Efficacy of vertebral axial decompression on chronic low back pain: study of dosage regimen

A Comprehensive Review of the Historical Description of Spine Surgery and Its Evolution

Major strides in the advancement of spine surgery came about in the 21st century. However, the extensive history of spine surgery can be traced back to long before this time. A clear description of the journey from a primitive yet accurate understanding of the human musculoskeletal system to today's modern aspects of spinal techniques is lacking. A narrative literature review was conducted to elucidate where spine surgery began and the techniques used that evolved over time. This review was conducted using PubMed and Google Scholar. Search terms used included "history of spine surgery," "evolution of spine surgery," "origins of spine surgery," "history of laminectomy," "history of spinal fusion," "history of lumbar interbody fusion," "minimally invasive spine surgery," and "navigation in spine surgery." We highlight the evolution of the basic understanding of anatomy and non-surgical and surgical techniques, including bracing, laminectomy, discectomy, and spinal fusion. The current evolution and integration of minimally invasive techniques, lumbar interbody fusion techniques, robotics, navigation, and motion preservation are discussed, as these are the major areas of focus for technological advancement. This review presents an overarching synopsis of the events that chronicle the progress made in spine surgery since its conception. The review uniquely contributes to the growing body of literature on the expansion of spine surgery and highlights major events in its history.

The association between pain intensity and disability in patients with failed back surgery syndrome, treated with spinal cord stimulation

OBJECTIVE

Pain researchers demonstrated that pain intensity is not the most reliable measure of the success of chronic-pain treatment. Several research groups have proposed "core outcome domains", such as measurements of disability, to assess the effect of an intervention in pain patients. Up till now, studies investigating the relation between pain intensity and disability in patients treated with spinal cord stimulation (SCS) are lacking. Therefore, the current objective is to examine which pain-reporting strategy, routinely used in pain research, associates best with the degree of disability in these patients.

METHODS

Eighty-one failed back surgery syndrome patients (37 males and 44 females, mean age 54.6 years), treated with high-dose spinal cord stimulation (HD-SCS) are recruited. Pain intensity was scored on an 11-point numerical rating scale (NRS) for leg and back pain, while disability was assessed with the Oswestry disability index (ODI). The association between both variables was investigated with Spearman's correlation and Cramér's V.

RESULTS

Significant correlations (p < 0.001) are found between the absolute and relative differences of the ODI and NRS. Significant associations were found between reported cut-offs in literature (≤3, ≤5, and 50% pain relief) and the degree of disability. Finally, a significant association (p < 0.001) was found between the minimal clinical important difference.

CONCLUSIONS

In this study, we showed that the degree of disability was strongly associated with the pain intensity as measured using different methods. The standard method for reporting pain intensity reduction (50%) seems to associate the strongest with the degree of disability. However, a low degree of disability does not always reflect a low pain intensity.Implications for rehabilitationThe degree of disability reveals a good association with the reporting methods of pain intensity from the literature.The Oswestry disability index could serve as a valid tool to measure the effect of spinal cord stimulation on pain.Disability measures offer a better insight in the clinical profile of chronic pain patients than a pain intensity score.

A proposed definition of remission from chronic pain, based on retrospective evaluation of 24-month outcomes with spinal cord stimulation

Objective: In the treatment of chronic diseases, remission is commonly used as a meaningful treatment goal, synonymous with the absence of significant clinical signs and symptoms of a disease, but not representing a cure. The objective of this paper is to propose a definition for remission for use as an outcome to evaluate the long-term efficacy of therapies for chronic pain. Methods: Data from a randomized clinical trial (NCT01609972) testing the efficacy of spinal cord stimulation in low back and leg pain subjects was used to evaluate the association between pain and functional outcomes and identify the cut-off value to predict remission. Available data over 24-month assessment period included visual analog score (VAS), disability (Oswestry Disability Index [ODI]), patient and clinician global impression of change (PGIC and CGIC), and patient satisfaction. Cluster analysis, Pearson's correlation coefficients, sensitivity, and specificity analyses were used to evaluate its utility in predicting higher patient functionality and satisfaction. Results: Though the term remission has been used in the chronic pain field, a consistent definition has not been previously established. Based on the analysis of the clinical data, we propose that a sustained (≥6 months) pain score of ≤3.0 cm out of 10 cm on VAS be defined as remission. Applying this definition to the clinical trial data: subjects in remission at 24 months versus non-remitters were significantly more likely to be in the highest functional category of minimally disabled according to the ODI (31.5 vs. 8.2%, respectively, p = 0.001), and be 'very satisfied' (75.7 vs 22.6%, respectively, p < 0.001). Conclusions: The validity of the proposed definition of remission is supported by the persistence of remission in this study group, and its correspondence with patient satisfaction, and reduced disability. Further evaluation of the definition using clinical data from other long-term studies is needed.

Diagnostic criteria and treatment of discogenic pain: a systematic review of recent clinical literature

BACKGROUND CONTEXT

Pain innate to intervertebral disc, often referred to as discogenic pain, is suspected by some authors to be the major source of chronic low back and neck pain. Current management of suspected discogenic pain lacks standardized diagnosis, treatment, and terminology.

PURPOSE

In an attempt to determine whether patterns existed that may facilitate standardization of care, we sought to analyze the terminologies used and the various modes of diagnosis and treatment of suspected discogenic pain.

STUDY DESIGN

A systematic review of the recent literature.

METHODS

A Medline search was performed using the terms degenerative disc disease, discogenic pain, internal disc disruption while using the limits of human studies, English language, and clinical trials, for the last 10 years. The search led to a total of 149 distinct citations, of which 53 articles, where the intervertebral disc itself was considered the principal source of patient's pain and was the main target of the treatment, were retained for further analysis.

RESULTS

The results of this review confirm and help quantify the significant differences that existed in the terminology and all the areas of diagnosis and treatment of presumed discogenic pain.

CONCLUSIONS

Our findings show that suspected discogenic pain, despite its extensive affirmation in the literature and enormous resources regularly devoted to it, currently lacks clear diagnostic criteria and uniform treatment or terminology.

Radiographic disk height increase after a trial of multimodal spine rehabilitation and vibration traction: a retrospective case series

OBJECTIVE

Although spinal decompression therapy has been touted as an effective treatment of disk pathologies, there is little existing research that specifically uses disk parameters as an outcome measure after a course of spinal decompression therapy. Our study presents multidimensional outcomes after a structured protocol of multimodal chiropractic rehabilitation and uses a radiographic parameter of disk disease as an indication of the effects of a vibration traction decompression-type table.

CLINICAL FEATURES

Patients selected for this retrospective cohort reported a medical history of lumbar herniated or bulging disk verified by previous magnetic resonance imaging/computed tomography, history of paresthesia in one or both lower extremities, pain level reported as a minimum of 8/10, and/or history of sciatica or other radicular pain finding.

INTERVENTION AND OUTCOME

A total of 6 patients' outcomes are reported in this study. All patients received a multimodal spinal rehabilitation treatment with vibration traction therapy. Positive and statistically significant outcomes were obtained in radiographic disk height, functional rating index, numeric pain rating, spirometry, and patient height. All patients achieved improved outcomes after treatment.

CONCLUSION

The multidimensional outcomes reported here were achieved after a structured protocol of multimodal chiropractic rehabilitation. It is unknown which, if any, of these procedures were responsible for the observed improvements.

Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?

Background

Traction therapy has been utilized in the treatment of low back pain for decades. The most recent incarnation of traction therapy is non-surgical spinal decompression therapy which can cost over $100,000. This form of therapy has been heavily marketed to manual therapy professions and subsequently to the consumer. The purpose of this paper is to initiate a debate pertaining to the relationship between marketing claims and the scientific literature on non-surgical spinal decompression.

Discussion

Only one small randomized controlled trial and several lower level efficacy studies have been performed on spinal decompression therapy. In general the quality of these studies is questionable. Many of the studies were performed using the VAX-D^® unit which places the patient in a prone position. Often companies utilize this research for their marketing although their units place the patient in the supine position.

Summary

Only limited evidence is available to warrant the routine use of non-surgical spinal decompression, particularly when many other well investigated, less expensive alternatives are available.