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Rolfsen MP, Gammelsrud KW, Espeland A, Bråten LC, Mjønes SB, Austevoll I, Dolatowski FC, Årrestad MB, Toppe MK, Orlien IE, Holberg-Petersen M, Fagerland M, Zwart JA, Storheim K, Hellum C. Bacterial growth in patients with low back pain and Modic changes: protocol of a multicentre, case-control biopsy study. BMJ Open 2024; 14:e082244. [PMID: 38719329 DOI: 10.1136/bmjopen-2023-082244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Bacterial infection and Modic changes (MCs) as causes of low back pain (LBP) are debated. Results diverged between two randomised controlled trials examining the effect of amoxicillin with and without clavulanic acid versus placebo on patients with chronic LBP (cLBP) and MCs. Previous biopsy studies have been criticised with regard to methods, few patients and controls, and insufficient measures to minimise perioperative contamination. In this study, we minimise contamination risk, include a control group and optimise statistical power. The main aim is to compare bacterial growth between patients with and without MCs. METHODS AND ANALYSIS This multicentre, case-control study examines disc and vertebral body biopsies of patients with cLBP. Cases have MCs at the level of tissue sampling, controls do not. Previously operated patients are included as a subgroup. Tissue is sampled before antibiotic prophylaxis with separate instruments. We will apply microbiological methods and histology on biopsies, and predefine criteria for significant bacterial growth, possible contamination and no growth. Microbiologists, surgeons and pathologist are blinded to allocation of case or control. Primary analysis assesses significant growth in MC1 versus controls and MC2 versus controls separately. Bacterial disc growth in previously operated patients, patients with large MCs and growth from the vertebral body in the fusion group are all considered exploratory analyses. ETHICS AND DISSEMINATION The Regional Committees for Medical and Health Research Ethics in Norway (REC South East, reference number 2015/697) has approved the study. Study participation requires written informed consent. The study is registered at ClinicalTrials.gov (NCT03406624). Results will be disseminated in peer-reviewed journals, scientific conferences and patient fora. TRIAL REGISTRATION NUMBER NCT03406624.
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Affiliation(s)
- Mads Peder Rolfsen
- Division of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo Faculty of Medicine, Oslo, Norway
| | - Karianne Wiger Gammelsrud
- Department of Microbiology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
- University of Oslo Faculty of Medicine, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
| | | | | | - Ivar Austevoll
- Kysthospitalet in Hagavik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | | | | | | | - Ingvild Elise Orlien
- Department of Microbiology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Mona Holberg-Petersen
- Department of Microbiology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Morten Fagerland
- Biostatistics & Epidemiology, Oslo University Hospital, Oslo, Norway
| | - John-Anker Zwart
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Kjersti Storheim
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
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Hermansen E, Myklebust TÅ, Austevoll IM, Hellum C, Storheim K, Banitalebi H, Indrekvam K, Brisby H. Dural Sac Cross-sectional area change from preoperatively and up to 2 years after decompressive surgery for central lumbar spinal stenosis: investigation of operated levels, data from the NORDSTEN study. Eur Spine J 2024:10.1007/s00586-024-08251-4. [PMID: 38587545 DOI: 10.1007/s00586-024-08251-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/18/2024] [Accepted: 03/31/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE The aim of the present study was to investigate how canal area size changed from before surgery and up to 2 years after decompressive lumbar surgery lumbar spinal stenosis. Further, to investigate if an area change postoperatively (between 3 months to 2 years) was associated with any preoperative demographic, clinical or MRI variables or surgical method used. METHODS The present study is analysis of data from the NORDSTEN- SST trial where 437 patients were randomized to one of three mini-invasive surgical methods for lumbar spinal stenosis. The patients underwent MRI examination of the lumbar spine before surgery, and 3 and 24 months after surgery. For all operated segments the dural sac cross-sectional area (DSCA) was measured in mm2. Baseline factors collected included age, gender, BMI and smoking habits. Furthermore, surgical method, index level, number of levels operated, all levels operated on and baseline Schizas grade were also included in the analysis. RESULTS 437 patients were enrolled in the NORDSTEN-SST trial, whereof 310 (71%) had MRI at 3 months and 2 years. Mean DSCA at index level was 52.0 mm2 (SD 21.2) at baseline, at 3 months it increased to 117.2 mm2 (SD 43.0) and after 2 years the area was 127.7 mm2 (SD 52.5). Surgical method, level operated on or Schizas did not influence change in DSCA from 3 to 24 months follow-up. CONCLUSION The spinal canal area after lumbar decompressive surgery for lumbar spinal stenosis increased from baseline to 3 months after surgery and remained thereafter unchanged 2 years postoperatively.
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Affiliation(s)
- Erland Hermansen
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway.
- Institute of Health Sciences, Norwegian University of Technology and Science, Ålesund, Norway.
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Oslo, Oslo, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Nordbyhagen, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Banitalebi H, Hermansen E, Hellum C, Espeland A, Storheim K, Myklebust TÅ, Indrekvam K, Brisby H, Weber C, Anvar M, Aaen J, Negård A. Preoperative fatty infiltration of paraspinal muscles assessed by MRI is associated with less improvement of leg pain 2 years after surgery for lumbar spinal stenosis. Eur Spine J 2024:10.1007/s00586-024-08210-z. [PMID: 38528161 DOI: 10.1007/s00586-024-08210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/08/2024] [Accepted: 03/01/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE Fatty infiltration (FI) of the paraspinal muscles may associate with pain and surgical complications in patients with lumbar spinal stenosis (LSS). We evaluated the prognostic influence of MRI-assessed paraspinal muscles' FI on pain or disability 2 years after surgery for LSS. METHODS A muscle fat index (MFI) was calculated (by dividing signal intensity of psoas to multifidus and erector spinae) on preoperative axial T2-weighted MRI of patients with LSS. Pain and disability 2 years after surgery were assessed using the Oswestry disability index, the Zurich claudication questionnaire and numeric rating scales for leg and back pain. Multivariate linear and logistic regression analyses (adjusted for preoperative outcome scores, age, body mass index, sex, smoking status, grade of spinal stenosis, disc degeneration and facet joint osteoarthritis) were used to assess the associations between MFI and patient-reported clinical outcomes. In the logistic regression models, odds ratios (OR) and 95% confidence intervals (CI) were calculated for associations between the MFI and ≥ 30% improvement of the outcomes (dichotomised into yes/no). RESULTS A total of 243 patients were evaluated (mean age 66.6 ± 8.5 years), 49% females (119). Preoperative MFI and postoperative leg pain were significantly associated, both with leg pain as continuous (coefficient - 3.20, 95% CI - 5.61, - 0.80) and dichotomised (OR 1.51, 95% CI 1.17, 1.95) scores. Associations between the MFI and the other outcome measures were not statistically significant. CONCLUSION Preoperative FI of the paraspinal muscles on MRI showed statistically significant association with postoperative NRS leg pain but not with ODI or ZCQ.
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Affiliation(s)
- Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Erland Hermansen
- Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | | | - Jørn Aaen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Negård
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Wänman J, Åkerstedt J, Banitalebi H, Myklebust TÅ, Weber C, Storheim K, Austevoll IM, Hellum C, Indrekvam K, Brisby H, Hermansen E. The association between lumbar lordosis preoperatively and changes in PROMs for lumbar spinal stenosis patients 2 years after spinal surgery: radiological and clinical results from the NORDSTEN-spinal stenosis trial. Eur Spine J 2024:10.1007/s00586-024-08137-5. [PMID: 38386059 DOI: 10.1007/s00586-024-08137-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/21/2023] [Accepted: 01/09/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Patients with lumbar spinal stenosis (LSS) sometimes have lower lumbar lordosis (LL), and the incidence of LSS correlates closely with the loss of LL. The few studies that have evaluated the association between LL and clinical outcomes after non-instrumented surgery for LSS show conflicting results. This study investigates the association between preoperative LL and changes in PROMs 2 years after decompressive surgery. METHOD This prospective cohort study obtained preoperative and postoperative data for 401 patients from the multicenter randomized controlled spinal stenosis trial as part of the NORwegian degenerative spondylolisthesis and spinal STENosis (NORDSTEN) study. Before surgery, the radiological sagittal alignment parameter LL was measured using standing X-rays. The association between LL and 2-year postoperative changes was analyzed using the oswestry disability index (ODI), a numeric rating scale (NRS) for low back and leg pain, the Zurich claudication questionnaire (ZCQ), and the global perceived effect (GPE) score. The changes in PROMs 2 years after surgery for quintiles of lumbar lordosis were adjusted for the respective baseline PROMs: age, sex, smoking, and BMI. The Schizas index and the Pfirrmann index were used to analyze multiple regressions for changes in PROMs. RESULTS There were no associations in the adjusted and unadjusted analyses between preoperative LL and changes in ODI, ZCQ, GPE, and NRS for back and leg pain 2 years after surgery. CONCLUSION LL before surgery was not associated with changes in PROMs 2 years after surgery. Lumbar lordosis should not be a factor when considering decompressive surgery for LSS.
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Affiliation(s)
- Johan Wänman
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden.
| | - Josefin Åkerstedt
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Akershus, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
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Tronstad S, Haug KJ, Myklebust TÅ, Weber C, Brisby H, Austevoll IM, Hellum C, Storheim K, Aaen J, Banitalebi H, Brox JI, Grundnes O, Franssen E, Indrekvam K, Solberg T, Hermansen E. Do patients with lumbar spinal stenosis benefit from decompression of levels with adjacent moderate stenosis? A prospective cohort study from the NORDSTEN study. Spine J 2024:S1529-9430(24)00017-2. [PMID: 38266826 DOI: 10.1016/j.spinee.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/03/2023] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) is characterized by pain that radiates to the buttocks and/or legs, aggravated by walking and relieved by forward flexion. There is poor correlation between clinical symptoms and severity of stenosis on MRI, and multi-level stenosis has not been described to present worse symptoms or treatment outcomes, compared with patients with single-level stenosis. In patients with one level with severe stenosis combined with an adjacent level with moderate stenosis, the surgeon must decide whether to decompress only the narrowest level or both, to achieve the best possible outcome. The potential benefits of performing surgery on an adjacent moderate stenosis is debated, and the scientific evidence in scarce. PURPOSE The aim of the present study was to investigate whether patients with a level of adjacent moderate stenosis, along with an index stenosis, benefitted from a dual-level decompression (DLD) compared with a single-level decompression (SLD). Furthermore, to investigate whether DLD patients had longer duration of surgery and hospital stay, higher rates of complications and/or lower rate of reoperations compared with SLD patients. STUDY DESIGN Prospective cohort study. PATIENT SAMPLE We analyzed data from the Norwegian Degenerative Spondylisthesis and Spinal Stenosis study- Spinal Stenosis Trial (NORDSTEN-SST). In this randomized multicenter study, 437 patients were included, evaluating clinical outcomes of three different surgical treatment options for LSS. Patients with degenerative spondylolisthesis were excluded. METHOD Based on preoperative MRI, the present analysis included all patients who had a moderate stenosis (defined as Schizas B or C) in addition to a predefined index stenosis (the level with the smallest cross-sectional area). We compared patients who, based on the surgeons` choice, received a dual-level decompression, with those receiving a single-level decompression. OUTCOME MEASURES The primary outcome was mean change in the Oswestry Disability Index (ODI) score from baseline to 2-year follow up. Secondary outcomes were proportion of success (30% reduction in ODI score), the Numeric Rating Scales for back and leg pain (NRS), the EuroQol 5-dimensional questionnaire utility index (EQ-5D), the Zurich Claudication Questionnaire (ZCQ), the Global Perceived Effect (GPE)-scale, duration of surgery, duration of hospital stay, perioperative complications and reoperation rates. RESULTS Among the 222 patients, included in the analysis, 108 underwent DLD and 114 underwent SLD. There was no difference in change scores for any of the investigated patient-reported outcomes between the groups after 2 years. However, the DLD group had longer duration of surgery and longer length of hospital stay. There was no difference in reoperation rates or perioperative complications. CONCLUSION This study, alongside the NORDSTEN-LSS trial on patients with adjacent moderate stenosis as well as an index stenosis, showed no superior clinical effectiveness for dual-level surgery compared with single-level surgery.
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Affiliation(s)
- Sara Tronstad
- Department of Orthopedic Surgery, Skien Hospital, Skien, Norway.
| | | | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway; Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway; Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Orthopedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Oslo, Oslo, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre og Romsdal Hospital Trust, Ålesund, Norway; Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Nordbyhagen, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Norbyhagen, Norway
| | - Eric Franssen
- Department of Orthopedic Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Neurosurgical Department, University Hospital of North Norway, Trømsø, Norway
| | - Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre og Romsdal Hospital Trust, Ålesund, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Austevoll IM, Hellum C, Försth P. Letter to the Editor Regarding the Paper of Shukla and Colleagues on Laminectomy With Fusion is Associated With Greater Functional Improvement Compared With Laminectomy Alone for the Treatment of Degenerative Lumbar Spondylolisthesis. Spine (Phila Pa 1976) 2024; 49:E17. [PMID: 37589286 DOI: 10.1097/brs.0000000000004800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Ivar Magne Austevoll
- Orthopedic Department, Haukeland University Hospital, Kysthospitalet in Hagevik, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Peter Försth
- Department of Surgical Sciences, Uppsala University, Sweden
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Espeland A, Kristoffersen PM, Bråten LCH, Grøvle L, Grotle M, Haugen AJ, Rolfsen MP, Hellum C, Zwart JA, Storheim K, Assmus J, Vetti N. Longitudinal Relationship Between Reduced Modic Change Edema and Disability and Pain in Patients With Chronic Low Back Pain. Spine (Phila Pa 1976) 2023; 48:1699-1708. [PMID: 37759351 PMCID: PMC10662590 DOI: 10.1097/brs.0000000000004837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023]
Abstract
STUDY DESIGN Secondary analyses of a randomized trial [Antibiotics In Modic changes (MCs) study]. OBJECTIVE To assess whether or not reduced MC edema over time is related to reduced disability and pain in patients with chronic low back pain (LBP). SUMMARY OF BACKGROUND DATA It is not clear whether or not reduced MC edema implies improved clinical outcomes. PATIENTS AND METHODS Linear regression was conducted separately in 2 subgroups with MC edema at baseline on short tau inversion recovery (STIR) or T1/T2-weighted magnetic resonance imaging, respectively. Independent variable: reduced edema (yes/no) at 1 year on STIR or T1/T2-series, respectively. Dependent variable: 1-year score on the Roland-Morris Disability Questionnaire (RMDQ), Oswestry Disability Index (ODI), or 0 to 10 numeric rating scale for LBP intensity, adjusted for the baseline score, age, smoking, body mass index, physical workload, and baseline edema on STIR (STIR analysis only). Post hoc, we, in addition, adjusted all analyses for baseline edema on STIR, treatment group (amoxicillin/placebo), and prior disc surgery-or for disc degeneration. RESULTS Among patients with MC edema on STIR at baseline (n = 162), reduced edema on STIR was not significantly related to the RMDQ ( B : -1.0, 95% CI: -2.8, 0.8; P = 0.27), ODI ( B :-1.4, 95% CI: -5.4, 2.6; P = 0.50), or LBP intensity scores ( B : -0.05, 95% CI: -0.8, 0.7; P = 0.90) after 1 year. Among patients with MC edema on T1/T2-series at baseline (n = 116), reduced edema on T1/T2 ( i.e ., reduced volume of the type 1 part of MCs) was not significantly related to RMDQ ( B: -1.7, 95% CI: -3.8, 0.3; P = 0.10) or ODI score ( B : -2.3, 95% CI: -7.1, 2.5; P = 0.34) but was significantly related to LBP intensity at 1 year ( B : -0.9, 95% CI: -1.8, -0.04; P = 0.04; correlation coefficient: 0.24). The post hoc analyses supported these results. CONCLUSION Reduced MC edema over 1 year was not significantly associated with pain-related disability but was (on T1/T2-series) significantly but weakly related to reduced LBP intensity. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Per Martin Kristoffersen
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Christian Haugli Bråten
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Nydalen, Oslo, Norway
| | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, Grålum, Norway
| | - Margreth Grotle
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Nydalen, Oslo, Norway
- Department of Rehabilitation Science and Health Technology, Centre for Intelligent Musculoskeletal Health, Oslo Metropolitan University, Oslo, Norway
| | | | - Mads Peder Rolfsen
- Faculty of Medicine, University of Oslo, Blindern, Oslo, Norway
- Department of Orthopedic Surgery, Oslo University Hospital, Nydalen, Oslo, Norway
| | - Christian Hellum
- Department of Orthopedic Surgery, Oslo University Hospital, Nydalen, Oslo, Norway
| | - John-Anker Zwart
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Nydalen, Oslo, Norway
- Faculty of Medicine, University of Oslo, Blindern, Oslo, Norway
| | - Kjersti Storheim
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Nydalen, Oslo, Norway
- Department of Rehabilitation Science and Health Technology, Centre for Intelligent Musculoskeletal Health, Oslo Metropolitan University, Oslo, Norway
| | - Jörg Assmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Nils Vetti
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Indrekvam K, Bånerud IF, Hermansen E, Austevoll IM, Rekeland F, Guddal MH, Solberg TK, Brox JI, Hellum C, Storheim K. The Norwegian degenerative spondylolisthesis and spinal stenosis (NORDSTEN) study: study overview, organization structure and study population. Eur Spine J 2023; 32:4162-4173. [PMID: 37395780 DOI: 10.1007/s00586-023-07827-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/10/2023] [Accepted: 06/12/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE To provide an overview of the The Norwegian Degenerative spondylolisthesis and spinal stenosis (NORDSTEN)-study and the organizational structure, and to evaluate the study population. METHODS The NORDSTEN is a multicentre study with 10 year follow-up, conducted at 18 public hospitals. NORDSTEN includes three studies: (1) The randomized spinal stenosis trial comparing the impact of three different decompression techniques; (2) the randomized degenerative spondylolisthesis trial investigating whether decompression surgery alone is as good as decompression with instrumented fusion; (3) the observational cohort tracking the natural course of LSS in patients without planned surgical treatment. A range of clinical and radiological data are collected at defined time points. To administer, guide, monitor and assist the surgical units and the researchers involved, the NORDSTEN national project organization was established. Corresponding clinical data from the Norwegian Registry for Spine Surgery (NORspine) were used to assess if the randomized NORDSTEN-population at baseline was representative for LSS patients treated in routine surgical practice. RESULTS A total of 988 LSS patients with or without spondylolistheses were included from 2014 to 2018. The clinical trials did not find any difference in the efficacy of the surgical methods evaluated. The NORDSTEN patients were similar to those being consecutively operated at the same hospitals and reported to the NORspine during the same time period. CONCLUSION The NORDSTEN study provides opportunity to investigate clinical course of LSS with or without surgical interventions. The NORDSTEN-study population were similar to LSS patients treated in routine surgical practice, supporting the external validity of previously published results. TRIAL REGISTRATION ClinicalTrials.gov; NCT02007083 10/12/2013, NCT02051374 31/01/2014 and NCT03562936 20/06/2018.
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Affiliation(s)
- Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Ingrid Fjeldheim Bånerud
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Erland Hermansen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Maren Hjelle Guddal
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Tore K Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway (UiT), Tromsø, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
- Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
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9
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Mikkelsen E, Ingebrigtsen T, Thyrhaug AM, Olsen LR, Nygaard ØP, Austevoll I, Brox JI, Hellum C, Kolstad F, Lønne G, Solberg TK. The Norwegian registry for spine surgery (NORspine): cohort profile. Eur Spine J 2023; 32:3713-3730. [PMID: 37718341 DOI: 10.1007/s00586-023-07929-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE To review and describe the development, methods and cohort of the lumbosacral part of the Norwegian registry for spine surgery (NORspine). METHODS NORspine was established in 2007. It is government funded, covers all providers and captures consecutive cases undergoing operations for degenerative disorders. Patients' participation is voluntary and requires informed consent. A set of baseline-, process- and outcome-variables (3 and 12 months) recommended by the International Consortium for Health Outcome Measurement is reported by surgeons and patients. The main outcome is the Oswestry disability index (ODI) at 12 months. RESULTS We show satisfactory data quality assessed by completeness, timeliness, accuracy, relevance and comparability. The coverage rate has been 100% since 2016 and the capture rate has increased to 74% in 2021. The cohort consists of 60,647 (47.6% women) cases with mean age 55.7 years, registered during the years 2007 through 2021. The proportions > 70 years and with an American Society of Anaesthesiologists' Physical Classification System (ASA) score > II has increased gradually to 26.1% and 19.3%, respectively. Mean ODI at baseline was 43.0 (standard deviation 17.3). Most cases were operated with decompression for disc herniation (n = 26,557, 43.8%) or spinal stenosis (n = 26,545, 43.8%), and 7417 (12.2%) with additional or primary fusion. The response rate at 12 months follow-up was 71.6%. CONCLUSION NORspine is a well-designed population-based comprehensive national clinical quality registry. The register's methods ensure appropriate data for quality surveillance and improvement, and research.
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Affiliation(s)
- Eirik Mikkelsen
- Department of Neurosurgery, Ophthalmology and Otorhinolaryngology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Tor Ingebrigtsen
- Department of Neurosurgery, Ophthalmology and Otorhinolaryngology, University Hospital of North Norway, Tromsø, Norway.
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.
- The Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway.
| | - Anette M Thyrhaug
- The Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Lena Ringstad Olsen
- Centre for Clinical Documentation and Evaluation, Northern Norway Regional Health Authority, Tromsø, Norway
| | - Øystein P Nygaard
- The Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway
- Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway
| | - Ivar Austevoll
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Jens Ivar Brox
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christian Hellum
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Frode Kolstad
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Greger Lønne
- Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway
- Department of Orthopaedic Surgery, Innlandet Hospital Trust, Lillehammer, Norway
| | - Tore K Solberg
- Department of Neurosurgery, Ophthalmology and Otorhinolaryngology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- The Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway
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10
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Hellum C, Rekeland F, Småstuen MC, Solberg T, Hermansen E, Storheim K, Brox JI, Furunes H, Franssen E, Weber C, Brisby H, Grundnes O, Algaard KRH, Böker T, Banitalebi H, Indrekvam K, Austevoll IM. Surgery in degenerative spondylolisthesis: does fusion improve outcome in subgroups? A secondary analysis from a randomized trial (NORDSTEN trial). Spine J 2023; 23:1613-1622. [PMID: 37355044 DOI: 10.1016/j.spinee.2023.06.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/16/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND CONTEXT Patients with spinal stenosis and degenerative spondylolisthesis are treated surgically with decompression alone or decompression with fusion. However, there is debate regarding which subgroups of patients may benefit from additional fusion. PURPOSE To investigate possible treatment effect modifiers and prognostic variables among patients operated for spinal stenosis and degenerative spondylolisthesis. DESIGN A secondary exploratory study using data from the Norwegian Degenerative Spondylolisthesis and Spinal Stenosis (NORDSTEN-DS) trial. Patients were randomized to decompression alone or decompression with instrumented fusion. PATIENT SAMPLE The sample in this study consists of 267 patients from a randomized multicenter trial involving 16 hospitals in Norway. Patients were enrolled from February 12, 2014, to December 18, 2017. The study did not include patients with degenerative scoliosis, severe foraminal stenosis, multilevel spondylolisthesis, or previous surgery. OUTCOME MEASURES The primary outcome was an improvement of ≥ 30% on the Oswestry Disability Index score (ODI) from baseline to 2-year follow-up. METHODS When investigating possible variables that could modify the treatment effect, we analyzed the treatment arms separately. When testing for prognostic factors we analyzed the whole cohort (both treatment groups). We used univariate and multiple regression analyses. The selection of variables was done a priori, according to the published trial protocol. RESULTS Of the 267 patients included in the trial (183 female [67%]; mean [SD] age, 66 [7.6] years), complete baseline data for the variables required for the present analysis were available for 205 of the 267 individuals. We did not find any clinical or radiological variables at baseline that modified the treatment effect. Thus, none of the commonly used criteria for selecting patients for fusion surgery influenced the chosen primary outcome in the two treatment arms. For the whole cohort, less comorbidity (American Society of Anesthesiologists Classification [ASA], OR = 4.35; 95% confidence interval (CI [1.16-16.67]) and more preoperative leg pain (OR = 1.23; CI [1.02-1.50]) were significantly associated with an improved primary outcome. CONCLUSIONS In this study on patients with degenerative spondylolisthesis, neither previously defined instability criteria nor other pre-specified baseline variables were associated with better clinical outcome if fusion surgery was performed. None of the analyzed variables can be applied to guide the decision for fusion surgery in patients with degenerative spondylolisthesis. For both treatment groups, less comorbidity and more leg pain were associated with improved outcome 2 years after surgery. TRIAL REGISTRATION NORDSTEN-DS ClinicalTrials.gov, NCT02051374.
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Affiliation(s)
- Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Fallanveien 6c, Oslo, Norway.
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Milada Cvancarova Småstuen
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Tore Solberg
- Institute of Clinical Medicine, The Arctic University of Norway (UiT), Tromsø, Norway; The Norwegian Registry for Spine Surgery (NORspine), University Hospital of North Norway, Tromsø, Norway
| | - Erland Hermansen
- Orthopedic Department, Møre and Romsdal Hospital Trust, Ålesund Hospital, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway; Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; Medical Faculty, University of Oslo, Oslo, Norway
| | - Håvard Furunes
- Gjøvik Hospital, Innlandet Hospital Trust, Brumunddal, Norway; Institute of Health and Society Studies, University of Oslo, Oslo, Norway
| | - Eric Franssen
- Department of Orthopedic, Stavanger University Hospital, Stavanger, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway; Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Helena Brisby
- Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Oliver Grundnes
- Department of Orthopedic, Akershus University Hospital, Oslo, Norway
| | | | - Tordis Böker
- Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Radiology and Nuclear Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital, Bergen, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital, Bergen, Norway
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Aaen J, Banitalebi H, Austevoll IM, Hellum C, Storheim K, Myklebust TÅ, Anvar M, Weber C, Solberg T, Grundnes O, Brisby H, Indrekvam K, Hermansen E. Is the presence of foraminal stenosis associated with outcome in lumbar spinal stenosis patients treated with posterior microsurgical decompression. Acta Neurochir (Wien) 2023; 165:2121-2129. [PMID: 37407851 PMCID: PMC10409656 DOI: 10.1007/s00701-023-05693-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/16/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND We aim to investigate associations between preoperative radiological findings of lumbar foraminal stenosis with clinical outcomes after posterior microsurgical decompression in patients with predominantly central lumbar spinal stenosis (LSS). METHODS The study was an additional analysis in the NORDSTEN Spinal Stenosis Trial. In total, 230 men and 207 women (mean age 66.8 (SD 8.3)) were included. All patients underwent an MRI including T1- and T2-weighted sequences. Grade of foraminal stenosis was dichotomized into none to moderate (0-1) and severe (2-3) category using Lee's classification system. The Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and numeric rating scale (NRS) for back and leg pain were collected at baseline and at 2-year follow-up. Primary outcome was a reduction of 30% or more on the ODI score. Secondary outcomes included the mean improvement on the ODI, ZCQ, and NRS scores. We performed multivariable regression analyses with the radiological variates foraminal stenosis, Pfirrmann grade, Schizas score, dural sac cross-sectional area, and the possible plausible confounders: patients' gender, age, smoking status, and BMI. RESULTS The cohort of 437 patients presented a high degree of degenerative changes at baseline. Of 414 patients with adequate imaging of potential foraminal stenosis, 402 were labeled in the none to moderate category and 12 in the severe category. Of the patients with none to moderate foraminal stenosis, 71% achieved at least 30% improvement in ODI. Among the patients with severe foraminal stenosis, 36% achieved at least 30% improvement in ODI. A significant association between severe foraminal stenosis and less chance of reaching the target of 30% improvement in the ODI score after surgery was detected: OR 0.22 (95% CI 0.06, 0.83), p=0.03. When investigating outcome as continuous variables, a similar association between severe foraminal stenosis and less improved ODI with a mean difference of 9.28 points (95%CI 0.47, 18.09; p=0.04) was found. Significant association between severe foraminal stenosis and less improved NRS pain in the lumbar region was also detected with a mean difference of 1.89 (95% CI 0.30, 3.49; p=0.02). No significant association was suggested between severe foraminal stenosis and ZCQ or NRS leg pain. CONCLUSION In patients operated with posterior microsurgical decompression for LSS, a preoperative severe lumbar foraminal stenosis was associated with higher proportion of patients with less than 30% improvement in ODI. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (22.11.2013) under the identifier NCT02007083.
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Affiliation(s)
- Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Nordbyhagen, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | | | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Dept. of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Tore Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Nordbyhagen, Norway
| | - Helena Brisby
- Dept of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Dept. of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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12
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Hermansen E, Myklebust TÅ, Weber C, Brisby H, Austevoll IM, Hellum C, Storheim K, Aaen J, Banitalebi H, Brox JI, Grundnes O, Rekeland F, Solberg T, Franssen E, Indrekvam K. Postoperative Dural Sac Cross-Sectional Area as an Association for Outcome After Surgery for Lumbar Spinal Stenosis: Clinical and Radiological Results From the NORDSTEN-Spinal Stenosis Trial. Spine (Phila Pa 1976) 2023; 48:688-694. [PMID: 36809364 PMCID: PMC10118242 DOI: 10.1097/brs.0000000000004565] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 02/23/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE The aim was to investigate the association between postoperative dural sac cross-sectional area (DSCA) after decompressive surgery for lumbar spinal stenosis and clinical outcome. Furthermore, to investigate if there is a minimum threshold for how extensive a posterior decompression needs to be to achieve a satisfactory clinical result. SUMMARY OF BACKGROUND DATA There is limited scientific evidence for how extensive lumbar decompression needs to be to obtain a good clinical outcome in patients with symptomatic lumbar spinal stenosis. MATERIALS AND METHODS All patients were included in the Spinal Stenosis Trial of the NORwegian Degenerative spondylolisthesis and spinal STENosis (NORDSTEN)-study. The patients underwent decompression according to three different methods. DSCA measured on lumbar magnetic resonance imaging at baseline and at three months follow-up, and patient-reported outcome at baseline and at two-year follow-up were registered in a total of 393 patients. Mean age was 68 (SD: 8.3), proportion of males were 204/393 (52%), proportion of smokers were 80/393 (20%), and mean body mass index was 27.8 (SD: 4.2).The cohort was divided into quintiles based on the achieved DSCA postoperatively, the numeric, and relative increase of DSCA, and the association between the increase in DSCA and clinical outcome were evaluated. RESULTS At baseline, the mean DSCA in the whole cohort was 51.1 mm 2 (SD: 21.1). Postoperatively the area increased to a mean area of 120.6 mm 2 (SD: 46.9). The change in Oswestry disability index in the quintile with the largest DSCA was -22.0 (95% CI: -25.6 to -18), and in the quintile with the lowest DSCA the Oswestry disability index change was -18.9 (95% CI: -22.4 to -15.3). There were only minor differences in clinical improvement for patients in the different DSCA quintiles. CONCLUSION Less aggressive decompression performed similarly to wider decompression across multiple different patient-reported outcome measures at two years following surgery.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tor Å. Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ivar M. Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital Oslo, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Nordbyhagen, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jens I. Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Oslo, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Eric Franssen
- Department of Orthopedic surgery, Stavanger University Hospital, Stavanger, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Riksaasen AS, Kaur S, Solberg TK, Austevoll I, Brox JI, Dolatowski FC, Hellum C, Kolstad F, Lonne G, Nygaard ØP, Ingebrigtsen T. Impact of the number of previous lumbar operations on patient-reported outcomes after surgery for lumbar spinal stenosis or lumbar disc herniation. Bone Joint J 2023; 105-B:422-430. [PMID: 36924173 DOI: 10.1302/0301-620x.105b4.bjj-2022-0704.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort. This is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS. The proportion reaching a PASS decreased from 66.0% (95% confidence interval (CI) 65.4 to 66.7) in cases with no previous operation to 22.0% (95% CI 15.2 to 30.3) in cases with four or more previous operations (p < 0.001). The odds of not reaching a PASS were 2.1 (95% CI 1.9 to 2.2) in cases with one previous operation, 2.6 (95% CI 2.3 to 3.0) in cases with two, 4.4 (95% CI 3.4 to 5.5) in cases with three, and 6.9 (95% CI 4.5 to 10.5) in cases with four or more previous operations. The ODI raw and change scores and the secondary outcomes showed similar trends. We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. This information should be considered in the shared decision-making process prior to elective spine surgery.
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Affiliation(s)
- Anniken S Riksaasen
- Faculty of Health Sciences, Department of Clinical Medicine, University of Tromsø - the Arctic University of Norway, Tromsø, Norway
| | | | - Tore K Solberg
- Faculty of Health Sciences, Department of Clinical Medicine, University of Tromsø - the Arctic University of Norway, Tromsø, Norway.,Department of Neurosurgery and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Ivar Austevoll
- Orthopedic Department, Kysthospitalet in Hagevik, Haukeland University Hospital, Bergen, Norway
| | - Jens-Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | | | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Frode Kolstad
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Greger Lonne
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Innlandet Hospital Trust, Brumunddal, Norway.,Department of Neurosurgery, St. Olavs Hospital and the National Advisory Unit on Spinal Surgery, Trondheim, Norway
| | - Øystein P Nygaard
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital and the National Advisory Unit on Spinal Surgery, Trondheim, Norway
| | - Tor Ingebrigtsen
- Faculty of Health Sciences, Department of Clinical Medicine, University of Tromsø - the Arctic University of Norway, Tromsø, Norway.,Department of Neurosurgery and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway.,Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Aaen J, Banitalebi H, Austevoll IM, Hellum C, Storheim K, Myklebust TÅ, Anvar M, Weber C, Solberg T, Grundnes O, Brisby H, Indrekvam K, Hermansen E. The association between preoperative MRI findings and clinical improvement in patients included in the NORDSTEN spinal stenosis trial. Eur Spine J 2022; 31:2777-2785. [PMID: 35930062 DOI: 10.1007/s00586-022-07317-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/24/2022] [Accepted: 07/04/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To investigate potential associations between preoperative MRI findings and patient reported outcome measures (PROMs) after surgery for lumbar spinal stenosis (LSS). METHODS The NORDSTEN trial included 437 patients. We investigated the association between preoperative MRI findings such as morphological grade of stenosis (Schizas grade), quantitative grade of stenosis (dural sac cross-sectional area), disc degeneration (Pfirrmann score), facet joint tropism and fatty infiltration of the multifidus muscle, and improvement in patient reported outcome measures (PROMs) 2 years after surgery. We dichotomized each radiological parameter into a moderate or severe category. PROMs i.e., Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ) and Numeric rating scale (NRS) for back and leg pain were collected before surgery and at 2 year follow-up. In the primary analysis, we investigated the association between MRI findings and ODI score (dichotomized to ≥ 30% improvement or not). In the secondary analysis, we investigated the association between MRI findings and the mean improvement on the ODI-, ZCQ- and NRS scores. We used multivariable regression models adjusted for patients' gender, age, smoking status and BMI. RESULTS The primary analysis showed that severe disc degeneration (Pfirrmann score 4-5) was significantly associated with less chance of achieving a 30% improvement on the ODI score (OR 0.54, 95% CI 0.34, 0.88). In the secondary analysis, we detected no clinical relevant associations. CONCLUSION Severe disc degeneration preoperatively suggest lesser chance of achieving 30% improvement in ODI score after surgery for LSS. Other preoperative MRI findings were not associated with patient reported outcome.
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Affiliation(s)
- Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | | | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Dept. of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Tore Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Lørenskog, Norway
| | - Helena Brisby
- Dept of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Dept. of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kari Indrekvam
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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15
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Banitalebi H, Aaen J, Storheim K, Negård A, Myklebust TÅ, Grotle M, Hellum C, Espeland A, Anvar M, Indrekvam K, Weber C, Brox JI, Brisby H, Hermansen E. A novel MRI index for paraspinal muscle fatty infiltration: reliability and relation to pain and disability in lumbar spinal stenosis: results from a multicentre study. Eur Radiol Exp 2022; 6:38. [PMID: 35854201 PMCID: PMC9296716 DOI: 10.1186/s41747-022-00284-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fatty infiltration of the paraspinal muscles may play a role in pain and disability in lumbar spinal stenosis. We assessed the reliability and association with clinical symptoms of a method for assessing fatty infiltration, a simplified muscle fat index (MFI). METHODS Preoperative axial T2-weighted magnetic resonance imaging (MRI) scans of 243 patients aged 66.6 ± 8.5 years (mean ± standard deviation), 119 females (49%), with symptomatic lumbar spinal stenosis were assessed. Fatty infiltration was assessed using both the MFI and the Goutallier classification system (GCS). The MFI was calculated as the signal intensity of the psoas muscle divided by that of the multifidus and erector spinae. Observer reliability was assessed in 102 consecutive patients for three independent investigators by intraclass correlation coefficient (ICC) and 95% limits of agreement (LoA) for continuous variables and Gwet's agreement coefficient (AC1) for categorical variables. Associations with patient-reported pain and disability were assessed using univariate and multivariate regression analyses. RESULTS Interobserver reliability was good for the MFI (ICC 0.79) and fair for the GCS (AC1 0.33). Intraobserver reliability was good or excellent for the MFI (ICC range 0.86-0.91) and moderate to almost perfect for the GCS (AC1 range 0.55-0.92). Mean interobserver differences of MFI measurements ranged from -0.09 to -0.04 (LoA -0.32 to 0.18). Adjusted for potential confounders, none of the disability or pain parameters was significantly associated with MFI or GCS. CONCLUSION The proposed MFI demonstrated high observer reliability but was not associated with preoperative pain or disability.
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Affiliation(s)
- Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Jørn Aaen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Anne Negård
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Margreth Grotle
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.,Department of Physiotherapy, Faculty of Health Science, Oslo Metropolitan University, P.O. box 4, St. Olafs plass, Oslo, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway.,Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Orthopaedics, Institute for clinical sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erland Hermansen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Hofseth BioCare, Ålesund, Norway
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16
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Hermansen E, Austevoll IM, Hellum C, Storheim K, Myklebust TÅ, Aaen J, Banitalebi H, Anvar M, Rekeland F, Brox JI, Franssen E, Weber C, Solberg TK, Furunes H, Grundnes O, Brisby H, Indrekvam K. Comparison of 3 Different Minimally Invasive Surgical Techniques for Lumbar Spinal Stenosis: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e224291. [PMID: 35344046 PMCID: PMC8961320 DOI: 10.1001/jamanetworkopen.2022.4291] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
IMPORTANCE Operations for lumbar spinal stenosis is the most often performed surgical procedure in the adult lumbar spine. This study reports the clinical outcome of the 3 most commonly used minimally invasive posterior decompression techniques. OBJECTIVE To compare the effectiveness of 3 minimally invasive posterior decompression techniques for lumbar spinal stenosis. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial used a parallel group design and included patients with symptomatic and radiologically verified lumbar spinal stenosis without degenerative spondylolisthesis. Patients were enrolled between February 2014 and October 2018 at the orthopedic and neurosurgical departments of 16 Norwegian public hospitals. Statistical analysis was performed in the period from May to June 2021. INTERVENTIONS Patients were randomized to undergo 1 of the 3 minimally invasive posterior decompression techniques: unilateral laminotomy with crossover, bilateral laminotomy, and spinous process osteotomy. MAIN OUTCOMES AND MEASURES Primary outcome was change in disability measured with Oswestry Disability Index (ODI; range 0-100), presented as mean change from baseline to 2-year follow-up and proportions of patients classified as success (>30% reduction in ODI). Secondary outcomes were mean change in quality of life, disease-specific symptom severity measured with Zurich Claudication Questionnaire (ZCQ), back pain and leg pain on a 10-point numeric rating score (NRS), patient perceived benefit of the surgical procedure, duration of the surgical procedure, blood loss, perioperative complications, number of reoperations, and length of hospital stay. RESULTS In total, 437 patients were included with a median (IQR) age of 68 (62-73) years and 230 men (53%). Of the included patients, 146 were randomized to unilateral laminotomy with crossover, 142 to bilateral laminotomy, and 149 to spinous process osteotomy. The unilateral laminotomy with crossover group had a mean change of -17.9 ODI points (95% CI, -20.8 to -14.9), the bilateral laminotomy group had a mean change of -19.7 ODI points (95% CI, -22.7 to -16.8), and the spinous process osteotomy group had a mean change of -19.9 ODI points (95% CI, -22.8 to -17.0). There were no significant differences in primary or secondary outcomes among the 3 surgical procedures, except a longer duration of the surgical procedure in the bilateral laminotomy group. CONCLUSIONS AND RELEVANCE No differences in clinical outcomes or complication rates were found among the 3 minimally invasive posterior decompression techniques used to treat patients with lumbar spinal stenosis. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02007083.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Hofseth BioCare, Ålesund, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Registration, Cancer Registry Norway, Oslo, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Eric Franssen
- Department of Orthopedics, Stavanger University Hospital, Stavanger, Norway
| | - Clemens Weber
- Department of Orthopedics, Stavanger University Hospital, Stavanger, Norway
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Tore K. Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Håvard Furunes
- Department of Surgery, Gjøvik Hospital, Innlandet Hospital Trust, Brumunddal, Norway
- Institute of Health and Society Studies, University of Oslo, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Oslo, Norway
| | - Helena Brisby
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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17
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Banitalebi H, Espeland A, Anvar M, Hermansen E, Hellum C, Brox JI, Myklebust TÅ, Indrekvam K, Brisby H, Weber C, Aaen J, Austevoll IM, Grundnes O, Negård A. Reliability of preoperative MRI findings in patients with lumbar spinal stenosis. BMC Musculoskelet Disord 2022; 23:51. [PMID: 35033042 PMCID: PMC8760672 DOI: 10.1186/s12891-021-04949-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022] Open
Abstract
Background Magnetic Resonance Imaging (MRI) is an important tool in preoperative evaluation of patients with lumbar spinal stenosis (LSS). Reported reliability of various MRI findings in LSS varies from fair to excellent. There are inconsistencies in the evaluated parameters and the methodology of the studies. The purpose of this study was to evaluate the reliability of the preoperative MRI findings in patients with LSS between musculoskeletal radiologists and orthopaedic spine surgeons, using established evaluation methods and imaging data from a prospective trial. Methods Consecutive lumbar MRI examinations of candidates for surgical treatment of LSS from the Norwegian Spinal Stenosis and Degenerative Spondylolisthesis (NORDSTEN) study were independently evaluated by two musculoskeletal radiologists and two orthopaedic spine surgeons. The observers had a range of experience between six and 13 years and rated five categorical parameters (foraminal and central canal stenosis, facet joint osteoarthritis, redundant nerve roots and intraspinal synovial cysts) and one continuous parameter (dural sac cross-sectional area). All parameters were re-rated after 6 weeks by all the observers. Inter- and intraobserver agreement was assessed by Gwet’s agreement coefficient (AC1) for categorical parameters and Intraclass Correlation Coefficient (ICC) for the dural sac cross-sectional area. Results MRI examinations of 102 patients (mean age 66 ± 8 years, 53 men) were evaluated. The overall interobserver agreement was substantial or almost perfect for all categorical parameters (AC1 range 0.67 to 0.98), except for facet joint osteoarthritis, where the agreement was moderate (AC1 0.39). For the dural sac cross-sectional area, the overall interobserver agreement was good or excellent (ICC range 0.86 to 0.96). The intraobserver agreement was substantial or almost perfect/ excellent for all parameters (AC1 range 0.63 to 1.0 and ICC range 0.93 to 1.0). Conclusions There is high inter- and intraobserver agreement between radiologists and spine surgeons for preoperative MRI findings of LSS. However, the interobserver agreement is not optimal for evaluation of facet joint osteoarthritis. Trial registration www.ClinicalTrials.gov identifier: NCT02007083, registered December 2013. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04949-4.
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Affiliation(s)
- Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Erland Hermansen
- Hofseth BioCare, Ålesund, Norway.,Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Registration, Cancer Registry of Norway, Oslo, Norway
| | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Orthopaedics, Institute for clinical sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway.,Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Jørn Aaen
- Department of Orthopaedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of medicine and health sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik. Orthopaedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Oliver Grundnes
- Department of Orthopaedics, Akershus University Hospital, Lørenskog, Norway
| | - Anne Negård
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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18
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Austevoll IM, Hermansen E, Fagerland MW, Storheim K, Brox JI, Solberg T, Rekeland F, Franssen E, Weber C, Brisby H, Grundnes O, Algaard KRH, Böker T, Banitalebi H, Indrekvam K, Hellum C. Decompression with or without Fusion in Degenerative Lumbar Spondylolisthesis. N Engl J Med 2021; 385:526-538. [PMID: 34347953 DOI: 10.1056/nejmoa2100990] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with lumbar spinal stenosis and degenerative spondylolisthesis, it is uncertain whether decompression surgery alone is noninferior to decompression with instrumented fusion. METHODS We conducted an open-label, multicenter, noninferiority trial involving patients with symptomatic lumbar stenosis that had not responded to conservative management and who had single-level spondylolisthesis of 3 mm or more. Patients were randomly assigned in a 1:1 ratio to undergo decompression surgery (decompression-alone group) or decompression surgery with instrumented fusion (fusion group). The primary outcome was a reduction of at least 30% in the score on the Oswestry Disability Index (ODI; range, 0 to 100, with higher scores indicating more impairment) during the 2 years after surgery, with a noninferiority margin of -15 percentage points. Secondary outcomes included the mean change in the ODI score as well as scores on the Zurich Claudication Questionnaire, leg and back pain, the duration of surgery and length of hospital stay, and reoperation within 2 years. RESULTS The mean age of patients was approximately 66 years. Approximately 75% of the patients had leg pain for more than a year, and more than 80% had back pain for more than a year. The mean change from baseline to 2 years in the ODI score was -20.6 in the decompression-alone group and -21.3 in the fusion group (mean difference, 0.7; 95% confidence interval [CI], -2.8 to 4.3). In the modified intention-to-treat analysis, 95 of 133 patients (71.4%) in the decompression-alone group and 94 of 129 patients (72.9%) in the fusion group had a reduction of at least 30% in the ODI score (difference, -1.4 percentage points; 95% CI, -12.2 to 9.4), showing the noninferiority of decompression alone. In the per-protocol analysis, 80 of 106 patients (75.5%) and 83 of 110 patients (75.5%), respectively, had a reduction of at least 30% in the ODI score (difference, 0.0 percentage points; 95% CI, -11.4 to 11.4), showing noninferiority. The results for the secondary outcomes were generally in the same direction as those for the primary outcome. Successful fusion was achieved with certainty in 86 of 100 patients (86.0%) who had imaging available at 2 years. Reoperation was performed in 15 of 120 patients (12.5%) in the decompression-alone group and in 11 of 121 patients (9.1%) in the fusion group. CONCLUSIONS In this trial involving patients who underwent surgery for degenerative lumbar spondylolisthesis, most of whom had symptoms for more than a year, decompression alone was noninferior to decompression with instrumented fusion over a period of 2 years. Reoperation occurred somewhat more often in the decompression-alone group than in the fusion group. (NORDSTEN-DS ClinicalTrials.gov number, NCT02051374.).
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Affiliation(s)
- Ivar M Austevoll
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Erland Hermansen
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Morten W Fagerland
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Kjersti Storheim
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Jens I Brox
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Tore Solberg
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Frode Rekeland
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Eric Franssen
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Clemens Weber
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Helena Brisby
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Oliver Grundnes
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Knut R H Algaard
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Tordis Böker
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Hasan Banitalebi
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Kari Indrekvam
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
| | - Christian Hellum
- From Kysthospitalet in Hagevik, Orthopedic Department, Haukeland University Hospital (I.M.A., E.H., F.R., K.I.), and the Department of Clinical Medicine, University of Bergen (E.H., F.R., K.I.), Bergen, Møre and Romsdal Hospital Trust, Ålesund Hospital, Orthopedic Department, Ålesund (E.H.), the Oslo Center for Biostatistics and Epidemiology, Research Support Services (M.W.F.), the Research and Communication Unit for Musculoskeletal Health, Division of Clinical Neuroscience (K.S.), and the Department of Physical Medicine and Rehabilitation (J.I.B.), Oslo University Hospital, the Department of Physiotherapy, Oslo Metropolitan University (K.S.), the Medical Faculty (J.I.B.), the Division of Radiology and Nuclear Medicine, Institute of Clinical Medicine, Faculty of Medicine (T.B.), and the Institute of Clinical Medicine (H. Banitalebi), University of Oslo, Akershus University Hospital, Orthopedic Department (O.G.), Radiology, Unilabs Radiology (K.R.H.A.), and the Department of Radiology and Nuclear Medicine (T.B.) and the Division of Orthopedic Surgery (C.H.), Oslo University Hospital Ullevål, Oslo, the Institute of Clinical Medicine, University of Tromsø-the Arctic University of Norway, and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø (T.S.), the Orthopedic Department (E.F.) and the Department of Neurosurgery (C.W.), Stavanger University Hospital, and the Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger (C.W.), Stavanger, and the Department of Diagnostic Imaging, Akershus University Hospital, Lorenskog (H. Banitalebi) - all in Norway; and the Spine Surgery Team, Department of Orthopedics, Sahlgrenska University Hospital, and the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (H. Brisby)
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Garratt AM, Furunes H, Hellum C, Solberg T, Brox JI, Storheim K, Johnsen LG. Evaluation of the EQ-5D-3L and 5L versions in low back pain patients. Health Qual Life Outcomes 2021; 19:155. [PMID: 34049574 PMCID: PMC8160396 DOI: 10.1186/s12955-021-01792-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/19/2021] [Indexed: 12/16/2022] Open
Abstract
Background The EuroQol EQ-5D is one of the most widely researched and applied patient-reported outcome measures worldwide. The original EQ-5D-3L and more recent EQ-5D-5L include three and five response categories respectively. Evidence from healthy and sick populations shows that the additional two response categories improve measurement properties but there has not been a concurrent comparison of the two versions in patients with low back pain (LBP). Methods LBP patients taking part in a multicenter randomized controlled trial of lumbar total disc replacement and conservative treatment completed the EQ-5D-3L and 5L in an eight-year follow-up questionnaire. The 3L and 5L were assessed for aspects of data quality including missing data, floor and ceiling effects, response consistency, and based on a priori hypotheses, associations with the Oswestry Disability Index (ODI), Pain-Visual Analogue Scales and Hopkins Symptom Checklist (HSCL-25). Results At the eight-year follow-up, 151 (87%) patients were available and 146 completed both the 3L and 5L. Levels of missing data were the same for the two versions. Compared to the EQ-5D-5L, the 3L had significantly higher floor (pain discomfort) and ceiling effects (mobility, self-care, pain/discomfort, anxiety/depression). For these patients the EQ-5D-5L described 73 health states compared to 28 for the 3L. Shannon’s indices showed the 5L outperformed the 3L in tests of classification efficiency. Correlations with the ODI, Pain-VAS and HSCL-25 were largely as hypothesized, the 5L having slightly higher correlations than the 3L. Conclusion The EQ-5D assesses important aspect of health in LBP patients and the 5L improves upon the 3L in this respect. The EQ-5D-5L is recommended in preference to the 3L version, however, further testing in other back pain populations together with additional measurement properties, including responsiveness to change, is recommended. Trial registration: retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT01704677.
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Affiliation(s)
- A M Garratt
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway.
| | - H Furunes
- Department of Surgery, Innlandet Hospital Gjøvik, Gjøvik, Norway.,University of Oslo, Oslo, Norway
| | - C Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - T Solberg
- Department of Neurosurgery and The Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway.,Institute for Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - J I Brox
- University of Oslo, Oslo, Norway.,Department for Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - K Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.,Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | - L G Johnsen
- Department of Neuromedicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim, Norway
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Kristoffersen PM, Bråten LCH, Vetti N, Grøvle L, Hellum C, Storheim K, Zwart JA, Assmus J, Espeland A. Oedema on STIR modified the effect of amoxicillin as treatment for chronic low back pain with Modic changes-subgroup analysis of a randomized trial. Eur Radiol 2020; 31:4285-4297. [PMID: 33247344 PMCID: PMC8128743 DOI: 10.1007/s00330-020-07542-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/23/2020] [Accepted: 11/18/2020] [Indexed: 12/19/2022]
Abstract
Objective To evaluate potential MRI-defined effect modifiers of amoxicillin treatment in patients with chronic low back pain and type 1 or 2 Modic changes (MCs) at the level of a previous lumbar disc herniation (index level). Methods In a prospective trial (AIM), 180 patients (25–64 years; mean age 45; 105 women) were randomised to receive amoxicillin or placebo for 3 months. Primary outcome was the Roland-Morris Disability Questionnaire (RMDQ) score (0–24 scale) at 1 year. Mean RMDQ score difference between the groups at 1 year defined the treatment effect; 4 RMDQ points defined the minimal clinically important effect. Predefined baseline MRI features of MCs at the index level(s) were investigated as potential effect modifiers. The predefined primary hypothesis was a better effect of amoxicillin when short tau inversion recovery (STIR) shows more MC-related high signal. To evaluate this hypothesis, we pre-constructed a composite variable with three categories (STIR1/2/3). STIR3 implied MC-related STIR signal increases with volume ≥ 25% and height > 50% of vertebral body and maximum intensity increase ≥ 25% and presence on both sides of the disc. As pre-planned, interaction with treatment was analysed using ANCOVA in the per protocol population (n = 155). Results The STIR3 composite group (n = 41) and STIR signal volume ≥ 25% alone (n = 45) modified the treatment effect of amoxicillin. As hypothesised, STIR3 patients reported the largest effect (− 5.1 RMDQ points; 95% CI − 8.2 to − 1.9; p for interaction = 0.008). Conclusions Predefined subgroups with abundant MC-related index-level oedema on STIR modified the effect of amoxicillin. This finding needs replication and further support. Key Points • In the primary analysis of the AIM trial, the effect of amoxicillin in patients with chronic low back pain and type 1 or 2 MCs did not reach the predefined cut-off for clinical importance. • In the present MRI subgroup analysis of AIM, predefined subgroups with abundant MC-related oedema on STIR reported an effect of amoxicillin. • This finding requires replication and further support. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-020-07542-w.
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Affiliation(s)
- Per Martin Kristoffersen
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway.
| | - Lars C H Bråten
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital HF, Ulleval, Bygg 37b, P.O. Box 4956, 0424, Oslo, Nydalen, Norway
| | - Nils Vetti
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
| | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, P.O. Box 300, 1714, Grålum, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital Ulleval, P.O. Box 4950, Nydalen, 0424, Oslo, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital HF, Ulleval, Bygg 37b, P.O. Box 4956, 0424, Oslo, Nydalen, Norway.,Faculty of Health Science, OsloMet - Oslo Metropolitan University, P.O. Box 4, St. Olavs plass, 0130, Oslo, Norway
| | - John-Anker Zwart
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital HF, Ulleval, Bygg 37b, P.O. Box 4956, 0424, Oslo, Nydalen, Norway.,Faculty of Medicine, University of Oslo, P.O. Box 1072, Blindern, 0316, Oslo, Norway
| | - Jörg Assmus
- Competence Centre for Clinical Research, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
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Austevoll IM, Gjestad R, Solberg T, Storheim K, Brox JI, Hermansen E, Rekeland F, Indrekvam K, Hellum C. Comparative Effectiveness of Microdecompression Alone vs Decompression Plus Instrumented Fusion in Lumbar Degenerative Spondylolisthesis. JAMA Netw Open 2020; 3:e2015015. [PMID: 32910195 PMCID: PMC7489859 DOI: 10.1001/jamanetworkopen.2020.15015] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Conflicting evidence and large practice variation are present in the surgical treatment of degenerative spondylolisthesis. More than 90% of surgical procedures in the United States include instrumented fusion compared with 50% or less in other countries. OBJECTIVE To evaluate whether the effectiveness of microdecompression alone is noninferior to decompression with instrumented fusion in a real-world setting. DESIGN, SETTING, AND PARTICIPANTS This multicenter comparative effectiveness study with a noninferiority design assessed prospective data from the Norwegian Registry for Spine Surgery. From September 19, 2007, to December 21, 2015, 1376 patients at 35 Norwegian orthopedic and neurosurgical departments underwent surgery for lumbar spinal stenosis with degenerative spondylolisthesis without scoliosis. After excluding patients undergoing laminectomy alone, fusion without instrumentation, or surgery in more than 2 levels and those with a former operation at the index level, 794 patients were included in the analyses, regardless of missing or incomplete follow-up data, before propensity score matching. Data were analyzed from March 20 to October 30, 2018. EXPOSURES Microdecompression alone or decompression with instrumented fusion. MAIN OUTCOMES AND MEASURES A reduction from baseline of 30% or greater in the Oswestry Disability Index at 12-month follow-up. RESULTS After propensity score matching, 570 patients (413 female [72%]; mean [SD] age, 64.7 [9.5] years) were included for comparison, with 285 undergoing microdecompression (mean [SD] age, 64.6 [9.8] years; 205 female [72%]) and 285 undergoing decompression with instrumented fusion (mean [SD] age, 64.8 [9.2] years; 208 female [73%]). The proportion of each type of procedure varied between departments. However, changes in outcome scores varied within patients but not between departments. The proportion of patients with improvement in the Oswestry Disability Index of at least 30% was 150 of 219 (68%) in the microdecompression group and 155 of 215 (72%) in the instrumentation group. The 95% CI (-12% to 5%) for the difference of -4% was above the predefined margin of noninferiority (-15%). Microdecompression alone was associated with shorter operation time (mean [SD], 89 [44] vs 180 [65] minutes; P < .001) and shorter hospital stay (mean [SD], 2.5 [2.4] vs 6.4 [3.0] days; P < .001). CONCLUSIONS AND RELEVANCE Among patients with degenerative spondylolisthesis, the clinical effectiveness of microdecompression alone was noninferior to that of decompression with instrumented fusion. Microdecompression alone was also associated with shorter durations of surgery and hospital stay, supporting the suggestion that the less invasive procedure should be considered for most patients.
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Affiliation(s)
- Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- The Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | - Rolf Gjestad
- Research Department, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Tore Solberg
- The Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health, Oslo University Hospital, Oslo, Norway
| | - Jens Ivar Brox
- The Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
- Department of Physical Medicine and Rehabilitation, Oslo, University Hospital, Oslo, Norway
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- The Norwegian Registry for Spine Surgery, University Hospital of Northern Norway, Tromsø, Norway
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
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22
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Hermansen E, Austevoll IM, Hellum C, Storheim K, Myklebust TÅ, Aaen J, Banitalebi H, Anvar M, Rekeland F, Brox JI, Franssen E, Weber C, Solberg T, Haug KJ, Grundnes O, Brisby H, Indrekvam K. Comparable increases in dural sac area after three different posterior decompression techniques for lumbar spinal stenosis: radiological results from a randomized controlled trial in the NORDSTEN study. Eur Spine J 2020; 29:2254-2261. [PMID: 32556585 DOI: 10.1007/s00586-020-06499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 05/27/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate changes in dural sac area after three different posterior decompression techniques in patients undergoing surgery for lumbar spinal stenosis. Decompression of the nerve roots is the main surgical treatment for lumbar spinal stenosis. The aim of this study was to radiologically investigate three commonly used posterior decompression techniques. METHODS The present study reports data from one of two multicenter randomized trials included in the NORDSTEN study. In the present trial, involving 437 patients undergoing surgery, we report radiological results after three different midline retaining posterior decompression techniques: unilateral laminotomy with crossover (UL) (n = 146), bilateral laminotomy (BL) (n = 142) and spinous process osteotomy (SPO) (n = 149). MRI was performed before and three months after surgery. The increase in dural sac area and Schizas grade at the most stenotic level was evaluated. Three different predefined surgical indicators of substantial decompression were used: (1) postoperative dural sac area of > 100 mm2, (2) increase in the dural sac area of at least 50% and (3) postoperative Schizas grade A or B. RESULTS No differences between the three surgical groups were found in the mean increase in dural sac area. Mean values were 66.0 (SD 41.5) mm2 in the UL-group, 71.9 (SD 37.1) mm2 in the BL-group and 68.1 (SD 41.0) mm2 in the SPO-group (p = 0.49). No differences in the three predefined surgical outcomes between the three groups were found. CONCLUSION For patients with lumbar spinal stenosis, the three different surgical techniques provided the same increase in dural sac area. CLINICAL TRIAL REGISTRATION The study is registered at ClinicalTrials.gov reference on November 22th 2013 under the identifier NCT02007083.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway. .,Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital,, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital,, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Frode Rekeland
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Eric Franssen
- Department of Orthopaedics, Stavanger University Hospital, Stavanger, Norway
| | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway.,Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Tore Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsö, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsö, Norway
| | - Knut Jørgen Haug
- Departement of Orthopedic Surgery, Telemark Regional Hospital, Skien, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Oslo, Norway
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborg, Sweden.,Department of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Kari Indrekvam
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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23
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Bråten LCH, Rolfsen MP, Espeland A, Wigemyr M, Aßmus J, Froholdt A, Haugen AJ, Marchand GH, Kristoffersen PM, Lutro O, Randen S, Wilhelmsen M, Winsvold BS, Kadar TI, Holmgard TE, Vigeland MD, Vetti N, Nygaard ØP, Lie BA, Hellum C, Anke A, Grotle M, Schistad EI, Skouen JS, Grøvle L, Brox JI, Zwart JA, Storheim K. Efficacy of antibiotic treatment in patients with chronic low back pain and Modic changes (the AIM study): double blind, randomised, placebo controlled, multicentre trial. BMJ 2019; 367:l5654. [PMID: 31619437 PMCID: PMC6812614 DOI: 10.1136/bmj.l5654] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To assess the efficacy of three months of antibiotic treatment compared with placebo in patients with chronic low back pain, previous disc herniation, and vertebral endplate changes (Modic changes). DESIGN Double blind, parallel group, placebo controlled, multicentre trial. SETTING Hospital outpatient clinics at six hospitals in Norway. PARTICIPANTS 180 patients with chronic low back pain, previous disc herniation, and type 1 (n=118) or type 2 (n=62) Modic changes enrolled from June 2015 to September 2017. INTERVENTIONS Patients were randomised to three months of oral treatment with either 750 mg amoxicillin or placebo three times daily. The allocation sequence was concealed by using a computer generated number on the prescription. MAIN OUTCOME MEASURES The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ) score (range 0-24) at one year follow-up in the intention to treat population. The minimal clinically important between group difference in mean RMDQ score was predefined as 4. RESULTS In the primary analysis of the total cohort at one year, the difference in the mean RMDQ score between the amoxicillin group and the placebo group was -1.6 (95% confidence interval -3.1 to 0.0, P=0.04). In the secondary analysis, the difference in the mean RMDQ score between the groups was -2.3 (-4.2 to-0.4, P=0.02) for patients with type 1 Modic changes and -0.1 (-2.7 to 2.6, P=0.95) for patients with type 2 Modic changes. Fifty patients (56%) in the amoxicillin group experienced at least one drug related adverse event compared with 31 (34%) in the placebo group. CONCLUSIONS In this study on patients with chronic low back pain and Modic changes at the level of a previous disc herniation, three months of treatment with amoxicillin did not provide a clinically important benefit compared with placebo. Secondary analyses and sensitivity analyses supported this finding. Therefore, our results do not support the use of antibiotic treatment for chronic low back pain and Modic changes. TRIAL REGISTRATION ClinicalTrials.gov NCT02323412.
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Affiliation(s)
- Lars Christian Haugli Bråten
- Research and Communication Unit for Musculoskeletal Health(FORMI), Oslo University Hospital HF, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mads Peder Rolfsen
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Monica Wigemyr
- Research and Communication Unit for Musculoskeletal Health(FORMI), Oslo University Hospital HF, Oslo, Norway
| | - Jörg Aßmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Anne Froholdt
- Department of Physical Medicine and Rehabilitation, Drammen Hospital, Drammen, Norway
| | | | - Gunn Hege Marchand
- Department of Physical Medicine and Rehabilitation, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Per Martin Kristoffersen
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Olav Lutro
- Stavanger University Hospital, Stavanger, Norway
| | - Sigrun Randen
- Department of Physical Medicine and Rehabilitation, Drammen Hospital, Drammen, Norway
| | - Maja Wilhelmsen
- Department of Rehabilitation, University Hospital of North Norway, Tromsø, Norway
- Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Bendik Slagsvold Winsvold
- Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Thomas Istvan Kadar
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway
| | | | - Maria Dehli Vigeland
- Research and Communication Unit for Musculoskeletal Health(FORMI), Oslo University Hospital HF, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nils Vetti
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øystein Petter Nygaard
- Department of Neurosurgery, St Olavs University Hospital, Trondheim, Norway
- Department of Neuroscience, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- National Advisory Unit on Spinal Surgery, St Olavs Hospital, Trondheim, Norway
| | - Benedicte Alexandra Lie
- Department of Medical Genetics, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Christian Hellum
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Audny Anke
- Department of Rehabilitation, University Hospital of North Norway, Tromsø, Norway
- Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Margreth Grotle
- Research and Communication Unit for Musculoskeletal Health(FORMI), Oslo University Hospital HF, Oslo, Norway
- Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | | | - Jan Sture Skouen
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, Grålum, Norway
| | - Jens Ivar Brox
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Oslo, Norway
| | - John-Anker Zwart
- Research and Communication Unit for Musculoskeletal Health(FORMI), Oslo University Hospital HF, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health(FORMI), Oslo University Hospital HF, Oslo, Norway
- Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
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Berg L, Thoresen H, Neckelmann G, Furunes H, Hellum C, Espeland A. Facet arthropathy evaluation: CT or MRI? Eur Radiol 2019; 29:4990-4998. [DOI: 10.1007/s00330-019-06047-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 12/31/2018] [Accepted: 01/25/2019] [Indexed: 02/06/2023]
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Hermansen E, Myklebust TÅ, Austevoll IM, Rekeland F, Solberg T, Storheim K, Grundnes O, Aaen J, Brox JI, Hellum C, Indrekvam K. Clinical outcome after surgery for lumbar spinal stenosis in patients with insignificant lower extremity pain. A prospective cohort study from the Norwegian registry for spine surgery. BMC Musculoskelet Disord 2019; 20:36. [PMID: 30669998 PMCID: PMC6343340 DOI: 10.1186/s12891-019-2407-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 01/08/2019] [Indexed: 01/25/2023] Open
Abstract
Background Spinal stenosis is a clinical diagnosis in which the main symptom is pain radiating to the lower extremities, or neurogenic claudication. Radiological spinal stenosis is commonly observed in the population and it is debated whether patients with no lower extremity pain should be labelled as having spinal stenosis. However, these patients is found in the Norwegian Registry for Spine Surgery, the main object of the present study was to compare the clinical outcomes after decompressive surgery in patients with insignificant lower extremity pain, with those with more severe pain. Methods This study is based on data from the Norwegian Registry for Spine Surgery (NORspine). Patients who had decompressive surgery in the period from 7/1–2007 to 11/3–2013 at 31 hospitals were included. The patients was divided into four groups based on preoperative Numeric Rating Scale (NRS)-score for lower extremity pain. Patients in group 1 had insignificant pain, group 2 had mild or moderate pain, group 3 severe pain and group 4 extremely severe pain. The primary outcome was change in the Oswestry Disability Index (ODI). Successfully treated patients were defined as patients reporting at least 30% reduction of baseline ODI, and the number of successfully treated patients in each group were recorded. Results In total, 3181 patients were eligible; 154 patients in group 1; 753 in group 2; 1766 in group 3; and 528 in group 4. Group 1 had significantly less improvement from baseline in all the clinical scores 12 months after surgery compared to the other groups. However, with a mean reduction of 8 ODI points and 56% of patients showing a reduction of at least 30% in their ODI score, the proportion of patients defined as successfully treated in group 1, was not significantly different from that of other groups. Conclusion This national register study shows that patients with insignificant lower extremity pain had less improvement in primary and secondary outcome parameters from baseline to follow-up compared to patients with more severe lower extremity pain.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway. .,Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Tor Åge Myklebust
- Department of Research, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway.,Department of Clinical Medicine, University of Tromsø The Arctic University of Norway, Tromsø, Norway.,University Hospital of North, Norwegian National Registry for spine surgery, Tromsø, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Oslo, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, University of Oslo, Oslo, Norway
| | - Christian Hellum
- Department of Orthopedics, Oslo University Hospital, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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26
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Austevoll IM, Gjestad R, Grotle M, Solberg T, Brox JI, Hermansen E, Rekeland F, Indrekvam K, Storheim K, Hellum C. Follow-up score, change score or percentage change score for determining clinical important outcome following surgery? An observational study from the Norwegian registry for Spine surgery evaluating patient reported outcome measures in lumbar spinal stenosis and lumbar degenerative spondylolisthesis. BMC Musculoskelet Disord 2019; 20:31. [PMID: 30658613 PMCID: PMC6339296 DOI: 10.1186/s12891-018-2386-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/19/2018] [Indexed: 11/21/2022] Open
Abstract
Background Assessment of outcomes for spinal surgeries is challenging, and an ideal measurement that reflects all aspects of importance for the patients does not exist. Oswestry Disability Index (ODI), EuroQol (EQ-5D) and Numeric Rating Scales (NRS) for leg pain and for back pain are commonly used patients reported outcome measurements (PROMs). Reporting the proportion of individuals with an outcome of clinical importance is recommended. Knowledge of the ability of PROMs to identify clearly improved patients is essential. The purpose of this study was to search cut-off criteria for PROMs that best reflect an improvement considered by the patients to be of clinical importance. Methods The Global Perceived Effect scale was utilized to evaluate a clinically important outcome 12 months after surgery. The cut-offs for the PROMs that most accurately distinguish those who reported ‘completely recovered’ or ‘much improved’ from those who reported ‘slightly improved’, unchanged’, ‘slightly worse’, ‘much worse’, or ‘worse than ever’ were estimated. For each PROM, we evaluated three candidate response parameters: the (raw) follow-up score, the (numerical) change score, and the percentage change score. Results We analysed 3859 patients with Lumbar Spinal Stenosis [(LSS); mean age 66; female gender 50%] and 617 patients with Lumbar Degenerative Spondylolisthesis [(LDS); mean age 67; 72% female gender]. The accuracy of identifying ‘completely recovered’ and ‘much better’ patients was generally high, but lower for EQ-5D than for the other PROMs. For all PROMs the accuracy was lower for the change score than for the follow-up score and the percentage change score, especially among patients with low and high PROM scores at baseline. The optimal threshold for a clinically important outcome was ≤24 for ODI, ≥0.69 for EQ-5D, ≤3 for NRS leg pain, and ≤ 4 for NRS back pain, and, for the percentage change score, ≥30% for ODI, ≥40% for NRS leg pain, and ≥ 33% for NRS back pain. The estimated cut-offs were similar for LSS and for LDS. Conclusion For estimating a ‘success’ rate assessed by a PROM, we recommend using the follow-up score or the percentage change score. These scores reflected a clinically important outcome better than the change score.
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Affiliation(s)
- Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland, University Hospital, Hagaviksbakken 25, 5217 Hagevik, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Christies gate 6, 5007 Bergen, Bergen, Norway. .,The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Postboks 20, 9038 Tromsø, Bodø, Norway.
| | - Rolf Gjestad
- Research Department, Division of Psychiatry, Haukeland University Hospital, Sanviksleitet 1, 5036 Bergen, Bergen, Norway
| | - Margreth Grotle
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, PB 4950 Nydalen, 0424, Oslo, Oslo, Norway.,Faculty of Health Science, OsloMet - Oslo Metropolitan University, PO box 4 St. Olavs plass, 0130, Oslo, Oslo, Norway
| | - Tore Solberg
- The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Postboks 20, 9038 Tromsø, Bodø, Norway.,Department of Neurosurgery, University Hospital of Northern Norway, Sykehusvegen 38, 90919 Tromsø, Tromsø, Norway
| | - Jens Ivar Brox
- The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Postboks 20, 9038 Tromsø, Bodø, Norway.,Department of Physical Medicine and Rehabilitation, Oslo University Hospital, PB 4950 Nydalen, 0424, Oslo, Oslo, Norway
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland, University Hospital, Hagaviksbakken 25, 5217 Hagevik, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Christies gate 6, 5007 Bergen, Bergen, Norway.,Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland, University Hospital, Hagaviksbakken 25, 5217 Hagevik, Bergen, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland, University Hospital, Hagaviksbakken 25, 5217 Hagevik, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Christies gate 6, 5007 Bergen, Bergen, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, PB 4950 Nydalen, 0424, Oslo, Oslo, Norway
| | - Christian Hellum
- The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Postboks 20, 9038 Tromsø, Bodø, Norway.,Division of Orthopaedic Surgery, Oslo University Hospital, 4950 Nydalen, 0424, Oslo, PB, Norway
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Austevoll IM, Hermansen E, Fagerland M, Rekeland F, Solberg T, Storheim K, Brox JI, Lønne G, Indrekvam K, Aaen J, Grundnes O, Hellum C. Decompression alone versus decompression with instrumental fusion the NORDSTEN degenerative spondylolisthesis trial (NORDSTEN-DS); study protocol for a randomized controlled trial. BMC Musculoskelet Disord 2019; 20:7. [PMID: 30611229 PMCID: PMC6320633 DOI: 10.1186/s12891-018-2384-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fusion in addition to decompression has become the standard treatment for lumbar spinal stenosis with degenerative spondylolisthesis (DS). The evidence for performing fusion among these patients is conflicting and there is a need for further investigation through studies of high quality. The present protocol describes an ongoing study with the primary aim of comparing the outcome between decompression alone and decompression with instrumented fusion. The secondary aim is to investigate whether predictors can be used to choose the best treatment for an individual. The trial, named the NORDSTEN-DS trial, is one of three studies in the Norwegian Degenerative Spinal Stenosis (NORDSTEN) study. METHODS The NORDSTEN-DS trial is a block-randomized, controlled, multicenter, non-inferiority study with two parallel groups. The surgeons at the 15 participating hospitals decide whether a patient is eligible or not according to the inclusion and exclusion criteria. Participating patients are randomized to either a midline preserving decompression or a decompression followed by an instrumental fusion. Primary endpoint is the percentage of patients with an improvement in Oswestry Disability Index version 2.0 of more than 30% from baseline to 2-year follow-up. Secondary outcome measurements are the Zürich Claudication Questionnaire, Numeric Rating Scale for back and leg pain, Euroqol 5 dimensions questionnaire, Global perceived effect scale, complications and several radiological parameters. Analysis and interpretation of results will also be conducted after 5 and 10 years. CONCLUSION The NORDSTEN/DS trial has the potential to provide Level 1 evidence of whether decompression alone should be advocated as the preferred method or not. Further on the study will investigate whether predictors exist and if they can be used to make the appropriate choice for surgical treatment for this patient group. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02051374 . First Posted: January 31, 2014. Last Update Posted: February 14, 2018.
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Affiliation(s)
- Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Hagavik, N- 5217, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, N- 5007, Bergen, Norway.
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Hagavik, N- 5217, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, N- 5007, Bergen, Norway.,Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, N-6026, Ålesund, Norway
| | - Morten Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, N-0424, Oslo, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Hagavik, N- 5217, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery, University Hospital of Northern Norway, N-9019, Tromsø, Norway.,Department of Clinical Medicine, University of Tromsø - The Arctic University of Norway, N-9019, Tromsø, Norway.,The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, N-9038, Tromsø, Bodø, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, N-0424, Oslo, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, N-0424, Oslo, Norway
| | - Greger Lønne
- Department of Orthopedic Surgery, Innlandet Hospital Trust, N-2609, Lillehammer, Lillehammer, Norway
| | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, N- 5007, Bergen, Norway.,Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, N-6026, Ålesund, Norway
| | - Jørn Aaen
- Department of Clinical Medicine, University of Bergen, N- 5007, Bergen, Norway.,Department of Research, Levanger Hospital, Nord-Trøndelag Hospital Trust, N-7600, Levanger, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, N-1474, Lørenskog, Oslo, Norway
| | - Christian Hellum
- Division of Orthopaedic Surgery, Oslo University Hospital, N-0424, Oslo, Norway
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Furunes H, Hellum C, Brox JI, Rossvoll I, Espeland A, Berg L, Brøgger HM, Småstuen MC, Storheim K. Lumbar total disc replacement: predictors for long-term outcome. Eur Spine J 2017; 27:709-718. [DOI: 10.1007/s00586-017-5375-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/02/2017] [Accepted: 10/30/2017] [Indexed: 01/08/2023]
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Furunes H, Storheim K, Brox JI, Johnsen LG, Skouen JS, Franssen E, Solberg TK, Sandvik L, Hellum C. Total disc replacement versus multidisciplinary rehabilitation in patients with chronic low back pain and degenerative discs: 8-year follow-up of a randomized controlled multicenter trial. Spine J 2017; 17:1480-1488. [PMID: 28583869 DOI: 10.1016/j.spinee.2017.05.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/01/2017] [Accepted: 05/08/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar total disc replacement (TDR) is a treatment option for selected patients with chronic low back pain (LBP) that is non-responsive to conservative treatment. The long-term results of disc replacement compared with multidisciplinary rehabilitation (MDR) have not been reported previously. PURPOSE We aimed to assess the long-term relative efficacy of lumbar TDR compared with MDR. DESIGN We undertook a multicenter randomized controlled trial at five university hospitals in Norway. PATIENT SAMPLE The sample consisted of 173 patients aged 25-55 years with chronic LBP and localized degenerative changes in the lumbar intervertebral discs. OUTCOME MEASURES The primary outcome was self-reported physical function (Oswestry Disability Index [ODI]) at 8-year follow-up in the intention-to-treat population. Secondary outcomes included self-reported LBP (visual analogue scale [VAS]), quality of life (EuroQol [EQ-5D]), emotional distress (Hopkins Symptom Checklist [HSCL-25]), occupational status, patient satisfaction, drug use, complications, and additional back surgery. METHODS Patients were randomly assigned to lumbar TDR or MDR. Self-reported outcome measures were collected 8 years after treatment. The study was powered to detect a difference of 10 ODI points between the groups. The study has not been funded by the industry. RESULTS A total of 605 patients were screened for eligibility, of whom 173 were randomly assigned treatment. Seventy-seven patients (90%) randomized to surgery and 74 patients (85%) randomized to rehabilitation responded at 8-year follow-up. Mean improvement in the ODI was 20.0 points (95% confidence interval [CI] 16.4-23.6, p≤.0001) in the surgery group and 14.4 points (95% CI 10.7-18.1, p≤.0001) in the rehabilitation group. Mean difference between the groups at 8-year follow-up was 6.1 points (95% CI 1.2-11.0, p=.02). Mean difference in favor of surgery on secondary outcomes were 9.9 points on VAS (95% CI 0.6-19.2, p=.04) and 0.16 points on HSCL-25 (95% CI 0.01-0.32, p=.04). There were 18 patients (24%) in the surgery group and 4 patients (6%) in the rehabilitation group who reported full recovery (p=.002). There were no significant differences between the groups in EQ-5D, occupational status, satisfaction with care, or drug use. In the per protocol analysis, the mean difference between groups was 8.1 ODI points (95% CI 2.3-13.9, p=.01) in favor of surgery. Forty-three of 61 patients (70%) in the surgery group and 26 of 52 patients (50%) in the rehabilitation group had a clinically important improvement (15 ODI points or more) from baseline (p=.03). The proportion of patients with a clinically important deterioration (six ODI points or more) was not significantly different between the groups. Twenty-one patients (24%) randomized to rehabilitation had crossed over and had undergone back surgery since inclusion, whereas 12 patients (14%) randomized to surgery had undergone additional back surgery. One serious adverse event after disc replacement is registered (<1%). CONCLUSIONS Substantial long-term improvement can be expected after both disc replacement and MDR. The difference between groups is statistically significant in favor of surgery, but smaller than the prespecified clinically important difference of 10 ODI points that the study was designed to detect. Future research should aim to improve selection criteria for disc replacement and MDR.
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Affiliation(s)
- Håvard Furunes
- Innlandet Hospital Gjøvik, Department of Surgery, Innlandet Hospital Gjøvik, Kyrre Grepps gate 11, 2819 Gjøvik, Norway; University of Oslo, Postbox 1072 Blindern, 0316 Oslo, Norway; Oslo University Hospital Ullevål, FORMI, Building 37B, Postbox 4950 Nydalen, 0424 Oslo, Norway.
| | - Kjersti Storheim
- University of Oslo, Postbox 1072 Blindern, 0316 Oslo, Norway; Oslo University Hospital Ullevål, FORMI, Building 37B, Postbox 4950 Nydalen, 0424 Oslo, Norway
| | - Jens Ivar Brox
- University of Oslo, Postbox 1072 Blindern, 0316 Oslo, Norway; Department for Physical Medicine and Rehabilitation, Oslo University Hospital, Postbox 4950 Nydalen, 0424 Oslo, Norway
| | - Lars Gunnar Johnsen
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Prinsesse Kristinas gate 3, 7030 Trondheim, Norway; Department of Neuromedicine, Faculty of Medicine, Norwegian University of Science and Technology, Høgskoleringen 1, 7491 Trondheim, Norway
| | - Jan Sture Skouen
- Department of Physical Medicine and Rehabilitation, The Outpatient Spine Clinic, Haukeland University Hospital, Postbox 1400, 5021 Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, PO Box 7804, 5007 Bergen, Norway
| | - Eric Franssen
- Orthopaedic Department, Stavanger University Hospital, Gerd Ragna Bloch Thorsens gate, 4011 Stavanger, Norway
| | - Tore K Solberg
- Department of Clinical Medicine, University of Tromsø-The Arctic University of Norway, Hansine Hansens veg 18, 9019 Tromsø, Norway; The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, University Hospital of Northern Norway, Sykehusvegen 38, 9019 Tromsø, Norway; Department of Neurosurgery, University Hospital of Northern Norway, Sykehusvegen 38, 9019 Tromsø, Norway
| | - Leiv Sandvik
- University of Oslo, Postbox 1072 Blindern, 0316 Oslo, Norway
| | - Christian Hellum
- University of Oslo, Postbox 1072 Blindern, 0316 Oslo, Norway; Division of Orthopaedic Surgery, Oslo University Hospital, Postbox 4950 Nydalen, 0424 Oslo, Norway
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Storheim K, Berg L, Hellum C, Gjertsen Ø, Neckelmann G, Espeland A, Keller A. Fat in the lumbar multifidus muscles - predictive value and change following disc prosthesis surgery and multidisciplinary rehabilitation in patients with chronic low back pain and degenerative disc: 2-year follow-up of a randomized trial. BMC Musculoskelet Disord 2017; 18:145. [PMID: 28376754 PMCID: PMC5381060 DOI: 10.1186/s12891-017-1505-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/29/2017] [Indexed: 01/12/2023] Open
Abstract
Background Evidence is lacking on whether fat infiltration in the multifidus muscles affects outcomes after total disc replacement (TDR) surgery and if it develops after surgery. The aims of this study were 1) to investigate whether pre-treatment multifidus muscle fat infiltration predicts outcome 2 years after treatment with TDR surgery or multidisciplinary rehabilitation, and 2) to compare changes in multifidus muscle fat infiltration from pre-treatment to 2-year follow-up between the two treatment groups. Methods The study is secondary analysis of data from a trial with 2-year follow-up of patients with chronic low back pain (LBP) and degenerative disc randomized to TDR surgery or multidisciplinary rehabilitation. We analyzed (aim 1) patients with both magnetic resonance imaging (MRI) at pre-treatment and valid data on outcome measures at 2-year follow-up (predictor analysis), and (aim 2) patients with MRI at both pre-treatment and 2-year follow-up. Outcome measures were visual analogue scale (VAS) for LBP, Oswestry Disability Index (ODI), work status and muscle fat infiltration on MRI. Patients with pre-treatment MRI and 2-year outcome data on VAS for LBP (n = 144), ODI (n = 147), and work status (n = 137) were analyzed for prediction purposes. At 2-year follow-up, 126 patients had another MRI scan, and change in muscle fat infiltration was compared between the two treatment groups. Three radiologists visually quantified multifidus muscle fat in the three lower lumbar levels on MRI as <20% (grade 0), 20–50% (grade 1), or >50% (grade 2) of the muscle cross-section containing fat. Regression analysis and a mid-P exact test were carried out. Results Grade 0 pre-treatment multifidus muscle fat predicted better clinical results at 2-year follow-up after TDR surgery (all outcomes) but not after rehabilitation. At 2-year follow-up, increased fat infiltration was more common in the surgery group (intention-to-treat p = 0.03, per protocol p = 0.08) where it was related to worse pain and ODI. Conclusions Patients with less fat infiltration of multifidus muscles before TDR surgery had better outcomes at 2-year follow-up, but findings also indicated a negative influence of TDR surgery on back muscle morphology in some patients. The rehabilitation group maintained their muscular morphology and were unaffected by pre-treatment multifidus muscle fat. Trial registration NCT 00394732 (retrospectively registered October 31, 2006).
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Affiliation(s)
- Kjersti Storheim
- Research and Communication unit for musculoskeletal disorders (FORMI), Oslo University Hospital Ullevål, Postbox 4956, Nydalen, 0424, Oslo, Norway. .,Faculty of Medicine, University of Oslo, Postbox 1078, Blindern, 0316, Oslo, Norway.
| | - Linda Berg
- Department of Radiology, Haukeland University Hospital, Postbox 1400, 5021, Bergen, Norway.,Section for Radiology, Department of Clinical Medicine, University of Bergen, Postbox 7804, N-5020, Bergen, Norway.,Department of Radiology, Nordland Hospital, Postbox 1480, 8092, Bodø, Norway.,Institute of Clinical Medicine, UiT, The Arctic University of Norway, Postbox 6050, Langnes, 9037, Tromsø, Norway
| | - Christian Hellum
- Department of Orthopaedics, Oslo University Hospital Ullevål, Postbox 4956, Nydalen, 0424, Oslo, Norway
| | - Øivind Gjertsen
- Department of Radiology and Nuclearmedicine, Oslo University Hospital Rikshospitalet, Postbox 4950, Nydalen, 0424, Oslo, Norway
| | - Gesche Neckelmann
- Department of Radiology, Haukeland University Hospital, Postbox 1400, 5021, Bergen, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Postbox 1400, 5021, Bergen, Norway.,Section for Radiology, Department of Clinical Medicine, University of Bergen, Postbox 7804, N-5020, Bergen, Norway
| | - Anne Keller
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital Ullevål, Postbox 4956, Nydalen, 0424, Oslo, Norway.,Center for Rheumatology and Spine Diseases, National Hospital, 2600, Glostrup, Denmark
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Hermansen E, Austevoll IM, Romild UK, Rekeland F, Solberg T, Storheim K, Grundnes O, Aaen J, Brox JI, Hellum C, Indrekvam K. Study-protocol for a randomized controlled trial comparing clinical and radiological results after three different posterior decompression techniques for lumbar spinal stenosis: the Spinal Stenosis Trial (SST) (part of the NORDSTEN Study). BMC Musculoskelet Disord 2017; 18:121. [PMID: 28327114 PMCID: PMC5361830 DOI: 10.1186/s12891-017-1491-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/15/2017] [Indexed: 11/22/2022] Open
Abstract
Background There are several posterior decompression techniques for lumbar spinal stenosis (LSS). There is a trend towards performing less invasive surgical procedures, but no multicentre randomized controlled trials have evaluated the relative efficacy of these techniques at short and long-term. Method/design A multicentre randomized controlled trial [the Spinal Stenosis Trial (SST) (part of the NORDSTEN study)] including 465 patients aged 18–80 years with neurogenic claudication or radiating pain and MRI findings indicating lumbar spinal stenosis without spondylolisthesis is performed to compare three posterior decompression techniques: unilateral laminotomy with crossover, bilateral laminotomy and spinous process osteotomy. The primary outcome is change in Oswestry Disability Index (ODI 2 years postoperatively). Secondary outcomes are change in EQ-5D, Zurich Claudication Questionnaire, and Numeric Rating Scale for leg-pain and back-pain. Also recorded were Global Perceived Effect score, complications, length of hospital stay, reoperation rate 2 years postoperatively, difference in recurrence of symptoms or postoperative instability, and MRI change in the dural sac area. Further, a 5 and 10 years follow-up is planned with the same outcome measures. Discussion Newer and less invasive techniques are increasingly favoured in surgery for LSS. This trial will compare the clinical and radiological results of three different techniques, and may contribute to better clinical decision making in the surgical treatment of LSS. Trial registration ClinicalTrials.gov reference: NCT02007083 (November 22, 2013).
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway. .,Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway. .,Department of Orthopaedics, Oslo University Hospital, Oslo, Norway.
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ulla Kristina Romild
- Department of Research, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway.,Department of Clinical Medicine, University of Tromsø The Arctic University of Norway, Tromsø, Norway.,Norwegian National Registry for spine surgery, University Hospital of North Norway, Tromsø, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Lørenskog, Norway
| | - Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, University of Oslo, Oslo, Norway
| | - Christian Hellum
- Department of Physical Medicine and Rehabilitation, University of Oslo, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Austevoll IM, Gjestad R, Brox JI, Solberg TK, Storheim K, Rekeland F, Hermansen E, Indrekvam K, Hellum C. The effectiveness of decompression alone compared with additional fusion for lumbar spinal stenosis with degenerative spondylolisthesis: a pragmatic comparative non-inferiority observational study from the Norwegian Registry for Spine Surgery. Eur Spine J 2016; 26:404-413. [PMID: 27421276 DOI: 10.1007/s00586-016-4683-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 06/02/2016] [Accepted: 06/22/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the effect of adding fusion to decompression in patients operated for lumbar spinal stenosis with a concomitant lumbar degenerative spondylolisthesis. METHODS After propensity score matching, 260 patients operated with decompression and fusion and 260 patients operated with decompression alone were compared. Primary outcome measures were leg and back pain [Numeric Rating Scale (NRS), 0-10] and Oswestry Disability Index (ODI, 0-100) at 12 months. RESULTS At 12-month follow-up, the fusion group rated their pain significantly lower than the decompression alone group [leg pain 3.0 and 3.6, respectively, mean difference -0.6, 95 % confidence interval (CI) -1.2 to -0.05, p = 0.03 and back pain 3.3 and 3.9, respectively, mean difference -0.6, 95 % CI -1.1 to -0.1, p = 0.02]. ODI was not significantly different between the groups (21.0 versus 23.3, mean difference -2.3, 95 % CI -5.8 to 1.1, p = 0.18). Seventy-four percent of the fusion group and 63 % of the decompression alone group achieved a clinically important improvement in back pain (difference in proportion of responders = 11 %, 95 % CI 2-20 %, p = 0.01), corresponding to a number needed to treat of 9 patients (95 % CI 5-50). There was no significant difference in responder rate for leg pain (74 and 67 %, respectively, difference 7 %, 95 % CI -1 to 16 %, p = 0.09) or for ODI (67 and 59 %, respectively, difference 8 %, 95 % CI 0-18 %, p = 0.06). The duration of surgery and hospital stay was longer for the fusion group (mean difference 68 min, 95 % CI 58-78, p < 0.01 and mean difference 4.2 days, 95 % CI 3.5-4.8, p < 0.01). CONCLUSION In the present non-inferiority study, we cannot conclude that decompression alone is as good as decompression with additional fusion. However, the small differences in the groups' effect sizes suggest that a considerable number of patients can be treated with decompression alone. A challenge in future studies will be to find the best treatment option for each patient.
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Affiliation(s)
- Ivar M Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.
| | - Rolf Gjestad
- Division of Mental Health Care, Haukeland University Hospital, Bergen, Norway.,Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Tore K Solberg
- Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway.,Department of Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Frode Rekeland
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
| | - Erland Hermansen
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway.,Clinic for Surgery and Neurology, Department of Orthopedics, Oslo University Hospital, University of Oslo, Oslo, Norway
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Hermansen E, Romild UK, Austevoll IM, Solberg T, Storheim K, Brox JI, Hellum C, Indrekvam K. Does surgical technique influence clinical outcome after lumbar spinal stenosis decompression? A comparative effectiveness study from the Norwegian Registry for Spine Surgery. Eur Spine J 2016; 26:420-427. [PMID: 27262561 DOI: 10.1007/s00586-016-4643-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/31/2016] [Accepted: 05/31/2016] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The aim of this study was to compare the clinical outcome of spinal process osteotomy with two other midline-retaining methods, bilateral laminotomy and unilateral laminotomy with crossover, among patients undergoing surgery for lumbar spinal stenosis. METHODS This cohort study was based on data from the Norwegian Registry for Spine Surgery (NORspine). Patients were operated on between 2009 and 2013 at 31 Norwegian hospitals. The patients completed questionnaires at admission for surgery, and after 3 and 12 months. The Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were duration of surgery and hospital stay, Numeric Rating Scale (NRS) for back pain and leg pain, and EQ-5D and EQ-VAS. The patients were classified into one of three treatment groups according to the surgery they had received, and a propensity score was utilized to minimize bias. The three treatment groups were divided into subgroups based on Propensity Scores, and the statistical analyses were performed with and within the Propensity Score stratified subgroups. RESULTS 103 patients had spinal process osteotomy, 966 patients had bilateral laminotomy, and 462 patients had unilateral laminotomy with crossover. Baseline clinical scores were similar in the three groups. There were no differences in improvement after 3 and 12 months between treatment groups. At 12 months, mean ODI improvement was 15.2 (SD 16.7) after spinous process osteotomy, 16.9 (SD 17.0) after bilateral laminotomy, and 16.7 (SD 16.9) after unilateral laminotomy with crossover. There were no differences in the secondary clinical outcomes or complication rates. Mean duration of surgery was greatest for spinal process osteotomy (p < 0.05). Length of stay was 2.1 days (SD 2.1) in the bilateral laminotomy group, 3.5 (SD 2.4) days for unilateral laminotomy, and 6.9 days (SD 4.1) for spinous process osteotomy group (p < 0.05). CONCLUSION In a propensity scored matched cohort, there were no differences in the clinical outcome 12 months after surgery for lumbar spinal stenosis performed using the three different posterior decompression techniques. Bilateral laminotomy had shortest duration of surgery and shortest length of hospital stay. Surgical technique does not seem to affect clinical outcome after three different midline-retaining posterior decompression techniques.
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Affiliation(s)
- Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway. .,Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Ulla Kristina Romild
- Department of Research, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tore Solberg
- Department of Neurosurgery, University Hospital of North Norway, Tromsø, Norway.,Norwegian National Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Christian Hellum
- Department of Orthopedics, Oslo University Hospital, Oslo, Norway
| | - Kari Indrekvam
- Kysthospitalet in Hagevik, Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Storheim K, Hellum C. No differences between physiotherapy and decompression surgery for patients considered surgical candidates for lumbar spinal stenosis [commentary]. J Physiother 2016; 62:49. [PMID: 26701160 DOI: 10.1016/j.jphys.2015.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 09/18/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Christian Hellum
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
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Johnsen LG, Hellum C, Nygaard OP, Storheim K, Brox JI, Rossvoll I, Leivseth G, Grotle M. Comparison of the SF6D, the EQ5D, and the oswestry disability index in patients with chronic low back pain and degenerative disc disease. BMC Musculoskelet Disord 2013; 14:148. [PMID: 23622053 PMCID: PMC3648434 DOI: 10.1186/1471-2474-14-148] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 04/19/2013] [Indexed: 12/04/2022] Open
Abstract
Background The need for cost effectiveness analyses in randomized controlled trials that compare treatment options is increasing. The selection of the optimal utility measure is important, and a central question is whether the two most commonly used indexes - the EuroQuol 5D (EQ5D) and the Short Form 6D (SF6D) – can be used interchangeably. The aim of the present study was to compare change scores of the EQ5D and SF6D utility indexes in terms of some important measurement properties. The psychometric properties of the two utility indexes were compared to a disease-specific instrument, the Oswestry Disability Index (ODI), in the setting of a randomized controlled trial for degenerative disc disease. Methods In a randomized controlled multicentre trial, 172 patients who had experienced low back pain for an average of 6 years were randomized to either treatment with an intensive back rehabilitation program or surgery to insert disc prostheses. Patients filled out the ODI, EQ5D, and SF-36 at baseline and two-year follow up. The utility indexes was compared with respect to measurement error, structural validity, criterion validity, responsiveness, and interpretability according to the COSMIN taxonomy. Results At follow up, 113 patients had change score values for all three instruments. The SF6D had better similarity with the disease-specific instrument (ODI) regarding sensitivity, specificity, and responsiveness. Measurement error was lower for the SF6D (0.056) compared to the EQ5D (0.155). The minimal important change score value was 0.031 for SF6D and 0.173 for EQ5D. The minimal detectable change score value at a 95% confidence level were 0.157 for SF6D and 0.429 for EQ5D, and the difference in mean change score values (SD) between them was 0.23 (0.29) and so exceeded the clinical significant change score value for both instruments. Analysis of psychometric properties indicated that the indexes are unidimensional when considered separately, but that they do not exactly measure the same underlying construct. Conclusions This study indicates that the difference in important measurement properties between EQ5D and SF6D is too large to consider them interchangeable. Since the similarity with the “gold standard” (the disease-specific instrument) was quite different, this could indicate that the choice of index should be determined by the diagnosis.
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Johnsen LG, Brinckmann P, Hellum C, Rossvoll I, Leivseth G. Segmental mobility, disc height and patient-reported outcomes after surgery for degenerative disc disease. Bone Joint J 2013; 95-B:81-9. [DOI: 10.1302/0301-620x.95b1.29829] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This prospective multicentre study was undertaken to determine segmental movement, disc height and sagittal alignment after total disc replacement (TDR) in the lumbosacral spine and to assess the correlation of biomechanical properties to clinical outcomes. A total of 173 patients with degenerative disc disease and low back pain for more than one year were randomised to receive either TDR or multidisciplinary rehabilitation (MDR). Segmental movement in the sagittal plane and disc height were measured using distortion compensated roentgen analysis (DCRA) comparing radiographs in active flexion and extension. Correlation analysis between the range of movement or disc height and patient-reported outcomes was performed in both groups. After two years, no significant change in movement in the sagittal plane was found in segments with TDR or between the two treatment groups. It remained the same or increased slightly in untreated segments in the TDR group and in this group there was a significant increase in disc height in the operated segments. There was no correlation between segmental movement or disc height and patient-reported outcomes in either group. In this study, insertion of an intervertebral disc prosthesis TDR did not increase movement in the sagittal plane and segmental movement did not correlate with patient-reported outcomes. This suggests that in the lumbar spine the movement preserving properties of TDR are not major determinants of clinical outcomes. Cite this article: Bone Joint J 2013;95-B:81–9.
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Affiliation(s)
- L. G. Johnsen
- Norwegian University of Science and Technology
(NTNU), Department of Clinical Neuromedicine, 7049
Trondheim, Norway
| | - P. Brinckmann
- Universitätsklinikum Münster, Klinik
und Poliklinik für Technische Orthopädie und Rehabilitation, Robert-Koch-Straße
30, Münster 48149, Germany
| | - C. Hellum
- Oslo University Hospital, Department
of Orthopaedics, Kirkevn 166, 0407
Oslo, Norway
| | - I. Rossvoll
- University Hospital of Trondheim, Orthopaedic
Department, Trondheim 7030, Norway
| | - G. Leivseth
- Norwegian University of Science and Technology
(NTNU), Department of Clinical Neuromedicine, 7049
Trondheim, Norway
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Hellum C, Johnsen LG, Gjertsen Ø, Berg L, Neckelmann G, Grundnes O, Rossvoll I, Skouen JS, Brox JI, Storheim K. Predictors of outcome after surgery with disc prosthesis and rehabilitation in patients with chronic low back pain and degenerative disc: 2-year follow-up. Eur Spine J 2012; 21:681-90. [PMID: 22246644 DOI: 10.1007/s00586-011-2145-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 12/15/2011] [Accepted: 12/31/2011] [Indexed: 01/24/2023]
Abstract
PURPOSE A prospective study to evaluate whether certain baseline characteristics can predict outcome in patients treated with disc prosthesis or multidisciplinary rehabilitation. METHODS Secondary analysis of 154 patients with chronic low back pain (LBP) for at least 1 year and degenerative discs originally recruited for a randomized trial. Outcome measures were Oswestry Disability Index (ODI) dichotomized to < or ≥15 points improvement and whether subjects were working at 2-year follow-up. A multiple logistic regression analysis was used. RESULTS In patients treated with disc prosthesis, long duration of LBP and high Fear-Avoidance Beliefs for work (FABQ-W) predicted worse ODI outcome [odds ratio (OR) = 1.9, 95% confidence interval (CI) 1.2-3.2 and OR = 1.7, CI 1.2-2.4 for every 5 years or 5 points]. Modic type I or II predicted better ODI outcome (OR = 5.3, CI 1.1-25.3). In patients treated with rehabilitation, a high ODI, low emotional distress (HSCL-25), and no daily narcotics predicted better outcome for ODI (OR = 2.5, CI 1.4-4.5 for every 5 ODI points, OR = 2.1, CI 1.1-5.1 for every 0.5 HSCL points and OR = 23.6, CI 2.1-266.8 for no daily narcotics). Low FABQ-W and working at baseline predicted working at 2-year follow-up after both treatments (OR = 1.3, CI 1.0-1.5 for every 5 points and OR = 4.1, CI 1.2-13.2, respectively). CONCLUSIONS Shorter duration of LBP, Modic type I or II changes and low FABQ-W were the best predictors of success after treatment with disc prosthesis, while high ODI, low distress and not using narcotics daily predicted better outcome of rehabilitation. Low FABQ-W and working predicted working at follow-up.
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Affiliation(s)
- Christian Hellum
- Department of Orthopaedics, Oslo University Hospital, University of Oslo, Kirkevn 166, 0407, Oslo, Norway.
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Berg L, Neckelmann G, Gjertsen Ø, Hellum C, Johnsen LG, Eide GE, Espeland A. Reliability of MRI findings in candidates for lumbar disc prosthesis. Neuroradiology 2011; 54:699-707. [PMID: 21947249 PMCID: PMC3382271 DOI: 10.1007/s00234-011-0963-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 09/13/2011] [Indexed: 01/09/2023]
Abstract
Introduction Limited reliability data exist for localised magnetic resonance imaging (MRI) findings relevant to planning of treatment with lumbar disc prosthesis and later outcomes. We assessed the reliability of such findings in chronic low back pain patients who were accepted candidates for disc prosthesis. Methods On pretreatment MRI of 170 patients (mean age 41 years; 88 women), three experienced radiologists independently rated Modic changes, disc findings and facet arthropathy at L3/L4, L4/L5 and L5/S1. Two radiologists rerated 126 examinations. For each MRI finding at each disc level, agreement was analysed using the kappa statistic and differences in prevalence across observers using a fixed effects model. Results All findings at L3/L4 and facet arthropathy at L5/S1 had a mean prevalence <10% across observers and were not further analysed, ensuring interpretable kappa values. Overall interobserver agreement was generally moderate or good (kappa 0.40–0.77) at L4–S1 for Modic changes, nucleus pulposus signal, disc height (subjective and measured), posterior high-intensity zone (HIZ) and disc contour, and fair (kappa 0.24) at L4/L5 for facet arthropathy. Posterior HIZ at L5/S1 and severely reduced subjective disc height at L4/L5 differed up to threefold in prevalence between observers (p < 0.0001). Intraobserver agreement was mostly good or very good (kappa 0.60–1.00). Conclusion In candidates for disc prosthesis, mostly moderate interobserver agreement is expected for localised MRI findings.
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Affiliation(s)
- Linda Berg
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021 Bergen, Norway
- Section for Radiology, Department of Surgical Sciences, University of Bergen, Bergen, Norway
| | - Gesche Neckelmann
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021 Bergen, Norway
| | - Øivind Gjertsen
- Department of Neuroradiology, Oslo University Hospital, Oslo, Norway
| | - Christian Hellum
- Department of Orthopaedics, Oslo University Hospital, Oslo, Norway
- Department of Orthopaedics, University of Oslo, Oslo, Norway
| | - Lars G. Johnsen
- National Centre for Diseases of the Spine, University Hospital of Trondheim, Trondheim, Norway
- Orthopaedic Department, University Hospital of Trondheim, Trondheim, Norway
| | - Geir E. Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
- Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021 Bergen, Norway
- Section for Radiology, Department of Surgical Sciences, University of Bergen, Bergen, Norway
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Hellum C, Johnsen LG, Storheim K, Nygaard OP, Brox JI, Rossvoll I, Rø M, Sandvik L, Grundnes O. Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: two year follow-up of randomised study. BMJ 2011; 342:d2786. [PMID: 21596740 PMCID: PMC3100911 DOI: 10.1136/bmj.d2786] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To compare the efficacy of surgery with disc prosthesis versus non-surgical treatment for patients with chronic low back pain. DESIGN A prospective randomised multicentre study. SETTING Five university hospitals in Norway. PARTICIPANTS 173 patients with a history of low back pain for at least one year, Oswestry disability index of at least 30 points, and degenerative changes in one or two lower lumbar spine levels (86 patients randomised to surgery). Patients were treated from April 2004 to September 2007. INTERVENTIONS Surgery with disc prosthesis or outpatient multidisciplinary rehabilitation for 12-15 days. MAIN OUTCOME MEASURES The primary outcome measure was the score on the Oswestry disability index after two years. Secondary outcome measures were low back pain, satisfaction with life (SF-36 and EuroQol EQ-5D), Hopkins symptom check list (HSCL-25), fear avoidance beliefs (FABQ), self efficacy beliefs for pain, work status, and patients' satisfaction and drug use. A blinded independent observer evaluated scores on the back performance scale and Prolo scale at two year follow-up. RESULTS The study was powered to detect a difference of 10 points on the Oswestry disability index between the groups at two years. At two years there was a mean difference of -8.4 points (95% confidence interval -13.2 to -3.6) in favour of surgery. In the analysis of prespecified secondary outcomes, there were significant differences in favour of surgery for low back pain (mean difference -12.2, -21.3 to -3.1), patients' satisfaction (63% (n = 46) v 39% (n = 26)), SF-36 physical component score (mean difference 5.8, 2.5 to 9.1), self efficacy for pain (mean difference 1.0, 0.2 to 1.9), and the Prolo scale (mean difference 0.9, 0.1 to 1.6). There were no significant differences in return to work, SF-36 mental component score, EQ-5D, fear avoidance beliefs, Hopkins symptom check list, drug use, and the back performance scale. One serious complication of leg amputation occurred during surgical revision of a polyethylene dislodgement. The drop-out rate was 20% (34) and the crossover rate was 6% (5). CONCLUSIONS Surgical intervention with disc prosthesis for chronic low back pain resulted in a significantly greater improvement in the Oswestry score compared with rehabilitation, but this improvement did not clearly exceed the prespecified minimally important clinical difference between groups of 10 points, and the data are consistent with a wide range of differences between the groups, including values well below 10 points. The potential risks of surgery and the substantial amount of improvement experienced by a sizeable proportion of the rehabilitation group also have to be incorporated into overall decision making. Trial registration NCT 00394732.
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Affiliation(s)
- Christian Hellum
- Department of Orthopaedics, Oslo University Hospital and University of Oslo, Kirkevn 166, 0407 Oslo, Norway.
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Wilkens P, Scheel IB, Grundnes O, Hellum C, Storheim K. Effect of glucosamine on pain-related disability in patients with chronic low back pain and degenerative lumbar osteoarthritis: a randomized controlled trial. JAMA 2010; 304:45-52. [PMID: 20606148 DOI: 10.1001/jama.2010.893] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Chronic low back pain (LBP) with degenerative lumbar osteoarthritis (OA) is widespread in the adult population. Although glucosamine is increasingly used by patients with chronic LBP, little is known about its effect in this setting. OBJECTIVE To investigate the effect of glucosamine in patients with chronic LBP and degenerative lumbar OA. DESIGN, SETTING, AND PARTICIPANTS A double-blind, randomized, placebo-controlled trial conducted at Oslo University Hospital Outpatient Clinic, Oslo, Norway, with 250 patients older than 25 years of age with chronic LBP (>6 months) and degenerative lumbar OA. INTERVENTIONS Daily intake of 1500 mg of oral glucosamine (n = 125) or placebo (n = 125) for 6 months, with assessment of effect after the 6-month intervention period and at 1 year (6 months postintervention). MAIN OUTCOME MEASURES The primary outcome was pain-related disability measured with the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes were numerical scores from pain-rating scales of patients at rest and during activity, and the quality-of-life EuroQol-5 Dimensions (EQ-5D) instrument. Data collection occurred during the intervention period at baseline, 6 weeks, 3 and 6 months, and again 6 months following the intervention at 1 year. Group differences were analyzed using linear mixed models analysis. RESULTS At baseline, mean RMDQ scores were 9.2 (95% confidence interval [CI], 8.4-10.0) for glucosamine and 9.7 (95% CI, 8.9-10.5) for the placebo group (P = .37). At 6 months, the mean RMDQ score was the same for the glucosamine and placebo groups (5.0; 95% CI, 4.2-5.8). At 1 year, the mean RMDQ scores were 4.8 (95% CI, 3.9-5.6) for glucosamine and 5.5 (95% CI, 4.7-6.4) for the placebo group. No statistically significant difference in change between groups was found when assessed after the 6-month intervention period and at 1 year: RMDQ (P = .72), LBP at rest (P = .91), LBP during activity (P = .97), and quality-of-life EQ-5D (P = .20). Mild adverse events were reported in 40 patients in the glucosamine group and 46 in the placebo group (P = .48). CONCLUSIONS Among patients with chronic LBP and degenerative lumbar OA, 6-month treatment with oral glucosamine compared with placebo did not result in reduced pain-related disability after the 6-month intervention and after 1-year follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00404079.
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Affiliation(s)
- Philip Wilkens
- Oslo University Hospital, Department of Orthopaedics, FOU, OS, BD, Bygg 73, Kirkeveien 166, Oslo 0460, Norway.
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Terjesen T, Hellum C. [Femoral shortening osteotomy for chronic hip dislocation in patients with cerebral palsy]. Tidsskr Nor Laegeforen 1998; 118:2773-6. [PMID: 9748806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Hip dislocation of several years duration in cerebral palsy needs treatment only if the patient has serious complaints. With the aim of reducing pain and problems with sitting function and perineal hygiene, we performed shortening osteotomy of the femur in 15 patients (12 girls and 3 boys) with spastic quadriplegia or diplegia at mean age of 14 (8-26) years. The patients were severely mentally and physically retarded, and only one patient had gait function, with support. A subtrochanteric shortening osteotomy of 3-5 cm was performed. The mean follow-up period was 5 (1-10) years. The symptomatic effect of the operation was good. The patients and parents were satisfied because the pain disappeared and the patients had less spasticity and stiffness. Complications were seen in two patients in the form of skin necrosis under both heels; this was caused by the plaster. Although reduction of the dislocation was not the aim of the surgery, radiographs at follow-up of 16 operated hips showed that five hips were reduced, whereas 11 hips remained subluxated or dislocated. We conclude that shortening osteotomy of the femur produces good symptomatic effects, probably due to reduction of the abnormally high muscle tension across the hip joint.
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Affiliation(s)
- T Terjesen
- Rikshospitalet, Senter for Ortopedi, Oslo
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Orstavik KH, Tangsrud SE, Nordshus T, Finnanger AM, Hellum C, Gjessing E. Orofaciodigital syndrome type I in a girl with unilateral tibial pseudarthrosis. J Med Genet 1992; 29:827-30. [PMID: 1453437 PMCID: PMC1016182 DOI: 10.1136/jmg.29.11.827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The orofaciodigital syndromes are a group of possibly seven different malformation syndromes including oral, facial, and digital malformations. Type I has X linked dominant inheritance whereas the other types show autosomal recessive inheritance. An exact diagnosis is therefore important for genetic counselling. We here report a girl with orofaciodigital syndrome type I. She had cystic kidney disease at the age of 8 months which has not previously been reported in an infant with orofaciodigital syndrome. In addition she had unilateral tibial pseudarthrosis which has only rarely been reported in the orofaciodigital syndromes and in type II only.
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Affiliation(s)
- K H Orstavik
- Department of Medical Genetics, Ullevaal Hospital, Oslo, Norway
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Reigstad A, Hetland KR, Hellum C. [Replantation of the forearm]. Tidsskr Nor Laegeforen 1985; 105:731-4. [PMID: 4012678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Abstract
Seventeen femoral lengthenings with an observation period of 1 year or more are reviewed. The mean leg length discrepancy was 6.9 cm, ranging from 3.8 to 14.8 cm. Mean lengthening was 5.8 cm, ranging from 3.6 to 10 cm. Osteosynthesis and bone grafting was done in all cases. Nonunion occurred in one lengthening, and five bones refractured. All failures, however, healed after reosteosynthesis. Transient peroneal paresis occurred in two cases, while in one case knee flexion was reduced to 55 degrees. In spite of minor pin-track drainage, no infections complicated the osteosynthesis. It is concluded that the Wagner procedure is an effective and fairly safe method for leg lengthening. Complications, however, are frequent and great caution is essential.
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Abstract
During the last years the advances of neurosurgery and urology have completely changes the prognosis of children with myelomeningocele. To the orthopedic surgeons these patients represent a great challenge in order to correct lower limb deformities, these children have a high incidence of leg fractures. some of the fractures show an unusual pattern of repair, characterized by healing with excessive callus formation which can be confused with tumor, osteomyelitis or other diseases of the bone.
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Abstract
Twenty-three patients with established contractures of the forearm, which were treated by excision of all irreparably damaged muscles, lengthening of the tendons and neurolysis of the median and ulnar nerves, are reported. Fourteen patients were children. Supracondylar fractures of the humerus, all treated by plaster-of-Paris, were associated with 10 contractures. Twelve patients achieved good or normal function of the hand after treatment; 5 had obvious functional disability, 4 achieved only a support function and 2 required forearm amputations. Early treatment improved the functional result. Treatment of displaced supracondylar fractures by traction seemed to be an important prophylactic procedure.
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Hellum C. [Surgical treatment of periarticular diseases]. Tidsskr Nor Laegeforen 1973; 93:2360-4. [PMID: 4771923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Hellum C. [Wrist operations in rheumatoid polyarthritis]. Nord Med 1971; 85:385. [PMID: 5574975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Hellum C, Vainio K. Arthroplasty of the metacarpophalangeal joints in rheumatoid arthritis with transposition of the interosseus muscles. Scand J Plast Reconstr Surg 1968; 2:139-43. [PMID: 5733936 DOI: 10.3109/02844316809010496] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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