Discogenic axial back pain: is there a role for nucleoplasty?

Brief review

이 논문은 추간판 조영술 시행 중 나타나는 동형의 통증과, 섬유륜의 찢어짐과 디스크 높이 감소가 nucleoplasty의 결과에 영향을 주는지를 밝히고, discogenic axial back pain의 치료방법으로서 nucleoplasty의 역할을 평가하기 위한 전향적 관찰연구 입니다.

Axial back pain으로 nucleoplasty를 받은 30명의 환자를 대상으로 VAS(허리 및 다리 통증지수 평가), ODI(기능적 장애 평가-일상생활 관련), SF-36(삶의 질 평가도구)를 술 후 6개월, 1년이 지났을 때 각각 조사한 결과, 세 항목 모두 통계적으로 유의하게 향상된 결과를 보였습니다.

또한, 추간판 조영술을 하는 동안 나타나는 동형의 통증과, 섬유륜의 찢어짐 및 디스크 높이의 감소는 axial back pain이 있는 환자가 nucleoplasty를 시행한 후의 결과에 영향을 끼치지 않는 것으로 나타났습니다.

밑에 있는 그림은 디스크 퇴행성 질환을 치료하는 다양한 방법을 사다리 모양으로 나타낸 그림 입니다. 가장 가벼운 방법인 금연, 운동부터 비교적 무거운 방법에 속하는 요추 유합술까지의 치료 방법을 순차적으로 나타내어 쉽게 이해가네요.

*Title: Discogenic axial back pain: is there a role for nucleoplasty?

디스크성 axial back pain: nucleoplasty의 역할은?

*Authros: Naresh Satyanarayan Kumar, Siddharth M Shah, Barry Wei Loong Tan, Salam Juned, Kaihan Yao

*Bibliography: Asian SpineJ. 2013 Dec;7(4):314-21. doi: 10.4184/asj.2013.7.4.314. Epub 2013 Nov 28.

STUDY DESIGN

A prospective observational study.

PURPOSE

1) To determine the influence of concordant pain during provocative discography, annular tear and loss of disc height on the outcome of nucleoplasty.

2) To evaluate the role of nucleoplasty in the management of discogenic axial back pain

OVERVIEW OF LITERATURE

The role of nucleoplasty in the management of radicular leg pain due to disc herniation is known. However, the data regarding its role in the management of discogenic axial back pain is scarce.

METHODS

▶Subjects: 30 patients with discogenic axial back pain undergoing nucleoplasty

(male:25 ,female:5/ mean age: 35yrs)

▶Evaluation method: pain(VAS), functional disability(ODI), quality of life(SF-36)

--> at 6months, 12months

-19patients: concordant pain during discography

RESULTS

▶Mean reduction: 6 months and at 12 months

-VAS: 31.03 and 29.03

-ODI: 24.53 and 20.60

-increment SF-36: 13.58 and 12.30

The differences were statistically significant (p <0.05). Concordant pain during provocative discography, annular tear and loss of disc height did not affect a clinically significant improvement in any of the three outcomes (p =0.882, 0.213, and 0.170; respectively).

CONCLUSIONS

-Nucleoplasty produced statistically significant improvements in pain, functional disability and quality of life in patients with discogenic low back pain. (at 6, 12 months)

-Concordant pain during provocative discography, annular tear and loss of disc height did not influence any of the outcomes after nucleoplasty in patients with discogenic axial back pain.

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.

Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability.

Brief review 2

*Title: Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability.

*Authors: Alan T. Villavicencio, MD,  Sigita Burneikiene, MD,  Ketan R. Bulsara, MD,  Jeffrey J. Thramann, MD

*Bibliography: J Spinal Disord Tech. 2006Apr;19(2):92-7.

OBJECTIVES: 

To assess clinical parameters for TLIF and AP reconstructive surgery for lumbar fusion.

(clinical parameters: 1)surgical blood loss, 2)duration of the procedure, 3)length of 

hospitalization, 4)complications)

METHODS: retrospective analysis -chart review (2002.01~2004.03)

▶Subject number: Total 167 cases

-TLIF: 124 patients (73 minimally invasive + 51 open cases) & AP surgery: 43 patients

▶Indications: 

-painful degenerative disc disease

-facet arthropathy

-degenerative instability

-spinal stenosis

-degenerative spondylolisthesis.

RESULTS:

1)blood loss, 2)operative times, 3)hospitalization times are listed belows.

 >OR Time: OpeRation Time

   EBL: Estimated Blood Loss

   LOS: Length Of Stay

4)complication rate are as follows.

-Major Complications

-Minor Complications

CONCLUSIONS:

1)blood loss : AP lumbar interbody fusion (significantly increased) > TLIF 

2)operative times: AP lumbar interbody fusion (more longer) > TLIF

3)hospitalization times: AP lumbar interbody fusion (more longer) > TLIF

4)complication rate: AP lumbar interbody fusion (more than 2 times higher) > TLIF

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.

Which procedure is better for lumbar interbody fusion: anterior lumbar interbody fusion or transforaminal lumbar interbody fusion?

1st journal review

*Title: Which procedure is better for lumbar interbody fusion: anterior lumbar interbody fusion or transforaminal lumbar interbody fusion?

*Author: Sheng-Dan Jiang, Jiang-Wei Chen, Lei-Sheng Jiang

*Bibliography: Arch Orthop Trauma Surg (2012) 132:1259-1266

Abstract
Introduction: This systematic review investigated whether surgical complications, non fusion rate, radiographic outcome and clinical outcome of ALIF were significantly different from those of TLIF.


Method: using MEDLINE data base.
>Eligibility criteria
selecting those articles: 1) target population, individuals: with lumbar spondylosis
2) intervention: ALIF compared with TLIF
3) English written article
and only the most recent papers were used..

>Identification of study
-Publications comparing ALIF and TLIF in the management of lumbar spondylosis were identified from a MEDLINE search. (1966.1~2011.6)
-using OVID search engine
-keyword: ALIF, TLIF, lumbar spondylosis

>Review method : Two authors reviewed the article using below method
1) review the title --> the article might meet eligibility criteria? -->2) then abstract review
-->3) review the complete article.
(only review the method section and blinded with author, institution, journal, results.)

>Statistical analysis
-using SPSS, unpaired Student's t test, Mann-Whitney U test/ Chi-squared test. ( p < 0.05 )


Result
-9 studies(comparing ALIF and TLIF) included in this systematic review.

1) Operative Time (7 studies)
ALIF >>>>>> TLIF

 2) Blood loss (7 studies)
ALIF >>>>>> TLIF

3) Complications (5 studies)
ALIF: 60 complications /244 patients
TLIF: 90 complications /371 patients

4) Radiographic outcomes: disc height, segmental lordosis, whole lumbar lordosis (3 studies)
ALIF >> TLIF

5) Clinical outcomes: using VAS(visual analog scale), ODI (oswestry disability index) (3 studies)
no significant difference

6) Nonfusion
ALIF: 23 /169 patients (13.6%)
TLIF: 23 /222 patients (10.4%)
no significant difference

7) Economic analysis
costs of ALIF were greater than those of TLIF.


Conclusion
OP Time and Blood loss, Radiographic outcomes, costs : ALIF > TLIF
Clinical outcomes and Nonfusion rate: ALIF ≒ TLIF