Non-specific low back pain

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140673611606107.pdf

In the study, skeletal status was evaluated in 2850 females aged 7 to 77 yr using quantitative ultrasound (QUS amplitude-dependent speed of sound [Ad-SoS]). Ad-SoS ranged from 1923 ± 30 to 1876 ± 81 m/s, and the peak value (2121 m/s) was achieved in 19-yr-old females. Ad-SoS increased significantly between subgroups aged 11 and 12 yr, 12 and 13 yr, 13 and 14 yr, 14 and 15 yr, and 15 and 16 yr. After the age of 19 yr the only significant drop was noted between age groups 47 and 48 yr. Ad-SoS was regressed on age, weight, and height for age ranges 7 to 11 yr. (before an increase in Ad-SoS), 12 to 19 yr (from the onset of the increase to the peak value), and older than 19 yr to menopause. In females after menopause, years since menopause (YSM) were taken into consideration. In the two youngest groups Ad-SoS was affected positively by age, and in the two next groups, age had a negative influence on Ad-SoS, whereas weight had a negative and height a positive influence in all groups. YSM did not influence the Ad-SoS value. It was concluded that QUS measurements at the hand phalanges are a useful tool in assessment of skeletal status in the female population.

/pdf/a-cross-sectional-study-5bxl913lpz.pdf

A Cross-Sectional Study

A new method for the treatment of scoliosis is described in which a metal system of rods and hooks is implanted, and distraction and compression forces applied, to correct the curve and stabilize the treated segments in the corrected position by skeletal fixation. The technique and principles of this method of treatment and a summary of the preliminary results are given.

JBJS classics: Treatment of scoliosis: Correction and internal fixation by spine instrumentation

STUDY DESIGN: Systematic literature review. OBJECTIVE: To evaluate the safety and efficacy of vertebroplasty and kyphoplasty using the data presented in published clinical studies, with respect to patient pain relief, restoration of mobility and vertebral body height, complication rate, and incidence of new adjacent vertebral fractures. SUMMARY OF BACKGROUND DATA: Vertebroplasty and kyphoplasty have been gaining popularity for treating vertebral fractures. Current reviews provide an overview of the procedures but are not comprehensive and tend to rely heavily on personal experience. This article aimed to compile all available data and evaluate the clinical outcome of the 2 procedures. METHODS: This is a systematic review of all the available data presented in peer-reviewed published clinical trials. The methodological quality of included studies was evaluated, and data were collected targeting specific standard measurements. Where possible, a quantitative aggregation of the data was performed. RESULTS: A large proportion of subjects had some pain relief, including 87% with vertebroplasty and 92% with kyphoplasty. Vertebral height restoration was possible using kyphoplasty (average 6.6 degrees ) and for a subset of patients using vertebroplasty (average 6.6 degrees ). Cement leaks occurred for 41% and 9% of treated vertebrae for vertebroplasty and kyphoplasty, respectively. New fractures of adjacent vertebrae occurred for both procedures at rates that are higher than the general osteoporotic population but approximately equivalent to the general osteoporotic population that had a previous vertebral fracture. CONCLUSIONS: The problem with stating definitely that vertebroplasty and kyphoplasty are safe and effective procedures is the lack of comparative, blinded, randomized clinical trials. Standardized evaluative methods should be adopted.

/pdf/vertebroplasty-and-kyphoplasty-a-systematic-review-of-69-27mm39raap.pdf

Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies.

STUDY DESIGN A prospective, randomized, multicenter, Food and Drug Administration-regulated Investigational Device Exemption clinical trial. OBJECTIVES The purpose of this study was to compare the safety and effectiveness of lumbar total disc replacement, using the CHARITE artificial disc (DePuy Spine, Raynham, MA), with anterior lumbar interbody fusion, for the treatment of single-level degenerative disc disease from L4-S1 unresponsive to nonoperative treatment. SUMMARY OF BACKGROUND DATA Reported results of lumbar total disc replacement have been favorable, but studies have been limited to retrospective case series and/or small sample sizes. METHODS Three hundred four (304) patients were enrolled in the study at 14 centers across the United States and randomized in a 2:1 ratio to treatment with the CHARITE artificial disc or the control group, instrumented anterior lumbar interbody fusion. Data were collected pre- and perioperatively at 6 weeks and at 3, 6, 12, and 24 months following surgery. The key clinical outcome measures were a Visual Analog Scale assessing back pain, the Oswestry Disability Index questionnaire, and the SF-36 Health Survey. RESULTS Patients in both groups improved significantly following surgery. Patients in the CHARITE artificial disc group recovered faster than patients in the control group. Patients in the CHARITE artificial disc group had lower levels of disability at every time interval from 6 weeks to 24 months, compared with the control group, with statistically lower pain and disability scores at all but the 24 month follow-up (P < 0.05). At the 24-month follow-up period, a significantly greater percentage of patients in the CHARITE artificial disc group expressed satisfaction with their treatment and would have the same treatment again, compared with the fusion group (P < 0.05). The hospital stay was significantly shorter in the CHARITE artificial disc group (P < 0.05). The complication rate was similar between both groups. CONCLUSIONS This prospective, randomized, multicenter study demonstrated that quantitative clinical outcome measures following lumbar total disc replacement with the CHARITE artificial disc are at least equivalent to clinical outcomes with anterior lumbar interbody fusion. These results support earlier reports in the literature that total disc replacement with the CHARITE artificial disc is a safe and effective alternative to fusion for the surgical treatment of symptomatic disc degeneration in properly indicated patients. The CHARITE artificial disc group demonstrated statistically significant superiority in two major economic areas, a 1-day shorter hospitalization, and a lower rate of reoperations (5.4% compared with 9.1%). At 24 months, the investigational group had a significantly higher rate of satisfaction (73.7%) than the 53.1% rate of satisfaction in the control group (P = 0.0011). This prospective randomized multicenter study also demonstrated an increase in employment of 9.1% in the investigational group and 7.2% in the control group.

A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes.

Study Design. A preliminary outcome assessment study of titanium cage implants with anterior cervical plating in anterior cervical reconstruction. Objectives. To evaluate the efficacy and safety of using titanium cage implants and anterior plating in cervical reconstruction. Summary of Background Data. Anterior decompression and interbody fusion is a widely accepted surgical treatment for patients with cervical spondylosis. Tricortical iliac crest autograft has been the gold standard but is associated with morbidity at the bone graft donor site, whereas allograft fibula is associated with pseudarthrosis. Problems such as pseudarthrosis, graft collapse, and extrusion still persist with the accepted method of harvesting and implanting bone autografts. Methods. Thirty-four patients were treated by channel corpectomy followed by placement of a titanium cage packed with autogenous bone graft from the vertebral bodies to reconstruct the anterior column. An anterior cervical plate was added in 30 of 34 cases that involved decompression of two or more levels. The follow-up period ranged from 24 to 56 months, with an average follow-up period of 32 months, and included examination and radiography. Results. Six months after surgery, there was radiographic evidence of fusion in 97% of the patients. Eighty-eight percent of the patients (30 of 34) did not experience any complications (neither cage dislodgment nor hardware failure). Four patients had complications that included pseudarthrosis (1), extruded cage (1), cage in kyphosis (1), and radiculopathy (1). Conclusions. Titanium cages provide immediate strong anterior column support with minimum hardware complications and avoid bone graft-site morbidity. Titanium cages, with concomitant use of anterior plating, offer an effective and safe alternative to bone autografts.

Anterior cervical reconstruction using titanium cages with anterior plating.

No previous study has compared the complications between anterior/posterior and transforaminal interbody fusions. We performed a retrospective analysis of 164 patients to compare the complications and associated predictive factors of the two techniques of circumferential lumbar fusion. Fifty-three had same-day anterior/posterior fusion (group 1), and 111 had transforaminal interbody fusion (group 2). Mean operating time (p < 0.0001) and hospital stay (p < 0.0001) was significantly longer for group 1 patients. Average blood loss was greater for group 1 patients (p < 0.01). Higher complication rates were found in group 1 patients (p < 0.004). Wound infection occurred more frequently in patients with adjunctive treatment (p < 0.04). Hospital stay was an independent predictor of complications in both groups. In group 1, body mass index was independently associated with complications. In group 2, both hospital stay and adjunctive treatment were predictive of complications. Transforaminal lumbar interbody fusion is the preferred technique because it is associated with shorter operating time, less blood loss, shorter hospital stay, and lower incidence of complications.

Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors.

Preliminary outcomes and efficacy of the first 360 consecutive kyphoplasties for the treatment of painful osteoporotic vertebral compression fractures.

Pseudarthrosis remains a significant problem in spinal fusion. The objective of our study was to investigate the effects of autologous growth factors (AGF) in instrumented transforaminal lumbar interbody spinal fusion (TLIF). A prospective review was carried out of 23 patients who underwent TLIF with application of AGF, with a minimum 2-year follow-up. Comparison with our historical cohort (without AGF application) was performed. Mean age at surgery was 44.3 years in the AGF treatment group. Twelve had a positive smoking history. Fourteen had undergone previous spinal surgeries. Thirteen received one-level fusions and ten received two-level fusions. The radiographic results showed a fusion rate of 100% in one-level fusions and 90% in two-level fusions. There was no significant difference in pseudarthrosis rates between the AGF treatment group and historical cohort. Excluding the cases with pseudarthrosis, there was faster bony healing in patients who had been treated with AGF application. This study indicates that although AGF may demonstrate faster fusions, it does not result in an overall increase in spinal fusion rates. Further studies are needed before AGF can routinely be used as an adjunct in spinal fusion.

Richard T. Holt

Papers

A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes.

Anterior cervical reconstruction using titanium cages with anterior plating.

Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors.

Preliminary outcomes and efficacy of the first 360 consecutive kyphoplasties for the treatment of painful osteoporotic vertebral compression fractures.

Do autologous growth factors enhance transforaminal lumbar interbody fusion