The Neck Disability Index (NDI) and its correlation with quality of life and mental health measures among patients with single-level cervical disc disease scheduled for surgery

BACKGROUND

The Neck Disability Index (NDI) is widely used as a self-rated disability score in patients with cervical radiculopathy. The purpose of this study was to evaluate whether the NDI score correlated with other assessments of quality of life and mental health in a specific group of patients with single-level cervical disc disease and corresponding radiculopathy.

METHODS

One hundred thirty-six patients were included in a prospective, randomized controlled clinical multicenter study on one-level anterior cervical discectomy with arthroplasty (ACDA) versus one-level anterior cervical discectomy with fusion (ACDF). The preoperative data were obtained at hospital admission 1 to 3 days prior to surgery. The NDI score was used as the dependent variable and correlation as well as regression analyses were conducted to assess the relationship with the short form-36, EuroQol-5Dimension-3 level and Hospital Anxiety and Depression Scale.

RESULTS

The mean age at inclusion was 44.1 years (SD ±7.0, range 26-59 years), of which 46.3 % were male. Mean NDI score was 48.6 (SD = 12.3, minimum 30 and maximum 88). Simple linear regression analysis demonstrated a significant correlation between NDI and the EuroQol-5Dimension-3 level [R = -0.64, 95 % confidence interval (CI) -30.1- -19.8, p < 0.001] and to a lesser extent between NDI and the short form-36 physical component summary [R = -0.49, 95 % CI (-1.10- -0.58), p < 0.001] and the short form-36 mental component summary [R = -0.25, 95 % CI (-0.47- -0-09), p = 0.004]. Regarding NDI and the Hospital Anxiety and Depression Scale, a significant correlation for depression was found [R = 0.26, 95 % CI (0.21-1.73), p = 0.01]. Multiple linear regression analysis showed a statistically significant and the strongest correlation between NDI and the independent variables in the following order: EuroQol-5Dimension-3 level [R = -0.64, 95 % CI (-23.5- -7.9), p <0.001], short form-36 physical component summary [R = -0.41, 95 % CI (-0.93- -0.23), p = 0.001] and short form-36 mental component summary [R = -0.36, 95 % CI (-0.53- -0.15), p = 0.001].

CONCLUSION

The results from the present study show that the NDI correlated significantly with a different quality of life and mental health measures among patients with single-level cervical disc disease and corresponding radiculopathy.

Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study

BACKGROUND

The aim of this study was to assess if transforaminal steroid injections applied to cohort of patients waiting for cervical disc surgery, reduce the pain of cervical radiculopathy and hence reduce the need for surgical intervention. Cervical radiculopathy due to cervical disc herniation or spondylosis is a common indication for cervical disc surgery. Surgery is however not always successful, and is not done without risk of complications. Transforaminal injection of steroids has gained popularity due to the rationale that inflammation of the spinal nerve roots causes radicular pain, and therefore steroids placed locally should relieve symptoms.

METHODS

During a 12-month period, 21 secondary referral patients with unilateral cervical radiculopathy entered the study. Cervical disc herniation or spondylosis affecting the corresponding nerve root was demonstrated by appropriate investigation (MRI or myelography). The patients then received 2 transforaminal steroid injections, at 2 weeks interval, while waiting for operative treatment. The pain intensity (VAS), Odom's criteria and operative indications were registered at 6 weeks and 4 months.

FINDINGS

After receiving injection treatment 5 of the 21 patients decided to cancel the operation due to clinical improvement. A statistically significant reduction (0.02) in radicular pain score was simultaneously measured. This corresponds well with the reduction in operative requirements since radicular pain is the main indication for operative treatment. The responders experienced a long-lasting effect. Those responding positively however improved neck pain to the same extent as radicular pain, and patients with cervical spondylosis responded as positively as those with disc herniation.

INTERPRETATION

This prospective cohort study indicates a reduction in the need for operative treatment due to injection treatment. The clinical effect is measurable, and a statistically significant improvement of the radicular pain is registered. Routine transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.

Eight year outcome after surgery for lumbar disc herniation: a comparison of reoperated and not reoperated patients

A retrospective study of 211 patients with unilateral sciatica operated on for lumbar disc herniation during 1988 and 1989 was performed in order to compare the results of reoperated patients with the results of patients operated on only once. The patients completed a standardized questionnaire in 1997 which included questions about reoperations, back and leg pain, functional status and disability pension. Outcome scores were calculated, giving values from 0 (no pain/normal function) to 100 (totally disabled). A follow-up status of 80.1% was obtained; 163 patients answered the questionnaire while six patients had died. 23.9% of the patients (n = 39) had been reoperated on. A recurrent disc herniation at the same level was suspected before the reoperation in 18.4%, but a recurrence was found in only 8.6%. 3.7% were reoperated on more than once. Outcome score was worse among "reoperated" patients (median 45.0, range 0-94) than among patients who only had the primary operation (median 10.5, range 0-81) (P < 0.001). In addition, 34.3% of the "reoperated" patients received a disability pension compared to 9.9% of the patients not reoperated on (P < 0.01). Patients reoperated upon at the same level without peroperative signs of recurrent disc herniation, had an outcome score of 53.0 (range 0-82) compared to a score of 30.0 (range 0-66) in patients with a confirmed recurrence (P < 0.05). The percentage of disability pension was 53.8% versus 9.1%, respectively, for those two groups (P < 0.05). Eight years after operation for lumbar disc herniation, the outcome was significantly worse in "reoperated" patients than in patients operated on once. In addition, reoperated patients with peroperatively confirmed recurrence of the same disc, seemed to have a better outcome than patients without peroperative signs of a recurrence.

[Long-term follow-up after surgery for lumbar disk herniation]

BACKGROUND

We wanted to evaluate long-term outcome after operation for lumbar disc herniation at a department of neurosurgery which train spinal surgeons. Both conventional and microsurgical technique were used during this period.

MATERIAL AND METHODS

Data were collected retrospectively from patient files. During 1988-89, 211 patients with lumbar disc herniation and unilateral sciatica were operated by microsurgical (n = 122) or by conventional technique (n = 89). In 1997, patients completed standardized questionnaires that included questions about pain and functional status (outcome score 0-100) and reoperations.

RESULTS

163 patients answered the questionnaire (77%). 39 patients (24%) had been reoperated. Median outcome score was 10.5 (range 0-81) in patients not reoperated, a score significantly better than the score of reoperated patients (45.0, range 0-94). There was no significant difference between patients operated by microsurgical and conventional technique.

INTERPRETATION

The frequency of reoperations was high. Outcome was satisfactory seven to nine years after surgery for lumbar disc herniation in patients not reoperated, but poor in reoperated patients. The retrospective design of our study does not allow any conclusion on whether conventional or microsurgical technique gives the best result.

Recovery of function in adjacent nerve roots after surgery for lumbar disc herniation: use of quantitative sensory testing in the exploration of different populations of nerve fibers

Results from experimental and clinical studies indicate that adjacent nerve roots may be affected in sciatica because of lumbar disc hemiation. This may be caused by proinflammatory mediators in the epidural space being transported into nerve roots at the same or neighboring lumbar segments. The aim of the present study was to investigate the recovery of function of sensory nerve fibers in the adjacent noncompressed nerve roots. Thirty-nine patients undergoing microdiscectomy for monoradiculopathy were investigated with quantitative sensory testing immediately before surgery, and at 6 weeks, 4 months, and 12 months after the operation. Twenty-one healthy volunteers were used as controls. The patients were classified as having a good or a poor result at the 1-year follow-up according to a clinical score. Significant improvement of function in the noncompressed nerve roots were only observed in the 31 patients with a good result. The improvement in small myelinated nerve fibers came within 12 months in the adjacent nerve roots in both the symptomatic as well as the asymptomatic leg. The improvement of function in small unmyelinated fibers also came within 12 months after surgery; however, significant improvement was only observed in the ipsilateral neighboring nerve root. The function in large myelinated fibers did not improve in any of the adjacent nerve roots during the observation period. The observed recovery of function in adjacent noncompressed nerve roots after successful surgical decompression in monoradiculopathy may be because of less production of proinflammatory mediators when the disc herniation is removed.

Nerve root signs on postoperative lumbar MR imaging. A prospective cohort study with contrast enhanced MRI in symptomatic and asymptomatic patients one year after microdiscectomy

The association between postoperative nerve root signs and outcome was investigated in 54 out of one hundred patients operated on by lumbar microdiscectomy in a prospective cohort study with one year follow up. The patients were classified as failures or successes at the 12 month follow up according to a clinical overall score. All the 14 failures were investigated with MRI at the one year follow up, and 40 patients classified as successes were picked at random for MRI. Three patients with signs of recurrent disc herniation on MRI were excluded from the study. The MRI scans were independently read by two neuroradiologists who were ignorant of treatment outcome. No association between nerve root thickening, nerve root enhancement or nerve root displacement and the clinical outcome was found when patients with recurrent disc herniation were excluded.

Duration of leg pain as a predictor of outcome after surgery for lumbar disc herniation: a prospective cohort study with 1-year follow up

OBJECT

The aim of this study was to investigate different variables in the duration of symptoms that can be used to predict outcome after lumbar microdiscectomy.

METHODS

In a prospective study of 132 consecutive patients who underwent surgery for lumbar disc herniation, the authors evaluated the prognostic value of different variables in the duration of symptoms for the 1-year period after surgery. The 1-year follow-up investigation was conducted by an independent observer. Assessment of outcome was performed using a clinical overall score (COS), which was recently assessed for its reliability and validity. As for factors predictive of outcome, only duration of leg pain and sick leave reached statistical significance in the multivariate analysis. Results of the univariate analysis demonstrated that in patients experiencing preoperative leg pain fewer than 4 months and between 4 and 8 months, a significantly lower COS at the 1-year follow up was demonstrated compared with those in whom the duration of leg pain was longer (> 8 months). One hundred eight patients returned to work within the 1st year after surgery. Patients who took a sick leave of more than 28 weeks before the operation were at higher risk of not returning to work.

CONCLUSIONS

Analysis of these results indicates that leg pain lasting more than 8 months correlates with an unfavorable postoperative outcome in patients with lumbar disc herniation, as well as a high risk of not returning to work.

Postoperative nerve root displacement and scar tissue. A prospective cohort study with contrast-enhanced MR imaging one year after microdiscectomy

PURPOSE

To investigate the association between postoperative nerve root displacement and epidural scar tissue.

MATERIAL AND METHODS

One hundred patients who had undergone lumbar microdiscectomy were included in a prospective cohort study with a 1-year follow-up. The patients were classified as failures or successes at the 12-month follow-up according to a clinical score. Patients with signs of recurrent disc herniation on MR were excluded from the study. All the 13 patients classified as failures were investigated with MR at the 1-year follow-up, and 40 patients classified as successes were picked at random for MR imaging; thus MR was performed in 53 patients. The MR images were independently evaluated by two neuroradiologists. The images were rated according to the presence or absence of nerve root displacement at the surgically treated disc interspace. Scar formation was rated according to two different classification systems.

RESULTS

Nerve root displacement was observed in 13 patients. No evidence of scar formation was found in 4 patients, a small amount in 11, intermediate in 37 and extensive scar formation in 1 patient. No association between nerve root displacement and the amount of scar tissue was found.

CONCLUSION

Postoperative nerve root displacement seems to be an independent clinical entity not associated to postoperative scar tissue.

[Surgical treatment of the rheumatic neck]

This paper reviews rheumatoid cervical spine disease with emphasis on surgical management. The rheumatoid process in the cervical spine is outlined, and the different clinical syndromes are explained according to the underlying pathology. Guidelines for the management of patients with this disease are suggested, and the indications for surgery are discussed. The different surgical approaches and techniques are briefly summarised.

No association between peridural scar and outcome after lumbar microdiscectomy

The association between postoperative scar formation on MRI and outcome was investigated in 54 out of one hundred patients operated on with microdiscectomy in a prospective cohort study with a one year follow up. The patients were classified as failures or successes at the 12 months follow up according to a clinical overall score. All the 14 failures were investigated with MRI, and 40 patients classified as successes were picked at random for MRI. Patients with signs of recurrent disc herniation on MRI were excluded. The MRI scans were rated according to the presence or absence of scar formation within the spinal canal and the degree of scar enhancement by two independent neuroradiologists ignorant of treatment outcome. No evidence of scar formation was found in 4 patients, a small amount in 11, intermediate in 38 and extensive scar tissue in 1 patient. Slightly enhancing scar tissue was found in 18 patients, intermediate in 27 patients and strong enhancement in 5 patients. No association between the amount or enhancement of peridural scar formation and clinical outcome was found. Both the total clinical score and the difference between pre- and post-operative clinical score were used in the calculations. Testing the different subsets in the clinical overall score, as well as the patient satisfaction VAS score, did not reveal any association.

The function of sensory nerve fibers in lumbar radiculopathy. Use of quantitative sensory testing in the exploration of different populations of nerve fibers and dermatomes

STUDY DESIGN

The function of sensory nerve fibers in patients with lumbar radiculopathy and in control individuals was evaluated using quantitative sensory testing.

OBJECTIVES

To investigate the effect of lumbar nerve root compression on different populations of nerve fibers and to explore the function of sensory nerve fibers in neighboring nerve roots not involved in the mechanical compression.

BACKGROUND DATA

Results from experimental and clinical studies indicate that chronic compression of lumbar nerve roots affects the large myelinated nerve fibers. The majority of nerve fibers involved in the sensation of pain, however, are small afferent nerve fibers. It is therefore of interest to study the effect of compression on large and small sensory afferent channels. Several authors have elucidated the biochemical interaction between disc tissue and nerve roots. Chemical substances in the epidural space can reach the nerve fibers in nerve roots at the same or neighboring lumbar segments. In this way, fibers not involved in the mechanical compression may be affected.

METHODS

The small nerve fibers were studied using tests for thermal thresholds (thermotest), and the large myelinated fibers were studied by vibrametry. Forty-two patients were investigated in the symptomatic and the asymptomatic leg, and the results were compared with those of 21 healthy individuals.

RESULTS

The thresholds of cold, warmth, and vibration were significantly increased in the dermatome of the compressed nerve root, indicating that large and small sensory nerve fibers were affected. Further, the thresholds were significantly increased in the neighboring dermatomes in the symptomatic and the asymptomatic leg.

CONCLUSION

Large and small sensory afferent nerve fibers are affected in lumbar radiculopathy. The increase in sensation thresholds in the ipsilateral neighboring dermatome and in the dermatomes in the asymptomatic leg indicates that adjacent nerve roots are involved in the pathophysiology of sciatica in patients with lumbar disc herniation.

Recovery of sensory nerve fibres after surgical decompression in lumbar radiculopathy: use of quantitative sensory testing in the exploration of different populations of nerve fibres

Thirty nine patients with unilateral lumbar nerve root compression at one level were examined with quantitative sensory testing immediately before microdiscectomy and at six weeks, four months, and 12 months after surgery. Twenty one healthy volunteers were used as controls. The patients were classified as having a good or a poor result at the one year follow up. The improvement of function in small unmyelinated nerve fibres came within six weeks in the patients with a good result. By contrast the improvement of function in small myelinated fibres was not found before 12 months after surgery. The function in large myelinated fibres did not improve during the observation period. The difference in the time course of the recovery between large and small nerve fibres is assumed to reflect differing severity in the damage to the fibres before surgical decompression. The preoperative warmth detection threshold reflecting the function in small unmyelinated C fibres was significantly higher in the patients with a poor result and this may indicate that damage to C fibres before surgery is a negative prognostic factor.

The inflammatory properties of contained and noncontained lumbar disc herniation

STUDY DESIGN

The inflammatory properties of nucleus pulposus were assessed in biopsy samples from patients who underwent surgery for lumbar disc herniation.

OBJECTIVES

To investigate the inflammatory properties of the different types of disc herniation.

BACKGROUND DATA

High levels of phospholipase A2 previously have been demonstrated in a small number of patients undergoing lumbar disc surgery. Phospholipase A2 is the enzyme responsible for the liberation of arachidonic acid from cell membranes at the site of inflammation and is considered to be the limiting agent in the production of prostaglandins and leukotrienes, which are powerful mediators of inflammation. Cytokines are among the many agonists inducing phospholipase A2 activation. Several reports previously have demonstrated the difference in clinical appearance of different types of lumbar disc herniation.

METHODS

Thirty-seven patients undergoing surgery for lumbar disc herniation were investigated. During surgery the disc pathology of each patient was classified into one of three groups: bulging disc, contained herniation, and noncontained disc herniation. Also during surgery, biopsy samples were taken from the nucleus, immediately frozen in liquid nitrogen, and subsequently stored at -70 C until analyzed.

RESULTS

No traces of interleukin-6 or tumor necrosis factor alpha were found in the biopsy samples. There was a significant difference in the levels of leukotriene B4 and thromboxane B2 in contained versus noncontained disc herniation, and the highest concentration was found in the noncontained disc herniation group.

CONCLUSION

The results support the theory that inflammatory mechanisms are involved in sciatica because of lumbar disc herniation and indicate that the different types of disc herniation have different inflammatory properties.

[Ten years of neurosurgery at the University Hospital in Tromsø. Need for further development]

The Department of Neurosurgery at the University Hospital of Tromsø was established in January 1986 to provide neurosurgical treatment for the population of northern Norway. During the first ten years, 3,225 patients were operated on, including 1,157 craniotomies and 1,335 spinal procedures. The annual number of operations increased from 201 to 442, and the number of hospitalized patients from 265 to 908. The number of patients treated per employee increased by 250%, while the mean duration of hospital stay decreased by 43% to 4.5 days. The growth in activity is expected to continue. This is because of improved diagnostics of nervous system disease, a growing number of elderly patients and new treatment options. The falling number of spinal surgical procedures in local hospitals is also a contributing factor. Neurosurgery is highly cost-effective. It is impossible to make further cost savings without a decline in quality. The department must be expanded to cater for more operations by increasing both the number of beds and employees.

Recovery of sensory function after surgical decompression in carpal tunnel syndrome

The function of thick and thin sensory nerve fibers after surgical decompression in carpal tunnel syndrome were evaluated using quantitative sensory testing (QST). The thin nerve fibers were studied using tests for thermal thresholds, and the thick myelinated fibers by vibrametry. The tests were performed before surgery and at 6 weeks, 4 and 10 months after surgery. The improvement of function in thin nerve fibers came within 6 weeks (P = 0.001). The improvement of function in thick myelinated fibers continued to improve until 4 months after the operation (P = 0.0001). This difference in the time course of the recovery indicates that the thick myelinated nerve fibers were more affected than the thin nerve fibers. The function of both type sensory nerve fibers did also improve in the fifth finger (P = 0.05). The function in thin nerve fibers worsened somewhat between 6 weeks and 4 months after surgery, possibly due to postoperative scar tissue.

Duration of symptoms as a predictor of outcome after lumbar disc surgery

Retrospectively 93 consecutive patients operated on for lumbar disc herniation were studied in order to evaluate the prognostic value of symptoms (lumbar pain and sciatica) and sick-leave. Surgical results were evaluated 1-3 years postoperatively by a questionaire. The duration of the present attack of sciatica and sick-leave prior to surgery was significantly longer in the group with unsatisfactory outcome compared to the group with satisfactory outcome. Patients with duration of the present attack of sciatica of less than 6 months had a significantly better result concerning outcome compared to patients with duration of 6-12 months and more than 12 months. Patients who returned to the same type of work had a preoperatively statistically significant shorter duration of present sick-leave, compared to the patients who had changed the type of work and the patients who did not return to work. The patients with duration of their present sick-leave of less than 6 months had a significantly higher percentage of returning to the same type of work compared to patients with duration of their present sick-leave of 6-12 months and more than 12 months. We conclude that the duration of sciatica and sick-leave before the operation has value as predictive factors concerning the over-all result after surgery for lumbar disc herniation.

Thromboplastin activity of blood monocytes after total hip replacement

Thromboplastin activity of monocytes from blood of seven patients with total hip replacement was investigated. At 24 h and 48 h after surgery, thromboplastin activity was significantly increased compared to the activity before surgery. Thromboplastin activity of endotoxin-stimulated monocytes was significantly increased at 24 h after surgery. There were no significant changes in Factor V after surgery, Factor VII was significantly lowered at 24 h after surgery, while Factor VIII and fibrinogen were significantly increased at 72 h after surgery. The results indicate that monocyte thromboplastin may be a thrombogenic factor after total hip replacement surgery.