Showing papers in "Spine in 2003"

Updated method guidelines for systematic reviews in the cochrane collaboration back review group.

Abstract: Study design Descriptive method guidelines. Objectives To help reviewers design, conduct, and report reviews of trials in the field of back and neck pain. Summary of background data In 1997, the Cochrane Collaboration Back Review Group published method guidelines for systematic reviews. Since its publication, new methodologic evidence emerged and more experience was acquired in conducting reviews. Methods All reviews and protocols of the Back Review Group were assessed for compliance with the 1997 method guidelines. Also, the most recent version of the Cochrane Handbook (4.1) was checked for new recommendations. In addition, some important topics that were not addressed in the 1997 method guidelines were included (e.g., methods for qualitative analysis, reporting of conclusions, and discussion of clinical relevance of the results). In May 2002, preliminary results were presented and discussed in a workshop. In two rounds, a list of all possible recommendations and the final draft were circulated for comments among the editors of the Back Review Group. Results The recommendations are divided in five categories: literature search, inclusion criteria, methodologic quality assessment, data extraction, and data analysis. Each recommendation is classified in minimum criteria and further guidance. Additional recommendations are included regarding assessment of clinical relevance, and reporting of results and conclusions. Conclusions Systematic reviews need to be conducted as carefully as the trials they report and, to achieve full impact, systematic reviews need to meet high methodologic standards.

Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion.

Abstract: Study Design. This retrospective, questionnaire-based investigation evaiuated iliac crest bone graft (ICBG) site morbidity in patients having undergone a single-level anterior cervical discectomy and fusion (ACDF) procedure performed by a single surgeon (T.J.A.). Objective. To evaluate acute and chronic problems associated with anterior ICBG donation, particularly long-term functional outcomes and impairments caused by graft donation. Summary of Background Data. Anterior cervical disc-ectomy and fusion procedures frequently use autologous anterior ICBG to facilitate osseous union. Although autologous ICBG offers several advantages over alternative grafting materials, donor site morbidity can be significant. Acute and chronic complications of donor sites have been reported, yet there are currently no reports of long-term functional outcomes after autologous anterior ICBG donation after single-level ACDF. Methods. A questionnaire was mailed to 187 consecutive patients who were retrospectively identified to have undergone autologous anterior ICBG harvest for single-level ACDF between 1994 and 1998. The questionnaire divided items into symptomatic (acute and chronic) and functional assessments. Patients answered yes, no, or not applicable; pain was assessed with a Visual Analogue Scale (VAS). Results. Surveys were completed either by mail or follow-up telephone interview by 134 patients (71.6%). Average follow-up was 48 months (range, 24-72 months). Acute symptoms were reported at the following rates: ambulation difficulty, 50.7%; extended antibiotic usage, 7.5%; persistent drainage, 3.7%; wound dehiscence, 2.2%; and incision and drainage, 1.5%. The chronic symptom questionnaire demonstrated a high degree of satisfaction with the cosmetic result (92.5%). Pain at the donor site was reported by 26.1% of patients with a mean VAS score of 3.8 in 10, and 11.2% chronically use pain medication. Twenty-one patients (15.7%) reported abnormal sensations at the donor site, but only 5.2% reported discomfort with clothing. A unique functional assessment revealed current impairments at the following rates: ambulation, 12.7%; recreational activities, 11.9%; work activities, 9.7%; activities of daily living, 8.2%; sexual activity, 7.5%; and household chores, 6.7%. Conclusions. A large percentage of patients report chronic donor site pain after anterior ICBG donation, even when only a single-level ACDF procedure is performed. Moreover, long-term functional impairment can also be significant. Patients should be counseled regarding these potential problems,and alternative sources of graft material should be considered.

Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration

Abstract: Study design Single blind randomized study. Objectives To compare the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Summary of background data To the authors' best knowledge, only one randomized study has evaluated the effectiveness of lumbar fusion. The Swedish Lumbar Spine Study reported that lumbar fusion was better than continuing physiotherapy and care by the family physician. Patients and methods Sixty-four patients aged 25-60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4-L5 and/or L5-S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index. Results At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (-6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%. Conclusion The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration randomized to cognitive intervention and exercises, or lumbar fusion.

Minimally invasive lumbar fusion.

Abstract: Study design Review article. Objectives To provide an overview of current techniques for minimally invasive lumbar fusion. Summary of background data Minimally invasive techniques have revolutionized the management of pathologic conditions in various surgical disciplines. Although these same principles have been used in the treatment of lumbar disc disease for many years, minimally invasive lumbar fusion procedures have only recently been developed. The goals of these procedures are to reduce the approach-related morbidity associated with traditional lumbar fusion, yet allow the surgery to be performed in an effective and safe manner. Methods The authors' clinical experience with minimally invasive lumbar fusion was reviewed, and the pertinent literature was surveyed. Results Minimally invasive approaches have been developed for common lumbar procedures such as anterior and posterior interbody fusion, posterolateral onlay fusion, and internal fixation. As with all new surgical techniques, minimally invasive lumbar fusion has a learning curve. As well, there are benefits and disadvantages associated with each technique. However, because these techniques are new and evolving, evidence to support their potential benefits is largely anecdotal. Additionally, there are few long-term studies to document clinical outcomes. Conclusions Preliminary clinical results suggest that minimally invasive lumbar fusion will have a beneficial impact on the care of patients with spinal disorders. Outcome studies with long-term follow-up will be necessary to validate its success and allow minimally invasive lumbar fusion to become more widely accepted.

The reliability and concurrent validity of the scoliosis research society-22 patient questionnaire for idiopathic scoliosis.

Abstract: STUDY DESIGN Outcome study to determine response distribution, internal consistency, reproducibility, and concurrent validity of the Scoliosis Research Society-22 (SRS-22) health-related quality-of-life (HRQL) questionnaire. OBJECTIVES Further refinement of an HRQL questionnaire specific for idiopathic scoliosis. SUMMARY OF BACKGROUND DATA Previous experience with the original and modified SRS HRQL questionnaires suggested a need for further refinement and more complete validation. METHODS The SRS-22 and Short Form 36 (SF-36) HRQL questionnaires were mailed to 83 previously surveyed postoperative idiopathic scoliosis patients. RESULTS Fifty-eight (70%) patients returned the first set of questionnaires. Their average age at surgery was 14.6 years, and their average follow-up interval since surgery was 10.8 years. Fifty-one (88%) of the 58 returned the second set of questionnaires an average of 28 days later. The psychometric attributes of the instruments were comparable: score distribution, SRS-22 56.9% ceiling and 1.7% floor, SF-36 79.3% ceiling and 1.7% floor; internal consistency (Cronbach alpha), SRS-22 0.92 to 0.75, SF-36 0.91 to 0.36; and reproducibility (intraclass correlation coefficient), SRS-22 0.96 to 0.85, SF-36 0.92 to 0.61. Concurrent validity, determined by Pearson Correlation Coefficients between SRS-22 and SF-36 domains, was 0.70 or greater ( < 0.0001) for 17 relevant comparisons. CONCLUSION The SRS-22 HRQL questionnaire is reliable with internal consistency and reproducibility comparable to SF-36. In addition, it demonstrated concurrent validity when compared to SF-36. It is shorter and more focused on the health issues related to idiopathic scoliosis than SF-36.

Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.

Abstract: STUDY DESIGN: A blinded, prospective diagnostic test study was conducted. OBJECTIVES: To assess the reliability and accuracy of individual clinical examination items and self-report instruments for the diagnosis of cervical radiculopathy, and to identify and assess the accuracy of an optimum test-item cluster for the diagnosis of cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Although cervical radiculopathy remains largely a clinical diagnosis, the reliability and diagnostic accuracy of clinical examination items, individually or in combination, for cervical radiculopathy is largely unknown. METHODS: Patients with suspected cervical radiculopathy or carpal tunnel syndrome received standardized electrophysiologic examination of the symptomatic upper quarter followed by a standardized clinical examination by physical therapist examiners blinded to diagnosis. Diagnostic properties were assessed using a neural impairment reference criterion standard. RESULTS: The study involved 82 patients. More than two thirds of 34 clinical examination items had reliability coefficients rated at least fair or better, and 13 items had likelihood ratio point estimates above 2 or below 0.50. A single diagnostic test item cluster of four variables was identified and produced a positive likelihood ratio point estimate of 30.3. The 95% confidence intervals for all likelihood ratio point estimates in this study were wide. CONCLUSIONS: Many items of the clinical examination were found to be reliable and to have acceptable diagnostic properties, but the test item cluster identified was more useful for indicating cervical radiculopathy than any single test item. Upper limb tension Test A was the most useful test for ruling out cervical radiculopathy. Further investigation is required both to validate the test item cluster and to improve point estimate precision.

Trunk muscle recruitment patterns in patients with low back pain enhance the stability of the lumbar spine.

Abstract: STUDY DESIGN: A comparative study of trunk muscle recruitment patterns in healthy control subjects and patients with chronic low back pain was conducted. OBJECTIVE: To assess trunk muscle recruitment in patients with low back pain. SUMMARY OF BACKGROUND DATA: Conflicting evidence has been reported on the level and pattern of trunk muscle recruitment in patients with low back pain. The disparities can be explained partly by methodologic differences. It was hypothesized that trunk muscle recruitment patterns may be altered in patients with low back pain to compensate for reduced spinal stability. METHODS: For this study, 16 patients with low back pain and 16 matched control subjects performed slow trunk motions about the neutral posture and isometric ramp contractions while seated upright. Ratios of electromyographic amplitudes and estimated moment contributions of antagonist over agonist muscles and of segmentally inserting muscles over muscles inserting on the thorax and pelvis only were calculated. In addition, model simulations were performed to assess the effect of changes in muscle recruitment on spinal stability. RESULTS: The ratios of antagonist over agonist, and of lumbar over thoracic erector spinae electromyographic amplitude and estimated moment contributions were greater in the patients than in the control subjects. The simulation model predicted that these changes would effectively increase spinal stability. CONCLUSIONS: Trunk muscle recruitment patterns in patients with low back pain are different from those in healthy control subjects. The differences are likely to be functional with respect to enhancement of spinal stability in the patients.

Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population

Abstract: STUDY DESIGN: Multiphase cross-sectional survey of musculoskeletal pain. OBJECTIVES: To estimate the prevalence of all reported and clinically significant spinal pain. To identify independent predictors of spinal pain. METHODS: A total of 5752 adults sampled from three general practice registers were mailed a screening questionnaire. Subjects who reported the spine as a predominant site of pain were sent a site-specific questionnaire (i.e., back or neck) that asked about severity. Prevalence estimates were calculated and extrapolated to the general population. Predictors of spinal pain were identified using logistic regression with comprehensive adjustment for confounders (including pain at other anatomic sites). RESULTS: The 1-month-period prevalence of all reported spinal pain was 29% (95% confidence interval 27-31%), of which about half was intense, half was chronic, 40% was disabling, and 20% was intense, disabling, and chronic. Most people with back (75%) or neck (89%) pain also reported pain at other sites. Age, female gender (neck pain only), high body mass index, living in an area of raised material deprivation, and south Asian ethnicity were significant predictors of spinal pain with disability. The association between body mass index and deprivation and neck pain was lost after adjustment for pain at other sites. However, even after full adjustment, obesity (OR, 1.7; 95% confidence interval, 1.1-2.5) and high deprivation (OR, 1.7; 95% confidence interval, 1.1-2.7) were predictors of back pain with disability. CONCLUSIONS: Adjustment for pain at other sites enabled assessment of whether observed associations were with spinal pain itself or with the other sites of pain. Obesity is an important independent predictor of back pain and its severity. This has implications for primary prevention. The prevalence of spinal pain with disability continues to rise into old age. This has implications for healthcare planning.

Comparison of Classification-Based Physical Therapy With Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain : A Randomized Clinical Trial

Abstract: Study design A randomized clinical trial was conducted. Objective To compare the effectiveness of classification-based physical therapy with that of therapy based on clinical practice guidelines for patients with acute, work-related low back pain. Summary of background data Clinical practice guidelines recommend minimal intervention during the first few weeks after acute low back injury. However, studies supporting this recommendation have not attempted to identify which patients are likely to respond to particular interventions. Methods For this study, 78 subjects with work-related low back pain of less than 3 weeks duration were randomized to receive therapy based on a classification system that attempts to match patients to specific interventions or therapy based on the Agency for Health Care Policy and Research guidelines. The subjects were followed for 1 year. Outcomes included the impairment index, Oswestry scale, SF-36 component scores, satisfaction, medical costs, and return to work status. Results After adjustment for baseline factors, subjects receiving classification-based therapy showed greater change on the Oswestry (P = 0.023) and the SF-36 physical component (P = 0.029) after 4 weeks. Patient satisfaction was greater (P = 0.006) and return to full-duty work status more likely (P = 0.017) after 4 weeks in the classification-based group. After 1 year, there was a trend toward reduced Oswestry scores in the classification-based group (P = 0.063). Median total medical costs for 1 year after injury were 1003.68 dollars for the guideline-based group and 774.00 dollars for the classification-based group (P = 0.13). Conclusions For patients with acute, work-related low back pain, the use of a classification-based approach resulted in improved disability and return to work status after 4 weeks, as compared with therapy based on clinical practice guidelines. Further research is needed on the optimal timing and methods of intervention for patients with acute low back pain.

Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain.

Abstract: Study Design. Cross-sectional study of electromyographic onsets of trunk and hip muscles in subjects with a clinical diagnosis of sacroiliac joint pain and matched control subjects. Objectives. To determine whether muscle activation of the supporting leg was different between control subjects and subjects with sacroiliac joint pain during hip flexion in standing. Background. Activation of the trunk and gluteal muscles stabilize the pelvis for load transference; however, the temporal pattern of muscle activation and the effect of pelvic pain on temporal parameters has not been investigated. Methods. Fourteen men with a clinical diagnosis of sacroiliac joint pain and healthy age-matched control subjects were studied. Surface electromyographic activity was recorded from seven trunk and hip muscles of the supporting leg during hip flexion in standing. Onset of muscle activity relative to initiation of the task was compared between groups and between limbs. Results. The onset of obliquus internus abdominis (OI) and multifidus occurred before initiation of weight transfer in the control subjects. the onset of obliquus internus abdominis, multifidus, and gluteus maximus was delayed on the symptomatic side in subjects with sacroiliac joint pain compared with control subjects, and the onset of biceps femoris electromyographic activity was earlier. IN addition, electromyographic onsets were different between the symptomatic and asymptomatic sides in subjects with sacroiliac joint pain. Conclusions. The delayed onset of obliquus internus abdominis, multifidus, and gluteus maximus electromyographic activity of the supporting leg during hip flexion, in subjects with sacroiliac joint pain. suggests an alteration in the strategy for lumbopelvic stabilization that may disrupt load transference through the pelvis.

The effect of cement augmentation on the load transfer in an osteoporotic functional spinal unit: finite-element analysis.

Abstract: Study design The effect of cement augmentation on an osteoporotic lumbar functional spinal unit was investigated using finite-element analysis. Objective To evaluate the influence of cement augmentation on load transfer, stresses, and strains. Summary of background data Osteoporosis is the most frequent skeletal disease of the elderly, leading to weakness of the bony structures. Cement injection into vertebral bodies has been used to treat osteoporotic compression fractures of the spine. The clinical results are encouraging. Experimental biomechanical studies showed significant increases in stiffness and strength of treated bodies. However, little is known about the consequences for the adjacent, nontreated levels. Methods Three-dimensional finite-element models of L2-L3 were developed and the material properties adapted to simulate osteoporosis. The influence of augmentation level as well as uni- and bipedicular filling with polymethylmethacrylate were investigated. Compression, flexion, and lateral bending were simulated. Results Augmentation increased the pressure in the nucleus pulposus and the deflection of the adjacent endplate. The stresses and strains in the vertebrae next to an augmentation were increased, and their distribution was changed. Larger areas were subjected to higher stresses and strains. The treatment clearly altered the load transfer. Changes to the overall stress and strain distribution were less pronounced for unipedicular augmentation. Conclusions Cement augmentation restores the strength of treated vertebrae, but leads to increased endplate bulge and an altered load transfer in adjacent vertebrae. This supports the hypothesis that rigid cement augmentation may facilitate the subsequent collapse of adjacent vertebrae. Further study is required to determine the optimal reinforcement material and filling volume to minimize this effect.

Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: single-level and bi-level.

Abstract: Study Design. Prospective, concurrently enrolled, multicenter trials of the Bryan Cervical Disc Prosthesis (Medtronic Sofamor Danek, Memphis, TN) were conducted for the treatment of patients with single-level and two-level (bi-level) degenerative disc disease of the cervical spine. Objectives. The studies were designed to determine whether new functional intervertebral cervical disc prosthesis can provide relief from objective neurologic symptoms and signs, improve the patient's ability to perform activities of daily living, decrease pain, and maintain stability and segmental motion. Summary of Background Data. The concept of accelerated degeneration of adjacent disc levels as a consequence of increased stress caused by interbody fusion of the cervical spine has been widely postulated. Therefore, reconstruction of a failed intervertebral disc with functional disc prosthesis should offer the same benefits as fusion while simultaneously providing motion and thereby protecting the adjacent level discs from the abnormal stresses associated with fusion. Methods. Patients with symptomatic cervical radiculopathy and/or myelopathy underwent implantation with the Bryan prosthesis after a standard anterior cervical-discectomy. At scheduled follow-up periods, the effectiveness of the device was characterized by evaluating each patient's pain, neurologic function, and radiographically measured range of motion at the implanted level. Results. Clinical success for both studies exceeded the study acceptance criteria of 85%. At 1-year follow-up, the flexion-extension range of motion per level averaged 7.9 +/- 5.3 degrees in the single-level study and 7.4 +/- 5.1 degrees in the bilevel study. No devices have been explanted. Conclusions. Discectomy and implantation of the device alleviates neurologic symptoms and signs similar to anterior cervical discectomy and fusion. Radiographic evidence supports maintenance of motion. The procedure is safe and the patients recover quickly. At least 5 years of follow-up will be needed to assess the long-term functionality of the prosthesis and protective influence on adjacent levels.

C5 Palsy after Decompression Surgery for Cervical Myelopathy : Review of the Literature

Abstract: Study design A literature review was conducted to integrate and compile available reports on postoperative C5 palsy. Objectives To review the clinical features, possible pathogenesis, and procedures for treatment and prevention of postoperative C5 palsy as a complication of surgery for cervical compression myelopathy. Summary of background data Although postoperative C5 palsy develops in approximately 5% of patients after decompression surgery of the cervical spine, its pathogenesis and the options for prevention and treatment remain unidentified and many controversies exist. Method We reviewed and analyzed papers published from 1986 to 2002 regarding C5 palsy as a postoperative complication. Statistical comparisons were made when appropriate. Results Postoperative C5 palsy is reported to occur in an average of 4.6% of patients after surgery for cervical compression myelopathy. No significant differences were noted between patients undergoing anterior decompression and fusion and laminoplasty, nor were distinctions apparent between unilateral hinge laminoplasty and French-door laminoplasty, or between cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. Two theories were put forth to account for the pathogenesis of C5 palsy: nerve root injury and segmental spinal cord disorder. Neither of these hypotheses has been consistently supported and evidence to refute each hypothesis can be found in the literature. Recently, surgeons have advocated foraminotomy combined with laminoplasty to prevent or treat C5 palsy, but further studies into the efficacy of this procedure are needed. Although patients with C5 palsy generally have a good prognosis for neurologic and functional recovery, those with severe paralysis require significantly longer recovery times when compared to more mild cases. Conclusion The incidence of postoperative C5 palsy has been reported at 4.6% after surgery for cervical compression myelopathy and this value has not varied with different surgical procedures or disease etiologies. The pathogenesis of postoperative C5 palsy remains unclear at the present time. Patients with postoperative C5 palsy generally have a good prognosis for functional recovery, but the severely paralyzed cases required significantly longer recovery times than the mild cases.

Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy

Abstract: Study design This retrospective study analyzed the effects of cervical alignment on surgical results of expansive laminoplasty (ELAP) for cervical spondylotic myelopathy (CSM). Objective To determine the limitation of posterior decompression by ELAP for CSM in the presence of local kyphosis. Summary of background data Several studies have reported that cervical malalignment affected surgical outcomes of ELAP. However, there has been no report to demonstrate crucial determinants of surgical outcomes of ELAP for CSM in relation to cervical sagittal alignment. Methods The study group comprised 114 patients who underwent ELAP for CSM. All were followed up for more than 2 years. The Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy (full score, 17 points) was used to evaluate surgical outcomes for each patient 2 years after surgery. Statistical analysis with multivariate logistic regression models was used to ascertain the risk factors affecting postoperative surgical outcomes. Results The average JOA scores were 9.9 points before surgery and 14 points 2 years after surgery. The recovery rate was 60.2%. Statistical analysis showed that signal intensity change on MRI and local kyphosis were the most crucial risk factors for poor surgical outcomes. Calculated with the logistic regression model, the highest risk of poor recovery was local kyphosis exceeding 13 degrees. Conclusions The influence of cervical malalignment on neurologic recovery after ELAP for CSM was shown. When patients have local kyphosis exceeding 13 degrees, anterior decompression or posterior correction of kyphosis as well as ELAP should be considered. Expansive laminoplasty for CSM is best indicated for patients with local kyphosis less than 13 degrees.

Lumbar repositioning deficit in a specific low back pain population

Abstract: STUDY DESIGN A cross-sectional observational design study was conducted to determine lumbar repositioning error in 15 subjects who had chronic low back pain with a clinical diagnosis of lumbar segmental instability and 15 asymptomatic participants. OBJECTIVE To determine whether individuals with lumbar segmental instability have a decreased ability to reposition their lumbar spine into a neutral spinal position. SUMMARY OF BACKGROUND DATA Proprioception of the lumbar spine has been investigated in individuals who have low back pain with variable results. The testing procedure's lack of sensitivity and the nonhomogeneity of groups may be responsible for the conflicting findings. METHODS Repositioning accuracy of the lumbar spine was assessed using the 3Space Fastrak to determine error in 15 participants with lumbar segmental instability and 15 asymptomatic subjects. The participants were assisted into a neutral spinal sitting posture and then asked to reproduce this position independently over five trials separated by periods of relaxed full lumbar flexion. RESULTS Lumbosacral repositioning error was significantly greater in participants with lumbar segmental instability than in the asymptomatic group (t[28] = 2.48; P = 0.02. There also was a significant difference between the groups at each individual sensor. CONCLUSIONS The results of this study indicate that individuals with a clinical diagnosis of lumbar segmental instability demonstrate an inability to reposition the lumbar spine accurately into a neutral spinal posture while seated. This finding provides evidence of a deficiency in lumbar proprioceptive awareness among this population.

The Lenke classification of adolescent idiopathic scoliosis: how it organizes curve patterns as a template to perform selective fusions of the spine.

Abstract: Study design Retrospective radiographic review. Objectives To analyze how the Lenke classification of adolescent idiopathic scoliosis provides a template of specific curve patterns that may be appropriate to perform selective fusion of the spine. Methods A new triad classification system of adolescent idiopathic scoliosis has been developed. It consists of a curve type, a lumbar spine modifier (A, B, C), and a sagittal thoracic modifier (-, N, +). A selective fusion is termed when both the thoracic and thoracolumbar/lumbar curves deviate completely from the midline, but only the major curve (largest Cobb measurement) is fused, leaving the minor curve unfused and mobile. In this manner, selective thoracic fusions of the spine are potentially indicated for major main thoracic/minor lumbar curves (Types 1C and potentially 2C and 3C patterns) when the lumbar apex deviates off the center sacral vertical line. Conversely, selective thoracolumbar/lumbar fusions may be indicated for major thoracolumbar/lumbar-minor main thoracic curves, when the thoracic apex lies off the C7 plumbline (Type 5C and potentially 6C patterns). Importantly, additional analysis of ratios of structural characteristics between the main thoracic and thoracolumbar/lumbar curves are necessary to predict when a successful selective main thoracic or thoracolumbar/lumbar fusion will be feasible. Lastly, the clinical appearance of the patient's truncal alignment is essential to confirm the aspirations of performing a selective spinal fusion. Results Successful selective thoracic fusion of 1C (n = 36) and 2C (n = 8) curves have been performed in 44 consecutive patients with adolescent idiopathic scoliosis. The average thoracic curve was 61 degrees before surgery and 39 degrees at final follow-up. The average preoperative lumbar curve was 48 degrees, decreasing to 32 degrees postoperatively. A group of 21 consecutive patients with Type 5C or 6C major thoracolumbar/lumbar-minor main thoracic curves underwent a selective thoracolumbar/lumbar fusion. The average preoperative thoracolumbar/lumbar curve was 56 degrees corrected to 22 degrees at the 2-year follow-up. The average minor main thoracic curve preoperative was 38 degrees, with spontaneous correction to 28 degrees at 2 years postoperative. Discussion Selective thoracic or thoracolumbar/lumbar fusion can be successfully performed in a variety of adolescent idiopathic scoliosis curve patterns. Careful attention to the preoperative Lenke curve classification, analysis of structural characteristics between the planned instrumented and noninstrumented regions of the spine, as well as a documented clinical examination that confirms the planned instrumented and fused regions of the spine to be the most clinically prominent are essential features to determine before surgery. No patients undergoing selective thoracic fusion have required extension of the fusion to the lumbar spine, whereas one patient with a selective thoracolumbar fusion required extension of the fusion up to include the thoracic spine due to continued thoracic progression with growth. Conclusions Selective thoracic or thoracolumbar/lumbar fusions of the major curve can be successfully performed even when the minor curve completely deviates from the midline, based on the Lenke classification system, the analysis of structural criteria between the planned fused and unfused regions of the spine, and the clinical examination of the patient. Selective fusions, when successfully performed, will optimize mobile segments of the spine in patients with adolescent idiopathic scoliosis.

The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation.

Abstract: Study design A prospective study of spondylolysis and spondylolisthesis was initiated in 1955 with a radiographic and clinical study of 500 first-grade children. Objective To determine the natural history of spondylolysis and spondylolisthesis. Summary of background data Most studies on the natural history of spondylolysis and spondylolisthesis are based on patient populations presenting with pain. Critical to any natural history investigation is the study of a population of affected individuals, whether symptomatic or not, from onset of the condition through their lives. Methods By study of a population from the age of 6 years to adulthood, 30 individuals were identified to have pars lesions. Data collection at a 45-year follow-up assessment included magnetic resonance imaging, a back pain questionnaire, and the SF-36 Survey. Results No subject with a pars defect was lost to follow-up evaluation once a lesion was identified. Subjects with unilateral defects never experienced slippage over the course of the study. Progression of spondylolisthesis slowed with each decade. There was no association of slip progression and low back pain. There was no statistically significant difference between the study population SF-36 scores and those of the general population the same age. Conclusions This report is the only prospective study to document the natural history of spondylolysis and spondylolisthesis from onset through more than 45 years of life in a population unselected for pain. Subjects with pars defects follow a clinical course similar to that of the general population. There appears to be a marked slowing of slip progression with each decade, and no subject has reached a 40% slip.

Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance.

Abstract: STUDY DESIGN Radiographic analysis, outcomes analysis (pain scale, Oswestry, SRS-24), and accumulation of complications. Outcomes and complications collected prospectively. Radiographic analysis performed retrospectively. OBJECTIVES To assess the benefits and stress complications of pedicle subtraction osteotomies for patients with fixed sagittal imbalance. SUMMARY OF BACKGROUND DATA Few reports on pedicle subtraction osteotomies exist in the peer-review literature for conditions other than trauma and ankylosing spondylitis. MATERIALS AND METHODS Thirty-three consecutive patients with sagittal imbalance treated with lumbar pedicle subtraction osteotomy at one institution (minimum 2-year follow-up) were analyzed. Complications were also analyzed for the entire group of consecutive pedicle subtraction osteotomies done at our institution to date (n = 66). RESULTS For the 33 patients with minimum 2-year follow-up, there were significant improvements in the overall Oswestry score (P 0.0001) and pain score (P = 0.0001). Most patients reported improvement in pain and self-image and reported overall satisfaction based on ultimate SRS-24 questionnaire. There was one pseudarthrosis in the lumbar spine through an area of pedicle subtraction osteotomy (area of previous laminectomy and nonunion), and six patients had thoracic pseudarthroses (levels other than the osteotomy level) and one patient had a pseudarthrosis at L5-S1. Two patients had acute angular kyphosis at the thoracolumbar junction at the proximal end of the construct. Five patients who experienced transient neurologic deficits resolved their deficits after central canal enlargement. CONCLUSIONS The clinical result with pedicle subtraction osteotomy is reduced with pseudarthrosis in the thoracic or lumbar spine and subsequent breakdown adjacent to the fusion. For patients with a degenerative sagittal imbalance etiology the results were worse and the complications were higher. Central canal enlargement is critical.

The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial.

Abstract: Study design: A randomized clinical trial with 4-week and 6-month follow-up periods. Objective: To compare the effect of a fear-avoidance-based physical therapy intervention with standard care physical therapy for patients with acute low back pain. Summary of background data: The disability reduction strategy of secondary prevention involves providing specific treatment for patients that are likely to have chronic disability from low back pain. Previous studies have indicated that elevated fear-avoidance beliefs are a precursor to chronic disability from low back pain. However, the effectiveness of physical therapy intervention based on a fear-avoidance model is unknown. Methods: Sixty-six consecutive patients referred to physical therapy with low back pain of less than 8 weeks' duration were randomly assigned to receive fear-avoidance-based physical therapy (n = 34) or standard care physical therapy (n = 32). The intervention period lasted 4 weeks for this study. Disability, pain intensity, and fear-avoidance beliefs measures were recorded before and after treatment. A 6-month follow-up of the same measures was obtained by mail. Results: An intention-to-treat principle (last value forward) was used for data analyses that tested the primary and secondary hypotheses. The prediction of disability at 4 weeks and 6 months after treatment was significantly improved by considering the interaction between the type of treatment and the initial level of fear-avoidance beliefs. Both groups had significant within group improvements for disability and pain intensity. The fear-avoidance treatment group had a significant improvement in fear-avoidance beliefs, and fear-avoidance beliefs about physical activity were significantly lower than the standard care group at 4 weeks and 6 months after treatment. Conclusion: Patients with elevated fear-avoidance beliefs appeared to have less disability from fear-avoidance-based physical therapy when compared to those receiving standard care physical therapy. Patients with lower fear-avoidance beliefs appeared to have more disability from fear-avoidance-based physical therapy, when compared to those receiving standard care physical therapy. In addition, physical therapy supplemented with fear-avoidance-based principles contributed to a positive shift in fear-avoidance beliefs.

Reliability, validity, and responsiveness of the short form 12-item survey (SF-12) in patients with back pain.

Abstract: Study design Secondary analysis of data collected from spine patients' normal clinic visits from 1998 to 2001. Objective To evaluate the reliability, validity, and responsiveness of the short form 12-item survey in patients with back pain. Summary of background data The reliability, validity, and responsiveness of the short form 12-item survey in patients with back pain has not been previously evaluated. Methods Patients were asked to complete a comprehensive computerized survey questionnaire during their regular clinic visits. A total of 2520 patients who indicated in their first surveys that they had back pain were included in the study of the reliability and validity of the short form 12-item survey. Of these, 506 patients completed another survey within 3-6 months of follow-up and were included in the responsiveness evaluation. Results The two summary scales of the short form 12-item survey, physical component summary and mental component summary, demonstrated internal consistency reliability, with Cronbach alpha for both scales exceeding the recommended level of 0.70. Correlation of physical component summary and mental component summary with six other measures theoretically related or unrelated to these scales performed as expected without exception, demonstrating the construct validity of the short form 12-item survey. The responsiveness of the short form 12-item survey was supported by several pieces of evidence. First, the changes in physical component summary and mental component summary scores were correlated with the changes in back pain intensity. Second, for patients whose back pain improved, there was a significant increase in the follow-up physical component summary and mental component summary scores as compared to the baseline. Third, small to moderate effect size was observed for patients whose back pain became improved or became worse. Conclusions The short form 12-item survey demonstrated good internal consistency reliability, construct validity, and responsiveness in patients with back pain.

A prospective, randomized, controlled cervical fusion study using recombinant human bone morphogenetic protein-2 with the CORNERSTONE-SR allograft ring and the ATLANTIS anterior cervical plate.

Abstract: Study Design. A prospective, randomized, pilot clinical trial compared recombinant human bone morphogenetic protein-2 (rhBMP-2) with iliac crest autograft bone for the treatment of human cervical disc disease. Objective. To examine the safety and effectiveness of using INFUSE™ Bone Graft (rhBMP-2 applied to an absorbable collagen sponge), as compared with an autogenous iliac crest bone graft placed inside the CORNERSTONE-SR™ fibular allograft, in anterior cervical discectomy and interbody fusion. Summary of Background Data. Recombinant human bone morphogenetic protein-2 is an osteoinductive protein that induces a reliable fusion in the lumbar spine, but it has not been studied in patients with degenerative cervical disc disease. Methods. For this study, 33 patients with degenerative cervical disc disease were randomly assigned to investigational or control groups. The investigational group received a fibular allograft (CORNERSTONE-SR™ Allograft Ring) with an rhBMP-2–laden collagen carrier inside the graft along with an ATLANTIS™ anterior cervical plate. The control group received a fibular allograft with cancellous iliac crest autograft placed inside it, along with an ATLANTIS anterior cervical plate. The patients underwent plain radiographs at 6 weeks, then at 3, 6, 12, and 24 months, and CT scans at 3 and 6 months after surgery. They also completed general health profiles and self-evaluation scales. Adverse events were evaluated for severity, duration, association with the implant, and the need for a second surgical procedure. Results. All the patients evaluated had solid fusions 6, 12, and 24 months after surgery. There were no device-related adverse events. At 24 months, the investigational group had mean improvement superior to that of the control group in neck disability and arm pain scores (P Conclusions. This pilot study demonstrates the feasibility of using rhBMP-2 safely and effectively in the cervical spine.

Association of the Japanese Orthopaedic Association score with the Oswestry Disability Index, Roland-Morris Disability Questionnaire, and short-form 36.

Abstract: STUDY DESIGN Cross-cultural translation and cross-sectional psychometric testing were performed. OBJECTIVES To cross-culturally translate the Oswestry Disability Index (ODI) and the Roland-Morris Disability Questionnaire (RMDQ) into Japanese, and to compare the Japanese Orthopaedic Association (JOA) score with the ODI and the RMDQ score. SUMMARY OF BACKGROUND DATA The two most widely used back-specific measures, the ODI and the RMDQ, have not been translated into Japanese. The JOA score has been used extensively in Japan. However, this score has not been tested in terms of its reliability and validity. METHODS The ODI and RMDQ were translated into Japanese using the process of forward translation, synthesis of translation, backward translation, expert committee, test of the prefinal version, and submission of the documentation to the developers. The JOA score, ODI, and RMDQ were tested with 97 patients who had degenerative lumbar spinal disorders (average age, 51 years). The correlation among the three disease-specific measures (JOA score, ODI, and RMDQ) and eight subscales of a generic health measure, the Medical Outcomes Survey Short-Form 36 (SF-36), was calculated. The reproducibility of the JOA score also was investigated. RESULTS Reliability, as estimated by internal consistency, reached a Cronbach alpha of 0.83 for the ODI and 0.86 for the RMDQ. The calculated test-retest reliability was 0.93 (P < 0.01; n = 20) for the ODI and 0.95 (P < 0.01; n = 20) for the RMDQ. The correlation of the JOA score with the ODI was -0.647 (P < 0.01), and with RMDQ was -0.568 (P < 0.01). There also was a significant correlation between the ODI and the RMDQ (r = 0.785; P < 0.01). There was a significant correlation between the three disease-specific measures (JOA score, ODI, and RMDQ) and all the subscales of the SF-36 (P < 0.01). The calculated reproducibility of the JOA score was as follows: interobserver error (r = 0.92, P < 0.01), test-retest reliability (r = 0.91, P < 0.01). CONCLUSIONS The Japanese versions of the ODI and the RMDQ were reliable and valid. The use of these translated instruments can be recommended for future clinical trials in Japan. The results also showed the JOA score had acceptable psychometric properties of reliability and construct validity, suggesting that this score is reliable and valid. Further studies are needed to verify the validity and responsiveness of the JOA score.

Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial.

Abstract: Study design A randomized controlled trial was conducted. Objective To determine the efficacy of osteopathic manipulative treatment as a complementary treatment for chronic nonspecific low back pain. Summary of background data Osteopathic manipulative treatment may be useful for acute or subacute low back pain. However, its role in chronic low back pain is unclear. Methods This trial was conducted in a university-based clinic from 2000 through 2001. Of the 199 subjects who responded to recruitment procedures, 91 met the eligibility criteria. They were randomized, with 82 patients completing the 1-month follow-up evaluation, 71 completing the 3-month evaluation, and 66 completing the 6-month evaluation. The subjects were randomized to osteopathic manipulative treatment, sham manipulation, or a no-intervention control group, and they were allowed to continue their usual care for low back pain. The main outcomes included the SF-36 Health Survey, a 10-cm visual analog scale for overall back pain, the Roland-Morris Disability Questionnaire, lost work or school days because of back pain, and satisfaction with back care. Results As compared with the no-intervention control subjects, the patients who received osteopathic manipulative treatment reported greater improvements in back pain, greater satisfaction with back care throughout the trial, better physical functioning and mental health at 1 month, and fewer cotreatments at 6 months. The subjects who received sham manipulation also reported greater improvements in back pain and physical functioning and greater satisfaction than the no-intervention control subjects. There were no significant benefits with osteopathic manipulative treatment, as compared with sham manipulation. Conclusions Osteopathic manipulative treatment and sham manipulation both appear to provide some benefits when used in addition to usual care for the treatment of chronic nonspecific low back pain. It remains unclear whether the benefits of osteopathic manipulative treatment can be attributed to the manipulative techniques themselves or whether they are related to other aspects of osteopathic manipulative treatment, such as range of motion activities or time spent interacting with patients, which may represent placebo effects.

Early radiographic and clinical results of balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures.

Abstract: STUDY DESIGN A prospective consecutive cohort study of clinical and radiographic outcomes after kyphoplasty for treatment of osteoporotic vertebral compression fractures. OBJECTIVES To measure changes in spinal deformity, activity level, and pain after kyphoplasty treatment. SUMMARY OF BACKGROUND DATA Pain and kyphosis caused by osteoporotic vertebral compression fractures adversely affect quality of life and survival. Kyphoplasty involves the inflation of a balloon bone tamp, percutaneously placed in a fractured vertebral body, followed by deposition of bone cement into the resulting cavity. Previous reports indicate that kyphoplasty improves patient function and restores height of collapsed vertebral bodies, but limited data about the effects of kyphoplasty on spinal sagittal alignment are available. METHODS Twenty-nine patients with osteoporotic vertebral compression fractures who did not respond to medical therapy were treated by kyphoplasty. These patients underwent 37 operations to treat 61 vertebral compression fractures between T6 and L5. Sagittal alignment was analyzed from standing radiographs (pre- and postkyphoplasty). Patient surveys were used to assess pain relief, improvement in activity, and satisfaction with the surgical procedure. RESULTS In this cohort, a mean of 8.8 degrees (range 0-29 degrees ) of correction of local spinal kyphosis was achieved with kyphoplasty. Thirty of 52 fractures (17 patients) were considered reducible and had >5 degrees of correction, with a mean improvement in sagittal alignment of this population of 14.2 degrees. Patient surveys revealed significant pain reduction within the first week after surgery and improved activity levels for a majority of patients. CONCLUSIONS Kyphoplasty improves physical function, reduces pain, and may correct kyphotic deformity associated with vertebral compression fractures.

Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: in vivo porcine studies.

Abstract: STUDY DESIGN: In vivo porcine study of intervertebral kinematics. OBJECTIVES: This study investigated the effect of transversus abdominis and diaphragm activity, and increased intra-abdominal press ...

Patterns and perceptions of care for treatment of back and neck pain: results of a national survey.

Abstract: Study design We conducted a nationally representative random household telephone survey to assess therapies used to treat back or neck pain. Objectives The main outcome was complementary therapies used in the last year to treat back or neck pain. Summary of background data Back pain and neck pain are common medical conditions that cause substantial morbidity. Despite the presumed importance of complementary therapies for these conditions, studies of care for back and neck pain have not gathered information about the use of complementary therapies. Methods Our nationally representative survey sampled 2055 adults. The survey gathered detailed information about medical conditions, conventional and complementary therapies used to treat those conditions, and the perceived helpfulness of those therapies. Results We found that of those reporting back or neck pain in the last 12 months, 37% had seen a conventional provider and 54% had used complementary therapies to treat their condition. Chiropractic, massage, and relaxation techniques were the most commonly used complementary treatments for back or neck pain (20%, 14%, and 12%, respectively, of those with back or neck pain). Chiropractic, massage, and relaxation techniques were rated as "very helpful" for back or neck pain among users (61%, 65%, and 43%, respectively), whereas conventional providers were rated as "very helpful" by 27% of users. We estimate that nearly one-third of all complementary provider visits in 1997 (203 million of 629 million) were made specifically for the treatment of back or neck pain. Conclusions Chiropractic, massage, relaxation techniques, and other complementary methods all play an important role in the care of patients with back or neck pain. Treatment for back and neck pain was responsible for a large proportion of all complementary provider visits made in 1997. The frequent use and perceived helpfulness of commonly used complementary methods for these conditions warrant further investigation.

Biomechanical Evaluation of Total Disc Replacement Arthroplasty : An In Vitro Human Cadaveric Model

Abstract: STUDY DESIGN This in vitro biomechanical study was undertaken to quantify the multidirectional intervertebral kinematics following total disc replacement arthroplasty compared to conventional stabilization techniques. OBJECTIVE Using an in vitro human cadaveric model, the primary objective was to compare the multidirectional flexibility properties and map the center of intervertebral rotation of total disc arthroplasty versus conventional threaded fusion cages and cages augmented with transpedicular fixation for single-level spinal instrumentation. SUMMARY OF BACKGROUND DATA The utilization of motion-preserving implants versus instrumentation systems, which stabilize the operative segments, necessitates improved understanding of their comparative biomechanical properties. METHODS A total of eight human cadaveric lumbosacral spines (L2 to sacrum) were utilized in this investigation and biomechanically evaluated under the following L4-L5 reconstruction conditions: 1) intact spine; 2) SB Charite disc prosthesis; 3) BAK cages; and 4) BAK cages + ISOLA pedicle screw/rod fixation (anteroposterior). The superior (L3-L4) and inferior (L5-S1) intervertebral levels remained uninstrumented to quantify adjacent level properties. Multidirectional flexibility included pure, unconstrained moments (+/-8 Nm) in axial rotation, flexion-extension, and lateral bending, with quantification of the operative and adjacent level range of motion and neutral zone, which were normalized to the intact spine condition. RESULTS The SB Charite prosthesis indicated an average percentage increase in axial rotation range of motion by 44% compared to the intact condition (P 0.05), whereas the BAK and anteroposterior stabilization groups resulted in significant decreases in range of motion (BAK = 57%, anteroposterior = 93%) (P < 0.05) when compared to the intact and SB Charite conditions. Based on flexion-extension radiographs, the intervertebral centers of rotation were in the posterior one-third of the operative intervertebral disc only for the SB Charite reconstruction and intact spine condition, with definitive evidence of physiologic intervertebral translation (intact 2.06 +/- 77 mm; SB III = 1.9 +/- 0.98 mm). CONCLUSIONS Total disc arthroplasty serves as the next frontier in the surgical management of discogenic spinal pathology. The SB Charite restored motion to the level of the intact segment in flexion-extension and lateral bending and increased motion in axial rotation. The anterior annular resection necessary for device implantation and unconstrained design of the prosthesis account for this change in rotation. The normal lumbar flexion-extension axis of rotation is an ellipse rather than a single point. Only disc replacement rather than pedicle instrumentation or BAK interbody instrumentation preserves the kinematic properties and normal mapping of segmental motion at the operative and adjacent intervertebral disc levels.

Retrograde Ejaculation After Anterior Lumbar Interbody Fusion : Transperitoneal Versus Retroperitoneal Exposure

Abstract: Study design In this multicenter, prospective, 2-year study, 146 male patients underwent a single-level anterior lumbar interbody fusion with a tapered threaded titanium fusion device. All the patients were advised before surgery of the risk for retrograde ejaculation. After surgery, any case of retrograde ejaculation was recorded as an adverse event, and the patient was observed up for the remainder of the study. Objective To determine the incidence of retrograde ejaculation in male patients treated for single-level degenerative lumbar disc disease at L4-L5 or L5-S1 with a stand-alone anterior interbody fusion using tapered, threaded titanium fusion cages. Summary of background data The incidence of retrograde ejaculation in men after anterior lumbosacral spinal surgery has been reported to range from 0.42% to 5.9%. Various risk factors that increase the chance of retrograde ejaculation have been proposed. Methods In this prospective study, 146 male patients underwent an open surgical exposure of the lumbosacral junction and a single-level interbody fusion at either L4-L5 or L5-S1. Assessment of a patient's clinical outcome was based on written questionnaires at 6 weeks and then 3, 6, 12, and 24 months after surgery. Patients were questioned about adverse events at each of these assessments, and any case of retrograde ejaculation was recorded and followed. Results Retrograde ejaculation developed in 6 of the 146 men after open anterior lumbar interbody fusion surgery. Two cases (1.7%; 2/116) involved patients who underwent a retroperitoneal surgical exposure. Four cases (13.3%; 4/30) involved patients who had a transperitoneal surgical exposure. This difference is statistically significant according to Fisher's exact test (P = 0.017). At 12 months after surgery, 2 patients had resolution of their symptoms: 1 in the retroperitoneal approach group and 1 in the transperitoneal group. At the final 2-year follow-up, no changes in symptoms were reported. One patient in the retroperitoneal approach group (0.86%) and three patients in the transperitoneal group (10%) reported permanent retrograde ejaculation (P = 0.027). Conclusions A transperitoneal approach to the lumbar spine at L4-L5 and L5-S1 has a 10 times greater chance of causing retrograde ejaculation in men than a retroperitoneal approach.

Discrimination validity of the scoliosis research society-22 patient questionnaire: relationship to idiopathic scoliosis curve pattern and curve size.

Abstract: STUDY DESIGN Prospective observational study. OBJECTIVE To determine the discriminant validity of the Scoliosis Research Society-22 (SRS-22) health-related quality-of-life (HRQL) questionnaire for idiopathic scoliosis patients based on curve pattern and curve size. SUMMARY OF BACKGROUND DATA An important psychometric attribute of the HRQL questionnaire is the capacity to discriminate between and among patients with differing condition severity. METHOD Three study groups, with subjects ranging in age from 10 to 16 years, were set up: a control group (C) of 19 persons with scoliosis suspected but unproven with an average age of 13 years; a nonsurgical group (NS) of 68 patients with an average age of 14 years and an average scoliosis (Cobb) of 30 degrees; and a presurgical group (PS) of 32 patients with an average age of 14 years and an average scoliosis of 61 degrees. The NS group was subdivided into untreated (NSU) (n = 54) and braced (NSB) patients (n = 14). Also created were subgroups of the NS and PS groups having similar curve sizes: nonsurgical similar (NSS) and presurgery similar (PSS). Statistical significance of the SRS-22 domain scores by comparison groups was tested by ANOVA. Relationships between the SRS-22 questionnaire and scoliosis deformity measurements were calculated using the Pearson Correlation Coefficients. RESULTS There were no significant differences between the control (C) and nonsurgical (NS) groups. The presurgical group (PS) scored significantly lower in the pain and self-image domains than the C or NS groups and lower than group C in the mental health domain. A subgroup of the nonsurgical group (NSS) with curves comparable to the presurgical subgroup (PSS) had significantly better self-image scores. There were no significant correlations between SRS-22 scores and curve pattern. For persons with scoliosis, curve size (Cobb) correlated with pain, self-image, and function; trunk asymmetry correlated with self-image. CONCLUSION The SRS-22 HRQL questionnaire successfully discriminated among persons with no scoliosis or moderate scoliosis and large scoliosis. It did not discriminate among patients with single, double, or triple curves. Self-image and, to a lesser extent, pain and function domain scores correlated with radiographic and trunk asymmetry severity. The SRS-22 HRQL questionnaire may be useful in choosing nonsurgical versus surgical treatment in borderline cases.

Disc chondrocyte transplantation in a canine model: a treatment for degenerated or damaged intervertebral disc.

Abstract: Study design Disc degeneration and osteoarthritis are diseases of the matrix. Chondrocytes that have been removed from damaged cartilaginous tissues maintain a capacity to proliferate, produce, and secrete matrix components, and respond to physical stimuli such as dynamic loading. A dog model was used to investigate the hypothesis that autologous disc chondrocytes can be used to repair damaged intervertebral disc. Objectives Given the capacity for the cells in vitro to produce matrix molecules that would be appropriate for disc chondrocytes, the focus of the experiment was to investigate whether the cells would continue to sustain metabolic function after transplantation. Summary of the background data No evidence for long-term integration exists for cell transplantation in species other than rats and rabbits. Furthermore, no controlled studies of 1-year duration have been published. Materials and methods Disc chondrocytes were harvested and expanded in culture under controlled and defined conditions, returned to the same animals from which they had been sampled (autologous transplantation) via percutaneous delivery. The animals were analyzed at specific times after transplantation by several methods to examine whether disc chondrocytes integrated with the surrounding tissue, produced the appropriate intervertebral disc extracellular matrix, and might provide a formative solution to disc repair. Results In the context of degenerative changes in an injury model: (1) autologous disc chondrocytes were expanded in culture and returned to the disc by a minimally invasive procedure after 12 weeks; (2) disc chondrocytes remained viable after transplantation as shown by Bromodeoxyuridine incorporation and maintained a capacity for proliferation after transplantation as depicted by histology; (3) transplanted disc chondrocytes produced an extracellular matrix that displayed composition similar to normal intervertebral disc tissue. Positive evidence of proteoglycan content was supported by accepted histochemical staining techniques such as Safranin O-Fast Green; (4) both type II and type I collagens were demonstrated in the regenerated intervertebral disc matrix by immunohistochemistry after chondrocyte transplantation; and (5) when the disc heights were analyzed for variance according to treatment, a statistically significantcorrelation between transplanting cells and retention of disc height was achieved. Conclusions Autologous chondrocyte transplantation is technically feasible and biologically relevant to repairing disc damage and retarding disc degeneration.