Spine Backpain

Spine. 2009 Jun 1; 34(13): 1337-1344Paoloni M, Di Sante L, Cacchio A, Apuzzo D, Marotta S, Razzano M, Franzini M, Santilli VSTUDY DESIGN.: Multicenter randomized, double-blind, simulated therapy-controlled trial in a cohort of patients with acute low back pain (LBP) due to lumbar disc herniation (LDH). OBJECTIVE.: To assess the benefit of intramuscular-paravertebral injections of an oxygen-ozone (O2O3) mixture. SUMMARY OF BACKGROUND DATA.: Recent findings have shown that O2O3 therapy can be used to treat LDH that fails to respond to conservative management. However, these findings are based on intradiscal/intraforaminal O2O3 injection, whereas intramuscular-paravertebral injection is the technique used most in clinical practice in Italy and other Western countries. METHODS.: Sixty patients suffering from acute LBP caused by LDH was randomized to an intramuscular O2O3 or control group. Patients were observed up to assess pain intensity, LBP-related disability, and drug intake (15 [V2] and 30 [V3] days after treatment started, and 2 weeks [V4], and 3 [V5] and 6 [V6] months after treatment ended). RESULTS.: A significant difference between the 2 groups in the percentage of cases who had become pain-free (61% vs. 33%, P < 0.05) was observed at V6. Patients who received O2O3 had a lower mean pain score than patients who received simulated therapy throughout the observation period. A significant improvement was observed in LBP-related disability in the study group patients when compared with the control group patients. Active O2O3 therapy was followed by a significantly lower number of days on nonsteroidal anti-inflammatory drugs at V2 and V3 and by a lower number of days at V4. No adverse events were reported. CONCLUSION.: Treatment of LBP and sciatica is a major concern. Although the natural history of acute LBP is often self-limiting, conservative therapies are not always effective; in such cases, O2O3 intramuscular lumbar paravertebral injections, which are minimally invasive, seem to safely and effectively relieve pain, as well as reduce both disability and the intake of analgesic drugs.

Altern Ther Health Med. 2009 May-Jun; 15(3): 30-4Tsubono K, Thomlinson P, Shealy CNCONTEXT: Many individuals suffer from various kinds of chronic pain. Some controlled studies on distant healing for chronic pain exist, but no definitive conclusion has been established. OBJECTIVE: To study the effects of distant healing performed by a professional Japanese healer on chronic pain. DESIGN: A double-blind randomized controlled study. SETTING: Holos University, Fair Grove, Missouri. SUBJECTS: People suffering from chronic pain (not caused by clear organic diseases or that persists long after a reasonable period of healing following injuries or surgery) were recruited through local radio and newspaper advertising. Subjects were randomly assigned to a treatment group or control group using a double-blind procedure. INTERVENTIONS: All subjects met the healer at the initial session at Holos University. At the session, a 20-minute group meditation was performed. The healer went back to Japan after the session and started distant healing only to the treatment group for a 2-month period. All participants were asked to meditate for 20 minutes every day during this 2-month period. OUTCOME MEASURES: The visual analog scale and McGill Pain Questionnaire. RESULTS: A total of 17 subjects were recruited, and 16 subjects completed the study. Comparison of pretreatment and posttreatment visual analog scale indicated a slightly significant effect of distant healing (P=.056). The Present Pain Intensity Scale showed significant improvement in the treatment group compared to the control group (P=.0016). The Pain Rating Index showed improvement in the treatment group, but the difference between both groups was not statistically significant (P=.12).

Eur Spine J. 2009 May 28; Rihn JA, Makda J, Hong J, Patel R, Hilibrand AS, Anderson DG, Vaccaro AR, Albert TJThe "off label" use of rhBMP-2 in the transforaminal lumbar interbody fusion (TLIF) procedure has become increasingly popular. Although several studies have demonstrated the successful use of rhBMP-2 for this indication, uncertainties remain regarding its safety and efficacy. The purpose of this study is to evaluate the clinical and radiographic outcomes of the single-level TLIF procedure using rhBMP-2. Patients who underwent a single-level TLIF between January 2004 and May 2006 with rhBMP-2 were identified. A retrospective evaluation of these patients included operative report(s), pre- and postoperative medical records, and dynamic and static lumbar radiographs. Patient-reported clinical outcome measures were obtained from a telephone questionnaire and included a modification of the Odom's criteria, a patient satisfaction score, and back and leg pain numeric rating scale scores. Forty-eight patients met the study criteria and were available for follow-up (avg. radiographic and clinical follow-up of 19.4 and 27.4 months, respectively). Radiographic fusion was achieved in 95.8% of patients. Good to excellent results were achieved in 71% of patients. On most recent clinical follow-up, 83% of patients reported improvement in their symptoms and 84% reported satisfaction with their surgery. Twenty-nine patients (60.4%) reported that they still had some back pain, with an average back pain numeric rating score of 2.8. Twenty patients (41.7%) reported that they still had some leg pain, with an average leg pain numeric rating score was 2.4. Thirteen patients (27.1%) had one or more complications, including transient postoperative radiculitis (8/48), vertebral osteolysis (3/48), nonunion (2/48), and symptomatic ectopic bone formation (1/48). The use of rhBMP-2 in the TLIF procedure produces a high rate of fusion, symptomatic improvement and patient satisfaction. Although its use eliminates the risk of harvesting autograft, rhBMP-2 is associated with other complications that raise concern, including a high rate of postoperative radiculitis.

BMC Musculoskelet Disord. 2009 May 28; 10(1): 55Hall AM, Maher CG, Latimer J, Ferreira ML, Lam PABSTRACT: BACKGROUND: Low back pain persisting for longer than 3 months is a common and costly condition for which many current treatments have low-moderate success rates at best. Exercise is among the more successful treatments for this condition, however, the type and dosage of exercise that elicits the best results is not clearly defined. Tai chi is a gentle form of low intensity exercise that uses controlled movements in combination with relaxation techniques and is currently used as a safe form of exercise for people suffering from other chronic pain conditions such as arthritis. To date, there has been no scientific evaluation of tai chi as an intervention for people with back pain. Thus the aim of this study will be to examine the effects of a tai chi exercise program on pain and disability in people with long-tem low back pain. Methods / Design: The study will recruit 160 healthy individuals from the community setting to be randomised to either a tai chi intervention group or a wait-list control group. Individuals in the tai chi group will attend 2 tai chi sessions (40 minutes) / week for 8 weeks followed by 1 tai chi session / week for 2 weeks. The wait-list control will continue their usual health care practices and have the opportunity to participate in the tai chi program once they have completed the follow-up assessments. The primary outcome will be bothersomeness of back symptoms measured with a 0-10 numerical rating scale. Secondary outcomes include, self-reports of pain-related disability, health-related quality of life and global perceived effect of treatment. Statistical analysis of primary and secondary outcomes will be based on the intention to treat principle. Linear mixed models will be used to test for the effect of treatment on outcome at 10 weeks follow up. This trial has received ethics approval from The University of Sydney Human Research Ethics Committee. HREC Approval No.10452 DISCUSSION: This study will be the first trial in this area and the information on its effectiveness will allow patients, clinicians and treatment funders to make informed choices regarding this treatment. Trial Registration: This trial has been registered with Australian New Zealand Clinical Trials Registry. ACTRN12608000270314.

Headache. 2009 May 15; Gunreben-Stempfle B, Grießinger N, Lang E, Muehlhans B, Sittl R, Ulrich KObjective.- To investigate if the effectiveness of a 96-hour multidisciplinary headache treatment program exceeds the effectiveness of a 20-hour program and primary care. Background.- When dealing with chronic back pain, low-intensity multidisciplinary treatment yields no significantly better results than standard care and monodisciplinary therapy; however, high-intensity treatment does. For multidisciplinary headache treatment, such comparisons are not yet available. In a previous study undertaken by our Pain Center, the outcome of a minimal multidisciplinary intervention model (20-hour) did not exceed primary care. Methods.- Forty-two patients suffering from frequent headaches (20 +/- 9 headache days/month; range: 8-30) were treated and evaluated in a 96-hour group program. The results were compared with the outcomes of the previous study. Subjects who had undergone either the 20-hour multidisciplinary program or the primary care were used as historical control groups. Findings.- A significant reduction in migraine days (P < .001), tension-type headache days (P < .001), frequency of migraine attacks (P = .004), and depression score (P < .001) was seen at the follow-up after 22 (+/-2) weeks. Comparing the intensive multidisciplinary program with primary care, repeated measures ANOVAs revealed significant time x group interactions for migraine days (P = .020), tension-type headache days (P = .016), and frequency of migraine attacks (P = .016). In comparison with the 20-hour multidisciplinary program, the 96-hour program showed significantly better effects only in the reduction of migraine days (P = .037) and depression score (P = .003). The responder-rates (>/=50% improvement) in the 96-hour program were significantly higher than in the 20-hour program (migraine days, P = .008; tension-type headache days, P = .044) and primary care (migraine days, P = .007; tension-type headache days, P = .003; tension-type headache intensity, P = .037). The effect sizes were small to medium in the 96-hour program. Particularly with the reduction of migraine symptomatology, the 96-hour program performed better than the 20-hour program, which produced only negligible or small effects. Conclusions.- Intensive multidisciplinary headache treatment is highly effective for patients with chronic headaches. Furthermore, migraine symptomatology responds especially well to this intensive treatment program, whereas effects on tension-type headaches were realized by both multidisciplinary programs. Randomized controlled trials and subgroup analysis are needed to find out if these results can be replicated and which patient characteristics allow for sufficient improvements for headache sufferers even with less complex treatment.

AJNR Am J Neuroradiol. 2009 May 20; Sharma A, Parsons MS, Pilgram TKBACKGROUND AND PURPOSE: Studies done mainly in adults have shown an association between annular tears and nuclear degeneration. We wanted to study this association in the pediatric population to better understand the natural history of disk degeneration in its early stages. We hypothesized that this association is discernible even at a young age and that annular tears precede nuclear degeneration. MATERIALS AND METHODS: Twenty-six children with back pain and known disk pathology were identified from our radiology report data base. Two neuroradiologists independently evaluated T12 through S1 intervertebral disks in these images. One reader evaluated the disks for the presence and type of annular tears. The other reader graded the signal intensity of the disks on an ordinal scale and the extent of disk degeneration on the Pfirrmann scale. Mean degeneration and signal-intensity grades were compared for disks with radial tears, disks with nonradial tears, and disks without annular tears. RESULTS: Fifty-six disks had radial tears. These demonstrated significantly higher nuclear degeneration grades and greater signal-intensity loss than disks with nonradial tears or disks with no annular tears. About one third (30.3%) of the disks with radial tears had a normal nuclear signal intensity. Only 3% of disks with a signal-intensity grade of >/=3 had an intact annulus. CONCLUSIONS: Nuclear degeneration in children is associated with radial annular tears and rarely occurs in the absence of annular tears.

J Sex Med. 2009 May; 6(5): 1474-8Köhler TS, Modder JK, Dupree JM, Bush NC, McVary KTIntroduction. Managing isolated scrotal pump erosion or infection in patients with inflatable penile prosthesis (IPP) is a challenging problem. We describe our malleable implant substitution technique to address this problem. Aim. The aim of this study was to describe and assess the outcomes of the malleable implant substitution technique. Methods. In this retrospective case series, six patients underwent removal of the infected and/or eroded scrotal pump, and replacement of the entire IPP with a malleable prosthesis. This procedure was only performed in men in the absence of penile pain on palpation or overwhelming sepsis. The procedure utilized components of the Mulcahy washout protocol with loose scrotal wound approximation and drains as necessary. Main Outcome Measures. The main outcome is a recurrent infection rate and prosthesis functionality of the malleable implant substitution technique. Results. All six men who underwent the procedure have done well and remain infection-free. Two men have undergone conversion from a malleable prosthesis back to IPP. Three are considering conversion to an IPP as they are satisfied with their current malleable prosthesis function. One man had a distal erosion of the malleable prosthesis that necessitated complete removal. Conclusions. We believe the malleable implant substitution technique provides an excellent option for management of isolated scrotal pump erosion or infection and prevents the problems associated with the other common management strategies.

Br J Cancer. 2009 May 26; Allan L, Baker L, Dewar J, Eljamel S, Grant RM, Houston JG, McLeay T, Munro AJ, Levack PThe aim of the study was to achieve earlier diagnosis of malignant cord compression (MCC) using urgent magnetic resonance imaging (MRI) for selected patients. A comparison was carried out of the current prospective audit of 100 patients referred by a general practitioner or a consultant over 32 months with both a previous national Clinical Research and Audit Group (CRAG) prospective audit (324 cases of MCC) and an earlier retrospective audit of 104 patients referred with suspected MCC. A telephone hotline rapid-referral process for patients with known malignancy and new symptoms (severe nerve root pain +/- severe back pain) was designed. Patients were considered for urgent MRI after discussion with a senior clinician responsible for the hotline. Appropriate referrals were discussed with radiology and oncology ensuring timely MRI reporting and intervention. The main outcome measures are as follows: time from referral to diagnosis; time from the onset of symptoms to diagnosis; and mobility at diagnosis. A total of 50 patients (52%) of those scanned had either MCC (44) or malignant nerve root compression (6) compared with the earlier rate of 23 out of 104 patients (22%). Ten out of 44 MCC patients (23%) were paralysed at diagnosis, compared with 149 out of 324 (46%) in the CRAG audit. Time from reporting pain to diagnosis was 32 days compared with 89 days in the CRAG audit. Median time from referral to diagnosis was 1 day, again considerably shorter than the CRAG audit time of 15 days (interquartile (IQ) range: 3-66). In patients at risk of MCC, fast-track referral with rapid access to MRI reduces time between symptom onset and diagnosis, improves mobility at diagnosis and reduces the number of negative MRI scans.British Journal of Cancer advance online publication, 26 May 2009; doi:10.1038/sj.bjc.6605079 www.bjcancer.com.

Arch Orthop Trauma Surg. 2009 May 27; Schofer MD, Efe T, Timmesfeld N, Kortmann HR, Quante MINTRODUCTION: As life expectancy in the population rises, osteoporotic fractures are seen most frequently in the proximal femur and the vertebral column. In balloon kyphoplasty and vertebroplasty, we have two minimally invasive treatment procedures available. Although they have both been controversially discussed in studies, they have seldom been directly compared. MATERIALS AND METHODS: Between 2002 and 2004, patients with fresh thoracic or lumbar single-segment vertebral compression fractures not involving neurological deficits were treated by balloon kyphoplasty (n = 30) or vertebroplasty(n = 30) using PMMA cement, and the results of the two interventions were compared in a prospective, nonrandomised cohort study. Surgery was indicated when patients had painful, dislocated fractures of type A1 and type A3 according to Magerl's classification. The outcome of treatment was assessed with special reference to the angle of kyphosis, back pain (VAS), health-related quality of life (SF-36) and complications. RESULTS: At the time of the follow-up examination, significant improvement in the angle of kyphosis was found to have been achieved both by kyphoplasty and by vertebroplasty (P < 0.001 and P = 0.002, respectively). Comparison showed that correction of the angle was significantly (P < 0.001) better in the kyphoplasty group. Both surgical procedures led to significant (P < 0.001) attenuation of the patients' pain; no difference was observed between the groups in the degree of pain relief achieved. There was no demonstrable correlation in either group between the preoperative pain experienced by the patients and the degree of dislocation of their fractures. In both study groups, the quality of life was in keeping with that of a reference group matched for age and sex. Cement leakage was observed in 7% of patients after kyphoplasty and in 33% of patients after vertebroplasty (P = 0.021). Adjacent-level fractures were checked for, but occurred in only one patient in the vertebroplasty group. CONCLUSION: The two surgical procedures were both followed by significant pain relief, and the quality of life was similar regardless of the procedure used. Balloon kyphoplasty led to an ongoing reduction of freshly fractured vertebrae and was followed by a lower rate of cement leakage.

JAMA. 2009 May 27; 301(20): 2099-110Kroenke K, Bair MJ, Damush TM, Wu J, Hoke S, Sutherland J, Tu WCONTEXT: Pain and depression are the most common physical and psychological symptoms in primary care, respectively. Moreover, they co-occur 30% to 50% of the time and have adverse effects on quality of life, disability, and health care costs. OBJECTIVE: To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression. Design, Setting, and PATIENTS: Randomized controlled trial (Stepped Care for Affective Disorders and Musculoskeletal Pain [SCAMP]) conducted at 6 community-based clinics and 5 Veterans Affairs general medicine clinics in Indianapolis, Indiana. Recruitment occurred from January 2005 to June 2007 and follow-up concluded in June 2008. The 250 patients had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity (Patient Health Questionnaire 9 score >/=10). INTERVENTION: Patients were randomly assigned to the intervention (n = 123) or to usual care (n = 127). The intervention consisted of 12 weeks of optimized antidepressant therapy (step 1) followed by 6 sessions of a pain self-management program over 12 weeks (step 2), and a continuation phase of therapy for 6 months (step 3). MAIN OUTCOME MEASURES: Depression (20-item Hopkins Symptom Checklist), pain severity and interference (Brief Pain Inventory), and global improvement in pain at 12 months. RESULTS: At 12 months, 46 of the 123 intervention patients (37.4%) had a 50% or greater reduction in depression severity from baseline compared with 21 of 127 usual care patients (16.5%) (relative risk [RR], 2.3; 95% confidence interval [CI], 1.5-3.2), corresponding to a much lower number of patients with major depression (50 [40.7%] vs 87 [68.5%], respectively; RR, 0.6 [95% CI, 0.4-0.8]). Also, a clinically significant (>/=30%) reduction in pain was much more likely in intervention patients (51 intervention patients [41.5%] vs 22 usual care patients [17.3%]; RR, 2.4 [95% CI, 1.6-3.2]), as was global improvement in pain (58 [47.2%] vs 16 [12.6%], respectively; RR, 3.7 [95% CI, 2.3-6.1]). More intervention patients also experienced benefits in terms of the primary outcome, which was a combined improvement in both depression and pain (32 intervention patients [26.0%] vs 10 usual care patients [7.9%]; RR, 3.3 [95% CI, 1.8-5.4]). CONCLUSION: Optimized antidepressant therapy followed by a pain self-management program resulted in substantial improvement in depression as well as moderate reductions in pain severity and disability. Trial Registration clinicaltrials.gov Identifier: NCT00118430.

Aust J Physiother. 2009; 55(2): 115-21Slade SC, Molloy E, Keating JLQuestion: What factors do participants in exercise programs for chronic low back pain perceive to be important for engagement and participation? Design: Qualitative study of three focus groups. Participants: 18 adults with chronic low back pain who had participated in exercise programs for chronic low back pain. Results: All focus group results concurred and two significant themes emerged from the focus group data. The first was that the experience of exercise informed participant preferences with respect to exercise environment and type of exercise. Participants described a range of positive and negative experiences, a desire to master exercise techniques, and a preference for exercise that matched their abilities and prior skills. The second significant theme was the helpful and empowering skills of the care-provider, and care-seeker ability to identify and articulate their own needs. Participants regarded carer expertise favourably when positive results were achieved early in the interaction, but were frustrated when they were not listened to and symptoms were aggravated. The relationship was enhanced by effective communication. Participants also recognised they needed to be aware of their own skills and abilities and, and that financial or family support incentives encouraged their adherence to a program. Conclusion: People are likely to prefer and participate in exercise programs that are designed with consideration of their preferences, circumstances, and past exercise experiences. We propose that information about patient exercise preferences should be collected systematically.

Clin J Pain. 2009 Jun; 25(5): 356-64Mangels M, Schwarz S, Worringen U, Holme M, Rief WOBJECTIVES: The aim of this randomized controlled study was to investigate whether additional psychologic interventions in the context of multidisciplinary inpatient pain treatment increases treatment efficacy compared with normal orthopedic rehabilitation. In addition, we aimed to demonstrate the additional benefit of a subsequent maintenance program in further stabilizing treatment successes. METHODS: We randomly assigned 363 chronic back pain patients to 1 of 3 treatment conditions: traditional orthopedic rehabilitation, multidisciplinary (behavioral-medical) rehabilitation alone, and multidisciplinary rehabilitation with subsequent booster sessions. Pain disability, depression, self-efficacy, health status, life satisfaction, and coping strategies were assessed at admission, discharge, and 12 months follow-up. The completion rate was 94%. RESULTS: All 3 treatment conditions were effective in improving core outcome measures in chronic back pain patients in the short term. The results were almost maintained at follow-up (small-to-medium within-group effect sizes). Significant advantages in favor of behavioral-medical interventions were found on almost all pain coping strategies and depression compared with traditional orthopedic rehabilitation. We found only slight advantages for the behavioral-medical treatment with subsequent booster sessions compared with the condition without a further maintenance program. DISCUSSION: The results concerning the efficacy of the multidisciplinary treatment are in accordance with former meta-analyses. Surprisingly, the findings suggest that the presented traditional orthopedic treatment was inherently very effective. The implications of these findings are discussed with respect to the benefit of additional psychologic interventions and the benefit of aftercare approaches for chronic pain patients.

Aust J Physiother. 2009; 55(2): 97-104Fanucchi GL, Stewart A, Jordaan R, Becker PQuestion: Does an eight-week exercise program reduce the intensity and prevalence of low back pain in 12-13 year old children? Does it decrease the childhood physical risk factors for low back pain and promote a sense of well-being? Design: Randomised trial with concealed allocation and assessor blinding. Participants: Seventy-two 12-13 year old children, who had complained of low back pain in the past three months. Intervention: The experimental group completed eight exercise classes of 40-45 minutes duration over eight weeks conducted by a physiotherapist, whilst the control group received no intervention. Outcome measures: The primary outcome was pain intensity measured on a 10-cm visual analogue scale. Secondary outcomes included 3-month prevalence of pain, childhood physical risk factors for low back pain, and sense of well-being. Measures were taken at baseline (Month 0), post-intervention (Month 3), and three months later (Month 6). Results: Pain intensity over the past month had decreased by 2.2 cm (95% CI 1.0 to 3.5) more for the experimental group than the control group at Month 3 and was still 2.0 cm (95% CI 0.5 to 3.5) less than the control group at Month 6. The absolute risk reduction for 3-month prevalence in low back pain in the experimental group was 24% (95% CI 4 to 41) compared with the control group at Month 3, and 40% (95% CI 18 to 57) at Month 6. There were also statistically-significant between-group differences in neural mobility. Conclusion: Exercise is effective in reducing the intensity and prevalence of low back pain in children. Trial registration: Clinical trials NCT00786864.

Eur J Pain. 2009 May 23; Bernardes SF, Lima MLLiving with chronic pain may be a threatening experience to one's own gender identity. Findings suggest that the presence of chronic pain does not allow individuals to achieve the most valued standards of being male or female in our societies. Such contention, however, has not yet been empirically supported. Therefore, our goal was to explore laypeople's and nurses' perceptions of the man/woman with chronic low-back pain (CLBP) as compared to the typical man/woman, respectively. Three hundred and sixteen laypeople (52.8% women) and 161 nurses (54% women) participated in this study. Half of the participants were presented with a written vignette depicting a man/woman with CLBP, followed by a list of 33 traits of the masculine and feminine stereotypes. Participants evaluated the extent to which each trait fit their image of the man/woman with CLBP. The other half of the participants described the image people in general had of the typical man/woman using the same list of traits. This study consisted on a quasi-experimental design, 2 (character's sex)x2 (type of character)x2 (participant's sex)x2 (health-care training). Results have generally supported our hypotheses. Both laypeople and nurses perceived: (1) the man with CLBP as having less masculinity and more femininity-related traits than the typical man; (2) the woman with CLBP as having less femininity and more masculinity-related traits than the typical woman; and (3) the man and woman with CLBP as more similar to each other than the typical man/woman. Issues on gender identity conflicts in CP patients are discussed.

Aten Primaria. 2009 May 20; Alvarez Theurer E, Llergo Muñoz A, Vaquero Abellán MOBJECTIVE: To analyse the length of sick leave (SL) and its associated factors in Andalusia. DESIGN: Descriptive observational study. SETTING: Andalusia. PARTICIPANTS: A total of 1,633,405 sick leave forms issued from the 1st January 2002 to the 31st of December 2006 for any reason by Primary Health Care doctors in the Public Health Service, were analysed. MAIN MEASUREMENTS: Descriptive and bivariate analysis of SL health complaints and their length according to gender, rural or urban environment, Social Security scheme, diagnosis and reason for discharge. A model of multiple lineal regression was completed. RESULTS: The overall incidence of SL was 15.83 health complaints per 100 Social Security members per year (14.73 in males and 17.24 in women). The most frequent diagnoses for the SL were, lower back pain and the common cold. The mean length of the SL health complaint episodes in men was lower than that of women by 7 days. The majority of the SL health complaints were resolved in less than one month (71.7%). The SL complaints that lasted longer were: endocrine diseases and immune disorders, neoplasms and mental disorders. The mean length of SL is higher in the rural environment (45.4) compared to urban (36.9). The variables that predict the length of sick leave in the model were gender, age and address location. CONCLUSIONS: Different factors to the diagnosis have a large influence on the length of SL. The main variables that affect this are, age, gender and a rural environment.

Br J Sports Med. 2009 May 21; Giannetti BM, Staiger C, Bulitta M, Predel HGThe objective was to show the superiority of Comfrey root extract ointment (Kytta-Salbe(R) f; Merck Selbstmedikation GmbH) to placebo ointment in patients with acute upper or low back pain. The study was conducted as a double-blind, multi-centre, randomised clinical trial with parallel group design over a period of 5 +/- 1 days. The patients (n = 120, mean age 36.9 years) were treated with verum or placebo ointment three times a day, 4 g ointment per application. The trial included four visits. The primary efficacy variable was the area-under-the-curve (AUC) of the Visual Analogue Scale (VAS) on active standardised movement values at visits 1 to 4. The secondary efficacy variables were back pain at rest using assessment by patient on VAS, pressure algometry (pain-time curve; AUC over 5 days), global assessment of efficacy by the patient and the investigator, consumption of analgesic medication, and functional impairment measured with the Oswestry Disability Index. There was a significant treatment difference between Comfrey extract and placebo regarding the primary variable. In the course of the trial the pain intensity on active standardised movement decreased on average (medians) about 95.2 % in the verum group and 37.8 % in the placebo group. The results of this clinical trial were clear-cut and consistent across all primary and secondary efficacy variables. Comfrey root extract showed a remarkably potent and clical relevant effect in reducing acute back pain. For the first time, also a fast acting effect of the ointment (1 hour) has been witnessed.

Sao Paulo Med J. 2009 Jan; 127(1): 52-54Madureira PR, De Capitani EM, Vieira RJ, Sakuma AM, Toledo AS, Mello SMCONTEXT: Lead poisoning due to retained gunshot bullets is a well-known clinical problem that is fairly frequently described in the literature. The risk factors for this occurrence relate mainly to whether the lead bullet is in contact with the joint fluid or cerebrospinal fluid (CSF). The treatment for these cases entails chelation therapy while symptoms are shown and definitive surgical removal of the bullet as a potential source of lead. The aim of this paper is to describe a clinical case of lead poisoning due to a retained gunshot bullet in contact with CSF. CASE REPORT: A 42-year-old male was hit by gunshot bullets during a holdup, and one of them was retained in the spinal cord. Six years later, he developed intense low back pain and underwent laminectomy. Nine years later, he then underwent arthrodesis on L5-S1, but he developed intense abdominal pain after the surgical procedure. For five years, he was treated with calcium versenate in five-day cycles, with a good response. The chelation therapy cycles showed great efficacy during symptomatic periods, thus reducing the symptoms and signs of poisoning and promoting great amounts of lead excretion, thereby reducing the total lead burden responsible for the symptoms. Fortunately, over the last four years, the symptoms have improved and the urine levels of aminolevulinic acid (ALA) have declined, to reach complete normalization. This shows that a healing process is probably taking place on the spinal wound, thereby isolating the bullet fragments from CSF contact.

BJOG. 2009 May 12; Hutton EK, Kasperink M, Rutten M, Reitsma A, Wainman BBackground Up to one-third of labouring women will experience painful 'back labour'. Sterile water injected lateral to the lumbosacral spine is a simple and well-researched approach to this pain. Objective To determine if sterile water injection for low back pain compared to placebo or alternative therapy increased or decreased the rate of Caesarean section. Search strategy We performed a literature search with no language restriction in four databases: the Cochrane library, EMBASE (1980-2009), Ovid Medline (1950-2009) and CINAHL (1982-2009). Selection criteria We included all randomised controlled trials (RCTs) of sterile water injection for labour pain that included outcomes of interest and original data. Data collection and analysis We compared Caesarean section rates among women who received sterile water injection in labour with those who received either placebo treatment or another non-pharmacological treatment modality. Other outcomes included pain scores, use of regional analgesia and women's assessment of treatment. We used Revman 5 for the meta-analysis. Data were entered by one reviewer and independently cross-checked. Pooled outcomes were reported as Relative Risk (RR) or Weighted Mean Difference using Mantel-Haenszel fixed-effects model except when the I(2) value >50% indicated significant heterogeneity in which case random-effects model was used. Main results We included eight RCTs. The Caesarean section rate was 4.6% in the sterile water injection group and 9.9% in the comparison group (n = 828) (RR 0.51, 95% CI: 0.30, 0.87). Conclusion We believe that a large RCT should be mounted to validate our findings regarding the impact of sterile water injections on mode of delivery.

J Neurosci. 2009 May 20; 29(20): 6691-9Akiyama T, Merrill AW, Carstens MI, Carstens EItch, an unpleasant sensation associated with the desire to scratch, is symptomatic of dermatologic and systemic disorders that often resist antihistamine treatment. Histamine-independent itch mediators include serotonin (5-HT) and agonists of the protease-activated receptor-2 (PAR-2). We used behavior, Fos immunohistochemistry, and electrophysiology to investigate if these mediators activate spinal dorsal horn neurons in a manner consistent with itch. Intradermal (i.d.) injection of the PAR-2 agonist SLIGRL-NH(2) in the rostral back evoked bouts of directed hindlimb scratches over 20-30 min. Hindpaw injection of SLIGRL-NH(2) produced Fos staining in superficial dorsal horn which was then targeted for single-unit recording. Small id microinjections of SLIGRL-NH(2) or 5-HT identified responsive single units in the superficial dorsal horn of mice anesthetized with pentobarbital. Thirty-eight units characterized as wide dynamic range, nociceptive specific, or mechanically insensitive exhibited significantly increased firing after i.d. SLIGRL-NH(2) for 9 min, to partial (25%) tachyphylaxis with repeated injection. A majority additionally responded to 5-HT (70%), mustard oil (79%), and capsaicin (71%). Seven units isolated with the 5-HT search stimulus exhibited significant and prolonged responses to 5-HT with tachyphylaxis to repeated injections. The majority also responded to SLIGRL-NH(2), mustard oil, and capsaicin. The prolonged responses of superficial dorsal horn neurons to SLIGRL-NH(2) and 5-HT suggest a role in signaling itch. However, their responsiveness to algogens is inconsistent with itch specificity. Alternatively, such neurons may signal itch, whereas noxious stimulus levels recruit these and a larger population of pruritogen-insensitive cells to signal pain which masks or occludes the itch signal.

J Endovasc Ther. 2009 Apr; 16(2): 233-7Go MR, Baril DT, Leers SA, Chaer RAPurpose: To present two cases of lower extremity paraplegia associated with acute iliocaval thrombosis successfully treated with thrombolysis. Case Reports: A 36-year-old morbidly obese woman with a history of lower extremity deep venous thrombosis (DVT), pulmonary embolism (PE), and inferior vena cava (IVC) filter placement 4 years prior presented with back pain. Imaging showed iliac vein engorgement consistent with thrombosis and common femoral vein DVT bilaterally. She was started on intravenous heparin but developed marked lower extremity weakness while anticoagulated. Given these progressive symptoms, systemic tissue plasminogen activator was administered, with subsequent improvement over 48 hours. At 6-month follow-up, she was living independently, with near normal strength and sensation in her lower extremities. While hospitalized following an assault, a 55-year-old man with a history of factor V Leiden, DVT/PE, and prior IVC filter developed marked left lower extremity swelling, which progressed to severe bilateral lower extremity edema and mottling, along with sensory and motor loss of the lower extremities. Lower extremity duplex confirmed extensive DVT extending from the level of the iliac veins down to the tibial vessels. He underwent successful pharmacomechanical thrombectomy. At 6 months, he was walking normally, with no residual neurological symptoms and no evidence of DVT. Conclusion: Acute cauda equina syndrome related to iliocaval thrombosis and epidural variceal engorgement presenting with complete paraplegia has not to our knowledge been reported. Pharmacomechanical thrombectomy affords an opportunity to achieve complete iliocaval clearance in a single procedure and is well-suited to cases in which neural infarction is imminent.

Clin J Pain. 2009 Jun; 25(5): 431-7Gerbershagen K, Gerbershagen HJ, Lutz J, Cooper-Mahkorn D, Wappler F, Limmroth V, Gerbershagen MOBJECTIVES: This study was designed to provide a cross-sectional analysis of pain prevalence, chronicity, and severity as well as the impact of pain on psychological and social variables in inpatients in various departments of a German teaching hospital. METHODS: Patients were asked to complete a questionnaire including sections on sociodemographic and socioeconomic data, pain variables, recent and past health care utilization, and screening questionnaires for depression, anxiety, and health-related quality of life. RESULTS: Of the 438 patients, 386 (88.1%) had experienced pain in the past 12 months; 367 (83.8%) reported having pain in the previous 3 months. Sixty-four percent of the pain patients stated that pain was the main reason for hospital admission; 48% reported having three or more pain sites. The most common location of pain was the back (26.9%). Pain patients showed significantly higher depression and anxiety scores and markedly reduced physical health when compared to non-pain patients. DISCUSSION: The results of this study indicate that in most medical disciplines pain is more than merely a symptom of disease. In many instances pain should be considered a serious comorbidity that can influence the outcome of medical and surgical treatment. Recent research has shown that prevention of the pain chronification process is the most promising strategy for avoiding the development of intractable pain. Acceptance, recognition, and assessment of pain as a risk factor at an early stage are essential factors. A first step might involve routine screening for pain on admission to any hospital facility, and subsequently evaluating the impact of pain on biopsychosocial functions.

Spine. 2009 May 20; 34(12): 1301-6Hicks GE, Morone N, Weiner DKSTUDY DESIGN: A case-control study of older adults with and without chronic low back pain (CLBP). OBJECTIVE: Compare and describe the radiographic severity of degenerative disc and facet disease in the lumbosacral spine of community-dwelling older adults with and without CLBP and to examine the relationship between spinal pathology and pain. SUMMARY OF BACKGROUND DATA: Degenerative spinal pathology is often implicated as the primary reason for CLBP in older adults. Despite evidence that spinal pathology may be ubiquitous in older adults regardless of pain status, radiography continues to be heavily used in the diagnostic process. METHODS: Participants in this case-control study included 162 older adults (> or =65) with CLBP and an age and gender matched pain-free group of 158 people. CLBP was characterized as pain of at least moderate intensity occurring daily or almost everyday for at least 3 months. Radiographic severity of disc and facet disease was graded using a reliable and valid system. RESULTS: Results demonstrated that the presence of degenerative disc and facet pathology in older adults is ubiquitous, regardless of clinical status, with greater than 90% demonstrating some level of degeneration. Higher radiographic severity scores were associated with the presence of CLBP. In fact, presence of severe disc pathology was associated with 2-fold greater odds of having CLBP. But, radiographic severity of disc and facet disease was not associated with pain severity among those with CLBP. CONCLUSION: From a research perspective, radiographic evaluation of spinal pathology provides additional information about older adults with CLBP compared to pain-free individuals, but its clinical utility for diagnostic purposes is still in question.

Transfusion. 2009 May 11; Daniel-Johnson J, Leitman S, Klein H, Alter H, Lee-Stroka A, Scheinberg P, Pantin J, Quillen KBACKGROUND: Hemolytic transfusion reactions (HTRs) can occur with transfusion of platelets (PLTs) containing ABO-incompatible plasma. Reported cases have involved group O donors. Two cases of PLT-mediated HTRs associated with the same group A plateletpheresis component, collected from a donor taking high doses of probiotics are reported. CASE REPORT: Case 1 was a 40-year-old 69-kg group B stem cell transplant patient who received one-half of a group A plateletpheresis component. Severe back pain occurred 10 minutes into the transfusion, accompanied by anemia and hyperbilirubinemia. Case 2 was a 5-year-old 26-kg group B male with aplastic anemia who received the other half of the same plateletpheresis component, volume reduced to 37 mL. Syncope occurred immediately after the transfusion, with laboratory evidence of hemolysis a few hours later. RESULTS: Serologic investigation of posttransfusion samples from both patients revealed positive direct antiglobulin tests: C3d only for Case 1 and immunoglobulin (Ig)G and C3d for Case 2; the eluates contained anti-B. The group A donor's anti-B titer was 16,384 at saline and IgG phases. Donor lookback revealed that the donor had donated 134 apheresis PLTs over many years. For 3 years, he had intermittently taken probiotics; 3 weeks before the index donation, he began taking three tablets of probiotics every day. Lookback of prior group B recipients uncovered a case of acute hemolysis that was not recognized at the time. The solubilized probiotic inhibited anti-B in vitro. CONCLUSION: Non-group O PLT donors can have high-titer anti-A or anti-B that might mediate HTRs, and probiotic ingestion in blood donors represents a novel mechanism of stimulating high-titer anti-B.

Pain Physician. 2009 May-Jun; 12(3): 541-59Manchikanti L, Glaser SE, Wolfer LR, Derby R, Cohen SPBACKGROUND: The intervertebral disc has been implicated as an etiology of chronic lumbar spine pain based on clinical, basic science, and epidemiological research. However, there is lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, the lumbar intervertebral discs have been shown to be sources of chronic back pain without disc herniation in 26% to 39%. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, controversy continues about provocation lumbar discography. STUDY DESIGN: A systematic review of the lumbar provocation discography literature. OBJECTIVES: To systematically assess the diagnostic accuracy of lumbar discography. METHODS: A systematic review of the literature was performed to assess the diagnostic accuracy of lumbar discography with respect to chronic low back pain. Study inclusion/exclusion criteria were based on International Association for the Study of Pain (IASP) standards with pain provocation and determination of controlled discs. Selected studies were then subjected to a rating instrument for diagnostic accuracy studies. Specific data were then culled from these studies and tabulated. Quality of evidence was assessed using modified Agency for Healthcare Research and Quality (AHRQ) diagnostic accuracy evaluation. Studies meeting methodologic quality criteria scores of 50 or higher were included in the assessment of the level of evidence. Qualitative analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II. The rating scheme was modified to evaluate the diagnostic accuracy. RESULTS: Based on a modified U.S. Preventive Services Task Force (USPSTF) level of evidence criteria, this systematic review indicates the strength of evidence as Level II-2 for the diagnostic accuracy of lumbar provocation discography utilizing IASP criteria. LIMITATIONS: Limitations include a paucity of literature, poor methodologic quality, and very few studies performed utilizing IASP criteria. CONCLUSION: Based on the current systematic review, lumbar provocation discography performed according to the IASP criteria with control disc (s) with minimum pain intensity of 7 of 10, or at least 70% reproduction of worst pain (i.e. worst spontaneous pain of 7 = 7 x 70% = 5) may be a useful tool for evaluating chronic lumbar discogenic pain. Discography is an important imaging and pain evaluation tool in identifying a subset of patients with chronic low back pain secondary to intervertebral disc disorders.

Spine. 2009 May 20; 34(12): 1287-91Cakir B, Carazzo C, Schmidt R, Mattes T, Reichel H, Käfer WSTUDY DESIGN: Retrospective radiographic analysis of lumbar spine range of motion (ROM) after monosegmental fusion and posterior dynamic stabilization at the level L4-L5. OBJECTIVE: Comparison of segmental ROM at the index level and the cranial and caudal adjacent levels and of global lumbar spine ROM after monosegmental fusion and posterior dynamic stabilization. SUMMARY OF BACKGROUND DATA: The postulated advantage of nonfusion technology compared with fusion is based on the assumption that preservation of motion at the treated segment reduces the incidence of adjacent segment effects. Therefore, it is imperative to provide evidence that dynamic stabilization devices avoid hypermobility at the adjacent segments because this might substantiate a protective effect on the adjacent segments. METHODS: Twenty-six patients with low back pain and claudication due to degenerative instability at the level L4-L5 with concomitant spinal stenosis were treated either with decompression and Dynesys (n = 11) or with decompression and fusion (n = 15). All patients underwent flexion/extension radiographs before surgery and at latest follow-up. ROM was assessed at the index level (L4-L5), the cranial/caudal adjacent levels (L3-L4/L5-S1), and at the lumbar spine from L2 to S1. RESULTS: There was a significant reduction of the global ROM of the lumbar spine (L2-S1) and the segmental ROM at the index level (L4-L5) in the fusion group, whereas adjacent level ROM did not change significantly. In the Dynesys group, no significant changes of global lumbar spine ROM (L2-S1) and segmental ROM (index level and cranial/caudal adjacent levels) were seen. CONCLUSION: This study shows that neither monosegmental instrumented fusion nor monosegmental posterior dynamic stabilization with Dynesys alter the ROM of the cranial and caudal adjacent levels. Consequently, monosegmental posterior dynamic stabilization with Dynesys has no effect with regard to adjacent segment mobility compared with monosegmental fusion.

Clin J Pain. 2009 Jun; 25(5): 376-85Wymer JP, Simpson J, Sen D, Bongardt S, OBJECTIVES: The aims of this multicenter, randomized, placebo-controlled, double-blind trial were to confirm the efficacy of lacosamide at a daily dose of 400 mg/d and to explore the efficacy, safety, and tolerability of lacosamide 200 mg/d and 600 mg/d in the treatment of painful diabetic neuropathy. METHODS: The trial consisted of a 2-week run-in period, a 6-week titration phase, and a 12-week maintenance phase, during which patients received placebo or fixed doses of lacosamide 200, 400, or 600 mg/d. No back titration was allowed during the trial. The primary efficacy criterion was the change in Likert pain score from baseline to the average over the last 4 weeks of the maintenance phase in the intent-to-treat population. RESULTS: The lacosamide 400 mg/d group demonstrated statistically significant improvement in Likert pain score over placebo for the primary efficacy measure. At the end of treatment, 58% of patients in the lacosamide 400 mg/d treatment group achieved at least a 2-point or 30% reduction in Likert pain score, compared with 46% of placebo-treated patients. The lacosamide 200 mg/d group separated from placebo, but failed to show statistical significance for any of the primary or secondary outcome measures. The lacosamide 600 mg/d group was significantly more efficacious than placebo in the observed cases but not in the intent-to-treat population. This was probably secondary to a relatively high-premature withdrawal rate due to adverse events that occurred during the titration phase in that group. Overall lacosamide at daily doses of 200 to 400 mg was well tolerated, with 8% of patients discontinuing due to an adverse event from the 200 mg/d group and 23% from the 400 mg/d group compared with 9% in the placebo group. Discontinuations due to adverse events were highest in the 600 mg/d group (40%). The most common adverse events consisted of dizziness, nausea, tremor, headache, and fatigue. Somnolence, cognitive and behavioral side effects, weight change, and edema were notably low. DISCUSSION: Safety and efficacy analyses indicated that lacosamide 400 mg/d provided an optimal balance between efficacy and side effects in patients with painful diabetic neuropathy.

Spine. 2009 May 15; 34(11): 1233-8Van Daele U, Hagman F, Truijen S, Vorlat P, Van Gheluwe B, Vaes PSTUDY DESIGN: A 2-group experimental design. OBJECTIVE: To investigate differences in postural control strategies of pelvis and trunk movement between nonspecific chronic low back pain (CLBP) patients and healthy control subjects using 3-dimensional motion analysis. SUMMARY OF BACKGROUND DATA: Increased postural sway assessed by center of pressure displacements have been documented in patients with low back pain (LBP). The 3-dimensional movement strategies used by patients with LBP to keep their balance are not well documented. METHODS: Nineteen CLBP patients and 20 control subjects were included based on detailed clinical criteria. Every subject was submitted to a postural control test in an unstable sitting position. A 3-dimensional motion analysis system, equipped with 7 infrared M1 cameras, was used to track 9 markers attached to the pelvis and trunk to estimate their angular displacement in the 3 cardinal planes. RESULTS: The total angular deviation in all 3 directions of pelvis and trunk was higher in the CLBP group compared with the control group. In 4 of the 6 calculated differences, a significant higher deviation was found in the CLBP group (significant P-values between 0.013 and 0.047). Subjects of both groups mostly used rotation compared with lateral flexion and flexion/extension displacements of pelvis and trunk to adjust balance disturbance. The CLBP group showed a high correlation (Pearson: 0.912-0.981) between movement of pelvis and trunk, compared with the control group. CONCLUSION: A higher postural sway and high correlation between pelvis and trunk displacements was found in the LBP group compared with healthy controls.

Eur J Pain. 2009 May 12; Demoulin C, Ostelo R, Knottnerus JA, Smeets RJAlthough the Roland disability questionnaire (RDQ) is a commonly used questionnaire for patients with low back pain (LBP), several important issues remain understudied. The purposes of this study were to investigate the impact that several parameters (length of test-retest interval, interpretation of the global perceived effect (GPE) scores, methods to estimate standard error of measurement (SEM), intervention and baseline scores) have on various measurement properties, such as agreement (Limits of Agreement (LOA), SEM(agreement)), responsiveness (area under the ROC curve, sensitivity, specificity) and interpretability (optimal cut-off point, Minimal Detectable Change), of the RDQ. RDQ was administered four times to 212 patients with chronic non-specific LBP (first consultation (T-1), eligibility check (T0), randomization/start of treatment (T1) and end of treatment (T2)). They also completed a GPE scale at T2. To study the influence of length of test interval between T-1, T0 and T1, six time intervals were assessed. Analyses of the impact of parameters on responsiveness and interpretability were based on the GPE score and on RDQ score changes (T1 versus T2). Results revealed that agreement parameters decreased with increasing time interval between test-retest. They confirmed the influence of the interpretation of the GPE as well as of the method to calculate the SEM on the magnitude of the Minimal Detectable Change and ROC parameters. Baseline RDQ scores and the way to cluster patients with regard to baseline scores influenced mainly the optimal cut-off point and responsiveness parameters; intervention did not affect the magnitude of the Minimal Detectable Change.

J Emerg Nurs. 2009 Jun; 35(3): 191-8Milbrett P, Halm MINTRODUCTION: Although frequent ED users account for a small percentage of ED visits, these patients can drain the system, contributing to overcrowding and lowered quality of care. METHODS: This retrospective descriptive correlational study explored characteristics of frequent ED users at a large Midwestern urban hospital and factors predictive of high ED utilization. The sample included adult patients with at least 6 visits in 2005-2006 (N = 201). For each, 6 visits were randomly chosen for chart review (N = 1200 visits) of demographic, health history, and clinical factors such as chief complaints. RESULTS: Frequent users were commonly female, 35 years old, white, single, unemployed, living alone, with private insurance/Medicaid and a primary care physician. Top chief complaints were abdominal pain, headache, chest pain, low back pain, and lower extremity pain. However, a Poisson regression found that the following characteristics were associated with a higher number of ED visits: male, non-Black race, part-time employment, retired/unemployed, having Medicare, and having a chief complaint of upper respiratory infection. Headache approached significance as an independent predictor of more visits. DISCUSSION: Almost 95% had fewer than 10 ED visits per year, with pain the overall top chief complaint. Seventy percent of frequent visits occurred during either the evening or night shift, perhaps indicating access issues to primary physicians or urgent care clinics. The rate of frequent users was comparable with other investigations, yet few similarities in patient characteristics and predictors of high ED utilization were found, partly because of the retrospective design, but certainly reinforcing limited generalizability of ED utilization patterns across centers in different metropolitan and geographic regions.

Spine J. 2009 May 15; Dimar JR, Glassman SD, Burkus JK, Pryor PW, Hardacker JW, Carreon LYBACKGROUND CONTEXT: Reported fusion rates for spine fusions using iliac crest bone graft (ICBG) vary between 40% and 100% because of different fusion techniques, patient comorbidity, diagnosis and assessment criteria. PURPOSE: We report two-year results of single-level instrumented posterolateral fusions evaluated with radiographs, fine-cut computed tomography (CT) scans with reconstructions and outcome measures. STUDY DESIGN/ SETTING: Retrospective analysis of data from a prospective multicenter randomized clinical controlled trial. PATIENT SAMPLE: Patients with various degenerative diagnoses enrolled in the control arm of a Food and Drug Administration (FDA)-regulated, multicenter trial of single-level decompression and posterolateral fusion for degenerative lumbar disease. OUTCOME MEASURES: Short Form-36 (SF-36), Oswestry Disability Index (ODI), Numeric Rating Scales (0-20) for back, leg, and graft site pain, CT scans, anteroposterior and lateral flexion/extension radiographs. METHODS: Patients enrolled in an FDA-regulated, multicenter trial at 29 sites with degenerative lumbar disease treated with single-level instrumented posterolateral fusion with ICBG were included in the analysis. Demographic and surgical data were collected. Clinical outcomes were followed using standard metrics. Fusion was assessed by independent radiologists at 6, 12, and 24 months postoperatively. Two fusion criteria were compared: anteroposterior and flexion/extension radiographs to assess motion and bridging bone, with CT scans as needed to confirm bridging bone; and CT scan assessment for bridging bone only. RESULTS: One hundred ninety-four of 224 subjects (86.6%) completed the study. The mean operative time was 2.9 hours with a blood loss of 448.6mL. The average graft volume was 36.3mL. There were 21 (9.4%) wound infections, 18 (8.0%) incidental durotomies, 3 (1.3%) implant displacements, 2 (0.9%) malpositioned implants, and 17 (7.6%) graft-related complications. Twenty-seven patients (13.9%) required reoperation, the majority for nonunions. Fusion rates based on radiographs with selective CTs at 6, 12, and 24 months were 65.3%, 82.5%, and 89.3%, respectively. Fusion rates based on bridging bone on CT scans were 56.1%, 71.5%, 83.9%, respectively. Two-year improvement for all outcome measures was significant (p

Spine. 2009 May 15; 34(11): 1192-1197Auvinen JP, Paananen MV, Tammelin TH, Taimela SP, Mutanen PO, Zitting PJ, Karppinen JISTUDY DESIGN.: A 2-year follow-up in a birth cohort of adolescents aged 15 to 19 years. OBJECTIVE.: To evaluate the prevalence of neck, shoulder, low back, peripheral (limb) pain, and combinations of pain at these anatomic locations. SUMMARY OF BACKGROUND DATA.: Few previous studies have evaluated combinations of musculoskeletal pain among adolescents. METHODS.: Prevalence of neck, shoulder, low back, and peripheral pain (elbow, wrist, knee, and ankle-foot pain) during the previous 6 months were obtained by questionnaire in a follow-up study of the Northern Finland Birth Cohort 1986 at 16 and 18 years of age (n = 1773). Latent class analysis was used in clustering of pain combinations at both time points. RESULTS.: No pain at all in the past 6 months at 16 and 18 years was reported by 17% and 8% of girls, and 33% and 24% of boys, respectively. Only 1 pain location (neck, shoulder, low back, or peripheral pain) was reported by 21% of girls and 25% of boys at 16, and 11% of girls and 20% of boys at 18 years, while all 4 pain locations were reported by 15% of girls and 9% of boys at 16, and 27% and 15%, respectively, at 18 years. Latent class analysis resulted in 2 to 3 pain clusters in both genders at both time points. Probability of pain increased during the 2-year follow-up, with subjects more likely to belong to a cluster with a higher likelihood of pain. CONCLUSION.: As very few adolescents did not report any pain, the relevance of self-reported pain is questionable without assessment of pain-related disability. The clinical relevance of these pain combinations must be evaluated in further studies.

J Tissue Eng Regen Med. 2009 May 14; Le Maitre CL, Fotheringham AP, Freemont AJ, Hoyland JALow back pain (LBP) is a major cause of disability worldwide that has been linked to intervertebral disc (IVD) degeneration. An improved understanding of the pathogenesis of disc degeneration is now developing, which is leading to the development of a number of possible future therapies targeted at the underlying pathology and regeneration strategies. Although results thus far are promising, the investigation of such therapies in an environment that mimics the mechanical environment of the human disc in vivo is problematic. The development of an in vitro model system that can maintain metabolically active IVD tissue within a loading environment pertaining to that of the human spine is crucial for testing the efficacy of future cell-based and tissue-engineering therapies for IVD degeneration. Here, using our novel loading rig, capable of mimicking the loading environment experienced within the human spine, we have cultured nucleus pulposus tissue explants, applied a daily hydrostatic loading regime for up to 2 weeks and investigated proteoglycan retention, metabolic activity and cellular phenotype. IVD tissue cultured under a loading environment pertaining to the in vivo loading environment maintained metabolic cell activity, proteoglycan content and cellular phenotype. Indeed, all parameters were improved in IVD tissue cultured with load compared to unloaded controls. Such a model is invaluable for investigations assessing the feasibility and efficacy of future therapeutic approaches to inhibiting degeneration or stimulating regeneration of the IVD, where the in vivo loading environment may be crucial to their success or failure. Copyright (c) 2009 John Wiley & Sons, Ltd.

Spine. 2009 May 15; 34(11): 1211-6Liu H, Tao H, Luo ZSTUDY DESIGN.: Translation, cross-cultural adaptation, and validation were performed on the Chinese version of the Oswestry Disability Index (ODI). OBJECTIVE.: The objective of this study was to translate and adapt the ODI into simplified Chinese and to then validate its use in Chinese patients with low back pain. SUMMARY OF BACKGROUND DATA.: A traditional Chinese version of the ODI (TCODI) has been developed and used in Hong Kong. However, there is no simplified Chinese version of the ODI (SCODI). METHODS.: Translation and cross-cultural adaptation of the latest version of the ODI (2.1a) were performed following instructions from the published international guidelines. The translation procedure included forward translation, back translation, and a discussion among experts. The prefinal version was tested in 40 outpatients with LBP. Then, 179 patients with LBP, including 140 outpatients and 39 inpatients, participated in the final test. They finished the SCODI, the Short-Form 36, and the Visual Analog Scale. Those 39 inpatients also finished a second ODI questionnaire within 24 hours. Last, the SCODI and TCODI were tested in another 25 inpatients for comparison. RESULTS.: All of the patients in the prefinal test understood the simplified Chinese version correctly. In the final test, Cronbach's alpha for internal consistency was 0.93. A very high intraclass correlation coefficient was observed (ICC = 0.99) in the test-retest group. The SCODI showed a significant correlation with the 8 subscales of the Short-Form 36, especially in physical functioning (r = 0.78, P < 0.001). There was a moderate correlation between the ODI scores and the Visual Analog Scale (r = 0.69, P < 0.001). A significant difference in the mean score was demonstrated between the SCODI and the TCODI. Patients who participated in the comparison test all agreed that the SCODI was easier to understand than the TCODI. CONCLUSION.: The results showed that the translation and adaptation were successful. The SCODI has proven to be valid and reliable when used in the simplified Chinese speaking population.

Arch Orthop Trauma Surg. 2009 May 14; Fan J, Yu GR, Liu F, Zhao J, Zhao WDINTRODUCTION: The aim of the study was to evaluate the biomechanical performance and clinical results of TSRH's Hook plus screw fixation after direct repair of spondylolysis defects in the pars interarticularis. MATERIALS AND METHODS: Biomechanical testing of eight calf cadaver lumbar spines were used to provide comparative biomechanical data on TSRH's Hook plus screw fixation, and for the intact and the destabilized spondylolytic spines, modified Scott's fixation, screw-rod construct and Buck's fixation were used. Eleven patients with bilateral spondylolysis were treated with segmental TSRH's Hook plus screw fixation and autogenous bone graft; after an average follow-up period of 28 months, the patients were reviewed. Conventional tomography and computed tomography scans were taken to assess the condition of the fixation and the healing of the bony defect separately. MR images were performed to assess the adjacent disk conditions. MacNab criteria were used to assess their pre- and postoperative status. RESULTS: Each fixation technique significantly increased stiffness and returned the intervertebral rotation stiffness nearly to intact levels. TSRH's Hook plus screw technique and screw-rod construct provided more rotational stability than the other two techniques. TSRH's Hook plus screw, pedicle rod construct and Buck's technique also provided more flexion/extension stability than the modified Scott's technique. Neither complications nor instrumentation failure was observed. Retrospective follow-up of patients showed complete radiographic healing but unilateral nonunion in one on CT scans and pain relief in all patients. MR images of lumbar spine showed no significant change of disk before and after the surgery. Excellent or good results were obtained in ten cases according to MacNab criteria, but fair results were obtained in case of unilateral nonunion. CONCLUSION: Biomechanical evaluation of the TSRH's Hook plus screw fixation showed excellent stability of the lumbar vertebrae. Excellent clinical results show direct repair of spondylolysis by TSRH's Hook plus screw fixation and bone grafting would be the alternative for treating patients with persistent back pain after 6 months of conservative treatment.

J Neurosurg Spine. 2009 May; 10(5): 496-9Xu H, Tang H, Li ZObject The transforaminal lumbar interbody fusion (TLIF) procedure was developed to provide the surgeon with a fusion procedure that may reduce many of the risks and limitations associated with posterior lumbar interbody fusion, yet produce similar stability in the spine. There are few large series with long-term follow-up data regarding instrumented TLIF and placement of 1 diagonal polyetheretherketone (PEEK) cage. The authors performed a prospective study to evaluate the outcome and safety of instrumented TLIF with 1 diagonal PEEK cage for degenerative spondylolisthesis in the Han nationality in China. Methods Between May 2001 and April 2006, 60 patients (35 men and 25 women; mean age 55.5 years, range 45-70 years) with symptomatic degenerative spondylolisthesis underwent the TLIF procedure with 1 diagonal PEEK cage and additional pedicle screw internal fixation at the authors' institution. The inclusion criteria involved degenerative spondylolisthesis (Grades I and II) in patients with chronic low-back pain with or without leg pain. Results One patient had a postoperative temporary motor and sensory deficit of the adjacent nerve root. Reoperation was required in 1 patient because of pedicle screw migration. One patient developed a pseudarthrosis and had increasing complaints of low-back pain 1 year postoperatively and underwent a subsequent revision surgery. Two patients had nerve root symptomatic compression resulting from cage migration and insufficient decompression after surgery, and they underwent revision. Two patients had a dural tear that required fibrin glue application during surgery. No implant fracture or subsidence occurred in any patient. Clinically, the pain index and Oswestry Disability Index (ODI) score improved significantly from before surgery to the 2-year follow-up. In the TLIF group, the pain index improved from 69 to 25 (p < 0.001). The postoperative ODI showed a significant postoperative reduction of disability during the whole period of follow-up (p < 0.001). The preoperative mean ODI score was 32.3 (16-80), and postoperative 13.1 (0-28). Disc space height and foraminal height were restored by the surgery and maintained at the latest follow-up time. Conclusions In the authors' experience, instrumented TLIF with 1 diagonal PEEK cage can be a surgical option for treatment of degenerative spondylolisthesis in the Han nationality in China.

J Neurosurg Spine. 2009 Apr; 10(4): 357-65Kong MH, Hymanson HJ, Song KY, Chin DK, Cho YE, Yoon do H, Wang JCObject The authors conducted a retrospective observational study using kinetic MR imaging to investigate the relationship between instability, abnormal sagittal segmental motion, and radiographic variables consisting of intervertebral disc degeneration, facet joint osteoarthritis (FJO), degeneration of the interspinous ligaments, ligamentum flavum hypertrophy (LFH), and the status of the paraspinal muscles. Methods Abnormal segmental motion, defined as > 10 degrees angulation and > 3 mm of translation in the sagittal plane, was investigated in 1575 functional spine units (315 patients) in flexion, neutral, and extension postures using kinetic MR imaging. Each segment was assessed based on the extent of disc degeneration (Grades I-V), FJO (Grades 1-4), interspinous ligament degeneration (Grades 1-4), presence of LFH, and paraspinal muscle fatty infiltration observed on kinetic MR imaging. These factors are often noted in patients with degenerative disease, and there are grading systems to describe these changes. For the first time, the authors attempted to address the relationship between these radiographic observations and the effects on the motion and instability of the functional spine unit. Results The prevalence of abnormal translational motion was significantly higher in patients with Grade IV degenerative discs and Grade 3 arthritic facet joints (p < 0.05). In patients with advanced disc degeneration and FJO, there was a lesser amount of motion in both segmental translation and angulation when compared with lower grades of degeneration, and this difference was statistically significant for angular motion (p < 0.05). Patients with advanced degenerative Grade 4 facet joint arthritis had a significantly lower percentage of abnormal angular motion compared to patients with normal facet joints (p < 0.001). The presence of LFH was strongly associated with abnormal translational and angular motion. Grade 4 interspinous ligament degeneration and the presence of paraspinal muscle fatty infiltration were both significantly associated with excessive abnormal angular motion (p < 0.05). Conclusions This kinetic MR imaging analysis showed that the lumbar functional unit with more disc degeneration, FJO, and LFH had abnormal sagittal plane translation and angulation. These findings suggest that abnormal segmental motion noted on kinetic MR images is closely associated with disc degeneration, FJO, and the pathological characteristics of interspinous ligaments, ligamentum flavum, and paraspinal muscles. Kinetic MR imaging in patients with mechanical back pain may prove a valuable source of information about the stability of the functional spine unit by measuring abnormal segmental motion and grading of radiographic parameters simultaneously.

Eur Spine J. 2009 May 15; Zagra A, Giudici F, Minoia L, Corriero AS, Zagra LGrob et al. (Eur Spine J 5:281-285, 1996) illustrated a new fixation technique in inveterate cases of grade 2-3 spondylolisthesis (degenerative or spondylolytic): a fusion without reduction of the spondylolisthesis. Fixation of the segment was achieved by two cancellous bone screws inserted bilaterally through the pedicles of the lower vertebra into the body of the upper slipped vertebra. Since 1998 we have been using this technique according to the authors' indications: symptomatic spondylolisthesis with at least 25% anterior slippage and advanced disc degeneration. Afterwards this technique was used also in spondylolisthesis with low reduction of the disc height and slippage less than 25%. In every case we performed postero-lateral fusion and fixation with two AO 6.5 Ø thread 16 mm cancellous screws. From 1998 to 2002 we performed 62 fusions for spondylolisthesis with this technique: 28 males (45.16%) and 34 females (54.84%), mean age 45 years (14-72 years). The slipped vertebra was L5 in 57 cases (92%), L4 in 2 cases (3.2%), L3 in 1 case (1.6%), combined L4 and L5 in 2 cases (3.2%). In all cases there was an ontogenetic spondylolisthesis with lysis. Lumbar pain was present in 22 patients and lumbar-radicular pain was present in 40 patients. The mean preoperative VAS was 6.2 (range 5-8) for lumbar pain, and 5.5 (range 4-7) for leg pain. The fusion area was L5-S1 in 53 cases (85.5%), L3-L4 in 1 case (1.6%), L4-S1 in 8 cases (12.9%). A decompression of the spinal canal by laminectomy was performed in 33 procedures (53%). When possible a bone graft was done from the removed neural arc, and from the posterior iliac crest in the other cases. The mean blood loss was about 254 ml (100-1,000). The mean operative time was 75 min (range 60-90). The results obtained by computerized analysis at follow-up at least 5 years after surgery showed a significant improvement in preoperative symptoms. The patients were asymptomatic in 52 cases (83.9%); strained-back pain was present in 8 cases (12.9%), and there was persistent lumbar-radicular pain in 2 cases (3.2%). The mean ODI score was 2.6%, the mean VAS back pain was 1.3, the mean VAS leg pain 0.7. Some complications were observed: a nerve root compression by a screw invasion of intervertebral foramen, resolved by screw removal; an iliac artery compression by a lateral exit screw from pediculo, resolved by screw removal; a deep iliac vein phlebitis with thrombosis caused by external compression due to a wrong intraoperative position, treated by medicine. Two cases of synthesis mobilization and two cases of broken screws was detected. No cases of pseudoarthrosis and immediate or late superficial or deep infection were observed. The analysis of the long-term results of the spondylolisthesis surgical treatment with direct pediculo-body screw fixation and postero-lateral fusion gave a very satisfactory response. The technique is reliable in allowing an optimal primary stability, creating the best biomechanical conditions to obtain a solid fusion.

Issues Ment Health Nurs. 2009 May; 30(5): 320-6Welsh DPredictors of depressive symptoms were identified in a sample of 150 female medical-surgical hospital nurses. Participants completed a demographic questionnaire and instruments to measure occupational stress (Nursing Stress Scale), major life events (Social Readjustment Rating Scale), somatic symptoms (Patient Health Questionnaire-15), and depressive symptoms (Center for Epidemiologic Studies-Depression Scale; CES-D) during a one time survey. Thirty-five percent of the nurses scored > or = 16 on the CES-D, the cutoff for mild to moderate depressive symptoms. Fatigue or low energy (43%), pain in their extremities or joints (30%), trouble sleeping (29%), back pain (28%), and headaches (18%) were the primary somatic complaints. Depressive symptoms were positively correlated with somatic symptoms (r = .55, p < .01), major life events (r = .41, p < .01), and occupational stress (r = .29, p < .01). Years employed in the hospital setting (r = -.22, p < .01) and household income (r = -.18, p < .05) were inversely related to depressive symptoms. Hierarchical multiple regression was used to identify predictors of nurses' depressive symptoms. Somatic symptoms (beta = .39, p < .01), occupational stress (beta = .18, p < .05), major life events (beta = .18, p < .05), and income (beta = -.15, p < .05) accounted for 34% of the variance in nurses' depressive symptom scores. The information from this study can guide the development of interventions to reduce depressive symptoms among hospital nurses. Reductions in depressive symptoms can advance health and quality of life for the hospital nurse. Symptom alleviation or reduction may improve nursing care delivery when distressing symptoms interfere with professional performance among nurses.

J Electromyogr Kinesiol. 2009 May 10; Marshall PW, Mannion J, Murphy BAOBJECTIVE: The objective of this study was to measure hamstring muscle eccentric and concentric strength in individuals with and without low back pain (LBP). Two composite scores for the relative balance of eccentric to concentric strength at the different movement velocities were calculated (the DEC and SEC), to determine whether or not self perceived pain, disability, or fear avoidance measures were associated with hamstring strength characteristics. DESIGN: Cross-sectional repeated measures design. SETTING: University laboratory. PARTICIPANTS: Fifteen individuals with chronic LBP and 15 matched controls. MAIN OUTCOME MEASURES: Isokinetic eccentric and concentric strength at 30 degrees s(-1) and 120 degrees s(-1)(.) Composite scores (DEC and SEC) based on peak torque were calculated to evaluate the relationship between the different muscle actions across the test velocities. Self report measures included the Oswestry disability index, general health and well being, fear avoidance, and pain. RESULTS: Eccentric/concentric strength ratio at 30 degrees s(-1) was higher for the LBP group (F(1,58)=4.81, p=0.032). The SEC was also higher for the LBP (F(1,58)=5.97, p=0.018). Fear avoidance beliefs and mental well-being were significantly associated with the SEC only in the LBP group (adjusted r(2)=0.26, (F(2,27)=5.8, p=.008). For the control group both the DEC and SEC were associated with self report measures. Matched differences between groups' for the SEC were best explained by fear avoidance beliefs about work (adjusted r(2)=0.12, F(1,28)=5.1, p=0.03). CONCLUSION: Reduced concentric relative to eccentric strength is best identified by the SEC. The SEC was significantly associated with impaired self report measures of fear avoidance and mental well being in individuals with LBP. Differences between groups for the SEC were best explained by fear avoidance beliefs about work.

Kyobu Geka. 2009 May; 62(5): 388-90Tatebayashi T, Yuda A, Noji SA 59-year-old man was admitted to the hospital, suspected of the rupture of descending thoracic aortic aneurysm due to sudden back pain. Enhanced computed tomography revealed a ruptured descending thoracic aortic aneurysm with huge hematoma and abdominal aortic aneurysm. Based on the above diagnosis, we performed urgent operation through left thoracotomy under unilateral lung ventilation. While dissecting the aneurysm, sudden hemodynamics deterioration occurred. Although cardiopulmonary bypass was introduced immediately through femoral artery and femoral vein cannulations, hemodynamics was not improved and unilateral lung ventilation got more unmanageable. We diagnosed right tension hemothorax due to the extension of aneurysm rupture into the right thoracic cavity. After placing a cannula at the distal arch for a central perfusion, we clamped the descending thoracic aorta at both the proximal and distal sites of the aneurysm. Thereafter we opened the aneurysm and drained the right thorax through the aneursym's tear. The aneurysm was replaced with a prosthetic woven-Dacron vascular graft. The patient's postoperative condition had been stable with no significant unfavorable event. The abdominal aortic aneurysm was replaced with a bifurcated graft on 51st postoperative day. He was discharged in good condition on the 69th postoperative day.

Acta Radiol. 2009 May 9; 1-10Kovacs FM, Royuela A, Jensen TS, Estremera A, Amengual G, Muriel A, Galarraga I, Martinez C, Arana E, Sarasibar H, Salgado RM, Abraira V, Lopez O, Campillo C, Gil Del Real MT, Zamora JBackground: Correlation between clinical features and magnetic resonance imaging (MRI) findings is essential in low-back-pain patients. Most previous studies have analyzed concordance in the interpretation of lumbar MRI among a few radiologists who worked together. This may have overestimated concordance. Purpose: To evaluate intra- and interobserver agreement in the interpretation of lumbar MRI performed in an open 0.2T system. Material and Methods: Seven radiologists from two different geographic settings in Spain interpreted the lumbar MRIs of 50 subjects representative of the general Danish population aged 40 years. The radiologists interpreted the images in routine clinical practice, having no knowledge of the clinical and demographic characteristics of the subjects and blinded to their colleagues' assessments. Six of the radiologists evaluated the same MRIs 14 days later, having no knowledge of the previous results. Data on the existence of disc degeneration, high-intensity zones, disc contour, Schmorl nodes, Modic changes, osteophytes, spondylolisthesis, and spinal stenosis were collected in the Nordic Modic Consensus Group Classification form. Intra- and interobserver agreement was analyzed for variables with a prevalence >/=10% and

Turk Neurosurg. 2009 Apr; 19(2): 145-8Seçer M, Muradov JM, Dalgiç AAIM: To investigate the correlation of congenital lumbosacral abnormalities with neurological signs in young patients with low back pain (LBP) MATERIAL and METHODS: The study included 401 patients with LBP that lasted longer than 2 weeks. All cases were screened by standard lumbosacral x-rays for the presence of the most common congenital vertebral abnormalities i.e. spina bifida occulta (SBO) and transitional vertebra (TV). Patients were divided into two groups according to presence of a neurological sign. Patients with a neurological sign were referred for computerized tomography and/or magnetic resonance imaging. RESULTS: Sixty-two patients had a neurological sign. Congenital vertebral abnormalities were detected in 52 patients (12.1%); 34 of these (8.5%) were spina bifida, whereas 18 (4.5%) were transitional vertebra. SBO was most commonly observed at the S1 level (30 patients). No correlation for SBO or TV was determined in patients with and without neurological signs but these groups showed significant difference for disc herniation in CT or MRI (P=0.001). Congenital abnormalities had no correlation with disc herniation in CT or MRI. CONCLUSION: LBP in young adults with TV or SBO showed no correlation with neurological signs. Therefore patients with prolonged LBP that present with neurological signs may be scheduled for CT and/or MRI, but reevaluation of the patient with psychometric tests is recommended if there is no neurological sign.

Skeletal Radiol. 2009 May 9; Kang CH, Kim YH, Lee SH, Derby R, Kim JH, Chung KB, Sung DJOBJECTIVE: To correlate magnetic resonance (MR) image findings with pain response by provocation discography in patients with discogenic low back pain, with an emphasis on the combination analysis of a high intensity zone (HIZ) and disc contour abnormalities. MATERIALS AND METHODS: Sixty-two patients (aged 17-68 years) with axial low back pain that was likely to be disc related underwent lumbar discography (178 discs tested). The MR images were evaluated for disc degeneration, disc contour abnormalities, HIZ, and endplate abnormalities. Based on the combination of an HIZ and disc contour abnormalities, four classes were determined: (1) normal or bulging disc without HIZ; (2) normal or bulging disc with HIZ; (3) disc protrusion without HIZ; (4) disc protrusion with HIZ. These MR image findings and a new combined MR classification were analyzed in the base of concordant pain determined by discography. RESULTS: Disc protrusion with HIZ [sensitivity 45.5%; specificity 97.8%; positive predictive value (PPV), 87.0%] correlated significantly with concordant pain provocation (P < 0.01). A normal or bulging disc with HIZ was not associated with reproduction of pain. Disc degeneration (sensitivity 95.4%; specificity 38.8%; PPV 33.9%), disc protrusion (sensitivity 68.2%; specificity 80.6%; PPV 53.6%), and HIZ (sensitivity 56.8%; specificity 83.6%; PPV 53.2%) were not helpful in the identification of a disc with concordant pain. CONCLUSION: The proposed MR classification is useful to predict a disc with concordant pain. Disc protrusion with HIZ on MR imaging predicted positive discography in patients with discogenic low back pain.

Yonsei Med J. 2009 Apr 30; 50(2): 252-6Kim SH, Jeon DH, Chang CH, Lee SJ, Shin YSPURPOSE: Previous lumbar spinal surgery (PLSS) is not currently considered as a contraindication for regional anesthesia. However, there are still problems that make spinal anesthesia more difficult with a possibility of worsening the patient's back pain. Spinal anesthesia using combined spinal-epidural anesthesia (CSEA) in elderly patients with or without PLSS was investigated and the anesthetic characteristics, success rates, and possible complications were evaluated. MATERIALS AND METHODS: Fifty patients without PLSS (Control group) and 45 patients with PLSS (PLSS group) who were scheduled for total knee arthroplasty were studied prospectively. A CSEA was performed with patients in the left lateral position, and 10 mg of 0.5% isobaric tetracaine was injected through a 27 G spinal needle. An epidural catheter was then inserted for patient controlled analgesia. Successful spinal anesthesia was defined as adequate sensory block level more than T12. The number of skin punctures and the onset time were recorded, and maximal sensory block level (MSBL), time to 2-segment regression, success rate and complications were observed. RESULTS: The success rate of CSEA in Control group and PLSS group was 98.0%, and 93.3%, respectively. The median MSBL in PLSS group was higher than Control group [T4 (T2-L1) vs. T6 (T3-T12)] (p < 0.001). There was a significant difference in the number of patients who required ephedrine for the treatment of hypotension in PLSS group (p = 0.028). CONCLUSION: The success rate of CSEA in patients with PLSS was 93.3%, and patients experienced no significant neurological complications. The MSBL can be higher in PLSS group than Control group.

Yonsei Med J. 2009 Apr 30; 50(2): 239-44Tsai SH, Lin YY, Hsu CW, Chen YL, Liao MT, Chu SJPURPOSE: Aortic dissection (AoD) is one of the most common catastrophes involving the aorta. Nevertheless, early diagnosis remains to be a challenge in the Emergency Department (ED), particularly in young individuals. In this study, we attempted to identify the characteristics of acute AoD among young individuals, particular in patients with Marfan syndrome. MATERIALS AND METHODS: This was an retrospective chart-review study conducted in a tertiary referring hospital. The hospital database was queried for the combination of AoD and patients under age of 40 years. The medical charts were reviewed to obtain demographic data, clinical data and laboratory characteristics by using a standardized data collection sheet. A comparison between Marfan syndrome and non-Marfan syndrome patients was performed. RESULTS: During the 10-years period, 18 of 344 patients with acute AoD were younger than 40 years-old. Patients with Marfan syndrome developed acute AoD at a younger age than patients without Marfan syndrome. The mean diastolic blood pressure was significantly lower in patients with Marfan syndrome upon presenting to the ED than those without. Patients with Marfan syndrome had trends toward higher risk of development of type A AoD, increased recurrence rate and higher mortality rate than those without. However, statistical significance was not present. CONCLUSION: ED physicians should have high alert to acute AoD in young patients presenting with severe unexplained chest and back pain, particularly in those patients with a history of heart diseases, hypertension, and Marfan syndrome or featuring Marfanoid habitus. Acute coronary syndrome, unexplained abdominal symptoms, and sudden cardiac arrest could be the initial manifestation of AoD in young patients. A low threshold to perform enhanced computed tomography may facilitate early diagnosis and timely treatment in this patient population.

Int J Dev Neurosci. 2009 May; 27(3): 215-22Lim EJ, Back SK, Kim MA, Li C, Lee J, Jeong KY, Na HSThe early postnatal period has been suggested to be the vulnerable time for structural and functional reorganization of sensory systems, and painful stimuli at this time may alter neuronal circuits, thereby leading to changes in an individual's response to pain later in life. In the present study, we examined whether inflammatory experience in the early life can affect pain responses to subsequent noxious insults later in life. The two groups of neonatal rats, treated with an inflammatory irritant and untreated, were subjected to inflammation and peripheral nerve injury in adulthood. Neonatal inflammation was induced by injection of complete Freund's adjuvant (CFA, 25mul) into the hindpaw or tail of newborn rat pups. Adult rats which had suffered from neonatal paw inflammation at P0 were subjected to re-injection of CFA into the paw neonatally exposed to CFA or L5 spinal nerve ligation. Paw thickness and histology of inflamed paw were examined to assess the neonatal inflammation. Adult animals whose tail had been subjected to CFA injection on P3 received tail-innervating nerve injury. The results showed that the neonatal CFA-treated rats suffered from chronic inflammation, confirmed by persistent increase of paw thickness and histological result of inflamed paw. These animals showed enhanced pain responses to re-inflammatory challenge by injection of CFA (200mul) into the neonatally inflamed paw 8 weeks after birth compared with the neonatally untreated animals. However, neuropathic pain on the hindpaw and the tail which had been induced by peripheral nerve injury in the neonatal CFA-treated group were not different from those of the untreated group. The present data suggest that early neonatal long-lasting inflammation differentially affects pain responses later in life, depending on the types of subsequent noxious insults.

Spine. 2009 May 4; Steenstra IA, Knol DL, Bongers PM, Anema JR, van Mechelen W, de Vet HCSTUDY DESIGN.: Exploratory subgroup analysis in a randomized controlled trial (RCT). OBJECTIVE.: To detect possible moderators in the effectiveness of a workplace intervention in a population of workers with sick leave due to sub acute nonspecific low back pain. SUMMARY OF BACKGROUND DATA.: In a recently published RCT, a workplace intervention was effective on return to work, compared to usual care. Examining the heterogeneity of effect sizes within the population in this RCT (n = 196) can lead to information on the effectiveness of the intervention in subgroups of patients. METHODS.: A subgroup analysis was performed by adding interaction terms to the statistical model. Before analysis the following possible moderators for treatment were identified: age, gender, pain, functional status, heavy work, and sick leave in the previous 12 months. Cox regression analyses were performed and survival curves were plotted. RESULTS.: The interaction (P = 0.02) between age (dichotomized at the median value) and the workplace intervention indicates a modifying effect. The workplace intervention is more effective for workers >/=44 years (HR, 95% CI = 2.5, [1.6, 4.1] vs. 1.2 [0.8, 1.8] for workers

J Endourol. 2009 Apr 27; Aravantinos E, Kalogeras N, Stamatiou G, Theodorou E, Moutzouris G, Karatzas A, Melekos MAbstract Objectives: To evaluate the possibility of performing percutaneous nephrolithotomy (PCNL) under a multimodal analgesia regime. Patients and Methods: During a period of 3 years, 51 patients requiring PCNL were enrolled in the study. All patients received a multimodal analgesic regime that included paracetamol, a COX(2) inhibitor, epidural morphine, and infiltration of the surgical field with local anesthetics. Percutaneous renal tract access was created with ultrasound guidance. All patients were informed about the possibility of experiencing short periods of discomfort or pain, and all patients completed a visual analog pain scale questionnaire postoperatively. Results: All 51 patients completed the study, and the procedure was well tolerated. Intraoperative problems or postoperative complications were attributed mainly to the procedure itself (PCNL) rather than to the analgesic regimen administered. We observed no morphine-related side effects. Patients were transferred directly back to the ward immediately after the operation. The use of analgesics postoperatively was minimal. Conclusions: The use of our multimodal analgesia regime is a well-tolerated and safe alternative to general or regional anesthesia for patients undergoing PCNL.

Anesth Analg. 2009 May; 108(5): 1662-70Williams BS, Cohen SPGreater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.

Spine. 2009 May 1; 34(10): E380-3Chung KJ, Hwang YS, Koh SHSTUDY DESIGN: A case report of stress fracture of bilateral lumbar posterior facet after implantation of interspinous process device is reported and the literature reviewed. OBJECTIVE.: To report the rare case of stress fracture of bilateral lumbar posterior facet after implantation of interspinous process device. SUMMARY OF BACKGROUND DATA: A 64-year-old woman presented with severe back pain and radiating pain in both legs. In her history, she had undergone implantation of L4-L5 interspinous process device (Coflex, Paradigm Spine, Wurmlingen, Germany) for her neurogenic claudication at 6 years ago. Magnetic resonance image demonstrated signal change suggesting bilateral L4 inferior process. To the best of the authors' knowledge, there has been no report stress fracture of posterior facet after implantation of interspinous process device. METHODS: This study reviewed the patient's medical record, her imaging studies, and related literatures. RESULTS: In the reported case, stress fracture of bilateral posterior facet was documented with MRI and confirmed with surgical treatment for the surgical treatment of spinal stenosis. The involved facet joint was at the site affected by previously implanted interspinous process device. CONCLUSION: Posterior facet fracture can occur as a complication of interspinous process device.

Spine. 2009 May 1; 34(10): 1060-5Glowacki M, Misterska E, Laurentowska M, Mankowski PSTUDY DESIGN: Polish adaptation of the original version of Scoliosis Research Society (SRS) instrument. OBJECTIVE: The transcultural adaptation of SRS-22 and evaluation of its internal consistency. SUMMARY OF BACKGROUND DATA: High psychometric value of the SRS-22 Questionnaire has made it an effective evaluation instrument in clinically assessing the functional status of patients with adolescent idiopathic scoliosis. METHODS: First, 2 translators translated the original version into Polish. Afterwards, the translators identified differences between the translations and produced a consensus version. In the third stage, 2 native English speakers produced back translations. Finally, a team of 2 orthopedic surgeons, translators, a statistician and a psychologist reviewed all the translations to produce a prefinal version. The questionnaire was administered to 60 girls at the age of 16.6, SD 2.0 with adolescent idiopathic scoliosis treated with the Cotrel-Dubousset method in Pediatric Orthopaedics and Traumatology Clinic in Poznań. RESULTS: The internal consistency in the Polish version equaled 0.89 for the overall result and 0.81 for function, 0.81 for pain, 0.80 for mental health, 0.77 for self-image, and 0.69 for treatment satisfaction domains, respectively. CONCLUSION: The Polish version of SRS-22 is characterized by high internal consistency for all domains and for the overall score, which makes it an evaluation tool after surgical treatment compatible with the original SRS-22.

Med J Aust. 2009 May 4; 190(9): 499-502Briggs AM, Buchbinder RThe aim of the National Health Priority Area (NHPA) initiative is to promote cooperation between government and non-government organisations to monitor, report on and develop strategies to improve health outcomes for Australians. The seven existing NHPAs (cancer control, injury prevention and control, cardiovascular health, mental health, diabetes mellitus, asthma and musculoskeletal conditions) were selected on the basis of their profound burden on the health of Australians. Up to eighty per cent of Australians will experience back pain at some point in their lives and 10% will experience significant disability as a result. Back pain disrupts individuals' quality of life and accounts for an enormous cost to the community. Integrating back pain into the NHPA framework has many potential benefits, including more systematic development and implementation of programs aimed at minimising back pain-related disability by providing a focus for policy, legislation and public awareness; and promotion of best-practice management of the condition. A disadvantage of making back pain an NHPA is the risk that back pain management could become further medicalised and ineffective interventions could become more accepted. Coordinated action on back pain is needed, and integrating back pain into the NHPA framework is one solution. Informed decision making through consultation with key stakeholders is a necessary first step towards ensuring that favourable outcomes are achieved.