Spine Backpain

Complement Ther Med. 2009 Jun; 17(3): 131-40Yuan J, Purepong N, Hunter RF, Kerr DP, Park J, Bradbury I, McDonough SOBJECTIVES: To examine the feasibility of a main RCT to compare the effectiveness of two frequencies (2 versus 5 times/week) of acupuncture treatment for chronic low back pain (LBP). METHODS: Participants (n=30) with chronic LBP were randomised into two groups to receive 10 acupuncture treatments: Low Frequency Group, 2 times/week for five weeks (n=15); High Frequency Group, 5 times/week for two weeks (n=15). The following outcomes were measured blindly at baseline, 2 weeks, 5 weeks, 3 months and 1 year: pain on a VAS, functional disability using the RMDQ, quality of life using the Measure Yourself Medical Outcome Profile (MYMOP-2), psychological impact with the Coping Strategies Questionnaire (CSQ) and Pain Locus of Control (PLC) questionnaire. Two objective outcomes, the Shuttle Walk Test (SWT) and Lateral Trunk Flexibility (LTF), were also measured. RESULTS: The compliance rate was 100% for each group. Some of the measurements were shown to be sensitive (VAS, RMDQ, MYMOP-2 Wellbeing). 66-330 participants would be required for a fully powered non-inferiority trial. The groups were balanced at baseline for LBP and demographic characteristics. There were no significant differences between the groups in terms of any of the outcomes, at each follow-up time point. It was notable however that the clinically important improvement in terms of pain, functional disability, quality of life, and SWT in both groups was achieved within the first two weeks, which was maintained at one year follow-up. CONCLUSIONS: It is feasible to conduct a main RCT, to compare different frequencies of acupuncture for LBP, using sensitive measurements. Also the trend for early clinically important improvement within a minimum of four measurements is worthy of further study.

Spine J. 2009 Apr 25; Perneros G, Tropp HBACKGROUND CONTENT: Questionnaires for measuring the functional status of patients with low back pain (LBP) focus on disability and present responses for each question in a predetermined, fixed relationship between "can do/difficulties and pain". Their design does not permit a separation of the two. PURPOSE: To present the development of The Assessment of Pain and Occupational Performance (POP) and to evaluate validity and reliability. STUDY DESIGN: A prospective, consecutive study of patients investigated by use of the POP. PATIENT SAMPLE: A total of 220 patients participated in the study. METHODS: In a cross-sectional study including 53 patients with chronic musculoskeletal pain, empirical tests of content and construct validity established the definitive version of the POP. The POP focuses on performance of activities. It is a disease-specific, discriminative assessment instrument designed for patients with back pain (BP) and LBP. Based on a semi-structured interview the POP investigates each of 36 activities in two dimensions, with separate, defined scales from "normally healthy" to "extremes" for level of activity (x-scale) and pain intensity (y-scale). The final scores are expressed in percent, 0% to 100%. Patients with chronic LBP (CLBP) (n = 142) were allocated to the specific (S) group, that is, patients with specific LBP problems (n = 97) or to the nonspecific (NS) group, that is, those with NS BP (n = 45). The ability of the POP to differentiate between the two known groups was evaluated. Construct-convergent validity between the POP and the Oswestry Disability Index (ODI) was carried out for the S group. Inter-rater reliability was established between six pairs of raters who examined 25 patients recruited from primary health care, the P-LBP group. RESULTS: In construct known group validity, the median, the interquartile range, and the Mann-Whitney U test showed that the S group had a significantly higher level of activity (p < .001) combined with worse pain (p = .001) compared with the NS group. There were significant differences between the two groups in performing activities in the forward bending position (10 ten items) and in the upright standing position (9 items). The result of Spearman rank order correlation showed a strong relationship between the ODI and the POP for level of activity (r = 0.70, p

Spine J. 2009 Apr 22; Rabinovitch DL, Peliowski A, Furlan ADBACKGROUND CONTEXT: Epidural injections are commonly used to treat low back disorders. It has been proposed that in addition to the anti-inflammatory effects, injected material displaces the dura forward and inward, producing a stretch of the nerve roots that leads to lysis of neural adhesions. Despite this, there are no controlled trials investigating the effect of volume injected with pain as an independent outcome. PURPOSE: Review the existing literature to assess the effect of epidural injection volume on relief of radicular leg and low back pain. STUDY DESIGN: A systematic review of published clinical trials to assess the correlation between volume of epidural injection and relief of radicular leg and low back pain. METHODS: We searched MEDLINE (1966 to January 2009), EMBASE (1980 to January 2009), The Cochrane Library, and the reference lists of retrieved articles. The literature search was limited to English and Human subjects. Studies were included if they involved the following: 1) a controlled clinical trial; 2) epidural injections in treatment groups compared with control injections; 3) the same approach to epidural space in both groups; and 4) pain relief as an independent outcome. Trials that measured pain relief for radicular leg and low back pain, before and after epidural injections were included. Using the Cochrane Back Review Group recommendations, pain relief data were extracted independently by two reviewers into four categories: immediate (6 weeks-3 months); intermediate (>/=3 months-1 year); and long-term (>/=1 year). Common effect sizes were calculated for each data point. Quality of the trials was assessed (two independent authors) using the 11-item criteria list recommended in the method guidelines for systematic reviews for the Cochrane Back Review Group. The data were analyzed by calculating the following: correlations between volume difference and effect size at each data point; and comparing the average effect sizes in the studies with same volume in both groups to ones with different volumes. RESULTS: Fifteen studies fulfilled the inclusion/exclusion criteria. The correlation between volume difference and pain relief was 0.8027 (p = .002) for the immediate category, 0.5019 (p = .168) for the short-term category, and 0.9470 (p = .014) for the intermediate category. Insufficient data were available to calculate the correlation coefficient in the long-term category. There was a statistically significant difference when comparing the mean effect size where the volume injected was the same between the two groups (mean, standard deviation [SD]: 0.07, -0.26) with those where the volumes were different between comparison groups (mean, SD: 0.81, -0.6), irrespective of the medications injected. CONCLUSIONS: These preliminary results suggest a positive correlation between larger volumes of fluid injected in the epidural space and greater relief of radicular leg pain and/or low back pain. Clinicians should not change their practice, until further high-quality clinical studies confirm these findings.

Nig Q J Hosp Med. 2008 Oct-Dec; 18(4): 231-43Sokunbi O, Watt P, Moore ABACKGROUND: There is limited evidence on the patients' perception of the treatment with spinal stabilisation exercises and their overall experience of the treatment programme. OBJECTIVE: The aim of this study was to elicit valuable information of the experiences of patients who participated in a spinal stabilisation programme within a randomised controlled trial (RCT). METHOD: A qualitative study. PARTICIPANTS: Nine participants (male = 3, female = 6) were selected, to participate in focus group interviews from among those who participated in the RCT on the use of stabilization exercises in the treatment of chronic low back pain. A semi-structured interview comprising of open ended questions were used. Audio recording was used to record participants' opinions during the interview process. Careful checking, reading and correction of the transcript from the interviews were carried out and a thematic analysis was conducted on the data. RESULTS: Participant's explanations for the perceived improvements were not limited to the positive effects of stabilisation exercise on pain severity, functional disability and quality of life but also reflected major increases in confidence and the formulation of self help strategies and the ability to exert better control over their back pain due to more knowledge of the spine and how it works. CONCLUSION: Participants views on the benefit of stabilisation exercise programme are heterogeneous. However, the opinions of many of the participants in this study seem to have indicated satisfaction with the programme.

Spine J. 2009 Apr 24; Tureyen K, Senol N, Sahin B, Karahan NBACKGROUND CONTEXT: Spinal extradural arachnoid cysts are uncommon expanding lesions. Idiopathic arachnoid cysts are not associated with trauma or other inflammatory insults. If they enlarge, they usually present with progressive signs and symptoms of neural compression. PURPOSE: Total removal of the cyst and repair of the dural defect is the primary treatment for large thoracolumbar spinal extradural arachnoid cysts causing neurogenic claudication. Laminoplasty may prevent spinal deformities in long segmental involvement. STUDY DESIGN: A clinical case was performed. PATIENT SAMPLE: We report a case of 25-year-old man with 1-year history of progressive back pain radiating to both legs. His diagnosis was dorsal intraspinal extradural cystic lesion longing from the level of T11 to L2 on magnetic resonance imaging. OUTCOME MEASURES: The patient's pain levels were noted as he reported. Physiologic outcome was assessed on pre- and postoperative motor and sensory examination. METHODS: The patient underwent a T11-L2 laminotomy and radical cyst wall resection was performed. A small communication with the subarachnoid space was seen at the level of T12. It was sealed with tissue fibrinogen after repair with primary suture. Titanium miniplates were used for laminoplasty. RESULTS: Follow-up magnetic resonance imaging demonstrated cyst resolution, and neurologic examination revealed no sensory and motor deficit. CONCLUSION: Extradural arachnoid cysts are primarily treated with total removal of the cyst wall and closure of the dural defect. Surgical treatment is curative for this rare lesion.

Zhongguo Zhen Jiu. 2009 Feb; 29(2): 103-5Ran QZ, Shi ALOBJECTIVE: To explore the rehabilitation effect of SHI's Bian stone comprehensive therapy on the patient after induced abortion. METHODS: Thirty cases of induced abortion were treated with SHI's Bian stone comprehensive therapy in peri-operative period. Before the operation, scraping therapy was given at the parts of The Urinary Bladder Channel and The Governor Vessel on the back and 30 min after the operation, the patient took a rest in a horizontal position on a mild heat Bian stone blanket and hot compress with a Bian stone plate was given at the lower abdomen. They received thrice return visits respectively on 1, 2, 3 weeks after the operation and SHI's Bian stone comprehensive therapy, including warm massage on The Governor Vessel, scraping the channel, patting Baliao (BL 31, BL 32, BL 33, BL 34), penetration needling Sanyinjiao (SP 6), oblique needling Qihai (CV 6), Guanyuan (CV 4), Zhongji (CV 3), Zigong (EX-CA 1), and the Bian stone plate was placed on the needle hand for warm compress. Colporrhagia, menstrual return, soreness of waist and other symptoms after the operation were observed. RESULTS: After SHI's Bian stone comprehensive therapy, in the patient of induced abortion the colporrhagia volume was less within 3 days after the operation and the colporrhagia stopped more early; of the 30 cases, only 2 has soreness of waist, abdominal pain, fearing cool and other symptoms, and only one case had obviously delayed mestrual cycle. CONCLUSION: SHI's Bian stone comprehensive therapy used in peri-operative period of induced abortion has a good promoting action on post operative rehabilitation.

Eur Spine J. 2009 Apr 25; Vaga S, Brayda-Bruno M, Perona F, Fornari M, Raimondi MT, Petruzzi M, Grava G, Costa F, Caiani EG, Lamartina CThe dynamic stabilization of lumbar spine is a non-fusion stabilization system that unloads the disc without the complete loss of motion at the treated motion segment. Clinical outcomes are promising but still not definitive, and the long-term effect on instrumented and adjacent levels is still a matter of discussion. Several experiments have been devised in order to gain a better understanding of the effect of the device on the intervertebral disc. One of the hypotheses was that while instrumented levels are partially relieved from loading, adjacent levels suffer from the increased stress. But this has not been proved yet. The aim of this study was to investigate the long-term effect of dynamic stabilization in vivo, through the quantification of glycosaminoglycans (GAG) concentration within instrumented and adjacent levels by means of the delayed Gadolinium-Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) protocol. Ten patients with low back pain, unresponsive to conservative treatment and scheduled for Dynesys implantation at one to three lumbar spine levels, underwent the dGEMRIC protocol to quantify GAG concentration before and 6 months after surgery. Each patient was also evaluated with visual analog scale (VAS), Oswestry, Prolo, Modic and Pfirrmann scales, both at pre-surgery and at follow-up. Six months after implantation, VAS, Prolo and Oswestry scales had improved in all patients. Pfirrmann scale could not detect any change, while dGEMRIC data already showed a general improvement in the instrumented levels: GAG was increased in 61% of the instrumented levels, while 68% of the non-instrumented levels showed a decrease in GAG, mainly in the posterior disc portion. In particular, seriously GAG-depleted discs seemed to have the greatest benefit from the Dynesys implantation, whereas less degenerated discs underwent a GAG depletion. dGEMRIC was able to visualize changes in both instrumented and non-instrumented levels. Our results suggest that the dynamic stabilization of lumbar spine is able to stop and partially reverse the disc degeneration, especially in seriously degenerated discs, while incrementing the stress on the adjacent levels, where it induces a matrix suffering and an early degeneration.

Rheumatol Int. 2009 Apr 17; Akbulut Aktekin L, Eser F, Malhan S, Oksüz E, Keskin D, Bodur HMost of musculoskeletal diseases involve pain and reduced physical functioning. Recognition of the coexistence of more than one musculoskeletal disease is important because they are relatively common and has a substantial impact on health-related quality of life (HRQoL). Our aim was to compare the results of four generic QoL questionnaires-QoL-5, Nottingham Health Profile (NHP), Short Form (SF)-6D, and Visual Analogue Scale (VAS)-in five different patient groups. Two hundred and one patients representing five different disease groups (knee osteoarthritis, osteoporosis, back pain, rheumatoid arthritis and ankylosing spondylitis), randomly selected through the Ankara Numune Education and Research Hospital Physical Medicine and Rehabilitation Outpatient Clinic, were included in the study. Scores indicating low QoL for each of the five diseases compared are reported. Patients in each disease group stated high disability. No strong correlation between any of the scales could be determined, and NHP was identified as the only scale able to differentiate between the diseases. Many instruments are available for measuring HRQoL. The QoL-5, NHP, SF-6D, and VAS are four commonly used generic (i.e., not disease-specific) measures for quantifying HRQoL in patients with musculoskeletal disorders. Most studies have focused on only one musculoskeletal disease, but comorbidity of musculoskeletal disorders is common. We emphasize in this study the effect of multiple musculoskeletal diseases on HRQoL.

Clin Exp Nephrol. 2009 Apr 21; Ishikawa E, Nomura S, Hamaguchi T, Obe T, Inoue-Kiyohara M, Oosugi K, Katayama K, Ito MBACKGROUND: Renal biopsy is essential for the diagnosis of kidney diseases, but complications, particularly bleeding incidents, remain problematic. METHODS: To evaluate the frequency of renal biopsy complications, and to reveal clinical and laboratory factors associated with overt bleeding complications, focusing on those available at hospital ward, we conducted a retrospective observational study for the period between 2001 and 2005 at Mie University Hospital in patients who underwent percutaneous renal biopsy of a native kidney. Of a total of 323 patients, 317 met the inclusion criteria. RESULTS: Only one patient (0.3%) required blood transfusion or intervention to stop bleeding. The mean decrease in hemoglobin (Hb) after biopsy was 0.43 +/- 0.7 g/dL. Hb decreased >/=1.0 g/dL in 66 patients (20.8%) and >/=10% in 32 patients (10.1%). On ultrasonography, perirenal hematoma was detected immediately after biopsy in 273 patients (86.1%), and 41 patients (12.9%) showed hematoma >/=2 cm in width. Analgesics were required for back pain in 67 patients (21.1%). Vasovagal response developed in 31 patients (9.8%). Macrohematuria occurred in 12 patients (3.8%). Urinary catheter was used in 161 patients (50.8%). For Hb decrease >/=10% after biopsy, multivariate analysis revealed perirenal hematoma (>/=2 cm) as a significant factor. Other significant factors were prolonged international normalized ratio of prothrombin time, elevated blood pressure on hospital admission, older age, increased serum creatinine level, and steroid use. CONCLUSION: Perirenal hematoma >/=2 cm on ultrasonography immediately after biopsy might well represent a predictive factor for bleeding complications.

J Biomech. 2009 Apr 16; Bazrgari B, Shirazi-Adl A, Larivière CAccurate quantification of the trunk transient response to sudden loading is crucial in prevention, evaluation, rehabilitation and training programs. An iterative dynamic kinematics-driven approach was used to evaluate the temporal variation of trunk muscle forces, internal loads and stability under sudden application of an anterior horizontal load. The input kinematics is hypothesized to embed basic dynamic characteristics of the system that can be decoded by our kinematics-driven approach. The model employs temporal variation of applied load, trunk forward displacement and surface EMG of select muscles measured on two healthy and one chronic low-back pain subjects to a sudden load. A finite element model accounting for measured kinematics, nonlinear passive properties of spine, detailed trunk musculature with wrapping of global extensor muscles, gravity load and trunk biodynamic characteristics is used to estimate the response under measured sudden load. Results demonstrate a delay of approximately 200ms in extensor muscle activation in response to sudden loading. Net moment and spinal loads substantially increase as muscles are recruited to control the trunk under sudden load. As a result and due also to the trunk flexion, system stability significantly improves. The reliability of the kinematics-driven approach in estimating the trunk response while decoding measured kinematics is demonstrated. Estimated large spinal loads highlight the risk of injury that likely further increases under larger perturbations, muscle fatigue and longer delays in activation.

Soc Psychiatry Psychiatr Epidemiol. 2009 Apr 23; Messias E, Saini A, Sinato P, Welch SBACKGROUND: Personality traits are reported to be associated with a variety of medical comorbidities. Correlational studies report an association between 'bearing grudges' and medical conditions. We hypothesize persons reporting "bearing grudges for years" would be more likely to have medical comorbidities and test this hypothesis in an epidemiological sample. METHODS: The National Comorbidity Survey Replication is a probability sample of the US population designed to constitute a nationally representative sample (N = 9,882). Associations were measured in odds ratios (95% CI) and adjusted using logistic regression. Confounders included: gender, age, race, and smoking status. We tested the hypothesis on 14 following medical conditions: heart disease, high blood pressure, history of heart attack, asthma, diabetes, cancer, epilepsy, arthritis, neck problems, headaches, stroke, and ulcers. Significance levels were adjusted for multiple comparisons using the Bonferoni procedure. RESULTS: Positive and statistically significant associations were found, after adjusting for confounders and correcting for multiple comparisons, between bearing grudges and history of heart attack (odds ratio 2.1, 95% CI 1.5-2.9) and disease (1.6, 1.2-2.2); high blood pressure (1.5, 1.3-1.7), stomach ulcers (1.6, 1.3-1.9); arthritis (1.5, 1.3-1.9); back problems (1.6, 1.4-1.8); headaches (1.8, 1.6-2.1); and chronic pain (1.7, 1.4-2.1). No association was found with history of asthma, diabetes, epilepsy, allergies, stroke, and cancer. CONCLUSIONS: In a population-based survey, bearing grudges is associated with a history of pain disorders, cardiovascular disease, and stomach ulcers. These results point to the importance of psychosomatic research in medical settings.

Minerva Med. 2009 Apr; 100(2): 167-70d'Ettorre G, Ceccarelli G, Zaffiri L, Falcone M, Mastroianni CM, Venditti M, Vullo VThe infection of endovascular stents remains one of the most problematic complications of aortic surgery. This article describes the case of a 61-year-old male with ascendant and descendent aorta endovascular stents, hospitalized for pyrexia, weight loss and back pain. Blood culture was positive for Staphylococcus hominis resistant to oxacillin and ciprofloxacin. Spiral computed tomography, magnetic resonance imaging and leukocyte-labelled scintigraphy showed that the patient developed a perigraft infection which spondylodiscitis in correspondence of D7, D8 and D9 vertebras. The biopsy CT-scan guided of vertebral inflammed tissue revealed a coagulase-negative Staphylo-coccus and the presence of numerous neutrophilis granulocytes. The reintervention for substituting an infected graft was excluded due to the high risk of death or paraplegia. A therapy with vancomycin, rifampicin and ceftazidime was started. On the basis of clinical and radiological findings, it was decided to switch empirical antimicrobial therapy to levofloxacin, minocycline and teicoplanin and a reduction of inflammation indices was observed. The patient was discharged maintaining this chronic suppressive antimicrobial therapy with a 28-day cycle of linezolid with complete regression of pain, and normalization of inflammation blood indices. After, therapy switched to teicoplanin three times a week while maintaining good clinical and radiological features. In the present, due to the high risk in performing a surgical procedure, a conservative chronic suppressive antimicrobial therapy with teicoplanin allowed to control the infection on an outpatient basis, thereby reducing the costs.

Acta Anaesthesiol Scand. 2009 Apr 14; Jacobsen R, Møldrup C, Christrup L, Sjøgren P, Hansen OBBackground: The modified version of the patients' Perceived Involvement in Care Scale (M-PICS) is a tool designed to assess cancer patients' perceptions of patient-health care provider pain communication process. The objective of this study was to examine the psychometric properties of the shortened Danish version of the M-PICS (SDM-PICS). Methods: The validated English version of the M-PICS was translated into Danish following the repeated back-translation procedure. Cancer patients were recruited for the study from specialized pain management facilities. Results: Thirty-three patients responded to the SDM-PICS, Danish Barriers Questionnaire II, Hospital Anxiety and Depression Scale, and Brief Pain Inventory Pain Severity Scale. A factor analysis of the SDM-PICS resulted in two factors: Factor one, patient information, consisted of four items assessing the extent to which the patient shared information with his/her health care provider, and Factor two, health care provider information, consisted of four items measuring the degree to which a health care provider was perceived as the one who shares information. Two separate items addressed the perceived level of information exchange between the patient and the health care provider. The SDM-PICS total had an internal consistency of 0.88. The SDM-PICS scores were positively related to pain relief and inversely related to the measures of cognitive pain management barriers, anxiety, and reported pain levels. Conclusion: The SDM-PICS seems to be a reliable and valid measure of perceived patient-health care provider communication in the context of cancer pain.

Instr Course Lect. 2009; 58: 657-68Daffner SD, Wang JCLumbar spinal stenosis, which affects an ever-increasing number of patients, is best defined as a collection of clinical symptoms that includes low back pain, bilateral lower extremity pain, paresthesias, and other neurologic deficits that occur concomitantly with anatomic narrowing of the neural pathway through the spine. The narrowing may be centrally located in the spinal canal or more laterally in the lateral recesses or neuroforamina. Lumbar spinal stenosis can have a congenital or acquired etiology, and the origin of acquired lumbar stenosis is classified as degenerative, posttraumatic, or iatrogenic. In degenerative lumbar stenosis, the anatomic changes result from a cascade of events that includes intervertebral disk degeneration, facet joint arthrosis, and hypertrophy of the ligamentum flavum. The altered biomechanical characteristics of the spinal segment perpetuate a cycle of degenerative changes, and the resulting stenosis produces radicular pain through a combination of direct mechanical compression of nerve roots, restriction of microvascular circulation and axoplasmic flow, and inflammatory mediators. The initial treatment of lumbar spinal stenosis is nonsurgical. The most effective nonsurgical treatment is a comprehensive combination of oral anti-inflammatory drugs, physical therapy and conditioning, and epidural steroid injections. A significant number of patients improve after nonsurgical treatment, although most studies have found that patients treated surgically have better clinical results. Delaying surgical treatment until after a trial of nonsurgical treatment does not affect the outcome. Surgical intervention should be considered only if a comprehensive program of nonsurgical measures fails to improve the patient's quality of life.

J Adv Nurs. 2009 Apr 3; Ahn S, Song RAim. This paper is a report of a study of the relationships between the factors influencing low back pain in postmenopausal women (i.e. menopausal symptoms, bone mineral density, duration of menopause, hormonal therapy, obesity, inactivity during leisure time, parity, osteoarthritis and drinking coffee). Background. Previous studies have shown that low back pain in postmenopausal women is associated with bone mineral density, menopausal symptoms and lifestyle factors, yet the factors influencing low back pain are not clear and vary with ethnicity. Method. A survey was conducted with postmenopausal women (n = 134) in Korea in 2006. Bone mineral density in the lumbar spine, back pain status, menopausal symptoms and health habits were assessed. Results. Participants' mean age was 59 years. About 70% experienced back pain on more than 1 day during the week prior to the survey and 35% suffered back pain daily. Women with back pain reported more severe menopausal symptoms than those without back pain. Based on bone mineral density scores, 26.9% of the women were considered to be at risk of osteoporosis. However, there was no association between back pain status and fracture risk status. Based on a multiple logistic regression model, menopausal symptoms, drinking coffee and inactivity during leisure time were statistically significant influencing factors for low back pain in this sample. Conclusion. The prevalence of low back pain in postmenopausal women should be recognized in association with menopausal symptoms and health habits. Further research is needed to develop interventions for the management of low back pain in postmenopausal women.

Int J Rehabil Res. 2009 Apr 17; Sloots M, Scheppers EF, van de Weg FB, Dekker JH, Bartels EA, Geertzen JH, Dekker JDropout from a rehabilitation programme often occurs in patients with chronic nonspecific low back pain of non-native origin. However, the exact dropout rate is not known. The objective of this study was to determine the difference in dropout rate between native and non-native patients with chronic nonspecific low back pain participating in a rehabilitation programme in The Netherlands. A retrospective study (n = 529) of patient files was performed in two rehabilitation centres and two rehabilitation departments of general hospitals in The Netherlands. Patient files were checked for diagnosis, status of origin, sex, age and outcome, that is, reason for finishing treatment. The difference in dropout rate between patients of Dutch and non-Dutch origin was tested by chi tests and logistic regression-analysis, controlling for age, sex, type of rehabilitation institute and phase of the rehabilitation programme. Dropout occurred among one fifth (18.7%) of the total patient population. Dropout among patients of non-Dutch origin was twice as high as among native Dutch patients (P < 0.001). In regression analyses dropout was related to status of non-Dutch origin, treatment in a rehabilitation centre and the diagnostic phase of a rehabilitation programme. In conclusion, patients of non-Dutch origin drop out considerably more frequently than native Dutch patients. Dropout is higher in the diagnostic phase than in the treatment phase and in rehabilitation centres than in hospitals. Future research should clarify the reasons for the high dropout rate in patients of non-native origin.

Gesundheitswesen. 2009 Apr 22; Erler A, Beyer M, Muth C, Gerlach FM, Brennecke RCONTEXT: ICD-10-coded diagnoses from claims records are frequently used as morbidity indicators for research as well as for risk adjustment purposes in quality management and remuneration. A requirement for this application is the high validity of the diagnoses. In GP practices in particular, it is questionable whether claims-based diagnoses realistically reflect the health problems of patients treated over a one year period. METHODS: In a retrospective cross-sectional study of a random sample of 250 patients from 10 GP practices we examined whether, on the basis of the patients' medical records, health problems treated in the year 2003 matched claims-based diagnoses within the same time period. RESULTS: In spite of a high mean of 6.1 claims-based diagnoses per patient, health problems treated within the study period were under-reported in 30% of the cases, mainly relating to non-severe diagnoses frequently encountered in GP practice, chronic conditions not requiring medication, and diagnoses justifying a screening test. An over-reporting for diseases not treated within the study period was observed in 19% of the cases, most often in the case of permanent chronic conditions. In 11% of cases the ICD-10 codes of claims-based diagnoses and the diagnoses in the medical records did not match ("erroneous codes"). For six of the diagnoses most common in GP practice (hypertension, diabetes, hyperlipoproteinemia, cardiovascular disease, back pain, and acute respiratory tract infections) correctness at 71-93% was higher than completeness (56-86%). CONCLUSION: The low validity of ICD-10-coded diagnoses from GP claims records calls their usefulness as morbidity indicators into question.

Anesthesiology. 2009 May; 110(5): 1116-26Cohen SP, Bogduk N, Dragovich A, Buckenmaier CC, Griffith S, Kurihara C, Raymond J, Richter PJ, Williams N, Yaksh TLBACKGROUND: Recent evidence implicates the inflammatory cytokine tumor necrosis factor as a major cause of radiculopathy. Yet, whereas open-label studies with systemically delivered tumor necrosis factor inhibitors have yielded positive results, a placebo-controlled study failed to demonstrate efficacy. One variable that may have contributed to poor outcomes is low drug levels at the site of nerve inflammation. To date, no studies have evaluated the efficacy or safety of epidurally administered anti-tumor necrosis factor agents. METHODS: A double-blind, placebo-controlled, dose-response study was conducted to evaluate an epidural tumor necrosis factor inhibitor. Twenty-four patients with subacute lumbosacral radiculopathy were randomly assigned to receive two transforaminal epidural injections of 2, 4, or 6 mg of entanercept 2 weeks apart in successive groups of eight. In each group, two patients received epidural saline. A parallel epidural canine safety study was conducted using the same injection doses and paradigm as in the clinical study. RESULTS: The animal and human safety studies revealed no behavioral, neurologic, or histologic evidence of drug-related toxicity. In the clinical arm, significant improvements in leg and back pain were collectively noted for the etanercept-treated patients, but not for the saline group, one month after treatment. One patient in the saline group (17%), six patients in the 2-mg group (100%), and four patients each in the 4-mg and 6-mg groups (67%) reported at least 50% reduction in leg pain and a positive global perceived effect one month after treatment. Six months after treatment, the beneficial effects persisted in all but one patient. CONCLUSION: Epidural entanercept holds promise as a treatment for lumbosacral radiculopathy.

Eur Spine J. 2009 Apr 24; Ramieri A, Domenicucci M, Cellocco P, Raco A, Costanzo GWe report results in the surgical treatment of thoracolumbar flexion-distraction fractures, both associated or not with neurological impairment. Items in the present study include function, pain (back pain rating scale) and neurological recovery (Asia Score). A prospective series of 19 consecutive flexion-extension thoracolumbar injuries (T11-L2), occurred in young patients (20-33 years) due to motor vehicle crashes wearing the 3-point safety belts, includes 2 Chance and 17 seat-belt fractures, with different amount of vertebral dislocation and neurological impairment. Fractures have been evaluated according to the Magerl's classification. All patients were operated via posterior approach using hybrid instrumentation or short pedicular fixation to reduce dislocation and to obtain spinal fusion. Posterior decompression was performed in all patients with neurological deficit. Posterior instrumented arthodesis was performed by wide constructs that preferably include 2 levels above and below the dislocated vertebra. Most of them were instrumented using thoracic hooks and lumbar pedicular screws. One postoperative vascular complication was successfully treated by selective embolization. All neurological patients were submitted to a postoperative rehabilitation program. Posterior procedure allows proper reduction and realignment. In our experience, the use of laminar hooks one level above the dislocation seems to reduce the potential risk of neurological and /or vascular damage during the intraoperative maneuvers on the dislocated pedicles. At follow-up, fusion was achieved in all patients. The clinical condition was totally satisfactory due to the absence of significant pain, confirming mechanical stability of the implants. In terms of neurological outcomes, patients presenting as ASIA A-B or ASIA E, maintained their preoperative neurological condition. Surgical treatment, together with an early postoperative rehabilitation program, can be of paramount importance in neurological patients' quality of life.

J Pain. 2009 Apr 20; Hechler T, Chalkiadis GA, Hasan C, Kosfelder J, Meyerhoff U, Vocks S, Zernikow BAlthough sex differences have been investigated in chronic pain populations, little is known about sex differences in the pain experience of paediatric oncology patients and also whether their parents rate the pain experience differently for boys and girls. The aim of the present study was to determine if (1) boys and girls with cancer differ in current perception and past recollection of cancer-related pain and (2) if adolescents' and parents' pain ratings differ in relation to the sex of the adolescent. One hundred twelve adolescents with malignant diagnoses (12 to 18 years) and their parents participated in the study. Girls reported higher pain intensity within the last 7 days and 4 weeks despite similar diagnosis, physical status, duration of diagnoses, and main pain causes. When asked for pain intensity that dated back in time, parent and adolescent ratings diverged, with a trend for parents to reporting higher pain intensity in boys and lower pain intensity in girls, particularly for pain in the preceding 7 days. The present study provides preliminary evidence for sex differences in the recalled pain experience of adolescents with malignant diagnoses. Although boys and girls experience present pain similarly and hence should be treated similarly, girls recall higher pain intensity than boys. Future studies should address whether negative memories in girls play a significant role and may have an impact on girls' well-being and pain-related distress. Additionally, psychosocial factors such as gender role expectations may need to be investigated. Parental variables and their impact on parents' pain ratings, especially for ratings of precedent pain, warrants further investigation. PERSPECTIVE: Girls with malignant diagnoses differ from boys in their recalled pain intensity ratings, with girls reporting higher pain intensity. Additional pain management strategies referring to the memory of pain may need to be implemented.

Am J Health Syst Pharm. 2009 May 1; 66(9): 834-7Schroeder WS, Tran MT, Gandhi PJPURPOSE: A case of lepirudin-induced thrombocytopenia is reported. SUMMARY: A 61-year-old white man arrived at the emergency department with complaints of pain in his left thigh that worsened with walking. His medical history was significant for extensive thromboses over a period of six months. He had recently been discharged from the hospital for suspected heparin-induced thrombocytopenia (HIT) while on enoxaparin. A venous duplex scan revealed two new deep venous thromboses in the left common, superficial, and popliteal veins. The patient was admitted and initiated on aspirin 325 mg and warfarin sodium 2 mg daily. Intravenous lepirudin with an activated partial thromboplastin time (aPTT) goal of 60-80 seconds was also started. Because of his recurrent thrombotic event, a new International Normalized Ratio (INR) goal of 3.0-3.5 was established for warfarin therapy. Eighteen days after admission, the patient's INR and aPTT were high; therefore, his warfarin dose was reduced and i.v. lepirudin was changed to subcutaneous administration. The patient was transferred to the intensive care unit (ICU) and, 5 days later, he developed melena. During the 7 days of treatment with subcutaneous lepirudin, a drop in platelet counts was observed. Subcutaneous lepirudin was discontinued after resolution of melena, and i.v. lepirudin was restarted. After 15 days, his platelet counts increased and he was switched back to subcutaneous lepirudin, which again led to a drop in platelets. After 27 days in the ICU, the patient's INR and aPTT remained high. Lepirudin was discontinued and i.v. bivalirudin was initiated. His platelet count increased and he was discharged. Eleven days later, the patient was found unresponsive with left-sided fasciculations. The patient died secondary to respiratory arrest as a consequence of intracranial hemorrhage. CONCLUSION: A 61-year-old white man with a history of thromboses and suspected HIT developed thrombocytopenia possibly associated with receiving two courses of subcutaneous lepirudin. Careful monitoring of platelet counts are warranted in patients who have a history of HIT and are receiving subcutaneous lepirudin.

Med Lav. 2009 Mar-Apr; 100(2): 151-7Marchì T, Magarotto GOBJECTIVES: The aim of our study was to assess the prevalence of neck pain in the working population not exposed to ergonomic risks. METHODS: A total of 373 male workers were recruited in the Venice area of Italy. The inclusion criterion was the absence of exposure to ergonomic risk factors at the workplace. We collected the data via interviews between March 2004 and December 2006 conducted by properly trained operators. The prevalence of neck pain episodes was calculated after selecting 347 subjects without functional outcomes for severe trauma or genetic and degenerative diseases involving the same anatomical area. The strength of the association of neck pain with the collected variables was tested by means of logistic regression analysis. RESULTS: The group had a good attitude to doing physical activity in their free time. Exposure to high stress at work involved 12% of the sample. Multivariate analysis suggested a more than 3-fold level of risk among individuals with high levels of stress at work. The O.R. was 3.51 for those suffering from back pain at the same time and 6.85 for those who reported shoulder pain. CONCLUSIONS: Our study, in agreement with the scientific literature, showed evidence of increased risk of neck pain in subjects exposed to stress. There was a clear association with neck pain and joint disorders of other areas of the spine and shoulder. The results showed that the quantification of painful joint disorders, considering the numerical importance and the brief latency, is well suited to models of cross sectional studies.

Can J Neurol Sci. 2009 Mar; 36(2): 196-200Cenic A, Kachur EBACKGROUND: To ascertain neurosurgical practices in the surgical management of one-level lumbar discectomies in the Canadian adult population. METHODS: One page questionnaire faxed to each Neurosurgeon in Canada with questions relating to their practice in the management of this common neurosurgical procedure. All data analyzed using Chi-square statistics. RESULTS: 112 completed surveys were returned hence, giving a 64% response rate with the respondents being predominantly adult neurosurgeons. Of the respondents, 88% perform lumbar discectomy in adults. Only 15% of respondents had a Spine Fellowship. For preoperative imaging, 44% use BOTH CT and MRI whereas 28% use only MRI and 15% use only CT. Prior to initial skin incision, 57% use a localization X-ray image. Preoperative antibiotics are prescribed by 92% of respondents. Majority of respondents (60%) use a pre-incision local anesthetic, whereas only a minority (44%) of respondents employ pre-closure intramuscular injection. With respect to magnification, 70% use microscope, 19% loupes, and 8% neither. Only 12% use minimally invasive tubular retractors. 68% remove "as much disc as possible", while 31% remove "ONLY herniated part". In the case of dural tears, 77% of respondents use fibrin glue (Tisseel). Prior to skin closure, majority of neurosurgeons do NOT use a fat graft (72%), whereas 61% of respondents use epidural steroids. With respect to discharge from the hospital, 58% are discharged on the next day, 18% on the same day, and 23% in two days. Return to work is not recommended until at least six weeks post-op (96%). Most neurosurgeons (93%) would not operate on an individual with a chief complaint of low back pain. CONCLUSIONS: Our survey has identified variations in practice patterns amongst Canadian Neurosurgeons with respect to performing one-level lumbar discectomies. This survey is expected to form a basis for the design of a randomized controlled trial in the evaluation of the best management approach for this common neurosurgical procedure.

Bone. 2009 Apr 16; Ho TL, Nguyen ND, Vu BQ, Pham HN, Nguyen TVBackground. Vertebral fracture is associated with an increased risk of atraumatic fracture and mortality. The prevalence of vertebral fractures among postmenopausal Caucasian women has been reported to range between 15% and 35%. Because there is no estimate of the magnitude of the problem in Vietnam, we undertook this study to estimate the prevalence and risk factors of vertebral fracture in Vietnam. Methods. Radiographs were taken from 209 post-menopausal women aged between 50-85 years (average 62) who were randomly sampled from various districts in Ho Chi Minh City. The presence of vertebral fracture was assessed by the Genant's semiquantitative method with two independent readers. Bone mineral density (BMD) at the lumbar spine (LS), femoral neck (FN) and whole body was measured by DXA (Hologic QDR4500). Anthropometric and clinical data were obtained by a standardized questionnaire. Results. Among the 209 women, 48 were found to have at least one radiographic vertebral fracture, which yielded a prevalence of 23% (95%CI: 18-29%). Although fracture occurred in all vertebrae, most (83%) occurred at the L1-L5. Most fractures occurred at one vertebra, and only 12% occurred at multiple vertebrae. The prevalence increased with age such that it reached 39% among those aged 70+ years. There was no significant association between vertebral fracture and back pain, fall history, and dietary calcium intake. In simple log binomial regression analysis, higher risk of vertebral fracture was associated with advancing age (prevalence ratio [PR] per 10 years: 1.40; 1.16-2.05) and lower lumbar spine BMD (PR per SD: 1.51; 1.18-1.92). In multivariable analysis, the two factors remained independently associated with fracture risk, with the area under the receiver operating characteristic curve being 0.66. Conclusions. These data suggest that approximately one out of 4 postmenopausal women in Vietnam have a radiographic vertebral fracture, and this prevalence is as common as in Caucasian populations. The number of women needed to screen to identify one vertebral fracture is about 4 to 5, which seems to be cost-effective.

BMC Musculoskelet Disord. 2009 Apr 20; 10(1): 39Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen JABSTRACT: BACKGROUND: It is unclear to what extent spinal pain varies between genders and in relation to age. It was the purpose of this study to describe the self-reported prevalence of 1) pain ever and pain in the past year in each of the three spinal regions, 2) the duration of such pain over the past year, 3) pain radiating from these areas, and 4) pain in one, two or three areas. In addition, 5) to investigate if spinal pain reporting is affected by gender and 6) to see if it increases gradually with age. METHOD: A cross-sectional survey was conducted in 2002 on 34,902 twin individuals, aged 20 to 71 years, representative of the general Danish population. Identical questions on pain were asked for the lumbar, thoracic and cervical regions. RESULTS: Low back pain was most common, followed by neck pain with thoracic pain being least common. Pain for at least 30 days in the past year was reported by 12%, 10% and 4%, respectively. The one-yr prevalence estimates of radiating pain were 22% (leg), 16%% (arm), and 5% (chest). Pain in one area only last year was reported by 20%, followed by two (13%) and three areas (8%). Women were always more likely to report pain and they were also more likely to have had pain for longer periods. Lumbar and cervical pain peaked around the middle years but the curves were flatter for thoracic pain. Similar patterns were noted for radiating pain. Older people did not have pain in a larger number of areas but their pain lasted longer. CONCLUSIONS: Pain reported for and from the lumbar and cervical spines was found to be relatively common whereas pain in the thoracic spine and pain radiating into the chest were much less common. Women were, generally, more likely to report pain than men. The prevalence stimates changed surprisingly little over age and was certainly not more common in the oldest groups, although the pain was reported as more long-lasting in the older group.