1
|
Young I, Dunning J, Butts R, Bliton P, Zacharko N, Garcia J, Mourad F, Charlebois C, Gorby P, Fernández-de-Las-Peñas C. Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial. Spine J 2024; 24:590-600. [PMID: 38103739 DOI: 10.1016/j.spinee.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/10/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND CONTEXT Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS. PURPOSE This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS. STUDY DESIGN/SETTING Randomized, single-blinded, multi-center, parallel-group clinical trial. PATIENT SAMPLE One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period. OUTCOME MEASURES The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months. METHODS Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63). RESULTS At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group. CONCLUSION Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.
Collapse
Affiliation(s)
- Ian Young
- American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, Montgomery, AL, USA; Tybee Wellness & Osteopractic, Tybee Island, GA, USA.
| | - James Dunning
- American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, Montgomery, AL, USA; Montgomery Osteopractic Physical Therapy & Acupuncture Clinic, Montgomery, AL, USA
| | | | - Paul Bliton
- American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, Montgomery, AL, USA; William S. Middleton Veterans Memorial Hospital, Madison, WI, USA
| | - Noah Zacharko
- American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, Montgomery, AL, USA; Osteopractic Physical Therapy of the Carolinas, Fort Mill, SC, USA
| | - Jodan Garcia
- Department of Physical Therapy, Georgia State University, Atlanta, GA, USA
| | - Firas Mourad
- Department of Physiotherapy, LUNEX International University of Health, Exercise and Sports, Differdange, Luxembourg
| | - Casey Charlebois
- American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, Montgomery, AL, USA
| | - Patrick Gorby
- American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, Montgomery, AL, USA; Gorby Osteopractic Physiotherapy, Colorado Springs, CO, USA
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain; Cátedra de Clínica, Investigación y Docencia en Fisioterapia: Terapia Manual, Punción Secay Ejercicio, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| |
Collapse
|
2
|
Peene L, Cohen SP, Kallewaard JW, Wolff A, Huygen F, Gaag AVD, Monique S, Vissers K, Gilligan C, Van Zundert J, Van Boxem K. 1. Lumbosacral radicular pain. Pain Pract 2024; 24:525-552. [PMID: 37985718 DOI: 10.1111/papr.13317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. METHODS The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. RESULTS Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. CONCLUSIONS The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.
Collapse
Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Andre Wolff
- Department of Anesthesiology UMCG Pain Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Huygen
- Department of Anesthesiology and Pain Medicine, Erasmusmc, Rotterdam, The Netherlands
- Department of Anesthesiology and Pain Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Antal van de Gaag
- Department of Anesthesiology and Pain Medicine, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Steegers Monique
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Chris Gilligan
- Department of Anesthesiology and Pain Medicine, Brigham & Women's Spine Center, Boston, Massachusetts, USA
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
3
|
Is EE, Aksu S, Karamursel S, Ketenci A, Sindel D. Effectiveness of transcranial direct current stimulation in chronic pain and neurogenic claudication related to lumbar spinal stenosis. Neurol Sci 2024; 45:769-782. [PMID: 38091212 DOI: 10.1007/s10072-023-07248-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/01/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVES Transcranial direct current stimulation (tDCS) is a promising non-invasive brain stimulation technique for treating chronic pain, yet its effectiveness in chronic lower extremity pain due to lumbar spinal stenosis (LSS) has not been studied. This research aimed to investigate the impact of tDCS on pain, walking capacity, functional status, and quality of life in LSS patients. PATIENTS AND METHODS In this prospective, randomized, double-blind, sham-controlled study, 32 LSS patients received either real or sham tDCS over the motor cortex contralateral to the patient's painful lower extremity for 10 consecutive weekdays (10 sessions). Evaluations were conducted at baseline, post-session, and 1-3 months later. The pain was evaluated by Visual Analog Scale (VAS), walking duration and distance by Treadmill Walking Test, functional status by Modified Oswestry Disability Questionnaire (MODQ) and quality of life by Short Form-36 (SF-36). RESULTS In-group comparisons, active tDCS showed sustained analgesic effects for 3-month post-treatment, distinct from sham. After the final session, active group exhibited significantly better asymptomatic walking distance and duration. Active stimulation led to notably lower MOLBDQ scores after 1 month. Significant improvements in SF-36 subscales were seen after 3 months, especially in pain, physical functioning, and general health. Positive tDCS effects on pain, claudication, and some quality of life aspects were evident at 3 months, while functional status improvements were mainly limited to 1 month. CONCLUSION tDCS shows potential as a safe, non-invasive technique for alleviating chronic LSS-related pain, enhancing mobility, functionality, and quality of life. TRIAL REGISTRATION Clinicaltrials.gov ID: NCT03958526.
Collapse
Affiliation(s)
- Enes Efe Is
- Department of Physical Medicine and Rehabilitation, University of Health Sciences Turkiye, Sisli Hamidiye Etfal Teaching and Research Hospital, Seyrantepe Campus, Cumhuriyet Ve Demokrasi Avenue, Sariyer, Istanbul, 34485, Turkey.
- Department of Physical Medicine and Rehabilitation, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey.
| | - Serkan Aksu
- Department of Physiology, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey
- Department of Physiology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Sacit Karamursel
- Department of Physiology, Koc University School of Medicine, Istanbul, Turkey
| | - Aysegul Ketenci
- Department of Physical Medicine and Rehabilitation, Koc University School of Medicine, Istanbul, Turkey
| | - Dilsad Sindel
- Department of Physical Medicine and Rehabilitation, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| |
Collapse
|
4
|
Zhao K, Bao T, Yang W, Wang C, Wang Y, Wang T, Xiao B, Zhang Q, Gao F, Liu H, Tao X, Gao G, Zhang T. Spinal‑pelvic sagittal imbalance and paraspinal muscle degeneration in patients with degenerative lumbar spinal stenosis: A monocentric, prospective and observational study. Exp Ther Med 2023; 26:479. [PMID: 37745044 PMCID: PMC10515119 DOI: 10.3892/etm.2023.12178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 07/14/2023] [Indexed: 09/26/2023] Open
Abstract
Degenerative lumbar spinal stenosis (DLSS) is a condition in which the body is held in a poor posture for a long period of time, resulting in a change in the stress structure of the lumbar spine that causes degenerative changes in the muscles of the spine. The sagittal balance of the spine and pelvis and the degeneration of the paravertebral muscles have been the focus of recent research. To explore the relationship between paraspinal muscle degeneration and changes in spine-pelvic sagittal parameters in patients with DLSS, 95 patients with DLSS (experimental group) and 70 healthy volunteers (control group) hospitalized in the Ordos Central Hospital between January 2020 and January 2022 were included as study subjects. All patients underwent lumbar magnetic resonance imaging and spinal X-ray using uniform criteria. The correlation between paravertebral muscle parameters and sagittal-pelvic sagittal parameters in patients with DLSS was obtained from two imaging examinations, and the data were organized and grouped in order to explore the correlation between these parameters. There was no significant difference in the general data between the two groups (P>0.05). In the L4-5 DLSS patient group, the ratio of fat infiltration in the right erector spinae (ES) muscle was negatively correlated with thoracic kyphosis (TK) (r=-0.536; P<0.05) but not significantly in the left side. The relative cross-sectional area of the left multifidus muscle (MF RCSA) was positively correlated with TK (r=0.685; r=0.615; P<0.05) but not significantly in the right side. In the L5-S1DLSS patient group, the right MF RCSA and right ES RCSA were significantly positively correlated with TK (r=0.685; r=0.615; P<0.05) but not significant in the left side. Thus, paravertebral muscle parameters were correlated with spinal-pelvic sagittal parameters in patients with DLSS.
Collapse
Affiliation(s)
- Keyu Zhao
- The Ordos Clinic Medical College, Inner Mongolia Medical University, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Tianlian Bao
- The Ordos Clinic Medical College, Inner Mongolia Medical University, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Wupeng Yang
- The Ordos Clinic Medical College, Inner Mongolia Medical University, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Chunmei Wang
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Yongjiang Wang
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Tiantian Wang
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Bin Xiao
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Qingxin Zhang
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Feng Gao
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Hao Liu
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Xiaoyang Tao
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Gang Gao
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Tinxin Zhang
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| |
Collapse
|
5
|
Urata R, Igawa T, Ito S, Suzuki A. Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis: A systematic review and meta-analysis. J Back Musculoskelet Rehabil 2023:BMR220220. [PMID: 36911930 DOI: 10.3233/bmr-220220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND The benefits of combining supervised exercise in the non-surgical treatment of lumbar spinal stenosis (LSS) is unclear. OBJECTIVE To compare the effectiveness of non-surgical treatments with and without supervised exercise for pain intensity, symptom severity, functional impairment/disability, walking distance, and quality of life (QOL) in LSS patients. METHODS Randomized controlled trials (RCTs) evaluating combinations of supervised exercises were searched using four electronic databases up to August 13, 2020. Meta-analysis was conducted for immediate and long-term results. RESULTS Three studies were identified, including 244 participants. Immediate-term results showed that leg pain intensity (mean distance [MD]: -0.94, 95% confidence intervals [95% CI]: -1.60 to -0.29, p< 0.01) and symptom severity (MD: -0.29, 95% CI: -0.50 to -0.08, p< 0.01) were lower in the study group than in the control group, and walking distance (MD: 415.83, 95% CI: 298.15-533.50, p< 0.001) and QOL were higher in the study group. Long-term results showed that functional disability/impairment (MD: 0.27, 95% CI: -0.49 to -0.04, p< 0.05) was lower in the study group than in the control group, and walking distance and QOL were higher in the study group. CONCLUSION The number of studies on this topic was small and limited. Combinations of non-surgical treatment and supervised exercise may not provide significant benefits.
Collapse
Affiliation(s)
- Ryunosuke Urata
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, Tokyo, Japan.,Department of Rehabilitation, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Tatsuya Igawa
- Department of Rehabilitation, International University of Health and Welfare Mita Hospital, Tokyo, Japan.,Department of Physical Therapy, School of Health Science, International University of Health and Welfare, Tochigi, Japan.,Department of Rehabilitation, International University of Health and Welfare Hospital, Tochigi, Japan.,Department of Rehabilitation, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Shomaru Ito
- Department of Rehabilitation, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | | |
Collapse
|
6
|
Evaluating 5-year outcomes of interlaminar devices as an adjunct to decompression for symptomatic lumbar spinal stenosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1367-1374. [PMID: 36840820 DOI: 10.1007/s00586-023-07610-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/26/2023] [Accepted: 02/14/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE To assess and compare 5-year outcomes following uninstrumented spinal decompression and decompression with interlaminar device (ILD). To determine whether improvement in clinical outcomes correlated with changes in the radiological indices studied. This is because comparative literature between the above two procedures is limited past the 2-year timeframe. METHODS We conducted a retrospective review of prospectively collected data from a single surgeon across 116-patients who underwent spinal decompression with or without ILD insertion between 2007 and 2015. Patients with symptomatic LSS who met the study criteria were offered spinal decompression with ILD insertion. Patients who accepted ILD were placed in the D + ILD group (n = 61); while those opting for decompression alone were placed in the DA group (n = 55). Clinical outcomes were assessed preoperatively and up to 5-years postoperatively using the ODI, Eq. 5d, VAS back and leg pain, and SF-36. Radiological indices were assessed preoperatively and up to 5-years postoperatively. RESULTS Both groups showed statistically significant (p < 0.001) improvement in all clinical outcome indicators at all timepoints as compared to their preoperative status. The D + ILD group achieved significant improvement in radiological parameters namely foraminal height and posterior disc height in the immediate postoperative period that was maintained while the DA group did not. CONCLUSION Our study found that in the management of LSS, clinical outcomes between those patients undergoing decompression alone compared to decompression with ILD showed statistically significant improvement in VAS back pain and radiological parameters namely foraminal height and posterior disc height at the 5-year mark. ILD does not predispose to increased reoperation rates.
Collapse
|
7
|
Mohamed B, Ramachandran R, Rabai F, Price CC, Polifka A, Hoh D, Seubert CN. Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review. J Neurosurg Anesthesiol 2023; 35:19-30. [PMID: 34354024 PMCID: PMC8816967 DOI: 10.1097/ana.0000000000000787] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023]
Abstract
Degenerative spine disease increases in prevalence and may become debilitating as people age. Complex spine surgery may offer relief but becomes riskier with age. Efforts to lessen the physiological impact of surgery through minimally invasive techniques and enhanced recovery programs mitigate risk only after the decision for surgery. Frailty assessments outperform traditional tools of perioperative risk stratification. The extent of frailty predicts complications after spine surgery such as reoperation for infection and 30-day mortality, as well as elements of social cost such as hospital length of stay and discharge to an advanced care facility. Symptoms of spine disease overlap with phenotypic markers of frailty; therefore, different frailty assessment tools may perform differently in patients with degenerative spine disease. Beyond frailty, however, cognitive decline and psychosocial isolation may interact with frailty and affect achievable surgical outcomes. Prehabilitation, which has reduced perioperative risk in colorectal and cardiac surgery, may benefit potential complex spine surgery patients. Typical prehabilitation includes physical exercise, nutrition supplementation, and behavioral measures that may offer symptomatic relief even in the absence of surgery. Nonetheless, the data on the efficacy of prehabilitation for spine surgery remains sparse and barriers to prehabilitation are poorly defined. This narrative review concludes that a frailty assessment-potentially supplemented by an assessment of cognition and psychosocial resources-should be part of shared decision-making for patients considering complex spine surgery. Such an assessment may suffice to prompt interventions that form a prehabilitation program. Formal prehabilitation programs will require further study to better define their place in complex spine care.
Collapse
Affiliation(s)
- Basma Mohamed
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
| | - Ramani Ramachandran
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
| | - Ferenc Rabai
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
- Perioperative Cognitive Anesthesia Network, University of Florida College of Medicine, Gainesville, Florida
| | - Catherine C. Price
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions, Gainesville, Florida
- Perioperative Cognitive Anesthesia Network, University of Florida College of Medicine, Gainesville, Florida
| | - Adam Polifka
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
| | - Daniel Hoh
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
| | - Christoph N. Seubert
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
- Perioperative Cognitive Anesthesia Network, University of Florida College of Medicine, Gainesville, Florida
| |
Collapse
|
8
|
Arora A, Wague A, Srinivas R, Callahan M, Peterson TA, Theologis AA, Berven S. Risk factors for extended length of stay and non-home discharge in adults treated with multi-level fusion for lumbar degenerative pathology and deformity. Spine Deform 2022; 11:685-697. [PMID: 36520257 PMCID: PMC10147745 DOI: 10.1007/s43390-022-00620-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/17/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE To identify independent risk factors, including the Risk Assessment and Prediction Tool (RAPT) score, associated with extended length of stay (eLOS) and non-home discharge following elective multi-level instrumented spine fusion operations for diagnosis of adult spinal deformity (ASD) and lumbar degenerative pathology. METHODS Adults who underwent multi-level ([Formula: see text] segments) instrumented spine fusions for ASD and lumbar degenerative pathology at a single institution (2016-2021) were reviewed. Presence of a pre-operative RAPT score was used as an inclusion criterion. Excluded were patients who underwent non-elective operations, revisions, operations for trauma, malignancy, and/or infections. Outcomes were eLOS (> 7 days) and discharge location (home vs. non-home). Predictor variables included demographics, comorbidities, operative information, Surgical Invasiveness Index (SII), and RAPT score. Fisher's exact test was used for univariate analysis, and significant variables were implemented in multivariate binary logistic regression, with generation of 95% percent confidence intervals (CI), odds ratios (OR), and p-values. RESULTS Included for analysis were 355 patients. Post-operatively, 36.6% (n = 130) had eLOS and 53.2% (n = 189) had a non-home discharge. Risk factors significant for a non-home discharge were older age (> 70 years), SII > 36, pre-op RAPT < 10, DMII, diagnosis of depression or anxiety, and eLOS. Risk factors significant for an eLOS were SII > 20, RAPT < 6, and an ASA score of 3. CONCLUSION The RAPT score and SII were most important significant predictors of eLOS and non-home discharges following multi-level instrumented fusions for lumbar spinal pathology and deformity. Preoperative optimization of the RAPT's individual components may provide a useful strategy for decreasing LOS and modifying discharge disposition.
Collapse
Affiliation(s)
- Ayush Arora
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, 500 Parnassus Ave, MUW320W, San Francisco, CA, USA
| | - Aboubacar Wague
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, 500 Parnassus Ave, MUW320W, San Francisco, CA, USA
| | - Ravi Srinivas
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, 500 Parnassus Ave, MUW320W, San Francisco, CA, USA
| | - Matt Callahan
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, 500 Parnassus Ave, MUW320W, San Francisco, CA, USA
| | - Thomas A Peterson
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, 500 Parnassus Ave, MUW320W, San Francisco, CA, USA.,Bakar Computational Health Sciences Institute, UCSF, San Francisco, CA, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, 500 Parnassus Ave, MUW320W, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, 500 Parnassus Ave, MUW320W, San Francisco, CA, USA.
| |
Collapse
|
9
|
Borja AJ, Farooqi AS, Golubovsky JL, Glauser G, Strouz K, Burkhardt JK, McClintock SD, Malhotra NR. Simple and actionable preoperative prediction of postoperative healthcare needs of single-level lumbar fusion patients. J Neurosurg Spine 2022; 37:633-638. [PMID: 35901736 DOI: 10.3171/2022.5.spine22282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Preoperative prediction of a patient's postoperative healthcare utilization is challenging, and limited guidance currently exists. The objective of the present study was to assess the capability of individual risk-related patient characteristics, which are available preoperatively, that may predict discharge disposition prior to lumbar fusion. METHODS In total, 1066 consecutive patients who underwent single-level, posterior-only lumbar fusion at a university health system were enrolled. Patients were prospectively asked 4 nondemographic questions from the Risk Assessment and Prediction Tool during preoperative office visits to evaluate key risk-related characteristics: baseline walking ability, use of a gait assistive device, reliance on community supports (e.g., Meals on Wheels), and availability of a postoperative home caretaker. The primary outcome was discharge disposition (home vs skilled nursing facility/acute rehabilitation). Logistic regression was performed to analyze the ability of each risk-related characteristic to predict likelihood of home discharge. RESULTS Regression analysis demonstrated that improved baseline walking ability (OR 3.17), ambulation without a gait assistive device (OR 3.13), and availability of a postoperative home caretaker (OR 1.99) each significantly predicted an increased likelihood of home discharge (all p < 0.0001). However, reliance on community supports did not significantly predict discharge disposition (p = 0.94). CONCLUSIONS Patient mobility and the availability of a postoperative caretaker, when determined preoperatively, strongly predict a patient's healthcare utilization in the setting of single-level, posterior lumbar fusion. These findings may help surgeons to streamline preoperative clinic workflow and support the patients at highest risk in a targeted fashion.
Collapse
Affiliation(s)
- Austin J Borja
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Ali S Farooqi
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Joshua L Golubovsky
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Gregory Glauser
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Krista Strouz
- 2McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia; and
| | - Jan-Karl Burkhardt
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Scott D McClintock
- 3The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Neil R Malhotra
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- 2McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia; and
| |
Collapse
|
10
|
Minetama M, Kawakami M, Teraguchi M, Enyo Y, Nakagawa M, Yamamoto Y, Matsuo S, Nakatani T, Sakon N, Nakagawa Y. Supervised physical therapy versus surgery for patients with lumbar spinal stenosis: a propensity score-matched analysis. BMC Musculoskelet Disord 2022; 23:658. [PMID: 35820887 PMCID: PMC9275154 DOI: 10.1186/s12891-022-05632-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background Previous studies comparing surgical with nonsurgical treatment for lumbar spinal stenosis (LSS) reported that surgery is superior to nonsurgical treatments, but intensive and adequate volume of physical therapy were rarely performed. The purpose of this study was to compare the 1-year follow-up outcomes of patients with LSS treated with supervised physical therapy or surgery using propensity score-matched analysis. Methods A total of 224 patients with LSS who received supervised physical therapy (n = 38) or surgery (n = 186) were included, of which 66 were matched on baseline demographics, radiological findings, and patient-reported outcomes. The physical therapy group received supervised physical therapy twice weekly for 6 weeks. The physical therapy sessions included manual therapy, individually tailored exercises, cycling, and body-weight supported treadmill walking. The surgery group underwent decompression surgery with or without spinal fusion. A propensity score analysis was performed using a one-to-one nearest neighbor approach. Results The surgery group showed greater improvements in Zurich claudication questionnaire symptom severity and physical function, SF-36 physical functioning, bodily pain, and mental health, but had more severe stenosis and symptoms and mental health problems than the physical therapy group at baseline (P < 0.05). After propensity score matching, there were no significant differences in baseline characteristics, and all clinical outcomes at 1 year, except for a higher percentage of responders achieving minimum clinically important difference in the role-emotional subscale of SF-36 in the surgery group (P < 0.05). Conclusions When baseline characteristics were considered, supervised physical therapy yielded similar effects to lumbar surgery. These results suggest that supervised physical therapy is preferred over surgery as first-choice treatment, to prevent complications and to minimize health care costs, especially in mild to moderate cases of LSS.
Collapse
Affiliation(s)
- Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan.
| | - Mamoru Kawakami
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan.,Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, 45 Jyunibancho, Wakayama city, Wakayama, 640-8158, Japan
| | - Masatoshi Teraguchi
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Yoshio Enyo
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Masafumi Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Yoshio Yamamoto
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Sachika Matsuo
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Tomohiro Nakatani
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Nana Sakon
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Yukihiro Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| |
Collapse
|
11
|
Reuschel V, Scherlach C, Pfeifle C, Krause M, Struck MF, Hoffmann KT, Schob S. Treatment Effect of CT-Guided Periradicular Injections in Context of Different Contrast Agent Distribution Patterns. Diagnostics (Basel) 2022; 12:diagnostics12040787. [PMID: 35453835 PMCID: PMC9028051 DOI: 10.3390/diagnostics12040787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/08/2022] [Accepted: 03/18/2022] [Indexed: 02/01/2023] Open
Abstract
Acutely manifesting radicular pain syndromes associated with degenerations of the lower spine are frequent ailments with a high rate of recurrence. Part of the conservative management are periradicular infiltrations of analgesics and steroids. The purpose of this study is to evaluate the dependence of the clinical efficacy of CT-guided periradicular injections on the pattern of contrast distribution and to identify the best distribution pattern that is associated with the most effective pain relief. Using a prospective study design, 161 patients were included in this study, ensuring ethical standards. Statistical analysis was performed, with the level of statistical significance set at p = 0.05. A total of 37.9% of patients experienced significant but not long-lasting (four weeks on average) complete pain relief. A total of 44.1% of patients experienced prolonged, subjectively satisfying pain relief of more than four weeks to three months. A total of 18% of patients had complete and sustained relief for more than six months. A significant correlation exists between circumferential, large area contrast distribution including the zone of action between the disc and affected nerve root contrast distribution pattern with excellent pain relief. Our results support the value of CT-guided contrast injection for achieving a good efficacy, and, if necessary, indicative repositioning of the needle to ensure a circumferential distribution pattern of corticosteroids for the sufficient treatment of radicular pain in degenerative spine disease.
Collapse
Affiliation(s)
- Vera Reuschel
- Institut für Neuroradiologie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany; (V.R.); (C.S.); (K.-T.H.)
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Cordula Scherlach
- Institut für Neuroradiologie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany; (V.R.); (C.S.); (K.-T.H.)
| | - Christian Pfeifle
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany;
| | - Matthias Krause
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany;
| | - Manuel Florian Struck
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany;
| | - Karl-Titus Hoffmann
- Institut für Neuroradiologie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany; (V.R.); (C.S.); (K.-T.H.)
| | - Stefan Schob
- Abteilung für Neuroradiologie, Universitätsklinik und Poliklinik für Radiologie, Universitätsklinikum Halle (Saale) Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany
- Correspondence: ; Tel.: +49-34-5557-2432
| |
Collapse
|
12
|
Effect of Patient Use of Physical Therapy After Referral for Musculoskeletal Conditions on Future Medical Utilization: A Retrospective Cohort Analysis. J Manipulative Physiol Ther 2022; 44:621-636. [DOI: 10.1016/j.jmpt.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/03/2022] [Accepted: 01/07/2022] [Indexed: 11/18/2022]
|
13
|
Artificial Intelligence Algorithm-Based Lumbar and Spinal MRI for Evaluation of Efficacy of Chinkuei Shin Chewan Decoction on Lumbar Spinal Stenosis. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2021:2700452. [PMID: 35035312 PMCID: PMC8731294 DOI: 10.1155/2021/2700452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/28/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
The study aimed to explore the application value of lumbar Magnetic Resonance Imaging (MRI) images processed by artificial intelligence algorithms in evaluating the efficacy of chinkuei shin chewan decoction (a traditional Chinese medicine to nourish the kidney) in the treatment of lumbar spinal stenosis (LSS). Specifically, 110 LSS patients admitted to the hospital were selected as the research subjects. They were randomly divided into the control group (n = 55) and experimental group (n = 55) according to different treatment methods. The control group was treated with traditional medicine, and the experimental group additionally took chinkuei shin chewan decoction on its basis. Based on the traditional U-net algorithm, a U-net registration algorithm based on artificial intelligence was designed by introducing the information entropy theory, and the algorithm was applied to the lumbar MRI image evaluation of LSS patients. Compared with the traditional U-net algorithm, the artificial intelligence-based U-net registration algorithm had a decreased noise level (P < 0.05), the Jaccard (J) value (0.84) and the Dice value (0.93) increased significantly versus the traditional algorithm (J = 0.63, Dice = 0.81), and the characteristics of the image were more accurate. Before treatment, the Oswestry Disability Index (ODI) scores of the experimental group and the control group were 44.32 ± 6.45 and 43.32 ± 5.45, respectively. After treatment, the ODI scores of the two groups were 10.21 ± 5.05 and 17.09 ± 5.23, respectively. Both showed significant improvement, while the improvement of the experimental group was more obvious than that of the control group (P < 0.05). The overall effective rates of the two groups of patients were 96.44% and 82.47%, respectively, and the experimental group was significantly higher than the control group (P < 0.05). Under the U-net registration algorithm based on artificial intelligence, the diagnostic accuracy of lumbar MRI in the experimental group was 94.45%, significantly higher than 67.5% before the introduction of the algorithm (P < 0.05). In conclusion, chinkuei shin chewan decoction are effective for the treatment of LSS, and lumbar MRI based on the artificial intelligence U-net registration algorithm can evaluate the efficacy of LSS well and is worthy of promotion.
Collapse
|
14
|
Lee S, Chae DS, Song BW, Lim S, Kim SW, Kim IK, Hwang KC. ADSC-Based Cell Therapies for Musculoskeletal Disorders: A Review of Recent Clinical Trials. Int J Mol Sci 2021; 22:ijms221910586. [PMID: 34638927 PMCID: PMC8508846 DOI: 10.3390/ijms221910586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 01/04/2023] Open
Abstract
Recently published clinical trials involving the use of adipose-derived stem cells (ADSCs) indicated that approximately one-third of the studies were conducted on musculoskeletal disorders (MSD). MSD refers to a wide range of degenerative conditions of joints, bones, and muscles, and these conditions are the most common causes of chronic disability worldwide, being a major burden to the society. Conventional treatment modalities for MSD are not sufficient to correct the underlying structural abnormalities. Hence, ADSC-based cell therapies are being tested as a form of alternative, yet more effective, therapies in the management of MSDs. Therefore, in this review, MSDs subjected to the ADSC-based therapy were further categorized as arthritis, craniomaxillofacial defects, tendon/ligament related disorders, and spine disorders, and their brief characterization as well as the corresponding conventional therapeutic approaches with possible mechanisms with which ADSCs produce regenerative effects in disease-specific microenvironments were discussed to provide an overview of under which circumstances and on what bases the ADSC-based cell therapy was implemented. Providing an overview of the current status of ADSC-based cell therapy on MSDs can help to develop better and optimized strategies of ADSC-based therapeutics for MSDs as well as help to find novel clinical applications of ADSCs in the near future.
Collapse
Affiliation(s)
- Seahyoung Lee
- Institute for Bio-Medical Convergence, College of Medicine, Catholic Kwandong University, Gangneung 210-701, Korea; (S.L.); (B.-W.S.); (S.L.); (S.W.K.)
| | - Dong-Sik Chae
- Department of Orthopedic Surgery, International St. Mary’s Hospital, Catholic Kwandong University, Gangneung 210-701, Korea;
| | - Byeong-Wook Song
- Institute for Bio-Medical Convergence, College of Medicine, Catholic Kwandong University, Gangneung 210-701, Korea; (S.L.); (B.-W.S.); (S.L.); (S.W.K.)
| | - Soyeon Lim
- Institute for Bio-Medical Convergence, College of Medicine, Catholic Kwandong University, Gangneung 210-701, Korea; (S.L.); (B.-W.S.); (S.L.); (S.W.K.)
| | - Sang Woo Kim
- Institute for Bio-Medical Convergence, College of Medicine, Catholic Kwandong University, Gangneung 210-701, Korea; (S.L.); (B.-W.S.); (S.L.); (S.W.K.)
| | - Il-Kwon Kim
- Institute for Bio-Medical Convergence, College of Medicine, Catholic Kwandong University, Gangneung 210-701, Korea; (S.L.); (B.-W.S.); (S.L.); (S.W.K.)
- Correspondence: (I.-K.K.); (K.-C.H.); Fax: +82-32-290-2774 (K.-C.H.)
| | - Ki-Chul Hwang
- Institute for Bio-Medical Convergence, College of Medicine, Catholic Kwandong University, Gangneung 210-701, Korea; (S.L.); (B.-W.S.); (S.L.); (S.W.K.)
- Correspondence: (I.-K.K.); (K.-C.H.); Fax: +82-32-290-2774 (K.-C.H.)
| |
Collapse
|
15
|
Schmidt CT, Ogarek J, Resnik L. Physical Therapy and Health Care Utilization for Older Adults With Lumbar Spinal Stenosis. J Geriatr Phys Ther 2021; 45:E145-E154. [PMID: 34570040 DOI: 10.1519/jpt.0000000000000328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Lumbar spinal stenosis (LSS) is associated with high health care utilization for older adults. Physical therapy (PT) offers low medical risk and reduced cost burden with functional outcomes that appear to be equivalent to higher risk interventions such as surgery. However, it is unknown whether receipt of PT following incident LSS diagnosis is associated with reduced health care utilization. The objectives of this study were to: (1) compare health characteristics for Medicare beneficiaries who received outpatient PT within 30 days of incident LSS diagnosis to those who did not; (2) compare the 1-year utilization rates for specific health care services for these 2 groups; and (3) quantify the likelihood of progression to specific health services based on the receipt of PT. METHODS This was a retrospective cohort study using nationally representative claims data for Medicare Part B beneficiaries between 2007 and 2010. Lumbar spinal stenosis was determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Beneficiaries 65 years and older were classified into 2 groups (PT and no PT) based on receipt of PT within 30 days of initial diagnosis. Baseline characteristics were identified at incident diagnosis. Hazard ratios (HRs) were estimated for the risk of receiving health services outcomes including spinal surgery, spinal injections, chiropractic care, advanced imaging, spinal radiographs, opioid medication, nonopioid analgesics, and hospitalizations beginning on day 31 up to 1 year following incident LSS diagnosis. RESULTS AND DISCUSSION Among 60 646 Medicare beneficiaries with incident LSS who met the inclusion criteria, 1124 were classified in the PT group and 59 522 in the no PT group. Compared with the PT group, beneficiaries in the no PT group had a greater risk of having hospitalizations (HR = 1.40), opioid medications (HR = 1.29), spinal surgery (HR = 1.29), and spinal radiographs (HR = 1.19) within 1 year. CONCLUSIONS Fewer than 2% of Medicare beneficiaries received PT within 30 days of initial LSS diagnosis. Receipt of PT was associated with less utilization of higher risk and costly health services for 1 year. These results may inform practitioners when making early decisions about rehabilitative care for older adults with LSS.
Collapse
Affiliation(s)
- Catherine T Schmidt
- MGH Institute of Health Professions, Boston, Massachusetts. Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island. Providence VA Medical Center, Providence, Rhode Island
| | | | | |
Collapse
|
16
|
Minetama M, Kawakami M, Teraguchi M, Kagotani R, Mera Y, Sumiya T, Nakagawa M, Yamamoto Y, Matsuo S, Sakon N, Nakatani T, Kitano T, Nakagawa Y. Supervised physical therapy versus unsupervised exercise for patients with lumbar spinal stenosis: 1-year follow-up of a randomized controlled trial. Clin Rehabil 2021; 35:964-975. [PMID: 33423549 DOI: 10.1177/0269215520986688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the 1-year outcomes of patients with lumbar spinal stenosis treated with supervised physical therapy or unsupervised exercise. DESIGN A single-center randomized controlled trial with concealed allocation, blinded assessor and intention-to-treat analysis. SETTING Spine care center. SUBJECTS A total of 86 patients presenting with symptoms of neurogenic claudication caused by lumbar spinal stenosis. INTERVENTIONS The physical therapy group received supervised physical therapy sessions twice a week for 6 weeks and home exercise program. The home exercise group received 6-week home exercise program only. MAIN MEASURES The primary outcome was symptom severity on the Zurich claudication questionnaire at 1 year. Secondary outcomes included physical function, pain, health-related quality of life and the surgery rate after 1 year. RESULTS At 1 year, more patients in the physical therapy group than in the home exercise group achieved minimum clinically important differences in Zurich claudication questionnaire symptom severity (60.5% vs 32.6%; adjusted odds ratio [AOR] 4.3, [95% CI [1.5-12.3], P = 0.01); Zurich claudication questionnaire physical function (55.8% vs 32.6%; AOR 3.0 [1.1-8.1], P = 0.03); SF-36 bodily pain (48.8% vs 25.6%; AOR 2.8 [1.1-7.3], P = 0.03), and SF-36 general health (20.9% vs 7.0%; AOR 6.1 [1.1-33.0], P = 0.04). The surgery rate at 1 year was lower in the physical therapy than in the home exercise group (7.0% vs 23.3%; AOR 0.2 [0.04-0.9] P = 0.04). CONCLUSIONS Supervised physical therapy produced greater improvements in symptom severity and physical function than unsupervised exercise and was associated with lower likelihood of receiving surgery within 1 year.
Collapse
Affiliation(s)
- Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Mamoru Kawakami
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan.,Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan
| | - Masatoshi Teraguchi
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Ryohei Kagotani
- Department of Orthopaedic Surgery, Wakayama Rosai Hospital, Wakayama, Japan
| | - Yoshimasa Mera
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Tadashi Sumiya
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Masafumi Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Yoshio Yamamoto
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Sachika Matsuo
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Nana Sakon
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Tomohiro Nakatani
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Tomoko Kitano
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| | - Yukihiro Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan
| |
Collapse
|
17
|
Costa F, Innocenzi G, Guida F, Agrillo U, Barbagallo G, Bocchetti A, Bongetta D, Cappelletto B, Certo F, Cimatti M, Cioffi V, Dobran M, Domenicucci M, Guizzardi G, Guizzardi G, Landi A, Marotta N, Marzetti F, Montano N, Anania CD, Nina P, Quaglietta P, Rispoli R, Somma T, Squillante E, Visocchi M, Vitali M, Vitiello V. Degenerative Lumbar Spine Stenosis Consensus Conference: the Italian job. Recommendations of the Spinal Section of the Italian Society of Neurosurgery. J Neurosurg Sci 2020; 65:91-100. [PMID: 32972117 DOI: 10.23736/s0390-5616.20.05042-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.
Collapse
Affiliation(s)
- Francesco Costa
- Department of Neurosurgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy - .,Department of Biomedical Sceinces, Humanitas University, Milan, Italy -
| | | | - Franco Guida
- Department of Neurosurgery, Ospedale dell'Angelo, Mestre, Venice, Italy
| | - Umberto Agrillo
- Department of Neurosurgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | | | - Antonio Bocchetti
- Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, Pozzuoli, Naples, Italy
| | - Daniele Bongetta
- Department of Neurosurgery, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Barbara Cappelletto
- Section of Spinal Column and Spinal Cord Surgery and Spinal Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Francesco Certo
- Department of Neurosurgery, University of Catania, Catania, Italy
| | - Marco Cimatti
- N.E.S.M.O.S Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Valentina Cioffi
- Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, Pozzuoli, Naples, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Marche Polytechnic University, Ancona, Italy
| | - Maurizio Domenicucci
- Department of Neurology and Psychiatry, Neurosurgery, Polo Pontino, Sapienza University, Rome, Italy
| | | | | | - Alessandro Landi
- Division of Neurosurgery and Spinal Surgery, San Carlo di Nancy Hospital, Rome, Italy
| | - Nicola Marotta
- Division of Neurosurgery and Spinal Surgery, San Carlo di Nancy Hospital, Rome, Italy
| | - Francesco Marzetti
- Neurosurgery Division, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Nicola Montano
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Carla D Anania
- Department of Neurosurgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Pierpaolo Nina
- Unit of Neurosurgery, San Giovanni Bosco Hospital, Naples, Italy
| | - Paolo Quaglietta
- Unit of Neurosurgery, General Hospital of Cosenza, Cosenza, Italy
| | - Rossella Rispoli
- Section of Spinal Column and Spinal Cord Surgery and Spinal Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Teresa Somma
- Division of Neurosurgery, Federico II University, Naples, Italy
| | | | | | - Matteo Vitali
- Unit of Neurosurgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | | |
Collapse
|
18
|
Carrignan JA, Simmet RT, Coddington M, Gill NW, Greenlee TA, McCafferty R, Rhon DI. Are Exercise and Physical Therapy Common Forms of Conservative Management in the Year Before Lumbar Spine Surgery? Arch Phys Med Rehabil 2020; 101:1389-1395. [DOI: 10.1016/j.apmr.2020.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/13/2020] [Accepted: 04/16/2020] [Indexed: 12/29/2022]
|
19
|
Fornari M, Robertson SC, Pereira P, Zileli M, Anania CD, Ferreira A, Ferrari S, Gatti R, Costa F. Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations. World Neurosurg X 2020; 7:100079. [PMID: 32613192 PMCID: PMC7322792 DOI: 10.1016/j.wnsx.2020.100079] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/25/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS. METHODS To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements. RESULTS During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS. CONCLUSIONS A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.
Collapse
Affiliation(s)
- Maurizio Fornari
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Scott C. Robertson
- Neurosurgery Department, Laredo Medical Center, University of the Incarnate Word School of Osteopathic Medicine, Laredo, Texas, USA
| | - Paulo Pereira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University Faculty of Medicine, Bornova, Izmir, Turkey
| | - Carla D. Anania
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ana Ferreira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | | | - Francesco Costa
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| |
Collapse
|
20
|
Systematic Review of Outcomes Following 10-year Mark of Spine Patient Outcomes Research Trial (SPORT) for Spinal Stenosis. Spine (Phila Pa 1976) 2020; 45:832-836. [PMID: 31770345 DOI: 10.1097/brs.0000000000003323] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN We performed a comprehensive search of Pubmed, MEDLINE, and EMBASE for all English-language studies of all levels of evidence pertaining to SPORT, in accordance with Preferred Reported Items for Systematic Reviews and Meta-analayses (PRISMA) guidelines. OBJECTIVE We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for spinal stenosis. SUMMARY OF BACKGROUND DATA The Spine Patient Outcomes Research Trial (SPORT) was a landmark randomized control trial including approximately 2,500 patients at 13 clinics across the country. SPORT compared surgical and nonoperative management of the three most common spinal pathologies. METHODS Keywords utilized in the literature search included: SPORT, spine patient outcomes research trial, spinal stenosis, and surgical outcomes. RESULTS Surgical intervention showed significantly greater improvement in pain and physical function scales from 6 weeks through 4 years. However, between 4 and 8 years, the difference between the two groups diminished, and the benefits in both groups stabilized. Secondary factors investigated showed that smoking was a confounding variable for treatment benefits and a positive sedimentation sign correlated with a greater surgical treatment effect. Obese patients were found to have higher rates of infection and reoperation and less improvement from baseline function. Risk factors for reoperation included duration of pretreatment symptoms for longer than 12 months, increased age, multiple levels of stenosis, predominant back pain, no physical therapy, greater leg pain, the use of antidepressants and no neurogenic claudication upon enrollment. CONCLUSION Ten years after its inception, SPORT has made strides in standardization and optimization of treatment for spinal pathologies. SPORT has provided clinicians with insight about outcomes of surgical and nonoperative treatment of spinal stenosis. Results showed significantly greater improvement through 4 year follow up in those patients that received surgical treatment, however the difference between the surgical and nonsurgical groups diminished at 8 year follow up. LEVEL OF EVIDENCE 3.
Collapse
|
21
|
Deer T, Sayed D, Michels J, Josephson Y, Li S, Calodney AK. A Review of Lumbar Spinal Stenosis with Intermittent Neurogenic Claudication: Disease and Diagnosis. PAIN MEDICINE 2020; 20:S32-S44. [PMID: 31808530 PMCID: PMC7101166 DOI: 10.1093/pm/pnz161] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective Lumbar spinal stenosis (LSS) is a degenerative spinal condition affecting nearly 50% of patients presenting with lower back pain. The goal of this review is to present and summarize the current data on how LSS presents in various populations, how it is diagnosed, and current therapeutic strategies. Properly understanding the prevalence, presentation, and treatment options for individuals suffering from LSS is critical to providing patients the best possible care. Results The occurrence of LSS is associated with advanced age. In elderly patients, LSS can be challenging to identify due to the wide variety of presentation subtleties and common comorbidities such as degenerative disc disease. Recent developments in imaging techniques can be useful in accurately identifying the precise location of the spinal compression. Treatment options can range from conservative to surgical, with the latter being reserved for when patients have neurological compromise or conservative measures have failed. Once warranted, there are several surgical techniques at the physician’s disposal to best treat each individual case.
Collapse
Affiliation(s)
- Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, Kansas
| | | | | | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey
| | - Aaron K Calodney
- Precision Spine Care, Texas Spine and Joint Hospital, Tyler, Texas, USA
| |
Collapse
|
22
|
Therapeutic Advantages of Frequent Physical Therapy Sessions for Patients With Lumbar Spinal Stenosis. Spine (Phila Pa 1976) 2020; 45:E639-E646. [PMID: 31842106 DOI: 10.1097/brs.0000000000003363] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study of a randomized clinical trial and a prospective study of patients with lumbar spinal stenosis (LSS). OBJECTIVE The aim of this study was to identify the effects of the number of physical therapy (PT) sessions on clinical outcomes of patients with LSS. SUMMARY OF BACKGROUND DATA Supervised PT for patients with LSS has been reported to lead to better short-term outcomes in terms of disability and leg pain than unsupervised exercise. However, no studies have investigated the relationship between the number of PT sessions and the therapeutic effects in patients with LSS. METHODS All patients received exercise therapy for 6 weeks. Included were 43 patients receiving supervised PT twice a week (P2 group), 38 patients receiving supervised PT once a week (P1 group), and 43 patients receiving a home exercise program alone (HE group). Clinical outcomes were measured using the Zurich Claudication Questionnaire (ZCQ), a numerical rating scale (NRS) of back pain and leg pain, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) at baseline and at 6 weeks. RESULTS At 6 weeks, the P2 group showed significant improvements in ZCQ physical function, back and leg pain on the NRS compared with the P1 group (P < 0.05). Compared with the HE group, the P2 group showed significant improvements in ZCQ symptom severity and physical function, back and leg pain on the NRS, and JOABPEQ gait disturbance (P < 0.05). There were no significant differences in mean changes after 6 weeks between the P1 and HE groups. CONCLUSION Six weeks of supervised PT twice a week resulted in significant short-term improvements in symptom severity, physical function, back and leg pain, and gait disturbance compared with once a week and/or home exercise alone. Patients with LSS should be treated with intensive and supervised exercise programs to obtain maximum benefit of exercise therapy. LEVEL OF EVIDENCE 3.
Collapse
|
23
|
Fors M, Enthoven P, Abbott A, Öberg B. Effects of pre-surgery physiotherapy on walking ability and lower extremity strength in patients with degenerative lumbar spine disorder: Secondary outcomes of the PREPARE randomised controlled trial. BMC Musculoskelet Disord 2019; 20:468. [PMID: 31651299 PMCID: PMC6813060 DOI: 10.1186/s12891-019-2850-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/23/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Degenerative lumbar spine disorders are common among musculoskeletal disorders. When disabling pain and radiculopathy persists after adequate course of rehabilitation and imaging confirms compressive pathology, surgical decompression is indicated. Prehabilitation aiming to augment functional capacity pre-surgery may improve physical function and activity levels pre and post-surgery. This study aims to evaluate the effect and dose-response of pre-surgery physiotherapy on quadriceps femoris strength and walking ability in patients with degenerative lumbar spine disorders compared to waiting-list controls and their association with postoperative physical activity level. METHOD In this single blinded, 2-arm randomised controlled trial, 197 patients were consecutively recruited. Inclusion criteria were: MRI confirmed diagnosis and scheduled for surgery due to disc herniation, lumbar spinal stenosis, degenerative disc disease or spondylolisthesis, ages 25-80 years. Patients were randomised to 9 weeks of pre-surgery physiotherapy or to waiting-list. Patient reported physical activity level, walking ability according to Oswestry Disability Index item 4, walking distance according to the SWESPINE national register and physical outcome measures including the timed ten-meter walk test, maximum voluntary isometric quadriceps femoris muscle strength, patient-rated were collected at baseline and follow-up. Parametric or non-parametric within and between group comparisons as well as multivariate regression was performed. RESULTS Patients who received pre-surgery physiotherapy significantly improved in all variables from baseline to follow-up (p < 0.001 - p < 0.05) and in comparison to waiting-list controls (p < 0.001 - p < 0.028). Patients adhering to ≥12 treatment sessions significantly improved in all variables (p < 0.001 - p < 0.032) and those receiving 0-11 treatment session in only normal walking speed (p0.035) but there were no significant differences when comparing dosages. Physical outcome measures after pre-surgery physiotherapy together significantly explain 27.5% of the variation in physical activity level 1 year after surgery with pre-surgery physical activity level having a significant multivariate association. CONCLUSION Pre-surgery physiotherapy increased walking ability and lower extremity strength in patients with degenerative lumbar spine disorders compared to waiting-list controls. A clear treatment dose-response response relationship was not found. These results implicate that pre-surgery physiotherapy can influence functional capacity before surgical treatment and has moderate associations with maintained postoperative physical activity levels mostly explained by physical activity level pre-surgery. TRIAL REGISTRATION NCT02454400 . Trial registration date: August 31st 2015, retrospectively registered.
Collapse
Affiliation(s)
- Maria Fors
- Department of Medical and Health Sciences, Division of Physiotherapy, Faculty of Medicine and Health Sciences, Linköping University, SE-581 83, Linköping, Sweden. .,Department of Activity and Health, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Paul Enthoven
- Department of Medical and Health Sciences, Division of Physiotherapy, Faculty of Medicine and Health Sciences, Linköping University, SE-581 83, Linköping, Sweden
| | - Allan Abbott
- Department of Medical and Health Sciences, Division of Physiotherapy, Faculty of Medicine and Health Sciences, Linköping University, SE-581 83, Linköping, Sweden
| | - Birgitta Öberg
- Department of Medical and Health Sciences, Division of Physiotherapy, Faculty of Medicine and Health Sciences, Linköping University, SE-581 83, Linköping, Sweden
| |
Collapse
|
24
|
Hug A, Hähnel S, Weidner N. [Diagnostics and conservative treatment of cervical and lumbar spinal stenosis]. DER NERVENARZT 2019; 89:620-631. [PMID: 29663022 DOI: 10.1007/s00115-018-0516-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Degenerative stenotic spondylosis is not an uncommon cause of cervical spondylotic myelopathy (CSM) and cauda equina lesions in the aged population. Limited standardization exists with respect to diagnostic and therapeutic procedures. OBJECTIVE Literature review with respect to diagnostic and therapeutic procedures for neurologically relevant cervical and lumbar spinals stenosis. MATERIAL AND METHODS Comprehensive literature review. RESULTS AND CONCLUSION Clinical neurological examination and diagnostic imaging are fundamental for the diagnosis of neurologically relevant cervical and lumbar spinal stenosis. Additional laboratory blood and cerebrospinal fluid testing might be required for a differential diagnosis. Neurophysiological testing is reserved for specific clinical problems. The clinical evidence for the efficacy of conservative therapeutic strategies is limited.
Collapse
Affiliation(s)
- A Hug
- Klinik für Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstr. 200a, 69118, Heidelberg, Deutschland.
| | - S Hähnel
- Abteilung Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - N Weidner
- Klinik für Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstr. 200a, 69118, Heidelberg, Deutschland
| |
Collapse
|
25
|
Abstract
The Spine Patient-Reported Outcomes Related Trial (SPORT) is arguably one of the most impactful and insightful studies conducted in spine surgery. Designed as a prospective, multicenter study with randomized and observational cohorts, SPORT has provided vast data on the pathogenesis, treatment effects, clinical outcomes, cost effectiveness of disk herniation, lumbar spinal stenosis, and degenerative spondylolisthesis. With regards to spinal stenosis and degenerative spondylolisthesis, SPORT has demonstrated a sustained benefit from surgical intervention at 2, 4, and 8 years postoperatively. Myriad subgroup analyses have subsequently been performed that have also resulted in clinically relevant findings. These analyses have assessed incidence and risk factors for reoperations and intraoperative complications, impact of patient comorbidities and host factors, influence of epidural injections, patient decision-making, and role of nonoperative therapy. This has resulted in significant findings that may allow spine surgeons to optimize patient outcomes while managing expectations appropriately.
Collapse
|
26
|
Supervised physical therapy vs. home exercise for patients with lumbar spinal stenosis: a randomized controlled trial. Spine J 2019; 19:1310-1318. [PMID: 30986577 DOI: 10.1016/j.spinee.2019.04.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Exercise has been reported to improve short-term outcomes for patients with LSS in terms of disability and back and leg pain. However, no studies have compared supervised exercise with unsupervised exercise or quantified physical activity using a pedometer to confirm compliance with a home exercise program. PURPOSE To compare the effectiveness of supervised physical therapy (PT) with unsupervised exercise for patients with lumbar spinal stenosis (LSS). STUDY DESIGN/SETTING A single-center, open-label, randomized controlled trial. PATIENT SAMPLE Patients presenting with symptoms of neurogenic claudication caused by LSS, which was confirmed by magnetic resonance imaging. OUTCOME MEASURES The primary outcome was improvement in symptom severity scores on the Zurich Claudication Questionnaire (ZCQ) at 6 weeks. Secondary outcomes included physical function on the ZCQ, self-paced walking test (SPWT) performance, pain indicated using a numerical rating scale (NRS), and the number of daily steps measured by pedometer. METHODS Patients with LSS were randomized to a PT group, who performed supervised PT twice a week for 6 weeks, or a home exercise (HE) group. PT sessions included manual therapy, individually tailored stretching and strengthening exercises, cycling, and body weight-supported treadmill walking. RESULTS Forty-three patients were randomly allocated to the PT group and 43 patients to the HE group. Compared with the HE group, the PT group had greater percentage of responders achieving minimum clinically important difference in ZCQ symptom severity (difference for percentage between groups [95%confidence interval], 30.2% [9.1-48.6], p=.01), ZCQ physical function (32.6% [11.6-50.6], p<.01), walking distance on the SPWT (39.5% [18.8-56.7], p<.01), leg pain on the NRS (34.9% [13.9-52.7], p<.01), and number of daily steps (25.6% [4.9-43.9], p=.01). CONCLUSIONS Supervised PT for patients with LSS resulted in significant short-term improvements in symptom severity, physical function, walking distance, pain, and physical activity compared with unsupervised exercise.
Collapse
|
27
|
Effectiveness of Physical Therapy Combined With Epidural Steroid Injection for Individuals With Lumbar Spinal Stenosis: A Randomized Parallel-Group Trial. Arch Phys Med Rehabil 2019; 100:797-810. [DOI: 10.1016/j.apmr.2018.12.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/29/2018] [Accepted: 12/01/2018] [Indexed: 12/15/2022]
|
28
|
Anderson DB, Ferreira ML, Harris IA, Davis GA, Stanford R, Beard D, Li Q, Jan S, Mobbs RJ, Maher CG, Yong R, Zammit T, Latimer J, Buchbinder R. SUcceSS, SUrgery for Spinal Stenosis: protocol of a randomised, placebo-controlled trial. BMJ Open 2019; 9:e024944. [PMID: 30765407 PMCID: PMC6398750 DOI: 10.1136/bmjopen-2018-024944] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/12/2018] [Accepted: 12/12/2018] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Central lumbar spinal stenosis (LSS) is a common cause of pain, reduced function and quality of life in older adults. Current management of LSS includes surgery to decompress the spinal canal and alleviate symptoms. However, evidence supporting surgical decompression derives from unblinded randomised trials with high cross-over rates or cohort studies showing modest benefits. This protocol describes the design of the SUrgery for Spinal Stenosis (SUcceSS) trial -the first randomised placebo-controlled trial of decompressive surgery for symptomatic LSS. METHODS AND ANALYSIS SUcceSS will be a prospectively registered, randomised placebo-controlled trial of decompressive spinal surgery. 160 eligible participants (80 participants/group) with symptomatic LSS will be randomised to either surgical spinal decompression or placebo surgical intervention. The placebo surgical intervention is identical to surgical decompression in all other ways with the exception of the removal of any bone or ligament. All participants and assessors will be blinded to treatment allocation. Outcomes will be assessed at baseline and at 3, 6, 12 and 24 months. The coprimary outcomes will be function measured with the Oswestry Disability Index and the proportion of participants who have meaningfully improved their walking capacity at 3 months postrandomisation. Secondary outcomes include back pain intensity, lower limb pain intensity, disability, quality of life, anxiety and depression, neurogenic claudication score, perceived recovery, treatment satisfaction, adverse events, reoperation rate and rehospitalisation rate. Those who decline to be randomised will be invited to participate in a parallel observational cohort. Data analysis will be blinded and by intention to treat. A trial-based cost-effectiveness analysis will determine the potential incremental cost per quality-adjusted life year gained. ETHICS AND DISSEMINATION Ethics approval has been granted by the NSW Health (reference:17/247/POWH/601) and the Monash University (reference: 12371) Human Research Ethics Committees. Dissemination of results will be via journal articles and presentations at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12617000884303; Pre-results.
Collapse
Affiliation(s)
- David B Anderson
- Insitute of Bone and Joint Research, The Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Insitute of Bone and Joint Research, The Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, University of New South Wales, St Leonards, New South Wales, Australia
| | - Gavin A Davis
- Department of Neurosurgery, Austin Health, Heidelberg, New South Wales, Australia
- Department of Neurosurgery, Cabrini Hospital, Malvern, Victoria, Australia
| | - Ralph Stanford
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, New South Wales, Australia
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, NIHR Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ralph J Mobbs
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, New South Wales, Australia
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Christopher G Maher
- School of Public Health, The University of Sydney, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Renata Yong
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Tara Zammit
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane Latimer
- School of Public Health, The University of Sydney, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
29
|
Schmidt CT, Ward RE, Suri P, Kiely DK, Goldstein R, Pensheng N, Anderson DE, Bean JF. Which Neuromuscular Attributes Are Associated With Changes in Mobility Among Community-Dwelling Older Adults With Symptomatic Lumbar Spinal Stenosis? Arch Phys Med Rehabil 2018; 99:2190-2197. [PMID: 29753734 PMCID: PMC6640144 DOI: 10.1016/j.apmr.2018.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 03/31/2018] [Accepted: 04/15/2018] [Indexed: 11/18/2022]
Abstract
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). DESIGN Secondary analysis of a longitudinal cohort study. SETTING Outpatient rehabilitation center. PARTICIPANTS Community-dwelling older adults ≥65 years with self-reported mobility limitations (N=430). SLSS was determined using self-reported symptoms of neurogenic claudication and imaging-detected lumbar spinal stenosis. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Basic and advanced mobility as measured by the Late-Life Function and Disability Instrument (LLFDI). RESULTS Among 430 community-dwelling older adults, 54 (13%) patients met criteria for SLSS, while 246 (57%) did not. On average LLFDI basic and advanced mobility scores decreased significantly from baseline through year 2 for participants with SLSS (basic: P=.04, 95% CI 0.18, 5.21; advanced P=.03, 95% CI 0.39, 7.84). Trunk extensor muscle endurance (trunk endurance) and leg strength were associated with baseline basic mobility (R2=0.27, P<.001) while leg strength and knee flexion range of motion (ROM) were associated with baseline advanced mobility among participants with SLSS (R2=0.47, P<.001). Among participants without SLSS trunk endurance, leg strength and ankle ROM were associated with baseline basic mobility (R2=0.38, P<.001), while trunk endurance, leg strength, leg strength asymmetry, and knee flexion ROM were associated with advanced mobility (R2=0.20, P<.001). Trunk endurance and leg strength were associated with change in basic mobility (R2=0.29, P<.001), while trunk endurance and knee flexion ROM were associated with change in advanced mobility (R2=0.42, P<.001) among participants with SLSS. Among participants without SLSS trunk endurance, leg strength, knee flexion ROM, and ankle ROM were associated with change in basic mobility (R2=0.22, P<.001), while trunk endurance, leg strength, and knee flexion ROM were associated with change in advanced mobility (R2=0.36, P<.001). CONCLUSIONS Patients with SLSS experience greater impairment in the neuromuscular attributes: trunk endurance, leg strength, leg strength asymmetry, knee flexion and extension ROM, and ankle ROM compared to patients without SLSS. Differences exist in the neuromuscular attributes associated with mobility at baseline and decline in mobility over 2 years of follow-up for patients with and without SLSS. These findings may help guide rehabilitative care approaches for patients with SLSS.
Collapse
Affiliation(s)
- Catherine T Schmidt
- Center for Interprofessional Studies and Innovation, MGH Institute of Health Professions, Boston, MA.
| | - Rachel E Ward
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, GRECC, Boston, MA
| | - Pradeep Suri
- Division of Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, WA
| | - Dan K Kiely
- Spaulding Rehabilitation Hospital, Cambridge, MA
| | - Richard Goldstein
- Department of Physical Medicine and Rehabilitation, Spaulding Hospital, Charlestown, MA
| | - Ni Pensheng
- Health and Disability Research Institute, Boston University, Boston, MA
| | - Dennis E Anderson
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jonathan F Bean
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, GRECC, Boston, MA
| |
Collapse
|
30
|
Abstract
PURPOSE OF REVIEW Our review of current literature within the past 12-24 months for the treatment of lumbar spinals stenosis (LSS) serves to update providers on recent advances and comparisons regarding therapy spanning lifestyle modification, pharmacologic therapy, minimally invasive interventions, and surgical interventions. RECENT FINDINGS Current literature supporting the inclusion of physical therapy and gabapentin/pregabalin within an initial treatment regimen have been positive. A recent randomized, double-blinded clinical trial of adding calcitonin to epidural steroid injections have shown improvement in pain and function up to 1 year. The minimally invasive lumbar decompression (mild) procedure is showing ongoing beneficial results in pain and function. Spinal cord stimulation (SCS) may have a role for select patients with lumbar spinal stenosis. Finally, the benefits of surgical treatment versus nonsurgical treatment is ultimately inconclusive because of the nature of data collection, inconsistencies with the clinical definition of LSS, and a lack of standardized treatment guidelines. SUMMARY Our review of current research demonstrates there is a positive role for the current conservative therapies, with favorable results for interventions such as minimally invasive decompression and SCS. Pharmacologic interventions such as systemic prostaglandin analogues and epidural agents such as calcitonin demonstrate early promise, but need to undergo additional safety testing and confirmatory trials. Further long-term research with validated, objective measurements for the aforementioned treatments are needed to draw any definitive conclusions for clinical practice.
Collapse
|
31
|
Minetama M, Kawakami M, Nakagawa M, Ishimoto Y, Nagata K, Fukui D, Sumiya T, Kitagawa T, Miyake T, Yamamoto Y, Sakon N, Matsuoka T, Nakagawa Y. A comparative study of 2-year follow-up outcomes in lumbar spinal stenosis patients treated with physical therapy alone and those with surgical intervention after less successful physical therapy. J Orthop Sci 2018; 23:470-476. [PMID: 29395806 DOI: 10.1016/j.jos.2018.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/22/2017] [Accepted: 01/09/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND The efficacy of physical therapy for patients with lumbar spinal stenosis (LSS) has been reported only for the short term, and few reports have compared outcomes of surgical treatment with nonsurgical treatment after physical therapy. The purpose of this study was to assess 2-year outcomes of LSS patients treated with surgery or under follow-up observation after physical therapy for 6 weeks. METHODS Patients presenting with neurogenic claudication, radiologically-confirmed central LSS affecting both legs and refractory symptoms to pharmacotherapy of more than 3 months were enrolled. Patients were treated with manual therapy, stretching and strengthening exercises, and body weight-supported treadmill walking once a week for 6 weeks. Clinical outcomes were measured using the Zurich Claudication Questionnaire (ZCQ), visual analog scale of low back pain, leg pain, and numbness, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire and the SF-36. Two years after physical therapy, patients were classified into the observation group (Group I) or the surgery group (Group II), whose patients failed to respond to physical therapy and wanted to undergo surgery. RESULTS Thirty-eight patients were enrolled; 28 had complete data at 2 years: 21 and 7 in Groups I and II, respectively. Group II had a higher body mass index (BMI) than Group I. There were no significant differences in clinical outcomes at baseline. Six weeks after physical therapy, Group I had significantly better outcomes for symptom severity and physical function on the ZCQ subscales, physical functioning and bodily pain on the SF-36 subscales. These outcomes in Group I were maintained or improved and did not differ significantly between groups at 2-years. However, the physical function on the ZCQ subscales was improved in Group II more than those in Group I (mean difference -0.6; 95% CI: -1.2 to -0.03, P < 0.05) at 2 years. CONCLUSIONS At 2 years, the outcomes except for the change in physical function score in the ZCQ subscale did not differ significantly between patients who had undergone surgery and those who avoided surgery.
Collapse
Affiliation(s)
- Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan.
| | - Mamoru Kawakami
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Masafumi Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Yuyu Ishimoto
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Keiji Nagata
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Daisuke Fukui
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Tadashi Sumiya
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Tomoko Kitagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Takahiro Miyake
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Yoshio Yamamoto
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Nana Sakon
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Toshiko Matsuoka
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Yukihiro Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| |
Collapse
|
32
|
Fishchenko IV, Kravchuk LD, Perepechay OA. Lumbar spinal stenosis: symptoms, diagnosis and treatment (meta-analysis of literature data). PAIN MEDICINE 2018. [DOI: 10.31636/pmjua.v3i1.83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Lumbar spinal stenosis is a disease in which degenerated discs, ligamentum flavum, facet joints, while aging, lead to a narrowing of the space around the neurovascular structures of the spine. This article presents a meta-analysis of literature data on epidemiology, causes, pathogenesis, diagnosis and various types of treatment of lumbar spinal stenosis.
Collapse
|
33
|
Affiliation(s)
| | - Jon D Lurie
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| |
Collapse
|
34
|
Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon RL, Wayne P, Zador V. Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper. Explore (NY) 2018; 14:177-211. [PMID: 29735382 DOI: 10.1016/j.explore.2018.02.001] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 02/08/2018] [Indexed: 02/06/2023]
Abstract
Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.
Collapse
Affiliation(s)
- Heather Tick
- Departments of Family Medicine, Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Arya Nielsen
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Kenneth R Pelletier
- Department of Medicine, University of California School of Medicine, San Francisco, CA
| | - Robert Bonakdar
- Department of Pain Management, Scripps Center for Integrative Medicine, La Jolla, CA
| | | | - Ronald Glick
- Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Emily Ratner
- MedStar Health, Institute for Innovation, Integrative Medicine Initiatives, MedStar Montgomery Medical Center, Washington, DC
| | - Russell L Lemmon
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Peter Wayne
- Osher Center for Integrative Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Veronica Zador
- Beaumont Hospital Integrative Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI
| | | |
Collapse
|
35
|
Fritz JM, Rundell SD, Dougherty P, Gentili A, Kochersberger G, Morone NE, Naga Raja S, Rodriguez E, Rossi MI, Shega J, Sowa G, Weiner DK. Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part VI: Lumbar Spinal Stenosis. ACTA ACUST UNITED AC 2017; 17:501-10. [PMID: 26962233 DOI: 10.1093/pm/pnw011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE . To present the sixth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. This article focuses on the evaluation and management of lumbar spinal stenosis (LSS), the most common condition for which older adults undergo spinal surgery. METHODS . The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a five-member content expert panel and a nine-member primary care panel were involved in the iterative development of these materials. The illustrative clinical case was taken from the clinical practice of a contributor's colleague (SR). RESULTS . We present an algorithm and supportive materials to help guide the care of older adults with LSS, a condition that occurs not uncommonly in those with CLBP. The case illustrates the importance of function-focused management and a rational approach to conservative care. CONCLUSIONS . Lumbar spinal stenosis exists not uncommonly in older adults with CLBP and management often can be accomplished without surgery. Treatment should address all conditions in addition to LSS contributing to pain and disability.
Collapse
Affiliation(s)
- Julie M Fritz
- *Department of Physical Therapy and College of Health, University of Utah, Salt Lake City, Utah
| | - Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Paul Dougherty
- Canandaigua VA Medical Center, Canandaigua, New York Department of Research, New York Chiropractic College, Seneca Falls, New York Division of Geriatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Angela Gentili
- Hunter Holmes McGuire VA Medical Center, Richmond, Virginia **Virginia Commonwealth University Health System, Richmond, Virginia
| | - Gary Kochersberger
- Canandaigua VA Medical Center, Canandaigua, New York Division of Geriatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Natalia E Morone
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and
| | - Srinivasa Naga Raja
- Department of Anesthesiology, Critical Care Medicines, and Division of Pain Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Rodriguez
- Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and
| | - Michelle I Rossi
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and
| | - Joseph Shega
- VITAS Healthcare, Miami, Florida; Departments of
| | - Gwendolyn Sowa
- Physical Medicine and Rehabilitation, Orthopedic Surgery, Bioengineering
| | - Debra K Weiner
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and Psychiatry, and ****Anesthesiolgoy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
36
|
Covaro A, Vilà-Canet G, de Frutos AG, Ubierna MT, Ciccolo F, Caceres E. Management of degenerative lumbar spinal stenosis: an evidence-based review. EFORT Open Rev 2017; 1:267-274. [PMID: 28461958 PMCID: PMC5367584 DOI: 10.1302/2058-5241.1.000030] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Lumbar spinal stenosis has become one of the most disabling pathologies in the elderly population.Some additional conditions such as foraminal stenosis or degenerative spondylosis with a history of back pain and leg pain must be considered before treatment.A completely appropriate protocol and unified management of spinal stenosis have not yet been well defined.The objective of this literature review is to provide evidence-based recommendations reflected in the highest-quality clinical literature available to address key clinical questions surrounding the management of degenerative lumbar spinal stenosis. Cite this article: Covaro A, Vilà-Canet G, García de Frutos A, Ubierna MT, Ciccolo F, Caceres E. Management of degenerative lumbar spinal stenosis: an evidence-based review article. EFORT Open Rev 2016;1:267-274. DOI: 10.1302/2058-5241.1.000030.
Collapse
Affiliation(s)
- Augusto Covaro
- ICATME, Institut Universitari Quirón-Dexeus, Barcelona, Spain
| | | | | | - Maite T Ubierna
- ICATME, Institut Universitari Quirón-Dexeus, Barcelona, Spain
| | | | | |
Collapse
|
37
|
Madera M, Brady J, Deily S, McGinty T, Moroz L, Singh D, Tipton G, Truumees E. The role of physical therapy and rehabilitation after lumbar fusion surgery for degenerative disease: a systematic review. J Neurosurg Spine 2017; 26:694-704. [PMID: 28291412 DOI: 10.3171/2016.10.spine16627] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The purpose of this study was to provide a systematic and comprehensive review of the existing literature regarding postfusion rehabilitation. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the authors conducted an exhaustive review of multiple electronic databases. Potential articles were screened using inclusion/exclusion criteria. Two authors independently analyzed these studies using predefined data fields, including study quality indicators such as level of evidence and availability of accepted patient-reported outcomes measures. These findings were synthesized in a narrative format. A third author resolved disagreements regarding the inclusion of a study. RESULTS Twenty-one articles with I or II levels of evidence were included in the review. The authors divided the findings of the literature review into several groups: rehabilitation terminology, timing and duration of postfusion rehabilitation, the need for rehabilitation relative to surgery-related morbidity, rehabilitation's relationship to outcomes, and cognitive and psychosocial aspects of postsurgical rehabilitation. Current evidence generally supports formal rehabilitation after lumbar fusion surgery. Starting physical therapy at the 12-week postoperative mark results in better outcomes at lower cost than an earlier, 6-week start. Where available, psychosocial support improves outcomes. However, a number of the questions could not be answered with high-grade evidence. In these cases, the authors used "best evidence available" to make recommendations. There are many cases in which different types of caregivers use clinical terminology differently. The data supporting an optimal protocol for postfusion rehabilitation remains elusive but, using the data available, the authors have crafted recommendations and a model protocol, which is currently undergoing prospective study. CONCLUSIONS Rehabilitation has long been a common feature in the postoperative management of patients undergoing spinal fusion. Although caregivers from multiple disciplines agree that the majority of their patients will benefit from this effort, the supporting data remain sparse. In creating a model protocol for postlumbar fusion rehabilitation, the authors hope to share a starting point for future postoperative lumbar fusion rehabilitation research.
Collapse
Affiliation(s)
- Marcella Madera
- Department of Surgery and Perioperative Care, The University of Texas Dell Medical School
| | | | | | | | - Lee Moroz
- Physical Medicine & Rehabilitation and
| | | | - George Tipton
- Orthopaedic Spine Surgery, Seton Spine & Rehabilitation; and
| | - Eeric Truumees
- Department of Surgery and Perioperative Care, The University of Texas Dell Medical School
| | | |
Collapse
|
38
|
Abstract
Lumbar spinal stenosis is the most frequent reason for spinal surgery in patients over age 65 years. In this condition, narrowing of the lumbar spinal canal and nerve root canals leads to painful, debilitating compression of spinal nerves and blood vessels. As the population ages, an increasing number of patients will be diagnosed and treated for lumbar spinal stenosis by primary care providers. This article reviews the pathophysiology, diagnosis, and management of lumbar spinal stenosis in adults over age 50 years.
Collapse
|
39
|
Schmidt CT, Ward RE, Suri P, Kurlinski L, Anderson DE, Kiely DK, Bean JF. Health Characteristics, Neuromuscular Attributes, and Mobility Among Primary Care Patients With Symptomatic Lumbar Spinal Stenosis: A Secondary Analysis. J Geriatr Phys Ther 2016; 40:135-142. [PMID: 27007991 DOI: 10.1519/jpt.0000000000000085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND PURPOSE Mobility problems are common among older adults. Symptomatic lumbar spinal stenosis (SLSS) is a major contributor to mobility limitations among older primary care patients. In comparison with older primary care patients with mobility problems but without SLSS, it is unclear how mobility problems differ in older primary care patients with SLSS. The purpose of this study was to compare health characteristics, neuromuscular attributes, and mobility status in a sample of older primary care patients with and without SLSS who were at risk for mobility decline. We hypothesized that patients with SLSS will manifest poorer health and greater severity of neuromuscular impairments and mobility limitations. METHODS This is a secondary analysis of the Boston Rehabilitative Study of the Elderly (Boston RISE). Fifty community-dwelling primary care patients aged 65 years or older at risk for mobility decline met inclusion criteria. SLSS was determined on the basis of computerized tomography (CT) scan and self-reported symptoms characteristic of neurogenic claudication. Outcome measures included health characteristics, neuromuscular attributes (trunk endurance, limb strength, limb speed, limb strength asymmetry, ankle range of motion [ROM], knee ROM, kyphosis, sensory loss), and mobility (Late-Life Function and Disability Instrument: basic and advanced lower extremity function subscales, 400-meter walk test, habitual gait speed, and Short Physical Performance Battery score). Health characteristics were collected at a baseline assessment. Neuromuscular attributes and mobility status were measured at the annual visit closest to conducting the CT scan. RESULTS AND DISCUSSION Five participants met criteria for having SLSS. Differences are reported in medians and interquartile ranges. Participants with SLSS reported more global pain, a greater number of comorbid conditions [SLSS: 7.0 (2.0) vs no-SLSS: 4.0 (2.0), P < .001], and experienced greater limitation in knee ROM [SLSS: 115.0° (8.0°) vs no-SLSS: 126.0° (10.0°), P = .04] and advanced lower extremity function than those without SLSS.A limitation of this study was its small sample size and therefore inability to detect potential differences across additional measures of neuromuscular attributes and mobility. Despite the limitation, the differences in mobility for participants with SLSS may support physical therapists in designing interventions for older adults with SLSS. Participants with SLSS manifested greater mobility limitations that exceeded meaningful thresholds across all performance-based and self-reported measures. In addition, our study identified that differences in mobility extended beyond not just walking capacity but also across a variety of tasks that make up mobility for those with and without SLSS. CONCLUSION Among older primary care patients who are at risk for mobility decline, patients with SLSS had greater pain, higher levels of comorbidity, greater limitation in knee ROM, and greater limitations in mobility that surpassed meaningful thresholds. These findings can be useful when prioritizing interventions that target mobility for patients with SLSS.
Collapse
Affiliation(s)
- Catherine T Schmidt
- 1Center for Interprofessional Studies and Innovation, MGH Institute of Health Professions, Boston, Massachusetts. 2New England Geriatric Research Education and Clinical Center, GRECC, VA Boston Healthcare System, Boston, Massachusetts. 3Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts. 4Division of Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington. 5Seattle Epidemiologic Research and Information Center (ERIC), VA Puget Sound Health Care System, Seattle, Washington. 6Department of Rehabilitation Medicine, University of Washington, Seattle. 7Center for Lifelong Health & Fitness, Spaulding Cambridge Outpatient Center, Cambridge, Massachusetts. 8Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, Massachusetts. 9Department of Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts. 10Spaulding Rehabilitation Hospital, Boston, Massachusetts. 11Department of PM&R, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.
Collapse
Affiliation(s)
- Jon Lurie
- Department of Medicine, Dartmouth Medical School, Dartmouth Hitchock Medical Center, NH, USA
| | - Christy Tomkins-Lane
- Department of Health and Physical Education, Mount Royal University, Calgary, Canada
| |
Collapse
|
41
|
National Trends in Ambulatory Surgery for Intervertebral Disc Disorders and Spinal Stenosis: A 12-Year Analysis of the National Surveys of Ambulatory Surgery. Spine (Phila Pa 1976) 2015; 40:1703-11. [PMID: 26267820 DOI: 10.1097/brs.0000000000001109] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A descriptive epidemiology study. OBJECTIVE The aim of this study is to investigate changes in the utilization of ambulatory surgical procedures performed for intervertebral disc disorders and spinal stenosis between 1994 and 2006 in the United States. SUMMARY OF BACKGROUND DATA Understanding trends in the utilization of ambulatory spine surgery may improve health care delivery in the Unites States. Epidemiologic studies evaluating national practice patterns for ambulatory spine surgery are limited. METHODS The National Survey of Ambulatory Surgery conducted in 1994, 1996, and 2006 by the Centers for Disease Control and Prevention was analyzed to identify surgically managed patients with intervertebral disc disorders and spinal stenosis. Patients were divided into 1 of 3 groups: discectomy, laminectomy, or fusion. The data were analyzed for trends in demographics, treatment, and utilization. RESULTS Between 1994 and 2006, the number of procedures increased by 540% for intervertebral disc disorders (6.1/100 000 capita to 34.2/100 000 capita) and 926% for spinal stenosis (0.38/100 000 capita to 3.46 per 100 000 capita). Intervertebral fusions increased from 5% of outpatient spine surgeries in 1994 to 17% in 2006. The utilization of freestanding ambulatory facilities as the location of surgery increased 340% for intervertebral disc disorders and more than 2000% for stenosis. Private insurance was the largest compensator, representing 91% of cases in 2006. An increasing proportion of females underwent surgery for intervertebral disc disorders and stenosis at these ambulatory facilities over this time period. Lumbar disc displacement remained the most common diagnosis at each time point. CONCLUSIONS The rate of ambulatory surgery for intervertebral disc disorders and spinal stenosis increased dramatically between 1994 and 2006 based upon the National Survey of Ambulatory Surgery data, which are the most up-to-date ambulatory surgery data available. These findings may aid policy-makers and caregivers in allocating health care resources to ensure the delivery of quality patient care. LEVEL OF EVIDENCE N/A.
Collapse
|
42
|
Delitto A, Piva SR, Moore CG, Fritz JM, Wisniewski SR, Josbeno DA, Fye M, Welch WC. Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Ann Intern Med 2015; 162:465-73. [PMID: 25844995 PMCID: PMC6252248 DOI: 10.7326/m14-1420] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary care management decisions for patients with symptomatic lumbar spinal stenosis (LSS) are challenging, and nonsurgical guidance is limited by lack of evidence. OBJECTIVE To compare surgical decompression with physical therapy (PT) for LSS and evaluate sex differences. DESIGN Multisite randomized, controlled trial. (ClinicalTrials.gov: NCT00022776). SETTING Neurologic and orthopedic surgery departments and PT clinics. PARTICIPANTS Surgical candidates with LSS aged 50 years or older who consented to surgery. INTERVENTION Surgical decompression or PT. MEASUREMENTS Primary outcome was physical function score on the Short Form-36 Health Survey at 2 years assessed by masked testers. RESULTS The study took place from November 2000 to September 2007. A total of 169 participants were randomly assigned and stratified by surgeon and sex (87 to surgery and 82 to PT), with 24-month follow-up completed by 74 and 73 participants in the surgery and PT groups, respectively. Mean improvement in physical function for the surgery and PT groups was 22.4 (95% CI, 16.9 to 27.9) and 19.2 (CI, 13.6 to 24.8), respectively. Intention-to-treat analyses revealed no difference between groups (24-month difference, 0.9 [CI, -7.9 to 9.6]). Sensitivity analyses using causal-effects methods to account for the high proportion of crossovers from PT to surgery (57%) showed no significant differences in physical function between groups. LIMITATION Without a control group, it is not possible to judge success attributable to either intervention. CONCLUSION Surgical decompression yielded similar effects to a PT regimen among patients with LSS who were surgical candidates. Patients and health care providers should engage in shared decision-making conversations that include full disclosure of evidence involving surgical and nonsurgical treatments for LSS. PRIMARY FUNDING SOURCE National Institutes of Health and National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Collapse
Affiliation(s)
- Anthony Delitto
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh
| | - Sara R. Piva
- Department of Physical Therapy, SHRS, University of Pittsburgh
| | | | - Julie M. Fritz
- Department of Physical Therapy, School of Health Professions, University of Utah
| | - Stephen R. Wisniewski
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh
| | | | - Mark Fye
- University of Pittsburgh Medical Center
| | | |
Collapse
|