https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30489-6.pdf

Prevention and treatment of low back pain: evidence, challenges, and promising directions.

BackgroundThe comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive laminectomy in patients with symptomatic lumbar grade I degenerative spondylolisthesis with spinal stenosis is unknown. MethodsIn this randomized, controlled trial, we assigned patients, 50 to 80 years of age, who had stable degenerative spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) and symptomatic lumbar spinal stenosis to undergo either decompressive laminectomy alone (decompression-alone group) or laminectomy with posterolateral instrumented fusion (fusion group). The primary outcome measure was the change in the physical-component summary score of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; range, 0 to 100, with higher scores indicating better quality of life) 2 years after surgery. The secondary outcome measure was the score on the Oswestry Disability Index (range, 0 to 100, with higher scores i...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1508788

Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis

Study Design.Analysis of National Inpatient Sample (NIS), 2004 to 2015.Objective.Describe recent trends in US rates of lumbar fusion procedures and associated costs, by surgical indication.Summary of Background Data.Spinal fusion is appropriate for spinal deformity and instability, but evidence of e

Trends in Lumbar Fusion Procedure Rates and Associated Hospital Costs for Degenerative Spinal Diseases in the United States, 2004 to 2015

Working at night results in a misalignment between the sleep-wake cycle and the output of the hypothalamic pacemaker that regulates the circadian rhythms of certain physiologic and behavioral variables. We evaluated whether such physiologic maladaptation to nighttime work could be prevented effectively by a treatment regimen of exposure to bright light during the night and darkness during the day. We assessed the functioning of the circadian pacemaker in five control and five treatment studies in order to assess the extent of adaptation in eight normal young men to a week of night work. In the control studies, on the sixth consecutive night of sedentary work in ordinary light (approximately 150 lux), the mean (=SEM) nadir of the endogenous temperature cycle continued to occur during the night (at 03:31 ±0:56 hours), indicating a lack of circadian adaptation to the nighttime work schedule. In contrast, the subjects in the treatment studies were exposed to bright light APROXIMATELY 7.3 million Americans work at night, either on permanent shifts or on schedules, requiring a rotation of day, evening, and night work.' These workers forgo nocturnal sleep and then attempt :o sleep during daylight hours. Yet, as Benedict first noted at the turn of the century, a complete physiologic adaptation of endogenous circadian rhythms to such inversion of the daily routine does not occur=; even after years of permanent nighttime work.' -6 Physiologic maladaptation to an inverted schedule results in diminished alertness and performance during nighttime work, with attendant increases in the number of fatigue-related accidents during nighttime hours.' Then, despite the nocturnal depri From the Center for Circadian and Sleep Disorders Medicine, Division of Endocrinology, Department of Medicine. Harvard Medical School, Brigham and Women's Hospital. Boston (C.A.C., M.P.J., J.F.D., E.N.B., J.M.R.); and the Division of Applied Sciences. Harvard University, Cambridge, Mass. (R.E.K.). Address reprint requests to Dr. Czeisler at the Center for Circadian and Sleep Disorders Medicine, Harvard Medical School, Brigham and Women's Hospital, 221 Longwood Ave., Boston, MA 02115. Supported in pan by research and raining grants (DRR-GCRC-5-MO1RR00888, DRR-BRSG-2-S07-RR05950. N1A-1-ROl-AG06072. NIMH-1-R01MH45130, N1DDK-5-T32-OK-07529) from the National Institutes of Health, by Brigham and Women's Hospital, and by the Center for Design of Industrial Schedules, a nonprofit service organization directed by Dr. Czeisler. 12,000 lux) at night and to nearly complete darkness during the day, and the temperature nadir shifted after four days of treatment to a significantly later, midafternoon hour (14:53±0:32; P<0.0001), indicating a successful circadian adaptation to daytime sleep and nighttime work. There were concomitant shifts in the 24-hour patterns of plasma cortisol concentration, urinary excretion rate, subjective assessment of alertness, and cognitive performance in the treatment studies. These shifts resulted in a significant improvement in both alertness and cognitive performance in the treatment group during the night-shift hours. We conclude that mal aidaptation of the human circadian system to night work, with its associated decline in alertness, performance, and quality of daytime sleep, can be treated effectively with scheduled exposure to bright light at night and darkness during the day. (N Engl J Med 1990; 322:1253-9.) vation of sleep, these workers typically experience daytime insomnia. 10-14 Long-term exposure to variable work schedules that include work at night is also associated with an increased risk of cardiovascular disease, gastrointestinal illness, reproductive dysfunction in women, and sleep disorder.' 5-18 Improvements in performance and well-being have been achieved as a result of modifications in work-schedule design, 14 but true physiologic adaptation to night work under field conditions has not previously been demonstrated. During the past 20 years, considerable progress has been made in understanding the underlying neurophysio!ogic processes that regulate adaptation to the periodic aspects of the external environment. Studies involving ablation, transplantation, and other procedures have demonstrated that the suprachiasmatic nuclei of the hypothalamus serve as the principal pacemaker of the circadian timing system in mammals. l9-21 A specialized retinohypothalamic tract links the retina to these nuclei, forming a nonvisual photoreceptive system that mediates the synchronization, or entrainment, of the circadian pacemaker with the light-dark cycle.22 Even though corresponding structures subserving rhythmicity and photic entrain

From New England

Low back pain (LBP) is one of the major disabling health conditions among older adults aged 60 years or older. While most causes of LBP among older adults are non-specific and self-limiting, seniors are prone to develop certain LBP pathologies and/or chronic LBP given their age-related physical and psychosocial changes. Unfortunately, no review has previously summarized/discussed various factors that may affect the effective LBP management among older adults. Accordingly, the objectives of the current narrative review were to comprehensively summarize common causes and risk factors (modifiable and non-modifiable) of developing severe/chronic LBP in older adults, to highlight specific issues in assessing and treating seniors with LBP, and to discuss future research directions. Existing evidence suggests that prevalence rates of severe and chronic LBP increase with older age. As compared to working-age adults, older adults are more likely to develop certain LBP pathologies (e.g., osteoporotic vertebral fractures, tumors, spinal infection, and lumbar spinal stenosis). Importantly, various age-related physical, psychological, and mental changes (e.g., spinal degeneration, comorbidities, physical inactivity, age-related changes in central pain processing, and dementia), as well as multiple risk factors (e.g., genetic, gender, and ethnicity), may affect the prognosis and management of LBP in older adults. Collectively, by understanding the impacts of various factors on the assessment and treatment of older adults with LBP, both clinicians and researchers can work toward the direction of more cost-effective and personalized LBP management for older people.

/pdf/low-back-pain-in-older-adults-risk-factors-management-2nq4i0km8y.pdf

Low back pain in older adults: risk factors, management options and future directions

BackgroundThe efficacy of fusion surgery in addition to decompression surgery in patients who have lumbar spinal stenosis, with or without degenerative spondylolisthesis, has not been substantiated in controlled trials. MethodsWe randomly assigned 247 patients between 50 and 80 years of age who had lumbar spinal stenosis at one or two adjacent vertebral levels to undergo either decompression surgery plus fusion surgery (fusion group) or decompression surgery alone (decompression-alone group). Randomization was stratified according to the presence of preoperative degenerative spondylolisthesis (in 135 patients) or its absence. Outcomes were assessed with the use of patient-reported outcome measures, a 6-minute walk test, and a health economic evaluation. The primary outcome was the score on the Oswestry Disability Index (ODI; which ranges from 0 to 100, with higher scores indicating more severe disability) 2 years after surgery. The primary analysis, which was a per-protocol analysis, did not include the 1...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1513721

Peter Fritzell

Papers

A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis