Capacitive biophysical stimulation improves the healing of vertebral fragility fractures: a prospective multicentre randomized controlled trial

BACKGROUND

Capacitively coupling electric fields (CCEF) is a method of non-invasive biophysical stimulation that enhances fracture repair and spinal fusion. This multicentre randomized controlled trial aimed to further examine the roles of CCEF in (1) the resolution of vertebral bone marrow oedema (VBME) using a follow-up MRI study and (2) pain relief, analgesic drug consumption and quality of life improvement in stimulated patients who were referred with acute vertebral fragility fractures (VFFs) compared to non-stimulated patients.

METHODS

Between September 2016 and December 2019, patients who were referred to the spine centres that participated in this multicentre randomized clinical study with acute VFFs of type OF1 or OF2 were included in the present study. All the VFFs were conservatively managed according to Good Clinical Practice. Moreover, the patients were randomized into two groups: the CCEF group received, as an adjunct to the clinical study protocol, biophysical stimulation with a CCEF device (Osteospine, IGEA) for 8 h per day for 60 days, whereas the control group was treated according to the clinical study protocol. At baseline (T0), the 30-day follow-up (T1), the 60-day follow-up (T2), and the 6-month follow-up (T3), each patient underwent clinical evaluation using the Visual Analogue Scale (VAS) for Pain and the Oswestry Disability Index (ODI). Analgesic therapy with paracetamol 1000 mg tablets for 7 days-or longer, depending on the pain intensity-was performed; patients were required to report their paracetamol consumption on a specific sheet between study day 8 to 180 days of follow-up. MRI studies of the thoracolumbar spine were performed at 0 (T0), 30 (T1) and 60 days of follow-up (T2) using a 1.5-T MRI system in all of the centres that took part in the study. For each VBME area examined via MRI, the vertebral body geometry (i.e. anterior wall height/posterior wall height and vertebral kyphosis) were assessed.

RESULTS

A total of 66 patients (male: 9, 13.63%; mean age: 73.15 years old) with 69 VFFs were included in the present study and randomized as follows: 33 patients were included in the control group and the remaining 33 patients were randomized into the CCEF group. In the CCEF group, good compliance with CCEF therapy was observed (adherence = 94%), and no adverse effects were recorded. In the stimulated patients, faster VBME resolution and significantly less vertebral body collapse during follow-up were observed compared to the control patients. Moreover, in the active group, faster pain reduction and improvement in the ODI mean score were observed. Stimulated patients also reported a significantly lower paracetamol consumption rate from the third follow-up after treatment until the 6-month follow-up. In terms of sex-related differences, in the CCEF group, VBME showed a faster resolution in male patients compared with females.

CONCLUSION

Biophysical stimulation with CCEF, as an adjunct to traditional conservative treatment, is a useful tool to hasten the VBME resolution process and prevent vertebral body deformation. These MRI findings also correlate with faster back pain resolution and quality of life improvement. From the third follow-up after treatment until the 6-month follow-up, stimulated patients reported a significantly lower paracetamol consumption than control patients, even though back pain and quality of life showed no significant differences between the two groups.

LEVEL OF EVIDENCE

II. Trial Registration Register: ClinicalTrials.gov, number: NCT05803681.

Assessing the quality and reliability of YouTube videos as a source of information on inflammatory back pain

Background

Inflammatory back pain is a chronic condition with localized pain, particularly in the axial spine and sacroiliac joints, that is associated with morning stiffness and improves with exercise. YouTube is the second most frequently used social media platform for accessing health information. This study sought to investigate the quality and reliability of YouTube videos on inflammatory back pain (IBP).

Methods

The study design was planned as cross-sectional. A search was conducted using the term "inflammatory back pain," and the first 100 videos that met the inclusion criteria were selected on October 19, 2023. The data of the videos selected according to the inclusion and exclusion criteria in the study settings were examined. Videos with English language, with audiovisual content , had a duration >30 s, non-duplicated and primary content related to IBP were included in the study. A number of video parameters such as the number of likes, number of views, duration, and content categories were assessed. The videos were assessed for reliability using the Journal of the American Medical Association (JAMA) Benchmark criteria and the DISCERN tool. Quality was assessed using the Global Quality Score (GQS). Continuous variables were checked for normality of distribution using Shapiro-Wilk test and Kolmogorov-Smirnov test. Kruskal-Wallis test and Mann-Whitney U test were used to analyze the continuous data depending on the number of groups. Categorical data were analyzed using Pearson's chi-square test.

Results

Reliability assessment based on JAMA scores showed 21% of the videos to have high reliability. Quality assessment based on GQS results showed 19% of the videos to have high quality. JAMA, DISCERN, and GQS scores differed significantly by source of video (p < 0.001, < 0.001, and = 0.002, respectively). Video duration had a moderate positive correlation with scores from the GQS (r = 0.418, p < 0.001), JAMA (r = 0.484, p < 0.001), and modified DISCERN (r = 0.418, p < 0.001).

Conclusion

The results of the present study showed that YouTube offers videos of low reliability and low quality on inflammatory back pain. Health authorities have a responsibility to protect public health and should take proactive steps regarding health information shared on social media platforms.

Considerations beyond spine pain: do different co-occurring lower body joint pains differentially influence physical function and quality of life ratings?

BACKGROUND

Patients seeking medical care for back pain often have coexisting painful joints and the effects of different combinations and number of coexisting pain sites (hip, knee, foot/ankle) to back pain on physical function domains and quality of life rating are not yet established. The purpose of this study was to determine the differences in functional outcomes and QOL among individuals with back pain who have concurrent additional pain sites or no pain sites.

METHODS

Data from the Osteoarthritis Initiative (OAI) cohort were used for this cross-sectional analysis. Men and women aged 45-79 years with back pain were binned into nine groups by presence or not of coexisting hip, knee, ankle/foot pain and combinations of these sites (N = 1,642). Healthy controls reported no joint pain. Main outcomes included Knee Injury and Osteoarthritis Outcome score (KOOS; quality of life and function-sports-and-recreation), Western Ontario McMaster Universities Osteoarthritis Index (WOMAC; Activities of Daily Living, Pain), Medical Outcomes Short Form-12 (SF-12) Physical Component score, and self-reported function in last 7-30 days (lifting 25-pound objects, housework). 20-m and 400-m walk times and gait speed and repeated chair rise test times were collected.

RESULTS

Compared to back pain alone, pain at all five sites was associated with 39%-86% worse KOOS, WOMAC, and SF-12 scores (p < .0001). Back-Hip and Back-Knee did not produce worse scores than Back pain alone, but Back-Hip-Knee and Back-Knee-Ankle/Foot did. The 20-m, 400-m walk, and repeated chair times were worse among individuals with pain at all five sites. Additional hip and knee sites to back pain, but not ankle/foot, worsened performance-based walk times and chair rise scores.

CONCLUSIONS

The number and type of coexistent lower body musculoskeletal pain among patients with back pain may be associated with perceived and performance-based assessments. Management plans that efficiently simultaneously address back and additional coexistent pain sites may maximize treatment functional benefits, address patient functional goals in life and mitigate disability.

Pain alleviation and functional improvement: ultra-early patient-reported outcome measures after full endoscopic spine surgery

OBJECTIVE

Questions regarding anticipated pain improvement and functional recovery postsurgery are frequently posed in preoperative consultations. However, a lack of data characterizing outcomes for the first postoperative days only allows for anecdotal answers. Hence, the assessment of ultra-early patient-reported outcome measures (PROMs) is essential for patient-provider communication and patient satisfaction. The aim of this study was to elucidate this research gap by assessing and characterizing PROMs for the first days after full endoscopic spine surgery (FESS).

METHODS

This multicenter study included patients undergoing lumbar FESS from March 2021 to July 2023. After informed consent was provided, data were collected prospectively through a smartphone application. Patients underwent either discectomy or decompression. Analyzed parameters included demographics, surgical details, visual analog scale scores for both back and leg pain, and the Oswestry Disability Index (ODI) score. Data were acquired daily for the 1st postoperative week, as well as after 2 weeks, 3 months, and 6 months.

RESULTS

A total of 182 patients were included, of whom 102 underwent FESS discectomy and 80 underwent FESS decompression. Significant differences between the discectomy and decompression groups were found for age (mean 50.45 ± 15.28 years and 63.85 ± 13.25 years, p < 0.001; respectively), sex (p = 0.007), and surgery duration (73.45 ± 45.23 minutes vs 98.05 ± 46.47 minutes, p < 0.001; respectively). Patients in both groups reported a significant amelioration of leg pain on the 1st postoperative day (discectomy group VAS score: 6.2 ± 2.6 vs 2.4 ± 2.9, p < 0.001; decompression group: 5.3 ± 2.8 vs 1.9 ± 2.2, p < 0.001) and of back pain within the 1st postoperative week (discectomy group VAS score: 5.5 ± 2.8 vs 2.8 ± 2.2, p < 0.001; decompression group: 5.2 ± 2.7 vs 3.1 ± 2.4, p < 0.001). ODI score improvement was most pronounced at the 3-month time point (discectomy group: 21.7 ± 9.1 vs 9.3 ± 9.1, p < 0.001; decompression group: 19.3 ± 7.8 vs 9.9 ± 8.3, p < 0.001). For both groups, pain improvement within the 1st week after surgery was highly predictive of later benefits.

CONCLUSIONS

Ultra-early PROMs reveal an immediate pain improvement after FESS. While the benefits in pain reduction plateaued within the 1st postoperative week for both groups, functional improvements developed over a more extended period. These results illustrate a biphasic rehabilitation process wherein initial pain alleviation transitions into functional improvement over time.

Bone scintigraphy with SPECT/CT in paediatric patients with neck and back pain in comparison with other imaging modalities: the experience of a tertiary paediatric referral centre

OBJECTIVE

Retrospective review of the additional clinical value provided by single photon emission computed tomography-computed tomography (SPECT/CT) in children and adolescents with back pain.

METHODS

A total of 207 consecutive paediatric patients (94 males, 113 females, age range 5-17 years, median age 14 years) were reviewed after referral to the spinal surgery clinic of a paediatric teaching hospital between November 2009 and February 2021. All patients had either only whole spine X-rays or whole spine x-rays and MRI, along with bone scan with planar whole-body images and SPECT/CT (with spot views of painful area).

RESULTS

X-ray identified the pain generator in 23 of 177 (13.0%) cases. MRI identified the pain generator in 49 of 165 (29.7%) cases. SPECT/CT reported relevant positive findings which identified the pain generator in 107 of 185 (57.8%) cases. SPECT/CT changed patients' management in 72 of 185 (38.9%) cases. SPECT/CT was most effective at identifying the pain generator in cases of facet arthropathy, previous vertebral fracture and patients with previous deformity correction, where the pain generator was identified in 76.5% (13 of 17), 71.4% (5 of 7) and 63.4% (26 of 41) of cases, respectively. CT settings were adjusted to minimise the radiation burden (50 mAs/80kVp under 8 years, 24 mAs/110 kVp over 8 years).

CONCLUSION

The role of SPECT/CT in diagnosing back pain is justified in selected paediatric patients, particularly with diagnostic uncertainty using conventional imaging. The CT component of the SPECT/CT study produced a lower radiation dose than conventional CT imaging, whilst producing bone images of diagnostic quality.

Comparative effectiveness of paravertebral Ozone injection and caudal epidural steroid-hyaluronidase injection in lumbosacral spinal stenosis

BACKGROUND

Lumbosacral spinal stenosis (LSS) is the narrowing of the lumbar spinal canal. LSS usually happens in older people who do not have the proper physical condition to undergo surgery. Therefore, minimally invasive methods such as Ozone therapy and epidural injection can be used in these patients.

OBJECTIVE

The objective this study was to compare the effect of caudal epidural steroid-hyaluronidase injection with paravertebral intramuscular Ozone injection on reducing pain in patients with LSS.

METHODS

A total of 30 patients suffering from LSS randomized to two groups. Group A (n = 15) received three paravertebral intramuscular infiltrations of the Ozone, Group B (n = 15) received a caudal epidural injection of steroid-hyaluronidase. The effects of the interventions were evaluated by measuring Visual analog scale (VAS), Oswestry Disability index (ODI), Quebec Back Pain Disability (QBPDS) and Roland Morris low back pain questionnaire (RMQ) before the interventions and at 2 weeks, 4 weeks, and 8 weeks after the interventions.

RESULTS

Within-group changes showed significant improvement in VAS, ODI, RMQ, and QBPDS scores in both groups from pre-treatment to end of follow-up (all p < 0.05). The mean VAS score at all follow-up had significant differences between the two groups (p < 0.01). The mean ODI, RMQ, and QBPDS scores at 2-week and 4-week had significant differences between the two groups (p < 0.01). At the 8-week follow-up, there was no significant difference between groups concerning mean ODI, RMQ, and QBPDS scores (p > 0.05).

CONCLUSION

Both intramuscular injection Ozone and caudal epidural injection steroid- hyalaz significantly reduce pain. The existing data suggested 8 weeks improvements in pain severity are more significant for paravertebral Ozone injection, compared to caudal epidural steroid-hyaluronidase injection.

Automated entry of paper-based patient-reported outcomes: Applying deep learning to the Japanese orthopaedic association back pain evaluation questionnaire

BACKGROUND

Health-related patient-reported outcomes (HR-PROs) are crucial for assessing the quality of life among individuals experiencing low back pain. However, manual data entry from paper forms, while convenient for patients, imposes a considerable tallying burden on collectors. In this study, we developed a deep learning (DL) model capable of automatically reading these paper forms.

METHODS

We employed the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, a globally recognized assessment tool for low back pain. The questionnaire comprised 25 low back pain-related multiple-choice questions and three pain-related visual analog scales (VASs). We collected 1305 forms from an academic medical center as the training set, and 483 forms from a community medical center as the test set. The performance of our DL model for multiple-choice questions was evaluated using accuracy as a categorical classification task. The performance for VASs was evaluated using the correlation coefficient and absolute error as regression tasks.

RESULT

In external validation, the mean accuracy of the categorical questions was 0.997. When outputs for categorical questions with low probability (threshold: 0.9996) were excluded, the accuracy reached 1.000 for the remaining 65 % of questions. Regarding the VASs, the average of the correlation coefficients was 0.989, with the mean absolute error being 0.25.

CONCLUSION

Our DL model demonstrated remarkable accuracy and correlation coefficients when automatic reading paper-based HR-PROs during external validation.

We Are All in This Together-Whole of Community Pain Science Education Campaigns to Promote Better Management of Persistent Pain

Persistent pain is a major public health issue-estimated to affect a quarter of the world's population. Public understanding of persistent pain is based on outdated biomedical models, laden with misconceptions that are contrary to best evidence. This understanding is a barrier to effective pain management. Thus, there have been calls for public health-based interventions to address these misconceptions. Previous pain-focussed public education campaigns have targeted pain beliefs and behaviours that are thought to promote recovery, such as staying active. However, prevailing pain-related misconceptions render many of these approaches counter-intuitive, at best. Pain Science Education improves understanding of 'how pain works' and has been demonstrated to improve pain and disability outcomes. Extending Pain Science Education beyond the clinic to the wider community seems warranted. Learning from previous back pain-focussed and other public health educational campaigns could optimise the potential benefit of such a Pain Science Education campaign. Pain Science Education-grounded campaigns have been delivered in Australia and the UK and show promise, but robust evaluations are needed before any firm conclusions on their population impact can be made. Several challenges exist going forward. Not least is the need to ensure all stakeholders are involved in the development and implementation of Pain Science Education public messaging campaigns. Furthermore, it is crucial that campaigns are undertaken through a health equity lens, incorporating underrepresented communities to ensure that any intervention does not widen existing health inequalities associated with persistent pain. PERSPECTIVE: Public misconceptions about pain are a significant public health challenge and a viable intervention target to reduce the personal, social, and economic burden of persistent pain. Adaptation of Pain Science Education, which improves misconceptions in a clinical setting, into the public health setting seems a promising approach to explore.

Placement of a Kickstand Rod in Adult Spinal Deformity Surgery: A Simple 8-Step Process With Intraoperative Images and Video

BACKGROUND AND OBJECTIVES

In adult spinal deformity (ASD) surgery, operative correction of coronal malalignment remains a challenging surgical task. Given the proven effectiveness and longevity of the kickstand rod (KSR) technique and its powerful ability to correct coronal malalignment, this technique is an important tool to have available. Therefore, we sought to provide a simple 8-step description of the KSR technique using intraoperative images and video in a patient undergoing combined sagittal and coronal malalignment correction.

METHODS

A 68-year-old female with a previous history of T11-S1 posterior spinal fusion presented with mid thoracic back pain, leg paresthesias, and a right-leaning posture. The patient underwent a T4-pelvis extension of fusion, T8-11 posterior column osteotomies, and placement of a right-sided KSR to address her coronal malalignment.

RESULTS

The KSR technique is summarized in the following steps: (1) place kickstand screw, (2) place contralateral main rod and tighten all set plugs, (3) place ipsilateral main rod and keep rod long distally, (4) place a domino in the lower/mid thoracic area, (5) place the KSR and leave the rod long proximally, (6) tighten the ipsilateral main rod above the domino, (7) loosen the ipsilateral main rod below the domino, and (8) place a rod gripper below the domino and distract. Postoperatively, the coronal vertical axis improved from 4.8 to 0.6 cm, and the sagittal vertical axis improved from 9.5 to 3.9 cm.

CONCLUSION

The current case report provides a simple 8-step description of the KSR technique to improve coronal malalignment accompanied by intraoperative images and video.

[Comparison of pain intensity measurements among patients with low-back pain]

Background and purpose

Pain intensity is the most frequently assessed health domain in clinical studies among patients with low-back pain. Visual analogue scale (VAS) and Numeric rating scale (NRS) have been the mostly used measurement tools for pain intensity. We proposed to correlate these instruments to a generic health-related quality of life measurement tool in order to show the scale with superior clinical relevance.

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Methods

We used cross-sectional, convenience sampling. 120 patients with chronic low-back pain administered the 29-item Patient Reported Outcomes Measurement Information System Profile with NRS included, and the VAS scale in the National Institute of Mental Health, Neurology and Neurosurgery. We determined the correlation between PROMIS domain T-scores and VAS and NRS scores.

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Results

We performed Spearman rank correlation test to calculate the correlation coefficient. We found VAS scales measuring pain had weak to moderate correlations with all PROMIS health domains (r = 0.24–0.55). Therefore, we compared correlation of PROMIS domain scores with PROMIS pain intensity numeric rating scale and VAS scales. PROMIS domains had moderate to strong correlations with pain intensity scale (r = 0.45–0.71). PROMIS physical function short form [r = –0.65, 95% CI (–0.75) – (–0.55)] and PROMIS pain interference short form (r = 0.71, 95% CI 0.63 – 0.79) had the strongest correlation with pain intensity item.

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Conclusion

NRS has showed greater correlation with PROMIS domain T-scores than VAS scale. This may prove that NRS has greater connection to another health domains, thus it correlated more to health-related quality of life than visual scale. We recommend NRS to use in further clinical studies conducted among patients with low-back pain.

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Relationships between the Spinal Dural Pulsations and the Short-Term Efficacy of Lumbar Epidural Steroid Injection

Background

Lumbar spinal stenosis (LSS) causes low back pain, leg pain, numbness in the leg, and neurogenic intermittent claudication. Epidural steroid injection (ESI) has been used for treating spinal stenosis symptoms. We hypothesized that dural pulsation was variable for lumbar spinal stenosis. In cases of the presence of dural pulsation, the pain relief after the ESI was better than in the absence of dural pulsation. This study aimed at investigating the relationships between the presence or absence of spinal dural pulsations and the efficacy of ESI.

Methods

A total of 71 patients were enrolled in this prospective study. Prior to the ESI, the dural pulsation was measured using a 5-1 MHz array ultrasound transducer. The visual analogue scale (VAS) score was measured pre-ESI and 2 weeks post-ESI and 4 weeks post-ESI. At 4 weeks post-ESI, dural pulsation was rechecked.

Results

The VAS scores improved after the ESI procedure regardless of the presence or absence of dural pulsation. There was a correlation between the pulsation of the dura and post-ESI VAS scores. However, VAS was not significantly different for different grades of stenosis.

Conclusion

The ESI was effective in patients with spinal stenosis in short-term follow-up. Dural pulsation of the spinal cord was a positive predictive factor for the ESI effect, but the grade of spinal stenosis severity had no effect on the effectiveness of ESI.

Distinctive Characteristics of Thoracolumbar Junction Region Stenosis

STUDY DESIGN

Retrospective case series and systemic literature meta-analysis.

BACKGROUND

Thoracolumbar junction region stenosis produces spinal cord compression just above the conus and may manifest with symptoms that are not typical of either thoracic myelopathy or neurogenic claudication from lumbar stenosis.

OBJECTIVE

As few studies describe its specific pattern of presenting symptoms and neurological deficits, this investigation was designed to improve understanding of this pathology.

METHODS

A retrospective review assessed surgically treated cases of T10-L1 degenerative stenosis. Clinical outcomes were evaluated with the thoracic Japanese Orthopedic Association score. In addition, a systematic review and meta-analysis was performed in accordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Of 1069 patients undergoing laminectomy at 1477 levels, 31 patients (16M/15F) were treated at T10-L1 a mean age 64.4 (SD=11.8). Patients complained of lower extremity numbness in 29/31 (94%), urinary dysfunction 11/31 (35%), and back pain 11/31 (35%). All complained about gait difficulty and objective motor deficits were detected in 24 of 31 (77%). Weakness was most often seen in foot dorsiflexion 22/31 (71%). Deep tendon reflexes were increased in 10 (32%), decreased in 11 (35%), and normal 10 (32%); the Babinski sign was present 8/31 (26%). Mean thoracic Japanese Orthopedic Association scores improved from 6.4 (SD=1.8) to 8.4 (SD=1.8) ( P <0.00001). Gait subjectively improved in 27/31 (87%) numbness improved in 26/30 (87%); but urinary function improved in only 4/11 (45%).

CONCLUSIONS

Thoracolumbar junction stenosis produces distinctive neurological findings characterized by lower extremity numbness, weakness particularly in foot dorsiflexion, urinary dysfunction, and inconsistent reflex changes, a neurological pattern stemming from epiconus level compression and the myelomeres for the L5 roots. Surgery results in significant clinical improvement, with numbness and gait improving more than urinary dysfunction. Many patients with thoracolumbar junction stenosis are initially misdiagnosed as being symptomatic from lumbar stenosis, thus delaying definitive surgery.

Incremental Contribution of the Minnesota Multiphasic Personality Inventory - 3 to Predicting One-Year Postoperative Spinal Cord Surgery/Spinal Cord Stimulation Outcomes

Pre-surgical psychological assessments are becoming common in the United States and are recommended or required prior to surgical/spinal cord stimulator intervention for chronic back pain. Psychological testing is often recommended for these evaluations and the various versions of the Minnesota Multiphasic Personality Inventory (MMPI) have demonstrated utility for predicting outcomes in this setting. This investigation sought to extend that literature with the newest version of the MMPI, the MMPI-3. The sample comprised of 909 patients (50.5% men, 49.5% women) who consented to participating in an outcome study and took the MMPI-3 along with other self-report measures of pain, functional disability, and emotional functioning prior to surgery as part of their pre-surgical psychological assessment. Self-report measures of pain, functional disability, and emotional functioning were administered again one-year following the intervention. MMPI-3 scale scores accounted for up to 9% of additional variance in the outcomes after controlling for pre-surgical measures. Measures of emotional/internalizing dysfunction, somatic dysfunction, and, to a lesser extent, behavioral/externalizing dysfunction contributed the most to the prediction of poorer outcomes.

Application of a Clinical Approach to Diagnosing Primary Pain: Prevalence and Correlates of Primary Back and Neck Pain in a Community Physiatry Clinic

Chronic back or neck pain (CBNP) can be primary (nociplastic or neuroplastic; without clear peripheral etiology) or secondary (to nociceptive or neuropathic causes). Expanding on available models of nociplastic pain, we developed a clinic-ready approach to diagnose primary/nociplastic pain: first, a standard physical exam and review of imaging to rule out secondary pain; and second, a detailed history of symptom presentation to rule in primary pain. We trained a physician who evaluated 222 patients (73.9% female, age M = 59.6) with CBNP; patients separately completed pain and psychosocial questionnaires. We estimated the prevalence of primary CBNP and explored biomedical, imaging, and psychological correlates of primary CBNP. Although almost all patients (97.7%) had at least 1 spinal anomaly on imaging, the diagnostic approach estimated that 88.3% of patients had primary pain, 5.0% had secondary pain, and 6.8% had mixed pain. Patients with primary pain were more likely than the other 2 groups of patients (combined as "non-primary pain") to report certain functional conditions, central sensitization, and features such as sensitivity to light touch, spreading pain, and pain worsening with stress; however, no difference was detected in depression, anxiety, and pain catastrophizing between those with primary and nonprimary pain. These findings are consistent with prior estimates that 85 to 90% of CBNP is "nonspecific." Further research is needed to validate and perhaps refine this diagnostic approach, which holds the potential for better outcomes if patients are offered treatments targeted to primary pain, such as pain neuroscience education and several emerging psychological therapies. PERSPECTIVE: We developed an approach to diagnose chronic primary pain, which was applied in a physiatry clinic to 222 patients with CBNP. Most patients (88.3%) had primary pain, despite almost universal anomalies on spinal imaging. This diagnostic approach can guide educational and psychological treatments tailored for primary pain.

The Oswestry Disability Index is reflective of pain interference and mobility in children

PURPOSE

The 9-item Oswestry Disability Index version 2.1a (ODI-9) has never been formally validated in children. Our primary purpose was to evaluate the ODI-9 using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Pain Interference (PI) and Mobility Computer Adapted Test (CAT) and Pain Catastrophizing Scale for Children (PCS-C) as anchors to determine concurrent validity in children.

METHODS

We retrospectively reviewed cross-sectional patient-reported outcomes data using a convenience sample of children referred to a tertiary pediatric orthopedic institution for any spine condition from April 2021 to April 2022. The ODI-9, PI, and Mobility were completed at clinic intake in 2,097 children (1453 girls, 644 boys) aged 14.2 ± 2.6 years (range 5-18 years) during the same visit. The ODI-9 was administered when children or caregivers responded "yes" to the presence of back pain. The PCS-C was administered only when pain intensity was rated as "very severe" or "the worst imaginable" on Item 1 of the ODI-9 (n = 51).

RESULTS

Average ODI-9 scores were 18.3% ± 14.8%, indicating minimal disability (ODI-9 ≤ 20%). Moderate, statistically and clinically significant associations were seen between the ODI-9 and PI (r = 0.68, p < 0.001), the ODI-9 and Mobility (r = - 0.68, p < 0.001), and the ODI-9 and PCS-C (r = 0.59, p < 0.001).

CONCLUSION

Worse ODI-9 scores correlate with worse PROMIS PI scores, worse PROMIS Mobility scores, and worse PCS-C scores. The associations were moderate (PROMIS PI [r = 0.68], PROMIS Mobility [r = - 0.68], PCS-C [r = 0.59]).

Effect of gender on the evolution of pain and quality of life after treatment of symptomatic vertebral fragility fractures

The evolution of pain and quality of life after a symptomatic vertebral fracture differs according to patient gender, with a worse evolution in women independently of the treatment received.

PURPOSE

In a previous randomized clinical study comparing the effect of vertebroplasty (VP) vs. conservative therapy (CT) on pain evolution and quality of life (QoL) of patients with symptomatic vertebral fractures (VF), we observed the development of chronic back pain in 23% of subjects, independently of the therapy received. This study analyses the effect of gender on the evolution of pain and QoL in these subjects.

METHODS

118/125 randomized patients (27 males/91 females) with recent symptomatic VFs were evaluated. All received a standardized analgesic and antiosteoporotic format of treatment. Pain and QoL were evaluated by VAS and Qualeffo-41, respectively, at baseline, at 2 weeks and 2 and 6 months. We compared pain evolution and QoL after treatment (CT vs. VP) according to gender, and analysed factors including age, time of evolution, treatment received, baseline VAS, previous VFs (total and recent), incidental VFs, lumbar and femoral T-scores, and analgesic and antiosteoporotic treatment.

RESULTS

At baseline, there were no differences in age (males 74.8 ± 11.2 vs. females:73.2 ± 8.7 years), time of evolution, number of VFs (males:3.8 ± 2.4 vs. females: 3.1 ± 2.4), treatment received (VP, males:59%, females:45%), lumbar or femoral T-score, baseline VAS (males:6.8 ± 2.1 vs. females:6.8 ± 2.2) or Qualeffo score (males:52.2 ± 24.4 vs. females:59.7 ± 20.6). Pain and QoL evolution differed according to gender, being better in males. These differences were significant after two months independently of the treatment and the development of incidental VF during follow-up.

CONCLUSIONS

Pain and QoL evolution after a symptomatic VF differs according to gender, with a worse evolution in women independently of the treatment received.

Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials

BACKGROUND AND OBJECTIVE

Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder characterized by the presence of trigger points. Among the treatment options, botulinum toxin injections have been investigated. The aim of this paper was to provide a synthesis of the evidence on intramuscular botulinum toxin injections for upper back MPS.

DATABASES AND DATA TREATMENT

A systematic review of the literature was performed on the PubMed, Scopus and Cochrane Library, using the following formula: ("botulinum") AND ("musculoskeletal") AND ("upper back pain") OR ("myofascial pain").

RESULTS

Ten studies involving 651 patients were included. Patients in the control groups received placebo (saline solution) injections, anaesthetic injections + dry needling or anaesthetic injections. The analysis of the trials revealed modest methodological quality: one "Good quality" study, one "Fair" and the other "Poor". No major complications or serious adverse events were reported. Results provided conflicting evidence and did not demonstrate the superiority of botulinum toxin over comparators. Most of the included trials were characterized by a small sample size, weak power analysis, different clinical scores used and non-comparable follow-up periods. Even if there is no conclusive evidence, the favourable safety profile and the positive results of some secondary endpoints suggest a potentially beneficial action in pain control and quality of life.

CONCLUSION

The currently available studies show conflicting results. Their overall low methodological quality does not allow for solid evidence of superiority over other comparison treatments. Further insights are needed to properly profile patients who could benefit more from this peculiar injective approach.

SIGNIFICANCE

The randomized controlled trials included in this review compared using botulinum toxin to treat upper back MPS with placebo or active treatments (e.g., dry needling or anaesthetics) showing mixed results overall. Despite the lack of clear evidence of superiority, our study suggests that the use of botulinum toxin should not be discouraged. Its safety profile and encouraging results in pain control, motor recovery and disability reduction make it an interesting treatment, particularly in the subset of patients with moderate to severe chronic pain and active trigger points. To support the safety and efficacy of botulinum toxin, further high-quality studies are needed.

Incidence of Severe Adverse Drug Reactions to Ultrasound Enhancement Agents in a Contemporary Echocardiography Practice

OBJECTIVES

Prior data indicate a very rare risk of serious adverse drug reaction (ADR) to ultrasound enhancement agents (UEAs). We sought to evaluate the frequency of ADR to UEA administration in contemporary practice.

METHODS

We retrospectively reviewed 4 US health systems to characterize the frequency and severity of ADR to UEA. Adverse drug reactions were considered severe when cardiopulmonary involvement was present and critical when there was loss of consciousness, loss of pulse, or ST-segment elevation. Rates of isolated back pain and headache were derived from the Mayo Clinic Rochester stress echocardiography database where systematic prospective reporting of ADR was performed.

RESULTS

Among 26,539 Definity and 11,579 Lumason administrations in the Mayo Clinic Rochester stress echocardiography database, isolated back pain or headache was more frequent with Definity (0.49% vs 0.04%, P < .0001) but less common with Definity infusion versus bolus (0.08% vs 0.53%, P = .007). Among all sites there were 201,834 Definity and 84,943 Lumason administrations. Severe and critical ADR were more frequent with Lumason than with Definity (0.0848% vs 0.0114% and 0.0330% vs 0.0010%, respectively; P < .001 for each). Among the 3 health systems with >2,000 Lumason administrations, the frequency of severe ADR with Lumason ranged from 0.0755% to 0.1093% and the frequency of critical ADR ranged from 0.0293% to 0.0525%. Severe ADR rates with Definity were stable over time but increased in more recent years with Lumason (P = .02). Patients with an ADR to Lumason since the beginning of 2021 were more likely to have received a COVID-19 vaccination compared with matched controls (88% vs 75%; P = .05) and more likely to have received Moderna than Pfizer-Biotech (71% vs 26%, P < .001).

CONCLUSION

Severe and critical ADR, while rare, were more frequent with Lumason, and the frequency has increased in more recent years. Additional work is needed to better understand factors, including associations with recently developed mRNA vaccines, which may be contributing to the increased rates of ADR to UEA since 2021.

Performance of ChatGPT Compared to Clinical Practice Guidelines in Making Informed Decisions for Lumbosacral Radicular Pain: A Cross-sectional Study

OBJECTIVE: To compare the accuracy of an artificial intelligence chatbot to clinical practice guidelines (CPGs) recommendations for providing answers to complex clinical questions on lumbosacral radicular pain. DESIGN: Cross-sectional study. METHODS: We extracted recommendations from recent CPGs for diagnosing and treating lumbosacral radicular pain. Relative clinical questions were developed and queried to OpenAI's ChatGPT (GPT-3.5). We compared ChatGPT answers to CPGs recommendations by assessing the (1) internal consistency of ChatGPT answers by measuring the percentage of text wording similarity when a clinical question was posed 3 times, (2) reliability between 2 independent reviewers in grading ChatGPT answers, and (3) accuracy of ChatGPT answers compared to CPGs recommendations. Reliability was estimated using Fleiss' kappa (κ) coefficients, and accuracy by interobserver agreement as the frequency of the agreements among all judgments. RESULTS: We tested 9 clinical questions. The internal consistency of text ChatGPT answers was unacceptable across all 3 trials in all clinical questions (mean percentage of 49%, standard deviation of 15). Intrareliability (reviewer 1: κ = 0.90, standard error [SE] = 0.09; reviewer 2: κ = 0.90, SE = 0.10) and interreliability (κ = 0.85, SE = 0.15) between the 2 reviewers was "almost perfect." Accuracy between ChatGPT answers and CPGs recommendations was slight, demonstrating agreement in 33% of recommendations. CONCLUSION: ChatGPT performed poorly in internal consistency and accuracy of the indications generated compared to clinical practice guideline recommendations for lumbosacral radicular pain. J Orthop Sports Phys Ther 2024;54(3):1-7. Epub 29 January 2024. doi:10.2519/jospt.2024.12151.

Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.

Therapeutic exercises for idiopathic scoliosis in adolescents

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a pathology that changes the three-dimensional shape of the spine and trunk. While AIS can progress during growth and cause cosmetic issues, it is usually asymptomatic. However, a final spinal curvature above the critical threshold of 30° increases the risk of health problems and curve progression in adulthood. The use of therapeutic exercises (TEs) to reduce the progression of AIS and delay or avoid other, more invasive treatments is still controversial.

OBJECTIVES

To evaluate the effectiveness of TE, including generic therapeutic exercises (GTE) and physiotherapeutic scoliosis-specific exercises (PSSE) in treating AIS, compared to no treatment, other non-surgical treatments, or between treatments.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, and two clinical trials registers to 17 November 2022. We also screened reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing TE with no treatment, other non-surgical treatments (braces, electrical stimulation, manual therapy), and different types of exercises. In the previous version of the review, we also included observational studies. We did not include observational studies in this update since we found sufficient RCTs to address our study aims.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. Our major outcomes were progression of scoliosis (measured by Cobb angle, trunk rotation, progression, bracing, surgery), cosmetic issues (measured by surface measurements and perception), and quality of life (QoL). Our minor outcomes were back pain, mental health, and adverse effects.

MAIN RESULTS

We included 13 RCTs (583 participants). The percentage of females ranged from 50% to 100%; mean age ranged from 12 to 15 years. Studies included participants with Cobb angles from low to severe. We judged 61% of the studies at low risk for random sequence generation and 46% at low risk for allocation concealment. None of the studies could blind participants and personnel. We judged the subjective outcomes at high risk of performance and detection bias, and the objective outcomes at high risk of detection bias in six studies and at low risk of bias in the other six studies. One study did not assess any objective outcomes. Comparing TE versus no treatment, we are very uncertain whether TE reduces the Cobb angle (mean difference (MD) -3.6°, 95% confidence interval (CI) -5.6 to -1.7; 2 studies, 52 participants). Low-certainty evidence indicates PSSE makes little or no difference in the angle of trunk rotation (ATR) (MD -0.8°, 95% CI -3.8 to 2.1; 1 study, 45 participants), may reduce the waist asymmetry slightly (MD -0.5 cm, 95% CI -0.8 to -0.3; 1 study, 45 participants), and may result in little to no difference in the score of cosmetic issues measured by the Spinal Appearance Questionnaire (SAQ) General (MD 0.7 points, 95% CI -0.1 to 1.4; 1 study, 16 participants). PSSE may result in little to no difference in self-image measured by the Scoliosis Research Society - 22 Patient Questionnaire (SRS-22) (MD 0.3 points, 95% CI -0.3 to 0.9; 1 study, 16 participants) and improve QoL slightly measured by SRS-22 Total score (MD 0.3 points, 95% CI 0.1 to 0.4; 2 studies, 61 participants). Only Cobb angle results were clinically meaningful. Comparing PSSE plus bracing versus bracing, low-certainty evidence indicates PSSE plus bracing may reduce Cobb angle (-2.2°, 95% CI -3.8 to -0.7; 2 studies, 84 participants). Comparing GTE plus other non-surgical interventions versus other non-surgical interventions, low-certainty evidence indicates GTE plus other non-surgical interventions may reduce Cobb angle (MD -8.0°, 95% CI -11.5 to -4.5; 1 study, 80 participants). We are uncertain whether PSSE plus other non-surgical interventions versus other non-surgical interventions reduces Cobb angle (MD -7.8°, 95% CI -12.5 to -3.1; 1 study, 18 participants) and ATR (MD -8.0°, 95% CI -12.7 to -3.3; 1 study, 18 participants). PSSE plus bracing versus bracing alone may make little to no difference in subjective measurement of cosmetic issues as measured by SAQ General (-0.2 points, 95% CI -0.9 to 0.5; 1 study, 34 participants), self-image score as measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -0.3 to 0.5; 1 study, 34 participants), and QoL measured by SRS-22 Total score (MD 0.2 points, 95% CI -0.1 to 0.5; 1 study, 34 participants). None of these results were clinically meaningful. Comparing TE versus bracing, we are very uncertain whether PSSE allows progression of Cobb angle (MD 2.7°, 95% CI 0.3 to 5.0; 1 study, 60 participants), changes self-image measured by SRS-22 Self-Image (MD 0.1 points, 95% CI -1.0 to 1.1; 1 study, 60 participants), and QoL measured by SRS-22 Total score (MD 3.2 points, 95% CI 2.1 to 4.2; 1 study, 60 participants). None of these results were clinically meaningful. Comparing PSSE with GTE, we are uncertain whether PSSE makes little or no difference in Cobb angle (MD -3.0°, 95% CI -8.2 to 2.1; 4 studies, 192 participants; very low-certainty evidence). PSSE probably reduces ATR (clinically meaningful) (-MD 3.0°, 95% CI -3.4 to -2.5; 2 studies, 138 participants). We are uncertain about the effect of PSSE on QoL measured by SRS-22 Total score (MD 0.26 points, 95% CI 0.11 to 0.62; 3 studies, 168 participants) and on self-image measured by SRS-22 Self-Image and Walter Reed Visual Assessment Scale (standardised mean difference (SMD) 0.77, 95% CI -0.61 to 2.14; 3 studies, 168 participants). Further, low-certainty evidence indicates that 38/100 people receiving GTE may progress more than 5° Cobb versus 7/100 receiving PSSE (risk ratio (RR) 0.19, 95% CI 0.67 to 0.52; 1 study, 110 participants). None of the included studies assessed adverse effects.

AUTHORS' CONCLUSIONS

The evidence on the efficacy of TE is currently sparse due to heterogeneity, small sample size, and many different comparisons. We found only one study following participants to the end of growth showing the efficacy of PSSE over TE. This result was weakened by adding studies with short-term results and unclear preparation of treating physiotherapists. More RCTs are needed to strengthen the current evidence and study other highly clinically relevant outcomes such as QoL, psychological and cosmetic issues, and back pain.

Socioeconomic variation in the prevalence of pain by anatomical sites among middle-aged and older adults in India: a cross-sectional study

BACKGROUND

Pain is a significant global public health concern, particularly among individuals aged 45 and above. Its impact on the overall lifestyle of the individuals varies depending on the affected anatomical parts. Despite its widespread impact, there is limited awareness of the attributes of pain, making effective pain management challenging, particularly in India. This study aims to estimate the prevalence and variation in pain in different anatomical sites among middle-aged and older adults in India.

METHODS

A cross-sectional design was employed, utilising data from the first wave of the Longitudinal Aging Study in India (LASI), 2017-2018. The age-sex adjusted prevalence of pain by anatomical sites (the back, joints, and ankles) was estimated using a multivariate logistic regression model.

RESULTS

47% of individuals aged 45 years and above reported joint pain, 31% reported back pain and 20% suffered from ankle or foot pain. The prevalence of pain at all the anatomical sites increased with age and was reported higher among females. Relative to respondents aged 45-59 years, those aged 75 years and older exhibited a 41% higher likelihood of experiencing back pain (AOR: 1.41, 95% CI: 1.19-1.67), a 67% higher likelihood of joint pain (AOR: 1.67, 95% CI: 1.49-1.89), and a 32% higher likelihood of ankle/foot pain (AOR: 1.32, 95% CI: 1.16-1.50). In comparison to males, females had a 56% higher likelihood of encountering back pain (AOR: 1.56, 95% CI: 1.40-1.74), a 38% higher likelihood of joint pain (AOR: 1.38, 95% CI: 1.27-1.50), and a 35% higher likelihood of ankle/foot pain (AOR: 1.35, 95% CI: 1.17-1.57). We also found significant regional variations in pain prevalence, with higher rates in the mountainous regions of India.

CONCLUSION

This research highlights the high burden of pain in major anatomical sites among middle-aged and older adults in India and emphasises the need for increased awareness and effective pain management strategies.

Window of opportunity in psoriatic arthritis: the earlier the better?

OBJECTIVES

To investigate whether there is a window of opportunity for psoriatic arthritis (PsA) patients and to assess which patient characteristics are associated with a longer diagnostic delay.

METHODS

All newly diagnosed, disease-modifying antirheumatic drug-naïve PsA patients who participated in the Dutch southwest Early PsA cohoRt and had ≥3 years of follow-up were studied. First, total delay was calculated as the time period between symptom onset and PsA diagnosis made by a rheumatologist and then split into patient and physician delays. The total delay was categorised into short (<12 weeks), intermediate (12 weeks to 1 year) or long (>1 year). These groups were compared on clinical (Minimal Disease Activity (MDA) and Disease Activity index for PSoriatic Arthritis (DAPSA) remission) and patient-reported outcomes during 3 years follow-up.

RESULTS

708 PsA patients were studied of whom 136 (19%), 237 (33%) and 335 (47%) had a short, intermediate and long total delay, respectively. Patient delay was 1.0 month and physician delay was 4.5 months. Patients with a short delay were more likely to achieve MDA (OR 2.55, p=0.003) and DAPSA remission (OR 2.35,p=0.004) compared with PsA patients with a long delay. Patient-reported outcomes showed numerical but non-significant differences between the short and long delay groups. Female patients and those presenting with enthesitis, chronic back pain or normal C-reactive protein (CRP) had a longer delay.

CONCLUSIONS

In PsA, referral and diagnosis within 1 year is associated with better clinical outcomes, suggesting the presence of a window of opportunity. The most gain in referral could be obtained in physician delay and in females, patients with enthesitis, chronic back pain or normal CRP.

Changes of trunk muscle stiffness in individuals with low back pain: a systematic review with meta-analysis

BACKGROUND

Low back pain (LBP) is one of the most common musculoskeletal conditions. People with LBP often display changes of neuromuscular control and trunk mechanical properties, including trunk stiffness. Although a few individual studies have examined back muscle stiffness in individuals with LBP, a synthesis of the evidence appears to be lacking. Therefore, the aim of this systematic review with meta-analysis was to synthesize and evaluate the available literature investigating back muscle stiffness in association with LBP.

METHODS

We conducted a systematic review of the literature according to the PRISMA guidelines. We searched Pubmed, Scopus, Web of Science and ScienceDirect for studies, that compared back muscle stiffness, measured either by ultrasound-based elastography or myotonometry, between individuals with and without LBP. Pooled data of the included studies were presented descriptively. Additionally, we performed two meta-analyses to calculate the standardized mean difference between the two groups for resting stiffness of the multifidus and erector spinae muscle. For both meta-analyses, the random effect model was used and the weight of individual studies was calculated using the inverse-variance method. The quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional studies. Furthermore, the certainty of evidence was evaluated using the GRADE approach.

RESULTS

Nine studies were included in our systematic review. Our results suggest that individuals with LBP have higher stiffness of the multifidus (SMD = 0.48, 95% CI: 0.15 - 0.81, p < 0.01; I2 = 48 %, p = 0.11) and erector spinae at rest (SMD = 0.37, 95% CI: 0.11 - 0.62, p < 0.01; I2 = 39 %, p = 0.14) compared to asymptomatic controls. On the other hand, the evidence regarding muscle stiffness during submaximal contractions is somewhat contradictory.

CONCLUSIONS

Based on the findings of this systematic review we conclude that people with LBP may have higher back muscle stiffness compared to asymptomatic controls. Addressing muscle stiffness might represent an important goal of LBP treatment. Nevertheless, our findings should be interpreted with extreme caution due to a limited quality of evidence, small number of included studies and differences in measurement methodology.

Decision-making Algorithm for the Surgical Treatment of Degenerative Lumbar Spondylolisthesis of L4/L5

STUDY DESIGN

A retrospective analysis of prospectively collected data.

OBJECTIVE

To report the decision-making process for decompression alone (DA) and decompression and fusion (DF) at a tertiary orthopedic center and compare the operative outcomes between both groups.

BACKGROUND

Controversy exists around the optimal operative treatment for DLS, either with DF or DA. Although previous studies tried to establish specific indications, clinical decision-making algorithms are needed.

MATERIALS AND METHODS

Patients undergoing spinal surgery for DLS at L4/5 were retrospectively analyzed. A survey of spine surgeons was performed to identify factors influencing surgical decision-making, and their association with the surgical procedure was tested in the clinical data set. We then developed a clinical score based on the statistical analysis and survey results. The predictive capability of the score was tested in the clinical data set with a receiver operating characteristic (ROC) analysis. To evaluate the clinical outcome, two years follow-up postoperative Oswestry Disability Index (ODI), postoperative low back pain (LBP) (Numeric Analog Scale), and patient satisfaction were compared between the DF and DA groups.

RESULTS

A total of 124 patients were included in the analysis; 66 received DF (53.2%) and 58 DA (46.8%). Both groups showed no significant differences in postoperative ODI, LBP, or satisfaction. The degree of spondylolisthesis, facet joint diastasis and effusion, sagittal disbalance, and severity of LBP were identified as the most important factors for deciding on DA or DF. The area under the curve of the decision-making score was 0.84. At a cutoff of three points indicating DF, the accuracy was 80.6%.

CONCLUSIONS

The two-year follow-up data showed that both groups showed similar improvement in ODI after both procedures, validating the respective decision. The developed score shows excellent predictive capabilities for the decision processes of different spine surgeons at a single tertiary center and highlights relevant clinical and radiographic parameters. Further studies are needed to assess the external applicability of these findings.

An online clinical decision tool to screen for vertebral fragility fractures (Vfrac) in older women presenting with back pain in general practice: protocol for a feasibility study in preparation for a future cluster randomised controlled trial

This feasibility study for a future definitive randomized trial assesses the use and acceptability of a new clinical decision tool to identify risk of a vertebral fracture and those who should be referred for spinal radiography in women aged 65 or over presenting to primary care with back pain.

PURPOSE

Approximately 12% of older adults have vertebral fragility fractures, but currently fewer than one-third are diagnosed, potentially limiting access to bone protection treatment. Vfrac is a vertebral fracture screening tool which classifies individuals into high or low risk of having a vertebral fracture, allowing targeting of spinal radiographs to high-risk individuals. The objective of this study was to investigate the feasibility of conducting a cluster randomized controlled trial to evaluate the use of an online version of Vfrac in primary care.

METHODS

The study will run in six general practices, with three given the Vfrac tool for use on older women (> 65 years) consulting with back pain and three using standard clinical processes for managing such back pain. Anonymised data covering a 12-month period will be collected from all sites on consultations by older women with back pain. Focus groups will be undertaken with healthcare professionals and patients on whom the tool was used to understand the acceptability of Vfrac and identify factors that impact its use. These patients will be sent a paper version of the Vfrac questionnaire to self-complete at home. Outputs of the self-completion Vfrac (high versus low risk) will be compared with the face-to-face Vfrac (high versus low risk), and agreement assessed using Cohen's kappa.

RESULTS

This study will evaluate the use and acceptability of Vfrac within primary care and determine if data on resource use can be collected accurately and comprehensively.

CONCLUSIONS

This article describes the protocol of the Vfrac feasibility study.

TRIAL REGISTRATION

ISRCTN18000119 (registered 01/03/2022) and ISRCTN12150779 (registered 10/01/2022).

Machine Learning Models for Predicting Disability and Pain Following Lumbar Disc Herniation Surgery

Importance

Lumber disc herniation surgery can reduce pain and disability. However, a sizable minority of individuals experience minimal benefit, necessitating the development of accurate prediction models.

Objective

To develop and validate prediction models for disability and pain 12 months after lumbar disc herniation surgery.

Design, Setting, and Participants

A prospective, multicenter, registry-based prognostic study was conducted on a cohort of individuals undergoing lumbar disc herniation surgery from January 1, 2007, to May 31, 2021. Patients in the Norwegian Registry for Spine Surgery from all public and private hospitals in Norway performing spine surgery were included. Data analysis was performed from January to June 2023.

Exposures

Microdiscectomy or open discectomy.

Main Outcomes and Measures

Treatment success at 12 months, defined as improvement in Oswestry Disability Index (ODI) of 22 points or more; Numeric Rating Scale (NRS) back pain improvement of 2 or more points, and NRS leg pain improvement of 4 or more points. Machine learning models were trained for model development and internal-external cross-validation applied over geographic regions to validate the models. Model performance was assessed through discrimination (C statistic) and calibration (slope and intercept).

Results

Analysis included 22 707 surgical cases (21 161 patients) (ODI model) (mean [SD] age, 47.0 [14.0] years; 12 952 [57.0%] males). Treatment nonsuccess was experienced by 33% (ODI), 27% (NRS back pain), and 31% (NRS leg pain) of the patients. In internal-external cross-validation, the selected machine learning models showed consistent discrimination and calibration across all 5 regions. The C statistic ranged from 0.81 to 0.84 (pooled random-effects meta-analysis estimate, 0.82; 95% CI, 0.81-0.84) for the ODI model. Calibration slopes (point estimates, 0.94-1.03; pooled estimate, 0.99; 95% CI, 0.93-1.06) and calibration intercepts (point estimates, -0.05 to 0.11; pooled estimate, 0.01; 95% CI, -0.07 to 0.10) were also consistent across regions. For NRS back pain, the C statistic ranged from 0.75 to 0.80 (pooled estimate, 0.77; 95% CI, 0.75-0.79); for NRS leg pain, the C statistic ranged from 0.74 to 0.77 (pooled estimate, 0.75; 95% CI, 0.74-0.76). Only minor heterogeneity was found in calibration slopes and intercepts.

Conclusion

The findings of this study suggest that the models developed can inform patients and clinicians about individual prognosis and aid in surgical decision-making.

A case report: Nonsecretory multiple myeloma presenting with bone pain

RATIONALE

Nonsecretory multiple myeloma (NSMM) is a rare subtype of multiple myelom, occurring in 1% to 2% of multiple myelom and characterized by the inability of clonal plasma cells to synthesize or secrete immunoglobulins. We describe a 71-year-old male patient who began with bone pain and was referred to hospital several times, but was not properly diagnosed and effectively treated.

PATIENT CONCERNS

A 71-year-old male patient visited our hematology department, complaining of lumbago for 1 year and back pain for half a year.

DIAGNOSES

Low-dose whole-body bone computed tomography: multiple bone destruction of the sternum, ribs, multiple vertebrae and accessories of the spine, pelvis, bilateral humerus, and proximal femur. Monoclonal plasma cells accounted for 17.5% of nuclear cells in bone marrow puncture smear. Fluorescence in situ hybridization detected amplification of CKS1B (1q21) gene. Immunofixation electrophoresis negative. About 10.72% of monoclonal plasma cells were detected by flow cytometry. Finally, he was diagnosed with NSMM.

INTERVENTIONS

The patients received VCD chemotherapy (bortezomib 1.3 mg/m2, d1, d4, d8, d11; cyclophosphamide 300 mg/m2, d1-2, d8-9; dexamethasone sodium phosphate 20 mg, d1-2, d4-5, d8-9, d11-12, once every 21 days).

OUTCOMES

After 2 cycles of VCD treatment, the symptoms of bone pain were significantly relieved, and the efficacy was evaluated as partial response. Follow-up chemotherapy will continue to be completed on schedule. We will continue to follow up to further evaluate the overall survival and progression-free survival.

LESSONS

This case shows that NSMM is easily missed or misdiagnosed.

Effectiveness of transcranial direct current stimulation in chronic pain and neurogenic claudication related to lumbar spinal stenosis

OBJECTIVES

Transcranial direct current stimulation (tDCS) is a promising non-invasive brain stimulation technique for treating chronic pain, yet its effectiveness in chronic lower extremity pain due to lumbar spinal stenosis (LSS) has not been studied. This research aimed to investigate the impact of tDCS on pain, walking capacity, functional status, and quality of life in LSS patients.

PATIENTS AND METHODS

In this prospective, randomized, double-blind, sham-controlled study, 32 LSS patients received either real or sham tDCS over the motor cortex contralateral to the patient's painful lower extremity for 10 consecutive weekdays (10 sessions). Evaluations were conducted at baseline, post-session, and 1-3 months later. The pain was evaluated by Visual Analog Scale (VAS), walking duration and distance by Treadmill Walking Test, functional status by Modified Oswestry Disability Questionnaire (MODQ) and quality of life by Short Form-36 (SF-36).

RESULTS

In-group comparisons, active tDCS showed sustained analgesic effects for 3-month post-treatment, distinct from sham. After the final session, active group exhibited significantly better asymptomatic walking distance and duration. Active stimulation led to notably lower MOLBDQ scores after 1 month. Significant improvements in SF-36 subscales were seen after 3 months, especially in pain, physical functioning, and general health. Positive tDCS effects on pain, claudication, and some quality of life aspects were evident at 3 months, while functional status improvements were mainly limited to 1 month.

CONCLUSION

tDCS shows potential as a safe, non-invasive technique for alleviating chronic LSS-related pain, enhancing mobility, functionality, and quality of life.

TRIAL REGISTRATION

Clinicaltrials.gov ID: NCT03958526.

How Well Do Seven Self-Report Measures Represent Underlying Back Pain Impact?

BACKGROUND

The extent to which different measures of back pain impact represent an underlying common factor has implications for decisions about which one to use in studies of pain management and estimating one score from others.

AIMS

To determine if different self-report back pain impact measures represent an underlying pain latent variable and estimate associations with it.

METHOD

Seven pain impact measures completed by Amazon Mechanical Turk adults are used to estimate internal consistency reliability and associations: Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), short form of the Örebro Musculoskeletal Pain Questionnaire (OMPQ), Subgroups for Targeted Treatment (STarT) Back Tool, the Graded Chronic Pain Scale (GCPS) disability score, PEG (Pain intensity, interference with Enjoyment of life, interference with General activity), and Impact Stratification Score (ISS).

RESULTS

The sample of 1,874 adults with back pain had an average age of 41 and 52% were female. Sixteen percent were Hispanic, 7% non-Hispanic Black, 5% non-Hispanic Asian, and 71% non-Hispanic White. Internal consistency reliability estimates ranged from 0.710 (OMPQ) to 0.923 (GCPS). Correlations among the measures ranged from 0.609 (RMDQ with OMPQ) to 0.812 (PEG with GCPS). Standardized factor loadings on the pain latent variable ranged from 0.782 (RMDQ) to 0.870 (ISS).

CONCLUSIONS

Scores of each measure can be estimated from the others for use in research.

[Treatment options for coccygodynia]

BACKGROUND

To this day, patients with coccyx problems are the most frequently underestimated patient population in orthopedic practices. The clinical picture of coccygodynia was first described in 1859. Nevertheless, discussions about the importance of coccyx problems remain a tiresome topic. All patients have in common that they have gone through a long ordeal with many therapists, examinations and therapeutic approaches without having received a real diagnosis.

DIAGNOSTIC

The main symptom of coccygodynia is the pain directly on the lowest segment of the coccyx, which often only occurs when sitting and is intensified by the change in position, usually from a sitting to a standing position. Trauma can only be described as the trigger in 50% of cases. Women are four times more likely to be affected than men. The gold standard for imaging should be viewed from standing and seated dynamic lateral radiographs of the coccyx.

TREATMENT

After the diagnosis has been made, conservative treatment should first be started with oral NSAIDs, relief with a coccyx cushion with a recess and, if necessary, physiotherapy to strengthen or loosen the pelvic floor. Local infiltrations with a glucocorticoid and local anesthetic directly in the painful area are also often promising. If the symptoms persist for more than 6 months, surgical treatment in the sense of removing the coccyx can be discussed with the patient. The literature shows a success rate of 80-90% if the indication was correct.

SPECT/CT and PET/CT for the Evaluation of Persistent or Recurrent Pain After Spine Surgery: A Systematic Review and Case Series

OBJECTIVE

The differential diagnosis for postoperative back pain is broad, and conventional imaging modalities are not always conclusive. Therefore, we performed a systematic review of the literature and present case studies describing the use of single-photon emission CT (SPECT)/CT or positron emission tomography (PET)/CT in the diagnosis of back pain following spine surgery.

METHODS

A systematic review was conducted according to PRISMA guidelines across 5 databases. Relevant keywords included PET/CT, bone SPECT/CT, and pseudarthrosis. The studies were assessed for diagnostic accuracy of the imaging technologies.

RESULTS

A total of 2,444 studies were screened, 91 were selected for full-text review, and 21 were ultimately included. Six retrospective studies investigated the use of SPECT/CT with a total sample size of 309 patients. Two of these studies used SPECT/CT to predict screw loosening in over 50% of patients. Eight studies examined the use of 18-fluoride sodium fluoride (18F-NaF) PET/CT. Among these studies, measures of diagnostic accuracy varied but overall demonstrated the ability of 18F-NaF PET/CT to detect screw loosening and pseudarthrosis. Seven studies examined 18F-fluorodeoxyglucose (FDG) PET/CT and supported its utility in the diagnosis of postoperative infections in the spine.

CONCLUSIONS

PET/CT and SPECT/CT are useful in the evaluation of postoperative pain of the spine, especially in patients for whom conventional imaging modalities yield inconclusive results. More diagnostic accuracy studies with strong reference standards are needed to compare hybrid imaging to conventional imaging.

A systematic review and network meta-analysis comparing different epidural steroid injection approaches

BACKGROUND

Low back pain (LBP) and lumbosacral radiculopathy are frequent disorders that cause nerve root injury, resulting in a variety of symptoms ranging from loss of sensation to loss of motor function depending on the degree of nerve compression.

OBJECTIVES

The goal of this study was to investigate the effectiveness of various epidural injection procedures in adult LBP patients.

STUDY DESIGN

Systematic review and network meta-analysis.

SETTING

Egypt.

METHODS

PubMed, Scopus, Web of Science, Cochrane Database, and Embase were used to conduct an electronic literature search. We included RCTs, cohorts, case controls, patients 30 years old with a clinical presentation of low back pain, and comprehensive data on the effects of the intervention on patients with lumbosacral radicular pain who got epidural steroid injections via various techniques. Only papers written in English were eligible.

RESULTS

Our analysis showed that parasagittal intralaminar (PIL) was the most effective approach in decreasing VAS (0-10) in the short term (< 6 months) (MD = -1.16 [95% CI -2.04, -0.28]). The next significant approach was transforaminal (TF) (MD = -0.37 [95% CI -1.14, -0.32]) in the long term; TF was the most effective approach (MD = -0.56 [95% CI -1, -0.13]). According to VAS (0-100) in the short term (< 6 months), our analysis showed an insignificant difference among the injection approaches and in the long term; TF was the most effective approach (MD = -24.20 [95% CI -43.80, -4.60]) and the next significant approach was PIL (MD = -23.89 [95% CI -45.78, -1.99]).

LIMITATIONS

The main limitations are the heterogeneity encountered in some of our analyses in addition to studies assessed as high risk of bias in some domains.

CONCLUSION

TF was the most effective steroid injection approach. In decreasing VAS for short-term PIL and TF were the most significant approaches, but TF was the most effective approach in decreasing VAS for the long term. Also, TF was the most effective approach in decreasing ODI for the long term.

Severe low back pain with mild leg symptoms due to lumbar spine stenosis

BACKGROUND

Some patients with lumbar spine stenosis (LSS) have severe low back pain (LBP) with only mild leg symptoms. The effects of decompression surgery for such patients remain unknown.

METHODS

Of 818 patients with LSS who underwent surgical treatment in our institution from 2011 to 2019, eight patients had a numeric rating scale (NRS) score of ≥7 for LBP and 3≤ for leg pain. The patients' age, sex, clinical characteristics, preoperative leg symptoms, and level of LSS were investigated. The detailed characteristics of LBP, such as the disease duration, location of LBP, and exacerbating factors, were obtained from each patient. The NRS and Japanese Orthopaedic Association (JOA) scores for LBP were evaluated on admission, at 1 and 3 months postoperatively, and at the final follow-up (>1 year postoperatively).

RESULTS

All patients were male with a mean age of 71.5 years (range, 57-82 years). LBP was exacerbated during walking in six patients and during an extension posture in three patients. The median duration of LBP was 2.9 years (range, 0.3-7 years). The stenosis was located at L2/3 in three patients, L3/4 in five patients, and L4/5 in seven patients. The stenosis involved one level in three patients and more than two levels in five patients. Other pathologies, such as sacroiliac joint lesions, facet pain, superior/middle cluneal nerve pain, and discogenic pain, were excluded by diagnostic anesthetic block and detailed physical examination. All patients underwent posterior decompression surgery without fusion. In all eight patients, the NRS score for LBP significantly improved from 7.6 (range, 7-10) to 1.7 (range, 0-3) and the JOA score improved from 13.1 (range, 4-19) to 21.8 (range, 18-27).

CONCLUSION

A low proportion of patients showed walking-evoked severe LBP with mild leg symptoms due to lumbar spine stenosis. The patients' pain was improved by decompression surgery with satisfactory results.

Approaches in Anterior Column Support in Adult Spinal Deformity Surgery: A Meta-Analysis of Clinical and Radiologic Outcomes

OBJECTIVE

This meta-analysis was conducted to compare anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) in terms of postoperative complications, improvement in radiographic parameters, and patient-reported outcomes.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) databases were searched up to June 2023. The studied outcomes were the rate of rod failures, rod failures requiring revision surgery, all complications, all revision surgeries, the change in pelvic tilt, sacral slope, Cobb angle, lumbar lordosis (LL), sagittal vertical axis, the postoperative pelvic incidence-LL, and LL, and the improvement in back pain and Oswestry Disability Index (ODI).

RESULTS

Six studies were included in this meta-analysis. ALIF showed higher postoperative lordosis (P = 0.003) and better improvement in ODI (P = 0.0001). No difference was seen in the remaining outcomes between ALIF and TLIF.

CONCLUSIONS

Although ALIF had better improvement in ODI, the mean difference was 6.5 points, which is below the minimal clinically important difference, stripping this result of any clinical value. Furthermore, even though ALIF had better postoperative lordosis, the change in LL postoperatively was not different between ALIF and TLIF. With no difference in complications, sagittal and coronal alignment, and patient-reported outcomes, TLIF was shown in this study to be favored instead of ALIF in adult spinal deformity surgery to avoid all the double approach-related comorbidity.

Spinal magnetic stimulation to treat chronic back pain: a feasibility study in veterans

Aim: Chronic low back pain represents a significant societal problem leading to increased healthcare costs and quality of life. This study was designed to evaluate the feasibility and effectiveness of non-invasive spinal electromagnetic simulation (SEMS) to treat nonspecific chronic low back pain (CLBP). Methods: A single-site prospective study was conducted to evaluate SEMS in reducing pain and improving disability. A total of 17 patients received SEMS two to three sessions a week. The Numeric Rating Scale and the Modified Oswestry Disability Questionnaire were used to assess pain and disability. Results: Participants receiving SEMS exhibited statistically significant reductions in pain and disability. Conclusion: Current results suggest that non-invasive SEMS can be an effective treatment in reducing pain and improving disability associated with CLBP.

Personalized assessment and management of non-specific low back pain

BACKGROUND AND OBJECTIVE

Low back pain (LBP), and in particular non-specific low back pain (NSLBP), which accounts for approximately 90% of LBP, is the leading cause of years lived with disability worldwide. In clinical trials, LBP is often poorly categorized into 'specific' versus 'non-specific' and 'acute' versus 'chronic' pain. However, a better understanding of the underlying pain mechanisms might improve study results and reduce the number of NSLBP patients.

DATABASES AND DATA TREATMENT

Narrative review.

RESULTS

NSLBP is a multi-dimensional, biopsychosocial condition that requires all contributing dimensions to be assessed and prioritized. Thereby, the assessment of the contribution of nociceptive, neuropathic and nociplastic pain mechanisms forms the basis for personalized management. In addition, psychosocial (e.g. anxiety, catastrophizing) and contextual factors (e.g. work situation) as well as comorbidities need to be assessed and individually weighted. Personalized treatment of NSLBP further requires individually choosing treatment modalities, for example, exercising, patient education, cognitive-behavioural advice, pharmacotherapy, as well as tailoring treatment within these modalities, for example, the delivery of tailored psychological interventions or exercise programs. As the main pain mechanism and psychosocial factors may vary over time, re-assessment is necessary and treatment success should ideally be assessed quantitatively and qualitatively.

CONCLUSIONS

The identification of the main contributing pain mechanism and the integration of the patients' view on their condition, including beliefs, preferences, concerns and expectations, are key in the personalized clinical management of NSLBP. In research, particular importance should be placed on accurate characterization of patients and on including outcomes relevant to the individual patient.

SIGNIFICANCE STATEMENT

Here, a comprehensive review of the challenges associated with the diagnostic label 'non-specific low back pain' is given. It outlines what is lacking in current treatment guidelines and it is summarized what is currently known with respect to individual phenotyping. It becomes clear that more research on clinically meaningful subgroups is needed to best tailor treatment approaches.

Association of initial opioid prescription duration and an opioid refill by pain diagnosis: Evidence from outpatient settings in ten US health systems

OBJECTIVE

The Centers for Disease Control and Prevention's 2022 Clinical Practice Guideline for Prescribing Opioids for Pain cautioned that inflexible opioid prescription duration limits may harm patients. Information about the relationship between initial opioid prescription duration and a subsequent refill could inform prescribing policies and practices to optimize patient outcomes. We assessed the association between initial opioid duration and an opioid refill prescription.

METHODS

We conducted a retrospective cohort study of adults ≥19 years of age in 10 US health systems between 2013 and 2018 from outpatient care with a diagnosis for back pain without radiculopathy, back pain with radiculopathy, neck pain, joint pain, tendonitis/bursitis, mild musculoskeletal pain, severe musculoskeletal pain, urinary calculus, or headache. Generalized additive models were used to estimate the association between opioid days' supply and a refill prescription.

RESULTS

Overall, 220,797 patients were prescribed opioid analgesics upon an outpatient visit for pain. Nearly a quarter (23.5%) of the cohort received an opioid refill prescription during follow-up. The likelihood of a refill generally increased with initial duration for most pain diagnoses. About 1 to 3 fewer patients would receive a refill within 3 months for every 100 patients initially prescribed 3 vs. 7 days of opioids for most pain diagnoses. The lowest likelihood of refill was for a 1-day supply for all pain diagnoses, except for severe musculoskeletal pain (9 days' supply) and headache (3-4 days' supply).

CONCLUSIONS

Long-term prescription opioid use increased modestly with initial opioid prescription duration for most but not all pain diagnoses examined.

Effects of elastic taping on kyphosis and body balance in the elderly: a randomized crossover study

Kyphosis produces abnormal posture and reduced body balance in the elderly. Elastic tape may be useful at improving kyphotic posture and body balance. This study aims to evaluate the effects of elastic taping on kyphosis and body balance in the elderly. Ten elderly participants with degenerative kyphotic posture were recruited and randomly assigned to two groups (back taped with stretched elastic tape for 15 min and back taped with non-stretched elastic tape for 15 min). After a 1-h washout period, the groups were swapped over to receive the other intervention. The outcomes measured after each taping technique were Cobb's angle measurement by inclinometer, perceived pain, and balance measurements by single leg stance test, time up and go test, center of gravity alignment (COG) and modified clinical test of sensory interaction on balance test (mCTSIB). There was a significant reduction in kyphotic angle and back pain in both the stretched and non-stretched taping groups (p < 0.05). We also found both taping techniques significantly reduced sway velocity on a foam surface with eyes closed and open (p < 0.05). However, there was no significant difference between taping groups for kyphotic angle, pain reduction or balance. The application of 15 min of stretched and non-stretched elastic tape in the elderly reduced kyphotic angle, back pain, and sway velocity while standing on foam surface in the mCTSIB test. If these changes persist over the long term (days and weeks) taping may be a useful intervention for elderly patients with kyphosis.

Having chronic back pain did not impact COVID-19 outcome in a low-income population - a retrospective observational study

INTRODUCTION

Chronic back pain (CBP) is a major cause of years lived with disability. Social inequalities increase the prevalence and burden of CBP. Management of CBP was affected by restricted access to non-pharmacological treatments and outdoor activities during COVID-19 pandemic.

OBJECTIVE

To determine the prevalence of CBP among patients with COVID-19 as well as the impact of having CBP in COVID-19 outcome in our low-income population.

METHODS

Retrospective cohort of individuals with confirmed COVID diagnosis from May 2020 - March 2021, at Hospital Regional UNIMED (HRU) in Fortaleza, Ceará, Brazil. Data included comorbidities and household income.

RESULTS

Among 1,487 patients, 600 (40.3%) were classified as having CBP. Mean age as well as income were similar in CBP and non-CBP groups, with more women in the CBP group. Hypertension and asthma, but not diabetes, were more prevalent in those with CBP. Need for emergency care, hospitalization, and admission to intensive care unit were similar regardless of having CBP. Dyspnea was more common in CBP vs. non-CBP groups, with 48.8% vs. 39.4% percentages, respectively (p = 0.0004).

CONCLUSION

Having CBP prior to COVID did not impact the acute clinical outcome of COVID individuals of a low-income population.

How to tackle non-specific low back pain among adult patients? A systematic review with a meta-analysis to compare four interventions

OBJECTIVE

To tackle non-specific low back pain (NSLBP) among patients and find the most effective solution and to quantitatively synthesize the overall effect of motor control training (MCT) compared with Pilates, McKenzie method, and physical therapy (PT) in pain and physical function.

METHODS

Randomized controlled trials (RCTs) of four types of intervention (MCT, Pilates, McKenzie method, and PT) for LBP were collected by searching PubMed, Web of Science, EBSCOhost (Cochrane Central Register of Controlled Trials), and Scopus databases from the establishment of the database to September 30, 2023. The risk of bias was evaluated for included studies using the Revised Cochrane Risk of Bias tool for randomized trials (RoB 2.0). Taking pain and physical function in the experimental and control groups as outcome indicators, subgroup analysis was performed according to the intervention method to calculate the standardized mean difference (SMD) and 95% confidence interval (CI).

RESULTS

A total of 25 RCTs, including 1253 patients, were included. Meta-analysis showed that MCT effectively relieved pain [SMD = -0.65, 95% CI (- 1.00, - 0.29), p < 0.01] and improved physical function [SMD = -0.76, 95% CI (- 1.22, - 0.31), p < 0.01] comparing with other 3 types of intervention. Subgroup analysis suggested that MCT could alleviate pain [SMD = -0.92, 95% CI (- 1.34, - 0.50), p < 0.01] and improve physical function [SMD = -1.15, 95% CI (- 1.72, - 0.57), p < 0.01] compared with PT, but it had no statistical significance compared with Pilates [pain: SMD = 0.13, 95% CI (- 0.56, 0.83), p = 0.71; physical function: SMD = 0.10, 95% CI (- 0.72, 0.91), p = 0.81] and the McKenzie method [pain: SMD = -0.03, 95% CI (- 0.75, 0.68), p = 0.93; physical function: SMD = -0.03, 95% CI (- 1.00, 0.94), p = 0.95].

CONCLUSIONS

MCT can effectively relieve pain and improve physical function in patients with NSLBP. It is more effective compared with PT for LBP, while no differences were detected between MCT and Pilates, as well as McKenzie method. Therefore, MCT, Pilates, and the McKenzie method should be encouraged as exercise interventions for NSLBP rehabilitation.

Intraoperative Closed Reduction of Traumatic Lateraloptosis: Operative Nuances

BACKGROUND AND IMPORTANCE

Traumatic lateral spondyloptosis, or lateraloptosis, is the complete lateral dislocation of the spine. Reduction in these dislocations presents unique challenges, especially in cases of preserved neurological function. Open techniques carry significant risks of cerebrospinal fluid leak and neurological injury. For traditional spondyloptosis, off-table closed techniques have been described but may result in loss of the reduction when the patient is transferred to the operative table. An on-table closed reduction technique has potential advantages over previously described open reduction or off-table techniques for the treatment of lateraloptosis.

CLINICAL PRESENTATION

The authors describe an on-table closed reduction technique for lateraloptosis, presenting an illustrative case in which the technique was applied. This technique is compared with alternative open and off-table reduction techniques described in the literature. The patient had good mechanical and neurological outcomes. At 14 months postoperatively, she is neurologically intact, back to work involving heavy lifting, and has only moderate back pain.

CONCLUSION

On-table closed reduction before open fixation should be considered in cases of lateraloptosis, particularly when there is preserved neurological function.

Is Full-Endoscopic Transforaminal Lumbar Interbody Fusion Superior to Open Transforaminal Lumbar Interbody Fusion for Single-Level Degenerative Lumbar Spondylolisthesis? A Retrospective Study

BACKGROUND

 In this study, we evaluate the clinical efficacy and safety of full-endoscopic transforaminal lumbar interbody fusion (TLIF) for treatment of single-level lumbar degenerative spondylolisthesis.

METHODS

 Fifty-three patients were divided into two groups according to the surgical techniques: Full endoscopic (Endo)-TLIF (n = 25) and TLIF (n = 28). Clinical efficacy was evaluated pre- and postoperatively. The operation time, operative blood loss, postoperative amount of serum creatine phosphokinase (CPK), postoperative drainage volume, postoperative hospital stay time, total cost, and operative complications were also recorded.

RESULTS

 Compared with the TLIF group, the Endo-TLIF group had similar intraoperative blood loss, less postoperative increased CPK, less postoperative drainage volume, and shorter postoperative hospital stay, but longer operative time and higher total cost. The postoperative visual analog scale (VAS) scores of back and leg pain and Oswestry Disability Index (ODI) scores significantly improved compared with the preoperative scores in both two groups; more significant improvement of postoperative VAS scores of back pain and ODI scores were shown in the Endo-TLIF group at the 1-month follow-up (p < 0.05). No difference was found in the intervertebral fusion rate between the two groups.

CONCLUSION

 The Endo-TLIF has similar clinical effect compared with the TLIF for the treatment of lumbar degenerative spondylolisthesis. It also has many surgical advantages such as less muscle trauma, less postoperative back pain, and fast functional recovery of the patient. However, steep learning curve, longer operative time, and higher total cost may be the disadvantages that limit this technique. Also, the Endo-TLIF treatment of patients with bilateral lateral recess stenosis is considered a relative contraindication.