The epidemiology of low back pain in the rest of the world

The diagnostic accuracy of imaging modalities to detect pseudarthrosis after spinal fusion-a systematic review and meta-analysis of the literature

OBJECTIVE

The aim of the study was to determine the diagnostic accuracy of imaging modalities to detect pseudarthrosis after thoracolumbar spinal fusion, with surgical exploration as reference standard.

MATERIALS AND METHODS

A systematic literature search for original studies was performed on the diagnostic accuracy of imaging as index test compared to surgical exploration as reference standard to diagnose pseudarthrosis after thoracolumbar spinal fusion. Diagnostic accuracy values were extracted and methodologic quality of studies was evaluated by the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Per modality, clinically comparable studies were included in subgroup meta-analysis and weighted odds ratios (ORs) were calculated using the random effects model.

RESULTS

Fifteen studies were included. Risk of bias was classified as high/unclear in 58% of the studies. Concerns of applicability was classified as high/unclear in 40% of the studies. Four scintigraphy studies including 93 patients in total were pooled to OR = 2.91 (95% confidence interval [CI]: 0.93-9.13). Five studies on plain radiography with 398 patients in total were pooled into OR = 7.07 (95% CI: 2.97-16.86). Two studies evaluating flexion-extension radiography of 75 patients in total were pooled into OR = 4.00 (95% CI: 0.15-105.96). Two studies of 68 patients in total were pooled for CT and yielded OR = 17.02 (95% CI: 6.42-45.10). A single study reporting on polytomography, OR = 10.15 (95% CI 5.49-18.78), was also considered to be an accurate study.

CONCLUSIONS

With a pooled OR of 17.02, CT can be considered the most accurate imaging modality for the detection of pseudarthrosis after thoracolumbar spinal fusion from this review.

Evaluation of a short dynamic 18F-fluoride PET/CT scanning method to assess bone metabolic activity in spinal orthopedics

OBJECTIVE

A complication after spinal fusion surgery is pseudarthrosis, but its radiological diagnosis is of limited value. (18)F-fluoride PET with its ability to assess bone metabolism activity could be of value. The goal of this study was to assess the clinical feasibility of calculating the static standardized uptake value (SUV) from a short dynamic scan without the use of blood sampling, thereby obtaining all dynamic and static parameters in a scan of only 30 min. This approach was tested on a retrospective patient population with persisting pain after spinal fusion surgery.

METHODS

In 16 patients, SUVs (SUV max, SUV mean) and kinetic parameters (K 1, k 2, k 3, v b, K i,NLR, K 1/k 2, k 3/(k 2 + k 3), K i,patlak) were derived from static and dynamic PET/CT scans of operated and control regions of the spine, after intravenous administration of 156-214 MBq (18)F-fluoride. Parameter differences between control and operated regions, as well as between pseudarthrosis and fused segments were evaluated. SUVmean at 30 and 60 min was calculated from kinetic parameters obtained from the dynamic data set (SUV mean,2TCM). Agreement between measured and calculated SUVs was evaluated through Bland-Altman plots.

RESULTS

Overall, statistically significant differences between control and operated regions were observed for SUV max, SUV mean, K i,NLR, K i,patlak, K 1/k 2 and k 3/(k 2 + k 3). Diagnostic CT showed pseudarthrosis in 6/16 patients, while in 10/16 patients, segments were fused. Of all parameters, only those regarding the incorporation of bone [K i,NLR, K i,patlak, k 3/(k 2 + k 3)] differed statistically significant in the intervertebral disc space between the pseudarthrosis and fused patients group. The mean values of the patient-specific blood clearance rate [Formula: see text] differed statistically significant between the pseudarthrosis and the fusion group, with a p value of 0.011. This may correspond with the lack of statistical significance of the SUV values between pseudarthrosis and fused patients. Bland-Altman plots show that calculated SUV mean,2TCM values corresponded well with the measured SUV mean values.

CONCLUSION

This study shows the feasibility of a 30-min dynamic (18)F-fluoride PET/CT scanning and this may provide dynamic parameters clinically relevant to the diagnosis of pseudarthrosis.

The prevalence and risk factors of low back pain in rural community residents of Korea

STUDY DESIGN

A community-based, cross-sectional study that is part of the prospective Korean Health and Genome Study.

OBJECTIVE

To determine the prevalence of low back pain (LBP) among middle-aged and elderly rural community residents in Korea and to examine the relevant risk factors, including activities reflecting the Asian lifestyle, and the relationship between radiographical features of degenerative changes in the lumbar spine and LBP.

SUMMARY OF BACKGROUND DATA

The prevalence and implication of LBP among the elderly, particularly Asians, are under-represented in previous reports.

METHODS

Data for LBP were collected for 4181 subjects from a rural farming community. The point and cumulative lifetime prevalences of LBP were obtained in addition to measurement of the severity of LBP. Lateral lumbar spine radiographs were obtained according to a standard protocol.

RESULTS

The mean age of the study subjects was 56 years and 55% were women. The lifetime prevalence of LBP was 61.3%, with women having a higher prevalence. The point and 6-month prevalences were also higher among women. The lifetime, point, and 6-month prevalences increased with age in both sexes, except for lifetime prevalence in men. The prevalence of LBP of grade 3 or more was significantly higher in women and increased significantly with age, particularly in women. Both lifetime and point of prevalence of LBP were significantly associated with age, female sex, and time spent squatting. After adjusting for age and sex, the presence of disc space narrowing, osteophytes, and advanced Kellgren-Lawrence grade in lumbar radiograph was associated with LBP.

CONCLUSION

The prevalence of LBP is comparable between these Korean community residents and other population groups. Risk factors associated with LBP included advanced age, female sex, squatting, the presence of osteophytes, joint space narrowing, and advanced Kellgren-Lawrence grading on lumbar radiograph.

Radiofrequency facet joint neurotomy in treatment of facet syndrome

STUDY DESIGN

Retrospective analyses of 50 patients with lumbar facet syndrome treated with lumbar facet joint neurotomy.

OBJECTIVE

To establish the efficacy of lumbar facet joint neurotomy under optimum conditions in selected patients.

SUMMARY OF BACKGROUND DATA

With the realization of the significance of facet joints in the etiology of chronic low back pain over the last decade, many studies were conducted about various methods of treating the facet joint syndrome.

METHODS

Fifty patients with lumbar facet syndrome with at least 80% pain relief by controlled, diagnostic medial branch blocks underwent lumbar facet joint neurotomy. Before surgery, all were examined carefully both clinically and radiologically and evaluated by visual analog scale (VAS) and descriptive system of health-related quality of life state (EQ5D) measures of pain, disability, and treatment satisfaction. All outcome measures were repeated postoperatively and at 12 months after surgery.

RESULTS

Of the 50 patients 35 were females and 15 were males with a mean age of 51.82±16.99 years. One level was treated in 26 patients, 2 levels in 14, 3 levels in 8, and 4 levels were treated in 2 patients. Symptom duration was ranging between 2 and 24 months with a mean of 7.64±5.98 months. Mean preoperative, postoperative, and at the 12th month VAS were 75.2±11.29, 23.8±10.28, and 24.6±11.817, respectively.Forty-eight percent of patients obtained a relative reduction of at least 70% in VAS, and 86% obtained a reduction of at least 60% at the 12th month. Health-related quality of life state was improved in all patients. When the VAS scores were evaluated with respect to the ages of patients, level numbers, and preoperative symptom duration, no significant differences were found, [0.106, 0.635 and 0.526 (preoperative VAS); 0.033, 0.555, and 0.235 (postoperative VAS); 0.701, 0.978, and 0.155 (follow-up VAS), respectively].

CONCLUSIONS

The most important factors determining success of this procedure is strict patient selection criteria and technique of the procedure.

A new non exercise-based VO2max prediction equation for patients with chronic low back pain

INTRODUCTION The measurement of the maximal oxygen uptake as a parameter of cardiorespiratory fitness is useful in exercise prescription in functional restoration programs but this measurement requires the subject's maximal exertion which is not always possible in patients with chronic low back pain. The purpose of this study was to develop a regression equation to predict maximal oxygen uptake based on non-exercise data in adult patients with chronic low back pain.

METHODS

Cross sectional study in which 70 participants completed a maximal graded exercise test in cycle ergometer to assess maximal oxygen uptake.

RESULTS

Patients achieved a mean +/- SD value of VO(2)max of 30.8 (+/-7.7) ml kg(-1) min(-1). The regression model included as data of non-exercise the patient's gender, body mass index and the intensity of physical activity during leisure time. Multiple linear regression analysis generated the following formula (R (2) = 38.3, SEE = 6.08 ml kg(-1) min(-1)): VO(2)max (ml kg(-1) min(-1)) = 35.3377 - 0.475411 x BMI + 0.155232 x PALT + 7.97682 x gender; where BMI = body mass index, PALT = physical activity during leisure time, women = 0, men = 1. The Durbin Watson statistic showed no problems with serial autocorrelation (D-W = 1.86). The Kolmogorov-Smirnov normality test demonstrated that the errors are distributed normally.

CONCLUSIONS

This study provides a new and relatively precise non-exercise regression model to predict VO(2)max in patients with chronic low back pain.

Effects of a single session of posterior-to-anterior spinal mobilization and press-up exercise on pain response and lumbar spine extension in people with nonspecific low back pain

BACKGROUND AND PURPOSE

Posterior-to-anterior (PA) mobilization and press-up exercises are common physical therapy interventions used to treat low back pain. The purpose of this study was to examine the immediate effects of PA mobilization and a press-up exercise on pain with standing extension and lumbar extension in people with nonspecific low back pain.

SUBJECTS

The study participants were 30 adults (19 women and 11 men) who were 18 to 45 years of age and had a diagnosis of nonspecific low back pain.

METHODS

Lumbar segmental extension during a press-up maneuver was measured by dynamic magnetic resonance imaging prior to and immediately following a single session of either PA spinal mobilization or a press-up exercise. Pain scores before and after intervention were recorded with a visual analog scale. Differences between the treatment groups in pain and total lumbar extension were compared over time by use of a 2-way analysis of variance.

RESULTS

Following both interventions, there was a significant reduction in the average pain scores for both groups (significant main effect for time, no interaction). Similarly, total lumbar extension significantly increased in both the PA mobilization group and the press-up group (significant main effect for time, no interaction). No significant differences between the 2 interventions in pain or lumbar extension were found.

DISCUSSION AND CONCLUSION

The findings of this study support the use of PA mobilization and a press-up exercise for improving lumbar extension in people with nonspecific low back pain. Although statistically significant within-group changes in pain were detected, the clinical meaningfulness of these changes is questionable.

Injection therapy of lumbar facet syndrome: a prospective study

BACKGROUND

Chronic low back pain remains a major health problem. Facet joint injection therapy is an easy to perform therapeutic option. However, few prospective studies use a standardized protocol to investigate injection therapy. The aim of our study was to evaluate quantity and duration of clinical improvement after this protocol, and to identify the best time for additional repetitive injection therapy.

MATERIALS AND METHODS

Thirty-nine patients (21 men, 18 women; mean age 55.2 years [range, 29-87 years]) with lumbar facet syndrome were treated with injection using a standardized protocol (prednisolone acetate, lidocaine 1%, phenol 5%) under fluoroscopic control. Follow-up was based on a specially designed questionnaire. Analysis included MacNab criteria, visual analogue scale, and pain disability index.

RESULTS

Reduction of pain was found up to 6 months after treatment. The outcome was assessed excellent or good by 62% (24 patients) of the patients after 1 month, by 41% (16 patients) after 3 months, and by 36% (14 patients) after 6 months. There was no influence of age, body mass index, or previous lumbar spinal surgery on improvement after treatment. There were no severe side effects. Short-lasting self limiting mild side effects were found in 26% (increased back pain, numbness, heartburn, headache, allergy).

CONCLUSION

Facet joint injection therapy using a standardized protocol is safe, effective, and easy to perform. The clinical effect is limited, and we recommend repetitive injection according to this protocol after 3 months.