Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review

How do information and physiotherapy affect health-related quality of life among patients with spinal stenosis undergoing decompression surgery: A qualitative study

BACKGROUND

There is a lack of qualitative research on how patients with lumbar spinal stenosis (LSS) undergoing surgery perceive their health-related quality of life (HRQOL). Research that increases our understanding in this area could facilitate a biopsychosocial approach to care.

AIM

We aimed to investigate the experiences of patients with LSS undergoing decompression surgery regarding their pre- and post-surgery perceptions of HRQOL and the pre-and post-operative information and physiotherapy.

METHOD

We used a qualitative design with semi-structured interviews to perform content analysis using an inductive approach. Twelve patients (7 female, 5 male) were included post-surgery and interviewed by phone. The interviews were recorded and transcribed verbatim.

RESULTS

Four distinct categories with nine associated subcategories were identified: Patients' feelings of safety and empowerment are enhanced by healthcare professionals; Divided perceptions of information and physiotherapy in a group context; Health-related quality of life is associated with patients' perceived physical capacity; Patients' optimism and concerns influence health-related quality of life.

CONCLUSION

Both physical and psychological factors pre- and post-surgery appear to influence patients' HRQOL. Inherent optimism and feelings of empowerment in the care process appear to be important factors, regardless of physical health status. A strong patient-provider relationship is important to promote self-efficacy, which may positively affect perceived HRQOL and is in line with the generally recommended biopsychosocial approach in the treatment of people with low back pain. As qualitative studies in this area are scarce, there is a need for further studies to validate our findings.

Effect of Acupuncture on Neurogenic Claudication Among Patients With Degenerative Lumbar Spinal Stenosis : A Randomized Clinical Trial

BACKGROUND

Acupuncture may improve degenerative lumbar spinal stenosis (DLSS), but evidence is insufficient.

OBJECTIVE

To investigate the effect of acupuncture for DLSS.

DESIGN

Multicenter randomized clinical trial. (ClinicalTrials.gov: NCT03784729).

SETTING

5 hospitals in China.

PARTICIPANTS

Patients with DLSS and predominantly neurogenic claudication pain symptoms.

INTERVENTION

18 sessions of acupuncture or sham acupuncture (SA) over 6 weeks, with 24-week follow-up after treatment.

MEASUREMENTS

The primary outcome was change from baseline in the modified Roland-Morris Disability Questionnaire ([RMDQ] score range, 0 to 24; minimal clinically important difference [MCID], 2 to 3). Secondary outcomes were the proportion of participants achieving minimal (30% reduction from baseline) and substantial (50% reduction from baseline) clinically meaningful improvement per the modified RMDQ.

RESULTS

A total of 196 participants (98 in each group) were enrolled. The mean modified RMDQ score was 12.6 (95% CI, 11.8 to 13.4) in the acupuncture group and 12.7 (CI, 12.0 to 13.3) in the SA group at baseline, and decreased to 8.1 (CI, 7.1 to 9.1) and 9.5 (CI, 8.6 to 10.4) at 6 weeks, with an adjusted difference in mean change of -1.3 (CI, -2.6 to -0.03; P = 0.044), indicating a 43.3% greater improvement compared with SA. The between-group difference in the proportion of participants achieving minimal and substantial clinically meaningful improvement was 16.0% (CI, 1.6% to 30.4%) and 12.6% (CI, -1.0% to 26.2%) at 6 weeks. Three cases of treatment-related adverse events were reported in the acupuncture group, and 3 were reported in the SA group. All events were mild and transient.

LIMITATION

The SA could produce physiologic effects.

CONCLUSION

Acupuncture may relieve pain-specific disability among patients with DLSS and predominantly neurogenic claudication pain symptoms, although the difference with SA did not reach MCID. The effects may last 24 weeks after 6-week treatment.

PRIMARY FUNDING SOURCE

2019 National Administration of Traditional Chinese Medicine "Project of building evidence-based practice capacity for TCM-Project BEBPC-TCM" (NO. 2019XZZX-ZJ).

Comparative clinical efficacy of percutaneous coaxial large-channel endoscopic lumbar interbody fusion and transforaminal lumbar interbody fusion for degenerative lumbar spinal stenosis: a retrospective study

This study aimed to evaluate the clinical efficacy of percutaneous coaxial large-channel endoscopic lumbar interbody fusion (PCLE-LIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of degenerative lumbar spinal stenosis. The clinical data of patients with degenerative lumbar spinal stenosis who underwent PCLE-LIF (experimental group) and TLIF (control group) surgery from September 2019 to September 2021 were retrospectively analyzed. We collected clinical data and compared the two groups in terms of perioperative parameters, treatment response rate, inflammatory response markers, postoperative complications, postoperative pain, and functional recovery. The results showed that the treatment outcomes in the experimental group were significantly better than those in the control group. Specifically, perioperative parameters and inflammatory response markers in the experimental group were significantly better than those in the control group, with statistically significant differences (P < 0.05). The overall treatment response rate in the experimental group was significantly higher than that in the control group (P < 0.05). Meanwhile, the incidence of postoperative complications in the experimental group was lower than that in the control group, postoperative VAS pain scores and ODI functional scores were lower, and postoperative JOA functional scores were higher than those in the control group, with statistically significant differences (P < 0.05). In conclusion, PCLE-LIF appears to be a promising technique with better clinical outcomes in the treatment of degenerative lumbar spinal stenosis.

Chronic pain for rheumatological disorders: Pathophysiology, therapeutics and evidence

Pain is the leading reason people seek orthopedic and rheumatological care. By definition, most pain can be classified as nociceptive, or pain resulting from non-neural tissue injury or potential injury, with between 15% and 50% of individuals suffering from concomitant neuropathic pain or the newest category of pain, nociplastic pain, defined as "pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage, or of a disease or lesion affecting the somatosensory system." Pain classification is important because it affects treatment decisions at all levels of care. Although several instruments can assist with classifying treatment, physician designation is the reference standard. The appropriate treatment of pain should ideally involve multidisciplinary care including physical therapy, psychotherapy and integrative therapies when appropriate, and pharmacotherapy with non-steroidal anti-inflammatory drugs for acute, mechanical pain, membrane stabilizers for neuropathic and nociplastic pain, and serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants for all types of pain. For nonsurgical interventions, there is evidence to support a small effect for epidural steroid injections for an intermediate-term duration, and conflicting evidence for radiofrequency ablation to provide at least 6months of benefit for facet joint pain, knee osteoarthritis, and sacroiliac joint pain. Since pain and disability represent the top reason for elective surgery, it should be reserved for patients who fail conservative interventions. Risk factors for procedural failure are the same as risk factors for conservative treatment failure and include greater disease burden, psychopathology, opioid use, central sensitization and multiple comorbid pain conditions, poorly controlled preoperative and postoperative pain, and secondary gain.

Orthopaedic Manual Physical Therapy: A Modern Definition and Description

Currently, orthopaedic manual physical therapy (OMPT) lacks a description of practice that reflects contemporary thinking and embraces advances across the scientific, clinical, and educational arms of the profession. The absence of a clear definition of OMPT reduces understanding of the approach across health care professions and potentially limits OMPT from inclusion in scientific reviews and clinical practice guidelines. For example, it is often incorrectly classified as passive care or incorrectly contrasted with exercise-therapy approaches. This perspective aims to provide clinicians, researchers, and stakeholders a modern definition of OMPT that improves the understanding of this approach both inside and outside the physical therapist profession. The authors also aim to outline the unique and essential aspects of advanced OMPT training with the corresponding examination and treatment competencies. This definition of practice and illustration of its defining characteristics is necessary to improve the understanding of this approach and to help classify it correctly for study in the scientific literature. This perspective provides a current definition and conceptual model of OMPT, defining the distinguishing characteristics and key elements of this systematic and active patient-centered approach to improve understanding and help classify it correctly for study in the scientific literature.

Effects of calcitonin on lumbar spinal stenosis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

There is some controversy about the effects of calcitonin (CT) on lumbar spinal stenosis (LSS). This systematic review and meta-analysis is to assess the strength of the evidence supporting the use of CT in the treatment of patients with LSS.

MATERIAL AND METHOD

We performed an electronic search depicting randomized controlled trials (RCTs) through 4 databases from the date of database creation to January 2023. 3 different researchers conducted independent literature screening, data extractions, and quality assessments. The outcome measures included visual analogue scale (VAS), walking distance, and oswestry disability index (ODI). Meta-analysis and trial sequence analysis (TSA) were carried out using RevMan 5.4, Stata 16.0, and TSA 0.9. GRADE 3.6 was used to evaluate the evidence quality.

RESULTS

We accepted 9 studies with 496 participants. The meta-analysis revealed that CT offered no significant improvement in VAS, walking distance, or ODI in patients with LSS.

CONCLUSION

There is no evidence that CT has a benefit in patients with LSS, either alone or in combination with other treatments, or depending on the route of administration, according to the systematic review and meta-analysis of relevant RCTs.

ChatGPT and its Role in the Decision-Making for the Diagnosis and Treatment of Lumbar Spinal Stenosis: A Comparative Analysis and Narrative Review

STUDY DESIGN

Comparative Analysis and Narrative Review.

OBJECTIVE

To assess and compare ChatGPT's responses to the clinical questions and recommendations proposed by The 2011 North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis (LSS). We explore the advantages and disadvantages of ChatGPT's responses through an updated literature review on spinal stenosis.

METHODS

We prompted ChatGPT with questions from the NASS Evidence-based Clinical Guidelines for LSS and compared its generated responses with the recommendations provided by the guidelines. A review of the literature was performed via PubMed, OVID, and Cochrane on the diagnosis and treatment of lumbar spinal stenosis between January 2012 and April 2023.

RESULTS

14 questions proposed by the NASS guidelines for LSS were uploaded into ChatGPT and directly compared to the responses offered by NASS. Three questions were on the definition and history of LSS, one on diagnostic tests, seven on non-surgical interventions and three on surgical interventions. The review process found 40 articles that were selected for inclusion that helped corroborate or contradict the responses that were generated by ChatGPT.

CONCLUSIONS

ChatGPT's responses were similar to findings in the current literature on LSS. These results demonstrate the potential for implementing ChatGPT into the spine surgeon's workplace as a means of supporting the decision-making process for LSS diagnosis and treatment. However, our narrative summary only provides a limited literature review and additional research is needed to standardize our findings as means of validating ChatGPT's use in the clinical space.

Clinical effects of arthroscopic-assisted uni-portal spinal surgery and unilateral bi-portal endoscopy on unilateral laminotomy for bilateral decompression in patients with lumbar spinal stenosis: a retrospective cohort study

OBJECTIVE

To investigate the clinical effectiveness of Arthroscopic-assisted Uni-portal Spinal Surgery (AUSS) in the treatment of lumbar spinal stenosis.

METHODS

A total of 475 patients with lumbar spinal stenosis from January 2019 to January 2023 were included in this study. Among them, 240 patients were treated with AUSS (AUSS group); the other 235 patients were treated with unilateral bi-portal endoscopy treatment (UBE group). The differences in surgery-related clinical indicators, pain degree before and after surgery, Oswestry Disability Index (ODI), CT imaging parameters of spinal stenosis, and clinical efficacy were compared between the two groups.

RESULTS

Patients in the AUSS group had a shorter operative time than those in the UBE group, and the length of incision and surgical bleeding were less than those in the UBE group, with statistically significant differences (P < 0.05). Before operation, there was no significant difference in the VAS score of low back pain and leg pain between the two groups (P > 0. 05). After operation, patients in both groups showed a significant reduction in low back and leg pain, and their VAS scores were significantly lower than before the operation (P < 0.05). Three months after surgery, the results of CT re-examination in both groups showed that the spinal stenosis of the patients was well improved, and the measurements of lumbar spinal interspace APDC, CAC, ICA, CAD and LAC were significantly higher than those before surgery (P < 0. 05). Besides, the lumbar function of patients improved significantly in both groups, and ODI measurements were significantly lower than those before surgery (P < 0.05).

CONCLUSION

Both AUSS and UBE with unilateral laminotomy for bilateral decompression can achieve good clinical results in the treatment of lumbar spinal stenosis, but the former has the advantages of simpler operation, shorter operation time, shorter incision length, and less surgical blood loss.

Exercise treatments for lumbar spinal stenosis: A systematic review and intervention component analysis of randomised controlled trials

OBJECTIVE

To analyse the components used in exercise interventions for people with symptoms of neurogenic claudication due to lumbar spinal stenosis and identify components associated with successful interventions.

DATA SOURCES

Eligible papers published up to April 2023 from MEDLINE, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and trial registry websites.

REVIEW METHODS

Literature searches were performed by an Information Specialist. We searched for randomised trials evaluating exercise interventions for people with neurogenic claudication symptoms (the primary symptom of lumbar spinal stenosis). Two authors independently performed study selection, data extraction, and quality assessments using the Cochrane Risk of Bias tool Version 2 and the TIDieR checklist for intervention reporting. Details of intervention components were extracted, tabulated, and synthesised using an intervention component analysis approach.

RESULTS

We found thirteen trials reporting 23 exercise interventions delivered to 1440 participants. These featured 60 different components. Most exercise interventions included supervision and flexion-based exercises. Balance exercises were rarely included. Exercise components featured more frequently in successful interventions included stretches, strength or trunk muscle exercises, fitness exercises, especially cycling, and psychologically informed approaches. Interpretation is limited by low study numbers and heterogeneity. No conclusions could be drawn about exercise supervision or dose.

DISCUSSION

Exercise interventions for people with neurogenic claudication typically feature multiple components. Common features such as supervision, lumbar flexion, and aerobic fitness exercises and also less common features such as stretches, strengthening exercises, and psychologically informed approaches warrant consideration for inclusion when designing and optimising exercise interventions for people with lumbar spinal stenosis.

Mechanical Needling With Sterile Water Versus Lidocaine Injection for Lumbar Spinal Stenosis

Study Design: This was a retrospective observational study that assessed the clinical outcome of ageing patients who received ultrasound-guided (USG) mechanical needling with sterile water injection. In addition, the clinical outcome of age-and gender matched patients randomly selected from patients who received needling with sterile water was compared to the patients injected with lidocaine in a 1:1 ratio.Objective: This present study aimed to explore the clinical effects of USG mechanical needling with sterile water injection for lumbar spinal stenosis (LSS).Methods: The data was extracted from the medical records of ageing patients with LSS who received USG injection at the lumbosacral spine by the first author. Low back pain or axial pain, and leg pain or radicular pain were assessed by the visual analogue scale, and gait ability with walking distance were obtained at six different time points.Results: A total of 4328 medical records were examined. Four thousand two hundred and twenty-eight ageing patients received mechanical needling with sterile water injection and found the efficacy lasted up to 6 months. One hundred patients were compared with 100 patients who received lidocaine injection. Those who received lidocaine had pain returned at 3 months and 6 months post-injection.Conclusions: USG mechanical needling with sterile water injection could help relieve axial and radicular pain for at least 6 months. Removal of calcification and fibrosis as well as reduction of sensitization are all possible mechanisms.

Similar improvements in patient-reported outcomes for non-specific low back pain patients with and without lumbar spinal stenosis symptoms following a structured education and exercise therapy program

BACKGROUND

People with nonspecific low back pain (NSLBP) can also experience overlapping symptoms of lumbar spinal stenosis (LSS), but the impact on treatment outcomes is unknown. This study investigated differences in treatment outcomes for disability, back pain intensity, and leg pain intensity following an education and exercise therapy program for NSLBP patients with and without comorbid LSS symptoms.

METHODS

This was a longitudinal analysis of 655 Danish participants in the GLA:D® Back program; an education and exercise therapy program for people with persistent NSLBP. Participants were classified as having comorbid LSS symptoms based on self-report. Linear mixed models were used to assess differences in change in disability (Oswestry Disability Index [0-100]) and back and leg pain intensity (Numeric Rating Scale [0-10]) at 3-, 6-, and 12-months between those with and without LSS symptoms.

RESULTS

28% of participants reported LSS symptoms. No certain differences in change in disability or back pain intensity improvement were observed at any time-point between those with and without LSS symptoms. Participants with LSS symptoms had slightly greater improvement in leg pain intensity at 6- (-0.7, 95% CI -1.2 to -0.2) and 12-months (-0.6, 95% CI -1.2 to -0.1).

CONCLUSION

Compared to those without LSS symptoms, patients with persistent NSLBP and LSS symptoms can expect similar improvements in disability and back pain intensity, and slightly greater improvements in leg pain intensity with treatment. Therefore, education and exercise therapy programs designed for NSLBP are likely helpful for those also experiencing LSS symptoms.

Development of CORE-CM core outcome domain sets for trials of Chinese medicine for lumbar spinal stenosis

OBJECTIVES

Most Asian countries have employed Chinese medicine (CM) and Western medicine to treat lumbar spinal stenosis (LSS). Evidence synthesis and comparison of effectiveness are difficult since outcomes examined and presented through trials possess heterogeneity. This study aimed to solve the outcome problems for CM clinical trials in LSS by building a core outcome set (COS).

METHODS

To achieve an agreement on a set of core outcome domains, a four-phase study was carried out. First, we identified candidate outcome domains by systematically reviewing trials. In addition, we identified outcome domains associated with patients by conducting semistructured interviews with patients. Next, outcome domains were processed through a national two-round Delphi survey, in which 18 patients and 21 experts were recruited. Finally, the above domains were converted as a core outcome domain set based on a consensus meeting, in which 24 stakeholders were recruited.

RESULTS

Seventeen outcome subdomains were identified by the systematic review and interviews. The Delphi survey assigned a priority to four outcome domains in the first round and four outcomes additionally in the second round. The core outcome domains were determined through discussion and redefinition of outcomes in the consensus meeting: pain and discomfort, health-related quality of life, lumbar function, activities of daily living, measures of walking, patient global assessment, adverse events and CM-specific outcomes.

CONCLUSION

COS-CM-LSS is likely to enhance the consistency of outcomes reported in clinical trials. In-depth research should be conducted for the exploration of the best methods to examine the above outcomes.

Validation and reliability of the Persian version of the Zurich Claudication Questionnaire in patients with lumbar spinal stenosis

Background

One of the applicable tools introduced as a specific tool for assessing claudication in patients with lumbar spinal stenosis is the Zurich Claudication Questionnaire (ZCQ). This questionnaire has been validated in different populations of patients. The present study aimed to determine the validation status of the Persian version of ZCQ.

Methods

After professional translation of the ZCQ by native English translators, it was executed twice before surgery with 1 day interval on 45 Iranian patients with spinal stenosis. The reliability was assessed by determining the Chronbach's Alpha coefficient as well as intraclass correlation coefficient (ICC). To assess the concurrent validity, the correlation across the 3 domains of the questionnaire was calculated by the Pearson's correlation test and the content validity was determined using a panel of experts.

Results

To assess test-retest reliability, the ICC for ZCQ for symptom severity, functional disability, and satisfaction domains were 0.80, 0.82, and 0.78, indicating acceptable reliability. Regarding internal consistency, Cronbach's alpha coefficients for the Persian version of ZCQ for the 3 above domains were shown to be 0.96, 0.92, and 0.90 respectively. On the subject of content validity, the 3 questionnaire's domains were marked as relevant with the content validity indices of 0.88, 0.82, and 0.80 respectively. Concerning concurrent validity, all 3 domains of the Persian ZCQ correlated strongly with 1 another.

Conclusions

The ZCQ questionnaire with the same original structure is completely functional and reliable in the Iranian patient community.

Pain and function in patients with chronic low back pain and leg pain after Zhineng Qigong - a quasi-experimental feasibility study

BACKGROUND

Qigong includes training for body and mind, one method is Zhineng Qigong. Scientific literature on qigong for chronic low back pain (LBP) is sparse. This study aimed to investigate feasibility including evaluation of a Zhineng Qigong intervention for pain and other lumbar spine-related symptoms, disability, and health-related quality of life in patients with chronic LBP and/or leg pain.

METHODS

Prospective interventional feasibility study without control group. Fifty-two chronic pain patients (18-75 years) with LBP and/or leg pain (Visual Analogue Scale ≥ 30) were recruited from orthopaedic clinics (spinal stenosis, spondylolisthesis, or segmental pain) and primary healthcare (chronic LBP). Patients from orthopaedic clinics were 1-6 years postoperative after lumbar spine surgery or on lumbar surgery waiting list. Patients received a 12-week training intervention with European Zhineng Qigong. The intervention consisted of face-to-face group activities in non-healthcare setting (4 weekends and 2 evenings per week), and individual Zhineng Qigong training. Main health outcomes were self-reported in a 14-day pain diary, Oswestry Disability Index (ODI), Short Form 36 version 2 (SF-36v2), and EuroQol 5 Dimensions 5 Levels (EQ-5D-5L), once directly before and once directly after the intervention.

RESULTS

Recruitment rate was 11% and retention rate was 58%. Dropouts did not report higher pain (baseline), only 3 dropped out because of lumbar spine-related pain. Adherence was median 78 h group attendance (maximum 94 h) and 14 min daily individual training. Ability to collect outcomes was 100%. Thirty patients completed (mean 15 years symptom duration). Twenty-five had degenerative lumbar disorder, and 17 history of lumbar surgery. Results showed statistically significant (within-group) improvements in pain, ODI, all SF-36v2 scales, and EQ-5D-5L.

CONCLUSIONS

Despite low recruitment rate, recruitment was sufficient. A multicentre randomized controlled trial is proposed, with efforts to increase recruitment and retention rate. After this Zhineng Qigong intervention patients with chronic LBP and/or leg pain, also patients with considerable remaining LBP/sciatica after lumbar surgery, had significantly improved in pain and function. Results support involvement of postoperative patients in a future study. The results are promising, and this intervention needs to be further evaluated to provide the most reliable evidence.

TRIAL REGISTRATION

NCT04520334. Retrospectively registered 20/08/2020.

Non-pharmaceutical Chinese medical therapies for degenerative lumbar spinal stenosis: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The objective of the study was to assess the effectiveness of utilizing Non-Pharmaceutical Chinese Medical (NPCM) therapy singularly or in combination for the treatment of Degenerative Lumbar Spinal Stenosis (DLSS).

METHODS

The comprehensive search for all randomized controlled trials regarding NPCM therapies for the treatment DLSS was performed through online databases searches, commencing from their inception to January 1st, 2023. The relevant literature underwent a thorough screening process, and the data was meticulously extracted and subjected to analysis through the implementation of RevMan 5.3 software. The Cochrane Risk of Bias tool was employed to assess the potential risk of bias. The synthesis of evidence was performed Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

The extensive search procedure produced 5674 records, including data from 37 studies of 38 comparisons (2965 participants). Moderate evidence was obtained demonstrating that the application of acupuncture for a duration of 6-8 weeks was significantly superior to sham acupuncture in terms of intermediate-term (6 months) alleviation of back pain (2 trials, n=128; MD, -1.08; 95% CI, -1.81~-0.34) and improvement in lumbar function (2 trials, n=128; MD, -1.40; 95% CI, -2.93~-0.13). The available low evidence suggested that, as compared to sham acupuncture, acupuncture was effective in reducing short-term (3 months) back pain and enhancing lumbar function but had no impact on leg pain. A trial with low risk of bias found that acupuncture was more effective than sham acupuncture in enhancing disability and walking capabilities. The other studies presented inconsistent evidence with regards to the efficacy of the various interventions employed.

CONCLUSIONS

Evidence of low-to-moderate quality suggests that for DLSS patients, the implementation of acupuncture in comparison to sham acupuncture presents favorable outcomes in terms of short- and intermediate-term alleviation of back pain, improvement in lumbar function, enhancement of disability and walking capacity. The conclusion regarding the efficacy of other NPCM therapies was not obtained due to the insufficient quality of the available evidence.

REGISTRATION

PROSPERO CRD42022307631.

Fascinating strategies of marine benthic organisms to cope with emerging pollutant: Titanium dioxide nanoparticles

Titanium dioxide nanoparticles (NPs) have numerous applications, and their demands have increased as an alternative for banned sunscreen filters. However, the underlying mechanisms of their toxicity, remain largely unknown. Here, we investigate the mechanism of TiO₂ NP cytotoxicity and detoxification through time-course experiments (1, 6, and 24 h) based on cellular observations and single-cell transcriptome analyses in a marine benthic foraminifer strain, derived from a common unicellular eukaryotic organism worldwide. After exposure for 1 h, cells enhanced the production of reactive oxygen species (ROS) in acidic endosomes containing TiO₂ NPs as well as in mitochondria. In acidic endosomes, ROS were produced through the Fenton reaction on the surface of charged TiO₂ NPs. In mitochondria, ROS were associated with porphyrin synthesis that chelated metal ions. Glutathione peroxide and neutral lipids acted as a sink for free radicals, whereas lipid peroxides were excreted to prevent further radical chain reactions. By 24 h, aggregated TiO₂ NPs were encapsulated in organic compounds, possibly ceramide, and excreted as mucus, thereby preventing their further uptake. Thus, we reveal that foraminifers can tolerate the toxicity of TiO₂ NPs and even prevent their further phagocytosis and uptake by trapping TiO₂ NPs inside mucus. This previously unknown strategy could be applied in bioremediation to sequester NPs from the marine environment and can guide management of TiO₂ pollution.

Does type 2 diabetes affect the efficacy of therapeutic exercises for degenerative lumbar spinal stenosis?

DESIGN

Propensity-matched retrospective study.

OBJECTIVES

To determine whether type 2 diabetes mellitus (T2D) would affect prognosis in patients with degenerative lumbar spinal stenosis (DLSS) who underwent therapeutic exercises.

METHODS

This study included consecutive patients with or without T2D who underwent therapeutic exercises for symptomatic DLSS from December 2018 to January 2020. Baseline demographics and clinical and radiological data were collected. The 2 groups of patients were further matched in a 1:1 fashion based on the propensity score, balancing the groups on pre-treatment factors including age, sex, leg and back pain, and low back disability. The primary outcomes included self-reported leg pain intensity (Numerical Rating Scale, NRS) and low back disability (Oswestry Disability Index, ODI) and the secondary outcomes included low back pain intensity and walking capacity (self-paced walking test, SPWT) were compared at baseline, 6 weeks, and 12 weeks.

RESULTS

Forty-one pairs of patients were selected by propensity matching. After 6-week therapeutic exercises, patients with T2D achieved a lower improvement in leg pain at 6 weeks (NRS leg change, 1.21 ± 0.40 vs. 1.78 ± 0.52, P = 0.021) and 12 weeks (NRS leg change, 1.52 ± 0.92 vs. 2.18 ± 0.96, P = 0.007) above minimal clinically important difference (MCID), with a significant Group × Time interactions (F_1,80 = 16.32, p < 0.001, ηp2 = 0.053). However, the two groups showed no difference in the improvement of ODI, although the sample had significant improvements at 6 weeks (ODI change 3.02 [95% CI, 2.08 to 2.77], P < 0.001) and 12 weeks ([ODI change 3.82 [95% CI, 4.03 to 4.90], P < 0.001), 46% of the patients achieved an MCID.

CONCLUSION

Six-week therapeutic exercises have an inferior effect on DLSS patients with T2D. Findings from this study will provide an increased understanding of exercise treatment in patients with DLSS.

Presentation, Diagnosis, and Management of Lower Back Pain Associated with Spinal Stenosis: A Narrative Review

Lower back pain (LBP) is an extremely common symptom experienced by people of all ages and is also one of the most frequent causes of disability worldwide. This article aims to review the presentation, diagnosis, and management of lower back pain associated with spinal stenosis. The paper we prepared was classified as a "literature narrative review." Nonetheless, when searching for manuscripts included in our work and reviewing them critically, we concentrated on the keywords: "lower back pain", "lumbar spine stenosis", "diagnostic", "rehabilitation", "neurosurgery", "spine", and "elderly". The incidence of chronic lower back pain (CLBP) increases linearly starting with the third decade of life until 60 years old, and it more often affects women. The course of non-specific LBP above all depends on factors not connected with the spine, which include psychological, behavioral, and social factors, determined by the way the condition is perceived by the patient the environment. Lumbar spine stenosis (LSS) is an age-related process of degeneration of the intervertebral discs, ligamentum flavum, and facet joints, which results in narrowing of the space around the neurovascular structures of the spine. Diagnosis of spinal pain syndromes includes radiography (RTG), computed tomography (CT), and magnetic resonance imaging (MRI). Based on the results of imaging studies, neurological examination, and the severity of the disease, treatment can consist of analgesics and rehabilitation, or, when conservative methods are insufficient, surgical treatment is indicated.

A Protocol for a Single-Centered, Pragmatic, Randomized, Controlled, Parallel Trial Comparing Comprehensive Nonsurgical Therapy Options for Individuals with Lumbar Spinal Stenosis

Aim

Lumbar spinal stenosis (LSS) is a long-term degenerative disease. Considering the risks and advantages of the patient's age range and the characteristics of the condition, non-surgical treatment is recommended. To determine the best first-line non-surgical therapy for LSS, few studies have examined different non-surgical therapies. Therefore, the main objective of this study is to determine whether the selection of comprehensive Chinese medicine (CM) treatment for LSS is more successful than non-surgical conservative treatment.

Patients and Methods

In this two-armed, parallel, single-centered, pragmatic randomized controlled study, 94 LSS participants will be randomized to receive 24 sessions of comprehensive CM therapy or conservative treatment for 3 months, with follow-up assessments at 6, 9, 12, and 15 months. The primary outcome will be based on the success rate of the Zurich Claudication Questionnaire (ZCQ) for the most clinical important difference (MCID) at 3 and 15 months. Secondary outcomes include Numerical Rating Scale (NRS) scores for back and leg pain, ZCQ scores, Oswestry Disability Index scores for lumbar dysfunction, and Short-Form 12 scores for health-related quality of life at 3, 6, 9, 12, and 15 months. Adverse events and incidences of surgery will be reported anytime during the trial and follow-up.

Conclusion

This protocol examines the comparative efficacy of comprehensive CM therapy compared with conventional care through a pragmatic randomized controlled trial to present data to facilitate clinical or policy decision-making. The outcomes will make it easier to decide which patient-centered treatments to prioritize for LSS.

Effectiveness of a 6-week specific rehabilitation program combining education and exercises on walking capacity in patients with lumbar spinal stenosis with neurogenic claudication: a randomized controlled clinical trial protocol

BACKGROUND

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is a leading cause of disability which is intimately related to a decrease in walking capacity. Walking limitation has negative physical and mental impacts on patients. Recent guidelines recommend the use of conservative treatment options such as exercises before considering surgery. Unfortunately, dedicated healthcare resources for the conservative management of patients with LSS causing NC are uncommon. Thus, it is important to develop accessible and specific rehabilitation programs aimed at improving patients' self-management, especially with regard to walking capacity. The aim of this study is to evaluate the effectiveness of a 6-week specific rehabilitation program combining education and exercises on walking capacity in patients with LSS causing NC.

METHODS/DESIGN

This is a prospective randomized controlled parallel-group clinical trial. Sixty-six patients with LSS causing NC will be recruited from identified clinics and local advertisements. The intervention group will receive standardized education and specific exercises while the control group will only receive a standardized education. The program in both groups will last for 6 weeks with 5 evaluation time points (baseline, week 2, week 4, week 6, and week 12). The primary outcome will be walking capacity measured with the Self-Paced Walking Test, and the secondary outcomes will be back and leg pain intensity, LSS-related disability, self-efficacy, level of physical activity, anxiety, depression, gait pattern characteristics, balance, and global perceived change.

DISCUSSION

This study will assess the effectiveness of a 6-week specific rehabilitation program combining education and exercises on walking capacity in patients with LSS causing NC. By measuring objective gait pattern characteristics, the study will also provide new information about the impact of NC on gait pattern that could eventually improve the evaluation and the management of LSS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05513326 . Registered on August 22, 2022.

Use of QR Codes for Promoting a Home-Based Therapeutic Exercise in Patients with Lumbar Disc Herniation and Lumbar Spinal Stenosis: A Prospective Randomized Study

Purpose

In the current study, we investigated the usefulness of the quick response (QR) code linked to the source of a video of home-based therapeutic exercise to promote home-based therapeutic exercise in patients with LDH and LSS.

Patients and Methods

Forty patients with LDH and LSS were included in this study. The patients were randomly assigned to one of two groups: QR codes or control groups (20 patients per group). The QR code group received QR code stickers linked with a video that includes a demonstration on how to exercise for the back muscles. We instructed the patients to perform home-based therapeutic exercises three or more days a week. Patients in the control group were asked to perform the therapeutic exercise without providing a QR code to them. The primary outcome was the number of exercises per week. The scores of the numeric rating scale (NRS) and Oswestry disability index (ODI) were investigated as secondary outcomes.

Results

The patients in the QR code group exercised for the lower back muscles on average about two times a week, and 40% of the patients in the QR code group performed the exercise three or more days a week. However, almost no patients in the control group performed therapeutic exercises. Patients in the QR code group showed significantly lower ODI scores at the 1-month and 2-month follow-ups compared with the control group. In addition, the patients who exercised ≥3 times per week showed more improvement in the disability than those who exercised <3 times per week. The NRS scores for lower back pain and radicular leg pain were not significantly different between the QR code and control groups.

Conclusion

We found that QR codes can be useful for encouraging patients with LDH or LSS to perform home-based therapeutic exercises.