The Spine Journal

One-year prognosis in sick-listed low back pain patients with and without radiculopathy. Prognostic factors influencing pain and disability

Ole Kudsk Jensen, Claus Vinther Nielsen, Kristian Stengaard-Pedersen — 2010-05-06

Abstract: Background context: Previous research has documented various psychosocial risk factors with influence on outcome in low back pain (LBP) patients, but the value of clinical predictors has been less well documented.Purpose: To identify clinical and psychosocial risk factors at baseline influencing disability and pain at 1 year in LBP patients sick-listed 3 to 16 weeks, and to look for differences between nonspecific LBP and radiculopathy.Study design: Cohort study with 1-year follow-up based on a randomized clinical trial.Outcome measures: Disability and change of disability, pain and change in pain at 1 year.Methods: In a randomized clinical study evaluating multidisciplinary versus brief intervention, 325 patients were followed for 1 year. At baseline, they completed a questionnaire and went through a clinical low back examination, including measure of forward flexion and side flexion as well as tender point examination, a method to estimate diffuse tenderness. Furthermore, degenerative changes on plain X-rays of the lumbar spine were quantified, and sciatica was investigated by magnetic resonance imaging.Results: Radiculopathy was verified by magnetic resonance imaging in 111 (34%) patients. At 1 year, questions of disability in daily life activities and pain were answered by 60% and 67%, respectively. The intensity of back+leg pain and disability was closely correlated. Statistically significant predictors for both disability and back+leg pain at 1 year were intensity of back+leg pain, worrying and health anxiety, many tender points, and little or moderate exercise in leisure time. Two additional risk factors were identified in patients with radiculopathy: older age and “drinking alcohol less than once per month.” Furthermore, disability at 1 year was associated with initial disability and compensation claim, and back+leg pain at 1 year was associated with fear avoidance about physical activity and the duration of pain. Change in disability was more closely associated with return to work than change in pain. Disc degeneration was not associated with disability or pain at 1 year. General health was not statistically significantly associated with outcome when adjusted for back+leg pain, disability, and worrying and health anxiety.Conclusions: Disability and pain at 1 year were associated with baseline disability and pain, diffuse tenderness, worrying and health anxiety, compensation claim, fear avoidance, and baseline exercise habits. Only in patients with verified nerve root affection, older age, and restrained alcohol seemed to play a role. The multivariate models were insufficient in predicting disability and pain, partly because disability and pain were also strongly associated with return to work.

Analysis of the incidence and clinical effect of the heterotopic ossification in a single-level cervical artificial disc replacement

Jung-Hoon Lee, Tag-Geun Jung, Hyung-Suk Kim, Jee-Soo Jang, Sang-Ho Lee — 2010-06-01

Abstract: Background context: Heterotopic ossification (HO) is a well-known phenomenon occurring after joint arthroplasty. However, its incidence and clinical effects have not yet been clearly identified with cervical disc replacement.Purpose: The first aim of this study was to evaluate the incidence of HO in single-level cervical disc replacement. The second aim was to identify the relationship of HO with clinical outcomes and radiological findings.Study design: A retrospective study of 48 patients who underwent single-level artificial disc replacement in one of our clinics.Patient sample: Between November 2004 and December 2008, 48 consecutive patients underwent single-level cervical artificial disc replacement in Seoul Wooridul Hospital, Seoul, Korea.Outcomes measures: Clinical outcomes were graded using visual analog scale (VAS) scores (score range, 0–10, with 0 reflecting no pain). Functional outcomes were measured using Oswestry Disability Index (ODI) scores. Radiological outcomes were evaluated with follow-up dynamic X-ray.Methods: Occurrence of HO was investigated with the McAfee classification on the follow-up cervical dynamic X-ray. We also measured cervical range of motion (ROM) to identify HO's biomechanical effects. For the clinical effects, the VAS and the ODI were evaluated in correlation with the occurrence of HO.Results: In 48 treated patients, a total of 13 HOs were detectable. Grade 1 and 2 HO occurred in 11 patients and Grade 3 HO in two patients. Mean occurrence of HO was observed on the 11th month after the surgery. HO that led to the restriction of the ROM was not present in any patients. The clinical outcome was not significantly correlated with the occurrence of HO.Conclusions: The overall incidence of HO after cervical artificial disc replacement was relatively high. However, Grade 3 and 4 HO that limit the ROM rarely occurred. Moreover, the occurrence of HO did not affect the clinical symptoms and biomechanical dynamics. A longer follow-up with a larger group of patients should be undertaken, which may demonstrate a higher rate of HO and long-term effects on the ROM.

Analysis of factors that may influence range of motion after cervical disc arthroplasty

2010-05-31

Abstract: Background context: Cervical artificial disc replacement is increasingly becoming popular among spine surgeons. Cervical disc arthroplasty aims to afford spinal stability and then balance this with flexibility. One of the fundamental benefits from performing cervical arthroplasty instead of fusion is preservation of motion in both the functional spinal unit (FSU) and the overall cervical spine. Eventually, preservation of segmental motion is believed to prevent the development of adjacent segment degeneration. But to justify its use, disc replacement prosthesis must demonstrate actual motion in vivo and preserve range of motion (ROM) after surgery as long as it allows. Without preservation of motion, disc prosthesis becomes just a functional arthrodesis equivalent.Purpose: The purpose of this study was to analyze the possible factors affecting cervical spine ROM after single-level cervical disc arthroplasty.Study design/setting: This is a retrospective radiological study of patients with symptomatic single-level cervical disc disorder who received the cervical disc prosthesis (Bryan Cervical Disc Prosthesis; Medtronic Sofamor Danek, Memphis, TN, USA).Patient sample: Procedure was performed in 39 patients.Outcome measures: The outcome measures were statistical correlation of possible factors and ROM.Methods: We investigated possible factors that could affect cervical ROM after surgical intervention using cervical disc replacement. For this, we focused on two main components, namely, patient factors and technical factors. First, we examined patient factors, such as age, sex, preoperative FSU ROM, and preoperative overall cervical spine (whole cervical spine) ROM. Second, we then investigated technical factors, such as the amount of bone resection, disc insertion angle, and disc insertion depth. Then, our study searched if there was any statistical correlation between these factors and the postoperative cervical ROM.Results: Significant correlation was found between the postoperative overall cervical spine ROM and preoperative overall cervical spine ROM (p<.0001, R2=0.9062). Postoperative FSU ROM is closely correlated to both the preoperative FSU ROM (p<.0001) and the disc insertion angle (p=.0097). However, no significant correlation was noted between age, sex, disc insertion angle, and disc insertion depth.Conclusion: Significant correlation was found between the postoperative overall cervical spine ROM and preoperative overall cervical spine ROM. Postoperative FSU ROM is closely correlated to both the preoperative FSU ROM and the disc insertion angle. Careful preoperative evaluation of the patient's radiographs and meticulous surgical technique during the surgical procedure could aid in achieving the goals and benefits of cervical disc arthroplasty.

The factors that influence the postoperative segmental range of motion after cervical artificial disc replacement

Kyung-Chung Kang, Chong-Suh Lee, Jeong-Hoon Han, Sung-Soo Chung — 2010-05-24

Abstract: Background context: Advantages of cervical artificial disc replacement (ADR) are to preserve segmental range of motion (ROM) and avoid adjacent segmental disease. To achieve successful outcome after cervical ADR, ROM maintenance is important, but few authors have investigated the factors that influence the postoperative segmental ROM.Purpose: To evaluate the factors that influence the postoperative segmental ROM after cervical ADR.Study design/setting: A retrospective clinical study.Patient sample: Forty-one consecutive cervical ADR cases were analyzed.Outcome measures: Disc height, segmental and overall ROM, and clinical parameters checked with Neck Disability Index (NDI) and visual analog scale (VAS) in neck and arm pain were assessed.Methods: There were 21 men and 20 women with a mean age of 45 years (range, 27–61 years). All cases were followed up for more than 2 years (range, 24–54 months; average, 31 months). Angles of the inserted implant on the immediate postoperative lateral radiographs, segmental and overall ROM (full flexion angle−full extension angle), disc height increment (immediate postoperative disc height−preoperative disc height), and adjacent segment changes at cephalad and caudal disc space were measured. Correlations between the factors and segmental ROM at last follow-up were analyzed.Results: Mean preoperative NDI was improved from 61.0 preoperatively to 11.5 at last follow-up, and mean VAS in the neck pain decreased from 56.8 preoperatively to 11.8 postoperatively and arm pain decreased from 68.1 to 18.0. The mean preoperative segmental ROM changed from 7.4±3.2° preoperatively to 10.4±5.9° at last follow-up, and mean preoperative disc height increased from 6.4±1.0 (4.1–8.4) mm preoperatively to 7.9±1.0 (6.3–9.9) mm postoperatively. The segmental ROM at last follow-up was not significantly correlated with preoperative segmental and overall ROM, angle of inserted implant, VAS, or age (p>.05). However, the segmental ROM at last follow-up was significantly correlated with the disc height increment (p=.046, r=0.374) and preoperative NDI (p=.026, r=0.412). The patient group with the postoperative segmental ROM greater than 10° had a significantly lower mean preoperative disc height than the group with the segmental ROM less than 10° (p=.050).Conclusions: At a minimum of 2 years after cervical ADR, clinical outcomes were satisfactory in terms of function and pain scores. Within our results, the segmental ROM was not affected by preoperative ROM but postoperative disc height increment positively and preoperative disc height negatively.

A scoring system for elective triage of referrals: Spine Severity Score

Shelly Lwu, Elizabeth Oddone Paolucci, R. John Hurlbert, Ken C. Thomas — 2010-08-01

Abstract: Background context: The Spine Severity Score (SSS) is a 15-point scoring system devised for the purpose of triaging elective surgical spine referrals. From the referral letter and the accompanying radiology report, a total score is calculated based on clinical, pathological, and radiological criteria; a maximum score of 5 can be obtained within each category. A higher total score represents a referral that should be seen more urgently.Purpose: To report interrater and intrarater reliability for the SSS and compare the scoring system against the traditional system for triage, that is, the surgeon's clinical experience.Study design: A prospective cross-comparison design was used to evaluate the reliability and convergent validity of the SSS using spine case referrals.Methods: Four spine surgeons (experts) and three administrative assistants (nonexperts) at the University of Calgary scored 25 referrals. A second iteration of scoring was performed with a minimum time interval elapsed of 6 weeks. Raters were instructed to choose the most concerning (the one with the highest associated score) descriptor in each category that was thought relevant to the individual referral. No further instructions were given on how to interpret the referral letter or the radiology report. The surgeons also scored the referrals using their own preexisting four-point scoring systems. The results were analyzed with independent and dependent t tests, Pearson product moment correlation coefficient, and generalizability and decision analysis.Results: An independent-measures t test (p>.05) revealed no statistical differences between experts and nonexperts (ie, interrater reliability) for both Iterations 1 and 2 on total scores of the SSS and a moderately strong relationship between their ratings across iterations (r=0.79, p .05) indicated a nonsignificant mean difference between Total SSS ratings at Time 1 and Time 2 (ie, intrarater reliability) and a high degree of agreement (r=0.96, p<.001) between the two iterations. These results were confirmed with correlational analyses. Pearson product moment correlation coefficients between the gold standard and the mean score were calculated from expert ratings on Total SSS at Time 1 (r=0.71, p<.001) and at Time 2 (r=0.69, p<.001).Conclusions: The SSS is a reliable scoring system for triage of elective spine referrals, even among nonexperts. We have been able to demonstrate strong interrater and intrarater reliability for the SSS and moderately strong correlation with the traditional triage system.

Occipitocervical dissociative injuries: common in blunt trauma fatalities and better detected with objective computed tomography-based measurements

Niv Dreiangel, Peleg Ben-Galim, Ran Lador, John A. Hipp — 2010-08-01

Abstract: Background context: Occipitocervical injuries (OCIs) are generally not common in blunt trauma victims, but autopsy studies of blunt trauma fatalities consistently report a high prevalence of these injuries. New computed tomography (CT)-based quantitative criteria have recently been developed for use in assessing the occipitocervical spine. The efficacy of these new criteria for detecting OCI would be supported if the high prevalence of OCI in blunt trauma fatalities can also be detected using these objective CT-based criteria.Purpose: To test the hypothesis that the prevalence of OCI in blunt trauma fatalities, determined using objective CT-based measurements and reliable reference data, will be similar to the prevalence reported in prior autopsy studies.Study design/setting: Retrospective assessment of the CT examinations of blunt trauma fatalities at a Level 1 trauma center.Patient sample: Seventy-four consecutive patients who died within 21 days of blunt trauma and had a CT examination of the cervical spine.Outcome measures: Quantitative measurements from CT examinations of the occiput–C1 and C1–C2 levels.Methods: Measurements were made on a Picture Archiving and Communication System (PACS) from the CT images that were originally used for diagnosis and also using imaging software that allowed for precisely reoriented slices that correct for variations in the alignment of the upper cervical spine. The prevalence of abnormal measurements found by each method and the interobserver reliability of the measurements were assessed.Results: At least one abnormal measurement was found in 50% of cases based on measurements made on the PACS, and in 34% of cases using measurements from carefully reoriented images. At least three abnormal measurements were found in 22% and 14% of patients, respectively. Only one of the patients had been diagnosed as having an OCI before death. Interobserver reliability measurements of more than 80% were found for most measurements.Conclusions: Using precise CT-based measurements and reliable reference data for diagnosis of occipitocervical dissociative injuries, the prevalence of injuries in severely injured blunt trauma patients was close to the levels reported in prior autopsy studies (approximately 30%). This supports that with careful measurements, both soft- and hard-tissue OCI can be detected by CT. This study is limited by the fact that a gold standard was not available to confirm the injuries.

Osteosarcoma of the spine: experience in 26 patients treated at the Massachusetts General Hospital

2010-08-01

Abstract: Background context: Because of the low incidence, treatment recommendations for spinal osteosarcoma are guided by the results of small series and case reports. Many include patients who presented for treatment over the course of three to four decades.Purpose: The goal of this investigation was to report the treatments, results, and overall survivorship of 26 patients treated for osteosarcoma of the spine at a single institution.Study design: Retrospective prognostic series (Level III evidence).Patient sample: Twenty-six patients treated at a single center for osteosarcoma of the spine over a 26-year period.Outcome measures: Estimation of patient survival, local recurrence, and the presence of metastatic disease.Methods: We performed a retrospective review of cases of osteosarcoma involving the spine treated at our institution between 1982 and 2008. Medical charts, radiology reports, pathology reports, and operative notes were reviewed for all patients. Available imaging studies were also reviewed. The log-rank test was used to compare baseline differences between groups. Survivorship analysis was performed using Kaplan–Meier methodology. The effect of Paget osteosarcoma, type of resection, presence of local recurrence, tumor size, surgical margins, and metastases on overall survival were also investigated using the log-rank test.Results: Twenty-six patients were included for review in this study. Twenty individuals were treated surgically, and 24 were treated with radiation with a mean dose of 62.2 Gy (range 20–84.7 Gy). Twenty-five patients received chemotherapy. Of those treated surgically, seven received en bloc resection. The median overall survival for all patients in our series was 29.5 months (standard error 14.7, 95% confidence interval 0.6–58). Local recurrence developed in 7 patients (27%), and metastasis occurred in 16 individuals (62%). Patients with Paget osteosarcoma had worse overall survival (p<.001).Conclusions: Results presented here confirm a poor prognosis for patients with spinal osteosarcoma. Although combination therapies, including surgery, chemotherapy, and high-dose radiation, achieve adequate short-term survival, the 5-year mortality rate remains high.

Brain-derived neurotrophic factor redistribution in the dorsal root ganglia correlates with neuropathic pain inhibition after resiniferatoxin treatment

Gabriel C. Tender, Yuan-Yuan Li, Jian-Guo Cui — 2010-05-10

Abstract: Background context: Brain-derived neurotrophic factor (BDNF) and its cognate receptor, the tyrosine kinase B (TrkB), are normally expressed in neurons and implicated in multiple pathological conditions. Brain-derived neurotrophic factor is produced in the central nervous system microglia in response to noxious stimuli and appear to potentiate central sensitization. Resiniferatoxin (RTX) is an excitotoxic agonist of the vanilloid receptor 1 (VR1), a cation channel protein considered an integrator for nociception. Resiniferatoxin, administered into the dorsal root ganglia (DRG), selectively eliminates the VR1-positive neurons and improves tactile allodynia in a neuropathic pain rat model.Purpose: The goal of the present study was to evaluate the role of BDNF in RTX-induced neuropathic pain suppression.Study design: The study design was a sciatic nerve injury animal model with intraganglionic RTX injection.Methods: Resiniferatoxin was injected into the DRG of the L3–L6 spinal nerves after the rats displayed tactile allodynia and thermal hyperalgesia produced by a photochemical injury to the sciatic nerve. Behavioral testing and immunohistochemical and mRNA analysis of the DRG were performed to determine BDNF's role in pain modulation.Results: Brain-derived neurotrophic factor expression in the DRG of neuropathic rats was upregulated in the small- and medium-size neurons, whereas the upregulation was observed in the large-size neurons of non-neuropathic rat DRG. A high-dose RTX injection in the DRG of neuropathic rats led to elimination of both thermal hyperalgesia and tactile allodynia and also upregulated BDNF in the large-size neurons, similar to the nonallodynic rats. Tyrosine kinase B changes mirrored the BDNF ones.Conclusion: Resiniferatoxin injection in the DRG of neuropathic rats upregulates BDNF expression in the same pattern as in the large-size neurons of non-neuropathic rats. Therefore, BDNF upregulation may have pain suppressive effects. These effects are likely mediated by TrkB.

Annulus cells from more degenerated human discs show modified gene expression in 3D culture compared with expression in cells from healthier discs

Helen E. Gruber, Gretchen L. Hoelscher, Edward N. Hanley — 2010-08-01

Abstract: Background context: Understanding gene expression patterns of disc cells in culture is important as we develop biologic therapies for disc degeneration. The objective of the present study was to determine if cells from more degenerated discs expressed different genes, or differed in their expression patterns, compared with patterns of cells from healthier discs.Purpose: To determine if annulus cells from more degenerated discs expressed different gene expression patterns compared with patterns of cells from healthier discs using genome-wide analysis.Study design: Cells from human annulus tissue were grown in three-dimensional (3D) culture and their gene expression patterns analyzed with Affymetrix microarray analysis. Gene expression patterns of cells from more degenerated discs (Thompson Grades IV and V) were compared with patterns from cells from healthier discs (Thompson Grades I, II, and III).Methods: After approval by our human subjects institutional review board, annulus cells were obtained from lumbar discs of seven subjects with Thompson Grades I, II, or III and from five subjects with discs of Thompson Grades IV and V. Cells were grown in 3D culture for 2 weeks; 3D cultures were used because this microenvironment more closely mimics the in vivo condition. mRNA was harvested, processed for Affymetrix genome-wide gene analysis, and data analyzed with p values adjusted so as to compensate for false discovery rates.Results: GeneSifter analyses showed that cells from more degenerated discs had 320 genes significantly upregulated, and 104 genes significantly downregulated compared with cells from healthier discs. Important genes included those related to: 1) the extracellular matrix (ECM) (keratin-associated protein 1-1, hyaluronan synthase 2, and nexin were upregulated; biglycan, collagen type VI alpha 2, thrombospondin 3, laminen alpha 1, fibronectin type III domain-containing protein 1, elastin microfibril interfacer 2, fibulin 2, and nidogen 1 and 2 were downregulated); 2) ECM proteolysis (ADAMTS6 was upregulated); 3) cell proliferation (never in mitosis gene 1-related kinase 3, cell division cycle 2-like 5 [cholinesterase-related cell division controller], RAB42 [member of RAS oncogene family], and cyclin-dependent kinase 6 were upregulated; RAS-like GTP-binding 1 was downregulated); 4) apoptosis (BCL2-like 11 and p53-inducible nuclear protein 1 were upregulated; caspase recruitment domain family, member 10, caspase-1 dominant-negative inhibitor pseudo-ICE, and caspase 9 and FADD-like apoptosis regulator were downregulated); and 5) growth factors, inflammatory mediators, and other genes (fibroblast growth factor 1, pregnancy-associated plasma protein-A, interleukin 1 alpha, and interleukin 7 were upregulated; TGF-β–induced transcript 1, interleukin 26 and interleukin 1 receptor-like 1, tumor necrosis factor, alpha-induced protein 2, and chemokine (C-X3-C motif) ligand 1 were downregulated).Conclusions: Data presented here show that annulus cells from more degenerated discs show modified gene expression in 3D culture. Important gene variations involved expression of interleukins, cytokines, ECM components, and apoptosis regulators. Results presented here have potential application in future cell-based biologic therapies for disc degeneration.

Predicting prognosis in sick-listed low back pain patients: sneaking a peak inside the black box

S. Samuel Bederman — 2010-08-01

COMMENTARY ON: Jensen OK, Nielsen CV, Stengaard-Pedersen K. One-year prognosis in sick-listed low back pain patients with and without radiculopathy. Prognostic factors influencing pain and disability. Spine J 2010;10:659–75 (in this issue).

Cervical arthroplasty: a success, failure, or both?

John M. Rhee — 2010-08-01

COMMENTARY ON: Lee JH, Jung TG, Kim HS, et al. Analysis of the incidence and clinical effect of the heterotopic ossification in a single-level cervical artificial disc replacement. Spine J 2010;10:676–82 (in this issue).

Is there an antinociceptive role for peripheral brain-derived neurotrophic factor?

Beth A. Winkelstein, Jeffrey V. Kras — 2010-08-01

COMMENTARY ON: Tender GC, Li Y-Y, Cui J-G. Brain-derived neurotrophic factor redistribution in the dorsal root ganglia correlates with neuropathic pain inhibition after resiniferatoxin treatment. Spine J 2010:10:715–20 (in this issue).

Déjà vu all over again

Ray M. Baker — 2010-08-01

COMMENTARY ON: Kapoor SG, Huff J, Cohen SP. Systematic review of the incidence of discitis after cervical discography. Spine J 2010;10:739–45 (in this issue).

Systematic review of the incidence of discitis after cervical discography

Shruti Gupta Kapoor, Jeremy Huff, Steven P. Cohen — 2010-02-22

Abstract: Background context: Cervical discography is not uniformly used in part because of the fear of discitis. Studies report widely varying rates of this life-threatening infection.Purpose: The aim of this study was to estimate the incidence of discitis after cervical discography, delineate the consequences of discitis, and identify factors that may influence this complication.Study design: Meta-analysis.Methods: Studies pertaining to cervical discography were identified by a literature review and bibliographic search. These were screened for inclusion into the meta-analysis by two reviewers. Data were collected on a wide range of clinical and demographic variables including age, gender, morbidities, number of patients, number of discograms, use of prophylactic antibiotics, type of surgical prep, number of needles used, and the number of patients and discs infected. Primary data were used to calculate the incidence of discitis per patient and per disc.Results: Fourteen studies were included in the analysis. Both procedural details and demographic information on patients were missing from eight studies. The mean age of patients ranged from 41 to 47 years, and gender distribution varied greatly. Antibiotics use was reported in three studies. Cervical discography was complicated by postprocedural discitis in 22 of 14,133 disc injections (0.15%) and 21 of 4,804 patients (0.44%). Only one patient suffered from an infection at more than one spinal level.Conclusions: The rate of discitis after cervical discography is relatively low. This can perhaps be further decreased by the use of prophylactic intradiscal antibiotics. Should the ability of cervical discography to improve surgical outcomes be proven, the fear of discitis should not preclude performance of disc provocation.

Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. Sweetland S, Green J, Liu B, et al. BMJ 2009;3(339):b4583

2010-08-01

OBJECTIVE: To examine the duration and magnitude of increased risk of venous thromboembolism after different types of surgery. DESIGN: Prospective cohort study (Million Women Study).

Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: minimally invasive procedure versus conventional open approach. Fan S, Hu Z, Zhao F, Zhao X, Huang Y, Fang X. Eur Spine J 2010;19(2):316–24. Epub 2009 Oct 30

2010-08-01

We set out to determine whether a minimally invasive approach for one-level instrumented posterior lumbar interbody fusion reduced undesirable changes in the multifidus muscle, compared to a conventional open approach. We also investigated associations between muscle injury during surgery (creatinine kinase levels), clinical outcome and changes in the multifidus at follow-up. We studied 59 patients treated by one team of surgeons at a single institution (minimally invasive approach in 28 and conventional open approach in 31, voluntarily chosen by patients). More than 1 year postoperatively, all the patients were followed up with the visual analogue scale (VAS) and Oswestry disability index (ODI), and 16 patients from each group were evaluated using MRI. This enabled the cross-sectional area (CSA) of lean multifidus muscle, and the T2 signal intensity ratio of multifidus to psoas muscle, to be compared at the operative and adjacent levels. The minimally invasive group had less postoperative back pain (P < 0.001) and lower postoperative ODI scores (P = 0.001). Multifidus atrophy was less in the minimally invasive group (P < 0.001), with mean reductions in CSA of 12.2% at the operative and 8.5% at the adjacent levels, compared to 36.8% and 29.3% in the conventional open group. The increase in the multifidus:psoas T2 signal intensity ratio was similarly less marked in the minimally invasive group where values increased by 10.6% at the operative and 8.3% at the adjacent levels, compared to 34.4 and 22.7% in the conventional open group (P < 0.001). These changes in multifidus CSA and T2 signal intensity ratio were significantly correlated with postoperative creatinine kinase levels, VAS scores and ODI scores (P < 0.01). The minimally invasive approach caused less change in multifidus, less postoperative back pain and functional disability than conventional open approach. Muscle damage during surgery was significantly correlated with long-term multifidus muscle atrophy and fatty infiltration. Furthermore these degenerative changes of multifidus were also significantly correlated with long-term clinical outcome.

Changes in paraspinal muscles and their association with low back pain and spinal degeneration: CT study. Kalichman L, Hodges P, Li L, Guermazi A, Hunter DJ. Eur Spine J 2010;19(7):1136–44. Epub 2009 Dec 24

2010-08-01

The objectives of the study were to evaluate the association between lumbar paraspinal muscle density, evaluated on computed tomography (CT) and age, sex and BMI; and to evaluate the association of those changes with low back pain (LBP) and spinal degeneration features in a community-based sample. This study was an ancillary project to the Framingham Study. A sample of 3,529 participants aged 40–80 years had a CT scan performed to assess aortic calcification. 187 individuals were randomly enrolled in this study. LBP in the last 12 months was evaluated using self-report questionnaire. Density (in Hounsfield units) of multifidus and erector spinae was evaluated on CT. The prevalence of intervertebral disc narrowing, facet joint osteoarthritis (FJOA), spondylolysis, spondylolisthesis and spinal stenosis were also evaluated. We used linear regression models to examine the association of paraspinal muscles density with age, sex, BMI, LBP, and spinal degeneration features. The results show that in our study, men have higher density of paraspinal muscles than women, younger individuals have higher density than older ones and individuals with lower weight have higher muscle density than overweight. No differences between individuals with and without LBP were found. Significant association was found between L4 multifidus/erector spinae density and FJOA at L4-L5; between multifidus at L4 and spondylolisthesis at L4-5; and between erector spinae at L4 and L5 with disc narrowing at L4-5 and L5-S1, respectively. We conclude that the paraspinal muscle density decreases with age, and increases BMI. It is associated with at some levels FJOA, spondylolisthesis and disc narrowing at the same level, but not associated with occurrence of LBP.

Whiplash-associated disorders: who gets depressed? Who stays depressed? Phillips LA, Carroll LJ, Cassidy JD, Côté P. Eur Spine J 2010;19(6):945–56. Epub 2010 Feb 2

2010-08-01

Depression is common in whiplash-associated disorders (WAD). Our objectives were to identify factors associated with depressive symptomatology occurring in the initial stages of WAD, and to identify factors predicting the course of depressive symptoms. A population-based cohort of adults sustaining traffic-related WAD was followed at 6 weeks, 3, 6, 9, and 12 months. Baseline measures (assessed a median of 11 days post-crash) included demographic and collision-related factors, prior health, and initial post-crash pain and symptoms. Depressive symptomatology was assessed at baseline and at each follow-up using the Centre for Epidemiological Studies Depression Scale (CES-D). We included only those who participated at all follow-ups (n = 3,452; 59% of eligible participants). Using logistic regression, we identified factors associated with initial (post-crash) depression. Using multinomial regression, we identified baseline factors predicting course of depression. Courses of depression were no depression; initial depression that resolves, recurs or persists, and later onset depression. Factors associated with initial depression included greater neck and low back pain severity, greater percentage of body in pain, numbness/tingling in arms/hand, dizziness, vision problems, post-crash anxiety, fracture, prior mental health problems, and poorer general health. Predictors of persistent depression included older age, greater initial neck and low back pain, post-crash dizziness, vision and hearing problems, numbness/tingling in arms/hands, anxiety, prior mental health problems, and poorer general health. Recognition of these underlying risk factors may assist health care providers to predict the course of psychological reactions and to provide effective interventions.

Assessment of the posterior ligamentous complex following acute cervical spine trauma. Rihn JA, Fisher C, Harrop J, Morrison W, Yang N, Vaccaro AR. J Bone Joint Surg Am 2010;92(3):583–9

2010-08-01

BACKGROUND: Magnetic resonance imaging is commonly used to assess the integrity of the posterior ligamentous complex following cervical trauma, but its accuracy and reliability have not been documented, to our knowledge. The purpose of this study was to determine the diagnostic accuracy of magnetic resonance imaging in detecting injury to specific components of the posterior ligamentous complex of the cervical spine.

Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. Lambeek LC, van Mechelen W, Knol DL, Loisel P, Anema JR. BMJ 2010;340:c1035

2010-08-01

OBJECTIVE: To evaluate the effectiveness of an integrated care programme, combining a patient directed and a workplace directed intervention, for patients with chronic low back pain.

Predictors of residual symptoms in lower extremities after decompression surgery on lumbar spinal stenosis. Hara N, Oka H, Yamazaki T, et al. Eur Spine J 2010 Mar 23. [Epub ahead of print]

2010-08-01

Leg pain/numbness and gait disturbance, two major symptoms in the lower extremities of lumbar spinal stenosis (LSS), are generally expected to be alleviated by decompression surgery. However, the paucity of information available to patients before surgery about specific predictors has resulted in some of them being dissatisfied with the surgical outcome when the major symptoms remain after the procedure. This prospective, observational study sought to identify the predictors of the outcome of a decompression surgery: modified fenestration with restorative spinoplasty. Of 109 consecutive LSS patients who underwent the decompression surgery, 89 (56 males and 33 females) completed the 2 year follow-up. Both leg pain/numbness and gait disturbance determined by the Japanese Orthopedic Association scoring system were significantly improved at 2 years after surgery compared to those preoperative, regardless of potential predictors including gender, preoperative presence of resting numbness in the leg, drop foot, cauda equina syndrome, degenerative spinal deformity or myelographic filling defect, or the number of decompressed levels. However, 27 (30.3%) and 13 (14.6%) patients showed residual leg pain/numbness and gait disturbance, respectively. Among the variables examined, the preoperative resting numbness was associated with residual leg pain/numbness and gait disturbance, and the preoperative drop foot was associated with residual gait disturbance, which was confirmed by logistic regression analysis after adjustment for age and gender. This is the first study to identify specific predictors for these two remaining major symptoms of LSS after decompression surgery, and consideration could be given to including this in the informed consent.

Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. Bode LG, Kluytmans JA, Wertheim HF, et al. N Engl J Med 2010;362(1):9–17

2010-08-01

BACKGROUND: Nasal carriers of Staphylococcus aureus are at increased risk for health care-associated infections with this organism. Decolonization of nasal and extranasal sites on hospital admission may reduce this risk.

Meetings Calendar

2010-08-01

Retethering of sectioned fibrolipomatous filum terminale in an adult: case report and review of the literature

Jonathan J. Stone, Curtis J. Rozzelle — 2010-08-01

Abstract: Background context: Recurrent tethering of the spinal cord is a rare late complication after sectioning of a fibrolipomatous filum terminale that has only been reported in two pediatric cases.Purpose: To report adult-onset recurrent tethering of the spinal cord after surgical sectioning of a fibrolipomatous filum terminale and review the literature in an attempt to identify similar cases.Study design/setting: The study was designed to be a case report and literature review.Methods: A 21-year-old woman with a history of previous surgical repair for a tethered spinal cord secondary to a fibrolipomatous filum terminale presented with low back and right lower extremity pain, urinary frequency, and fecal incontinence. Progressive bladder and sphincter dysfunction was confirmed on urodynamic testing. Lumbar spine magnetic resonance imaging demonstrated a low-lying and dorsally positioned conus medullaris.Results: The patient underwent neurosurgical exploration of the previous site of sectioning with rerelease of the proximal fatty filum stump from dorsal dural adhesions. Postoperatively, her pain resolved, and her bowel and bladder control improved.Conclusions: Sectioning of both abnormal and apparently normal fila has become a relatively common procedure in pediatric neurosurgery. As more children with this surgical history mature and present for neurosurgical consultation as adults, retethering must be considered in the differential diagnosis.

Salvage percutaneous vertebral augmentation in failed spinal interbody fusions associated with multiple myeloma

Ajit S. Puri, Eren Erdem — 2010-08-01

Abstract: Background context: Failed posterior spinal interbody fusion is a known phenomenon with clinical consequences.Purpose: This technical note of percutaneous vertebral augmentation in patients with failed posterior interbody construct can be used in patients at high risk for repeat surgery, like patients with multiple myeloma.Study design/setting: Retrospective analysis of the two procedures was done. Clinical and radiologic follow-up was available for 1.5 years at the time of manuscript preparation.Patient sample: Both patients were referred to us after undergoing posterior spinal interbody fusion from outside institutions with persistent pain. The patients had a pain level requiring opioid analgesics and changes in the activities of daily living. The patients had active multiple myeloma at the time of the surgical intervention and vertebral augmentation procedure.Outcome measures: Visual analog scales were used to gauge the pain relief after the procedure and during further follow-ups. In addition, radiologic follow-up was obtained by means of computed tomography and magnetic resonance imaging scans.Methods: Vertebral augmentation procedures in both patients were done under intravenous conscious sedation with the patient prone. High-quality biplane fluoroscopy was used for the procedure. No immediate- or long-term complications were noted.Results: Both patients had an appreciable relief from pain immediately after the procedure and on follow-up. Follow-up radiologic imaging revealed consistent cement distribution around the construct, no further collapse of the vertebra, with no new lucency surrounding the construct.Conclusions: This modified technique of vertebral augmentation can be helpful in management of cases with clinical or radiologic evidence of failed posterior spinal interbody fusion. The cage construct can be stabilized with the injection of cement. The cement surrounding the construct provides strength to the axis and prevents further loosening.

Editorial Board

2010-08-01

The Spine Journal

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Déjà vu all over again

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Whiplash-associated disorders: who gets depressed? Who stays depressed? Phillips LA, Carroll LJ, Cassidy JD, Côté P. Eur Spine J 2010;19(6):945–56. Epub 2010 Feb 2

Assessment of the posterior ligamentous complex following acute cervical spine trauma. Rihn JA, Fisher C, Harrop J, Morrison W, Yang N, Vaccaro AR. J Bone Joint Surg Am 2010;92(3):583–9

Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. Lambeek LC, van Mechelen W, Knol DL, Loisel P, Anema JR. BMJ 2010;340:c1035

Predictors of residual symptoms in lower extremities after decompression surgery on lumbar spinal stenosis. Hara N, Oka H, Yamazaki T, et al. Eur Spine J 2010 Mar 23. [Epub ahead of print]

Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. Bode LG, Kluytmans JA, Wertheim HF, et al. N Engl J Med 2010;362(1):9–17

Meetings Calendar

Retethering of sectioned fibrolipomatous filum terminale in an adult: case report and review of the literature

Salvage percutaneous vertebral augmentation in failed spinal interbody fusions associated with multiple myeloma

Editorial Board

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