In healthy subjects, the sitting position can be used to validate the postural effects induced by wearing a lumbar lordosis brace

Brief review

*Title: In healthy subjects, the sitting position can be used to validate the postural effects induced by wearing a lumbar lordosis brace

*Author: M. Mathias, P.R. Rougier

*Bibliography: Annals of Physical andRehabilitation Medicine 53 (2010) 511–519

Aim of the study

To assess the validity of the sitting position when testing lumbar braces for the maintenance of lordosis.

Patients and methods

▶Subject number: 12 young adults (seated on force platform)

▶Experimental conditions (4 ways)

1. with a brace

2. without a brace

3. with enforced lordosis

4. without enforced lordosis

(For distinguish between the roles played by lordosis and the brace)

-The trajectories of the centre of pressure (CP) were analyzed and compared.

(To assess postural orientation and stabilisation processes)

Results

-Using the lumbar brace led to reduction in CP displacement (along the mediolateral and anteroposterior axes).

-Lordosis barely affected postural performance and only an increase in the mean CP velocity was observed.

-An analysis of variance failed to reveal an interaction between the “lordosis” and “brace” factors.

Conclusion

-A lumbar brace (in the absence or presence of lordosis) helps subjects to improve their sitting performance.

-Function of brace wear emphasises the discriminant power of the sitting position: significant differences

-This task should be applied more widely in the development of more appropriate, validated equipment for lower back pain sufferers.

Low back pain sufferers: Is standing postural balance facilitated by a lordotic lumbar brace?

Brief review

*Title: Low back pain sufferers: Is standing postural balance facilitated by a lordotic lumbar brace?

요추부 환자: 요추 전만증 보조기에 의해 기립자세의 균형이 가능한가?

*Author: F. Munoza, J.-F. Salmochib, P. Faouënc, P. Rougiera,

*Bibliography: Orthopaedics &Traumatology: Surgery & Research (2010) 96, 362—366

Introduction

▶Lumbar Lordosis Brace:

-could be a valuable option and rehabilitation tool in the treatment of discogenic low back pain.

-exerts the necessary degree of compression in the lumbar region.

-achieves correction of the sagittal plane spine balance to improve postural control of the lumbar spine.

Quantitative analysis of the centre of pressure (CoP) deviations to maintain the standing posture helps evaluate the impact of such device on postural balance.

Patients and methods

▶Subject number: 11 patients (suffering from lumbar pain with discopathy)

-Stand on a force with eyes closed under fitted or not with a lumbar lordosis brace.

Results

On the antero-posterior axis, the lordosis brace achieved as below

-6 mm CP deviation (from its mean position)

-51% reduction (in the mean displacement)

Discussion

-Lumbar lordosis brace can be improve the quality of the patient's balance strategy.

-Posturography achieved when using a thoracolumbosacral orthosis in patients suffering from lumbar pain (in situ investigation of the postural benefits).

Postoperative bracing after spine surgery for degenerative conditions: a questionnaire study

Brief review

이 연구는 한 학회에 참가한 척추전문의들에게 본인의 환자에게 보조기를 사용하는 것과 관련하여 설문을 진행한 질의연구 입니다. 

설문의 초점은 외과의들이 환자 수술 후에 사용하는 보조기의 종류, 치료기간, 사용이유 등에 관한 것 입니다.

응답자들이 수술을 마친 본인의 환자들에게 보조기를 사용 할 때에, 고정을 위한 가장 적절한 종류, 기간, 적응증에 따른 합의가 부족하다는 결론입니다.

*Title: Postoperative bracing after spine surgery for degenerative conditions

: a questionnaire study

퇴행성질환을 위한 척추수술 후의 보조기 착용: 질의 연구

*Author: Jesse E. Bible, Debdut Biswas, Peter G. Whang, Andrew K. Simpson, Glenn R. Rechtine, Jonathan N. Grauer

*Bibliography: The Spine Journal Volume 9, Issue 4 ,Pages 309-316, April 2009

Background context:

-A variety of orthoses are routinely applied after spinal procedures.

-But the proper indications for postoperative bracing are not well established.

Purpose

To assess the postoperative bracing patterns of spine surgeons.

Study design/setting

Questionnaire study

Patient sample

Spine surgeons attending the “Disorders of the Spine” conference (January 2008, Whistler, Canada).

Outcome measures

Frequencies of bracing after specific surgical procedures.

Methods

▶Subject: spine surgeons attending the “Disorders of the Spine” conference.

▶Questionnaire contents: typically immobilize patients after specific spinal procedures, the type of orthosis used, the duration of treatment, the rationale for bracing.

Results

-Ninety-eight of 118 surgeons completed the survey (response rate: 83%).

1. The frequency of bracing in academic and private/ in orthopedic and neurosurgical practices

--> similar

2.The difference in the bracing tendencies of fellowship and non-fellowship trained surgeons: -----> statistically significant (61% vs. 46%, p<.0001).

3. The duration (clinical experience): no influence the propensity of surgeons to use orthoses.

4. Employed more regularly: after cervical surgery > lumbar surgery (63% vs. 49%, p<.0001).

6. In the anterior cervical spine, orthoses were used more often as the complex procedure.

(increased single --▶ multilevel constructs (55% vs. 76%, p<.0001) )

7. The frequencies of bracing in noninstrumented and instrumented lumbar fusions

-->not significantly different.

Conclusions

-Most of the respondents brace their patients postoperatively, there is an obvious lack of consensus regarding the most appropriate type, duration, and indications for immobilization.

-Clinical studies may play a helpful role in evaluating the efficacy of postoperative bracing protocols.

Interface corrective force measurements in Boston brace treatment

Brief review

*Title: Interface corrective force measurements in Boston brace treatment

Boston보조기 치료에서 정확한 힘의 측정 인터페이스

*Author: J. van den Hout, L. van Rhijn, R. van den Munckhof, A. van Ooy

*Bibliography: EuropeanSpine Journal August 2002, Volume 11, Issue 4, pp 332-335

Background:

Brace application has been reported to be effective in treating idiopathic adolescent scoliosis.

Problem:

The exact working mechanism of a thoracolumbo spinal orthosis is not completely understood.

In this article, working mechanisms is a direct compressive force working through the brace upon the body and thereby correcting the scoliotic deformity, achieving optimal fit of the individual orthosis.

Purpose:

Measured these direct forces exerted by the pads in a Boston brace.

Method:

▶Subject number: 16 patients (with idiopathic adolescent scoliosis)

▶Measurement method: using the electronic PEDAR measuring device (Novel, Munich, Germany).

(Designed as an inshoe measuring system. wired to a computer, recording static and dynamic pressure distribution under the plantar surface of the foot.)

-After positioning the inserts between the lumbar and thoracic pads and the body, measured the forces acting upon the body in 8 different postures.

Result:

-Mean corrective force (through the brace pad): lumbar > thoracic (in all positions)

-Changes in body posture: significant alterations in the exerted forces.

-Between the magnitude of the compressive force over the lumbar and thoracic brace-pad and the degree of correction of the major curve: no significant correlation

-Corrective forces in new (<6 months) and old (>6 months) brace: no statistically difference.

Conclusion:

-The use of this pressure measurement device is practicable and of value for studies of the working mechanism of brace treatment.

-In the future, it might be of help in achieving optimal fit of the individual orthosis.

Determining the quality and effectiveness of surgical spine care: patient satisfaction is not a valid proxy

Brief review

이 논문은 환자 만족도의 질과 유효성을 평가하는 내용 입니다.

10가지 항목으로 평가하였고, 환자의 만족도는 척추 수술의 질과 유효성을 결정하기에는 충분치 않다는 결론 입니다. 

이와 관련하여 The Spine Journal에 환자만족도가 합리적인 측정결과인지에 대한 Commentary도 출판되어 있으니 참고하시기 바랍니다.

(http://www.thespinejournalonline.com/article/S1529-9430(12)00996-5/abstract) 

*Title: Determining the quality and effectiveness of surgical spine care: patient satisfaction is not a valid proxy.

수술적 척추 치료의 질과 유효성의 결정: 환자의 만족도는 유효한 대용물이 아니다.

*Author: Saniya S. Godil, Scott L. Parker, Scott L. Zuckerman, Stephen K. Mendenhall, Clinton J. Devin, Anthony L. Asher, Matthew J. McGirt

*Bibliography: Spine J. 2013 Sep;13(9):1006-12.

BACKGROUND CONTEXT: .

Patients' satisfaction has commonly used metric as a proxy. But It has yet to be validated as a measure of overall quality of surgical spine care.

PURPOSE:

To determine whether patient satisfaction is a valid measure of safety and effectiveness of care in a prospective longitudinal spine registry.

STUDY DESIGN: Prospective longitudinal cohort study.

PATIENT POPULATION:

All patients undergoing elective spine surgery for degenerative conditions over a 6-month period at a single medical center.

OUTCOME MEASURES:

Patient-reported outcome instruments as follow.

1. numeric rating scale [NRS]

2. Oswestry disability index [ODI]

3. neck disability index [NDI]

4. short-form 12-item survey [SF-12]

5. Euro-Qol-5D [EQ-5D]

6. Zung depression scale

7. Modified Somatic Perception Questionnaire[MSPQ] (anxiety scale)

8. return to work

9. patient satisfaction with outcome

10. patient satisfaction with provider care.

METHODS:

▶Subject: undergoing elective spine surgery for degenerative conditions (over a 6-month period)

▶Measurement: NRS, ODI, NDI, SF-12, EQ-5D, Zung depression scale, and MSPQ anxiety scale, return to work, patient satisfaction with outcome, and patient satisfaction (3 months after treatment)

RESULTS:

422 patients (84%) completed all questionnaires 3 months after surgery during the reviewed time period (mean age 55±14 years).

(Lumbar surgery was performed in 287 (68%) and Cervical surgery in 135 (32%) patients)

-complications: 51 patients (12.1%) (90-day)

-readmissions: 21 (5.0%)

-return to operating room: 12 (2.8%)

-patients satisfied with provider care: 358 (84.8%)

-patients satisfied with outcome: 288 (68.2%)

-In ROC analyses, improvement in quality of life(SF-12), disability(ODI/NDI) differentiated satisfaction VS dissatisfaction with care with very poor accuracy (AUC 0.49-0.69).

CONCLUSIONS:

-Patient satisfaction is not a valid measure of overall quality or effectiveness of surgical spine care.

-Patient satisfaction metrics likely represent the patient's subjective contentment with health-care service, a distinct aspect of care.

-Satisfaction metrics are important patient-centered measures of health-care service but should not be used as a proxy for overall quality, safety, or effectiveness of surgical spine care.

the autumn sky

Influence of bone mineral density on pedicle screw fixation: a study of pedicle screw fixation augmenting posterior lumbar interbody fusion in elderly patients

Brief review

*Title: Influence of bone mineral density on pedicle screw fixation: a study of pedicle screw fixation augmenting posterior lumbar interbody fusion in elderly patients

척추경나사못고정술에서 골밀도의 영향: 고령환자의 후방 요추체간 유합술에서 척추경 나사못 고정의 연구

*Author: Koichiro Okuyama, Eiji Abe, Tetsuya Suzuki, Yasuki Tamura, Mitzuho Chiba, Kozo Sato

*Bibliography: TheSpine Journal1(2001)402-407.

Background context: 

-Some biomechanical studies have demonstrated that bone mineral density of the lumbar spine (BMD) affects the stability of pedicle screws in vitro.

-Common problem: screw bending, breakage, loosening(radiolucency in the bone screw interface).

Purpose: 

-To investigate influence of BMD on loosening and related failure of pedicle screws in vivo.

Study design/setting: 

-A clinical study of 52 patients who underwent pedicle screw fixation augmenting posterior lumbar interbody fusion (PLIF).

Patient sample:

▶Subject number: 52 patients (13 men + 39 women)

▶Mean age: 63 years (range, 45–76 yr)

▶Mean follow-up period: 2.8 years (range, 2–6 yr).

Outcome measures: 

-statistically analyzed(Relationship between BMD, screw loosening, and its related failures)

Methods:

-BMD was measured by the dual energy X-ray absorptiometry (DEXA) method.

-Two authors did radiographic assessments.

▶52 patients were divided into 3 groups as below.

1. Union: n=40

(no movement on the lateral view in the flx-ext in the fixed segment and continuity of trabecular bony bridging at the fixed interbody space.)

2. Non union: n=4

(any movement or discontinuity)

3. Undetermined union: n=8

(continuity of the trabecular bony bridging was vague in spite of no movement of the fixed segment in the flx-ext.)

Results:

The mean BMD values are as follow. (Unit: g/cm2 / mean±S.D.)

▶All patients: 0.879±0.215

▶Patients with or without screw loosening

-with screw loosening: 0.720±0.078 (n=11)

-without screw loosening: 0.922±0.221 (n=41).

>>Significant difference between with and without screw loosening 

(the mean BMD of patients ,P<.01).

▶Union patients

-Union patients: 0.934±0.210 (n=40)

-Non union: 0.674±0.104 (n=4)

-Undetermined union: 0.710±0.116 (n=8)

>>Union was significantly greater than those with Nonunion and Undetermined union (P<.05).

Conclusion:

-BMD has a close relation with the stability of pedicle screws

-BMD value below 0.674±0.104 g/cm2 suggests a potential increased risk of “nonunion” when pedicle screw fixation is performed in conjunction with PLIF.

Preliminary results on feasibility of outpatient instrumented transforaminal lumbar interbody fusion.

Brief review

*Title: Preliminary results on feasibility of outpatient instrumented transforaminal lumbar interbody fusion.

외래환자의 신경공경유요추체유합술 시행 가능성에 대한 예비결과

*Author: Alan T. Villavicencio, Ewell Lee Nelson, Alexander Mason, Sharad Rajpal, Sigita Burneikiene

*Bibliography: JSpinal Disord Tech. 2013 Aug;26(6):298-304

STUDY DESIGN: A retrospective chart review study

OBJECTIVE:

-The primary objective: To examine whether it is safe and effective to perform instrumented lumbar interbody fusions by comparing 2 groups (same day vs stayed overnight).

-The secondary objective: To identify the need for prolonged observation for complications that may occur in the immediate postoperative period.

SUMMARY OF BACKGROUND DATA: 

There is currently no information in the literature on the safety and complication rates of instrumented transforaminal lumbar interbody fusions performed in an ambulatory surgery setting.

METHODS:

▶Subject number: Ambulatory Surgery Center(ASC): 27/  Hospital Outpatient Departments (HOD): 25

▶Mean age: 49.8 years (19-72 y)

▶evaluation method:

-The safety of outpatient lumbar fusions: analyzing complications that occurred when the seventh postoperative day (0-7 POD).

- The efficacy of surgical intervention: change in pain, patient satisfaction scores, and fusion rates

RESULTS:

-no cases of pneumonia, urinary tract infection, or thromboembolic complications.

-4 patients(14%) in ASC and 1 patient(4%) in HOD had complications within 7 days postoperatively.

-->not statistically significant in difference (P=0.36, Fisher exact test).

-Lower back and leg pain was significantly (P<0.0001) decreased postoperatively as follow.

>The average back pain: 74.5 (range: 0-100)  --> 18.8 (range: 0-90)

>The average leg pain: 54.2 (range, 0-100) --> 9.1 (range, 0-60)

*using 0-100 visual analog scale

CONCLUSIONS: 

This study discusses the possibility of performing instrumented lumbar interbody fusions with the transforaminal lumbar interbody fusion technique as an outpatient procedure.

Who should have surgery for spinal stenosis?: Treatment effect predictors in SPORT

Brief review

*Title: Who should have surgery for spinal stenosis?: Treatment effect predictors in SPORT.

누가 척추 협착증을 위한 수술을 받아야 하는가?

: SPORT(Spine Patient Outcome Research Trial)에서의 치료효과의 예측변수

*Author: Adam Pearson, Jon Lurie, Tor Tosteson, Wenyan Zhao, William Abdu, James N. Weinstein

*Bibliography: Spine(Phila Pa 1976). 2012 Oct 1;37(21):1791-802.

STUDY DESIGN: Combined prospective randomized controlled trial and observational cohort study of spinal stenosis (SpS) with an as-treated analysis.

OBJECTIVE: To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for SpS using subgroup analysis.

SUMMARY OF BACKGROUND DATA: The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for SpS at the group level. However, individual characteristics may affect TE. No previous studies have evaluated TE modifiers in SpS.

METHODS:

▶Study design: Spinal stenosis patients were treated with either surgery (n = 419) or nonoperative care (n = 235) and were analyzed according to treatment received.

▶Patient Population

-Inclusion criteria: had neurogenic claudication or radicular pain for at least 12 weeks, a confirmatory cross-sectional imaging study demonstrating stenosis at 1 or more levels.

-Exclusion criteria: cauda equina syndrome, malignancy, significant deformity, previous back surgery, instability on flexion-extension radiographs, and other established contraindications to elective surgery.

▶Statistical Considerations: The TE of surgery was defined as:

TE (Treatment Effect)= change in ODI (surgery) – change in ODI (nonoperative)

RESULTS:

-All analyzed subgroups improved significantly more with surgery than with nonoperative treatment 

(P < 0.05).

-Details of the below were associated with greater TE.

baseline ODI ≤ 56 (TE -15.0 vs. -4.4, ODI > 56, P < 0.001),

not smoking (TE -11.7 vs. -1.6 smokers, P < 0.001),

neuroforaminal stenosis (TE -14.2 vs. -8.7 no neuroforaminal stenosis, P = 0.002),

predominant leg pain (TE -11.5 vs. -7.3 predominant back pain, P = 0.035),

not lifting at work (TE -12.5 vs. -0.5 lifting at work, P = 0.017),

the presence of a neurological deficit (TE -13.3 vs. -7.2 no neurological deficit, P < 0.001).

CONCLUSION:

-Patients improved more with surgery than with nonoperative treatment, regardless of other specific characteristics.

-However, TE varied significantly across certain subgroups, and these data can be used to individualize shared decision making discussions about likely outcomes.

Key Points

●Other than smokers, all patient subgroups improved more with surgery than with nonoperative treatment.

●Baseline ODI score less than 56, not smoking, neuroforaminal stenosis, predominant leg pain, not lifting at work, and baseline neurological deficit predicted a greater TE of surgery.

●Smoking cessation should be considered before surgery for SpS.

●These data can be used to help to individualize shared decision-making discussions about likely outcomes after surgical or nonoperative treatment for SpS.