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Showing papers in "Spine in 2005"


Journal ArticleDOI
15 Sep 2005-Spine
TL;DR: This study shows that although even mildly positive sagittal balance is somewhat detrimental, severity of symptoms increases in a linear fashion with progressive sagittal imbalance, and shows that kyphosis is more favorable in the upper thoracic region but very poorly tolerated in the lumbar spine.
Abstract: Study Design.This study is a retrospective review of 752 patients with adult spinal deformity enrolled in a multicenter prospective database in 2002 and 2003. Patients with positive sagittal balance (N = 352) were further evaluated regarding radiographic parameters and health status measures, includ

1,531 citations


Journal ArticleDOI
01 Jun 2005-Spine
TL;DR: Clinicians can be confident that a 2-point change on the numerical pain rating scale (NPRS) represents clinically meaningful change that exceeds the bounds of measurement error.
Abstract: Study design Cohort study of patients with low back pain (LBP) receiving physical therapy. Objective To examine the responsiveness characteristics of the numerical pain rating scale (NPRS) in patients with LBP using a variety of methods. Summary of background data Although several studies have assessed the reliability and validity of the NPRS, few studies have characterized its responsiveness in patients with LBP. Methods Determination of change on the NPRS during 1 and 4 weeks was examined by calculating mean change, standardized effect size, Guyatt Responsiveness Index, area under a receiver operating characteristic curve, minimum clinically important difference, and minimum detectable change. Change in the NPRS from baseline to the 1 and 4-week follow-up was compared to the average of the patient and therapist's perceived improvement using the 15-point Global Rating of Change scale. Results The majority of patients had clinically meaningful improvement after both 1 and 4 weeks of rehabilitation. The standard error of measure was equal to 1.02, corresponding to a minimum detectable change of 2 points. The area under the curve at the 1 and 4-week follow-up was 0.72 (0.62, 0.81) and 0.92 (0.86, 0.97), respectively. The minimum clinically important difference at the 1 and 4-week follow-up corresponded to a change of 2.2 and 1.5 points, respectively. Conclusions Clinicians can be confident that a 2-point change on the NPRS represents clinically meaningful change that exceeds the bounds of measurement error.

1,132 citations


Journal ArticleDOI
01 Feb 2005-Spine
TL;DR: To describe, quantify, and classify common variations in the sagittal alignment of the spine, sacrum, and pelvis may help to discover the association between spinal balance and the development of degenerative changes in the spine.
Abstract: Study design A prospective radiographic study of 160 volunteers without symptoms of spinal disease was conducted. Objectives The objective of this study was to describe, quantify, and classify common variations in the sagittal alignment of the spine, sacrum, and pelvis. Summary of background data Previous publications have documented the high degree of variability in the sagittal alignment of the spine. Other studies have suggested that specific changes in alignment and the characteristics of the lumbar lordosis are responsible for degenerative changes and symptomatic back pain. Methods In the course of this study, anteroposterior and lateral radiographs of 160 volunteers in a standardized standing position were taken. A custom computer application was used to analyze the alignment of the spine and pelvis on the lateral radiographs. A four-part classification scheme of sagittal morphology was used to classify each patient. Results Reciprocal relationships between the orientation of the sacrum, the sacral slope, the pelvic incidence, and the characteristics of the lumbar lordosis were evident. The global lordotic curvature, lordosis tilt angle, position of the apex, and number or lordotic vertebrae were determined by the angle of the superior endplate of S1 with respect to the horizontal axis. Conclusions Understanding the patterns of variation in sagittal alignment may help to discover the association between spinal balance and the development of degenerative changes in the spine.

1,103 citations


Journal ArticleDOI
15 Mar 2005-Spine
TL;DR: This study suggests that restoration of a more normal sagittal balance is the critical goal for any reconstructive spine surgery and suggests that magnitude of coronal deformity and extent of Coronal correction are less critical parameters.
Abstract: Study design This study is a retrospective review of the initial enrollment data from a prospective multicentered study of adult spinal deformity. Objectives The purpose of this study is to correlate radiographic measures of deformity with patient-based outcome measures in adult scoliosis. Summary of background data Prior studies of adult scoliosis have attempted to correlate radiographic appearance and clinical symptoms, but it has proven difficult to predict health status based on radiographic measures of deformity alone. The ability to correlate radiographic measures of deformity with symptoms would be useful for decision-making and surgical planning. Methods The study correlates radiographic measures of deformity with scores on the Short Form-12, Scoliosis Research Society-29, and Oswestry profiles. Radiographic evaluation was performed according to an established positioning protocol for anteroposterior and lateral 36-inch standing radiographs. Radiographic parameters studied were curve type, curve location, curve magnitude, coronal balance, sagittal balance, apical rotation, and rotatory subluxation. Results The 298 patients studied include 172 with no prior surgery and 126 who had undergone prior spine fusion. Positive sagittal balance was the most reliable predictor of clinical symptoms in both patient groups. Thoracolumbar and lumbar curves generated less favorable scores than thoracic curves in both patient groups. Significant coronal imbalance of greater than 4 cm was associated with deterioration in pain and function scores for unoperated patients but not in patients with previous surgery. Conclusions This study suggests that restoration of a more normal sagittal balance is the critical goal for any reconstructive spine surgery. The study suggests that magnitude of coronal deformity and extent of coronal correction are less critical parameters.

1,040 citations


Journal ArticleDOI
15 Jun 2005-Spine
TL;DR: Lumbar fusion rates rose even more rapidly in the 90s than in the 80s, and the most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures.
Abstract: Study design Retrospective cohort study using national sample administrative data. Objectives To determine if lumbar fusion rates increased in the 1990s and to compare lumbar fusion rates with those of other major musculoskeletal procedures. Summary of background data Previous studies found that lumbar fusion rates rose more rapidly during the 1980s than did other types of lumbar surgery. Methods We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1988 through 2001 to examine trends. U.S. Census data were used for calculating age and sex-adjusted population-based rates. We excluded patients with vertebral fractures, cancer, or infection. Results In 2001, over 122,000 lumbar fusions were performed nationwide for degenerative conditions. This represented a 220% increase from 1990 in fusions per 100,000. The increase accelerated after 1996, when fusion cages were approved. From 1996 to 2001, the number of lumbar fusions increased 113%, compared with 13 to 15% for hip replacement and knee arthroplasty. Rates of lumbar fusion rose most rapidly among patients aged 60 and above. The proportion of lumbar operations involving a fusion increased for all diagnoses. Conclusions Lumbar fusion rates rose even more rapidly in the 90s than in the 80s. The most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures. The most rapid increases in fusion rates were among adults aged 60 and above. These increases were not associated with reports of clarified indications or improved efficacy, suggesting a need for better data on the efficacy of various fusion techniques for various indications.

921 citations


Journal ArticleDOI
01 Oct 2005-Spine
TL;DR: The consistency rate between the predicted prognosis from the criteria of the total scores and the actual survival period was high in patients within each score range and a similar result was also observed in both the surgical procedure group and conservative treatmentgroup.
Abstract: Study design A semi-prospective clinical study was conducted. Objectives To evaluate the accuracy of a revised scoring system predicting metastatic spinal tumor prognosis and the suitability of the subsequent treatment strategy. Summary of the background data We used a scoring system for the preoperative evaluation of the prognosis of metastatic spinal tumors and selected treatment methods for the predicted prognosis. In the previous version of our scoring system, the reliability of the predicting prognosis was 63.3% in 128 patients with metastatic spinal tumors. Methods The study participants were 164 patients who died after surgery and 82 who died after conservative treatment. Six parameters were used in the revised scoring system. Each parameter ranged from 0 to 5 points, and the total score was 15 points. In principle, conservative treatment or palliative procedures were indicated in patients with a total score of 8 or less (predicted survival period, less than 6 months) or those with multiple vertebral metastases, while excisional procedures were performed in patients with a total score of 12 or more (predicted survival period, 1 year or more) or those with a total score of 9 to 11 (predicted survival period, 6 months or more) and with metastasis in a single vertebra. The selection of treatment modality was followed faithfully according to the criteria of the revised scoring system after 1998. The prognosis predicted by the revised scoring system and the actual survival period after treatment were compared, and the reliability of the prognostic criteria was analyzed for the group subjected to it prospectively after 1998 (n = 118) and for all 246 patients it was applied to retrospectively. Results The total score for each patient could be correlated with the survival period. This correlation was also observed in each treatment group. The consistency rate between the predicted prognosis from the criteria of the total scores and the actual survival period was high in patients within each score range (0-8, 9-11, or 12-15), 86.4% in the 118 patients evaluated prospectively after 1998, and 82.5% in the 246 patients evaluated retrospectively. Furthermore, a similar result was also observed in both the surgical procedure group and conservative treatment group. The rate of consistency between the predicted prognosis and the actual survival period in each local extension of the lesion was 75% or more in all types, excluding Type 6 in the surgical classification of Tomita et al. Conclusion The prognostic criteria using the total scores from our revised scoring system were useful for the pretreatment evaluation of metastatic spinal tumor prognosis irrespective of treatment modality or local extension of the lesion.

913 citations


Journal ArticleDOI
15 Oct 2005-Spine
TL;DR: A new proposed classification system for thoracolumbar (TL) spine injuries, including injury severity assessment, designed to assist in clinical management and to facilitate clinical decision-making as a practical alternative to cumbersome classification systems already in use is devised.
Abstract: Study design A new proposed classification system for thoracolumbar (TL) spine injuries, including injury severity assessment, designed to assist in clinical management. Objective To devise a practical, yet comprehensive, classification system for TL injuries that assists in clinical decision-making in terms of the need for operative versus nonoperative care and surgical treatment approach in unstable injury patterns. Summary of background data The most appropriate classification of traumatic TL spine injuries remains controversial. Systems currently in use can be cumbersome and difficult to apply. None of the published classification schemata is constructed to aid with decisions in clinical management. Methods Clinical spine trauma specialists from a variety of institutions around the world were canvassed with respect to information they deemed pivotal in the communication of TL spine trauma and the clinical decision-making process. Traditional injury patterns were reviewed and reconsidered in light of these essential characteristics. An initial validation process to determine the reliability and validity of an earlier version of this system was also undertaken. Results A new classification system called the Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based on three injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurologic status of the patient. A composite injury severity score was calculated from these characteristics stratifying patients into surgical and nonsurgical treatment groups. Finally, a methodology was developed to determine the optimum operative approach for surgical injury patterns. Conclusions Although there will always be limitations to any cataloging system, the TLICS reflects accepted features cited in the literature important in predicting spinal stability, future deformity, and progressive neurologic compromise. This classification system is intended to be easy to apply and to facilitate clinical decision-making as a practical alternative to cumbersome classification systems already in use. The TLICS may improve communication between spine trauma physicians and the education of residents and fellows. Further studies are underway to determine the reliability and validity of this tool.

730 citations


Journal ArticleDOI
01 May 2005-Spine
TL;DR: The scoliosis prevalence rate of 68% found in this study reveals a rate significantly higher than reported in other studies, and appears to reflect the targeted selection of an elderly group.
Abstract: Study design A prospective self-assessment analysis and evaluation of nutritional and radiographic parameters in a consecutive series of healthy adult volunteers older than 60 years. Objectives To ascertain the prevalence of adult scoliosis, assess radiographic parameters, and determine if there is a correlation with functional self-assessment in an aged volunteer population. Summary of background data There exists little data studying the prevalence of scoliosis in a volunteer aged population, and correlation between deformity and self-assessment parameters. Methods There were 75 subjects in the study. Inclusion criteria were: age > or =60 years, no known history of scoliosis, and no prior spine surgery. Each subject answered a RAND 36-Item Health Survey questionnaire, a full-length anteroposterior standing radiographic assessment of the spine was obtained, and nutritional parameters were analyzed from blood samples. For each subject, radiographic, laboratory, and clinical data were evaluated. The study population was divided into 3 groups based on frontal plane Cobb angulation of the spine. Comparison of the RAND 36-Item Health Surveys data among groups of the volunteer population and with United States population benchmark data (age 65-74 years) was undertaken using an unpaired t test. Any correlation between radiographic, laboratory, and self-assessment data were also investigated. Results The mean age of the patients in this study was 70.5 years (range 60-90). Mean Cobb angle was 17 degrees in the frontal plane. In the study group, 68% of subjects met the definition of scoliosis (Cobb angle >10 degrees). No significant correlation was noted among radiographic parameters and visual analog scale scores, albumin, lymphocytes, or transferrin levels in the study group as a whole. Prevalence of scoliosis was not significantly different between males and females (P > 0.03). The scoliosis prevalence rate of 68% found in this study reveals a rate significantly higher than reported in other studies. These findings most likely reflect the targeted selection of an elderly group. Although many patients with adult scoliosis have pain and dysfunction, there appears to be a large group (such as the volunteers in this study) that has no marked physical or social impairment. Conclusions Previous reports note a prevalence of adult scoliosis up to 32%. In this study, results indicate a scoliosis rate of 68% in a healthy adult population, with an average age of 70.5 years. This study found no significant correlations between adult scoliosis and visual analog scale scores or nutritional status in healthy, elderly volunteers.

693 citations


Journal ArticleDOI
15 Apr 2005-Spine
TL;DR: Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically, and these results support a shared decision-making approach among physicians and patients when considering treatment options.
Abstract: Study design A prospective observational cohort study. Objective To assess long-term outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically. Summary of background data The relative benefit of various treatments for lumbar spinal stenosis is uncertain. Surgical treatment has been associated with short-term improvement, but recurrence of symptoms has been documented. Few studies have compared long-term outcomes of surgical and nonsurgical treatments. Methods Patients recruited from the practices of orthopaedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Most patients initially undergoing surgery had a laminectomy without fusion performed. Outcomes including patient-reported symptoms of leg and back pain, functional status, and satisfaction were assessed at 8- to 10-year follow-up. Primary analyses were based on initial treatment received with secondary analyses examining actual treatment received by 10 years. Results Of 148 eligible consenting patients initially enrolled, 105 were alive after 10 years (67.7% survival rate). Among surviving patients, long-term follow-up between 8 and 10 years was available for 97 of 123 (79%) patients (including 11 patients who died before the 10-year follow-up but completed a 8 or 9 year survey); 56 of 63 (89%) initially treated surgically and 41 of 60 (68%) initially treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. Outcomes at 1 and 4 years favored initial surgical treatment. After 8 to 10 years, a similar percentage of surgical and nonsurgical patients reported that their low back pain was improved(53% vs. 50%, P = 0.8), their predominant symptom (either back or leg pain) was improved (54% vs. 42%, P = 0.3), and they were satisfied with their current status (55% vs. 49%, P = 0.5). These treatment group findings persisted after adjustment for other determinants of outcome in multivariate models. However, patients initially treated surgically reported less severe leg pain symptoms and greater improvement in back-specific functional status after 8 to 10 years than nonsurgically treated patients. By 10 years, 23% of surgical patients had undergone at least one additional lumbar spine operation, and 39% of nonsurgical patients had at least one lumbar spine operation. Patients undergoing subsequent surgical procedures had worse outcomes than those continuing with their initial treatment. Outcomes according to actual treatment received at 10 years did not differ because individuals undergoing additional surgical procedures had worse outcomes than those continuing with their initial treatment. Conclusions Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis.

597 citations


Journal ArticleDOI
15 Jul 2005-Spine
TL;DR: The results support earlier reports in the literature that total disc replacement with the CHARITÉ™ artificial disc is a safe and effective alternative to fusion for the surgical treatment of symptomatic disc degeneration in properly indicated patients.
Abstract: STUDY DESIGN A prospective, randomized, multicenter, Food and Drug Administration-regulated Investigational Device Exemption clinical trial. OBJECTIVES The purpose of this study was to compare the safety and effectiveness of lumbar total disc replacement, using the CHARITE artificial disc (DePuy Spine, Raynham, MA), with anterior lumbar interbody fusion, for the treatment of single-level degenerative disc disease from L4-S1 unresponsive to nonoperative treatment. SUMMARY OF BACKGROUND DATA Reported results of lumbar total disc replacement have been favorable, but studies have been limited to retrospective case series and/or small sample sizes. METHODS Three hundred four (304) patients were enrolled in the study at 14 centers across the United States and randomized in a 2:1 ratio to treatment with the CHARITE artificial disc or the control group, instrumented anterior lumbar interbody fusion. Data were collected pre- and perioperatively at 6 weeks and at 3, 6, 12, and 24 months following surgery. The key clinical outcome measures were a Visual Analog Scale assessing back pain, the Oswestry Disability Index questionnaire, and the SF-36 Health Survey. RESULTS Patients in both groups improved significantly following surgery. Patients in the CHARITE artificial disc group recovered faster than patients in the control group. Patients in the CHARITE artificial disc group had lower levels of disability at every time interval from 6 weeks to 24 months, compared with the control group, with statistically lower pain and disability scores at all but the 24 month follow-up (P < 0.05). At the 24-month follow-up period, a significantly greater percentage of patients in the CHARITE artificial disc group expressed satisfaction with their treatment and would have the same treatment again, compared with the fusion group (P < 0.05). The hospital stay was significantly shorter in the CHARITE artificial disc group (P < 0.05). The complication rate was similar between both groups. CONCLUSIONS This prospective, randomized, multicenter study demonstrated that quantitative clinical outcome measures following lumbar total disc replacement with the CHARITE artificial disc are at least equivalent to clinical outcomes with anterior lumbar interbody fusion. These results support earlier reports in the literature that total disc replacement with the CHARITE artificial disc is a safe and effective alternative to fusion for the surgical treatment of symptomatic disc degeneration in properly indicated patients. The CHARITE artificial disc group demonstrated statistically significant superiority in two major economic areas, a 1-day shorter hospitalization, and a lower rate of reoperations (5.4% compared with 9.1%). At 24 months, the investigational group had a significantly higher rate of satisfaction (73.7%) than the 53.1% rate of satisfaction in the control group (P = 0.0011). This prospective randomized multicenter study also demonstrated an increase in employment of 9.1% in the investigational group and 7.2% in the control group.

593 citations


Journal ArticleDOI
01 Jan 2005-Spine
TL;DR: The needle puncture approach, using 16G to 21G needles, resulted in a reproducible decrease of disc height and magnetic resonance imaging grade, which will benefit researchers studying disc degeneration.
Abstract: Study design An in vivo study to radiographically and histologically assess a new method of induction of disc degeneration. OBJECTIVE.: To establish a reproducible rabbit model of disc degeneration by puncturing the anulus with needles of defined gauges and to compare it to the classic stab model. Summary of background data New treatment approaches to disc degeneration are of great interest. Although animal models for disc degenerative disease exist, the quantitative measurement of disease progression remains difficult. A reproducible, progressive disc degeneration model, which can be induced in a reasonable time frame, is essential for development of new therapeutic interventions. Methods The classic anular stab model and the new needle puncture model were used in the rabbit. For the needle puncture model, 3 different gauges of needle (16G, 18G, and 21G) were used to induce an injury to the disc to a depth of 5 mm. Radiographic and histologic analyses were performed; magnetic resonance images were also assessed in the needle puncture model. Results Significant disc space narrowing was observed as early as 2 weeks after stabbing in the classic stab model; there was no further narrowing of the disc space. In the needle puncture model, all needle sizes tested induced a slower and more progressive decrease in disc height than in the classic stab model. The magnetic resonance imaging supported the results of disc height data. Conclusions The needle puncture approach, using 16G to 21G needles, resulted in a reproducible decrease of disc height and magnetic resonance imaging grade. The ease of the procedure and transfer of the methodology will benefit researchers studying disc degeneration.

Journal ArticleDOI
01 Sep 2005-Spine
TL;DR: The dual growing rod technique is safe and effective, provides adequate stability, increases the duration of treatment period, and has an acceptable rate of complication compared with previous reports using the single rod technique.
Abstract: Study design A retrospective case review of children treated with dual growing rod technique at our institutions. Patients included had no previous surgery and a minimum of 2 years follow-up from initial surgery. Objectives To determine the safety and effectiveness of the previously described dual growing rod technique in achieving and maintaining scoliosis correction while allowing spinal growth. Summary of background data Historically, the growing rod techniques have used a single rod and the reported results have been variable. There has been no published study exclusively on the results of dual growing rod technique for early-onset scoliosis. Methods From 1993 to 2001, 23 patients underwent dual growing rod procedures using pediatric Isola instrumentation and tandem connectors. Diagnoses included infantile and juvenile idiopathic scoliosis, congenital, neuromuscular, and other etiologies. All had curve progression over 10 degrees following unsuccessful bracing or casting. Of 189 total procedures within the treatment period, 151 were lengthenings with an average of 6.6 lengthenings per patient. Analysis included age at initial surgery and final fusion (if applicable), number and frequency of lengthenings, and complications. Radiographic evaluation included measured changes in scoliosis Cobb angle, kyphosis, lordosis, frontal and sagittal balance, length of T1-S1 and instrumentation over the treatment period, and space available for lung ratio. Results The mean scoliosis improved from 82 degrees (range, 50 degrees-130 degrees) to 38 degrees (range, 13 degrees-66 degrees) after initial surgery and was 36 degrees (range, 4 degrees-53 degrees) at the last follow-up or post-final fusion. T1-S1 length increased from 23.01 (range, 13.80-31.20) to 28.00 cm (range, 19.50-35.50) after initial surgery and to 32.65 cm (range, 25.60-41.00) at last follow-up or post-final fusion with an average T1-S1 length increase of 1.21 cm per year (range, 0.13-2.59). Seven patients reached final fusion. The space available for lung ratio in patients with thoracic curves improved from 0.87 (range, 0.7-1.1) to 1.0 (range, 0.79-1.23, P = 0.01). During the treatment period, complications occurred in 11 of the 23 patients (48%), and they had a total of 13 complications. Four of these patients (17%) had unplanned procedures. Following final fusion, 2 patients required extensions of their fusions because of curve progression and lumbosacral pain. Conclusion The dual growing rod technique is safe and effective. It maintains correction obtained at initial surgery while allowing spinal growth to continue. It provides adequate stability, increases the duration of treatment period, and has an acceptable rate of complication compared with previous reports using the single rod technique.

Journal ArticleDOI
01 Jan 2005-Spine
TL;DR: The results of this study indicate that the Korean version of the ODI is a reliable and valid instrument for the measurement of disability in Korean patients with lower back problems.
Abstract: Study Design. Validation of a translated, culturally adapted questionnaire. Objectives. To translate and culturally adapt a Korean version of the Oswestry Disability Index (ODI) and to validate its use in Korean patients. Summary of Background Data. The ODI is one of the most widely used and validated instruments for measuring disability in spinal disorders. However, no validated Korean version of the index was available at the time our study was initiated. Methods. The study was carried out in three phases: the first was translation into Korean and cultural adaptation of the questionnaire; the second was a pilot study to assess the comprehensibility of the prefinal version and modification; the third was a reliability and validity study of the final version. The Korean version was tested on 206 patients with lumbar spinal disorders who had undergone operations at the authors’ institute. Test-retest reliability, internal consistency, concurrent validity, and construct validity were investigated. Follow-up questionnaires were obtained from 39 patients at the 3-month postoperative follow-up meeting. Differences in the ODI, visual analog scale (VAS), and World Health Organization (WHO) quality of life assessment (WHOQOL-BREF) between preoperative and follow-up questionnaires were evaluated. The correlation of the postoperative ODI with the pain rating on a visual analog scale and WHOQOL-BREF was also analyzed. Results. Test-retest reliability was assessed with 88 patients in a time interval of 48 hours. The intraclass correlation coefficient of test-retest reliability was 0.9167. Reliability estimated by the internal consistency reached a Cronbach’s alpha of 0.84. The correlation of the preoperative ODI with the pain rating on a visual analog scale (100 mm) was r 0.425 (P 0.0001). The correlation between three of the WHOQOL-BREF domains (physical health, psychological health, and environment) and the ODI was statistically significant. The correlation coefficient between the ODI and physical health domain of the WHOQOL-BREF was r 0.48 (P 0.05). The correlations with psychological health and environment domains were low with r 0.192 and 0.160, respectively, even though statistically significant (P 0.05). The correlation of the postoperative ODI with the pain rating on a visual analog scale (100 mm) was r 0.626 (P 0.0001). The correlation between all four domains of the WHOQOL-BREF and the postoperative ODI was statistically significant. Conclusions. The results of this study indicate that the Korean version of the ODI is a reliable and valid instrument for the measurement of disability in Korean patients with lower back problems. The authors recommend this Korean version of the ODI for use in future clinical studies in Korea.

Journal ArticleDOI
15 Jul 2005-Spine
TL;DR: Investigation in adults undergoing long posterior spinal fusion found incidence of proximal junctional kyphosis was high, but SRS-24 scores were not significantly affected in patients with PJK, and the sagittal C7 plumb was not significantly more positive in PJK patients.
Abstract: Study design To analyze patient outcomes and risk factors associated with proximal junctional kyphosis (PJK) in adults undergoing long posterior spinal fusion. Objectives To determine the incidence of PJK and its effect on patient outcomes and to identify any risk factors associated with developing PJK. Summary of background data The incidence of PJK and its affect on outcomes in adult deformity patients is unknown. No study has concentrated on outcomes of patients with PJK. Risk factors for developing PJK are unknown. Methods Radiographic data on 81 consecutive adult deformity patients with minimum 2-year follow-up (average 5.3 years, range 2-16 years) treated with long instrumented segmental posterior spinal fusion was collected. Preoperative diagnosis was adult scoliosis, sagittal imbalance or both. Radiographic measurements analyzed included the sagittal Cobb angle at the proximal junction on preoperative, early postoperative, and final follow-up standing long cassette radiographs. Additional measurements used for analysis included the C7-Sacrum sagittal plumb and the T5-T12 sagittal Cobb. Postoperative SRS-24 scores were available on 73 patients. Results Incidence of PJK as defined was 26%. Patients with PJK did not have lower outcomes scores. PJK did not produce a more positive sagittal C7 plumb. PJK was more common at T3 in the upper thoracic spine. Conclusions Incidence of proximal junctional kyphosis was high, but SRS-24 scores were not significantly affected in patients with PJK. The sagittal C7 plumb was not significantly more positive in PJK patients. No patient, radiographic, or instrumentation variables were identified as risk factors for developing PJK.

Journal ArticleDOI
15 Jun 2005-Spine
TL;DR: Understanding a patient’s preoperative risk factors may help the physician to optimize a patient's preoperative condition and increase the duration of prophylactic antibiotics or implement other measures to decrease the incidence of infection for high risk patients.
Abstract: Study design A retrospective case control analysis of 48 cases of postoperative infection following spinal procedures Objectives Spinal procedures that became infected after surgery were analyzed to identify the significance of preoperative and intraoperative risk factors Characterization of the nature and timing of the infections was also performed Summary of background data The rate of postoperative infection following spinal surgery varies widely depending on the nature of the procedure and the patient's diagnosis Preoperative comorbidities and risk factors also influence the likelihood of infection Methods A review of 1629 procedures performed on 1095 patients revealed that a postoperative infection developed in 48 patients (44%) Data regarding preoperative and intraoperative risk factors were gathered from patient charts for these and a randomly selected control group of 95 uninfected patients For analysis, these patient groups were further divided into adult and pediatric subgroups, with an age cutoff of 18 years Preoperative risk factors reviewed included smoking, diabetes, previous surgery, previous infection, steroid use, body mass index, and alcohol abuse Intraoperative factors reviewed included staging of procedures, estimated blood loss, operating time, and use of allograft or instrumentation Results The majority of infections occurred during the early postoperative period (less than 3 months) Age >60 years, smoking, diabetes, previous surgical infection, increased body mass index, and alcohol abuse were statistically significant preoperative risk factors The most likely procedure to be complicated by an infection was a combined anterior/posterior spinal fusion performed in a staged manner under separate anesthesia Infections were primarily monomicrobial, although 5 patients had more than 4 organisms identified The most common organism cultured from the wounds was Staphylococcus aureus All patients were treated with surgical irrigation and debridement, and appropriate antibiotics to treat the cultured organism Conclusions Aggressive treatment of patients undergoing complex or prolonged spinal procedures is essential to prevent and treat infections Understanding a patient's preoperative risk factors may help the physician to optimize a patient's preoperative condition Additionally, awareness of critical intraoperative parameters will help to optimize surgical treatment It may be appropriate to increase the duration of prophylactic antibiotics or implement other measures to decrease the incidence of infection for high risk patients

Journal ArticleDOI
15 Apr 2005-Spine
TL;DR: Surgically treated patients with a herniated lumbar disc had more complete relief of leg pain and improved function and satisfaction compared with nonsurgicallytreated patients over 10 years, and the relative benefit persisted over the follow-up period.
Abstract: Study design A prospective cohort study. Objective To assess 10-year outcomes of patients with sciatica resulting from a lumbar disc herniation treated surgically or nonsurgically. Summary of background data There is little information comparing long-term outcomes of surgical and conservative therapy of lumbar disc herniation in contemporary clinical practice. Prior studies suggest that these outcomes are similar. Methods Patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Primary analyses were based on initial treatment received, either surgical or nonsurgical. Secondary analyses examined actual treatments received by 10 years. Outcomes included patient-reported symptoms of leg and back pain, functional status, satisfaction, and work and disability compensation status. Results Of 507 eligible consenting patients initially enrolled, 10-year outcomes were available for 400 of 477 (84%) surviving patients; 217 of 255 (85%) treated surgically, and 183 of 222 (82%) treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. By 10 years, 25% of surgical patients had undergone at least one additional lumbar spine operation, and 25% of nonsurgical patients had at least one lumbar spine operation. At 10-year follow-up, 69% of patients initially treated surgically reported improvement in their predominant symptom (back or leg pain) versus 61% of those initially treated nonsurgically (P = 0.2). A larger proportion of surgical patients reported that their low back and leg pain were much better or completely gone (56% vs. 40%, P = 0.006) and were more satisfied with their current status (71% vs. 56%, P = 0.002). Treatment group differences persisted after adjustment for other determinants of outcome in multivariate models. Change in the modified Roland back-specific functional status scale favored surgical treatment, and the relative benefit persisted over the follow-up period. Despite these differences, work and disability status at 10 years were comparable among those treated surgically or nonsurgically. Conclusions Surgically treated patients with a herniated lumbar disc had more complete relief of leg pain and improved function and satisfaction compared with nonsurgically treated patients over 10 years. Nevertheless, improvement in the patient's predominant symptom and work and disability outcomes were similar regardless of treatment received. For patients in whom elective discectomy is a treatment option, an individualized treatment plan requires patients and their physicians to integrate clinical findings with patient preferences based on their symptoms and goals.

Journal ArticleDOI
15 Jun 2005-Spine
TL;DR: The X STOP provides a conservative yet effective treatment for patients suffering from lumbar spinal stenosis and in the continuum of treatment options, the X STOP offers an attractive alternative to both conservative care and decompressive surgery.
Abstract: Study design A randomized, controlled, prospective multicenter trial comparing the outcomes of neurogenic intermittent claudication (NIC) patients treated with the interspinous process decompression system (X STOP) with patients treated nonoperatively. Objective To determine the safety and efficacy of the X STOP interspinous implant. Summary of background data Patients suffering from NIC secondary to lumbar spinal stenosis have been limited to a choice between nonoperative therapies and decompressive surgical procedures, with or without fusion. The X STOP was developed to provide an alternative therapeutic treatment. METHODS.: 191 patients were treated, 100 in the X STOP group and 91 in the control group. The primary outcomes measure was the Zurich Claudication Questionnaire, a patient-completed, validated instrument for NIC. Results At every follow-up visit, X STOP patients had significantly better outcomes in each domain of the Zurich Claudication Questionnaire. At 2 years, the X STOP patients improved by 45.4% over the mean baseline Symptom Severity score compared with 7.4% in the control group; the mean improvement in the Physical Function domain was 44.3% in the X STOP group and -0.4% in the control group. In the X STOP group, 73.1% patients were satisfied with their treatment compared with 35.9% of control patients. Conclusions The X STOP provides a conservative yet effective treatment for patients suffering from lumbar spinal stenosis. In the continuum of treatment options, the X STOP offers an attractive alternative to both conservative care and decompressive surgery.

Journal ArticleDOI
15 Sep 2005-Spine
TL;DR: Optimal inclusion criteria for future adolescent idiopathic scoliosis brace studies consist of: age is 10 years or older when brace is prescribed, Risser 0−2, primary curve angles 25°−40°, no prior treatment, and, if female, either premenarchal or less than 1 year post menarchal.
Abstract: Study Design. Literature review. Objective. To establish consistent parameters for future adolescent idiopathic scoliosis bracing studies so that valid and reliable comparisons can be made. of Background Data. Current bracing literature lacks consistency for both inclusion criteria and the definitions of brace effectiveness. Methods. A total of 32 brace treatment studies and the current bracing in adolescent idiopathic scoliosis proposal were analyzed to: (1) determine inclusion criteria that will best identify those patients most at risk for progression, (2) determine the most appropriate definitions for bracing effectiveness, and (3) identify additional variables that would provide valuable information. Results. Early brace studies lacked clarity in their inclusion criteria. In more recent studies, inclusion criteria have narrowed considerably to include primarily those patients most at risk for curve progression who may benefit from the use of a brace. Brace effectiveness was usually defined by various degrees of curve progression at maturity. Less frequently, it was defined by the resultant curve magnitude at maturity, whether or not surgical intervention was needed, or if there was change to another brace. Conclusions. Optimal inclusion criteria for future adolescent idiopathic scoliosis brace studies consist of: age is 10 years or older when brace is prescribed, Risser 0-2, primary curve angles 25°-40°, no prior treatment, and, if female, either premenarchal or less than 1 year postmenarchal. Assessment of brace effectiveness should include: (1) the percentage of patients who have ≤5° curve progression and the percentage of patients who have a6° progression at maturity, (2) the percentage of patients with curves exceeding 45° at maturity and the percentage who have had surgery recommended/undertaken, and (3) 2-year follow-up beyond maturity to determine the percentage of patients who subsequently undergo surgery. All patients, regardless of subjective reports on compliance, should be included in the results (intent to treat). Every study should provide results stratified by curve type and size grouping.

Journal ArticleDOI
15 May 2005-Spine
TL;DR: Most degenerative disc “abnormalities” were moderately associated with LBP and the strongest associations were noted for Modic changes and anterolisthesis.
Abstract: Study design Cross-sectional cohort study of a general population. Objective To investigate "abnormal" lumbar spine magnetic resonance imaging (MRI) findings, and their prevalence and associations with low back pain (LBP). Summary of background data The clinical relevance of various "abnormal" findings in the lumbar spine is unclear. Distinguishing between inevitable age-related findings and degenerative findings with deleterious consequences is a challenge. Methods Lumbar spine MRI was obtained in 412, 40-year-old individuals. Predefined "abnormal" MRI findings were interpreted without any knowledge of patient symptoms. Associations between MRI abnormalities and LBP were calculated using odds ratios. The "overall picture" of each MRI finding was established on the basis of the frequencies, diagnostic values, and the strength and consistency of associations. Results Most "abnormal" MRI findings were found at the lowest lumbar levels. Irregular nucleus shape and reduced disc height were common (>50% of individuals). Relatively common (25% to 50%) were hypointense disc signal, anular tears, high intensity zones, disc protrusions, endplate changes, zygapophyseal joint degeneration, asymmetry, and foraminal stenosis. Nerve root compromise, Modic changes, central spinal stenosis, and anterolisthesis/retrolisthesis were rare ( 4). Significantly positive associations with all LBP variables were seen for hypointense disc signals, reduced disc height, and Modic changes. All disc "abnormalities" except protrusion were moderately associated with LBP during the past year. Conclusion Most degenerative disc "abnormalities" were moderately associated with LBP. The strongest associations were noted for Modic changes and anterolisthesis. Further studies are needed to define clinical relevance.

Journal ArticleDOI
01 Jan 2005-Spine
TL;DR: Although percutaneous pedicle screw fixation had positive effects on postoperative trunk muscle performance, clinical outcomes were not significantly different in areas of pain score, JOA score, and patient’s opinion regarding the outcome of the surgery.
Abstract: Study Design.This study was conducted by retrospective case selection and prospective observation of longitudinal changes of the multifidus muscle cross-sectional area and of trunk extension muscle strength in percutaneous and open pedicle screw fixations.Objectives.To compare postoperative multifid

Journal ArticleDOI
15 Apr 2005-Spine
TL;DR: The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain and that acupuncture is not more effective than other conventional and “alternative” treatments.
Abstract: Objectives To assess the effects of acupuncture and dry-needling for the treatment of nonspecific low back pain. Background Low back pain is usually a self-limiting condition that tends to improve spontaneously over time. However, for many people, back pain becomes a chronic or recurrent problem for which a large variety of therapeutic interventions are employed. Search strategy We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February 2003. Selection criteria Randomized controlled trials of acupuncture (that involved needling) or dry-needling for adults with nonspecific acute/subacute or chronic low back pain. Data collection and analysis Two reviewers independently assessed methodologic quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analysis methods or levels of evidence when the data reported did not allow statistical pooling. Results Thirty-five randomized clinical trials were included: 20 were published in English, 7 in Japanese, 5 in Chinese, and 1 each in Norwegian, Polish, and German. There were only 3 trials of acupuncture for acute low back pain. These studies did not justify firm conclusions because of their small sample sizes and low methodologic quality. For chronic low back pain, there is evidence of pain relief and functional improvement for acupuncture compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and in short-term follow-up. There is also evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, the effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low back pain. No clear recommendations could be made about the most effective acupuncture technique. Conclusions The data do not allow firm conclusions regarding the effectiveness of acupuncture for acute low back pain. For chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and "alternative" treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain. Because most of the studies were of lower methodologic quality, there is a clear need for higher quality trials in this area.

Journal ArticleDOI
01 Nov 2005-Spine
TL;DR: MSCs transplanted to degenerative discs in rabbits proliferated and differentiated into cells expressing some of the major phenotypic characteristics of nucleus pulposus cells, suggesting that these MSCs may have undergone site-dependent differentiation.
Abstract: Study design An in vivo study to assess the differentiation status of mesenchymal stem cells (MSCs) transplanted to the nucleus pulposus of degenerative discs in a rabbit model. Objectives To evaluate the fate of MSCs transplanted to the nucleus pulposus of degenerative discs in a rabbit and to determine whether they are a suitable alternative for cell transplantation therapy for disc degeneration. Summary of background data Although MSCs have been proposed as candidate donor cells for transplantation to treat intervertebral disc degeneration, their differentiation after transplantation has not been adequately investigated. Methods Autologous MSCs, labeled with green fluorescent protein, were transplanted into mature rabbits. Consecutive counts of transplanted MSCs in the nucleus area were performed for 48 weeks after transplantation. Differentiation of transplanted cells was determined by immunohistochemical analysis. The proteoglycan content of discs was measured quantitatively using a dimethylmethylene blue assay, and mRNA expression of Type I and II collagen, aggrecan and versican was measured semi-quantitatively using reverse transcription polymerase chain reaction. Results Many cells that were positive for green fluorescent protein were observed in the nucleus pulposus of cell-transplanted rabbit discs 2 weeks after transplantation. Their number increased significantly by 48 weeks. Some GFP-positive cells were positive for cell-associated matrix molecules, such as Type II collagen, keratan sulfate, chondroitin sulfate, aggrecan, and the nucleus pulposus phenotypic markers, hypoxia inducible factor 1 alpha, glutamine transporter 1, and matrix metalloproteinase 2. MSCs did not show significant expression of these molecules before transplantation. Biochemical and gene expression analyses showed significant restoration of total proteoglycan content and matrix-related genes compared with nontransplanted discs. Conclusions MSCs transplanted to degenerative discs in rabbits proliferated and differentiated into cells expressing some of the major phenotypic characteristics of nucleus pulposus cells, suggesting that these MSCs may have undergone site-dependent differentiation. Further studies are needed to evaluate their functional role.

Journal ArticleDOI
01 Jan 2005-Spine
TL;DR: Despite an increase in the number of studies over the last 10 years, the level of evidence for the efficacy and safety of spinal cord stimulation in patients with chronic back and leg pain/failed back surgery syndrome remains “moderate.”
Abstract: STUDY DESIGN: Systematic review. OBJECTIVES: To assess efficacy and safety of spinal cord stimulation in patients with chronic leg and back pain and failed back surgery syndrome and to examine prognostic factors that predict spinal cord stimulation outcome. SUMMARY OF BACKGROUND DATA: A previous systematic review of spinal cord stimulation in patients with chronic back and leg pain and failed back surgery syndrome by Turner et al in 1995 identified 39 case studies and no controlled studies. METHODS: A number of electronic databases were searched through January 2002. Citation searching of included papers was undertaken, and gray literature was sought through contact with clinical experts. No language restrictions were applied. All controlled and noncontrolled study designs were included. Study selection was carried out independently by two reviewers. Prognostic factors (age, sex, duration of pain, time post surgery, follow-up duration, publication year, data collection year, indication, data collection country, study setting, and quality score) responsible for pain relief outcome across case series were examined using univariate and multivariate metaregression. RESULTS: One randomized controlled trial, one cohort study, and 72 case studies were included. The randomized controlled trial reported a significant benefit (P = 0.047) in the proportion of patients with failed back surgery syndrome reporting 50% or more pain relief with spinal cord stimulation (37.5%) compared with patients undergoing back reoperation (11.5%). There was evidence of substantial statistical heterogeneity (P < 0.0001) in the level of pain relief following spinal cord stimulation reported across case series studies. The four principal prognostic factors found to be predictive of increased level of pain relief with spinal cord stimulation were poor study quality score, short follow-up duration, multicenter (versus single center) studies, and the inclusion of patients with failed back surgery syndrome (versus chronic back and leg pain). Overall, 43% of patients with chronic back and leg pain/failed back surgery syndrome experienced one or more complications following a spinal cord stimulation implant, although no major adverse events were reported. CONCLUSIONS: Despite an increase in the number of studies over the last 10 years, the level of evidence for the efficacy of spinal cord stimulation in chronic back and leg pain/failed back surgery syndrome remains "moderate." Prognostic factors found to be predictive of the level of pain relief following spinal cord stimulation were study quality, follow-up duration, study setting, and patient indication.

Journal ArticleDOI
15 Dec 2005-Spine
TL;DR: Most new and recurrent LBP episodes are mild, and less than one third of cases resolve annually, and more than 20% recur within 6 months.
Abstract: Study design Population-based, prospective cohort. Objectives To estimate incidence and course of severity-graded low back pain (LBP) episodes in adults. Summary of background data Past studies report variable estimates that do not differentiate LBP severity. Methods An incidence cohort of 318 subjects free of LBP and a course cohort of 792 prevalent cases was formed from respondents to a mailed survey. Incident, recurrent, persistent, aggravated, improved, and resolved episodes were defined by the Chronic Pain Questionnaire. The follow-up at 6 and 12 months was 74% and 62%, respectfully. Annual estimates were age and sex standardized. Results The cumulative incidence was 18.6% (95% confidence interval [CI], 14.2%-23.0%). Most LBP episodes were mild. Only 1.0% (95% CI, 0.0%-2.2%) developed intense and 0.4% (95% CI, 0.0%-1.0%) developed disabling LBP. Resolution occurred in 26.8% (95% CI, 23.7%-30.0%), and 40.2% (95% CI, 36.7%-43.8%) of episodes persisted. The severity of LBP increased for 14.2% (95% CI, 11.5%-16.8%) and improved for 36.1% (95% CI, 29.7%-42.2%). Of those that recovered, 28.7% (95% CI, 21.2%-36.2%)had a recurrence within 6months,and 82.4% of it was mild LBP. Younger subjects were less likely to have persistent LBP (incidence rate ratio, 0.88; 95% CI, 0.80-0.97) and more likely to have resolution (incidence rate ratio, 1.26; 95% CI, 1.02-1.56). Conclusions Most new and recurrent LBP episodes are mild. Less than one third of cases resolve annually, and more than 20% recur within 6 months. LBP episodes are more recurrent and persistent in older adults.

Journal ArticleDOI
15 Apr 2005-Spine
TL;DR: Parity, LBPP during a previous pregnancy, body mass index, a history of hypermobility, and amenorrhea are factors influencing the risk of developing low back pain and pelvic pain during pregnancy.
Abstract: Study design Cross-sectional study. Women giving birth at one of two hospitals of northern Sweden from 1 January 2002 until 30 April 2002 were invited to fill in a questionnaire on their obstetric and gynecological history, actual pregnancy, and delivery. Objective The aim of this study was to investigate prevalence and risk factors for low back pain and pelvic pain (LBPP) during pregnancy. Summary of background data Although low back pain and pelvic pain during pregnancy is a most common complication of pregnancy, its etiology is unknown and the pathophysiology is poorly understood. Methods The sample was analyzed by calculating the prevalence of LBPP during pregnancy. Univariate and multivariate logistic regression was performed to calculate odds ratio (OR) and its 95% confidence intervals (CI) where applicable. Parametric and nonparametric testing was used to establish differences between groups. Results The response rate was 83.2% (N = 891). The prevalence of LBPP during pregnancy was 72%. Most cases reported both anterior and posterior pain. Increasing parity, history of hypermobility, and reported periods of amenorrhea were risk factors for LBPP. Women with LBPP had significantly higher prepregnancy weight, end-pregnancy weight, and prepregnancy and end-pregnancy body mass index. Age at menarche and use of oral contraceptives were not associated with LBPP. Nonrespondents were of the same age and parity as respondents. Conclusions A majority of pregnant women report LBPP. Parity, LBPP during a previous pregnancy, body mass index, a history of hypermobility, and amenorrhea are factors influencing the risk of developing LBPP during pregnancy.

Journal ArticleDOI
15 Oct 2005-Spine
TL;DR: No conclusions are possible about the relative effectiveness of anterior, posterior, or circumferential fusion, and the preliminary results of three small trials of intradiscal electrotherapy suggest it is ineffective, except possibly in highly selected patients.
Abstract: Study design An updated Cochrane review. Objective To review current scientific evidence on the effectiveness of surgical interventions for degenerative lumbar spondylosis. Summary of background data There is still limited scientific evidence on spinal surgery. Methods Use of standard Cochrane review methods to analyze all randomized controlled trials published to March 31, 2005. Results A total of 31 randomized controlled trials were identified. Most of the earlier trials reported mainly surgical outcomes; more of the recent trials also reported patient-centered outcomes of pain or disability. There is still very little information on occupational outcomes or long-term outcomes beyond 2-3 years. Seven heterogeneous trials on spondylolisthesis, spinal stenosis, and nerve compression permitted limited conclusions. There were two new trials on fusion that showed conflicting results. One trial showed that fusion gave better clinical outcomes than conventional physiotherapy, and the other showed that fusion was no better than a modern exercise and rehabilitation program. There were 8 trials that showed that instrumented fusion produces a higher fusion rate, but any improvement in clinical outcomes is probably marginal. Conclusions No conclusions are possible about the relative effectiveness of anterior, posterior, or circumferential fusion. The preliminary results of three small trials of intradiscal electrotherapy suggest it is ineffective, except possibly in highly selected patients. Preliminary data from three trials of disc arthroplasty do not permit firm conclusions.

Journal ArticleDOI
01 Dec 2005-Spine
TL;DR: The delayed muscle reflex response significantly increases the odds of sustaining a low back injury (LBI) and these delayed latencies appear to be a preexisting risk factor and not the effect of an LBI.
Abstract: Study design Prospective observational study with a 2- to 3-year follow-up. Objectives To determine whether delayed muscle reflex response to sudden trunk loading is a result of or a risk factor for sustaining a low back injury (LBI). Summary of background data Differences in motor control have been identified in individuals with chronic low back pain and in athletes with a history of LBI when compared with controls. However, it is not known whether these changes are a risk for or a result of LBI. Methods Muscle reflex latencies in response to a quick force release in trunk flexion, extension, and lateral bending were measured in 303 college athletes. Information was also obtained regarding their personal data, athletic experience, and history of LBI. The data were entered into a binary logistic regression model to identify the predictors of future LBI. RESULTS.: A total of 292 athletes were used for the final analysis (148 females and 144 males). During the follow-up period, 31 (11%) athletes sustained an LBI. The regression model, consisting of history of LBI, body weight, and the latency of muscles shutting off during flexion and lateral bending load releases, predicted correctly 74% of LBI outcomes. The odds of sustaining LBI increased 2.8-fold when a history of LBI was present and increased by 3% with each millisecond of abdominal muscle shut-off latency. On average, this latency was 14 milliseconds longer for athletes who sustained LBI in comparison to athletes who did not sustain LBI (77 [36] vs. 63 [31]). There were no significant changes in any of the muscle response latencies on retest following the injury. Conclusions The delayed muscle reflex response significantly increases the odds of sustaining an LBI. These delayed latencies appear to be a preexisting risk factor and not the effect of an LBI.

Journal ArticleDOI
01 Jan 2005-Spine
TL;DR: Its occurrence in adults of more advanced age suggests that tumor necrosis factor; is not involved in the initiation of disc degeneration, but may be associated with further promotion of degenerative disarrangement and pain induction.
Abstract: STUDY DESIGN Immunohistochemical study of tumor necrosis factor alpha expression in autopsy and surgical specimens of human lumbar intervertebral discs. OBJECTIVES To investigate the occurrence and localization of tumor necrosis factor alpha in intervertebral disc tissue and to correlate its expression with age and the degree of disc degeneration. SUMMARY OF BACKGROUND DATA The source and origin of discogenic pain are as yet unknown. Recently identified changes of the cellular phenotype during senescence and disc pathology with partly phagocytic properties suggest an 'inflammatory' phenotype. Tumor necrosis factor alpha is one of the most potent proinflammatory cytokines possibly modulating cellular phenotypes. It may also promote pain induction. Very little is known about the occurrence and localization of tumor necrosis factor alpha in intervertebral disc tissue of defined age and degree of histologic tissue degeneration. METHODS The study population comprised 20 cross-sections of the complete motion segment of human lumbar vertebrae (age range 0-86 years) obtained at autopsy and 28 surgical disc specimens of individuals undergoing lumbar surgical interventions for various reasons. The temporospatial distribution of tumor necrosis factor alpha-positive cells using a polyclonal antibody was correlated with a histologic degeneration score. RESULTS Tumor necrosis factor alpha is expressed substantially in (nonsymptomatic) autopsy material in fetal/infantile and older adult nucleus pulposus, whereas it is sparsely expressed in adolescent and young adult nucleus pulposus. In the anulus fibrosus, tumor necrosis factor alpha is not found in young adults (<25 years), but then significantly increases in extent. In contrast, symptomatic nucleus pulposus and anulus fibrosus (surgical material) contain substantially more tumor necrosis factor alpha-positive cells. A significant positive correlation of tumor necrosis factor alpha expression and disc degeneration (histologic degeneration score) was found for the anulus fibrosus in both sample groups. In the surgical material, an additional significant positive correlation was identified for nuclear tumor necrosis factor alpha, disc degeneration, and age. CONCLUSIONS Tumor necrosis factor alpha is substantially expressed in disc material of symptomatic patients (surgical specimens) in comparison to samples taken at autopsy. The expression of tumor necrosis factor alpha in early fetal/infantile nucleus pulposus may indicate 'physiologic' tissue disarrangement with closure of the blood vessel canals. The expression of tumor necrosis factor alpha in adult discs, in contrast, is statistically associated with disc degeneration. Its occurrence in adults of more advanced age suggests that tumor necrosis factor alpha is not involved in the initiation of disc degeneration, but may be associated with further promotion of degenerative disarrangement and pain induction.

Journal ArticleDOI
01 Oct 2005-Spine
TL;DR: The use of allografts and plate fixation in combination for anterior cervical discectomy and fusion does not compromise the radiologic and clinical outcomes while providing the advantages of donor site morbidity elimination, restoration of cervical segmental lordosis, and not requiring postoperative immobilization.
Abstract: Study design A retrospective review. Objectives To determine the clinical and radiologic outcomes beyond 5 years after anterior cervical discectomy and fusion with allograft and plating. Summary of background data Anterior cervical discectomy and fusion is commonly performed for cervical disc disease. The routine use of allografts and plating, though increasing in popularity, has not been well studied for long-term results and complications. Methods Seventy-one patients who had anterior cervical discectomy and fusion with allograft and plating an average of 7.2 years prior responded to an invitation to return for a follow-up clinical and radiographic review. Results At final review, symptom resolution remained greater than 82% and fusion occurred in 92.6% of the disc spaces operated on. No graft extrusion or migration occurred. Based on our strict criteria, the rates of collapse and subsidence were high, at 47.9% (34 patients) overall. However, in only 6 patients (8.5%) did segmental kyphosis result, none of whom required any revision surgery in the follow-up period. Implant complications occurred in 7 patients (9.9%), none of whom required revision surgeries. Adjacent level degeneration occurred in 52 patients (73.2%). Further cervical spine surgeries were required in 14 patients (19.7%), 2 for inadequate decompression, and 12 for adjacent level disease. Segmental and global cervical lordosis was restored and maintained by the surgery over the study period. Conclusions The use of allografts and plate fixation in combination for anterior cervical discectomy and fusion does not compromise the radiologic and clinical outcomes while providing the advantages of donor site morbidity elimination, restoration of cervical segmental lordosis, and not requiring postoperative immobilization.

Journal ArticleDOI
01 Feb 2005-Spine
TL;DR: The results of the present study indicate that both back and leg pain are, on average, still moderately high 2 years after instrumentation with the Dynesys system, providing no support for the notion that semirigid fixation of the lumbar spine results in better patient-oriented outcomes than those typical of fusion.
Abstract: Fusion is a widespread and accepted treatment for painful degenerative conditions of the lumbar spine. However, the inconsistent results reported in the literature indicate a basic lack of understanding regarding the exact mechanism of pain relief. Overall, the outcome after fusion appears to be quite inconsistent: a systematic review of mainly retrospective case series reported that satisfactory clinical outcomes ranged from just 16% to as high as 95%, with an average of around 68%. 1 Although technical errors and inaccurate indications might be responsible for failure in some instances, there is some suggestion that additional factors may play a role in governing the outcome. In the course of the degenerative process, during which the segment undergoes various anatomic alterations, there are significant changes in both the motion characteristics of, and the load distribution across, the affected (and possibly also neighboring) segments. 2 The loading pattern and motion are to a certain extent interdependent, and alterations in either (or both) may contribute to the generation of pain. 3 The concept of spinal fusion originally arose from the notion that a degenerated motion segment is often “unstable” or shows “movement abnormalities,” and that accordingly, the elimination of motion in the affected segment would prevent it from undertaking the movements associated with the generation of pain. Recent thinking, however, suggests that the prevention of movement per se may not be the most important factor accounting for the success of fusion.