Spine Backpain

To examine the relationships between well-being and different levels of both low back pain intensity and disability in women living in the community.

METHODS:
A detailed, self-administered questionnaire was mailed to 542 community-dwelling women, aged 24-80 years. Participants provided demographic data and completed the Chronic Pain Grade Questionnaire and Psychological General Well-being Index (PGWB).

RESULTS:
A total of 506 participants (93.4%) returned completed questionnaires. Multivariate analysis revealed associations between lower total PGWB scores and both low (odds ratio (OR) -5.53; 95% confidence interval (CI) -9.01, -2.06) and high pain intensity (OR -8.36; 95% CI -13.8, -2.92) compared with no pain intensity, after adjusting for confounders.

Lower total scores on the PGWB were also associated with low (OR -4.72; 95% CI -9.04, -0.41) and high disability (OR -9.26; 95% CI -15.2, -3.30), compared with no disability. There were also statistically significant associations between lower scores on the PGWB subdomains and low and high pain intensities, and low and high disabilities.

CONCLUSIONS:
We found that it is not only women with high pain intensity and disability who experience reduced well-being, but also those with low levels of pain and disability. Longitudinal investigation is needed to investigate the predictive nature of both low and high levels of pain and disability in determining poor well-being in community-based women.



"Are low levels of low back pain intensity and disability associated with reduced well-being in community-based women?"
Climacteric. 2009 Jun; 12(3): 266-75Urquhart DM, Shortreed S, Davis SR, Cicuttini FM, Bell RJ

To evaluate the preliminary clinical outcomes of percutaneous endoscopic lumbar discectomy (PELD) for patient with discogenic chronic low back pain (CLBP) and failing to respond to conservative treatment.

METHODS:
From June 2007 to May 2008, 52 patients with CLBP and failing to respond to conservative treatment were treated, including 15 males and 37 females aged 29-46 years old (average 38.2 years old). Those patients were diagnosed with discogenic pain by low pressure discography. Duration of CLBP was 6-110 months with an average of 32.1 months.

MRI exam revealed 108 "black intervertebral discs" low in signal on T2 image, including 3 discs of L2,3, 17 of L3,4, 48 of L4,5 and 40 of L5-S1. Pressure-controlled discography showed positive response, fluoroscopy or intraoperative CT confirmed annulus fibrosus tears of posterior intervertebral disc in 79 discs. PELD was performed. Visual analogue scale (VAS) was evaluated before operation, 1 month after operation and at the final follow-up. The clinical outcome was determined by modified Macnab criteria at the final follow-up.

RESULTS:
The average operation time of each disc was 30.7 minutes (range 21-36 minutes), and the mean length of postoperative hospital stay was 3.7 days (range 2-5 days). No complications such as infection and the injury of blood vessels and nerves occurred. Transient paralysis of nerve occurred in 5 cases on operation day, and those symptoms were disappeared at the final follow-up visit without special treatment.

Fifty-two cases were followed up for 3-15 months (average 7.3 months). VAS score before operation, 1 month after operation and at the final follow-up was (7.34 +/- 1.52), (3.62 +/- 0.92) and (1.57 +/- 0.48) points, respectively, indicating there were significant differences compared with preoperative score (P < 0.01). According to the modified Macnab criteria, 11 cases were graded as excellent, 23 as good, 13 as fair, 5 as bad, and the excellent and good rate was 65.38%.

CONCLUSION:
Preliminary study suggests that PELD is safe and effective in treating patient with discogenic CLBP and failing to respond to conservative treatment.



"Percutaneous endoscopic lumbar discectomy for treatment of chronic discogenic low back pain"
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009 Apr; 23(4): 400-3Wang J, Zhou Y, Li C, Zhang Z, Zhang N

To investigate the causes and preventive methods of the bone cement leakage in percutaneous kyphoplasty (PKP) for osteoporotic vertebral body compression fracture (OVCF).

METHODS:
From April 2003 to November 2007, 116 patients with OVCF were treated with PKP, including 57 males and 59 females aged 65-92 years old (average 67.7 years old). All the patients suffered from trauma and the course of disease was 1-14 days (average 5.7 days).

There were 159 compressed and fractured vertebral bodies, including one vertebral body in 83 cases, two vertebral bodies in 24 cases, three vertebral bodies in 8 cases, and four vertebral bodies in 1 case.

The diagnosis of OVCF was confirmed by imaging examination before operation. All the patients had intact posterior vertebral walls, without symptoms of spinal and nerve root injury. During operation, 3.5-7.1 mL bone cement (average 4.8 mL) was injected into single vertebral body.

RESULTS:
The operation time was 30-90 minutes (average 48 minutes). Obvious pain relief was achieved in all the patients after operation. X-rays examination 2 days after operation revealed that the injured vertebral bodies were well replaced without further compression and deformation, and the bone cement was evenly distributed.

Fourteen vertebral bodies had bone cement leakage (4 of anterior leakage, 4 of lateral leakage, 3 of posterior leakage, 2 of intervertebral leakage, 1 of spinal canal leakage). The reason for the bone cement leakage included the individuality of patient, the standardization of manipulation and the time of injecting bone cement.

During the follow-up period of 12-30 months (average 24 months), all the patients got their normal life back, without pain, operation-induced spinal canal stenosis, obvious height loss of injured vertebral bodies and other complications.

CONCLUSION:
For OVCF, PKP is a mini-invasive, effective and safe procedure that provides pain relief and stabilization of spinal stability. The occurrence of bone cement leakages can be reduced by choosing the suitable case, improving the viscosity of bone cement, injecting the proper amount of bone cement and precise location during operation.


"Prevention and treatment of bone cement leakage in percutaneous kyphoplasty for osteoporotic vertebral body compression fracture"
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009 Apr; 23(4): 404-7Zhao L, Wang L, Wang G, Xu J, Zeng Y, Zheng S, Jiang C, Gui J

Ann Plast Surg. 2009 Sep 4; Mavili ME, Canter HI, Saglam-Aydinatay BAlthough the use of rigid fixation of bony segments in orthognathic surgery has become a standard of care, the question remains, 'With use of rigid fixation has stability of common orthognathic surgical procedures improved?' Because of the problems with various methods of osteosynthesis for the osteotomies commonly used in orthognathic surgery, we have developed our own way of semirigid fixation method to stabilize the osteotomized fragments for bone healing with enough flexibility to avoid the problems arising from absolute rigid fixation. The purpose of this article is to review the existing data to determine whether our method of semirigid fixation yields enough short-term and long-term stability after orthognathic surgery procedures.The study was designed as a retrospective trial. A total of 23 patients with double jaw surgery and 12 patients with mandibular set back surgery were reviewed. Preoperative lateral cephalometric radiographs obtained 1 month before the surgery, early postoperative cephalometric radiographs obtained after intermaxillary fixation was opened and late postoperative cephalometric radiographs were evaluated. Pog-McNamara vertical (mm) was used to measure the anteroposterior movement of mandible. Facial axis ( degrees ) was used to measure the vertical movement of the anterior part of the mandible. A-McNamara vertical (mm) was used to measure the anteroposterior movement of maxilla. Maxillary height ( degrees ) was used to measure rotational movement of the osteotomized maxillary segment in vertical dimension. The raw data obtained from cephalometric analysis were evaluated by using the computerized statistical program SPSS version 11.5 for Windows. The differences in linear and angular measurements between time intervals were tested for statistical significance, using repeated measures analysis of variance. A value of P < 0.05 was considered significant.None of the patients had infection at maxillary osteotomy side. Unilateral local infection at osteotomy side was seen in only one patient after double jaw surgery. Condylar malpositioning was not observed in any of the patients. Although postoperative maxillaomandibular fixation with elastics was applied routinely to all patients for 15 days, none of the patients had complaint related with temporomandibular joint discomfort, such as pain, restricted joint motion, etc. There is significant difference in anteroposterior movement of mandible in all time intervals. In terms of facial axis, the differences at T1 and T2 and at T2 and T3 are significant, while the difference at T1 and T3 is not significant. There is significant difference in anteroposterior movement of maxilla in all time intervals. In terms of maxillary height, the differences at T1 and T2 and at T2 and T3 are significant, while the difference at T1 and T3 is not significant.Method of semirigid fixation with 2 plates for maxillary fixation and 2 screws for mandibular fixation provide enough stability after LeFort I and bilateral sagittal split osteotomy procedures where mainly anteroposterior linear displacements were performed. There was no significant clinical short-term or long-term relapse. Stability in rotational movements needs to be further evaluated.

BMC Complement Altern Med. 2009 Sep 7; 9(1): 33Sundberg T, Petzold M, Wandell P, Ryden A, Falkenberg TABSTRACT: BACKGROUND: A model for integrative medicine (IM) adapted to Swedish primary care was previously developed. The aim of this study was to explore the feasibility of a pragmatic randomised clinical trial to investigate the effectiveness of the IM model versus conventional primary care in the management of patients with non-specific back/neck pain. Specific objectives included the exploration of recruitment and retention rates, patient and care characteristics, clinical differences and effect sizes between groups, selected outcome measures and power calculations to inform the basis of a full-scale trial. METHODS: Eighty patients with back/neck pain of at least two weeks duration were randomised to the two types of care. Outcome measures were standardised health related quality of life (the eight domains of SF-36) complemented by a set of exploratory "IM tailored" outcomes targeting self-rated disability, stress and well-being (0-10 scales); days in pain (0-14); and the use of analgesics and health care over the last two weeks (yes/no). Data on clinical management were derived from medical records. Outcome changes from baseline to follow-up after 16 weeks were used to explore the differences between the groups. RESULTS: Seventy-five percent (80/107) of screened patients in general practice were eligible and feasible to enrol into the trial. Eighty-two percent (36/44) of the integrative and 75% (27/36) of the conventional care group completed follow-up after 16 weeks. Most patients had back/neck pain of at least three months duration. Conventional care typically comprised advice and prescription of analgesics, occasionally complemented with sick leave or a written referral to physiotherapy. IM care generally integrated seven treatment sessions from two different types of complementary therapies with conventional care over ten weeks. The study was underpowered to detect any statistically significant differences between the groups. One SF-36 domain showed a clinically relevant difference between groups that was also supported by a small distribution based effect size, i.e. vitality (-7.3 points, Cohen's d -0.34) which was in favour of IM. There was a clinical trend between groups showing that IM contributed to less use of prescription and non-prescription analgesics (-11.7 and - 9.7 percent units respectively) compared to conventional care. Exploring clinically relevant differences and the SF-36 as the basis for a main outcome measure showed that the sample sizes needed per arm to adequately power a full-scale trial depended on the target domain, i.e. ranging from 60 (vitality) to 339 (role emotion). CONCLUSIONS: This pilot study investigated the implementation of IM in the primary care management of non-specific back and neck pain. Recruiting patients and implementing IM in routine clinical practice was feasible. The results warrant further exploration into different perspectives and relevant combinations of outcome measures including the use of health resources, drugs and cost-effectiveness to help understand the relevance of IM in primary care. Future research should prioritise larger scale studies considering variability, pain duration and small to moderate treatment effects. Trial registration: Clinical trials NCT00565942.

Spine (Phila Pa 1976). 2009 Sep 1; 34(19): E712-5Apostolopoulos V, David KM, Malcolm A, King ASTUDY DESIGN: Case Report. OBJECTIVE: To share our experience about the unique histological appearances of a calcified intradural, extramedullary lesion involving a nerve root. SUMMARY OF BACKGROUND DATA: A 53-year-old man presented with a long history of low back pain and a few months of occasional left groin pain with no neurological deficit. Imaging of the spine revealed a calcified intradural extramedullary lesion at L1, separate from vertebrae. Intraoperatively, the lesion was found to involve closely one of the roots and was heavily calcified but relatively easy to excise. The histology revealed calcifying fibroblastic proliferation associated with a nerve root. This is an unusual pathological entity, which appears distinct from the rare but occasionally reported reactive process known, as heterotopic bone formation in a nerve or "neuritis ossificans," and it is important to distinguish it from other calcified intradural neoplasms. METHODS: The histology of an excised calcified intradural extramedullary lesion was initially reviewed by our local neuropathologist. A second opinion was requested from Prof. Malcolm, who is a histopathologist and bone specialist. The unique histological features of the lesion were confirmed. The literature (no date limitations) was reviewed. RESULTS: A calcified intradural extramedullary lesion, closely related to nerve root was found to have unique histological features, not reported in the literature so far. CONCLUSION: The histological features of the calcified lesion that we report here have not been described before. It is highly likely they represent a reactive process. We think these features are useful to be added to the differential diagnosis of a calcified intradural extramedullary lesion involving a nerve root.

Spine (Phila Pa 1976). 2009 Sep 1; 34(19): 2060-5Ferguson SA, Marras WS, Burr DL, Woods S, Mendel E, Gupta PSTUDY DESIGN: Repeated measures study design. OBJECTIVE: Determine a meaningful change in low back functional impairment as measured with the lumbar motion monitor. SUMMARY OF BACKGROUND DATA: A quantitative functional performance probability (P(n)) measure has been developed and is scored from 0.00 to 1.00. Previous research has shown that a 0.5 cut-off provides excellent sensitivity and specificity for identifying impaired and healthy low back function. However, a meaningful change in the P(n) measure has not been defined. METHODS: The lumbar motion monitor was used to repeatedly measure P(n) in 3 groups of subjects including (1) asymptomatic, (2) recovering low back pain (LBP) and, (3) nonrecovering LBP. The asymptomatic group had 20 subjects. The recovering and nonrecovering LBP had 18 and 8 subjects, respectively. The asymptomatic group was tested 5 times at 1-week intervals. The 2 LBP groups were tested every 2 weeks for 3 months (6 evaluations). RESULTS: The P(n) in the asymptomatic group did not significantly change over the observed period. On the basis of the variability in the asymptomatic group it was hypothesized that a meaningful change in P(n) was 0.14. The defined meaningful change was evaluated in 2 patient with LBP populations. The P(n) in the recovered LBP group significantly improved during the 3 month observation period and there was a corresponding reduction of symptoms. In the recovering LBP group the within subject standard deviation was 0.14 and all patients had at least 1 visit to visit change greater than 0.14. Furthermore, 11 of the 18 recovering patients with LBP had a meaningful change between the first 2 visits. In contrast, none of the nonrecovering LBP group had a meaningful change between the first 2 visits. CONCLUSION: A meaningful change in P(n) was defined as 0.14.

Int J Nurs Stud. 2009 Sep 4; Chen YH, Lin LC, Watson RBACKGROUND: Several behaviourally observed tools have been developed to assess pain among cognitively impaired older people with communication difficulty. However, no adequate pain observation instrument is available for this group in Taiwan. OBJECTIVE: The study was undertaken to translate the French version of the Doloplus-2 scale into Chinese and to evaluate the psychometric properties and the clinical feasibility of the translated instrument. DESIGN: A prospective, descriptive design was used. SETTINGS: Five dementia special care units in the Northern Taiwan were used. PARTICIPANTS: Two hundred and forty-one residents with dementia and 14 registered nurses in charge of these residents were recruited. METHODS: The Doloplus-2 scale was translated into Chinese using the back-translation technique and pilot testing was performed to determine the comprehensibility and the initial psychometric characteristics. Internal consistency and inter-rater reliability were evaluated by Cronbach's alpha and intra-class correlation coefficient, respectively. Based on the known correlated validity model, the association between C-Doloplus-2 and empirically supported correlates of pain such as the past pain history, the presence of pain related condition, functional disability, agitation and depression were examined using Pearson's correlation coefficient for validating the construct validity. Furthermore, factor structure was investigated using Principal Components Analysis. RESULTS: The internal consistency was adequate for the total scale (alpha 0.74) and the subscales (alpha range 0.67-0.87). The intra-class correlation coefficient of the total scale was 0.81 and of the subscales ranged from 0.60 to 0.81. The association between pain latent variable and disability or depression was demonstrated, partially supporting the construct validity. Three factors were extracted to confirm the original three-dimensional structure perfectly, accounting 65% of the total variance. CONCLUSIONS: The psychometric qualities of Chinese Doloplus-2 were supported. Further research is needed to assess the clinical value of the translated scale performed in the institutions.

Spine (Phila Pa 1976). 2009 Sep 1; 34(19): 2008-13Murata Y, Kato Y, Miyamoto K, Takahashi KSTUDY DESIGN: Randomized control trial (RCT) for L2 spinal nerve infiltration (L2 block) in clinical cases. OBJECTIVES: To confirm or refute the effect of L2 block using RCT, and to study the pathway of low back pain (LBP) and radicular pain in clinical cases. SUMMARY OF BACKGROUND DATA: It has been reported in animal experiments that one of the main pathways of pain originating from the lumbar spine is the sympathetic trunk through the L2 spinal nerve rootvia sympathetic afferents. METHODS: To evaluate the effectiveness of L2 block, patients who had LBP and were treated with nonsteroidal anti-inflammatory drugs for at least 2 weeks were then randomized to the L2 block or control block groups. The intensities of LBP and radicular pain were measured using visual analog scale and face scale before and at 5 minutes and 7 days after the injection. These values were compared, and the effects of the injections on the pain pathway were studied. RESULTS: The average visual analog scale scores for LBP before and at 5 minutes and 7 days after the injection were 69, 14, and 44 mm in the L2 block group and 68, 62, and 59 mm in the control block group, respectively. After L2 block, 28 patients reported adequate therapeutic effect at 10 weeks, and the effect lasted for more than 24 weeks in 10 of these patients. After control block, 9 patients reported adequate therapeutic effect at 10 and 24 weeks. CONCLUSION: The LBP and radicular pain pathways were likely interrupted by L2 block. An L2 block is useful in reducing LBP due to the disorders of L2 spinal nerve-innervated structures, such as the disc, facet joint, and sacroiliac joint. However, the therapeutic value of an L2 block may be occasionally insufficient to alleviate pain completely because of the short duration of its' effect.

Spine (Phila Pa 1976). 2009 Sep 1; 34(19): 2090-5Monticone M, Baiardi P, Ferrari S, Foti C, Mugnai R, Pillastrini P, Vanti C, Zanoli GSTUDY DESIGN: Evaluation of the psychometric properties of a translated, culturally adapted questionnaire. OBJECTIVE: Translating, culturally adapting, and validating the Italian version of the Oswestry Disability Index (ODI-I), allowing its use in Italian-speaking patients with low back pain inside and outside Italy. SUMMARY OF BACKGROUND DATA: Growing attention is devoted to standardized outcome measures to improve interventions for low back pain. A translated form of the ODI in patients with low back pain has never been validated within the Italian population. METHODS: The ODI-I questionnaire was developed involving forward-backward translation, final review by an expert committee and test of the prefinal version to establish as better as possible proper correspondence with the original English latest version (2.1a). Psychometric testing included factor analysis, reliability by internal consistency (Cronbach alpha) and test-retest repeatability (Intraclass Coefficient Correlation), concurrent validity by comparing the ODI-I to Visual Analogue Scale, (Pearson correlation), and construct validity by comparing the ODI-I to Roland Morris Disability Questionnaire, RMDQ, and to Short Form Health Survey, Short Form Health Survey-36 (Pearson correlation). RESULTS: The authors required a 3-month period before achieving a shared version of the ODI-I. The questionnaire was administered to 126 subjects, showing satisfying acceptability. Factor analysis demonstrated a 1-factor structure (45% of explained variance). The questionnaire showed high internal consistency (alpha = 0.855) and good test-retest reliability (ICC = 0.961). Concurrent validity was confirmed by a high correlation with Visual Analogue Scale (r = 0.73, P < 0.001), Construct validity revealed high correlations with RMDQ (r = 0.819, P < 0.001), and with Short Form Health Survey-36 domains, highly significant with the exception of Mental Health (r = -0.139, P = 0.126). CONCLUSION: The ODI outcome measure was successfully translated into Italian, showing good factorial structure and psychometric properties, replicating the results of existing language versions of the questionnaire. Its use is recommended in research practice.

Spine (Phila Pa 1976). 2009 Sep 1; 34(19): 2085-9Carreon LY, Glassman SD, McDonough CM, Rampersaud R, Berven S, Shainline MSTUDY DESIGN: Cross-sectional cohort. OBJECTIVE: The purpose of this study is to provide a model to allow estimation of utility from the Short Form (SF)-6D using data from the Oswestry Disability Index (ODI), Back Pain Numeric Rating Scale (BPNRS), and the Leg Pain Numeric Rating Scale (LPNRS). SUMMARY OF BACKGROUND DATA: Cost-utility analysis provides important information about the relative value of interventions and requires a measure of utility not often available from clinical trial data. The ODI and numeric rating scales for back (BPNRS) and leg pain (LPNRS), are widely used disease-specific measures for health-related quality of life in patients with lumbar degenerative disorders. The purpose of this study is to provide a model to allow estimation of utility from the SF-6D using data from the ODI, BPNRS, and the LPNRS. METHODS: SF-36, ODI, BPNRS, and LPNRS were prospectively collected before surgery, at 12 and 24 months after surgery in 2640 patients undergoing lumbar fusion for degenerative disorders. Spearman correlation coefficients for paired observations from multiple time points between ODI, BPNRS, and LPNRS, and SF-6D utility scores were determined. Regression modeling was done to compute the SF-6D score from the ODI, BPNRS, and LPNRS. Using a separate, independent dataset of 2174 patients in which actual SF-6D and ODI scores were available, the SF-6D was estimated for each subject and compared to their actual SF-6D. RESULTS: In the development sample, the mean age was 52.5 +/- 15 years and 34% were male. In the validation sample, the mean age was 52.9 +/- 14.2 years and 44% were male. Correlations between the SF-6D and the ODI, BPNRS, and LPNRS were statistically significant (P < 0.0001) with correlation coefficients of 0.82, 0.78, and 0.72, respectively. The regression equation using ODI, BPNRS,and LPNRS to predict SF-6D had an R of 0.69 and a root mean square error of 0.076. The model using ODI alone had an R of 0.67 and a root mean square error of 0.078. The correlation coefficient between the observed and estimated SF-6D score was 0.80. In the validation analysis, there was no statistically significant difference (P = 0.11) between actual mean SF-6D (0.55 +/- 0.12) and the estimated mean SF-6D score (0.55 +/- 0.10) using the ODI regression model. CONCLUSION: This regression-based algorithm may be used to predict SF-6D scores in studies of lumbar degenerative disease that have collected ODI but not utility scores.

An Pediatr (Barc). 2009 Aug 31; Tapia Moreno R, Espinosa Fernández MG, Martínez León MI, González Gómez JM, Moreno Pascual PINTRODUCTION: Spondylodiscitis is an uncommon disease in children. It is often misdiagnosed or the diagnosis is made late in the course of illness. OBJECTIVES: To review the clinical, analytical and radiological characteristics of children with spondylodiscitis in the Materno-Infantil Hospital of Malaga. PATIENTS AND METHODS: Retrospective cohort study on children diagnosed with spondylodiscitis, during a period of 11 years. RESULTS: Eighteen patients were included in the study. Spondylodiscitis was more frequent in patients younger than 3 years old and older than 12 years old. The average time of delay in diagnosis was 26.9 days. In 8 cases the diagnosis was missed initially. Three clinical patterns appeared: in children under 3 years of age, refusing to walk and sit (100%) and irritability (42%); between 3 and 12 years of age, limb (100%) and abdominal pain (100%); in adolescents, back pain (75%). Fever was present in 38% of the cases, and low-grade fever in 8 (44%). A total of 50% of the patients had a moderate leucocytosis, and a slight increase in ESR; the most frequent location was L3-L4. X-ray diagnosis was pathological in 88% of the cases. The initial MRI diagnosed 100% of the cases. In addition, nerve roots damage (5 cases), inflammatory masses/paravertebral abscesses (5), epidural abscess (1) and psoas abscesses (2) were detected. A total of 94% of the children received antibiotics and 100% of the children underwent immobilization. All patients recovered early after the beginning of treatment, with the exception of those affected by psoas abscesses. The radiological follow-up was done in 17 patients (12 by MRI). After a mean of 14 months (rank 1-48), persistent diminution of disc space was seen in 100% of the children, and improvement of soft-tissue inflammation. Clinically (follow-up only in 11 patients) all patients regained normal mobility and only 27% had moderate pain. CONCLUSION: Spondylodiscitis, whose delay in the diagnosis is frequent, is a serious illness. Complications include abscesses and nerve root damage. MRI is the study of choice to determine the extension to neighbouring tissues.

J Orthop Trauma. 2009 Sep; 23(8): 588-94Stadhouder A, Buskens E, Vergroesen DA, Fidler MW, de Nies F, Oner FCOBJECTIVES: To evaluate and compare nonoperative treatment methods for traumatic thoracic and lumbar compression fractures and burst fractures. DESIGN: Prospective randomized controlled trial with long-term follow-up. SETTING: Two general hospitals in the Netherlands. PATIENTS/PARTICIPANTS: Patients with a traumatic thoracic or lumbar spine fracture, without neurologic damage, with less than 50% loss of height of the anterior column and less than 30% reduction of the spinal canal were included. INTERVENTION: Patients in the compression group were randomized to physical therapy and postural instructions, a brace for 6 weeks, or a Plaster of Paris cast for 6 or 12 weeks. Patients in the burst group received a brace or a Plaster of Paris cast, both for 12 weeks. MAIN OUTCOME MEASUREMENTS: Follow-up examinations included radiographs, Visual Analogue Scores for toleration of treatment and persistent pain, and an Oswestry Disability Index at long-term follow-up. RESULTS: There were 133 patients: 108 in the compression group and 25 in the burst group. For compression fractures, physical therapy and brace were considered the most tolerable. Brace therapy scored significantly better on the Visual Analogue Scores for residual pain and on the Oswestry Disability Index. None of the treatments had any significant effect on the residual deformity measurements. For burst fractures, no significant differences were found. CONCLUSIONS: Brace treatment with supplementary physical therapy is the treatment of choice for patients with compression fractures of the thoracic and lumbar spine. Furthermore, more than 20% of all patients had moderate or severe back pain at long-term follow-up.

Scand J Rheumatol. 2009 Aug 27; 1-7Hestbaek L, Rasmussen C, Leboeuf-Yde CObjectives: Financial compensation has been shown to be a negative prognostic factor for pain and disability in patients with neck or low back pain. It is unclear whether this association is causal and to what extent it hampers return to work. The objective of this study was to assess the direct influence of a financial compensation process on the ability to remain in regular employment in patients with suspected disc herniation. Methods: A prospective cohort study with a register-based follow-up at 1, 3, and 5 years after baseline was carried out at two multidisciplinary, non-surgical spine clinics in two public hospitals in Denmark. The study population comprised consecutive patients in regular employment with neck pain radiating to the arm or low back pain radiating to the leg. The exposure variable was any type of claim for financial compensation for the actual low back/leg or neck/arm pain. The outcome measure was receiving income compensation benefits. This information was obtained through national registers. Follow-up points were 1, 3, and 5 years after inclusion. Results: The study included 1243 low back pain patients and 202 neck pain patients. The odds ratio, adjusted for relevant confounders, of receiving income compensation benefits in case of baseline financial claim was approximately 2 for low back/leg pain patients and about 4 for neck/arm pain patients at 1, 3, and 5 years. Conclusions: In employed patients, a claim for financial compensation for low back or neck pain with radiating pain was found to be independently associated with receipt of income compensation benefits after 1, 3, and 5 years.

J Manipulative Physiol Ther. 2009 Jul-Aug; 32(6): 414-22Ndetan HT, Bae S, Evans MW, Rupert RL, Singh KPOBJECTIVE: The causes of death in the United States have moved from infectious to chronic diseases with modifiable behavioral risk factors. Simultaneously, there has been a paradigm shift in health care provisions with increased emphases on prevention and health promotion. Use of professional complementary and alternative medicine, such as chiropractic care, has increased. The purpose of this study was to characterize typical conditions, modifiable risk behaviors, and perceived changes in overall general health of patients seeing chiropractors as compared with general medical doctors in the United States. METHODS: Secondary analyses of the National Health Interview Survey 2005 adult sample (n = 31,248) were performed. Multiple logistic regression models were applied to assess associations of health conditions/risk behaviors of patients with the doctors (chiropractors vs medical doctors) they saw within the past 12 months. RESULTS: Respondents who saw/talked to chiropractors were 9.3%. Among these, 21.4% did not see a medical doctor. Comparing chiropractor-only with medical doctor-only patients, we found no significant difference in smoking/alcohol consumption status, but chiropractor-only patients were more likely to be physically active (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2-1.8) and less likely to be obese (OR, 0.7; 95% CI, 0.6-0.9). Respondents reporting acute neck (OR, 2.7; 95% CI, 2.2-3.2) and low back pain (OR, 2.4; 95% CI, 2.0-2.8) were more likely to have seen a chiropractor. CONCLUSIONS: Based on these analyses, Americans seem to be using chiropractic care for acute neck and low back pain more so than for other health conditions. However, there is no marked difference in their overall health promotion habits and changes in overall general health based on health care provider types.

Osteopath Med Prim Care. 2009 Aug 27; 3(1): 7Clark BC, Walkowski S, Conatser RR, Eland DC, Howell JNABSTRACT: BACKGROUND: Muscle functional magnetic resonance imaging (mfMRI) measures transverse relaxation time (T2), and allows for determination of the spatial pattern of muscle activation. The purposes of this pilot study were to examine whether MRI-derived T2 or side-to-side differences in T2 (asymmetries) differ in low back muscles between subjects with acute low back pain (LBP) compared to asymptomatic controls, and to determine if a single osteopathic manipulative treatment (OMT) session alters these T2 properties immediately and 48-hours after treatment. Methods: Subjects with non-specific acute LBP (mean score on 1-10 visual analog score=3.02+/-2.81) and asymptomatic controls (n=9/group) underwent an MRI, and subsequently the LBP subjects received OMT and then underwent another MRI. The LBP subjects reported back for an additional MRI 48-hours following their initial visit. T2 and T2 asymmetry were calculated from regions of interest for the psoas, quadratus lumborum (QL), multifidus, and iliocostalis lumborum/longissimus thoracis (IL/LT) muscles. Results: No differences were observed between the groups when T2 was averaged for the left and right side muscles. However, the QL displayed a significantly greater T2 asymmetry in LBP subjects when compared to controls (29.1+/-4.3 vs. 15.9+/-4.1%; p=0.05). The psoas muscle also displayed a relatively large, albeit non-significant, mean difference (22.7+/-6.9 vs. 9.5+/-2.8%; p=0.11). In the subjects with LBP, psoas T2 asymmetry was significantly reduced immediately following OMT (25.3+/-6.9 to 6.1+/-1.8%, p=0.05), and the change in LBP immediately following OMT was correlated with the change in psoas T2 asymmetry (r=0.75, p=0.02). Conclusion: Collectively, this pilot work demonstrates the feasibility of mfMRI for quantification and localization of muscle abnormalities in patients with acute low back pain. Additionally, this pilot work provides insight into the mechanistic actions of OMT during acute LBP, as it suggests that it may attenuate muscle activity asymmetries of some of the intrinsic low back muscles.

Am J Orthop. 2009 Jul; 38(7): E115-22Arnold PM, Robbins S, Paullus W, Faust S, Holt R, McGuire RThe clinical benefits and complications of posterior lumbar interbody fusion (PLIF) have been studied over the past 60 years. In recent years, spine surgeons have had the option of treating low back pain caused by degenerative disc disease using PLIF with machined allograft spacers and posterior pedicle fixation. The purpose of this clinical series was to assess the clinical benefits of using a machined PLIF allograft spacer and posterior pedicle fixation to treat degenerative disc disease, both in terms of fusion rates and patient outcomes, and to compare these results with those in previous studies using autograft and metal interbody fusion devices. Results were also compared with results from studies using transverse process fusion. This prospective, nonrandomized clinical series was conducted at 10 US medical centers. Eighty-nine (55 male, 34 female) patients underwent PLIF with a presized, machined allograft spacer and posterior pedicle fixation between January 2000 and April 2003. Their outcomes were compared with outcomes in previous series described in the literature. All patients had experienced at least 6 months of low back pain that had been unresponsive to nonsurgical treatment. Physical examinations were performed before surgery, after surgery, and at 4 follow-up visits (6 weeks, 6 months, 12 months, 24 months). At each interval, we obtained radiographs and patient outcome measures, including SF-36 Bodily Pain Score, visual analog scale pain rating, and Oswestry Disability Index. The primary outcome was fusion results at 12 and 24 months; the secondary outcomes were pain, disability, function/quality of life, and satisfaction. One-level PLIFs were performed in 65 patients, and 2-level PLIFs in 24 patients. Flexion-extension radiographs at 12 and 24 months revealed a 98% fusion rate. Of the 72 patients who reached the 12-month follow-up, 86% reported decreased pain and disability as measured with the Oswestry Disability Index. Decreased pain as measured with the SF-36 Bodily Pain Score was reported by 74% of patients who reached the 12-month follow-up. The graft-related complication rate among all patients who underwent PLIF was 1.61%. When performed with machined allograft spacers and posterior pedicle fixation, PLIF is a safe and effective surgical treatment for low back pain caused by degenerative disc disease. The patients in this clinical series had outcomes equal or superior to the outcomes in previous series.

J Thorac Imaging. 2009 Aug; 24(3): 212-5Oschatz E, Prosch H, Kohansal R, Valipour A, Mostbeck GPURPOSE: Chronic obstructive pulmonary disease (COPD) is a complex disease that is highly associated with osteoporosis, which tends to be underdiagnosed and therefore, undertreated. Our purpose was to examine the interobserver variability of the detection and grading of vertebral fractures on routine chest radiographs in patients presenting with severe COPD. MATERIALS AND METHODS: Routine lateral chest x-rays from 43 patients (male=25) suffering from severe COPD (Global Initiative on Obstructive Lung Diseases III/IV) were evaluated retrospectively by 2 board certified radiologists and 1 radiology resident for signs of osteoporosis and vertebral fractures by using a validated semiquantitative method according to H. Genant et al. No patient suffered from significant back pain or radicular symptoms. The presence or absence of signs of osteoporosis and/or vertebral fractures were analysed in the official radiologic report. RESULTS: The mean age of the population was 61 years, and the median body mass index was 23. All patients had a history of severe smoking (median 51 pack/y). Seventy-two chest radiographs, including follow-up examinations, were evaluated independently. Overall interobserver variability was moderate (kappa 0.42 to 0.50). However, regarding the detection of moderate and severe or severe fractures alone, interobserver variability was 0.76, respectively. Vertebral fractures were mentioned in only 4 of 72 (9%) official radiology reports. CONCLUSIONS: Osteoporotic vertebral fractures are frequently underdiagnosed in patients with COPD. There is an overall moderate interobserver variability for the detection and scoring of vertebral fractures even in a study setting, but variability regarding diagnosis of moderate and/or severe fractures is substantial.

J Chiropr Med. 2009 Sep; 8(3): 125-30Dunn AS, Baylis S, Ryan DOBJECTIVE: This case report describes the evaluation and conservative management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran within a Veterans Affairs Medical Center chiropractic clinic. CLINICAL FEATURES: The 43-year-old patient had a 20-year history of mechanical back pain secondary to an injury sustained during active military duty. He had intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. Radiographs of the lumbosacral region demonstrated a grade I spondylolisthesis of L3 in relation to L4 and a grade II spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects. There was marked narrowing of the L4-5 disk space with associated subchondral sclerosis. INTERVENTION AND OUTCOME: A course of conservative management consisting of 10 treatments including lumbar flexion/distraction and activity modification was provided over an 8-week period. Despite the long-standing nature of the complaint and underlying multiple-level lumbar spondylolysis with spondylolisthesis, there was a 25% reduction in low back pain severity on the numeric rating scale and a 22% reduction in perceived disability related to low back pain on the Revised Oswestry Disability Questionnaire. CONCLUSIONS: Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

Zhongguo Gu Shang. 2009 Jul; 22(7): 488-90Liu X, Bai RX, Li DD, Zhu B, Wu JOBJECTIVE: To review the clinical features of the thoracolumbar fracture with ankylosing spondylitis (AS) in order to avoid delayed or missed diagnosis. METHODS: Five patients of thoracolumbar fracture with AS treated from April 2005 to June 2007 in our department were studied retrospectively, male 4 cases, female 1 case, the age from 26- to 72-years-old with an average of 44.8 years. Analysis including: case history, number of the ankylosed vertebras, characteristic of fracture, active state rheumatism. RESULTS: The patients had the history of AS for average 22.6 years. The mean number of the ankylosed vertebras was 18.2. Of the 5 cases, 1 case encountered traffic accident, 1case was sprained, and 3 cases without trauma were diagnosed as stress fracture. Two cases were trans-vertebra fracture: the fracture line was through T6, T7, or L1 vertebral body respectively; 3 cases were through the disc space: 2 cases were through L1,2 disc space, 1 case was through L2,3. No compression fracture and neurological injury were found. The acute inflammatory index such as ESR and CRP in 4 cases didn't correlate with the degree of pain. The non-steroidal anti-inflammatory drugs (NSAIDs) hadn't significant effectiveness in relieving pain. The patients were diagnosed as 'relapse' of AS in other hospital, and had been misdiagnosed for average 1.51 months. CONCLUSION: 1) the fracture is prevalent at the middle or late period of AS when extensive ankylosis has been existed at the thoracolumbar region; 2) the fracture is common at the lower thoracal spine and the upper lumbar spine, and the majority is the stress fracture; 3) the fracture line may be through the vertebral body, but more often through the disc space; 4) it is like an exacerbation of AS and therefore to be missed diagnosis; 5) when the back pain exacerbated suddenly in the middle or late period of AS, the degree of pain not correlating with acute inflammatory index, and the NSAIDs ineffective, the thoracolumbar fracture should be considered.

Eur Spine J. 2009 Aug 22; Karppinen J, Solovieva S, Luoma K, Raininko R, Leino-Arjas P, Riihimäki HAccording to recent systematic reviews, Modic changes are associated with low-back pain. However, their pathophysiology remains largely unknown. A previous study of Northern Finnish males implicated that IL1A and MMP3 polymorphisms play a role in type II Modic changes. The purpose of the current study was to examine the association of IL1 cluster polymorphisms with Modic changes amongst middle-aged men in Southern Finland. The final study sample consisted of 108 men from three different occupations, who underwent magnetic resonance imaging (MRI) with a 0.1 T-scanner. Six single nucleotide polymorphisms (SNP) in the IL1 gene cluster (IL1A c.1-889C>T; IL1B c.3954C>T; IL1RN c.1812G>A; IL1RN c.1887G>C; IL1RN c.11100T>C; IL1RN c.1506G>A) were genotyped with the SNP-TRAP method or by allele-specific primer extension on modified microarray. In all, 45 subjects had Modic changes at one or more disc levels. The presence of the minor allele of IL1A (c.1-889C>T) was associated with these changes (any Modic change p = 0.031, type II changes p = 0.036). The carriers of the T-allele had a 2.5-fold risk of Modic change and the association was independent of the other IL1 gene cluster loci studied. In addition, a minor haplotype, with a frequency of 7.5% in the study population, including the minor alleles of IL1A c.1-889C>T, IL1RN c.1812G>A, and IL1RN c.1506G>A, was significantly associated with Modic changes. This observation is in accordance with the previous finding from a different geographical area, and thus confirms the importance of the IL1A gene in the pathophysiology of Modic changes.

Spine (Phila Pa 1976). 2009 Aug 21; Williams K, Abildso C, Steinberg L, Doyle E, Epstein B, Smith D, Hobbs G, Gross R, Kelley G, Cooper LSTUDY DESIGN.: The effectiveness and efficacy of Iyengar yoga for chronic low back pain (CLBP) were assessed with intention-to-treat and per-protocol analysis. Ninety subjects were randomized to a yoga (n = 43) or control group (n = 47) receiving standard medical care. Participants were followed 6 months after completion of the intervention. OBJECTIVE.: This study aimed to evaluate Iyengar yoga therapy on chronic low back pain. Yoga subjects were hypothesized to report greater reductions in functional disability, pain intensity, depression, and pain medication usage than controls. SUMMARY OF BACKGROUND DATA.: CLBP is a musculoskeletal disorder with public health and economic impact. Pilot studies of yoga and back pain have reported significant changes in clinically important outcomes. METHODS.: Subjects were recruited through self-referral and health professional referrals according to explicit inclusion/exclusion criteria. Yoga subjects participated in 24 weeks of biweekly yoga classes designed for CLBP. Outcomes were assessed at 12 (midway), 24 (immediately after), and 48 weeks (6-month follow-up) after the start of the intervention using the Oswestry Disability Questionnaire, a Visual Analog Scale, the Beck Depression Inventory, and a pain medication-usage questionnaire. RESULTS.: Using intention-to-treat analysis with repeated measures ANOVA (group x time), significantly greater reductions in functional disability and pain intensity were observed in the yoga group when compared to the control group at 24 weeks. A significantly greater proportion of yoga subjects also reported clinical improvements at both 12 and 24 weeks. In addition, depression was significantly lower in yoga subjects. Furthermore, while a reduction in pain medication occurred, this was comparable in both groups. When results were analyzed using per-protocol analysis, improvements were observed for all outcomes in the yoga group, including a greater trend for reduced pain medication usage. Although slightly less than at 24 weeks, the yoga group had statistically significant reductions in functional disability, pain intensity, and depression compared to standard medical care 6-months postintervention. CONCLUSION.: Yoga improves functional disability, pain intensity, and depression in adults with CLBP. There was also a clinically important trend for the yoga group to reduce their pain medication usage compared to the control group.

J Neurosci Nurs. 2009 Aug; 41(4): 217-24Crossley L, Mueller L, Horstman PBack disorders encompass a spectrum of conditions, from those of acute onset and short duration to lifelong disorders. The use of a traditional spine center model of patient flow, in which the patient is scheduled the first available appointment without an initial assessment of spine-related symptoms at West Virginia University Spine Center, Morgantown, West Virginia, resulted in frustration and delays for the spine patient and referring physician dissatisfaction. Today, the use of a software-assisted spine patient triage and registered nurse care coordinator patient navigation system in this multidiscipline, multimodality comprehensive spine program provides quick and efficient patient triage to the appropriate level of spine care (surgeon vs. nonsurgeon). The model consists of five major steps, which are explored in this article: medical history intake; films or studies retrieval; rapid review of the patient's medical condition and diagnostics by a spine specialist preappointment and subsequent triage to the appropriate level of spine care; registered nurse care coordinator patient education and guided navigation through the patient's preferred treatment plan; and last, diagnostic study, pain injection, and provider scheduling. Patient satisfaction scores, referring physician satisfaction scores, and resultant impact on referral volumes, ancillary utilization, workload productivity, and surgical yield demonstrate that this new approach to patient triage has made significant improvements in efficiency, productivity, and service.

J Chiropr Med. 2009 Mar; 8(1): 1-8Jacobson BH, Boolani A, Smith DBOBJECTIVE: This study compared sleep quality and stress-related symptoms between older beds (>/=5 years) and new bedding systems. METHODS: A convenience sample of healthy subjects (women = 30; men = 29) with minor musculoskeletal sleep-related pain and compromised sleep, but with no clinical history of disturbed sleep, participated in the study. Subjects recorded back discomfort and sleep quality upon waking for 28 consecutive days in their own beds (baseline) and for 28 consecutive days (post) on a new bedding system using visual analog scales. Following baseline measures, participant's beds were replaced by new, medium-firm beds, and they again rated their sleep quality and back discomfort. Stress was assessed by a modified stress questionnaire. RESULTS: Repeated-measures analysis of variance was used to treat sleep quality and efficiency and factored responses of the stress items. Results indicated that the subjects' personal bedding systems average 9.5 years old and were moderately priced. Significant (P < .01) improvements were found between pre- and posttest mean values in sleep quality and efficiency. Continued improvement was noted for each of the 4-week data gathering period. Stress measures yielded similar positive changes between pre- and posttest mean values. CONCLUSION: Based on these data, it was concluded that, in this population, new bedding systems increased sleep quality and reduced back discomfort, factors that may be related to abatement of stress-related symptoms.

J Orthop Sports Phys Ther. 2009 Aug; 39(8): 604-611Koppenhaver SL, Parent EC, Teyhen DS, Hebert JJ, Fritz JMSTUDY DESIGN: Clinical measurement, reliability study. OBJECTIVES: To investigate the improvements in precision when averaging multiple measurements of percent change in muscle thickness of the transversus abdominis (TrA) and lumbar multifidus (LM) muscles. BACKGROUND: Although the reliability of TrA and LM muscle thickness measurements using rehabilitative ultrasound imaging (RUSI) is good, measurement error is often large relative to mean muscle thickness. Additionally, percent thickness change measures incorporate measurement error from both resting and contracted conditions. METHODS: Thirty volunteers with nonspecific low back pain participated. Thickness measurements of the TrA and LM muscles were obtained using RUSI at rest and during standardized tasks. Percent thickness change was calculated with the formula (thicknesscontracted - thicknessrest/thicknessrest). Standard error of measurement (SEM) quantified precision when using 1 or a mean of 2 to 6 consecutive measurements. RESULTS: Compared to when using a singlemeasurement, SEM of both the TrA and LM decreased by nearly 25% when using a mean of 2 measures, and by 50% when using the mean of 3 measures. Little precision was gained by averaging more than 3 measurements. CONCLUSION: When using RUSI to determine percent change in TrA and LM muscle thickness, intraexaminer measurement precision appears to be optimized by using an average of 3 consecutive measurements. J Orthop Sport Phys Ther 2009;39(8):604-611 Epub 24 June 2009. doi:10.2519/jospt.2009.3088.

Our aim was to histologically evaluate the thermal changes in bovine intervertebral discs caused by 980-nm diode and 1064-nm Nd:YAG lasers. Further aims were to standardize the technique for in vivo animal research and to study its efficacy for clinical practice.

BACKGROUND:
When conservative methods fail, surgery has so far been the only measure for severe back pain due to disc prolapse and herniation. Recently, the minimally invasive technique of laser disc decompression has become more popular because it has advantages over open surgery in properly selected cases.

METHODS:
In vitro studies were done with Nd:YAG and diode lasers (1064 and 980 nm, respectively) on bovine intervertebral discs using a bare fiber tip or a focusing lens attached to a fiber tip. These studies were followed by in vivo studies in a canine model using a Nd:YAG laser with a bare fiber tip. Autopsies were done immediately and at 3, 6, 9, and 12 mo after ablation and the histopathology of excised discs was evaluated.

RESULTS:
Depending upon the depth of ablation and the intensity of charring and carbonization, a standardized energy density and pulse duration were identified.

CONCLUSION:
Nd:YAG laser with initial delivery of 40-W laser power and a reduced power of 10-15 W thereafter, delivering a total energy density of 1500-2000 J/cm(2) using a bare fiber tip, is recommended for clinical applications.


Effect of 980-nm diode laser and 1064-nm Nd:YAG laser on the intervertebral disc--in vitro and in vivo studies.
Photomed Laser Surg. 2009 Aug; 27(4): 547-52Jayasree RS, Gupta AK, Bodhey NK, Mohanty M

To determine the presence of lumbar multifidus atrophy and pain after successful lumbar medial branch radiofrequency neurotomy for zygapophysial joint mediated pain.

DESIGN:
A prospective observational analysis of 5 patients who had undergone successful unilateral radiofrequency neurotomy (RFN) of the lumbar medial branch divisions of the lumbar dorsal rami. At 17 to 26 months after RFN, 3 blinded radiologists evaluated the relative composition and size of the multifidus muscle at different segmental levels on lumbar magnetic resonance imaging (MRI). They were asked to determine the lesioned levels by evidence of multifidus atrophy. The accuracy of predicting the correct side and level lesioned was evaluated.

SETTING:
Private spine practice in Tyler, Texas.

PATIENTS: Five patients who had unilateral lumbar medial branch RFN for proven lumbar zygapophysial joint-mediated pain were selected.

INTERVENTIONS:
MRI of the lumbar spine at a mean of 21 months (range, 17-26) after successful lumbar RFN. OUTCOME MEASURES: Multifidus atrophy on a lumbar MRI, pain assessment and use of cointerventions.

RESULTS: Diffuse lumbar multifidus atrophy was detectable with MRI. However, radiologists could not reliably predict the side and segments lesioned. Despite denervation of the multifidus, at 12 months after RFN all subjects had ongoing pain relief and did not require or request additional treatment.

CONCLUSIONS:
This preliminary study provides evidence that successful medial branch RFN for lumbar zygapophysial-mediated pain does cause initial denervation but no discernable segmental atrophy of the multifidus at long-term follow-up. Previous denervation and diffuse atrophy in these subjects was not associated with pain.


The significance of multifidus atrophy after successful radiofrequency neurotomy for low back pain.
PM R. 2009 Aug; 1(8): 719-22Dreyfuss P, Stout A, Aprill C, Pollei S, Johnson B, Bogduk N

The role of the patient as an active partner in health care, and not just a passive object of diagnostic testing and medical treatment, is widely accepted. Providing information to patients is considered a crucial issue and the central focus in patient educational activities.

It is necessary to educate patients on the nature of the outcomes and the benefits and risks of the procedures to involve them in the decision-making process and enable them to achieve fully informed consent.

Information materials must contain scientifically reliable information and be presented in a form that is acceptable and useful to patients. Given the mismatch between public beliefs and current evidence, strategies for changing the public perceptions are required. Traditional patient education programmes have to face the potential barriers of storage, access problems and the need to keep content materials up to date.

A computer-based resource provides many advantages, including "just-in-time" availability and a private learning environment. The use of the Internet for patient information needs will continue to expand as Internet access becomes readily available. However, the problem is no longer in finding information, but in assessing the credibility and validity of it.

Health Web sites should provide health information that is secure and trustworthy. The large majority of the Web sites providing information related to spinal disorders are of limited and poor quality. Patient Line (PL), a patient information section in the Web site of Eurospine, was born in 2005 to offer patients and the general population the accumulated expertise represented by the members of the society and provide up-to-date information related to spinal disorders.

In areas where evidence is scarce, Patient Line provides a real-time opinion of the EuroSpine membership. The published data reflect the pragmatic and the common sense range of treatments offered by the Eurospine membership. The first chapters have been dedicated to sciatica, scoliosis, cervical pain syndromes, low back pain and motion preservation surgery.

Since 2008, the information has been available in English, German, French and Spanish. The goal is for Patient Line to become THE European patient information Web site on spinal disorders, providing reliable and updated best practice and evidence-based information where the evidence exists.



Patient information and education with modern media: the Spine Society of Europe Patient Line.
Eur Spine J. 2009 Apr 19; Pellisé F, Sell P,

Pain Med. 2009 Aug 18; Bogduk N, Dreyfuss P, Govind JABSTRACT Background. Confusion persists concerning the nature and efficacy of procedures variously known as facet denervation, lumbar medial branch radiofrequency neurotomy, and radiofrequency neurotomy or denervation for the treatment of back pain. Systematic reviews have not recognized the importance of patient selection and correct surgical technique when appraising the literature. As a result, negative conclusions about procedures have been drawn because lack of efficacy of one procedure has been misattributed to other, cognate, but different procedures. Objectives. To demonstrate how the rationale and efficacy of lumbar medial branch neurotomy depends critically on correct selection of patients and use of surgically correct technique. Methods. A narrative review and description of the available evidence, drawn from the personal libraries of the authors and from the bibliographies of systematic reviews. Results. Three studies, commonly accepted as evidence of lack of effectiveness, were not valid tests of lumbar medial branch neurotomy because of errors in selection of patients or errors in surgical technique, or both. Two descriptive studies and three controlled studies that used valid or acceptable techniques consistently showed that lumbar medial branch neurotomy had positive effects on pain and disability. All valid, randomized controlled trials showed medial branch neurotomy to be more effective than sham treatment. Discussion. Negative results have been reported only in studies that selected inappropriate patients or used surgically inaccurate techniques. All valid studies showed positive outcomes that cannot be attributed to placebo. Inappropriate conclusions have been drawn by systematic reviews that misrepresent invalid studies as providing evidence against the efficacy of lumbar medial branch neurotomy.

Arthritis Res Ther. 2009 Aug 20; 11(4): R126Richardson SM, Doyle P, Minogue BM, Gnanalingham K, Hoyland JAABSTRACT: INTRODUCTION: Matrix metalloproteinases (MMPs) are known to be involved in the degradation of the nucleus pulposus (NP) during intervertebral disc (IVD) degeneration. This study investigated MMP-10 (stromelysin-2) expression in the NP during IVD degeneration and correlated its expression with proinflammatory cytokines and molecules involved in innervation and nociception during degeneration which results in low back pain (LBP). METHODS: Human NP tissue was obtained at post-mortem (PM) from patients without a history of back pain and graded as histologically normal or degenerate. Symptomatic degenerate NP samples were also obtained at surgery for LBP. Expression of MMP-10 mRNA and protein was analysed using real-time PCR and immunohistochemistry. Gene expression for proinflammatory cytokines IL-1 and TNF-alpha, nerve growth factor (NGF) and the pain-associated neuropeptide Substance P were also analysed. Correlations between MMP-10 and IL-1, TNF-alpha and NGF were assessed along with NGF with Substance P. RESULTS: MMP-10 mRNA was significantly increased in surgical degenerate NP when compared to PM normal and PM degenerate samples. MMP-10 protein was also significantly higher in degenerate surgical NP samples compared to PM normal. IL-1 and MMP-10 mRNA demonstrated a significant correlation in surgical degenerate samples, while TNF-alpha was not correlated with MMP-10 mRNA. NGF was significantly correlated with both MMP-10 and Substance P mRNA in surgical degenerate NP samples. CONCLUSIONS: MMP-10 expression is increased in the symptomatic degenerate IVD, where it may contribute to matrix degradation and initiation of nociception. Importantly, this study suggests differences in the pathways involved in matrix degradation between painful and pain-free IVD degeneration.

Value Health. 2009 Aug 20; Manca A, Eldabe S, Buchser E, Kumar K, Taylor RSABSTRACT Objectives: Patients with failed back surgery syndrome (FBSS) and chronic neuropathic pain experience levels of health-related quality of life (HRQoL) that are considerably lower than those reported in other areas of chronic pain. The aim of this article was to quantify the extent to which reductions in (leg and back) pain and disability over time translate into improvements in generic HRQoL as measured by the EuroQoL-5D and SF-36 instruments. Methods: Using data from the multinational Prospective, Randomized, Controlled, Multicenter Study of Patients with Failed Back Surgery Syndrome trial, we explore the relationship between generic HRQoL-assessed using two instruments often used in clinical trials (i.e., the SF-36 and EuroQol-5D)-and disease-specific outcome measures (i.e., Oswestry disability index [ODI], leg and back pain visual analog scale [VAS]) in neuropathic patients with FBSS. Results: In our sample of 100 FBSS patients, generic HRQoL was moderately associated with ODI (correlation coefficient: -0.462 to -0.638) and mildly associated with leg pain VAS (correlation coefficient: -0.165 to -0.436). The multilevel regression analysis results indicate that functional ability (as measured by the ODI) is significantly associated with HRQoL, regardless of the generic HRQoL instrument used. On the other hand, changes over time in leg pain were significantly associated with changes in the EuroQoL-5D and physical component summary scores, but not with the mental component summary score. Conclusions: Reduction in leg pain and functional disability is statistically significantly associated with improvements in generic HRQoL. This is the first study to investigate the longitudinal relationship between generic and disease-specific HRQoL of neuropathic pain patients with FBSS, using multinational data.

PM R. 2009 Aug; 1(8): 709-18Marshall PW, Mannion J, Murphy BAOBJECTIVE: To examine the relationship between hamstring extensibility by use of the instrumented straight leg raise; mechanical components of muscle contraction, including muscle recruitment, passive torque measures of tissue stiffness, and eccentric strength; and self-reported measures of pain and disability. DESIGN: Cross-sectional study. SETTING: University laboratory. PARTICIPANTS: Twenty-one individuals with chronic nonspecific axial lower back pain and 15 healthy control subjects. ASSESSMENT: Instrumented straight leg raise, concentric and eccentric hamstring strength, self-reported measures of pain, disability, fear avoidance, general health and well-being MAIN OUTCOME MEASUREMENTS: Objective measures included hamstring extensibility, hamstring muscle stiffness, absolute and relative concentric/eccentric strength, concentric/eccentric strength ratios. Self-reported measures included Oswestry disability index, visual analog pain scale, fear avoidance beliefs, and general health and well being. RESULTS: Patients with lower back pain had lower range of motion, greater changes in muscle stiffness, and impaired concentric-to-eccentric strength levels. Stepwise regression identified measures of stiffness as significantly predicting hamstring extensibility (adjusted r(2) = 0.58, F = 23.76, P < .001). Self-reported measures were not associated with extensibility. Gender differences were noted for passive stiffness and absolute strength. For women, later onset of the medial hamstrings also was associated with greater hamstring extensibility. CONCLUSIONS: Decreased extensibility of the hamstrings was associated with increased passive stiffness during the common range of motion (20 to 50 degrees ). Impaired stretch tolerance is associated with actual mechanical restriction, not behavioral measures indicating increased pain or fear-avoidant behavior. With no relationship to actual disability and contradictory findings in the literature for the relationship of the hamstrings to the mechanics of the low back, it is unclear whether decreased hamstring extensibility should be targeted in rehabilitation programs for axial lower back pain.

Can Urol Assoc J. 2009 Aug; 3(4): E31-E35Lefresne S, Fairchild A, Bistritz A, Venner P, Yee DWe report the case of a patient with metastatic hormone refractory prostate cancer in whom "indirect" cauda equina syndrome developed concurrent with multilevel spinal cord compression (SCC). Three months after his first positive bone scan, a 65-year-old otherwise healthy man presented with severe back pain, bilateral lower extremity paresthesias, leg weakness and urinary retention. Magnetic resonance imaging (MRI) showed a dural-based mass causing SCC at the T9, T10 and T11 vertebrae, with a normal cauda equina. He received corticosteroids and palliative external beam radiotherapy, resulting in good pain control and gradual improvement in his neurological symptoms. He did well for 8 months, at which time his residual bilateral leg weakness abruptly worsened and he experienced numbness, paresthesias, urinary incontinence and constipation. Repeat MRI showed progression of epidural metastatic disease compressing the spinal cord or thecal sac at 7 thoracic vertebral levels. The cauda equina was also distorted and flattened without evidence of direct solid tumour impingement. We hypothesized that the etiology was increased intrathecal pressure due to disrupted cerebrospinal fluid flow resulting from multiple levels of upstream thecal sac compression. It is essential to image the entire spinal cord and cauda equina when patients with metastatic bone disease present with neurological symptoms to institute correct treatment and preserve function and mobility.

Fundam Clin Pharmacol. 2009 Aug 12; Depont F, Hunsche E, Abouelfath A, Diatta T, Addra I, Grelaud A, Lagnaoui R, Molimard M, Moore NA retrospective, observational, cohort study in primary care. To determine the total direct medical and non-medical cost of chronic low back pain (LBP) in France and its associated factors. Chronic LBP affects 5-10% of the population its burden in France is unknown. Ninety-eight randomly selected general practitioners included 796 adult patients with chronic LBP between October 2001 and December 2002. Direct costs due to physician visits, investigations, medications, hospitalizations, and other medical and non-medical resource use were collected for the 6 months prior to study visit. Costs both reimbursed and not by the French health insurance system were considered. Quality of life (QoL) and disease severity were measured using Short Form (SF)-8 and Roland-Morris disability questionnaire (RMDQ), respectively. Costs were updated to represent 2007 prices. Men represented 50.6% of the 796 patients, mean age was 53 +/- 11.3 years, and the duration of LBP was more than 1 year in 80.9% of patients. The total mean cost per patient over six months was 715.6euro (95% CI: 644.2-797.8). Of these costs, 22.9% related to care provided by physiotherapists and allied specialists, 19.5% to medications, 17.4% to hospitalizations, 9.6% to investigations, and 12.5% to physician fees. In multivariate analysis, the factors associated with the cost of chronic LBP were disease severity (RMDQ score) and age of the patients. LBP is a disease that is both common and costly.

Zhen Ci Yan Jiu. 2009 Apr; 34(2): 93-6Fang JQ, Shao XM, Ma GZOBJECTIVE: To observe the effect of electroacupuncture (EA) of "Zusanli" (ST 36) and "Sanyinjiao" (SP 6) on collagen-induced arthritis (CIA) and its underlying mechanism in regulating the secretory function of knee-joint synovial cells in CIA rats. METHODS: Thirty-six Wistar rats were equally randomized into control, model and EA groups. CIA model (rheumatoid arthritis) was duplicated by intradermal injection of Bovine type II collagen into the back of the anesthetized rats. EA (2 Hz, 2 mA) was applied to "Zusanli" (ST 36) and "Sanyinjiao" (SP 6) for 30 min, once a day for 30 days. The paw volume was measured by using a Plethysmometer and hot water tail-flick tests (50 degrees C) were conducted for detecting the rats' pain threshold (PT) before and after the treatment. The contents of PGE2, IL-1beta and TNF-alpha in supernatant of the cultured joint synoviocytes were detected by enzyme linked immunosorbent assay (ELISA). RESULTS: In comparison with control group, the swelled paw volume, the declined PT, PGE2, TNF-alpha and IL-1beta contents in knee-joint synoviocyte supernatant were significantly higher in model group (P < 0.05). Compared with model group, PT increased obviously (P < 0.05); paw volume, supernatant PGE2, TNF-alpha and IL-1beta contents decreased obviously (P < 0.05) in EA group. CONCLUSION: EA of ST 36 and SP 6 has a pronounced therapeutic effect in relieving knee joint pain and inflammation in CIA rats, which may be related to its effect in regulating the secretory function of the knee-joint synoviocytes.

Eur J Pain. 2009 Aug 14; Bergström G, Bergström C, Hagberg J, Bodin L, Jensen IA valid method for classifying chronic pain patients into more homogenous groups could be useful for treatment planning, that is, which treatment is effective for which patient, and as a marker when evaluating treatment outcome. One instrument that has been used to derive subgroups of patients is the Multidimensional Pain Inventory (MPI). The primary aim of this study was to evaluate a classification method based on the Swedish version of the MPI, the MPI-S, to predict sick leave among chronic neck and back pain patients for a period of 7 years after vocational rehabilitation. As hypothesized, dysfunctional patients (DYS), according to the MPI-S, showed a higher amount of sickness absence and disability pension expressed in days than adaptive copers (AC) during the 7-years follow-up period, even when adjusting for sickness absence prior to rehabilitation (355.8days, 95% confidence interval, 71.7; 639.9). Forty percent of DYS patients and 26.7% of AC patients received disability pension during the follow-up period. However, this difference was not statistically significant. Further analyses showed that the difference between patient groups was most pronounced among patients with more than 60days of sickness absence prior to rehabilitation. Cost-effectiveness calculations indicated that the DYS patients showed an increase in production loss compared to AC patients. The present study yields support for the prognostic value of this subgroup classification method concerning long-term outcome on sick leave following this type of vocational rehabilitation.

Eur J Pain. 2009 Aug 13; Carleton RN, Abrams MP, Kachur SS, Asmundson GJHeterogeneity has been identified within chronic musculoskeletal pain (CMP) patient samples; however, investigations have typically focused on psychological constructs or coping (e.g., pain-related anxiety, catastrophizing) in this regard. Furthermore, studies to date have included either samples presenting with a specific anatomical site (e.g., only lower back pain) or a mix of anatomical sites (e.g., lower back, shoulder, or leg pain) as the primary pain complaint, without making comparisons based on the anatomical site of reported pain. For example, patients with chronic lower back pain (CLBP) may differ from those with chronic upper or lower extremity pain (ULEP) in presentation, recovery trajectory, and psychological variables. The current investigation explored whether systematic differences existed between patients participating in a multidisciplinary reconditioning third-party-payer program who have CLBP relative to patients with ULEP. Patients included those with CLBP (n=23; 35% women) or ULEP (e.g., arm, shoulder, leg, knee; n=28; 29% women). The ULEP group began and finished the program with more pain-related anxiety, more catastrophic thoughts, and more fearful cognitions than the CLBP group. There were no significant correlations between functional deficit and perceived levels of disability or associations between group and return to work status; however, there was an unexpected significant interaction between group and perceived disability. Specifically, CLBP patients reported increasing perceived disability despite improvements in functional deficit, whereas ULEP patients did not. These findings suggest a disconnect between perceived disability and function that may be specific to lower back pain. Implications and directions for future research are discussed.

Spine (Phila Pa 1976). 2009 Aug 15; 34(18): 1906-9Gubin AV, Ulrich EV, Taschilkin AI, Yalfimov ANSTUDY DESIGN: The results of MRI study of 10 children with acute stiff-neck who were treated in the Department of Spine Surgery in Saint-Petersburg State Pediatric Medical Academy. OBJECTIVES: To demonstrate the MRI findings in children with acute stiff neck and suggest other explanations to this findings. SUMMARY OF BACKGROUND DATA: The etiology of child's acute stiff-neck has been debated in the published data. Most authors supported the basic role of atlantoaxial fixation in this condition. But modern investigations using MRI and CT show another explanations. METHODS: A total of 10 patients aged 5 to 14 years with typical stiff neck with acute onset were studied by MRI in first 12 hours. RESULTS: In all 10 investigations typical changes that disappeared in a few days were found. There were triangle or oblong high intensity zone near the external edges of backbone discs C2-C3 or C3-C4. The zones were always on the side where the patients felt pain. CONCLUSION: In our opinion, the main reason of the child's acute stiff-neck is a rapid or gradual strangulation of the vascularized tissue in uncovertebral zones in C2-C3, C3-C4 caused by a head movement or a neck's prolonged incurvationed position during a profound sleep. It causes a "wedge" of hydropic tissues that irritate the back longitudinal ligaments. As the result, a head has antalgic position and, in the most severe cases, is blocked.

Spine J. 2009 Aug 5; Martha JF, Swaim B, Wang DA, Kim DH, Hill J, Bode R, Schwartz CEBACKGROUND CONTEXT: Lumbar facet joint synovial cysts are benign degenerative abnormalities of the lumbar spine. Previous reports have supported operative and nonoperative management. Facet joint steroid injection with cyst rupture is occasionally performed, but there has been no systematic evaluation of this treatment option. PURPOSE: To profile the role of facet joint steroid injections with cyst rupture in the treatment of lumbar facet joint synovial cysts. STUDY DESIGN/SETTING: Retrospective chart review and long-term follow-up of patients treated for lumbar facet joint synovial cysts. PATIENT SAMPLE: One hundred one patients treated for lumbar facet joint synovial cysts with fluoroscopically guided corticosteroid facet joint injection and attempted cyst rupture. OUTCOME MEASURES: Oswestry Disability Index and numeric rating scale score for back and leg pain. METHODS: A retrospective review and a subsequent interview were conducted to collect pretreatment and posttreatment pain and disability scores along with details of subsequent treatment interventions. Group differences in pain and disability scores were assessed using paired t test. Multiple clinical factors were analyzed in terms of risk for surgical intervention using logistic regression modeling and Cox proportional hazards modeling. RESULTS: Successful cyst rupture was confirmed fluoroscopically in 81% of cases. Fifty-five patients (54%) required subsequent surgery over a period averaging 8.4 months because of inadequate symptom relief. All patients reported significant improvement in back pain, leg pain, and disability at 3.2 years postinjection, regardless of their subsequent treatment course (p

Cancer. 2009 Aug 12; Schootman M, Aft R, Jeffe DBBACKGROUND:: The authors examined potential reasons (sociodemographics, psychologic distress, health behavior, chronic health conditions, access to medical care) for increased prevalence of lower-body functional limitations among long-term (>/=5 years) cancer survivors. METHODS:: The authors used National Health Interview Survey data from 2005 through 2007, and defined lower-body functional limitation as reporting difficulty/inability to perform at least 1 of 5 activities (walking approximately one-quarter of a mile; walking up and down 10 steps without rest; standing for 2 hours; stooping, crouching, or kneeling; and lifting 10 lbs). Increased prevalence of lower-body functional limitations was compared between long-term survivors of each of 11 cancer types reported by >/=50 respondents (n = 2143) and persons without cancer history (controls; n = 72,618). RESULTS:: Among cancer survivors, 57.0% had a lower-body functional limitation versus 26.6% of controls. The unadjusted prevalence of lower-body functional limitations varied by cancer type, ranging from 44.9% (lymphoma survivors) to 88.8% (lung cancer survivors). Long-term lung (odds ratio [OR], 7.91), uterine (OR, 2.41), thyroid (OR, 2.27), cervical (OR, 1.76), ovarian (OR, 1.75), and breast (OR, 1.35) cancer survivors had increased odds of reporting a lower-body functional limitation than controls after adjusting for sociodemographic factors (all P < .05). Differences in the prevalence of arthritis and lower-back pain and in access to medical care explained differences in lower-body functional limitation prevalence between controls and long-term breast, cervical, ovarian, and uterine cancer survivors. Long-term bladder, colorectal, lymphoma, melanoma, and prostate cancer survivors were equally likely to report a lower-body functional limitation as controls. CONCLUSIONS:: Treatment of arthritis and lower-back pain and increasing access to medical care might help reduce the risk of lower-body functional limitations and improve quality of life among specific long-term cancer survivors. Cancer 2009. (c) 2009 American Cancer Society.

Spine (Phila Pa 1976). 2009 Aug 15; 34(18): E635-9Kim HJ, Lee HM, Chun HJ, Kang KT, Kim HS, Park JO, Moon ES, Park KH, Moon SHSTUDY DESIGN: Prospective short-term longitudinal study. OBJECTIVE: To investigate changes in the bone turnover rate in patients with lumbar spinal stenosis (LSS) before and after decompression surgery. SUMMARY OF BACK GROUND DATA: Decompression surgery enables elderly patients with LSS to participate in daily activities and physical exercise by reducing or alleviating leg and back pain. However, there have been no studies to date regarding the effect of decompression surgery on bone metabolism in such patients. METHODS: Twenty-three patients with spinal stenosis who were scheduled to undergo decompression surgery were enrolled in our study. Ten patients were given oral bisphosphonates after the operation (B+ group), while the remaining 13 patients did not receive oral bisphosphonate (B- group). In both groups, walking distance without rest, the Oswestry Disability Index (ODI) scores, duration of symptoms, bone formation, and resorption markers, and bone mineral density were recorded before surgery. Three months after surgery, bone turnover markers, a single trial for walking distance without rest and ODI scores were measured for both groups. RESULTS: Three months after the operation, the bone resorption marker u-NTx was decreased significantly for both groups. Although there was a decrease in bALP, a bone formation maker, in both groups, the change in each group was not statistical significant. Distance in a single trial walk was increased and ODI scores were decreased significantly for both groups. CONCLUSION: This study suggests that decompression surgery has a beneficial effect on bone metabolism in patients with LSS who have walking intolerance and limited physical activity.

Spine (Phila Pa 1976). 2009 Aug 15; 34(18): E673-6Lee SHSTUDY DESIGN: A case report of a spinal subarachnoid hematoma (SSAH) associated with hyperextension fractures complicating diffuse idiopathic skeletal hyperostosis (DISH). OBJECTIVE: To report the first case of a SSAH complicating spinal fracture in DISH. SUMMARY OF BACKGROUND DATA: A SSAH is very rare condition. And there had been several reports on spinal fractures in DISH through fused spinal segments, but no report related with SSAH associated with spinal fracture in DISH patient. METHODS: A 78-year-old female patient was admitted for pain in the back and lower limbs and paraparesis after being fall on her back. On simple radiographs, DISH with anterior cortical bone deficit and increased height were presented at the level of L1. MR and Myelography computed tomography images revealed an extension type of fracture with an irregular shaped subarachnoid hematoma within the dura. Differential diagnosis from infection or tumorous condition was required. RESULTS: Durotomy and 1 to 2 laminectomy was performed to improve neurologic symptoms. The posterior yellow ligament was seen partially ossified and adhered to dura without dura tear. The hematoma was found adherent to the nerve roots of the cauda equina and pia mater. After posterior segmental screw instrumentation and fusion from T10 to L3, anterior interbody fusion was performed with extrapleural approach after dissected the 11th rib, using L1 corpectomy and titanium mesh cages. There was no evidence of infection or tumor. After surgery, motor and sensory function of the lower limbs improved remarkably with solid bony union. CONCLUSION: The first case of a SSAH complicating spinal fracture in DISH is presented. The patient was successfully treated with a staged operation including posterior decompression with fusion and anterior interbody fusion.

Spine (Phila Pa 1976). 2009 Aug 15; 34(18): 1929-41Furlan AD, Pennick V, Bombardier C, van Tulder M, STUDY DESIGN: Method guidelines for systematic reviews of trials of treatments for neck and back pain. OBJECTIVE: To help review authors design, conduct and report systematic reviews of trials in this field. SUMMARY OF BACKGROUND DATA: In 1997, the Cochrane Back Review Group published Method Guidelines for Systematic Reviews, which was updated in 2003. Since then, new methodologic evidence has emerged and standards have changed. Coupled with the upcoming revisions to the software and methods required by The Cochrane Collaboration, it was clear that revisions were needed to the existing guidelines. METHODS: The Cochrane Back Review Group editorial and advisory boards met in June 2006 to review the relevant new methodologic evidence and determine how it should be incorporated. Based on the discussion, the guidelines were revised and circulated for comment. As sections of the new Cochrane Handbook for Systematic Reviews of Interventions were made available, the guidelines were checked for consistency. A working draft was made available to review authors in The Cochrane Library 2008, issue 3. RESULTS: The final recommendations are divided into 7 categories: objectives, literature search, inclusion criteria, risk of bias assessment, data extraction, data analysis, and updating your review. Each recommendation is classified into minimum criteria (mandatory) and further guidance (optional). Instead of recommending Levels of Evidence, this update adopts the GRADE approach to determine the overall quality of the evidence for important patient-centered outcomes across studies and includes a new section on updating reviews. CONCLUSION: Citations of previous versions of the method guidelines in published scientific articles (1997: 254 citations; 2003: 209 citations, searched February 10, 2009) suggest that others may find these guidelines useful to plan, conduct, or evaluate systematic reviews in the field of spinal disorders.

Rev Bras Anestesiol. 2009 Jul-Aug; 59(4): 481-6Pitombo PF, Moura R, Miranda RBACKGROUND AND OBJECTIVES: Due to the high incidence of technical and neurological complications, continuous spinal blocks were not performed for several years. With the advent of intermediate catheters the technique has been used more often and gaining acceptance among anesthesiologists. The objective of this report was to demonstrate the usefulness of the technique as a viable alternative for medium and major size surgeries. CASE REPORT: This is a 58 years old female patient, weighing 62 kg, physical status ASA I, with a history of migraines, low back pain, and prior surgeries under spinal block without intercurrence. The patient was scheduled for exploratory laparotomy for a probable pelvic tumor. After venoclysis with an 18G catheter, monitoring with cardioscope, non-invasive blood pressure and pulse oximetry was instituted; she was sedated with 2 mg of midazolam and 100 (1/4)g of fentanyl, and placed in left lateral decubitus. The patient underwent continuous spinal block through the median approach in L3-L4; 9 mg of 0.5% hyperbaric bupivacaine and 120 (1/4)g of morphine sulfate were administered. Inspection of the abdominal cavity revealed a gastric stromal tumor that required an increase in the incision for a partial gastrectomy. A small dose of hyperbaric solution was required for the entire procedure, which was associated with complete hemodynamic stability. Postoperative admission to the ICU was not necessary; the patient presented a good evolution without complaints and with a high degree of satisfaction. She was discharged from the hospital after 72 hours without intercurrence. CONCLUSIONS: Intermediate catheters used in continuous spinal blocks have shown the potential to turn it an attractive and useful technique in medium and large size surgeries and it can even be an effective alternative in the management of critical patients to whom hemodynamic repercussions can be harmful.

Spine (Phila Pa 1976). 2009 Aug 15; 34(18): 1976-83Svensson E, Schillberg B, Kling AM, Nyström BSTUDY DESIGN: A prospective validation study. OBJECTIVE: To validate the Balanced Inventory for Spinal Disorders (BIS), a questionnaire concerning the extent to which pain affects perceived physical health, social life, mental health, and quality of life. The operational definitions of the items and the verbal descriptive scales were compared with corresponding items in the Short-Form 36 (SF-36), European Quality of Life Scale (EQ), and Oswestry Disability Index (ODI). SUMMARY OF BACKGROUND DATA: In validation studies, scales that intend to measure the same variable are compared. METHODS: The SF-36, EQ, ODI, and the BIS were filled in by 101 patients before surgical treatment. The comparisons were analyzed by statistical methods that take account of the nonmetric properties of ordered categorical data to obtain reliable results. The level of order-consistency between BIS and comparing items, when present, was calculated. The Spearman rank-order correlation coefficient was also calculated. RESULTS: In the paired comparisons between the BIS pain scales and the other pain scales about 80% units more pairs were ordered than disordered, and the disorder was explained by the discriminating ability of the BIS back and leg pain items. The BIS and ODI items of limitation in walking were comparable, and the assessments of social limitations on the questionnaires were consistent; the disordered pairs being explained by different coverage of activities in the items. The assessments of physical and mental health on BIS were disordered, with the responses in SF-36 in favor of the BIS type of scale categories. The few items and response categories in the EQ did not discriminate the assessments. CONCLUSION: The BIS assessments can be regarded as being a valid disease-specific questionnaire that provides interpretable information regarding the impact of back end leg pain on well-defined physical, social and mental aspects, and on the quality of life.

Spine (Phila Pa 1976). 2009 Aug 15; 34(18): 1970-5Wand BM, McAuley JH, Marston L, De Souza LHSTUDY DESIGN: Prospective observational study of prognostic indicators, using data from a randomized, controlled trial of physiotherapy care of acute low back pain (ALBP) with follow-up at 6 weeks, 3 months, and 6 months. OBJECTIVE: To evaluate which patient profile offers the most useful guide to long-term outcome in ALBP. SUMMARY OF BACKGROUND DATA: The evidence used to inform prognostic decision-making is derived largely from studies where baseline data are used to predict future status. Clinicians often see patients on multiple occasions so may profile patients in a variety of ways. It is worth considering if better prognostic decisions can be made from alternative profiles. METHODS: Clinical, psychological, and demographic data were collected from a sample of 54 ALBP patients. Three clinical profiles were developed from information collected at baseline, information collected at 6 weeks, and the change in status between these 2 time points. A series of regression models were used to determine the independent and relative contributions of these profiles to the prediction of chronic pain and disability. RESULTS: The baseline profile predicted long-term pain only. The 6-week profile predicted both long-term pain and disability. The change profile only predicted long-term disability (P < 0.01). When predicting long-term pain, after the baseline profile had been added to the model, the 6-week profile did not add significantly when forced in at the second step (P > 0.05). A similar result was obtained when the order of entry was reversed. When predicting long-term disability, after the 6-week profile was entered at the first step, the change profile was not significant when forced in at the second step. However, when the change profile was entered at the first step and the 6-week clinical profile was forced in at the second step, a significant contribution of the 6-week profile was found. CONCLUSION: The profile derived from information collected at 6 weeks provided the best guide to long-term pain and disability. The baseline profile and change in status offered less predictive value.

Rev Bras Anestesiol. 2009 Aug; 59(4): 481-486Pitombo PF, Moura R, Miranda RBACKGROUND AND OBJECTIVES: Due to the high incidence of technical and neurological complications, continuous spinal blocks were not performed for several years. With the advent of intermediate catheters the technique has been used more often and gaining acceptance among anesthesiologists. The objective of this report was to demonstrate the usefulness of the technique as a viable alternative for medium and major size surgeries. CASE REPORT: This is a 58 years old female patient, weighing 62 kg, physical status ASA I, with a history of migraines, low back pain, and prior surgeries under spinal block without intercurrence. The patient was scheduled for exploratory laparotomy for a probable pelvic tumor. After venoclysis with an 18G catheter, monitoring with cardioscope, non-invasive blood pressure and pulse oximetry was instituted; she was sedated with 2 mg of midazolam and 100 (1/4)g of fentanyl, and placed in left lateral decubitus. The patient underwent continuous spinal block through the median approach in L3-L4; 9 mg of 0.5% hyperbaric bupivacaine and 120 (1/4)g of morphine sulfate were administered. Inspection of the abdominal cavity revealed a gastric stromal tumor that required an increase in the incision for a partial gastrectomy. A small dose of hyperbaric solution was required for the entire procedure, which was associated with complete hemodynamic stability. Postoperative admission to the ICU was not necessary; the patient presented a good evolution without complaints and with a high degree of satisfaction. She was discharged from the hospital after 72 hours without intercurrence. CONCLUSIONS: Intermediate catheters used in continuous spinal blocks have shown the potential to turn it an attractive and useful technique in medium and large size surgeries and it can even be an effective alternative in the management of critical patients to whom hemodynamic repercussions can be harmful.

Pain Physician. 2009 July/August; 12(4): E35-E70Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JAPersistent pain interfering with daily activities is common. Chronic pain has been defined in many ways. Chronic pain syndrome is a separate entity from chronic pain. Chronic pain is defined as, "pain that persists 6 months after an injury and beyond the usual course of an acute disease or a reasonable time for a comparable injury to heal, that is associated with chronic pathologic processes that cause continuous or intermittent pain for months or years, that may continue in the presence or absence of demonstrable pathologies; may not be amenable to routine pain control methods; and healing may never occur." In contrast, chronic pain syndrome has been defined as a complex condition with physical, psychological, emotional, and social components. The prevalence of chronic pain in the adult population ranges from 2% to 40%, with a median point prevalence of 15%. Among chronic pain disorders, pain arising from various structures of the spine constitutes the majority of the problems. The lifetime prevalence of spinal pain has been reported as 54% to 80%. Studies of the prevalence of low back pain and neck pain and its impact in general have shown 23% of patients reporting Grade II to IV low back pain (high pain intensity with disability) versus 15% with neck pain. Further, age related prevalence of persistent pain appears to be much more common in the elderly associated with functional limitations and difficulty in performing daily life activities. Chronic persistent low back and neck pain is seen in 25% to 60% of patients, one-year or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Estimates and patterns of productivity losses and direct health care expenditures among individuals with back and neck pain in the United States continue to escalate. Recent studies have shown significant increases in the prevalence of various pain problems including low back pain. Frequent use of opioids in managing chronic non-cancer pain has been a major issue for health care in the United States placing a significant strain on the economy with the majority of patients receiving opioids for chronic pain necessitating an increased production of opioids, and escalating costs of opioid use, even with normal intake. The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in spinal pain and add significant complexities to the interventionalist's clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/Evidence-Based Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of spinal pain and its relevance to health care interventions.