Showing papers in "European Spine Journal in 2011"
TL;DR: It is concluded that there are insufficient data to draw firm conclusion on the clinical effect of back schools, low-level laser therapy, patient education, massage, traction, superficial heat/cold, and lumbar supports for chronic LBP.
Abstract: Low back pain (LBP) is a common and disabling disorder in western society. The management of LBP comprises a range of different intervention strategies including surgery, drug therapy, and non-medical interventions. The objective of the present study is to determine the effectiveness of physical and rehabilitation interventions (i.e. exercise therapy, back school, transcutaneous electrical nerve stimulation (TENS), low level laser therapy, education, massage, behavioural treatment, traction, multidisciplinary treatment, lumbar supports, and heat/cold therapy) for chronic LBP. The primary search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to 22 December 2008. Existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria. The search strategy outlined by the Cochrane Back Review Groups (CBRG) was followed. The following were included for selection criteria: (1) randomized controlled trials, (2) adult (≥18 years) population with chronic (≥12 weeks) non-specific LBP, and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery, or return to work). Two reviewers independently selected studies and extracted data on study characteristics, risk of bias, and outcomes at short, intermediate, and long-term follow-up. The GRADE approach was used to determine the quality of evidence. In total 83 randomized controlled trials met the inclusion criteria: exercise therapy (n = 37), back school (n = 5), TENS (n = 6), low level laser therapy (n = 3), behavioural treatment (n = 21), patient education (n = 1), traction (n = 1), and multidisciplinary treatment (n = 6). Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. Behavioural treatment was found to be effective in reducing pain intensity at short-term follow-up compared to no treatment/waiting list controls. Finally, multidisciplinary treatment was found to reduce pain intensity and disability at short-term follow-up compared to no treatment/waiting list controls. Overall, the level of evidence was low. Evidence from randomized controlled trials demonstrates that there is low quality evidence for the effectiveness of exercise therapy compared to usual care, there is low evidence for the effectiveness of behavioural therapy compared to no treatment and there is moderate evidence for the effectiveness of a multidisciplinary treatment compared to no treatment and other active treatments at reducing pain at short-term in the treatment of chronic low back pain. Based on the heterogeneity of the populations, interventions, and comparison groups, we conclude that there are insufficient data to draw firm conclusion on the clinical effect of back schools, low-level laser therapy, patient education, massage, traction, superficial heat/cold, and lumbar supports for chronic LBP.
617 citations
TL;DR: The genuine shape of the spine is probably one of the main mechanical factors of degenerative evolution and the only signature to determine the original spine shape the authors have to restore the balance of the patient.
Abstract: Introduction
Standing in an erect position is a human property. The pelvis anatomy and position, defined by the pelvis incidence, interact with the spinal organization in shape and position to regulate the sagittal balance between both the spine and pelvis. Sagittal balance of the human body may be defined by a setting of different parameters such as (a) pelvic parameters: pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS); (b) C7 positioning: spino-pelvic angle (SSA) and C7 plumb line; (c) shape of the spine: lumbar lordosis.
521 citations
TL;DR: A three steps algorithm is proposed to analyse the balance status and determine the presence or not of these compensatory mechanisms: measurement of pelvis incidence, assessment of global sagittal alignment and analysis of compensatory mechanism successively in the spine, pelvis and lower limbs areas.
Abstract: Introduction
Aging of the spine is characterized by facet joints arthritis, degenerative disc disease and atrophy of extensor muscles resulting in a progressive kyphosis. Recent studies confirmed that patients with lumbar degenerative disease were characterized by an anterior sagittal imbalance, a loss of lumbar lordosis and an increase of pelvis tilt. The aim of this paper was thus to describe the different compensatory mechanisms which are observed in the spine, pelvis and/or lower limbs areas for patients with severe degenerative spine.
335 citations
TL;DR: Subgroup analysis indicates that percutaneously operated patients required less opioids, had a shorter hospitalization and lower rate of adverse events in the perioperative period, and patients seem to have a better per ioperative course following percutaneous procedures.
Abstract: Robotic-guided and percutaneous pedicle screw placement are emerging technologies. We here report a retrospective cohort analysis comparing conventional open to open robotic-guided and percutaneous robotic-guided pedicle screw placement. 112 patient records and CT scans were analyzed concerning the intraoperative and perioperative course. 35 patients underwent percutaneous, 20 open robotic-guided and 57 open conventional pedicle screw placement. 94.5% of robot-assisted and 91.4% of conventionally placed screws were found to be accurate. Percutaneous robotic and open robotic-guided subgroups did not differ obviously. Average X-ray exposure per screw was 34 s in robotic-guided compared to 77 s in conventional cases. Subgroup analysis indicates that percutaneously operated patients required less opioids, had a shorter hospitalization and lower rate of adverse events in the perioperative period. The use of robotic guidance significantly increased accuracy of screw positioning while reducing the X-ray exposure. Patients seem to have a better perioperative course following percutaneous procedures.
318 citations
TL;DR: The occurrence of LBP is related to the nature and intensity of the physical activities undertaken, however, physical activities can be subdivided into separate types and intensities and the ultimate physical load is the sum of all these activities.
Abstract: The objective of the study is to systematically evaluate the available evidence on the association between physical activity (i.e. occupational load and non-occupational physical activities) and low back pain (LBP). A systematic approach was used to explore the literature between 1999 and 2009. Studies were selected for inclusion following a comprehensive search of Medline, Embase and CINAHL. The methodological quality of each study was assessed. Studies were considered to be of ‘high quality’ if they met the cut-off criterion of 60% of the maximum available quality score. Thirty-six cohort or case–control studies were retrieved. Heavy workload and the accumulation of loads or frequency of lifts were moderate to strong risk factors for LBP. Strong associations were found for flexed, rotated and the awkward positions of the lumbar spine. Inconsistent results were found for leisure time physical activities, sports and physical exercise. Studies focusing on daily habitual physical activities (e.g. domestic activities and commuting) in association with LBP are lacking. In conclusion, the occurrence of LBP is related to the nature and intensity of the physical activities undertaken. However, physical activities can be subdivided into separate types and intensities and the ultimate physical load is the sum of all these activities. This makes it difficult to designate one particular activity as the cause of LBP.
292 citations
TL;DR: A large low-risk-of-bias trial demonstrated that early surgery in patients with 6–12 weeks of radicular pain leads to faster pain relief when compared with prolonged conservative treatment, but there were no differences after 1 and 2 years.
Abstract: The effectiveness of surgery in patients with sciatica due to lumbar disc herniations is not without dispute. The goal of this study was to assess the effects of surgery versus conservative therapy (including epidural injections) for patients with sciatica due to lumbar disc herniation. A comprehensive search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to October 2009. Randomised controlled trials of adults with lumbar radicular pain, which evaluated at least one clinically relevant outcome measure (pain, functional status, perceived recovery, lost days of work) were included. Two authors assessed risk of bias according to Cochrane criteria and extracted the data. In total, five studies were identified, two of which with a low risk of bias. One study compared early surgery with prolonged conservative care followed by surgery if needed; three studies compared surgery with usual conservative care, and one study compared surgery with epidural injections. Data were not pooled because of clinical heterogeneity and poor reporting of data. One large low-risk-of-bias trial demonstrated that early surgery in patients with 6-12 weeks of radicular pain leads to faster pain relief when compared with prolonged conservative treatment, but there were no differences after 1 and 2 years. Another large low-risk-of-bias trial between surgery and usual conservative care found no statistically significant differences on any of the primary outcome measures after 1 and 2 years. Future studies should evaluate who benefits more from surgery and who from conservative care.
287 citations
TL;DR: It was showed that navigation provided a higher accuracy in the placement of pedicle screws compared with conventional methods and the superiority of navigation systems was obvious when they were applied to abnormal spinal structure.
Abstract: Studies revealed that navigation systems that provided intraoperative assistance might improve pedicle screw insertion accuracy, and also implied that different systems provided different pedicle screw insertion accuracy. A systematic review and meta-analysis was conducted to focus on the pedicle screw insertion accuracy with or without the assistance of image-guided system, and the variance among the different navigation systems. Comparative studies were searched on pedicle screw insertion accuracy between conventional and navigated method, and among different navigation systems. A total of 43 papers, including 28 clinical, 14 cadaveric and 1 model studies, were included in the current study. For clinical articles, there were 3 randomized clinical trials, 4 prospective comparative studies and 21 retrospective comparative studies. The incidence of pedicle violation among computer tomography-based navigation method group was statistically significantly less than that observed among the conventional group (OR 95% CI, in vivo: 0.32–0.60; in vitro: 0.24–0.75 P < 0.01). Two-dimensional fluoroscopy-based navigation system (OR 95% CI, in vivo: 0.27–0.48; in vitro: 0.43–0.88 P < 0.01) and three-dimension fluoroscopy-based navigation system (OR 95% CI, in vivo: 0.09–0.38; in vitro: 0.09–0.36 P < 0.01) also obtained significant reduced screw deviation rate over traditional methods. Between navigated approaches, statistically insignificant individual and pooled RR values were observed for all in vivo subgroups. Pooled estimate of in vitro studies show that computer tomography-based and three-dimension fluoroscopy-based navigation system provided more accurate pedicle screw insertion over two-dimension fluoroscopy-based navigation system. Our review showed that navigation provided a higher accuracy in the placement of pedicle screws compared with conventional methods. The superiority of navigation systems was obvious when they were applied to abnormal spinal structure. Although no strong in vivo evidence has detected significantly different pedicle screw placement accuracy among the three major navigation systems, meta-analysis revealed the variance in pedicle screw insertion accuracy with different navigation methods.
282 citations
TL;DR: Patients with NSLBP exhibit greater postural instability than healthy controls, signified by greater COP excursions and a higher mean velocity, and the decreased postural stability in NSL BP sufferers seems unrelated to the exact location and pain duration.
Abstract: Over the past 20 years, the center of pressure (COP) has been commonly used as an index of postural stability in standing. While many studies investigated COP excursions in low back pain patients and healthy individuals, no comprehensive analysis of the reported differences in postural sway pattern exists. Six online databases were systematically searched followed by a manual search of the retrieved papers. The selection criteria comprised papers comparing COP measures derived from bipedal static task conditions on a force-plate of non-specific low back pain (NSLBP) sufferers to those of healthy controls. Sixteen papers met the inclusion criteria. Heterogeneity in study designs prevented pooling of the data so only a qualitative data analysis was conducted. The majority of the papers (14/16, 88%) concluded that NSLBP patients have increased COP mean velocity and overall excursion as compared to healthy individuals. This was statistically significant in the majority of studies (11/14, 79%). An increased sway in anteroposterior direction was also observed in NSLBP patients. Patients with NSLBP exhibit greater postural instability than healthy controls, signified by greater COP excursions and a higher mean velocity. While the decreased postural stability in NSLBP sufferers further appears to be associated with the presence of pain, it seems unrelated to the exact location and pain duration. No correlation between the pain intensity and the magnitude of COP excursions could be identified.
281 citations
TL;DR: Global spinal balance involves harmonisation of lumbar lordosis and thoracic kyphosis taking into account the pelvic parameters, which affect the entire underlying sagittal spinal profile.
Abstract: Introduction
The adoption by humans of an upright position resulted in broadening and verticalisation of the pelvis together with the appearance of characteristic spinal curves, has profoundly modified the structure of the muscles supporting the spine.
265 citations
TL;DR: Comprehensive analysis of the pelvic and subpelvic sectors as part of the sagittal, frontal and cross-sectional balance of the trunk sheds new light on some spinal diseases and their relation to the pelvis.
Abstract: Introduction
The role of the pelvic area in sagittal balance is evident for spinal surgeons, but the influence of the coxofemoral joint is underestimated and inadequately explained by conventional imagery. Comprehensive analysis of the pelvic and subpelvic sectors as part of the sagittal, frontal and cross-sectional balance of the trunk sheds new light on some spinal diseases and their relation to the pelvis.
248 citations
TL;DR: Both curves of the thoraco-lumbar spine may be divided at the Inflexion Point where lordosis turns into kyphosis, and the top of thoracic curve on C7 is very stable over the sacrum.
Abstract: According to the anatomical segmentation, spine curves are the sacral kyphosis (sacrum), lumbar lordosis (L1 to L5), thoracic kyphosis (T1 to T12) and cervical lordosis (C1 to C7). From the morphological point of view the vertebrae of a curve are not identical: from cranial to caudal and vice versa there is a progressive anatomical modification. Both curves of the thoraco-lumbar spine may be divided at the Inflexion Point where lordosis turns into kyphosis. A geometrical construct of each curve by two tangent arcs of circle allows understanding the reciprocal changes between both curves. Lumbar Lordosis is mainly dependent on SS orientation, and the top of thoracic curve on C7 is very stable over the sacrum. Thoracic curve is dependent on lumbar lordosis orientation and C7 positioning. On a reverse effect, structural changing of thoracic kyphosis may affect the shape of the lumbar lordosis and the orientation of the pelvis.
TL;DR: The degree of urgency of early surgery in CES-R is still not in clear focus but it cannot be doubted that earliest decompression removes the mechanical and perhaps chemical factors which are the causes of progressive neurological damage.
Abstract: Cauda equina syndrome (CES) is a rare condition with a disproportionately high medico-legal profile. It occurs most frequently following a large central lumbar disc herniation, prolapse or sequestration. Review of the literature indicates that around 50–70% of patients have urinary retention (CES-R) on presentation with 30–50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression by a suitably experienced surgeon. Every effort should be made to avoid CES-I with its more favourable prognosis becoming CES-R while under medical supervision either before or after admission to hospital. The degree of urgency of early surgery in CES-R is still not in clear focus but it cannot be doubted that earliest decompression removes the mechanical and perhaps chemical factors which are the causes of progressive neurological damage. A full explanation and consent procedure prior to surgery is essential in order to reduce the likelihood of misunderstanding and litigation in the event of a persistent neurological deficit.
TL;DR: This review summarises recent studies on the response of the IVD and stem cells to applied cyclic compression and hydrostatic pressure as well as quantifying a physiological loading condition for the study of disc degeneration biological therapy and a possible physiological/beneficial loading range is proposed.
Abstract: Loading is important to maintain the balance of matrix turnover in the intervertebral disc (IVD). Daily cyclic diurnal assists in the transport of large soluble factors across the IVD and its surrounding circulation and applies direct and indirect stimulus to disc cells. Acute mechanical injury and accumulated overloading, however, could induce disc degeneration. Recently, there is more information available on how cyclic loading, especially axial compression and hydrostatic pressure, affects IVD cell biology. This review summarises recent studies on the response of the IVD and stem cells to applied cyclic compression and hydrostatic pressure. These studies investigate the possible role of loading in the initiation and progression of disc degeneration as well as quantifying a physiological loading condition for the study of disc degeneration biological therapy. Subsequently, a possible physiological/beneficial loading range is proposed. This physiological/beneficial loading could provide insight into how to design loading regimes in specific system for the testing of various biological therapies such as cell therapy, chemical therapy or tissue engineering constructs to achieve a better final outcome. In addition, the parameter space of ‘physiological’ loading may also be an important factor for the differentiation of stem cells towards most ideally ‘discogenic’ cells for tissue engineering purpose.
TL;DR: Sagittal spino-pelvic alignment is significantly different in chronic LBP with respect to SS, PI, LT, lordotic levels, TK, TT and LSA, but not PT, LL and kyphotic levels.
Abstract: Introduction
The differences in sagittal spino-pelvic alignment between adults with chronic low back pain (LBP) and the normal population are still poorly understood. In particular, it is still unknown if particular patterns of sagittal spino-pelvic alignment are more prevalent in chronic LBP. The current study helps to better understand the relationship between sagittal alignment and low back pain.
TL;DR: Clinicians need to keep in mind when planning treatment that subjects with L5-S1 spondylolisthesis are a heterogeneous group with various adaptations of their posture, and the value of a classification based on spino-pelvic alignment is supported.
Abstract: Introduction
In L5-S1 spondylolisthesis, it has been clearly demonstrated over the past decade that sacro-pelvic morphology is abnormal and that it can be associated to an abnormal sacro-pelvic orientation as well as to a disturbed global sagittal balance of the spine. The purpose of this article is to review the work done within the Spinal Deformity Study Group (SDSG) over the past decade, which has led to a classification incorporating this recent knowledge.
TL;DR: To analyse sagittal balance, the parameters concerned and the relationships between them are defined and the spino-sacral angle, which is an intrinsic parameter, is defined.
Abstract: Introduction
Bipedalism is a distinguishing feature of the human race and is characterised by a narrow base of support and an ergonomically optimal position thanks to the appearance of lumbar and cervical curves.
TL;DR: It was concluded that free-hand technique will only be safe and accurate when it is in the hands of an experienced surgeon and the accuracy of screw placement with O-arm can reach 100%.
Abstract: Transpedicular screw fixation has been accepted worldwide since Harrington et al. first placed pedicle screws through the isthmus. In vivo and in vitro studies indicated that pedicle screw insertion accuracy could be significantly improved with image-assisted systems compared with conventional approaches. The O-arm is a new generation intraoperative imaging system designed without compromise to address the needs of a modern OR like no other system currently available. The aim of our study was to check the accuracy of O-arm based and S7-navigated pedicle screw implants in comparison to free-hand technique described by Roy-Camille at the lumbar and sacral spine using CT scans. The material of this study was divided into two groups, free-hand group (group I) (30 patients; 152 screws) and O-arm group (37 patients; 187 screws). The patients were operated upon from January to September 2009. Screw implantation was performed during PLIF or TLIF mainly for spondylolisthesis, osteochondritis and post-laminectomy syndrome. The accuracy rate in our work was 94.1% in the free-hand group compared to 99% in the O-arm navigated group. Thus it was concluded that free-hand technique will only be safe and accurate when it is in the hands of an experienced surgeon and the accuracy of screw placement with O-arm can reach 100%.
TL;DR: NSAIDs and opioids seem to lead to a somewhat higher relief in pain on the short term, as compared to placebo, in patients with non-specific chronic low back pain; opioids seems to have a small effect in improving function for a selection of patients who responded with an exacerbation of their symptoms after stopping their medication.
Abstract: The objective of this review was to determine the effectiveness of pharmacological interventions [i.e., non-steroid anti-inflammatory drugs (NSAIDs), muscle relaxants, antidepressants, and opioids] for non-specific chronic low-back pain (LBP). Existing Cochrane reviews for the four interventions were screened for studies fulfilling the inclusion criteria. Then, the literature searches were updated. Only randomized controlled trials on adults (≥18 years) with chronic (≥12 weeks) non-specific LBP and evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery, or return to work) were included. The GRADE approach was used to determine the quality of evidence. A total of 17 randomized controlled trials was included: NSAIDs (n = 4), antidepressants (n = 5), and opioids (n = 8). No studies were found for muscle relaxants; 14 studies had a low risk of bias. The studies only reported effects on the short term (<3 months). The overall quality of the evidence was low. NSAIDs and opioids seem to lead to a somewhat higher relief in pain on the short term, as compared to placebo, in patients with non-specific chronic low back pain; opioids seem to have a small effect in improving function for a selection of patients who responded with an exacerbation of their symptoms after stopping their medication. However, both types of medication show more adverse effects than placebo. There seems to be no difference in effect between antidepressants and placebo in patients with non-specific chronic LBP.
TL;DR: Knee flexion as a compensatory mechanism to sagittal imbalance was well correlated to the lack of lordosis and, depending on the importance of the former parameter, the best procedure to correct sagittal balance could be chosen.
Abstract: Introduction
It has become well recognised that sagittal balance of the spine is the result of an interaction between the spine and the pelvis. Knee flexion is considered to be the last compensatory mechanism in case of sagittal imbalance, but only few studies have insisted on the relationship between spino-pelvic parameters and lower extremity parameters. Correlation between the lack of lumbar lordosis and knee flexion has not yet been established.
TL;DR: In this paper, the authors evaluated the association between physical activity and the incidence/prevalence of neck and low back pain in both general population and school children and concluded that the evidence was too heterogeneous and more research is needed before any final conclusion can be reached.
Abstract: The effect of physical activity on neck and low back pain is still controversial. No systematic review has been conducted on the association between daily physical activity and neck and low back pain. The objective of this study was to evaluate the association between physical activity and the incidence/prevalence of neck and low back pain. Publications were systematically searched from 1980 to June 2009 in several databases. The following key words were used: neck pain, back pain, physical activity, leisure time activity, daily activity, everyday activity, lifestyle activity, sedentary, and physical inactivity. A hand search of relevant journals was also carried out. Relevant studies were retrieved and assessed for methodological quality by two independent reviewers. The strength of the evidence was based on methodological quality and consistency of the results. Seventeen studies were included in this review, of which 13 were rated as high-quality studies. Of high-quality studies, there was limited evidence for no association between physical activity and neck pain in workers and strong evidence for no association in school children. Conflicting evidence was found for the association between physical activity and low back pain in both general population and school children. Literature with respect to the effect of physical activity on neck and low back pain was too heterogeneous and more research is needed before any final conclusion can be reached.
TL;DR: In this paper, the authors investigated the cost-effectiveness of guideline-endorsed treatments for low back pain (LBP) and found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP.
Abstract: Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.
TL;DR: It is indicated that sleep disturbance is common in patients with LBP, and the intensity of back pain was only weakly associated with sleep disturbance, suggesting that other factors contribute to sleep problems for LBP patients.
Abstract: Low back pain (LBP) is a common health condition that is often associated with disability, psychological distress and work loss. Worldwide, billions of dollars are expended each year trying to manage LBP, often with limited success. Recently, some researchers have reported that LBP patients also report sleep disturbance as a result of their LBP. However, as most of this evidence was obtained from highly selected groups of patients or from studies with small samples, high quality data on prevalence of sleep disturbance for patients with LBP are lacking. It is also unclear whether sleep disturbance is more likely to be reported by patients with recent-onset LBP than by patients with persistent LBP. Finally, it is not known whether high pain intensity, the most relevant condition-specific variable, is associated with higher rates of reported sleep disturbance. The present study aimed to determine the prevalence of reported sleep disturbance in patients with LBP. In addition, we aimed to determine whether sleep disturbance was associated with the duration of back pain symptoms and whether pain intensity was associated with reported sleep disturbance. Data from 1,941 patients obtained from 13 studies conducted by the authors or their colleagues between 2001 and 2009 were used to determine the prevalence of sleep disturbance. Logistic regression analyses explored associations between sleep disturbance, the duration of low back symptoms and pain intensity. The estimated prevalence of sleep disturbance was 58.7% (95% CI 56.4–60.7%). Sleep disturbance was found to be dependent on pain intensity, where each increase by one point on a ten-point visual analogue scale (VAS) was associated with a 10% increase in the likelihood of reporting sleep disturbance. Our findings indicate that sleep disturbance is common in patients with LBP. In addition, we found that the intensity of back pain was only weakly associated with sleep disturbance, suggesting that other factors contribute to sleep problems for LBP patients.
TL;DR: The largest cohort of asymptomatic adults in the literature dedicated to the evaluation of sagittal sacropelvic morphology and balance is presented, presenting the range of values corresponding to the mean ± 2 SD can provide invaluable information to clinicians about the normal range ofvalues expected in 95% of the normal population.
Abstract: Introduction
Many studies suggest the importance of the sagittal sacropelvic balance and morphology in spinal and hip disorders. This study describes the normal age- and sex-related changes in sacropelvic morphology and balance in a prospective cohort of asymptomatic adults without spinal disorder.
TL;DR: In conclusion, QOL of the middle-aged and elderly male subjects was related to sagittal balance, lumbar lordosis angle, spinal ROM, and back muscle strength.
Abstract: With aging of society, clarification of the relationship between QOL and abnormal posture in the elderly may allow improvement of QOL through any preventive methods and training. However, sagittal balance has not been studied widely and most studies have focused on postmenopausal patients with osteoporosis. In this report, we provide the first evaluation of the simultaneous effects of degenerative changes on radiograph, spinal range of motion (ROM), sagittal balance, and back muscle strength, and examine the influence of these effects on QOL of the middle-aged and elderly male subjects. The subjects were 100 Japanese males who underwent a basic health checkup. Lumbar lateral radiograph, sagittal balance and spinal mobility determined with SpinalMouse® and back muscle strength were measured. The thoracic/lumbar angle ratio (T/L ratio) was used as an index of sagittal balance. SF-36 physical component summary (PCS) scores showed a significant negative correlation with age (r = −0.377), osteophyte score (r = −0.246) and T/L ratio (r = −0.214), and a significant positive correlation with lumbar lordosis angle (r = 0.271), thoracic ROM (r = 0.282), and back muscle strength (r = 0.549). Multiple regression analysis indicated that thoracic spinal ROM (r = 0.254, p < 0.01) and back muscle strength (r = 0.488, p < 0.0001) were significantly associated with SF-36 PCS (R2 = 0.403). In conclusion, QOL of the middle-aged and elderly male subjects was related to sagittal balance, lumbar lordosis angle, spinal ROM, and back muscle strength. Exercise including muscle strength and spinal ROM may be able to influence these primary factors related to QOL. Back muscle strength and thoracic ROM impact on improvement of QOL in the middle-aged and the elderly.
TL;DR: Sagittal balance is evaluated on a sagittal full spine standing X-ray from C2 to the pelvis, including the first 10 cm of the femur, and the newly described method called full balance integrated (FBI) is taken into account.
Abstract: Introduction
The main objective of all the sagittal compensating mechanisms is to allow a subject to stand and keep an erect position.
TL;DR: Consensus definitions were reached in both areas with 95% of panel members supporting the definition of a ‘recurrence of an episode of LBP’ and 92% ofpanel members supportingThe definition of ‘Recurrent LBP'.
Abstract: Lack of standardization of terminology in low back pain (LBP) research has significantly impeded progress in this area. The diversity in existing definitions for a ‘recurrence of an episode of LBP’ and ‘recurrent LBP’ is an important example. The variety of definitions used by researchers working in this area has prevented comparison of results between trials and made meta-analyses of this data unfeasible. The aim of this study was to use a modified Delphi approach to gain consensus on definitions for a ‘recurrence of an episode of LBP’ (e.g. outcome event) and for ‘recurrent LBP’ (e.g. patient population). Existing definitions for both constructs were classified into the main features comprising the definition (e.g. ‘duration of pain’) and the items that defined each feature (e.g. ‘pain lasting at least 24 h’). In each round, participants were asked to rate the importance of each feature to a definition of a ‘recurrence of an episode of LBP’, and a definition of ‘recurrent LBP’ and rank the items (defining each feature) in order of decreasing importance. Forty-six experts in LBP research, from nine different countries, participated in this study. Four rounds were completed with responses rates of 94, 91, 83, and 97% in rounds 1, 2, 3, and 4, respectively. Consensus definitions were reached in both areas with 95% of panel members supporting the definition of a ‘recurrence of an episode of LBP’ and 92% of panel members supporting the definition of ‘recurrent LBP’. Future research is necessary to evaluate these definitions.
TL;DR: Comparison of conservative and surgical treatment in mild and moderate forms of CSM in a 10-year follow-up has not shown a significant difference in results, but can serve as a worthy odds-on hypothesis which needs the confirmation.
Abstract: It is not known whether the results of decompressive surgery to treat the mild and moderate forms of spondylotic cervical myelopathy (CSM) are any better than those of a conservative approach. A 10-year prospective randomised study was performed. The objective of the study was to compare conservative and operative treatments of mild and moderate, non-progressive, or slowly progressive, forms of CSM. Sixty-four patients were randomised into two groups of 32. Group A was treated conservatively while group B was treated surgically. The clinical outcome was evaluated by modified JOA score, timed 10-m walk, score of daily activities recorded by video and evaluated by two observers blinded to the type of therapy, and by subjective assessment by the patients themselves. Seventeen patents died of natural, unrelated causes, during the follow-up. A total of 25 patients in the conservatively and 22 in the surgically treated group were used for the final evaluation. There was no statistically significant difference between both groups in mJOA score, in subjective evaluation by the patients themselves and in evaluation of video-recordings of daily living activities by two observers blinded to treatment mode. There was neither any difference found in the percentage of patients losing the ability to walk nor in the time taken to cover the 10-m track from a standing start. Comparison of conservative and surgical treatment in mild and moderate forms of CSM in a 10-year follow-up has not shown, on average, a significant difference in results. In both groups, patients get better and worse. According to the power analysis it is necessary admit that these results possess the low ability to answer definitely the question which treatment is better for the patients with a mild and moderate non-progressive CSM because of the low number of patients for the final evaluation and for clinically negligible differences between two compared arms. These findings can serve as a worthy odds-on hypothesis which needs the confirmation.
TL;DR: Combined SEP and TES-MEP monitoring must be regarded as the neurophysiological standard for intraoperative detection of emerging spinal cord injury during corrective spinal deformity surgery.
Abstract: Iatrogenic spinal cord injury is the most feared complication of scoliosis surgery. The importance of combined somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) monitoring during spine surgery is well known. The current authors retrospectively evaluated the results of neurophysiological intraoperative monitoring (IOM) in a large population of patients who underwent surgical treatment for spinal deformity. Intraoperative monitoring of SEPs and transcranial electrical stimulation MEPs (TES-MEP) was performed in 172 successive patients who underwent surgical treatment of idiopathic (128 pts), congenital (15 pts) or syndromic (29 pts) scoliosis. The first 106 patients (Group 1) underwent only SEP monitoring, while the other 66 patients (Group 2) underwent combined SEP and TES-MEP monitoring, when the technique was introduced in the current authors’ institution. Halogenate anaesthesia (Sevoflurane, MAC 0.6–1.2) was performed in Group 1 cases, total intravenous anaesthesia (Propofol infusion, 6–10 mg/kg/h) in Group 2 patients. A neurophysiological “alert” was defined as a reduction in amplitude (unilateral or bilateral) of at least 50% for SEPs and of 65% for TES-MEPs compared with baseline. In Group 1, two patients (1.9%) developed postoperative neurologic deficits following surgical correction of spinal deformity, consisting of permanent paraparesis in one case and transient paraparesis secondary to spinal cord ischaemia in the other. Twelve patients presented intraoperative significant changes of neurophysiological parameters that improved following corrective actions by surgeons and anaesthesiologists, and did not show any postoperative neurologic deficits. In ten cases the alert was apparently unrelated to surgical manoeuvres or to pharmacological interventions and no postoperative neurologic deficits were noted. Considering the patients of Group 2, two patients (3.0%) presented transient postoperative neurologic deficits preceded by significant intraoperative changes in SEPs and TES-MEPs. In five cases a transient reduction in the amplitudes of SEPs (1 patient) and/or TES-MEPs (5 patients) was recorded intraoperatively with no postoperative neurologic deficits. In conclusion, in the current series of 172 patients the overall prevalence of postoperative neurologic deficit was 2.3% (4 patients). When combined SEP and TES-MEP monitoring was performed, the sensitivity and specificity of IOM for sensory-motor impairment was 100 and 98%, respectively. Combined SEP and TES-MEP monitoring must be regarded as the neurophysiological standard for intraoperative detection of emerging spinal cord injury during corrective spinal deformity surgery. Early detection affords the surgical team an opportunity to perform rapid intervention to prevent injury progression or possibly to reverse impending neurologic sequelae.
TL;DR: Although the L1–S1 lordosis keeps comparable to the reference group, the increase of pelvic tilt suggests a posterior tilt of the pelvis as a compensation mechanism in patients with high pelvic incidence, and the detailed analysis of segmental lordosis revealed that the lordosis increased at the levels above the spondylolisthesis, which might subsequently increase posterior stress on facet joints.
Abstract: The sagittal orientation and osteoarthritis of facet joints, paravertebral muscular dystrophy and loss of ligament strength represent mechanical factors leading to degenerative spondylolisthesis. The importance of sagittal spinopelvic imbalance has been described for the developmental spondylolisthesis with isthmic lysis. However, it remains unclear if these mechanisms play a role in the pathogenesis of degenerative spondylolisthesis. The purpose of this study was to analyze the sagittal spinopelvic alignment, the body mass index (BMI) and facet joint degeneration in degenerative spondylolisthesis. A group of 49 patients with L4–L5 degenerative spondylolisthesis (12 males, 37 females, average age 65.9 years) was compared to a reference group of 77 patients with low back pain without spondylolisthesis (41 males, 36 females, average age 65.5 years). The patient’s height and weight were assessed to calculate the BMI. The following parameters were measured on lateral lumbar radiographs in standing position: L1–S1 lordosis, segmental lordosis from L1–L2 to L5–S1, pelvic tilt, pelvic incidence and sacral slope. The sagittal orientation and the presence of osteoarthritis of the facet joints were determined from transversal plane computed tomography (CT). The average BMI was significantly higher (P = 0.030) in the spondylolisthesis group compared to the reference group (28.2 vs. 24.8) and 71.4% of the spondylolisthesis patients had a BMI > 25. The radiographic analysis showed a significant increase of the following parameters in spondylolisthesis: pelvic tilt (25.6° vs. 21.0°; P = 0.046), sacral slope (42.3° vs. 33.4°; P = 0.002), pelvic incidence (66.2° vs. 54.2°; P = 0.001), L1–S1 lordosis (57.2° vs. 49.6°; P = 0.045). The segmental lumbar lordosis was significantly higher (P < 0.05) at L1–L2 and L2–L3 in spondylolisthesis. The CT analysis of L4–L5 facet joints showed a sagittal orientation in the spondylolisthesis group (36.5° vs. 44.4°; P = 0.001). The anatomic orientation of the pelvis with a high incidence and sacral slope seems to represent a predisposing factor for degenerative spondylolisthesis. Although the L1–S1 lordosis keeps comparable to the reference group, the increase of pelvic tilt suggests a posterior tilt of the pelvis as a compensation mechanism in patients with high pelvic incidence. The detailed analysis of segmental lordosis revealed that the lordosis increased at the levels above the spondylolisthesis, which might subsequently increase posterior stress on facet joints. The association of overweight and a relatively vertical inclination of the S1 endplate is predisposing for an anterior translation of L4 on L5. Furthermore, the sagittally oriented facet joints do not retain this anterior vertebral displacement.
TL;DR: This report is presented as a guide for studying the prevalence of idiopathic scoliosis in a large population, and the increasing trend in the prevalence in the Korean population emphasizes the need for awareness.
Abstract: Cross-sectional epidemiologic scoliosis screening was carried out to determine the current prevalence of scoliosis in the Korean population and to compare with the results of previous studies. Between 2000 and 2008, 1,134,890 schoolchildren underwent scoliosis screening. The children were divided into two age groups, 10–12-year-olds (elementary school) and 13–14-year-olds (middle school), to calculate age- and sex-specific prevalence rates. Children with a scoliometer reading ≥5° were referred for radiograms. Two surgeons independently measured curve types, magnitudes, and Risser scores (inter-observer r = 0.964, intra-observer r = 0.978). Yearly and overall prevalence rates of scoliosis were calculated. There were 584,554 boys and 550,336 girls in the sample, with a male to female ratio of 1.1:1. There were 77,910 (6.2%) children (26,824 boys and 51,086 girls) with scoliometer readings >5°, and 37,339 of them had positive results with Cobb angles ≥10° (positive predictive value, 46.4%). The overall scoliosis prevalence rate was 3.26%; girls had a higher prevalence (4.65%) than boys (1.97%). Prevalence rates increased progressively from 1.66 to 6.17% between 2000 and 2008, with the exception of 2002. According to age and gender, 10–12-year-old girls had the highest scoliosis prevalence rates (5.57%), followed by 13–14-year-old girls (3.90%), 10–12-year-old boys (2.37%), and 13–14-year-old boys (1.42%). In girls and boys, prevalence rates dropped by 64.53 and 60.65% among 10–12-year-olds and 13–14-year-olds, respectively (P = 0.00). The proportion of 10°–19° curves was 95.25 and 84.45% in boys and girls, respectively; and the proportion of 20°–29° curves was 3.91 and 11.28%, which was a significant difference (P = 0.00). Thoracic curves were the most common (47.59%) followed by thoracolumbar/lumbar (40.10%), double (9.09%), and double thoracic (3.22%) curves. A comparison of the curve patterns revealed significant differences between genders (P = 0.00). We present this report as a guide for studying the prevalence of idiopathic scoliosis in a large population, and the increasing trend in the prevalence of idiopathic scoliosis emphasizes the need for awareness.