The outcome of posterolateral fusion in highly selected patients with discogenic low back pain

Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review

Background

The accuracy of diagnostic tests available in primary care to identify the disc, sacroiliac joint, and facet joint as the source of low back pain is uncertain.

Methods

Systematic review of diagnostic tests available in primary care. MEDLINE, CINAHL, and EMBASE were searched between March 2006 and 25th January 2023. Pairs of reviewers independently screened all studies, extracted data, and assessed risk of bias using QUADAS-2. Pooling was performed for homogenous studies. Positive likelihood ratios (+LR) ≥2 and negative likelihood ratios (-LR) ≤0.5 were considered informative. This review is registered with PROSPERO (CRD42020169828).

Findings

We included 62 studies: 35 investigated the disc, 14 the facet joint, 11 the sacroiliac joint, and 2 investigated all three structures in patients with persistent low back pain. For risk of bias, the domain 'reference standard' scored worst, however approximately half the studies were of low risk of bias for every other domain. For the disc, pooling demonstrated MRI findings of disc degeneration and annular fissure resulted in informative +LRs: 2.53 (95% CI: 1.57-4.07) and 2.88 (95% CI: 2.02-4.10) and -LRs: 0.15 (95% CI: 0.09-0.24) and 0.24 (95% CI: 0.10-0.55) respectively. Pooled results for Modic type 1, Modic type 2, and HIZ on MRI, and centralisation phenomenon yielded informative +LRs: 10.00 (95% CI: 4.20-23.82), 8.03 (95% CI: 3.23-19.97), 3.10 (95% CI: 2.27-4.25), and 3.06 (95% CI: 1.44-6.50) respectively, but uninformative -LRs: 0.84 (95% CI: 0.74-0.96), 0.88 (95% CI: 0.80-0.96), 0.61 (95% CI: 0.48-0.77), and 0.66 (95% CI: 0.52-0.84) respectively. For the facet joint, pooling demonstrated facet joint uptake on SPECT resulted in informative +LRs: 2.80 (95% CI: 1.82-4.31) and -LRs: 0.44 (95% CI: 0.25-0.77). For the sacroiliac joint, a combination of pain provocation tests and absence of midline low back pain resulted in informative +LRs of 2.41 (95% CI: 1.89-3.07) and 2.44 (95% CI: 1.50-3.98) and -LRs of 0.35 (95% CI: 0.12-1.01) and 0.31 (95% CI: 0.21-0.47) respectively. Radionuclide imaging yielded an informative +LR 7.33 (95% CI: 1.42-37.80) but an uninformative -LR 0.74 (95% CI: 0.41-1.34).

Interpretation

There are informative diagnostic tests for the disc, sacroiliac joint, and facet joint (only one test). The evidence suggests a diagnosis may be possible for some patients with low back pain, potentially guiding targeted and specific treatment approaches.

Funding

There was no funding for this study.

Internal lumbar disc derangement with instability catch from monosegmental discopathy. The forgotten mechanical and kinetic surgical back pain syndrome

STUDY DESIGN

This is a retrospective cohort experience reported with concurrent survey PROM outcomes.

OBJECTIVE

To describe the results of open PLIF reconstruction for a select group of mechanical back pain patients who have mono- or bi-segmental discopathy on MRI imaging, a clinical history of repeated severe and disabling acute mechanical back pain symptoms, and the irregular lumbar motion pattern in returning erect from the flexed position known as the "instability catch".

SUMMARY OF BACKGROUND DATA

The literature of fusion surgery for back pain relief in "mechanical" back pain reveals inconsistent results and in the majority presents only a vague description of these syndromes. Internal Lumbar Disc Degeneration with Instability catch "ILDDIC" may be one subset of these patients who are uniquely benefitted from spine stabilization.

METHODS

The senior author (DAB) in midsummer 2015 began to offer smaller fusion procedures to selected patients on an overnight-stay basis using a standard perioperative care protocol. For practice audit, in December 2020 a mailed survey questionnaire requesting VAS pain scores and SF-36 physical function scores was sent out to all 111 patients who had been treated this way, which group included 30 cases of ILDDIC. We report here on the success of open PLIF reconstruction in achieving back pain relief for these patients.

RESULTS

Some 24 of 30 patients returned the mailed survey questionnaire, and the remaining six could not be reached. All 24 responders reported significant relief of back pain and improved physical function, at a mean of 30 months from surgery. Review of the available clinical records (LFU < 1 year) from the six nonresponders also recorded positive early benefit.

CONCLUSION

The diagnosis of ILDDIC requires both imaging and clinical correlates and may define a subgroup of the mechanical back pain population uniquely suited to achieve pain relief through lumbar fusion.

Does Workers' Compensation Status Affect Outcomes after Lumbar Spine Surgery? A Systematic Review and Meta-Analysis

Low back pain (LBP) is currently the leading cause of disability worldwide and the most common reason for workers’ compensation (WC) claims. Studies have demonstrated that receiving WC is associated with a negative prognosis following treatment for a vast range of health conditions. However, the impact of WC on outcomes after spine surgery is still controversial. The aim of this meta-analysis was to systematically review the literature and analyze the impact of compensation status on outcomes after lumbar spine surgery. A systematic search was performed on Medline, Scopus, CINAHL, EMBASE and CENTRAL databases. The review included studies of patients undergoing lumbar spine surgery in which compensation status was reported. Methodological quality was assessed through ROBINS-I and quality of evidence was estimated using the GRADE rating. A total of 26 studies with a total of 2668 patients were included in the analysis. WC patients had higher post-operative pain and disability, as well as lower satisfaction after surgery when compared to those without WC. Furthermore, WC patients demonstrated to have a delayed return to work. According to our results, compensation status is associated with poor outcomes after lumbar spine surgery. Contextualizing post-operative outcomes in clinical and work-related domains helps understand the multifactorial nature of the phenomenon.

INDIRECT DECOMPRESSION BY LATERAL FUSION: ANALYSIS OF SAGITAL ALIGNMENT

ABSTRACT Objective: To verify the effectiveness of indirect decompression after lateral access fusion in patients with high pelvic incidence. Methods: A retrospective, non-comparative, non-randomized analysis of 22 patients with high pelvic incidence who underwent lateral access fusion, 11 of whom were male and 11 female, with a mean age of 63 years (52-74), was conducted. Magnetic resonance exams were performed within one year after surgery. The cross-sectional area of the thecal sac, anterior and posterior disc heights, and bilateral foramen heights, measured pre- and postoperatively in axial and sagittal magnetic resonance images, were analyzed. The sagittal alignment parameters were measured using simple radiographs. The clinical results were evaluated using the ODI and VAS (back and lower limbs) questionnaires. Results: In all cases, the technique was performed successfully without neural complications. The mean cross-sectional area increased from 126.5 mm preoperatively to 174.3 mm postoperatively. The mean anterior disc height increased from 9.4 mm preoperatively to 12.8 mm postoperatively, while the posterior disc height increased from 6.3 mm preoperatively to 8.1 mm postoperatively. The mean height of the right foramen increased from 157.3 mm in the preoperative period to 171.2 mm in the postoperative period and that of the left foramen increased from 139.3 mm in the preoperative to 158.9 mm in the postoperative. Conclusions: This technique is capable of correcting misalignment in spinal deformity, achieving fusion and promoting the decompression of neural elements. Level of evidence III; Retrospective study.

Critical analysis of trends in lumbar fusion for degenerative disorders revisited: influence of technique on fusion rate and clinical outcomes

PURPOSE

Lumbar fusion for degenerative disorders is among the most common spine surgical procedures performed. The purpose of this study was to analyze fusion, complications, and clinical success for lumbar fusion performed with various surgical techniques as reported in the literature from 2000 to 2015 and compare with previous critical analysis of outcomes from 1980 to 2000.

METHODS

A systematic review of the literature to identify all studies of adult lumbar fusion for degenerative disorders published between January 1, 2000, and August 31, 2015, was performed adhering to PRISMA guidelines. Studies were included if they enabled analysis of outcomes of individual fusion techniques.

RESULTS

Data from 8599 patients extracted from 160 studies were recorded. Posterior and transforaminal lumbar interbody fusion (PLIF and TLIF) had significantly higher fusion rates compared to instrumented posterolateral fusion (PLF) (OR 3.20 and 2.46, respectively). Clinical success rate was statistically higher with MIS versus non-MIS fusion (OR 2.44). While methodological quality was higher in studies from 2000 to 2015 than prior decades, the outcomes of comparable procedures were about the same.

CONCLUSIONS

Lumbar fusions for degenerative disorders from 2000 to 2015 demonstrate a trend toward more interbody fusions and MIS techniques than prior decades. Clinical success with MIS appears more likely than with non-MIS fusions, despite equivalent fusion and complication rates. While these data are intriguing, they should be interpreted cautiously considering the level of heterogeneity of the studies available. Further, high-quality comparative studies are warranted to better understand the relative benefits of more complex interbody and MIS fusions for these conditions. These slides can be retrieved under Electronic Supplementary Material.

A Review of the Clinical Side Effects of Bone Morphogenetic Protein-2

Bone morphogenetic protein-2 (BMP-2) is currently the only Food and Drug Administration (FDA)-approved osteoinductive growth factor used as a bone graft substitute. However, with increasing clinical use of BMP-2, a growing and well-documented side effect profile has emerged. This includes postoperative inflammation and associated adverse effects, ectopic bone formation, osteoclast-mediated bone resorption, and inappropriate adipogenesis. Several large-scale studies have confirmed the relative frequency of adverse events associated with the clinical use of BMP-2, including life-threatening cervical spine swelling. In fact, the FDA has issued a warning of the potential life-threatening complications of BMP-2. This review summarizes the known adverse effects of BMP-2, including controversial areas such as tumorigenesis. Next, select animal models that replicate BMP-2's adverse clinical effects are discussed. Finally, potential molecules to mitigate the adverse effects of BMP-2 are reviewed. In summary, BMP-2 is a potent osteoinductive cytokine that has indeed revolutionized the bone graft substitute market; however, it simultaneously has accrued a worrisome side effect profile. Better understanding of these adverse effects among both translational scientists and clinicians will help determine the most appropriate and safe use of BMP-2 in the clinical setting.

Association between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies

BACKGROUND CONTEXT

Numerous studies have demonstrated poorer outcomes in patients with Workers' compensation (WC) when compared with those without WC following treatment of various of health conditions, including spine disorders. It is thus important to consider compensation status when assessing treatment outcomes in spine surgery. However, reported strengths of association have varied significantly (1.31-7.22).

PURPOSE

The objective of this study was to evaluate the association of unsatisfactory outcomes on compensation status in spine surgery patients.

STUDY DESIGN/SETTING

A meta-analysis was performed.

PATIENT SAMPLE

Patient sample is not applicable in this study.

OUTCOME MEASURE

Demographics, type of surgery, country, follow-up time, patient satisfaction, return to work and non-union events were the outcome measures.

METHODS

Both prospective and retrospective studies that compared outcomes between compensated and non-compensated patients in spine surgery were included. Two independent investigators extracted outcome data. The meta-analysis was performed using Revman software. Random effects model was used to calculate risk ratio (RR, 95% confidence interval [CI]) for dichotomous variables.

RESULTS

Thirty-one studies (13 prospective; 18 retrospective) with a total of 3,567 patients were included in the analysis. Follow-up time varied from 4 months to 10 years. Twelve studies involved only decompression; the rest were fusion. Overall RR of an unsatisfactory outcome was 2.12 [1.74, 2.58; p<.001] in patients with WC when compared with those without WC after surgery. The RR of an unsatisfactory outcome in patients with WC, compared with those without, was 2.09 [1.38, 3.17]; p<.01 among studies from Europe and Australia, and 2.14 [1.48, 2.60]; p<.01 among US studies. The RR of decompression-only procedures was 2.53 [1.85, 3.47]; p<.01,and 1.79 [1.45, 2.21]; p<.01 for fusion. Forty-three percent (209 of 491) of patients with WC did not return to work versus 17% (214 of 1250) of those without WC (RR 2.07 [1.43, 2.98]; p<.001). Twenty-five percent (74 of 292) and 13.5% (39 of 287) of patients had non-union in the compensated and non-compensated groups, respectively. This was not statistically significant (RR 1.33 [0.92, 1.91]; p=.07).

CONCLUSIONS

Workers' compensation patients have a two-fold increased risk of an unsatisfactory outcome compared with non-compensated patients after surgery. This association was consistent when studies were grouped by country or procedure. Compensation status must be considered in all surgical intervention studies.

Low Back Pain in Athletes

CONTEXT

Low Back Pain (LBP) in athletes is common and has a broad spectrum of differential diagnoses that must be taken in to account when a clinician approaches the patient with LBP. The physicians should take into account spinal and extra spinal causes of low back pain in athletes.

EVIDENCE ACQUISTION

A literature review was performed for the years 1951 through 2013. Keywords used were Low Back Pain and Athletes. We searched MEDLINE, EMBASE, OVID, PUBMED, the Cochrane Library, ELSEVIER, and the references of reviewed articles, for English-language of Low Back Pain in Athletes.

RESULTS

The two most common causes of LBP arising from spine in athletes are degenerative disc disease and spondylolysis with or without listhesis. Although most athletes, respond well to conservative treatment, surgical treatment is indicated when conservative treatment failes.

CONCLUSIONS

The major concern in athletes with LBP is return to play and previous level of their activity after treatment. There is insufficient evidence regarding this issue in literature to define the optimal time of return to play following treatment.

Fusion via transpsoas lateral approach: considerations and initial results

OBJECTIVE: To present some technical considerations about interbody fusion by direct lateral retroperitoneal transpsoas approach and its initial results. METHODS: Non-randomized prospective study of 14 patients undergoing interbody fusion via lateral approach, with evaluation of initial results and complications. RESULTS: We collected and analyzed data from 14 patients with a total of 27 levels operated. The average operative time was 146 minutes and blood loss was on average less than 50 ml. Ten patients required supplemental percutaneous fixation with pedicle screws. VAS scores for the lumbar region and lower limbs and ODI had significant improvement in the postoperative period. There was an associated case of postoperative infection and thromboembolism that required reoperations. CONCLUSION: This technique has revolutionized the care of patients requiring fusion of T6-7 to L4-5. Following the five basic steps and using intraoperative monitoring, this technique is safe and reproducible with encouraging clinical results and low rate of serious complications.

Nonoperative management of discogenic back pain: a systematic review

STUDY DESIGN

Systematic review of the literature.

OBJECTIVE

A systematic evaluation of the literature was performed to investigate current nonoperative management of the treatment of discogenic low back pain.

SUMMARY OF BACKGROUND DATA

Back pain is a major health care concern with up to 39% being discogenic in origin according to one study. Nonoperative therapy is likely to be the initial treatment strategy for discogenic low back pain.

METHODS

PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for clinical studies evaluating nonoperative methods of treating discogenic back pain that were published between 2000 and 2012. Only prospective randomized controlled studies that compared a nonsurgical intervention with sham or placebo therapy were included. After removal of duplicate citations, a total of 226 articles were initially identified from the search terms. From these, we identified 11 randomized controlled trials (RCTs) from which data analysis was performed.

RESULTS

The 11 RCTs investigated traction therapy, injections, and ablative techniques. Results from 5 RCTs investigating methylene blue injection, steroid injection, ramus communicans ablation, intradiscal electrothermal therapy, and biacuplasty favored intervention over sham therapy. However, results from the study on methylene blue injections have not been replicated in other RCTs. Evaluation of the selection criteria used in the studies on ramus communicans ablation and intradiscal biacuplasty and a stratified analysis of results from the RCTs on intradiscal electrothermal therapy casts doubt on whether the conclusions from these RCTs can be applied to the general patient population with discogenic pain.

CONCLUSION

There are few high-quality studies evaluating nonoperative treatments for reducing discogenic low back pain. Although conclusions from several studies favor intervention over sham, it is unclear whether these interventions confer stable long-term benefit. There is some promise in newer modalities such as biacuplasty; however, more inclusive studies need to be performed.

Clinical evaluation and surgical decision making for patients with lumbar discogenic pain and facet syndrome

In industrialized countries, more than two thirds of the population suffers from low back pain (LBP) in their lifetime. LBP associated with lumbar disc herniation, stenosis, and instability is a well-known and documented entity. On the other hand, the lumbar discogenic pain and facet syndrome are difficult to be clearly identified, and they are not always detectable by imaging. This article describes the causes of these painful syndromes, which are typically without radicular component, explains the modern diagnostic procedures, and provides guidelines for surgical decision making.

Artrodesis circunferencial: Plif más tornillos translaminofacetarios

OBJETIVO: Evaluar el resultado clínico y radiológico de 10 pacientes operados por patología degenerativa lumbar, en los que se les realizó artrodesis intersomática con injerto óseo tricortical de cresta ilíaca y artrodesis posterolateral instrumentada con tornillos translaminofacetarios. MÉTODOS: Se evaluaron 10 pacientes, 4 hombres y 6 mujeres operados por el mismo cirujano entre junio de 2006 y diciembre de 2007. RESULTADOS: Se obtuvo un significativo descenso de la discapacidad y del dolor (según las escalas de Oswestry y la escala visual analógica), obteniéndose una tasa de fusión del 100% al año de seguimiento. CONCLUSIONES: Los resultados clínicos y radiológicos de este estudio establecen a éste procedimiento como confiable, de bajo costo y baja morbilidad, con una alta tasa de fusión y buenos resultados clínicos.

Provocative lumbar discography versus functional anesthetic discography: a comparison of the results of two different diagnostic techniques in 52 patients with chronic low back pain

BACKGROUND CONTEXT

There is mounting evidence that the currently available techniques for the diagnosis of discogenic low back pain are insufficiently accurate-this may explain some of the variability in outcomes of surgery for this important clinical problem. New diagnostic methods are needed to address this diagnostic issue; improvements here may do as much to improve overall patient outcomes as improvements in surgical treatment methods.

PURPOSE

To compare the results of standard pressure-controlled provocative discography (PD) to those of the functional anesthetic discogram (FAD) in a series of patients presenting with chronic low back pain and considering surgical treatment.

STUDY DESIGN

Prospective clinical series in an academic spinal surgical practice.

PATIENT SAMPLE

Fifty-two patients presenting with chronic low back pain; mean age 45 years (range, 24-70 years); 28 women, 24 men; and 25% in workman's compensation program.

OUTCOME MEASURES

Oswestry, visual analog scale for back pain, distress and risk assessment method psychometric analysis, demographic data, magnetic resonance imaging scan of lumbar spine. During provocative discogram: pressurization at pain, pain level, and concordancy. During FAD: position or activity used to elicit typical pain, baseline pain level before injection, during injection, at 5, 10, and 20 minutes after the injection, and substance injected.

METHODS

Standard pressure-controlled PD was performed, followed by (in positive cases or in patients with clinical features and imaging studies felt to be highly suggestive of symptomatic disc degeneration) the FAD test-an assessment of the response to injection of a low dose of local anesthetic into the disc during a position productive of the patient's typical pain.

RESULTS

Discordant results of the two tests were noted in 46% of the patients in the series. Of them, 26% of patients with positive PD had negative findings on the FAD test; 16% had positive findings at a single level only, whereas the provocative discogram had been positive at two or more levels; 4% had new positive findings on the FAD test.

CONCLUSIONS

We have presented the results of a new diagnostic technique in 52 patients with chronic low back pain presumed discogenic in origin that was designed to help differentiate between symptomatic and asymptomatic disc degeneration. The findings of the test differed from those of standard pressure-controlled PD in 46% of the cases reported on here. Further studies are needed to demonstrate the clinical utility of the test.

A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned

BACKGROUND CONTEXT

Increasingly, reports of frequent and occasionally catastrophic complications associated with use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in spinal fusion surgeries are being published. In the original peer review, industry-sponsored publications describing the use of rhBMP-2 in spinal fusion, adverse events of these types and frequency were either not reported at all or not reported to be associated with rhBMP-2 use. Some authors and investigators have suggested that these discrepancies were related to inadequate peer review and editorial oversight.

PURPOSE

To compare the conclusions regarding the safety and related efficacy published in the original rhBMP-2 industry-sponsored trials with subsequently available Food and Drug Administration (FDA) data summaries, follow-up publications, and administrative and organizational databases.

STUDY DESIGN

Systematic review.

METHODS

Results and conclusions from original industry-sponsored rhBMP-2 publications regarding safety and related efficacy were compared with available FDA data summaries, follow-up publications, and administrative and organizational database analyses.

RESULTS

There were 13 original industry-sponsored rhBMP-2 publications regarding safety and efficacy, including reports and analyses of 780 patients receiving rhBMP-2 within prospective controlled study protocols. No rhBMP-2-associated adverse events (0%) were reported in any of these studies (99% confidence interval of adverse event rate <0.5%). The study designs of the industry-sponsored rhBMP-2 trials for use in posterolateral fusions and posterior lateral interbody fusion were found to have potential methodological bias against the control group. The reported morbidity of iliac crest donor site pain was also found to have serious potential design bias. Comparative review of FDA documents and subsequent publications revealed originally unpublished adverse events and internal inconsistencies. From this review, we suggest an estimate of adverse events associated with rhBMP-2 use in spine fusion ranging from 10% to 50% depending on approach. Anterior cervical fusion with rhBMP-2 has an estimated 40% greater risk of adverse events with rhBMP-2 in the early postoperative period, including life-threatening events. After anterior interbody lumbar fusion rates of implant displacement, subsidence, infection, urogenital events, and retrograde ejaculation were higher after using rhBMP-2 than controls. Posterior lumbar interbody fusion use was associated with radiculitis, ectopic bone formation, osteolysis, and poorer global outcomes. In posterolateral fusions, the risk of adverse effects associated with rhBMP-2 use was equivalent to or greater than that of iliac crest bone graft harvesting, and 15% to 20% of subjects reported early back pain and leg pain adverse events; higher doses of rhBMP-2 were also associated with a greater apparent risk of new malignancy.

CONCLUSIONS

Level I and Level II evidence from original FDA summaries, original published data, and subsequent studies suggest possible study design bias in the original trials, as well as a clear increased risk of complications and adverse events to patients receiving rhBMP-2 in spinal fusion. This risk of adverse events associated with rhBMP-2 is 10 to 50 times the original estimates reported in the industry-sponsored peer-reviewed publications.

Intradiscal injection therapy for degenerative chronic discogenic low back pain with end plate Modic changes

BACKGROUND CONTEXT

The effect of intradiscal steroid therapy for patients with degenerative chronic discogenic low back pain remains an issue of debate.

PURPOSE

To evaluate the effect of various intradiscal injection regimens for patients with degenerative chronic discogenic low back pain and end plate Modic changes.

STUDY DESIGN

Double-blind, randomized, controlled, prospective clinical study.

PATIENT SAMPLE

One hundred twenty patients with discogenic low back pain and end plate Modic changes on magnetic resonance imaging (MRI) who received discography but were unwilling to accept surgical operation.

OUTCOME MEASURES

Pain and function were determined by the visual analog scale (VAS) and the Oswestry Disability Index (ODI) assessment.

METHODS

Patients who received diagnostic discography for suspected degenerative discogenic low back pain were recruited. A total of 120 patients with positive discography and end plate Modic changes at a single level were enrolled in the study and allocated into Groups A and B according to the type of Modic changes on MRI. Then, the patients in Groups A and B were randomized into three subgroups, respectively. Intradiscal injection of normal saline was performed in Subgroups A1 and B1, intradiscal injection of diprospan was performed in Subgroups A2 and B2, and intradiscal injection of a mixed solution of diprospan+songmeile (cervus and cucumis polypeptide) was performed in Subgroups A3 and B3. The clinical outcome of each patient was evaluated and recorded by using the VAS and ODI at 3 and 6 months after the procedure.

RESULTS

The subgroups were comparable with respect to gender, age, pain, and percentage disability. Neither VAS pain scores nor Oswestry function scores of the patients within Group A had any improvement at 3 or 6 months after saline injection, but both of them improved significantly at the two time points after diprospan and diprospan+songmeile injection, respectively. Meanwhile, the latter two injection protocols led to no significant difference in pain relief and functional recovery. Similar results were obtained in patients within Group B. Furthermore, no difference of the improvement of VAS pain scores or Oswestry function scores was found between the patients within Group A and within Group B at different time points after various interventions.

CONCLUSION

Intradiscal injection of corticosteroids could be a short-term efficient alternative for discogenic low back pain patients with end plate Modic changes on MRI who were still unwilling to accept surgical operation when conservative treatment failed.

Opção minimamente invasiva lateral para artrodese intersomática tóraco-lombar

OBJETIVO: O objetivo deste artigo é mostrar resultados clínicos e radiográficos do acesso lateral transpoas na experiência brasileira em condições degenerativas do disco intervertebral. MÉTODOS: 46 pacientes foram submetidos à fusão intersomática lombar por via lateral. Dentre os casos, 18 eram do sexo masculino e 28 do sexo feminino, com idade média de 57,3 (84-32 anos) e média de IMC de 25,9 ± 3,1. Todos os pacientes completaram um ano de acompanhamento. Foram coletados exames radiológicos, como raio X e tomografia computadorizada, exame neurológico e resultados clínicos usando os questionários ODI e VAS (costas e membros inferiores). RESULTADOS: Os procedimentos foram realizados, sem ocorrência de complicações intra-operatórias importantes, em uma média de 103,9 ± 105,5 minutos e com menos de 50cc de perda sanguínea. Em oito dos 46 procedimentos (17,4%) foi utilizada suplementação por parafusos pediculares percutâneos por apresentarem instabilidade segmentar. Foram tratados 80 níveis (de um a cinco níveis) tóraco-lombares (de T12-L1 a L4-L5). Os resultados clínicos avaliados pelos questionários revelaram melhora significante de dor logo após uma semana da cirurgia e da função física após seis semanas. A lordose lombar foi de 36,5 ± 14,7 no pré-operatório para 43,4 ± 12,4 no seguimento de 12 meses. Todos os pacientes apresentaram formação óssea após 12 meses da cirurgia. Sete casos foram revisados (15,2%), ainda de forma minimamente invasiva devido à estenose persistente (três casos; 6,5%), afundamento do espaçador (três casos; 6,5%) ou mal-alinhamento de barra da suplementação (um caso; 2,8%). CONCLUSÕES: Com melhora de parâmetros clínicos e radiológicos, a técnica se mostrou segura e eficaz no tratamento de condições degenerativas da coluna lombar.

Lumbar posterolateral fusion inhibits sensory nerve ingrowth into punctured lumbar intervertebral discs and upregulation of CGRP immunoreactive DRG neuron innervating punctured discs in rats

Degeneration of lumbar intervertebral discs is thought to be a cause of low back pain. Studies have found that a cause of discogenic low back pain is intervertebral disc inflammation and axonal growth of afferent fibers innervating the disc. Lumbar spine fusion for chronic discogenic low back pain is considered an effective procedure. However, no study has investigated the mechanism of pain relief. We did this by applying Fluoro-Gold (FG) to the ventral aspect of the L4-L5 intervertebral discs of 40 rats. We exposed the nucleus pulposus to the annulus fibrosus in a disc punctured model. Rats were divided into 4 groups. Group A: Punctured intervertebral disc with sham posterolateral fusion (PLF) (n = 10), Group B: Punctured intervertebral disc with PLF (n = 15), Group C: Normal intervertebral disc (no puncture) with PLF (n = 10), and Group D: Normal disc (no disc puncture) with sham PLF (n = 5). Four weeks after surgery, bilateral L1-L5 dorsal root ganglia (DRGs) were stained with growth-associated protein 43 (GAP43), a marker of axonal growth, and calcitonin gene-related peptide (CGRP), a neuropeptide marker of pain. Bone union was evaluated using X-ray imaging. Of the FG-labeled neurons, the proportions of GAP43- and CGRP-immunoreactive (IR) neurons in Group A were significantly higher than in Group D (P < 0.05). The proportions of GAP43- and CGRP-IR neurons in bone union rats in Group B were significantly lower than in nonunion rats in Group B and in the rats in Group A (P < 0.05). No significant differences in GAP43- and CGRP-IR neurons were observed between bone union and nonunion rats in Group C and the rats in Group D (P > 0.05). PLF is strongly related to the downregulation of GAP43 and CGRP expression. Therefore, PLF may suppress the increase of inflammatory neuropeptides and the process of axonal growth. Moreover, these results may explain, in part, the mechanism of pain relief following lumbar spinal fusion for chronic discogenic low back pain in humans.

ADULT DEGENERATIVE SCOLIOSIS

OBJECTIVE

To review and define principles and features of treatment for adult degenerative scoliosis, the most common cause of adult spinal deformities.

STUDY DESIGN

We conducted a comprehensive review of the literature and our clinical experience.

METHODS

A systematic review of Medline was conducted, including journal articles published in March 2007 and before. We searched for articles related to adult spinal deformities (scoliosis) and treatments.

CONCLUSION

Degenerative scoliosis is a complex disorder. The primary surgical aims are to decompress the neural elements, normalize both sagittal balance and coronal and rotational deformity, fixate to the sacrum/ilium when appropriate, and optimize conditions for osteogenesis and fusion.

The use of electromyography to predict functional outcome following transforaminal epidural spinal injections for lumbar radiculopathy

This study aimed to determine if electromyographic (EMG) diagnostic evaluation can predict functional outcome in patients undergoing transforaminal lumbar spine epidural injections. In this retrospective study, functional outcome by Oswestry Disability Index (ODI) and verbal rating scale (VRS) for current pain severity was evaluated in 39 patients undergoing lumbar transforaminal epidural spinal injections (ESI). Subjects with low back pain (mean age, 60 +/- 12.5 years) were evaluated for functional improvement post EMG and ESI. Of 39 patients tested with EMG before injection, 18 patients were positive for radiculopathy and 21 had a normal or negative examination. The patients were followed postinjection on average of 10.8 (SD +/- 3.9) weeks. Pretreatment ODI scores were not significantly different between groups showing positive (72.3 SD +/- 12.7) and negative (65.9 SD +/- 18.6, P > .05) EMG findings. There was significantly greater improvement of ODI for EMG positive radiculopathy (7.11 SD +/- 9.5) compared with negative EMG (3.2 SD +/- 17.4, P < .05). Positive radiculopathy subjects complained of more pain by VRS before ESI than subjects with negative EMG findings, 8.1 SD +/- 1.0 and 7.3 SD +/- 0.8, respectively, which was not significant (P > .05). VRS mean improvement was not significantly different in the positive EMG group (1.8 SD +/- 1.2) compared with a negative EMG (1.2 SD +/- 1.2, P > .05).

PERSPECTIVE

The results appear to show that patients undergoing transforaminal ESI, who have a positive radiculopathy by EMG before injection, will have significant improvement in functional outcome by ODI but not with current pain intensity by VRS. This study suggests the importance and diagnostic value of ordering electromyography studies for lumbar radiculopathy evaluation, which may lead to prediction of outcome with lumbar transforaminal epidural spinal procedures. Furthermore, the current study highlights the difficulty of pain evaluation outcome by VRS.

Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain

Clinical practice guidelines state that the tissue source of low back pain cannot be specified in the majority of patients. However, there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain. The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint or sacroiliac joint (SIJ) as the source of low back pain. MEDLINE, EMBASE and CINAHL were searched up to February 2006 with citation tracking of eligible studies. Eligible studies compared index tests with an appropriate reference test (discography, facet joint or SIJ blocks or medial branch blocks) in patients with low back pain. Positive likelihood ratios (+LR) > 2 or negative likelihood ratios (-LR) < 0.5 were considered informative. Forty-one studies of moderate quality were included; 28 investigated the disc, 8 the facet joint and 7 the SIJ. Various features observed on MRI (high intensity zone, endplate changes and disc degeneration) produced informative +LR (> 2) in the majority of studies increasing the probability of the disc being the low back pain source. However, heterogeneity of the data prevented pooling. +LR ranged from 1.5 to 5.9, 1.6 to 4.0, and 0.6 to 5.9 for high intensity zone, disc degeneration and endplate changes, respectively. Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain: +LR = 2.8 (95%CI 1.4-5.3). Absence of degeneration on MRI was the only test found to reduce the likelihood of the disc as the source of pain: -LR = 0.21 (95%CI 0.12-0.35). While single manual tests of the SIJ were uninformative, their use in combination was informative with +LR of 3.2 (95%CI 2.3-4.4) and -LR of 0.29 (95%CI 0.12-0.35). None of the tests for facet joint pain were found to be informative. The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. However, the changes in probability are usually small and at best moderate. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear.

Women's Experience in the Workers' Compensation System

INTRODUCTION

Gender differences is a question of major importance within workers' compensation given the increased role of women in the workforce over the past several decades. This article reviews literature relating to women's experiences following work injury.

METHODS

An Australian study is used as background to exploring the broad issue of the question of gender equity in workers' compensation. In doing so it takes account of historical, legal and medical issues.

RESULTS

Women's experience in the workers' compensation system is different to that of men due to a range of factors. It is heavily influenced by the industrial environment in which they work. Women are paid less than men in many instances and work in gender-segregated circumstances, which often reduces their industrial bargaining power. Women also suffer different forms of injury and disease to men because of the different nature of their work.

CONCLUSION

The Australian experience suggests that as a consequence of the combination of lesser industrial bargaining power, lower wages and differing forms of injury and disease women often receive less than men in compensation payments, struggle to obtain equity in the dispute resolution process and experience greater difficulties in returning to work following injury or disease.

Diskography in the evaluation of low back pain

Diskography is evolving to play a crucial role in the evaluation of axial low back pain, especially in regard to surgical decision making. Despite advances in other forms of imaging, diskography remains unique in that it is the only test that seeks to provoke a pain response during the study. It has been suggested that patients with axial low back pain who experience a concordant pain response during diskography are more likely to respond favorably to surgical intervention. However, the efficacy of using this potential correlation is dependent on the technical application and interpretation. The validity of diskography remains controversial, in part because postdiskography surgical outcomes have been inconsistent. Therefore, in select patients with recalcitrant back pain, diskography remains a second-line diagnostic modality that is used to clarify surgical indications. Despite well-defined guidelines, the technical aspects of diskography and its interpretation are still evolving.

Adult low-grade acquired spondylolytic spondylolisthesis: evaluation and management

STUDY DESIGN

Literature review.

OBJECTIVE

To discuss the presentation and evaluation of adult patients with acquired spondylolytic spondylolisthesis of low-grade severity and to review surgical treatment options.

SUMMARY OF BACKGROUND DATA

Low-grade adult acquired spondylolytic spondylolisthesis is one of the most common forms of spondylolisthesis.

METHODS

Literature review.

RESULTS

Adults with symptomatic low-grade spondylolytic spondylolisthesis are treated predominantly nonoperatively, with activity modification, physiotherapy, nonsteroidal anti-inflammatory agents, and local injections. Surgical treatment is reserved for individuals with intractable back pain and/or radicular symptoms. A number of surgical options exist, including direct pars repair, and fusion with or without decompression. Fusion can be achieved by providing anterior column support alone, posterior support alone, or a combined circumferential approach; the optimal method by which fusion should be achieved has not been established.

CONCLUSIONS

The management of low-grade acquired spondylolytic spondylolisthesis requires a thoughtful and individualized approach, recognizing the frequently benign natural history of the deformity and the potentially good clinical outcomes from surgery in those select patients with intolerable back and leg pain. While fusion is the mainstay of surgical management, a prospective randomized study would be extremely useful to delineate the optimal fusion technique.

Radiofrequency Heating of Painful Annular Disruptions

OBJECTIVE

Although several studies have reported on outcomes following heating of annular tears with a thermoresistive catheter (SpineCATH), no data are available on the efficacy of thermal treatment with a flexible radiofrequency electrode (discTRODE). A prospective case-control study was conducted to determine the efficacy of radiofrequency heating of painful annular tears in the lumbar spine.

METHODS

After at least 6 months of conservative treatment, 46 patients were studied for the presence of single-level painful annular tears with magnetic resonance imaging and provocative discography. Thirty-one patients underwent heating of their annular tears with a flexible radiofrequency electrode placed across the posterior annulus. The remaining 15 patients, who mostly could not obtain funding for the procedure, continued with conservative management and acted as a control group. The Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Medication Quantification Score (MQS) were obtained before and at 3-monthly intervals after treatment.

RESULTS

The VAS decreased significantly after the radiofrequency treatment, and this decrease persisted at 12 months of follow-up. The VAS did not change over 12 months in untreated control subjects. The decrease in VAS was significantly greater in the treated patients than the control subjects. The ODI also decreased in treated patients but not in control subjects. The MQS did not change in either group over the 12-month follow-up period.

CONCLUSIONS

Radiofrequency heating of annular tears can lead to an improvement in the pain of internal disc disruption. The improvement gained by this treatment method is significantly better than that obtained from conservative management.

TLIF: transforaminal lumbar interbody fusion

Transforaminal lumbar interbody fusion (TLIF) is a relatively new technique of lumbar arthrodesis via posterior transforaminal approach to the disc, indicated mainly in cases of degenerative disc disease, low grade spondylolisthesis and reoperation for disc herniation, specially when there is indication for interbody fusion and posterior decompression. The main advantage of TLIF is that it allows the complete removal of the intervertebral disc through the vertebral foramen, decompression of the spinal canal and vertebral foramen with minimum risk of neural lesion, due to the access being lateral to the nerve roots. In this study, we describe the first 24 cases of TLIF that we have done, wich shows to be very safe and efficient in our serie, with an relief of pain in 83.3% of patients, great improvements in the life quality in 75% of cases and satisfaction with the surgery in 79.1% of patients.

Critical analysis of trends in fusion for degenerative disc disease over the past 20 years: influence of technique on fusion rate and clinical outcome

STUDY DESIGN

Critical analysis of the results reported in published literature.

OBJECTIVES

The purpose of this study was to evaluate whether various technical advancements have affected the outcome of lumbar spinal fusion for degenerative disease by critically analyzing the available literature from the past two decades.

SUMMARY OF BACKGROUND DATA

To improve fusion rate and clinical outcome, various surgical options for lumbar spinal fusion for degenerative disc disorders have been introduced over the past 20 years. However, an important fundamental question still remains: What has been the impact of these new techniques and innovations on surgical results?

METHODS

A comprehensive computer search of the English literature from 1979 to 2000 concerning lumbar/lumbosacral spinal fusion was performed using the keywords degenerative, lumbar, and fusion.

RESULTS

Numerous deficiencies were noted in the reviewed literature. Nearly half of the studies failed to specify methodologic design, and documentation of brace use, graft source, fusion location, and fusion rate was missing in 38, 10, 2, and 4 of the 84 articles reviewed, respectively. From the data gathered, a noticeable trend toward the increasing use of internal fixation was noted, accounting for 23% of fusions in the 1980s versus 41% in the 1990s. Despite this trend, an improvement in overall fusion rate or clinical outcome could not be demonstrated.

CONCLUSIONS

Numerous technologic advancements in lumbar spine fusion have been made over the past 20 years. Future advances in care are dependent on review of reported results. The numerous deficiencies detected in the analyzed literature herald the necessity for a uniform system of outcomes reporting containing a core of critical demographic, perioperative, and postsurgical information. Although a shift toward a greater use of technology was noted in the published literature, the clinical benefit of this trend remains unclear.

Low-back pain in athletes

While most occurrences of low-back pain in athletes are self-limited sprains or strains, persistent, chronic, or recurrent symptoms are frequently associated with degenerative lumbar disc disease or spondylolytic stress lesions. The prevalence of radiographic evidence of disc degeneration is higher in athletes than it is in nonathletes; however, it remains unclear whether this correlates with a higher rate of back pain. Although there is little peer-reviewed clinical information on the subject, it is possible that chronic pain from degenerative disc disease that is recalcitrant after intensive and continuous nonoperative care can be successfully treated with interbody fusion in selected athletes. In general, the prevalence of spondylolysis is not higher in athletes than it is in nonathletes, although participation in sports involving repetitive hyperextension maneuvers, such as gymnastics, wrestling, and diving, appears to be associated with disproportionately higher rates of spondylolysis. Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, independent of radiographic evidence of defect healing. In recalcitrant cases, direct surgical repair of the pars interarticularis with internal fixation and bone-grafting can yield high rates of pain relief in competitive athletes and allow a high percentage to return to play. Sacral stress fractures occur almost exclusively in individuals participating in high-level running sports, such as track or marathon. Treatment includes a brief period of limited weight-bearing followed by progressive mobilization, physical therapy, and return to sports in one to two months, when the pain has resolved.

The current status of lumbar total disc replacement

Total disc replacement is an exciting technology that may one day replace fusion as the gold standard treatment for DDD, but it is currently an experimental procedure in the United States. Promising short- and mid-term results have been reported for TDR, but longer follow-up and randomized trials comparing TDR to fusion and nonsurgical treatment are needed to fully define the role of TDR in the spine surgeon's armamentarium. Short-term complication rates have been acceptably low, but in the long term the durability of TDR implants and the vertebral endplate will provide challenges. Finally, it is essential that practitioners understand that a limited subset of patients are good candidates for TDR and that indiscriminate application of this technology will result in poor outcomes.

Intervertebral cages for degenerative spinal diseases

Interbody fusion techniques have been used for many years for the treatment of a variety of lumbar spine diagnoses. Part of the interest in increasing methods of interbody fusion has stemmed from concern that posterior fusion alone may allow micro-motion, which may generate pain in a ruptured or degenerated disc. Stabilization of the anterior segment led to the development of interbody fusion cages. These devices were designed to stabilize the spine while bony ingrowth from the vertebrae to the bone graft occurred. There are a variety of techniques for cage insertion, including open and laparoscopic techniques anteriorly, and open posterior approach. A lateral approach for cage placement has also been reported. The purpose of this paper is to present a review of the literature on lumbar intervertebral fusion performed using interbody cages. The reported results for these procedures vary, but in general the majority of patients have had favorable results. The complications are similar to those encountered with traditional interbody fusion procedures using bone grafts. There is a learning curve associated with the procedures, particularly with the laparoscopic techniques. Appropriate training for the spine surgeon as well as the access surgeon is important. There is a great deal of disparity in reports on using the cages as stand-alone devices as well as on laparoscopic approaches. Overall, the use of interbody cages for fusion appears to be a viable treatment, yielding good results. Fusion cages appear to have a role in spine care; however, as with any procedure, patient selection and proper training of the surgeon are critical.

Lumbar discography

STUDY DESIGN

A comprehensive review of the literature dealing with lumbar discography was conducted.

OBJECTIVE

The purpose of the review is to update the North American Spine Society position statement published in 1994 that addressed criticisms of lumbar discography, to identify indications for

SUMMARY OF BACKGROUND DATA

Lumbar discography remains a controversial diagnostic procedure. There are concerns about its safety and clinical value, although many support its use in specific applications.

METHODS

Articles dealing with lumbar discography were reviewed and are summarized in this report.

RESULTS

Most of the recent literature supports the use of discography in selected patients. Although not to be taken lightly, many of the serious complications and high complication rates reported before 1970 have decreased since then because of improvement in injection technique, imaging and contrast materials.

CONCLUSIONS

Most of the current literature supports the use of discography in select situations. Indications for discography include, but are not limited to: (1) Further evaluation of demonstrably abnormal discs to help assess the extent of abnormality or correlation of the abnormality with the clinical symptoms. Such symptoms may include recurrent pain from a previously operated disc and lateral disc herniation. (2) Patients with persistent, severe symptoms in whom other diagnostic tests have failed to reveal clear confirmation of a suspected disc as the source of pain. (3) Assessment of patients who have failed to respond to surgical intervention to determine if there is painful pseudarthrosis or a symptomatic disc in a posteriorly fused segment and to help evaluate possible recurrent disc herniation. (4) Assessment of discs before fusion to determine if the discs within the proposed fusion segment are symptomatic and to determine if discs adjacent to this segment are normal. (5) Assessment of candidates for minimally invasive surgical intervention to confirm a contained disc herniation or to investigate dye distribution pattern before chemonucleolysis or percutaneous procedures. Lumbar discography should be performed by those well experienced with the procedure and in sterile conditions with a double-needle technique and fluoroscopic imaging for proper needle placement. Information assessed and recorded should include the volume of contrast injected, pain response, with particular emphasis on its locations and similarity to clinical symptoms, and the pattern of dye distribution. Frequently, discography is followed by axial computed tomography scanning to obtain more information about the condition of the disc.

Indications, techniques, and outcomes of posterior surgery for chronic low back pain

This article summarizes a number of issues surrounding the diagnosis, indications, and techniques of posterior lumbar spine surgery for chronic low back pain. It would not be entirely unjustified for a spine surgeon to adhere to a totally avoidant approach to chronic low back pain, rationalized by a reasonably legitimate nihilism regarding the presently available means of diagnosing and surgically managing low back pain [64]. Judging by the number of lumbar fusions performed in North America and the tremendous intellectual and financial investment currently being made in technologies to enhance spinal fusion, such an approach is evidently not achieving wide-spread acceptance on this continent. A rationale approach is therefore required for the many low back pain sufferers with degenerative disk disease who arrive in the office having exhausted almost every imaginable form of nonoperative therapy. Every effort should be made to establish a pathoanatomic etiology of the back pain with a combination of diagnostic modalities. Surgical intervention should be approached cautiously and only after extensive dialog with the patient to establish realistic goals and expectations. Posteriorly performed interbody fusion procedures may provide a high fusion rate and satisfactory clinical outcomes for this challenging problem, although further research is necessary to determine more conclusively the role of surgery and the relative effectiveness of the various arthrodesis techniques.

Circumferential and posterolateral fusion for lumbar disc disease

Clinical outcome of low back fusion is unpredictable. There are various reports discussing the merits and clinical outcome of these two procedures. The patients were selected from a population of patients who had chronic low back pain unresponsive to conservative treatment. Thirty-six instrumented posterolateral fusions and 35 instrumented circumferential fusions with posterior lumbar interbody fusions were done simultaneously. Preoperative radiographic assessment included plain radiographs, magnetic resonance imaging scans, and provocative discography in all the patients. Posterolateral fusion or anterior lumbar interbody fusion was done for internal disc disruption. The Oswestry disability index, subjective scoring, and assessment of fusion were done at a minimum followup of 2 years. On subjective scoring assessment there was a satisfactory outcome of 63.9% (23 patients) in the posterolateral fusion group and 82.8% (29 patients) in the posterior lumbar interbody fusion group. On assessment by the Oswestry index no difference was found in outcome between the two groups. The posterolateral fusion group had a 63.9% satisfactory outcome and the posterior lumbar interbody fusion group had an 80% satisfactory outcome using the Oswestry disability index for postoperative assessment. There was 61.1% improvement in working ability in the posterolateral fusion group and 77.1% improvement in the posterior lumbar interbody fusion group which was not statistically significant. The authors consider instrumented circumferential fusion with posterior lumbar interbody fusion better than instrumented posterolateral fusion for managing chronic disabling low back pain.

The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs

BACKGROUND CONTEXT

The selection of appropriate patients for lumbar disc surgery is a challenging task involving a highly variable, multifactorial decision process complicated by a lack of reliable, validated clinical signs and imaging findings. Recently, multiple studies have demonstrated the reliability and diagnostic utility of a standardized form of spinal assessment using repeated end-range test movements while monitoring patterns of pain response (McKenzie assessment).

PURPOSE

It is the aim of this article to evaluate the utility of this assessment system and its literature support in the selection of candidates for surgery for disc-related pain.

STUDY DESIGN AND METHODS

A literature review.

RESULTS

Most patients under consideration for lumbar disc surgery, when examined using this form of dynamic mechanical spinal evaluation, based on patients' patterns of pain response to standardized repeated end-range lumbar test movements and positions, fall into one of three subgroups: 1) a reversible condition, 2) an irreversible condition or 3) an unaffected condition. Reversible conditions in acute to chronic low back and/or leg pain are recoverable, often rapidly so, using nonoperative self-care dictated by the patient's assessment findings. The elicitation of pain "centralization," an improvement (favorable change) in pain location in response to repetitive end-range testing, typically occurring with only one direction of test movement(s), predicts a high likelihood of successful response to conservative care, even in the presence of neurologic deficits. Irreversible conditions are characterized by symptom aggravation by all directions of testing, including the absence of the centralization response, predicting a poor response to nonsurgical care. In those whose pain is unaffected with similar testing, evidence indicates the pain is likely nondiscogenic. A dynamic disc model has been described as a possible model for these varying pain responses. Insight into annular integrity of symptomatic discs is also provided using this repeated end-range/pain response (McKenzie) assessment.

CONCLUSIONS

As described, the literature supports the use of a repeated end-range/pain response assessment (dynamic mechanical evaluation) in obtaining diagnostic and therapeutic information in patients with low back and leg pain. This may contribute to improving the selection process of surgical patients.

Treatment of chronic discogenic low back pain with intradiskal electrothermal therapy

The treatment of chronic, nonradicular, discogenic low back pain remains controversial. The posterior anulus fibrosus appears to be a potential site of origin of the pain, which is mediated by nociceptors in the inner layers of the anulus. Diagnosis requires a thorough history, physical examination, and imaging protocol; provocative diskography is key. Nonsurgical treatment options have been limited to physical therapy and pharmacotherapy. Success rates of spinal fusion range from 39% to 96%. Reported therapeutic success rates of intradiskal electrothermal therapy, a possible intermediate treatment, range from 60% to 80%. Despite this apparent therapeutic effect, however, a more precise quantification of clinical benefits remains to be proved in randomized prospective trials.

Is there a connection between the clinical response after an external fixation test or a subsequent lumbar fusion and the pre-test intervertebral kinematics?

STUDY DESIGN

Evaluation of a possible correlation of clinical symptoms of chronic low back pain (LBP) patients before and after application of external spinal fixation (ESF) with three-dimensional motion patterns.

OBJECTIVE

To determine whether the intervertebral kinematics in chronic LBP patients correlate with pain relief after stabilization of the suspected painful segments.

SUMMARY OF BACKGROUND DATA

Chronic LBP is a complex clinical entity with mechanical, biochemical, and psychosocial components. Although clinically controversial, ESF has been shown to reduce intervertebral motion, and thus, it provides a mechanism to investigate the mechanical aspect of LBP.

METHODS

Thirty-four chronic LBP patients were tested with ESF of the suspected painful segments. The subjective pain relief experienced by the patients during the test and 2 years after spinal fusion surgery was determined, along with the Oswestry Disability Index. Before removal of ESF, the three-dimensional intervertebral kinematics of the painful segments (specifically range of motion, coupling patterns, and motion asymmetries) were analyzed with a precision optoelectronic camera system during active trunk motions. A series of linear correlations were performed between the clinical measures and the motion parameters.

RESULTS

The subjective pain relief during the ESF test was nominally, but not significantly, associated with lateral bending asymmetry ( = 0.22) and "abnormal" axial rotation-lateral bending coupling ( = 0.13). The improvement in the Oswestry Disability Index both post-test and at 2 years after lumbar fusion surgery was significantly correlated with the extension range of motion ( = 0.049 and = 0.036, respectively) and the extension-to-flexion range of motion ratio ( = 0.035 and = 0.044, respectively).

CONCLUSIONS

The "abnormal" motion patterns of chronic LBP patients did not correlate with subjective pain relief after ESF of the suspected symptomatic levels or with the midterm outcome of subsequent lumbar fusion surgery. The results suggest that preserved motion of the symptomatic segments before surgery is positively correlated with the clinical result of the subsequent spinal fusion in case of a positive ESF test result.

Surgical management of adjacent level degeneration following lumbar spine fusion

Thirty-eight patients who underwent extension of a prior lumbar fusion for treatment of adjacent level degeneration were retrospectively evaluated. Patient age, pain relief with the initial surgical procedure, and distal level of fusion significantly affected outcome. Overall, this study suggests that adjacent level fusion yields results that are not optimal but provides sigificant clinical improvement for patients with symptomatic adjacent level degeneration.

Characteristics of patients with chronic low back pain selected for surgery: a comparison with the general population reported from the Swedish lumbar spine study

STUDY DESIGN

A group of surgical candidates with chronic low back pain was compared with a random sample of the general population.

OBJECTIVES

To compare the sociodemographic, physical, and psychological characteristics of patients enrolled in a randomized trial of fusion surgery for chronic low back pain with those of an age- and gender-matched general population, and to assess whether the results of the current study can be generalized to other groups of subjects with chronic low back pain.

SUMMARY OF BACKGROUND DATA

The patients with low back pain in industry, primary care, and rehabilitation clinics are well described, with evidence of increased psychological distress, social disturbance, and occupational dissatisfaction. The characteristics of surgical candidates with chronic low back pain are less well described and not compared with the general population.

METHODS

Social, occupational, psychological, and physical data from self-administered questionnaires completed by 294 consecutive surgical candidates with chronic low back pain were compared with the same data from 278 subjects in an age- and gender-matched random sample of the Swedish general population. Data were analyzed with the general population sample divided in two subgroups: subjects with and those without back pain.

RESULTS

The surgical candidates with chronic low back pain differed significantly from the control subjects free of back pain by demonstrating more smoking, general morbidity, and depressive symptoms as well as heavier occupation and self-assessed workload. However, they did not differ from the control subjects with back pain in these respects. In a multiple logistic regression analysis, physical disability was the only variable that independently discriminated between all three groups. The groups did not differ in terms of depressive symptoms. Differences were more obvious between the two general population groups than between the two groups with back pain. The rate of major depression was lower (9%) among the surgical candidates than in other reported groups with chronic low back pain.

CONCLUSIONS

The surgical candidates in the current study resembled the average Swedish citizen with back pain. Although selected for treatment because of symptom severity, they did not otherwise differ substantially from the general population with back pain. On the contrary they unexpectedly were affected only a little by depressive symptoms, distinguishing them from patients with chronic low back pain in pain clinics and rehabilitation centers. Therefore, the results of the this outcome study are not generally applicable to every patient with chronic low back pain.

Three-question depression screener used for lumbar disc herniations and spinal stenosis

STUDY DESIGN

A depression screener was used to determine positive responses amongst patients with two disorders commonly treated with surgery.

OBJECTIVE

To examine the relation between positive responses to the depression screener and pain characteristics, sociodemographic responses, and Short-Form 36-Item Health Survey subscale scores among patients with lumbar disc herniation or spinal stenosis.

SUMMARY OF BACKGROUND DATA

Numerous studies have reported a correlation between depression and low back pain, but few have examined this relation among patients with a diagnosis of sciatica from lumbar disc herniation or spinal stenosis. The Health Status Questionnaire 2.0 includes both the Short-Form 36-Item Health Survey (a validated, multidimensional, generic instrument measuring health-related quality of life and functional status) and the three-question depression screener.

METHODS

The database of the National Spine Network (a nonprofit collaboration of physicians caring for patients with back and neck problems that pools patient data) was queried for patients 18 to 65 years of age with a diagnosis of lumbar disc herniation (n = 2878) and patients 30 to 80 years of age with a diagnosis of spinal stenosis (n = 3801). Depression screeners scored positive when patients reported depressive symptoms within the year to any question about symptoms.

RESULTS

The screener elicited positive responses from 36.4% of the patients with spinal stenosis and 38.4% of the patients with lumbar disc herniation. Among the patients with spinal stenosis or lumbar disc herniation, those with positive depression screener responses reported longer duration of symptoms (>7 weeks) and failure to improve. They were more likely to be obese, recipients of workers' compensation, unmarried, and less educated (below Grade 12). In multivariate analyses, positive depression screener responses were significantly associated with an attorney's services and a longer duration of symptoms.

CONCLUSIONS

A positive depression screener response is strongly associated with poorer functional status and health-related quality of life, as measured by the Short-Form 36-Item Health Survey, among patients with lumbar disc herniation or spinal stenosis, and higher symptom intensity.

Provocative discography in volunteer subjects with mild persistent low back pain

BACKGROUND CONTEXT

Whether discographic injections would be positive in subjects with benign persistent "backache" who are not seeking treatment is unknown. This information is important, because benign backache undoubtedly co-exists in patients with chronic low back pain (CLBP) illness that is not discogenicin origin. If these subjects had a high rate of positive discography, the high background incidence of common backache would allow many positive tests in patients in whom discogenic processes were unrelated to their severe CLBP illness. Conversely, if subjects with benign low back pain rarely if ever had significant concordant pain reproduction on disc injections, the basic tenet of discographic diagnosis would be strengthened.

PURPOSE

To compare, using a strict experimental design, the relative pain and concordancy response to provocative discography in subjects with clinically insignificant "backache" and clinical subjects with CLBP illness considering surgical treatment.

STUDY DESIGN

Comparison of experimental disc injections in subjects with persistent mild backache and those with chronic low back pain (CLBP) illness.

PATIENT SAMPLE

Twenty-five subjects with mild persistent low back pain (LBP) were recruited for an experimental discography study. Subjects were recruited from a clinical study of patients having had cervical spine surgery. Inclusion criteria required that subjects not be receiving or seeking medical treatment for LBP, be taking no medications for backache, have no activity restrictions because of LBP, and have normal psychometric scores. To more closely approximate the pain behavior in CLBP illness, 50% (12) of the "backache" group were recruited with a chronic painful condition (neck/shoulder) unrelated to the low back. CLBP subjects, patients coming to discography for consideration of surgical treatment, were used as control subjects.

OUTCOME MEASURES

Results of discography were determined using the criteria of Walsh et al.: pain response of 3 or greater, two or more pain behaviors, a negative "control" discographic injection, and a similar or exact concordancy rating.

METHODS

Discography was performed on experimental subjects and control patients. Experienced raters, who were blinded to control versus experimental status of the subjects, scored the magnetic resonance image, discogram, psychometric tests and discography videotapes of the subjects' pain behavior.

RESULTS

Thirteen of 25 volunteer subjects had pain rated as "bad" or worse with disc injection. There were 12 painful and fully concordant disc injections in 9 of these 25 "backache" subjects (36%). These injections met all the Walsh et al. criteria for a positive diagnosis of discogenic pain. All positive discs had annular disruption to or through the outer annulus. Of the 9 subjects with positive discograms, 3 had no chronic pain states and 6 did. All subjects with positive injections had negative control discs. In comparison, in 52 subjects with CLBP illness 38 (73%) had at least one positive disc injection.

CONCLUSIONS

In a group of volunteer subjects with persistent "backache," 36% were found to have significant pain on disc injection, which is reported to be concordant with their usual pain. The presence of positive concordant pain responses and negative control discs in 33% of subjects without CLBP illness seriously challenges the specificity of provocative discography in identifying a clinically relevant spinal pathology.

A prospective randomized comparison of 270 degrees fusions to 360 degrees fusions (circumferential fusions)

STUDY DESIGN

Prospective randomized comparison of anterior lumbar interbody fusion (ALIF) plus transpedicular instrumentation plus posterolateral fusion (PLF) (360 degrees fusion) to ALIF plus transpedicular instrumentation without PLF (270 degrees fusion).

OBJECTIVES

To compare the clinical outcomes, costs, and utilization of health resources of 360 degrees versus 270 degrees fusions.

BACKGROUND

The 360 degrees fusion is effective, but its costs and utilization of health resources are high. The PLF often resorbs and may not be necessary.

METHODS

Before and after surgery pain was measured by the Numerical Rating Scale (NRS), and function was measured by the Oswestry Low Back Disability Index (OSI). Costs were calculated by billing records. Operating times, blood loss, and hospital stays were measured at the time of hospital discharge.

RESULTS

There were 48 patients: 21 women and 27 men. Mean age was 42 years. Follow-up averaged 35 months (range 24-45 months). In both 360 degrees and 270 degrees fusions, there were significant improvements in NRS and OSI, and the percentage of solid ALIF was high. Only 14% of PLF appeared solid bilaterally and 18% appeared solid on one side only. There were no significant differences in changes in NRS, changes in OSI, or percentage solid ALIF between the 360 degrees and 270 degrees fusions. However, the 270 degrees fusion group had significantly less blood loss, shorter operative times, shorter hospital stays, and lower professional fees, and although hospital charges were lower, this difference was not significant.

CONCLUSION

Both the 360 degrees and 270 degrees fusions significantly reduce pain and improve function, and there are no significant clinical differences between them. However, there were shorter operating times, less blood loss, lower costs, and less utilization of health care resources associated with the 270 degrees fusions.

Outcomes after posterolateral lumbar fusion with instrumentation in patients treated with adjunctive pulsed electromagnetic field stimulation

Fusion success and clinical outcome were determined in 48 high-risk patients who underwent posterolateral lumbar fusions with internal fixation and were treated with adjunctive pulsed electromagnetic field (PEMF) stimulation postoperatively. An independent radiographic assessment demonstrated a success rate of 97.9%. Following treatment, 59% of the working patients returned to their employment. Overall clinical assessment was excellent in 4.2% of patients, good in 79.2%, and fair in 16.7%; no patient had a poor clinical assessment.

Twelve-month follow-up of a controlled trial of intradiscal thermal anuloplasty for back pain due to internal disc disruption

STUDY DESIGN

Case-control study.

OBJECTIVES

To determine the prima facie efficacy of intradiscal electrothermal anuloplasty (IDTA).

SUMMARY OF BACKGROUND DATA

Although it is being used increasingly as a putative treatment for internal disc disruption, no studies have been published on the efficacy of IDTA.

METHODS

Fifty-three patients with back pain determined by computed tomographic (CT)-discography to be due to internal disc disruption were offered treatment. The outcomes of 35 patients treated with IDTA were compared with those of a convenience sample of 17 patients treated with a physical rehabilitation program, by using a visual analog pain scale, use of analgesics, and return to work as measures.

RESULTS

At 3 months, only one control patient obtained any significant degree of relief of pain, compared with 23 in the index group. Relief of pain was sustained at 6 and 12 months and was associated with improvement in disability, reduced drug use, and a return to work rate of 53%. Depending on the stringency of criteria used, the success rate of IDTA may be as low as 23% or as high as 60% with confidence intervals of +/-16%.

CONCLUSIONS

In carefully selected cases, IDTA can eliminate or dramatically reduce the pain of internal disc disruption in a substantial proportion of patients and appears to be superior to conventional conservative care for internal disc disruption.