum of grades for all intervertebral levels (0-15). We classified subjects into three groups according to age and DDD score: Low DD (mild DD relative to age), Appropriate (age-appropriate DD), and High DD (severe DD relative to age). We compared the three groups in terms of LBP prevalence, LBP intensity, LBP-specific quality of life (QOL) according to the Roland-Morris Disability Questionnaire (RDQ), and the Short Form-36 Item Health Survey (SF-36).

Results:

Of 382 subjects, there were 35% in the Low DD group, 54% in the Appropriate group, and 11% in the High DD group. There were no significant differences among the groups in terms of prevalence of LBP, LBP intensity, RDQ score, or SF-36 score.

Conclusion:

No association was found between age-inappropriate DD (Low or High DD group) and age-appropriate DD (Appropriate group) in terms of prevalence of LBP, LBP intensity, RDQ, or SF-36.

Prevention of Neurological Deficit With Intraoperative Neuromonitoring During Anterior Lumbar Interbody Fusion

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

While intraoperative neuromonitoring (IONM) has been increasingly used in spine surgery to have a real-time evaluation of the neurological injury, we aim here to assess its utility during anterior lumbar interbody fusion (ALIF) and its association with postoperative neurological deficit.

SUMMARY OF BACKGROUND DATA

ALIF is a beneficial surgical approach for patients with degenerative disease of the lower lumbar spine who would benefit from increased lordosis and restoration of neuroforaminal height. One risk of ALIF is iatrogenic nerve root injury. IONM may be useful in preventing this injury.

MATERIALS AND METHODS

We performed a retrospective cohort study of 111 consecutive patients who underwent ALIF at a tertiary care academic center by 6 spine surgeons. We aimed to describe the association between IONM, postoperative weakness, and factors that predispose our center to using IONM.

RESULTS

The 111 patients had a median age of 62 years [interquartile range (IQR): 53-69 y]. Neuromonitoring was used in 67 patients (60.3%) and not used in 44 patients. Seven neuromonitoring patients had IONM changes during the surgery. Three of these patients' surgeries featured intraoperative adjustments to reduce iatrogenic neural injury. The IONM cohort underwent significantly more complex procedures [5 levels (IQR: 3-7) vs. 2 levels (IQR: 2-5), P=0.001]. There was no difference in rates of new or worsened postoperative weakness (IONM: 20.6%, non-IONM: 20.5%).

CONCLUSIONS

We demonstrate evidence of the potential benefits of IONM for patients undergoing ALIF. Intraoperative changes in neuromonitoring signals resulted in surgical adjustments that likely prevented neurological deficits postoperatively. IONM was protective so that more complex surgeries did not have a higher rate of postoperative weakness.

Rare SLC13A1 variants associate with intervertebral disc disorder highlighting role of sulfate in disc pathology

Back pain is a common and debilitating disorder with largely unknown underlying biology. Here we report a genome-wide association study of back pain using diagnoses assigned in clinical practice; dorsalgia (119,100 cases, 909,847 controls) and intervertebral disc disorder (IDD) (58,854 cases, 922,958 controls). We identify 41 variants at 33 loci. The most significant association (OR_IDD = 0.92, P = 1.6 × 10⁻³⁹; OR_dorsalgia = 0.92, P = 7.2 × 10⁻¹⁵) is with a 3’UTR variant (rs1871452-T) in CHST3, encoding a sulfotransferase enzyme expressed in intervertebral discs. The largest effects on IDD are conferred by rare (MAF = 0.07 − 0.32%) loss-of-function (LoF) variants in SLC13A1, encoding a sodium-sulfate co-transporter (LoF burden OR = 1.44, P = 3.1 × 10⁻¹¹); variants that also associate with reduced serum sulfate. Genes implicated by this study are involved in cartilage and bone biology, as well as neurological and inflammatory processes.

Little is known about the biology of back pain, a leading cause of disability. Here the authors report 30 new back pain loci, implicating genes involved in cartilage/bone biology, as well as neurological and inflammatory processes.

Effects of Photobiomodulation Therapy Combined With Exercise in Patients Who Have Chronic Low Back Pain: Protocol for a Randomized Controlled Trial

OBJECTIVE

Although commonly prescribed, exercise therapy alone is insufficient for the treatment of low back pain (LBP). Thus, studies recommend a combination of interventions. Photobiomodulation therapy (PBMT) involving low-level laser is an effective intervention for relieving LBP; however, scientific evidence on the effects of laser therapy combined with exercise therapy is scarce and contradictory. The aim of this clinical trial is to evaluate the short-term and long-term effects of the combination of PBMT and an exercise protocol in individuals with persistent nonspecificLBP.

METHODS

This 2-armed, randomized, placebo-controlled trial with blinded participants, assessors, and therapists will be conducted in the outpatient physical therapy clinic of a university in Diamantina, Brazil. Participants are 90 individuals between 18 and 65 years of age with self-reported LBP. The participants will be randomly allocated to (1) a 6-week exercise program combined with active PBMT at a frequency of twice per week, totaling 12 sessions (n = 45), or (2) a 6-week exercise program combined with placebo PBMT (n = 45). Clinical outcomes will be measured at baseline as well as at 8 and 20 weeks and 12 months after randomization. The primary outcomes will be pain intensity and disability. The secondary outcomes will be mental health, mobility, disability, and strength of the trunk extensor muscles.

IMPACT

The findings will help determine whether adding PBMT to a physical therapist-supervised exercise protocol is more effective than the exercise protocol alone for persistent LBP. This study has the potential to guide clinical practice toward innovative ways of providing health care.

Associations between Paraspinal Muscle Morphology, Disc Degeneration, and Clinical Features in Patients with Lumbar Spinal Stenosis

Objective

The purpose of this study was to examine the relationships between intervertebral disc degeneration in the lumbar spine, paraspinal muscle morphology, and clinical features in patients with lumbar spinal stenosis (LSS).

Methods

A total of 52 patients with LSS participated in this study. Magnetic resonance imaging was used to assess intervertebral disc degeneration at L4/5 and to measure the standardized cross-sectional areas (SCSAs) of the multifidus and erector spinae muscles. The intensity of low back pain (LBP) and lower limb pain, the level of disability, and the quality of life (QoL) were evaluated using patient-reported outcome measures. The associations between the image findings and clinical features, including the disability score, the pain score for low back pain, and the QoL score, were calculated using Spearman's rank correlation coefficient.

Results

No associations were found between disc degeneration and clinical features. However, disc degeneration and the SCSA of the multifidus muscle (r=-0.38, P <0.01) and of the erector spinae muscle (r=-0.29, P=0.04) were significantly associated. Analysis of the associations between muscle morphology and clinical features found that the SCSA of the multifidus muscle was associated with LBP (r=0.31, P=0.03).

Conclusions

These results suggest that there is some correlation between atrophy of the multifidus and pain intensity. Consequently, focusing on the CSA of the multifidus muscle may help to clarify the causes of LBP in patients with LSS. However, because of the cross-sectional nature of this study, causal relationships could not be determined and further research is needed.

Reconnecting the Brain With the Rest of the Body in Musculoskeletal Pain Research

A challenge in understanding chronic musculoskeletal pain is that research is often siloed between neuroscience, physical therapy/rehabilitation, orthopedics, and rheumatology which focus respectively on 1) neurally mediated effects on pain processes, 2) behavior and muscle activity, 3) tissue structure, and 4) inflammatory processes. Although these disciplines individually study important aspects of pain, there is a need for more cross-disciplinary research that can bridge between them. Identifying the gaps in knowledge is important to understand the whole body, especially at the interfaces between the silos-between brain function and behavior, between behavior and tissue structure, between musculoskeletal and immune systems, and between peripheral tissues and the nervous system. Research on "mind and body" practices can bridge across these silos and encourage a "whole person" approach to better understand musculoskeletal pain by bringing together the brain and the rest of the body. PERSPECTIVE: Research on chronic musculoskeletal pain is limited by significant knowledge gaps. To be fully integrated, musculoskeletal pain research will need to bridge across tissues, anatomical areas, and body systems. Research on mind and body approaches encourages a "whole person" approach to better understand musculoskeletal pain.

Intervertebral Disc Diseases PART 2: A Review of the Current Diagnostic and Treatment Strategies for Intervertebral Disc Disease

With an aging population, there is a proportional increase in the prevalence of intervertebral disc diseases. Intervertebral disc diseases are the leading cause of lower back pain and disability. With a high prevalence of asymptomatic intervertebral disc diseases, there is a need for accurate diagnosis, which is key to management. A thorough understanding of the pathophysiology and clinical manifestation aids in understanding the natural history of these conditions. Recent developments in radiological and biomarker investigations have potential to provide noninvasive alternatives to the gold standard, invasive discogram. There is a large volume of literature on the management of intervertebral disc diseases, which we categorized into five headings: (a) Relief of pain by conservative management, (b) restorative treatment by molecular therapy, (c) reconstructive treatment by percutaneous intervertebral disc techniques, (d) relieving compression and replacement surgery, and (e) rigid fusion surgery. This review article aims to provide an overview on various current diagnostic and treatment options and discuss the interplay between each arms of these scientific and treatment advancements, hence providing an outlook of their potential future developments and collaborations in the management of intervertebral disc diseases.

Mineralized collagen-modified PMMA cement enhances bone integration and reduces fibrous encapsulation in the treatment of lumbar degenerative disc disease

As a minimally invasive surgery, percutaneous cement discoplasty (PCD) is now contemplated to treat lumbar disc degeneration disease in elder population. Here, we investigated whether the osteogenic mineralized collagen (MC) modified polymethylmethacrylate (PMMA) cement could be a suitable material in PCD surgery. Injectability, hydrophilicity and mechanical properties of the MC-modified PMMA (PMMA-MC) was characterized. The introduction of MC did not change the application and setting time of PMMA and was easy to be handled in minimally invasive operation. Hydrophilicity of PMMA-MC was greatly improved and its elastic modulus was tailored to complement mechanical performance of bone under dynamic stress. Then, PCD surgery in a goat model with induced disc degeneration was performed with implantation of PMMA-MC or PMMA. Three months after implantation, micro-computed tomography analysis revealed a 36.4% higher circumferential contact index between PMMA-MC and bone, as compared to PMMA alone. Histological staining confirmed that the surface of PMMA-MC was in direct contact with new bone, while the PMMA was covered by fibrous tissue. The observed gathering of macrophages around the implant was suspected to be the cause of fibrous encapsulation. Therefore, the interactions of PMMA and PMMA-MC with macrophages were investigated in vitro. We discovered that the addition of MC could hinder the proliferation and fusion of the macrophages. Moreover, expressions of fibroblast-stimulating growth factors, insulin-like growth factor, basic fibroblast growth factor and tumor necrosis factor-β were significantly down-regulated in the macrophages cocultured with PMMA-MC. Together, the promoted osteointegration and reduced fibrous tissue formation observed with PMMA-MC material makes it a promising candidate for PCD surgery.

Effects of simvastatin-loaded PLGA microspheres on treatment of rats with intervertebral disk degeneration and on 6-K-PGF1α and HIF-1α

Effects of simvastatin-loaded PLGA sustained release microspheres on the treatment of rats with intervertebral disk degeneration (IVDD) and on 6-keto-prostaglandin F1α (6-K-PGF1α) and hypoxia inducible factor-1α (HIF-1α) were investigated. Eighty female rats were selected and randomized into a model group (modeled for IVDD), a treatment group (modeled and treated with simvastatin-loaded PLGA sustained release microspheres), a sham operation group (only operated without excision), and a control group (not treated) (n=20 each). After modeling, 6-K-PGF1α and HIF-1α in the peripheral blood of the rats were, respectively, detected before simvastatin injection (T0), at 2 weeks (T1) and 4 weeks (T2) after simvastatin injection. The bone mineral density (BMD) of L₅ and L₆ was detected by X-ray. The trabecular thickness, number, and separation of the vertebral body were detected. Changes in the sagittal T2-weighted signal of intervertebral disc nucleus pulposus were detected by MRI. There were no differences between the control and sham operation groups in the indices (P>0.050). Compared with those in the model group during the treatment, BMD, 6-K-PGF1α, HIF-1α, and trabecular number in the treatment group significantly increased (P<0.050), while the trabecular separation significantly decreased (P<0.050). The sagittal T2-weighted MRI signal in the model group was the lowest between the four groups (P<0.050). Simvastatin-loaded PLGA sustained release microspheres can improve the BMD of the vertebral body and increase the contents of 6-K-PGF1α and HIF-1α in the treatment of rats with IVDD, so they are important for the clinical treatment of the disease.

A novel magnetic resonance imaging postprocessing technique for the assessment of intervertebral disc degeneration-Correlation with histological grading in a rabbit disc degeneration model

INTRODUCTION

Estimation of intervertebral disc degeneration on magnetic resonance imaging (MRI) is challenging. Qualitative schemes used in clinical practice correlate poorly with pain and quantitative techniques have not entered widespread clinical use.

METHODS

As part of a prior study, 25 New Zealand white rabbits underwent annular puncture to induce disc degeneration in 50 noncontiguous lumbar discs. At 16 weeks, the animals underwent multi-echo T2 MRI scanning and were euthanized. The discs were stained and examined histologically. Quantitative T2 relaxation maps were prepared using the nonlinear least squares method. Decay Variance maps were created using a novel technique of aggregating the deviation in the intensity of each echo signal from the expected intensity based on the previous rate of decay.

RESULTS

Decay Variance maps showed a clear and well demarcated nucleus pulposus with a consistent rate of decay (low Decay Variance) in healthy discs that showed progressively more variable decay (higher Decay Variance) with increasing degeneration. Decay Variance maps required significantly less time to generate (1.0 ± 0.0 second) compared with traditional T2 relaxometry maps (5 (±0.9) to 1788.9 (±116) seconds). Histology scores correlated strongly with Decay Variance scores (r = 0.82, P < .01) and weakly with T2 signal intensity (r = 0.32, P < .01) and quantitative T2 relaxometry (r = 0.39, P < .01). Decay Variance had superior sensitivity and specificity for the detection of degenerate discs when compared to T2 signal intensity or Quantitative T2 mapping.

CONCLUSION

Our results show that using a multi-echo T2 MRI sequence, Decay Variance can quantitatively assess disc degeneration more accurately and with less image-processing time than quantitative T2 relaxometry in a rabbit disc puncture model. The technique is a viable candidate for quantitative assessment of disc degeneration on MRI scans. Further validation on human subjects is needed.

Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature

BACKGROUND CONTEXT

The accurate determination of a patient's functional status is necessary for therapeutic decision-making and to critically appraise treatment efficacy. Current subjective patient-reported outcome measure (PROM)-based assessments have limitations and can be complimented by objective measures of function.

PURPOSE

To systematically review the literature and provide an overview on the available objective measures of function for patients with degenerative diseases of the lumbar spine.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Two reviewers independently searched the PubMed, Web of Science, EMBASE, and SCOPUS databases for permutations of the words "objective," "assessment," "function," "lumbar," and "spine" including articles on human subjects with degenerative diseases of the lumbar spine that reported on objective measures of function, published until September 2018. Risk of bias was not assessed. No funding was received. The authors report no conflicts of interest.

RESULTS

Of 2,389 identified articles, 82 were included in the final analysis. There was a significant increase of 0.12 per year in the number of publications dealing with objective measures of function since 1989 (95% CI 0.08-0.16, p<.001). Some publications studied multiple diagnoses and objective measures. The United States was the leading nation in terms of scientific output for objective outcome measures (n=21; 25.6%), followed by Switzerland (n=17; 20.7%), Canada, Germany, and the United Kingdom (each n=6; 7.3%). Our search revealed 21 different types of objective measures, predominantly applied to patients with lumbar spinal stenosis (n=67 publications; 81.7%), chronic/unspecific low back pain (n=28; 34.2%) and lumbar disc herniation (n=22; 26.8%). The Timed-Up-and-Go test was the most frequently applied measure (n=26 publications; 31.7%; cumulative number of reported subjects: 5,181), followed by the Motorized Treadmill Test (n=25 publications; 30.5%, 1,499 subjects) and with each n=9 publications (11.0%) the Five-Repetition Sit-To-Stand test (955 subjects), as well as accelerometry analyses (336 subjects). The reliability and validity of many of the less-applied objective measures was uncertain. There was profound heterogeneity in their application and interpretation of results.

CONCLUSIONS

Clinical studies on patients with lumbar degenerative diseases increasingly employ objective measures of function, which offer high potential for improving the quality of outcome measurement in patient-care and research. This review provides an overview on available options. Our findings call for an agreement and standardization in terms of test selection, conduction and analysis to facilitate comparison of results across cohorts.

PROSPERO REGISTRATION NUMBER

CRD42019122622.

Trends of surgical treatment for spinal degenerative disease in China: a cohort of 37,897 inpatients from 2003 to 2016

Purpose

Given the aging Chinese population and the inevitable degenerative process of the spine, more elderly patients with spinal degenerative disease (SDD) are surgical candidates, placing a significant burden on health care resources. Few studies have investigated recent trends in hospital admissions and procedures for SDD in China. This study aimed to identify the trends, if any, in the number of surgical procedures undertaken for SDD in a large patient cohort.

Materials and methods

This retrospective cohort analysis used data from inpatient medical records at Peking University Third Hospital between 2003 and 2016. Descriptive statistical analysis, regression models, and a Holt–Winters seasonal model were used to analyze trends.

Results

Altogether, 38,676 surgery records from 37,897 SDD patients who had undergone surgical treatment were included in our study, among whom 49.60%, 47.81%, and 2.59% were treated because of cervical, lumbar, and thoracic degenerative disease, respectively. There was an increasing trend for spinal surgery performance with an increasing mean age at surgery, from 50.65 years of age in 2003 to 55.29 years in 2016. We also revealed interesting seasonal variation in our study – that is, most of the spinal procedures were performed during the winter and spring months.

Conclusion

Our study showed a significantly increasing surgical workload for addressing SDD in China. Both the public and the health care system should be aware of this increase in chronic degenerative disease in the aging population.

Which Seems to Be Worst? Pain Severity and Quality of Life between Patients with Lateral Hip Pain and Low Back Pain

Purpose

The aim of this study was to compare the pain severity, health-related quality of life (HRQoL), and risk of continue having pain with prognostic risk scores (PRS), between patients referring greater trochanteric pain syndrome (GTPS) and chronic low back pain (CLBP).

Methods

A descriptive, cross-sectional design using nonprobability convenience sampling was performed. A total sample of 102 patients were recruited from two primary health-care centers and divided into GTPS (n = 51) and CLBP (n = 51) groups. The primary outcome was pain severity which was assessed with the Spanish version of the Graded Chronic Pain Scale (GCPS). The secondary outcome was the HRQoL which was measured using the Spanish version of EuroQoL Five Dimensions and Five Levels (EQ-5D-5L) as well as the PRS.

Results

Significant differences (P<0.05) were found within both groups in the pain severity global score with a medium effect size showing greater values for the CLBP group with regards to the GTPS group. The PRS in both groups did not show statistical differences (P>0.05). Nevertheless, subjects referring CLBP showed greater levels in the PRS than patients with GTPS. Comparing both groups, the HRQoL showed statistical differences (P<0.05) in the “pain/discomfort” domain in the CLBP group with respect to the GTPS group, but not in the other domains.

Conclusions

Patients who suffered from CLBP showed greater pain severity and HRQoL discomfort with regard to patients with GTPS. Despite greater scores for CLBP, the PRS did not seem to be different between both conditions.

The value of short-term pain relief in predicting the long-term outcome of 'indirect' cervical epidural steroid injections

BACKGROUND

The predictive value of short-term arm pain relief after 'indirect' cervical epidural steroid injection (ESI) for the 1-month treatment response has been previously demonstrated. It remained to be answered whether the long-term response could be estimated by the early post-interventional pain course as well.

METHODS

Prospective observational study, following a cohort of n = 45 patients for a period of 24 months after 'indirect' ESI for radiculopathy secondary to a single-level cervical disk herniation (CDH). Arm and neck pain on the visual analog scale (VAS), health-related quality of life with the Short Form-12 (SF-12), and functional outcome with the Neck Pain and Disability (NPAD) Scale were assessed. Any additional invasive treatment after a single injection (second injection or surgery) defined treatment outcome as 'non-response'.

RESULTS

At 24 months, n = 30 (66.7%) patients were responders and n = 15 (33.3%) were non-responders. Non-responders exited the follow-up at 1 month (n = 10), at 3 months (n = 4), and at 6 months (n = 1). No patients were injected again or operated on between the 6- and 24-month follow-up. Patients with favorable treatment response at 24 months had significantly lower VAS arm pain (p < 0.05) than non-responders at days 6, 8-11, and at the 3-month follow-up. The previously defined cut-off of > 50% short term pain reduction was not a reliable predictor of the 24-month responder status. SF-12 and NPAD scores were better among treatment responders in the long term.

CONCLUSIONS

Patients who require a second injection or surgery after 'indirect' cervical ESI for a symptomatic CDH do so within the first 6 months. Short-term pain relief cannot reliably predict the long-term outcome.

Are Modic changes in patients with chronic low back pain indicative of a worse clinical course? 10 years of follow-up

OBJECTIVE

Establish the long-term (10 years) predictive value of Modic changes in the course of lumbar pain and the need for surgical treatment.

MATERIAL AND METHOD

Observational longitudinal prospective cohort study. Comparison of progression at 10 years of 2 groups of patients with chronic lumbar pain: group A with Modic changes in MRI and group B with no Modic changes.

EXCLUSION CRITERIA

neoplasia, inflammatory or infectious diseases, or previous surgery. Assessment was done with the aid of the VAS for low lumbar and radicular pain and the Oswestry Disability Questionnaire. The need for surgical or medical treatment and occupational disability during the study period was analyzed. For the statistical analyses, the Mann-Whitney U test and logistic regression were applied.

RESULTS

Seventy patients, 24 male and 46 female, with a mean age of 56.5 years (35 in each group) were included in the study. No statistically significant differences in the intensity of lumbar pain, degree of impairment, or need for medical or surgical treatment (P>.05) were found in patients with Modic changes types 1, 2, or 3 between the baseline assessment and 10 years after. No statistically significant differences between patients with/without changes in Modic at 10 years of follow-up (P>.05) were determined.

CONCLUSIONS

There is no relationship between Modic changes in MRI and greater intensity of lumbar pain or need for medical or surgical treatment at 10 years of follow-up. Modic changes cannot be considered a sign of bad prognosis by themselves, or an indication for surgery.

Validation of the baseline severity stratification of objective functional impairment in lumbar degenerative disc disease

OBJECTIVE

The Timed Up and Go (TUG) test is a simple, objective, and standardized method to measure objective functional impairment (OFI) in patients with lumbar degenerative disc disease (DDD). The objective of the current work was to validate the OFI baseline severity stratification (BSS; with levels of “none,” “mild,” “moderate,” and “severe”).

METHODS

Data were collected in a prospective IRB-approved 2-center study. Patients were assessed with a comprehensive panel of scales for measuring pain (visual analog scale [VAS] for back and leg pain), functional impairment (Roland-Morris Disability Index [RMDI] and Oswestry Disability Index [ODI]), and health-related quality of life (HRQOL; EQ-5D and SF-12). OFI BSS was determined using age- and sex-adjusted cutoff values.

RESULTS

A total of 375 consecutive patients scheduled for lumbar spine surgery were included. Each 1-step increase on the OFI BSS corresponded to an increase of 0.53 in the back pain VAS score, 0.69 in the leg pain VAS score, 1.81 points in the RMDI, and 5.93 points in the ODI, as well as to a decrease in HRQOL of −0.073 in the EQ-5D, −1.99 in the SF-12 physical component summary (PCS), and −1.62 in the SF-12 mental component summary (MCS; all p < 0.001). Patients with mild, moderate, and severe OFI had increased leg pain by 0.90 (p = 0.044), 1.54 (p < 0.001), and 1.94 (p < 0.001); increased ODI by 7.99 (p = 0.004), 12.64 (p < 0.001), and 17.13 (p < 0.001); and decreased SF-12 PCS by −2.57 (p = 0.049), −3.63 (p = 0.003), and −6.23 (p < 0.001), respectively.

CONCLUSIONS

The OFI BSS is a valid measure of functional impairment for use in daily clinical practice. The presence of OFI indicates the presence of significant functional impairment on subjective outcome measures.

Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 intervertebral disc herniation

Objective

To discuss the significance and the short-term effect of bone puncture technique in transiliac approach to intervertebral endoscopic discectomy for the treatment of L5/S1 intervertebral disc herniation.

Methods

Nineteen patients were diagnosed as L5/S1 disc herniation and treated using transiliac approach to endoscopic discectomy (group I), and 20 patients were diagnosed as non-L5/S1 disc herniation and underwent conventional approach (group R). Leg pain was evaluated by VAS. MacNab ratings of the last follow-up were recorded to evaluate early clinical efficacy, and postoperative complications were recorded to evaluate surgical safety. The imaging changes of the patients 3 months after surgery were observed.

Results

One patient in group I, who felt abnormal in nerve roots, underwent symptomatic treatments, such as rehydration and hormone, and the abnormalities disappeared 3 days after treatment. There were no significant significances in operative time and intraoperative fluoroscopy times between groups I and R (p > 0.05), but there was a higher tendency in group I. The VAS scores of post-operation were significantly lower than that of pre-operation in the two groups (p < 0.05), but there were no significant differences between the two groups (p > 0.05). The MacNab score of the last follow-up showed excellent rate (95%) and good rate (90%) in groups I and R, respectively.

Conclusions

Bone puncture-combined transiliac approach to intervertebral endoscopic surgery could locate iliac puncture point individually, and establish a good iliac channel, which is safe, effective, and minimally invasive.

The usefulness of radiological grading scales to predict pain intensity, functional impairment, and health-related quality of life after surgery for lumbar degenerative disc disease

PURPOSE

The goal of this study is to determine the relationship of radiological grading scales of lumbar degenerative disc disease (DDD) with postoperative pain intensity, functional impairment, and health-related quality of life (HRQoL).

METHODS

Response to surgical treatment at 6 weeks (W6) on the visual analogue scale (VAS) for back and leg pain, Oswestry-Disability (ODI) and Roland-Morris Disability Index (RMDI), Timed Up and Go (TUG) test, EuroQol (EQ) 5D, and Short-Form Health-Survey (SF-12) physical component summary (PCS) was compared between patients with different Modic (MOD) and Pfirrmann (PFI) grades. Longitudinal outcomes at day 3 (D3), W6, 6 months (M6), and 1 year (Y1) were compared.

RESULTS

The study included 338 patients (mean age, 58.6 years), of which n = 202 (59.8%) had MOD 1-3 and n = 217 (64.2%) PFI 4-5 changes. Patients with MOD 1-3 were as likely as patients without MOD changes to be treatment-responders at W6 in terms of VAS leg pain, ODI, RMDI, TUG, EQ5D, and SF-12 PCS. Similarly, patients with PFI 4-5 were as likely as patients with PFI 1-3 changes to be treatment-responders at W6. Longitudinal outcomes were similar at D3, W6, M6, and Y1 between patients with and without MOD changes. Patients with PFI 4-5 fared similar to those with PFI 1-3 except for inferior HRQoL on the SF-12 PCS metric at Y1.

CONCLUSIONS

There was no distinct relationship between commonly used radiological grading scales of lumbar DDD with clinical outcome. Therefore, no prognosis should be made on the grounds of preoperative PFI and MOD classifications for patients undergoing spine surgery for lumbar DDD.

Relationship of depression in participants with nonspecific acute or subacute low back pain and no-pain by age distribution

BACKGROUND AND PURPOSE

Nonspecific low back pain (LBP) is the most prevalent musculoskeletal condition in various age ranges and is associated with depression. The aim of this study was to determine the Beck Depression Inventory (BDI) scores in participants with nonspecific LBP and no-pain by age distribution.

METHODS

A case-control study was carried out following the Strengthening the Reporting of Observational Studies in Epidemiology criteria. A sample of 332 participants, divided into the following age categories: 19-24 (n=11), 25-39 (n=66), 40-64 (n=90), 65-79 (n=124), and ≥80 (n=41) years was recruited from domiciliary visits and an outpatient clinic. The BDI scores were self-reported in participants with nonspecific acute or subacute (≤3 months) LBP (n=166) and no-pain (n=166).

RESULTS

The BDI scores, mean ± standard deviation, showed statistically significant differences (p<0.001) between participants with nonspecific acute or subacute LBP (9.590±6.370) and no-pain (5.825±5.113). Significantly higher BDI scores were obtained from participants with nonspecific acute and subacute LBP in those aged 40-64 years (p<0.001; 9.140±6.074 vs 4.700±3.777) and 65-79 years (p<0.001; 10.672±6.126 vs 6.210±5.052). Differences were not significant in younger patients aged 19-24 (p=0.494; 5.000±2.646 vs 8.250±7.498), 25-39 (p=0.138; 5.440±5.245 vs 3.634±4.397), and in those aged ≥80 years (p=0.094; 13.625±6.1331 vs 10.440±5.591).

CONCLUSION

Participants with nonspecific acute and subacute LBP present higher BDI depression scores, influenced by age distribution. Specifically, patients in the age range from 40 to 80 years with LBP could require more psychological care in addition to any medical or physical therapy. Nevertheless, physical factors, different outcomes, and larger sample size should be considered in future studies.

Influence of age on pain intensity, functional impairment and health-related quality of life before and after surgery for lumbar degenerative disc disease

BACKGROUND

Demographic changes will lead to an increase of elderly people in our population and consecutively to a higher prevalence of patients suffering from degenerative disc disease (DDD). The goal of this study was to investigate age-related differences in pain intensity, subjective and objective functional impairment and health-related quality of life (HRQoL) in patients with lumbar DDD.

METHODS

In a prospective two-center study, back and leg pain intensity (visual analogue scale (VAS)), functional impairment (Oswestry Disability Index (ODI), Roland-Morris Disability Index (RMDI)) and HRQoL (EuroQol-5D (EQ-5D), Short-Form (SF12)) were collected for consecutive patients undergoing lumbar spine surgery. Objective functional impairment (OFI) was measured using the Timed Up and Go (TUG) test. Adjusted partial correlation was used to correlate age to each scale preoperatively, as well as to the postoperative improvement at six weeks.

RESULTS

A total of n=377 patients (161 females, 42.7%) with a mean age of 58.5 years (SD 15.7, range 18.0-93.7) were included. Unadjusted TUG test raw times naturally increased with age, whereas the age-effect on standardized OFI T-scores was close to zero in patients with a lumbar disc herniation (LDH; r=-0.0666, p=0.367) or lumbar spinal stenosis (LSS; r=-0.0134, p=0.879). There was a weak correlation between age and higher ODI (LDH: r=0.1289, p=0.089; LSS: r=0.1975; p=0.027), lower EQ-5D (LSS: r=-0.1824, p=0.042) and higher RMDI by trend (LSS: r=0.1679, p=0.061). The correlation between age and postoperative improvement was negative on the VAS for back pain (LDH: r=-0.3189, p=0.026), VAS for leg pain (LDH: r=-0.3656, p=0.009) and RMDI by trend (LSS: r=-0.2004, p=0.069), as well as positive on the EQ-5D index (r=0.2412, p=0.011), indicating that younger patients showed better improvement. Due to in-group heterogeneity, no age-effect could be calculated for patients scheduled for surgical fusion.

CONCLUSIONS

The influence of age on subjective and objective measures of pain, functional impairment and HRQoL is limited for patients with LDH and LSS, but suggests an age-dependent increase of functional disability. Younger patients generally showed greater postoperative improvement at six weeks than older patients.