Dynamic stability of the trunk during unstable sitting in people with low back pain

Brief review

spine저널에서 이번 달에 출판된 논문 입니다.

*Title: Dynamic stability of the trunk during unstable sitting in people with low back pain

*Authors: Freddolini Marco, Strike Siobhan, Lee Raymond

*Bibliography: Spine (Phila Pa 1976). 2014 May1;39(10):785-90.

STUDY DESIGN

Cross-sectional study

OBJECTIVE

To evaluate the dynamic stability and kinematics of the trunk during unstable sitting.

To determine the differences in these biomechanical parameters between healthy participants and participants with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

Patients with LBP exhibited alterations in trunk kinematics while performing different dynamic tasks and in static posture as a result of pain. It is not clear if changing in trunk motion may reduce postural control and the ability to perform a balancing task.

METHODS

Group1: 23 participants with LBP

Group2: 31 healthy participants

*Protocol:

1) participants were sitted on a custom-made swinging chair

2) To regain the balance after tilting the chair backward for 10° and 20°

-Lumbar spine, pelvis, and chair motions were recorded using FASTRAK sensors.

-The thoracolumbar curvature of all participants was also evaluated in the standing position.

-The angular displacement of the chair was fitted in an equation describing the underdamped second-order response to a step input.

RESULTS

Kinematic analysis showed that the hip range of motion increased whereas spine range of motion angle decreased in participants with LBP for both tilt angles (P < 0.05). There were no significant differences between the 2 subject groups in the time required to regain balance, and the natural frequency and damping ratio of the kinematic equation. Lumbar lordosis significantly decreased in LBP group.

CONCLUSION

Participants with LBP showed trunk postural and movement adaptations that seems to be compensatory strategies to decrease the risk of further injuries and aggravation of the symptoms, but their ability to regain the balance was not affected by LBP. Clinicians should encourage patients with LBP to remain active while they are experiencing pain.

Interspinous spacers compared with decompression or fusion for lumbar stenosis: complications and repeat operations in the medicare population

Brief review

*Title: Interspinous spacers compared with decompression or fusion for lumbar stenosis: complications and repeat operations in the medicare population.

*Author: Richard A. Deyo, Brook I. Martin, Alex Ching, Anna N. A. Tosteson, Jeffrey G. Jarvik, William Kreuter, Sohail K. Mirza.

*Bibliography: Spine (Phila Pa 1976). 2013 May1;38(10):865-72.

STUDY DESIGN

Retrospective cohort analysis of Medicare claims for 2006-2009.

OBJECTIVE

To examine whether interspinous distraction procedures are 1)used selectively in patients with more advanced age or comorbidity.

2)associated with fewer complications, lower costs, and less revision surgery than laminectomy or fusion surgery.

SUMMARY OF BACKGROUND DATA

There are few population-based data evaluating patterns of interspinous spacer surgery and nonsurgical care.

METHODS

Medicare inpatient claims data divided into 4 groups. (with stenosis undergoing surgery, n = 99,084)

(1) interspinous process spacer alone

(2) laminectomy and a spacer

(3) decompression alone

(4) lumbar fusion (1-2 level)

-To compare age and comorbidity, cost of surgery, rates of revision surgery, major medical complications, wound complications, mortality, and 30-day readmission rates.

RESULTS

▶Age: received spacers > decompression or fusion

▶Comorbidity: received spacers > decompression or fusion

▶Complications (major medical): spacer alone < decompression or fusion surgery

▶Hospital payments: fusion procedures > spacer surgery > decompression alone

-These associations persisted in multivariate models adjusting for patient age, sex, comorbidity score, and previous hospitalization.

CONCLUSION

Interspinous distraction procedures fewer complications, higher rates of revision surgery to compared with decompression or fusion.

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.

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.

Does the presence of the nerve root sedimentation sign on MRI correlate with the operative level in patients undergoing posterior lumbar decompression for lumbar stenosis?

Brief review 1

*Title: Does the presence of the nerve root sedimentation sign on MRI correlate with the operative level in patients undergoing posterior lumbar decompression for lumbar stenosis?

*Authors: Akil Fazal, MD,  Andrew Yoo, BA,  John A. Bendo, MD

*Bibliography: Spine J. 2013 Aug;13(8):837-42.

BACKGROUND CONTEXT:

-Recent research describes the use of a nerve root sedimentation sign to diagnose lumbar spinal stenosis (LSS).

-The lack of sedimentation of the nerve roots (positive sedimentation sign) to the dorsal part of the dural sac is the characteristic feature of this new radiological parameter.

PURPOSE: To demonstrate how the nerve root sedimentation sign compares with other more traditional radiological parameters in patients who have been operated for LSS.

STUDY DESIGN/SETTING: A retrospective chart and image review.

PATIENT SAMPLE: Preoperative MRI were reviewed from 71 consecutive operative patients who presented with LSS and received spinal decompression surgery (2006-2010).

OUTCOME MEASURES: Preoperative T2-weighted MRIs were reviewed for each patient.

METHODS:

▶Measurements

134 vertebral levels (L1-5) were measured for

1)     sedimentation sign

2)     cross-sectional area (CSA)

3)     anterior/posterior (A/P) diameter of the dural sac

4)     thickness of the ligamentum flavum

5)     Fujiwara grade of facet hypertrophy.

-using Surgimap 1.1.2.169 software (Nemaris, Inc., New York, NY, USA)

-Exclusion criteria: 1) previous spine surgeries 2) absence of MRI on extended dynamic range 3) surgeries for primary diagnosis other than LSS

▶Statistical analyses

-using the SPSS 17.0 statistical software (SPSS Inc., Chicago, IL, USA).

-Significance was demonstrated using unpaired t tests and chi-squared tests.

RESULTS: The measurements are listed below.

CONCLUSIONS:

-The sign is most often present in patients who have clinically significant lumbar stenosis and require surgery.

-The sedimentation sign is a new measurement tool that can enable physicians to objectively assess and quantify spinal stenosis.

*Fujiwara grading system: aim to assess the severity of the facet joint osteoarthritis.

REFERENCE: Fujiwara A, Tamai K, Yamato M, et al. The relationshipbetween facet joint osteoarthritis and disc degeneration of the lumbar spine: anMRI study. Eur Spine J 1999;8:396–401.

Factors affecting dynamic foraminal stenosis in the lumbar spine

2nd journal review

*Title: Factors affecting dynamic foraminal stenosis in the lumbar spine

*Author: Vijay Singh,MD, Scott R. Montgomery,MD, Bayan Aghdasi,BA, Hirokazu Inoue,MD,PhD, Jeffrey C.Wang,MD, Michael D. Daubs,MD

*Bibliography: Spine J. 2013 Sep;13(9):1080-7.


Background Context: Minimal in vivo data exists quantifying changes in foraminal area(FA) as the spine moves from flextion to extension in the lumbar spine.

Purpose: To evaluate the relationship between foraminal stenosis and lumbar segmental 1)angular motion, 2)translational motion(TM), 3)disc bulge migration.

Study design: A retrospective radiographic study.

Patient sample: 45patients undergoing kMRI for symptoms of low back pain of radiculopathy(44years).

Outcome measures: MRI measurements of FA, angular motion, TM, disc bulge migration.

Methods:
>Study population
-45patients with clinically symptomatic low back pain or radiculopathy were reffered to lumbar kMRI.  (2011.03~2011.06)
-sex: 27males / 18females
-age: 44.7 years
-exclusion criteria: patients with unclear foraminal margins owing to rotation or scoliosis and with previous surgery, trauma, tumor, and infection.
    total 204 foramina met the inclusion criteria for analysis...

>MRI imaging protocol
-MRI of lumbar spine was performed using a 0.6-T Upright Multi-Position MRI (Fornar Corporation, Melville, NY, USA).

>MRI measurements
-Foraminal Area
1) The FA was calculated after outlining the perimeter of the neural foramen on parasagittal images using Image J software (ver. 1.45, US, National Institutes of Health, Bethesda, MD, USA)

2) assessed qualitatively using a modification of the grading system published bt Wildermuth et al.
Grade 1: normal foramina with normal foraminal epidural fat.
Grade 2: slight foraminal stenosis and deformity of epidural fat with remaining fat still completely surrounding the exiting nerve root.
Grade 3: marked foraminal stenosis with epidural fat only partially surrounding the nerve root or complete stenosis of foraminal epidural fat.

-Angular motion, TM, disc bulge
Images were evaluated with digital imaging software(MR Analyzer, ver. 2.0; TrueMRI Corporation, Bell-flower, CA, USA).
1) segmental angular motion: defined as the difference in intervertebral angles between two adjacent vertebrae from flextion to extension.
2) TM: calculated as the amount of anteroposterior movement at each vertebral level (flex to ext).
3) disc bulge: measured as the difference in the amount of disc bulging in the foramen from posterior vertebral margins at the level of foramina (flex to ext).

>Statistical analysis
-disc bulge, TM, angular motion data underwent statistical significance testing using the Shapiro-Wilk test and Mann-Whitney U test, Bonferroni inequality (p<0.05).

Results:
-There was a significant decrease in the FA from flx to neutral at all levels except L5-S1 and from neutral to ext at all levels.
-The average percent decrease in FA was 30.0%.
-Greatest decrease from flx to ext at L2-L3.
-Smallest change at L5-S1.
-The magnitude of change in FA increased as angular motion at a segment increased.
-The mean change in FA was 32.3㎟ when angular motion was less than 5º and was 75.16㎟ when angular motion exceeded 15º.
-The extent of disc bulging posteriorly in the neural foramen was also correlated with the reduction in the FA from flx to ext, but TM had no effect.

Conclusions:
-Foraminal area decreased significantly in extension compared with flexion and neutral on MRI.
-Disc bulge migration and angular motion at each level contributed to the decrease in FA(from flx to ext).
-TM was not strongly correlated to changes in FA.