The evidence on surgical interventions for low back disorders, an overview of systematic reviews. Eur Spine J. 2013;22:1936-1949. [PMID: 23681497 DOI: 10.1007/s00586-013-2823-4]

Prognostic Factors for Outcome of Fusion Surgery in Patients With Chronic Low Back Pain - A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

This systematic review aims to identify prognostic factors, encompassing biomedical and psychosocial variables, linked to outcome of fusion surgery for chronic low back pain (CLBP) in single or two-level lumbar degenerative spinal disorders. Identifying these factors is crucial for decision making and therefore long-term treatment outcome.

METHODS

A systematic search (PROSPERO ID: CRD4202018927) from January 2010 to October 2022 was conducted, utilizing Medline, Embase, and the Cochrane Database of Systematic Reviews (CDSR, CENTRAL). Prognostic factors associated with various outcomes, including functional status, back and leg pain, health-related quality of life, complications, return to work, and analgesic use, were assessed. Risk of bias was determined using QUIPS, and the quality of evidence was evaluated using GRADE approach.

RESULTS

Of the 9852 initially screened studies, eleven studies (n = 16,482) were included in the analysis. In total, 161 associations were identified, with 67 prognostic factors showing statistical significance (P < 0.05). Thirty associations were supported by two or more studies, and only eight associations were eligible for meta-analyses: female gender remained statistically significant associated with decreased postoperative back pain, but negatively associated with complication rates and functional status, and smoking with increased postoperative back pain.

CONCLUSION

Only female gender and smoking were consistently associated with outcome of fusion for CLBP. Most of the included studies exhibited low to moderate methodological quality, which may explain the relatively weak associations identified for the assessed prognostic factors.

Practice variation in surgical treatment for lumbar degenerative disc disease: exploring regional and hospital factors influencing surgical rates

The presence of significant, unwarranted variation in treatment suggests that clinical decision making also depends on where patients live instead of what they need and prefer. Historically, high practice variation in surgical treatment for lumbar degenerative disc disease (LDDD) has been documented. This study aimed to investigate current regional variation in surgical treatment for sciatica resulting from LDDD. We conducted a retrospective, cross-sectional analysis of all Dutch adults (>18 years) between 2016 and 2019. Demographic data from Statistics Netherlands were merged with a nationwide claims database, covering over 99% of the population. Inclusion criteria comprised LDDD diagnosis codes and relevant surgical codes. Practice variation was assessed at the level of postal code areas and hospital service areas (HSAs). Multivariable logistic regression analysis was employed to identify variables associated with surgical treatment. Among the 119,148 hospital visitors with LDDD, 14,840 underwent surgical treatment. Practice variation for laminectomies and discectomies showed less than two-fold variation in both postal code and HSAs. However, instrumented fusion surgery demonstrated a five-fold variation in postal code areas and three-fold variation in HSAs. Predictors of receiving surgical treatment included opioid prescription and patient referral status. Gender differences were observed, with males more likely to undergo laminectomy or discectomy, and females more likely to receive instrumented fusion surgery. Our study revealed low variation rates for discectomies and laminectomies, while indicating a high variation rate for instrumented fusion surgery in LDDD patients. High-quality research is needed on the extent of guideline implementation and its influence on practice variation.

Neurotechnology for Pain

Neurotechnologies for treating pain rely on electrical stimulation of the central or peripheral nervous system to disrupt or block pain signaling and have been commercialized to treat a variety of pain conditions. While their adoption is accelerating, neurotechnologies are still frequently viewed as a last resort, after many other treatment options have been explored. We review the pain conditions commonly treated with electrical stimulation, as well as the specific neurotechnologies used for treating those conditions. We identify barriers to adoption, including a limited understanding of mechanisms of action, inconsistent efficacy across patients, and challenges related to selectivity of stimulation and off-target side effects. We describe design improvements that have recently been implemented, as well as some cutting-edge technologies that may address the limitations of existing neurotechnologies. Addressing these challenges will accelerate adoption and change neurotechnologies from last-line to first-line treatments for people living with chronic pain.

The role of spinal surgery in the treatment of low back pain

Low back pain (LBP) is common and a leading cause of disability and lost productivity worldwide. Acute LBP is frequently self-resolving, but recurrence is common, and a significant proportion of patients will develop chronic pain. This transition is perpetuated by anatomical, biological, psychological and social factors. Chronic LBP should be managed with a holistic biopsychosocial approach of generally non-surgical measures. Spinal surgery has a role in alleviating radicular pain and disability resulting from neural compression, or where back pain relates to cancer, infection, or gross instability. Spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of LBP is poor and suggests it is ineffective. Emerging areas of interest include selection of a minority of patients who may benefit from surgery based on spinal sagittal alignment and/or nuclear medicine scans, but an evidence base is absent. Spinal surgery for back pain has increased substantially over recent decades, and disproportionately among privately insured patients, thus the contribution of industry and third-party payers to this increase, and their involvement in published research, requires careful consideration.

Practice Variation Research in Degenerative Lumbar Disc Surgery: A Literature Review on Design Characteristics and Outcomes

STUDY DESIGN

Literature review.

OBJECTIVE

To describe whether practice variation studies on surgery in patients with lumbar degenerative disc disease used adequate study methodology to identify unwarranted variation, and to inform quality improvement in clinical practice. Secondary aim was to describe whether variation changed over time.

METHODS

Literature databases were searched up to May 4^th, 2021. To define whether study design was appropriate to identify unwarranted variation, we extracted data on level of aggregation, study population, and case-mix correction. To define whether studies were appropriate to achieve quality improvement, data were extracted on outcomes, explanatory variables, description of scientific basis, and given recommendations. Spearman's rho was used to determine the association between the Extreme Quotient (EQ) and year of publication.

RESULTS

We identified 34 articles published between 1990 and 2020. Twenty-six articles (76%) defined the diagnosis. Prior surgery cases were excluded or adjusted for in 5 articles (15%). Twenty-three articles (68%) adjusted for case-mix. Variation in outcomes was analyzed in 7 articles (21%). Fourteen articles (41%) identified explanatory variables. Twenty-six articles (76%) described the evidence on effectiveness. Recommendations for clinical practice were given in 9 articles (26%). Extreme Quotients ranged between 1-fold and 15-fold variation and did not show a significant change over time (rho= -.33, P= .09).

CONCLUSIONS

Practice variation research on surgery in patients with degenerative disc disease showed important limitations to identify unwarranted variation and to achieve quality improvement by public reporting. Despite the availability of new evidence, we could not observe a significant decrease in variation over time.

How is recovery defined and measured in patients with low back pain? Protocol for a mixed study systematic review

INTRODUCTION

This protocol describes the methods for a mixed study systematic review aiming to explore the definitions and measurements of recovery in patients with low back pain, and how perspectives of recovery differ between patients and providers. This review will be the first to review the concept of recovery in patients with low back pain across both quantitative and qualitative literature.

METHODS AND ANALYSIS

This protocol has been designed and reported in line with Preferred Reporting Items of Systematic Reviews and Meta-Analyses Protocols. The following databases will be electronically searched from database inception until 30 November 2021: Medline, EMBASE, CINAHL, Cochrane, PEDro. Grey literature will be searched for through targeted searching of ProQuest Dissertations and Theses and handsearching of the references of all included studies. Studies will be included if they include a patient population of >50% with low back pain (with or without leg pain), and mention the concept of recovery within the abstract, methods or results. The Mixed Methods Appraisal Tool will be used for quality assessment of both quantitative and qualitative included studies. Two independent reviewers will conduct the search, screen titles/abstracts and extract relevant data from full texts. Discrepancies between reviewers will be settled by a third reviewer with spinal pain expertise. For syntheses, thematic analysis will be used to analyse both qualitative and quantitative investigations to explore meanings, measurement and perspectives of recovery from a diverse evidence base. There is no clinical trial associated with this protocol.

ETHICS AND DISSEMINATION

There are no ethical issues associated with this systematic review, and ethics approval was not required. Once completed, the results of this review will be published in a peer-reviewed journal within the realm of spinal pain to help guide future research inquiries.

PROSPERO REGISTRATION NUMBER

CRD42022295804.

Comparison of 3 Different Minimally Invasive Surgical Techniques for Lumbar Spinal Stenosis: A Randomized Clinical Trial

IMPORTANCE

Operations for lumbar spinal stenosis is the most often performed surgical procedure in the adult lumbar spine. This study reports the clinical outcome of the 3 most commonly used minimally invasive posterior decompression techniques.

OBJECTIVE

To compare the effectiveness of 3 minimally invasive posterior decompression techniques for lumbar spinal stenosis.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial used a parallel group design and included patients with symptomatic and radiologically verified lumbar spinal stenosis without degenerative spondylolisthesis. Patients were enrolled between February 2014 and October 2018 at the orthopedic and neurosurgical departments of 16 Norwegian public hospitals. Statistical analysis was performed in the period from May to June 2021.

INTERVENTIONS

Patients were randomized to undergo 1 of the 3 minimally invasive posterior decompression techniques: unilateral laminotomy with crossover, bilateral laminotomy, and spinous process osteotomy.

MAIN OUTCOMES AND MEASURES

Primary outcome was change in disability measured with Oswestry Disability Index (ODI; range 0-100), presented as mean change from baseline to 2-year follow-up and proportions of patients classified as success (>30% reduction in ODI). Secondary outcomes were mean change in quality of life, disease-specific symptom severity measured with Zurich Claudication Questionnaire (ZCQ), back pain and leg pain on a 10-point numeric rating score (NRS), patient perceived benefit of the surgical procedure, duration of the surgical procedure, blood loss, perioperative complications, number of reoperations, and length of hospital stay.

RESULTS

In total, 437 patients were included with a median (IQR) age of 68 (62-73) years and 230 men (53%). Of the included patients, 146 were randomized to unilateral laminotomy with crossover, 142 to bilateral laminotomy, and 149 to spinous process osteotomy. The unilateral laminotomy with crossover group had a mean change of -17.9 ODI points (95% CI, -20.8 to -14.9), the bilateral laminotomy group had a mean change of -19.7 ODI points (95% CI, -22.7 to -16.8), and the spinous process osteotomy group had a mean change of -19.9 ODI points (95% CI, -22.8 to -17.0). There were no significant differences in primary or secondary outcomes among the 3 surgical procedures, except a longer duration of the surgical procedure in the bilateral laminotomy group.

CONCLUSIONS AND RELEVANCE

No differences in clinical outcomes or complication rates were found among the 3 minimally invasive posterior decompression techniques used to treat patients with lumbar spinal stenosis.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02007083.

Global trends of researches on bone metastasis: A bibliometric and visualization study

BACKGROUND

Bone metastasis (BM) has become an important health problem. In recent years, studies on BM are growing rapidly, but there were no bibliometric studies regarding BM. This study aimed to illustrate the overall knowledge structure and development trends of BM.

METHODS

Research datasets were acquired from the Web of Science database. The time span was defined as "1980-2020". VOS viewer and Citespace software was provided to analyze the data and generate visualization knowledge maps. Annual trends of publications, distribution, H-index status, co-authorship status, and research hotspots were analyzed.

RESULTS

Six hundred eighty-two publications met the requirement. USA published most papers (264, 38.7%), and both total citations (13,997) and H-index (57) of USA ranked first. The most productive institution on BM is Amgen Inc. (43). Supportive Care in Cancer (24) published the most papers on BM. "Safety", "skeletal related event", "open label", "management", "health", and "prognosis" are the research hotspots in the recent years.

CONCLUSION

In this study, we conduct a systematic and comprehensive analysis on the research in BM field. The publication number was rising in recent years stably. USA contributed mostly not only in quality, but also in quantity. Amgen Inc. published the largest number of articles, Supportive Care in Cancer was the most productive journal related to BM. "Safety", "skeletal related event", "open label", "management", "health", and "prognosis" are the research hotspots in recent years. We believe this study can not only show the global research overview in past 40 years but also point the research trend of BM in the future.

Global Trends of Researches on Lumbar Spinal Stenosis: A Bibliometric and Visualization Study

STUDY DESIGN

Bibliometric and visualization analysis.

OBJECTIVE

Lumbar spinal stenosis (LSS) has become a common health problem and the most frequent indication for spinal surgery. This study aimed to illustrate the overall knowledge structure, and development trends of LSS, using a bibliometric analysis and newly developed visualization tools.

MATERIALS AND METHODS

Research data sets were acquired from the Web of Science. The time span was defined as "2000-2019". VOS viewer and Citespace software was provided to analyze the data and generate visualization knowledge maps. Annual trend of publications, distribution, H-index status, co-authorship status and research hotspots were analyzed.

RESULTS

A total of 1934 publications met the requirement. The United States published most papers (521, 26.9%), both total citations (17,626) and H-index (61) ranked first of all the countries. The most productive organizations on LSS is Seoul National University (50). Spine (43) published the most papers on LSS. Quality of life, risk factor, disability, double blind trials, and decompression surgery are the research hotspots in the recent years.

CONCLUSION

The number of publications showed an upward trend with a stable rise in recent years. The United States is a country with the highest productivity, not only in quality, but also in quantity. Seoul National University has been the largest contributor in this field. Spine is the best journal related to LSS. Quality of life, risk factor, disability, and decompression surgery are the research hotspots in the recent years. Indeed, this study provides a new insight to the growth and development of LSS. Moreover, it will contribute to the growth of the international frontier of LSS.

A Study on COMP and CTX-II as Molecular Markers for the Diagnosis of Intervertebral Disc Degeneration

Background

Diagnosis of intervertebral disc degeneration (IVDD) is challenging at the early stage. The cartilage oligomeric matrix protein (COMP) and extracellular matrix degradation products of C-telopeptide of type II collagen (CTX-II) serve as markers for the serological diagnosis of IVDD. Oxidative stress might cause IVDD and matrix degeneration.

Methods

A total of 128 male adult Sprague–Dawley (SD) rats were randomly and equally assigned to the experimental and control groups. The experimental group was used to construct IVDD models by acupuncture, while the control group underwent sham operation. The animals were executed every week for 8 weeks after intervertebral disc acupuncture, and serum samples were collected for the estimation of CTX-II and COMP concentrations by enzyme-linked immunosorbent assay (ELISA). Also, the histological changes and caudal magnetic resonance imaging (MRI) changes were examined in the intervertebral disc.

Results

IVDD in rats worsened with prolonged follow-up after acupuncture. At all the time points, the experimental group showed altered histological and caudal vertebra MRI signals, and serum CTX-II and COMP concentrations were significantly greater than those of the control group. These levels increase with the process of IVDD.

Conclusion

Serum CTX-II and COMP estimation is a reliable method to diagnose IVDD, and their concentrations show a positive correlation with the process of IVDD.

The Effect of Patient Position on Psoas Morphology and in Lumbar Lordosis

INTRODUCTION

Among the interbody fusions, lateral lumbar interbody fusion allows access to the lumbar spine through the major psoas muscle, which offers several advantages to the spine surgeon. However, some of its drawbacks cause surgeons to avoid using it as a daily practice. Therefore, to address some of these challenges, we propose the prone transpsoas technique, differing mainly from the traditional technique on patient position-moving from lateral to prone decubitus, theoretically enhancing the lordosis and impacting the psoas morphology.

METHODS

Twenty-four consecutive patients were invited to have magnetic resonance imaging examinations in 3 different positions (prone, dorsal, lateral). Two observers measured the following parameters: vertebral body size, psoas diameter, psoas anterior border distance, plexus distance, total lumbar lordosis, distal lumbar lordosis, and proximal lumbar lordosis. Values of P < 0.05 were deemed significant.

RESULTS

The prone position yielded a significant increase in the lumbar lordosis, both in L1-S1 (57° vs. 46.5°) and proximal lordosis (40.4° vs. 36.9°) compared with the lateral position. Regarding the morphologic aspects, patients in the prone position presented lesser psoas muscles forward shift, but no difference was noted in the plexus position neither for L3-L4 nor L4-L5.

CONCLUSIONS

The prone position resulted in a significantly increased lumbar lordosis, both distal and proximal, which may enable the spine surgeon to achieve significant sagittal restoration just by positioning. The prone position also produced a posterior retraction of the psoas muscle. However, it did not significantly affect the position of the plexus concerning the vertebral body.

Invasive Treatments for Low Back Disorders

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders.

METHODS

Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders.

RESULTS

Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations.

CONCLUSION

Quality evidence should guide invasive treatment for all phases of managing low back disorders.

The Influence of Unemployment and Disability Status on Clinical Outcomes in Patients Receiving Surgery for Low Back-Related Disorders: An Observational Study

Introduction

Employment status plays an essential role as a social determinant of health.

Unemployed are more likely to have a longer length of hospital stay and a nearly twofold greater rate of 30 day readmission than those who were well employed at the time of back surgery. This study aimed to investigate whether employment status influenced post-surgery outcomes and if so, the differences were clinically meaningful among groups.

Methods

This retrospective observational study used data from the Quality Outcomes Database Lumbar Registry. Data refinement was used to isolate individuals 18 to 64 who received primary spine surgeries and had a designation of employed, unemployed, or disabled. Outcomes included 12 and 24 month back and leg pain, disability, patient satisfaction, and quality of life. Differences in descriptive variables, comorbidities, and outcomes measures (at 12 and 24 months) were analyzed using chi-square and linear mixed-effects modeling. When differences were present among groups, we evaluated whether they were clinically significant or not.

Results

Differences (between employed, unemployed, and disabled) among baseline characteristics and comorbidities were present in nearly every category (p<0.01). In all cases, those who were disabled represented the least healthy, followed by unemployed, and then employed. Clinically meaningful differences for all outcomes were present at 12 and 24 months (p<0.01). In post hoc analyses, differences between each group at nearly all periods were found.

Conclusions

The findings support that the health-related characteristics are markedly different among employment status groups. Group designation strongly differentiated outcomes. These findings suggest that disability and unemployment should be considered when determining prognosis of the individual.

TCM nonpharmacological interventions for chronic low-back pain: A protocol for systematic review and network meta-analysis

BACKGROUND

chronic low back pain (CLBP) are common symptoms bothering people in daily life. Traditional Chinese medicine (TCM) nonpharmacological interventions are gaining an increasing popularity for CLBP. Nevertheless, the evidence of efficacy and safety of random controlled trials (RCTs) remains controversial. This study aims to evaluate the efficacy and acceptability of different TCM nonpharmacological therapies by systematic review and network meta-analysis.

METHODS

According to the strategy, The authors will retrieve a total of 7 electronic databases by September 2020, including PubMed, the Cochrane Library, EMbase, China National Knowledge Infrastructure, China Biological Medicine, Chongqing VIP, and Wan-fang databases After a series of screening, 2 researchers will use Aggregate Data Drug Information System and Stata software to analyze the data extracted from the randomized controlled trials of TCM nonpharmacological interventions for CLBP. The primary outcome will be the improvement of Pain intensity and functional status/disability and the secondary outcomes will include lobal improvement, health-related quality of life, satisfaction with treatment, and adverse events. Both classical meta-analysis and network meta-analysis will be implemented to investigate direct and indirect evidences on this topic. The quality of the evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation instrument.

RESULTS

This study will provide a reliable evidence for the selection of TCM nonpharmacological therapies in the treatment of CLBP.

CONCLUSION

This study will generate evidence for different TCM nonpharmacological therapies for CLBP and provide a decision-making reference for clinical research.

ETHICS AND DISSEMINATION

This study does not require ethical approval. The results will be disseminated through a peer-reviewed publication.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/4H3Y9.

Histomorphology and immunohistochemical patterns in degenerative disc disease and clinical-radiological correlations: a prospective study

PURPOSE

Degenerative disc disease (DDD) is a common condition causing low-back pain, disability and, eventually, neurological symptoms. This investigation aimed to investigate intervertebral disc DDD-related changes, evaluating histomorphology and cytokines secretion, and their clinical-radiological correlations.

METHODS

This is a monocentric prospective observational study. A cohort of patients who underwent microdiscectomy for DDD, from June 2018 to January 2019, were enrolled. Discs samples were examined for histomorphology, chondrons count, immunohistochemistry for Hif-1α, Nf200 and Egr-1. Demographical and clinical data were also collected.

RESULTS

Twenty patients were finally included. MRI evaluation showed a Modic I alteration in nine patients and a Modic II in 11. The disability grade was low-moderate (ODI score was ≤ 40%) in eight patients and high (ODI score > 40%) in 12. The Modic I was associated with a low-moderate disability in two (22%) patients and to a high disability in seven (88%) (p < 0.01). In Modic I group and in ODI > 40% groups, there were a significative higher mean disability grade 48.4 (± 8.3)%, number of chondrons per section, cells per chondron, Nf200+ nerve fibers and Hif-1α expression, compared with Modic II and ODI ≤ 40% groups, respectively. There were no differences in terms of Egr-1 expression.

CONCLUSIONS

The discs with Modic I MRI signal could represent potential targets for medical treatments, whereas Modic II seems to be a more likely point of no return in a degenerative process. Therefore, further investigations are to better investigate inflammatory pathways and degenerative mechanisms in DDD.

Effects of pre-surgery physiotherapy on walking ability and lower extremity strength in patients with degenerative lumbar spine disorder: Secondary outcomes of the PREPARE randomised controlled trial

BACKGROUND

Degenerative lumbar spine disorders are common among musculoskeletal disorders. When disabling pain and radiculopathy persists after adequate course of rehabilitation and imaging confirms compressive pathology, surgical decompression is indicated. Prehabilitation aiming to augment functional capacity pre-surgery may improve physical function and activity levels pre and post-surgery. This study aims to evaluate the effect and dose-response of pre-surgery physiotherapy on quadriceps femoris strength and walking ability in patients with degenerative lumbar spine disorders compared to waiting-list controls and their association with postoperative physical activity level.

METHOD

In this single blinded, 2-arm randomised controlled trial, 197 patients were consecutively recruited. Inclusion criteria were: MRI confirmed diagnosis and scheduled for surgery due to disc herniation, lumbar spinal stenosis, degenerative disc disease or spondylolisthesis, ages 25-80 years. Patients were randomised to 9 weeks of pre-surgery physiotherapy or to waiting-list. Patient reported physical activity level, walking ability according to Oswestry Disability Index item 4, walking distance according to the SWESPINE national register and physical outcome measures including the timed ten-meter walk test, maximum voluntary isometric quadriceps femoris muscle strength, patient-rated were collected at baseline and follow-up. Parametric or non-parametric within and between group comparisons as well as multivariate regression was performed.

RESULTS

Patients who received pre-surgery physiotherapy significantly improved in all variables from baseline to follow-up (p < 0.001 - p < 0.05) and in comparison to waiting-list controls (p < 0.001 - p < 0.028). Patients adhering to ≥12 treatment sessions significantly improved in all variables (p < 0.001 - p < 0.032) and those receiving 0-11 treatment session in only normal walking speed (p0.035) but there were no significant differences when comparing dosages. Physical outcome measures after pre-surgery physiotherapy together significantly explain 27.5% of the variation in physical activity level 1 year after surgery with pre-surgery physical activity level having a significant multivariate association.

CONCLUSION

Pre-surgery physiotherapy increased walking ability and lower extremity strength in patients with degenerative lumbar spine disorders compared to waiting-list controls. A clear treatment dose-response response relationship was not found. These results implicate that pre-surgery physiotherapy can influence functional capacity before surgical treatment and has moderate associations with maintained postoperative physical activity levels mostly explained by physical activity level pre-surgery.

TRIAL REGISTRATION

NCT02454400 . Trial registration date: August 31st 2015, retrospectively registered.

Lumbar spine fusion: what is the evidence?

Lumbar spine fusion is a common procedure associated with a high cost burden and risk of serious complications. We aimed to summarise systematic reviews on the effectiveness of lumbar spine fusion for most diagnoses. We found no high-quality systematic reviews and the risk of bias of the randomised controlled trials in the reviews was generally high. The available evidence does not support a benefit from spine fusion compared to non-operative alternatives for back pain associated with degeneration. The available evidence does not support a clinical benefit from spine fusion compared to non-operative treatment or stabilisation without fusion for thoracolumbar burst fractures. Benefits of spine fusion compared to non-operative treatment for isthmic spondylolisthesis are unclear (one trial at high risk of bias). Surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome (based on a single trial). Better evidence is required to determine more accurately the effectiveness of spine fusion surgery for all indications. Patients contemplating spinal fusion should be fully informed about the evidence base for their particular problem, including the relative potential benefits and harms of fusion compared with non-operative treatments.

Clinical outcome after surgery for lumbar spinal stenosis in patients with insignificant lower extremity pain. A prospective cohort study from the Norwegian registry for spine surgery

Background

Spinal stenosis is a clinical diagnosis in which the main symptom is pain radiating to the lower extremities, or neurogenic claudication. Radiological spinal stenosis is commonly observed in the population and it is debated whether patients with no lower extremity pain should be labelled as having spinal stenosis. However, these patients is found in the Norwegian Registry for Spine Surgery, the main object of the present study was to compare the clinical outcomes after decompressive surgery in patients with insignificant lower extremity pain, with those with more severe pain.

Methods

This study is based on data from the Norwegian Registry for Spine Surgery (NORspine). Patients who had decompressive surgery in the period from 7/1–2007 to 11/3–2013 at 31 hospitals were included. The patients was divided into four groups based on preoperative Numeric Rating Scale (NRS)-score for lower extremity pain. Patients in group 1 had insignificant pain, group 2 had mild or moderate pain, group 3 severe pain and group 4 extremely severe pain. The primary outcome was change in the Oswestry Disability Index (ODI). Successfully treated patients were defined as patients reporting at least 30% reduction of baseline ODI, and the number of successfully treated patients in each group were recorded.

Results

In total, 3181 patients were eligible; 154 patients in group 1; 753 in group 2; 1766 in group 3; and 528 in group 4. Group 1 had significantly less improvement from baseline in all the clinical scores 12 months after surgery compared to the other groups. However, with a mean reduction of 8 ODI points and 56% of patients showing a reduction of at least 30% in their ODI score, the proportion of patients defined as successfully treated in group 1, was not significantly different from that of other groups.

Conclusion

This national register study shows that patients with insignificant lower extremity pain had less improvement in primary and secondary outcome parameters from baseline to follow-up compared to patients with more severe lower extremity pain.

Lumbar spinal stenosis: comparison of surgical practice variation and clinical outcome in three national spine registries

BACKGROUND CONTEXT

Decompression surgery for lumbar spinal stenosis (LSS) is the most common spinal procedure in the elderly. To avoid persisting low back pain, adding arthrodesis has been recommended, especially if there is a coexisting degenerative spondylolisthesis. However, this strategy remains controversial, resulting in practice-based variation.

PURPOSE

The present study aimed to evaluate in a pragmatic study if surgical selection criteria and variation in use of arthrodesis in three Scandinavian countries can be linked to variation in treatment effectiveness.

STUDY DESIGN

This is an observational study based on a combined cohort from the national spine registries of Norway, Sweden, and Denmark.

PATIENT SAMPLE

Patients aged 50 and older operated during 2011-2013 for LSS were included.

OUTCOME MEASURES

Patient-Reported Outcome Measures (PROMs): Oswestry Disability Index (ODI) (primary outcome), Numeric Rating Scale (NRS) for leg pain and back pain, and health-related quality of life (Euro-Qol-5D) were reported. Analysis included case-mix adjustment. In addition, we report differences in hospital stay.

METHODS

Analyses of baseline data were done by analysis of variance (ANOVA), chi-square, or logistic regression tests. The comparisons of the mean changes of PROMs at 1-year follow-up between the countries were done by ANOVA (crude) and analysis of covariance (case-mix adjustment).

RESULTS

Out of 14,223 included patients, 10,890 (77%) responded at 1-year follow-up. Apart from fewer smokers in Sweden and higher comorbidity rate in Norway, baseline characteristics were similar. The rate of additional fusion surgery (patients without or with spondylolisthesis) was 11% (4%, 47%) in Norway, 21% (9%, 56%) in Sweden, and 28% (15%, 88%) in Denmark. At 1-year follow-up, the mean improvement for ODI (95% confidence interval) was 18 (17-18) in Norway, 17 (17-18) in Sweden, and 18 (17-19) in Denmark. Patients operated with arthrodesis had prolonged hospital stay.

CONCLUSIONS

Real-life data from three national spine registers showed similar indications for decompression surgery but significant differences in the use of concomitant arthrodesis in Scandinavia. Additional arthrodesis was not associated with better treatment effectiveness.

Geographic variation in the surgical management of lumbar spondylolisthesis: characterizing practice patterns and outcomes

BACKGROUND CONTEXT

The role of arthrodesis in the surgical management of lumbar spondylolisthesis remains controversial. We hypothesized that practice patterns and outcomes for this patient population may vary widely.

PURPOSE

This study aimed to characterize geographic variation in surgical practices and outcomes for patients with lumbar spondylolisthesis.

STUDY DESIGN/SETTING

A retrospective analysis on a national longitudinal database between 2007 and 2014 was carried out.

METHODS

We calculated arthrodesis rates, inpatient and long-term costs, and key quality indicators (eg, reoperation rates). Using linear and logistic regression models, we then calculated expected quality indicator values, adjusting for patient-level demographic factors, and compared these values with the observed values, to assess quality variation apart from differences in patient populations.

RESULTS

We identified a cohort of 67,077 patients (60.7% female, mean age of 59.8 years (standard deviation, 12.0) with lumbar spondylolisthesis who received either laminectomy or laminectomy with arthrodesis. The majority of patients received arthrodesis (91.8%). Actual rates of arthrodesis varied from 97.5% in South Dakota to 81.5% in Oregon. Geography remained a significant predictor of arthrodesis even after adjusting for demographic factors (p<.001). Marked geographic variation was also observed in initial costs ($32,485 in Alabama to $78,433 in Colorado), 2-year postoperative costs ($15,612 in Arkansas to $34,096 in New Jersey), length of hospital stay (2.6 days in Arkansas to 4.5 in Washington, D.C.), 30-day complication rates (9.5% in South Dakota to 22.4% in Maryland), 30-day readmission rates (2.5% in South Dakota to 13.6% in Connecticut), and reoperation rates (1.8% in Maine to 12.7% in Alabama).

CONCLUSIONS

There is marked geographic variation in the rates of arthrodesis in treatment of spondylolisthesis within the United States. This variation remains pronounced after accounting for patient-level demographic differences. Costs of surgery and quality outcomes also vary widely. Further study is necessary to understand the drivers of this variation.

Patient-Oriented Aesthetic Outcome After Lumbar Spine Surgery: A 1-Year Follow-Up Prospective Observational Study Comparing Minimally Invasive and Standard Open Procedures

BACKGROUND

Despite recent treatment developments, back pain and related disabilities still represent a challenge for practitioners. Among the available surgical techniques, many different features and outcomes have been investigated; however, aesthetic result was missing among them. The present investigation was designed to prospectively compare patient-oriented aesthetic results after minimally invasive surgery (MIS) and standard open surgery (SOS) for the lumbar spine.

METHODS

This was a prospective observational study with 1-year follow-up. Patients who underwent SOS were assigned to group 1 and MIS to group 2. Patient-oriented aesthetic result evaluation was collected using a dedicated visual aesthetic analogue scale. The Vancouver Scar Scale was used to exclude objective underlying influencing factors. The Oswestry Disability Index and a 10-point itemized visual analogue scale for back pain were administered to assess the clinical and functional status. Follow-up data were collected before discharge at 1, 6, and 12 months. Statistical analysis was conducted, and P < 0.05 was considered as significant.

RESULTS

We enrolled 74 patients, 44 in group 1 and 30 in group 2. The 2 groups were homogeneous for demographic and clinical data. No clinical or functional differences were measured at the end of follow-up. Visual aesthetic analogue scale reported greater mean values in group 1 at every follow-up time.

CONCLUSIONS

Patients seem to prefer the aesthetic result from a single midline incision after SOS compared with MIS. The use of specific techniques could be considered if there is scientific evidence reporting greater aesthetic outcome, having similar clinical and functional ones.

Unique aspects of clinical trials of invasive therapies for chronic pain

Nearly all who review the literature conclude that the role of invasive procedures to treat chronic pain is poorly characterized because of the lack of “definitive” studies. The overt nature of invasive treatments, along with the risks, technical skills, and costs involved create challenges to study them. However, these challenges do not completely preclude evaluating invasive procedure effectiveness and safety using well-designed methods. This article reviews the challenges of studying outcomes of invasive therapies to treat pain and discuss possible solutions. Although the following discussion can apply to most invasive therapies to treat chronic pain, it is beyond the scope of the article to individually cover every invasive therapy used. Therefore, most of the examples focus on injection therapies to treat spine pain, spinal cord stimulation, and intrathecal drug therapies.

Short-Term Efficacy of Pulsed Radiofrequency Thermal Stimulation on Acupoints for Chronic Low Back Pain: A Preliminary Study of a Randomized, Single-Blinded, Placebo-Controlled Trial

Background

The objective of this study was to evaluate the pain-relief efficacy of thermal stimulation induced by a pulsed radiofrequency (PRF) thermal stimulation applied to acupoints (APs) in patients with low back pain (LBP). The study was designed as a randomized, single-blinded, placebo-controlled trial. Methods. Fifty-six LBP patients whose minimum pain intensity score on a visual analogue scale (VAS, 0-100 mm) was more than 30 mm were randomly allocated to either the placebo-controlled or the treatment group at a 1:1 ratio. The treatment and placebo-controlled groups received PRF thermal stimulation plus cupping therapy and cupping therapy only, respectively. Each patient was scheduled to receive a total of three treatment sessions over one week with allowing a window up to 4 days. Six of the 13 predefined APs were selected differently for each session depending on the change in patient's symptoms and intensity of pain. The primary outcome was the mean difference between the placebo-controlled and treatment group of VAS changes from the baseline to the end of the follow-up period.

Results

The patients' reported VAS scores from baseline to the end of follow-up (average: 9.8 days) were significantly decreased by 8.036 points (two-sided 95% CI, -11.841 to -4.231) and 13.393 points (two-sided 95% CI: 17.198 to -9.588) in the treatment and the placebo-controlled groups, respectively. However, the change in VAS scores between the treatment group and the placebo-controlled group was not significantly different (2.015 mm, two-sided 95% CI: -5.288 to 9.317).

Conclusion

The trial results indicated that treatment with either PRF thermal stimulation with cupping therapy or cupping therapy alone effectively relieved LBP. The efficacy of PRF thermal stimulation combined with cupping therapy was not superior to that of cupping therapy alone. Trial registration number: Clinical Research Information Service (KCT0002137). The trial was registered retrospectively on 10 November, 2016.

Tuina for low back pain: Protocol for a systematic review and meta-analysis

BACKGROUND

Low back pain (LBP) is one of the most common symptoms prompting patients to seek treatment. In China, tuina is a common treatment for LBP, but its effects and safety remain uncertain. This protocol is to provide the methods used to assess the effectiveness and safety of tuina for the treatment of patients with LBP.

METHODS

We will search the following databases by electronic methods: MEDLINE, PUBMED, EMBASE, CINAHL, the Chinese Biomedical Literature Database (CBM), the China National Knowledge Infrastructure (CNKI), Wanfang Data (WAN FANG), and VIP Information (VIP). The time limit for retrieving studies is set to be built in and before July 2018 for each database. The therapeutic effects according to the Visual Analog Scale (VAS) will be accepted as the primary outcomes. We will use RevMan V.5.3 software as well to compute the data synthesis carefully when a meta-analysis is allowed.

RESULTS

This study will provide a high-quality synthesis of current evidence of tuina for the treatment of patients with LBP.

CONCLUSION

The conclusion of our systematic review will provide evidence to judge whether tuina is an effective intervention for patient with LBP.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD 42018096762.

Efficacy and safety of thread embedding acupuncture combined with conventional acupuncture for chronic low back pain: A study protocol for a randomized, controlled, assessor-blinded, multicenter clinical trial

BACKGROUND

Back pain is one of the most common diseases, and many patients with recurrent pain seek alternative treatment strategies. Thread embedding acupuncture involves thread insertion at the acupuncture point for continuous physical and chemical stimulation. Although thread embedding is widely used in clinical practice, there is no sound evidence of its efficacy for chronic back pain. We describe the protocol for a randomized controlled trial for investigation of the efficacy and safety of thread embedding acupuncture combined with conventional acupuncture for chronic low back pain.

METHODS

This randomized, controlled, assessor-blinded, 2-armed, parallel, multicenter clinical trial will include 38 outpatients with chronic low back pain recruited from 4 traditional Korean Medicine hospitals. The patients will be randomly allocated to a treatment group (conventional acupuncture + thread embedding acupuncture) and a control group (only conventional acupuncture) in a 1:1 ratio. The treatment group patients will receive thread embedding acupuncture treatment at 10 acupuncture points (multifidus muscle, 4 points; spinal erector muscles, four points; lumbar quadrate muscle, 2 points) once a week for 8 weeks (8 sessions). In addition, all patients will receive conventional acupuncture treatment at 14 acupuncture points (GV3, EX-B5, and bilateral BL23, BL24, BL25, BL26, BL40, and BL60) twice a week for 8 weeks (16 sessions). The primary outcome will be the change in the visual analog scale score from visit 1 to visit 16, analyzed by independent t tests, in both groups. The groups will also be compared with regard to the clinical relevance (minimal clinically important difference), quality of life (3-level version of Euroqol-5D), disability level (Roland and Morris Disability Questionnaire), global assessment (patient global impression of change), and safety. Cost data for cost-benefit and cost-effectiveness analyses will be collected.

DISCUSSION

Our study results will provide evidence of the efficacy and safety of thread embedding acupuncture combined with conventional acupuncture for the management of chronic low back pain. Even though the assessors will be blinded, the patients will not be blinded to treatment because of the lack of a sham embedding acupuncture group; this is a limitation of our study.

TRIAL REGISTRATION

Clinical Research Information Service: KCT0002666.

Quality ratings of reviews in overviews: a comparison of reviews with and without dual (co-)authorship

BACKGROUND

Previous research shows that many authors of Cochrane overviews were also involved in some of the included systematic reviews (SRs). This type of dual (co-)authorship (DCA) may be a conflict of interest and a potential source of bias. Our objectives were to (1) additionally investigate DCA in non-Cochrane overviews; (2) investigate whether there is an association between DCA and quality assessments of SRs in Cochrane and non-Cochrane overviews.

METHODS

We selected a sample of Cochrane (n = 20) and non-Cochrane (n = 78) overviews for analysis. We extracted data on the number of reviews affected by DCA and whether quality assessment of included reviews was conducted independently. Differences in mean quality scores between SRs with and without DCA were calculated in each overview. These differences were standardized (using the standardized mean difference (SMD)) and meta-analyzed using a random effects model.

RESULTS

Forty out of 78 non-Cochrane overviews (51%) and 18 out of 20 Cochrane overviews (90%) had included at least one SR with DCA. For Cochrane overviews, a median of 5 [interquartile range (IQR) 2.5 to 7] SRs were affected by DCA (median of included reviews 10). For non-Cochrane overviews a median of 1 [IQR 0 to 2] of the included SRs were affected (median of included reviews 14). The meta-analysis showed a SMD of 0.58 (95% confidence interval (CI) 0.27 to 0.90) indicating higher quality scores in reviews with overlapping authors. The test for subgroup differences shows no evidence of a difference between Cochrane (SMD 0.44; 95% CI 0.07 to 0.81) and non-Cochrane overviews (SMD 0.62; 95% CI 0.06 to 1.17).

CONCLUSIONS

Many authors of overviews also often have an authorship on one or more of the underlying reviews. Our analysis shows that, on average, authors of overviews give higher quality ratings to SRs in which they were involved themselves than to other SRs. Conflict of interest is one explanation, but there are several others such as reviewer expertise. Independent and blinded reassessments of the reviews would provide more robust evidence on potential bias arising from DCA.

Navigated minimally invasive unilateral laminotomy with crossover for intraoperative prediction of outcome in degenerative lumbar stenosis

BACKGROUND

Different surgical techniques have been described for treatment of degenerative lumbar stenosis (DLS). Only postoperative measures have been identified as predictors of efficacy of decompression. The objective of this study is to assess the role of navigated unilateral laminotomy with crossover to achieve and predict a satisfying decompression and outcome in DLS.

MATERIALS AND METHODS

We enrolled patients with DLS who underwent navigation-assisted unilateral laminotomy with crossover. The extent of decompression was evaluated during surgery using neuronavigation. The outcome was assessed through the Oswestry disability index (ODI) and visual analog scale (VAS) for leg pain. Outcome correlation with the extent of the intraoperative bone decompression was analyzed. Finally, the outcome, surgical time, and in-hospital length-of-stay were compared with a control group treated through standard unilateral laminotomy.

RESULTS

Twenty-five patients were treated using the navigated technique (Group A), 25 using the standard unilateral laminotomy (Group B). In Group A, a cut-off value ≥0.9 cm for bone decompression revealed to be an intraoperative predictor of good outcome, both regarding the ODI and VAS scores (P = 0.0005; P = 0.002). As compared with Group B, patients operated using the navigated technique showed similar operative times, in-hospital length-of-stay, ODI scores, but improved VAS scores for leg pain (P = 0.04).

CONCLUSIONS

The intraoperative navigated evaluation of the bone decompression could predict the outcome allowing satisfactory results in unilateral laminotomy for DLS. The navigated technique also could lead to an improved decompression of lateral recesses resulting in better control of leg pain as compared to standard unilateral laminotomy.

The Predictive Value of Preoperative Health-Related Quality-of-Life Scores on Postoperative Patient-Reported Outcome Scores in Lumbar Spine Surgery

STUDY DESIGN

A single-center, retrospective cohort study.

OBJECTIVE

To predict patient-reported outcomes (PROs) using preoperative health-related quality-of-life (HRQoL) scores by quantifying the correlation between them, so as to aid selection of surgical candidates and preoperative counselling.

METHODS

All patients who underwent single-level elective lumbar spine surgery over a 2-year period were divided into 3 diagnosis groups: spondylolisthesis, spinal stenosis, and disc herniation. Patient characteristics and health scores (Oswestry Low Back Pain and Disability Index [ODI], EQ-5D, and Short Form-36 version 2 [SF-36v2]) were collected at 6 and 24 months and compared between the 3 diagnosis groups. Multivariate modelling was performed to investigate the predictive value of each parameter, particularly preoperative ODI and EQ-5D, on postoperative ODI and EQ-5D scores for all the patients.

RESULTS

ODI and EQ-5D at 6 and 24 months improved significantly for all patients, especially in the disc herniation group, compared to the baseline. The magnitude of improvement in ODI and EQ-5D was predictable using preoperative ODI, EQ-5D, and SF-36v2 Mental Component Score. At 6 months, 1-point baseline ODI predicts for 0.7-point increase in changed ODI, and a 0.01-point increase in baseline EQ-5D predicts for 0.01-point decrease in changed EQ-5D score. At 24 months, 1-point baseline ODI predicts for 1-point increase in changed ODI, and a 0.01-point increase in baseline EQ-5D predicts for 0.009-point decrease in changed EQ-5D. A younger age is shown to be a positive predictor of ODI at 24 months.

CONCLUSIONS

Poorer baseline health scores predict greater improvement in postoperative PROs at 6 and 24 months after the surgery. HRQoL scores can be used to decide on surgery and in preoperative counselling.

Indication Variability in Degenerative Lumbar Spine Surgery: A Four-nation Survey

STUDY DESIGN

Electronic survey.

OBJECTIVE

The aim of this study was to identify the international nuances in surgical treatment patterns for severals lumbar degenerative conditions, specifically, to identify differences in responses in each country groupand different treatment trends across countries.

SUMMARY OF BACKGROUND DATA

Significant variations in treatment of lumbar degenerative conditions exist among spine surgeons, related to the lack of established consensus in the literature.

METHODS

An online survey with preformulated answers was submitted to 52 orthopedic surgeons, 50 neurosurgeons from four different countries (United States, France, Spain, and Germany) regarding five vignette-cases. Cases included: multilevel stenosis, monolevel stenosis, lytic spondylolisthesis, isthmic lysis, and degenerative scoliosis. The variability for each country was calculated according to the Index of Qualitative Variation (IQV = 0: no variability and 1: maximal variability). We used Fleiss kappa (range: from -1, poor agreement, to 1, almost perfect agreement) for assessing the reliability of agreement between the participants concerning specialties, countries, and age groups.

RESULTS

For the two stenosis cases, US surgeons were more likely to propose decompression (IQV multilevel = 0.47 and monolevel = 0.32) comparing with European countries more heterogeneous (all IQV >0.70) and more frequently proposing fusion. As regards degenerative scoliosis, all attitudes were extremely heterogeneous with IQV >0.8. Fusion for isthmic spondylolisthesis was more consensual (all IQV <0.63), but attitudes were more heterogeneous for isthmic lysis (IQV ranged from 0.48 to 0.76) with anterior approach proposed in France (37%) and United States (19.2%).The overall interrater agreement was equally slight not only for neurosurgeons (Fleiss Kappa = 0.04) and orthopedic surgeons (Kappa = 0.13), but also for countries (Kappa <0.13) and age groups (Kappa <0.1).

CONCLUSION

In this study, we found substantial agreement for some spinal conditions but a high variability in some others: intranational and international variations were observed, reflecting the lack of literature consensus.

LEVEL OF EVIDENCE

2.

Outcomes of multisegmental transforaminal enlarged decompression plus posterior pedicle screw fixation for multilevel lumbar spinal canal stenosis associated with lumbar instability

PURPOSE

The aim of this study was to evaluate the clinical and radiologic results of multisegmental transforaminal enlarged decompression (TED) plus posterior pedicle screw fixation in the treatment of multilevel lumbar spinal canal stenosis (LSCS) with lumbar instability (MLSCSI).

METHODS

113 patients with MLSCSI underwent surgery were recruited in this study. All patients were suffering from symptoms typical of degenerative LSCS and treated with either TED plus fusion (TEDF group) or conventional laminectomy plus fusion (CLF group). Clinical and radiologic parameters were evaluated. The clinical data, including Visual Analog Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), operative time, intraoperative blood loss, postoperative drainage, hospital stay, and the rate of postoperative complications, were assessed. With respect to radiologic parameters, mean disc height (MDH) and lumbar lordotic angle (LLA) were measured using plain radiographs. Patient satisfaction was evaluated according to the North American Spine Society (NASS) Outcome Questionnaire.

RESULTS

No serious complications occurred during the follow-up. The operative time was significantly shorter for TEDF group than for CLF group, and similar results were found with regard to the blood loss and postoperative drainage (p < .05). The improvements in ODI, leg and back VAS scores were observed in both groups after surgery and follow-up (P < .05). In the last follow-up, ODI and back VAS scores in TEDF group were significantly higher than those in CLF group (P < .05). Regarding radiologic variants, MDH and LLA were improved after operation for 3 months (P > .05) and were all well maintained in the final follow-up in both groups. Patients in TEDF group were more satisfied than patients in the CLF group (85.2% vs 76.9%, p = .092).

CONCLUSIONS

Satisfactory clinical and radiological outcomes can be achieved with the use of multisegmental TED plus lumbar fusion for the treatment of MLSCSI. This technique can reduce surgically induced instability and obviously improve the symptoms and signs of the patients, suggesting a safe and effective therapeutic procedure for MLSCSI.

Spinal fusion without instrumentation - Experimental animal study

BACKGROUND

The number and cost of instrumented spinal fusion surgeries have increased rapidly, primarily for the treatment of lumbar segmental instabilities. However, what if the organism itself is able to restore segmental stability over time? This large-animal study using sheep aimed to investigate whether the reparative response after destabilization via facetectomy and nucleotomy without instrumentation can effectively fuse the spinal segment comparable to instrumented standard fusion surgery.

METHODS

The following four surgical interventions were investigated: dorsal fixation via internal fixator, ventral fixation via cage as well as facetectomy and nucleotomy without additional instrumentation. Six months postoperatively, the animals were sacrificed, and the lumbar spines were used for biomechanical tests.

FINDINGS

Spinal stability was restored to the destabilized spinal segments at six months postoperatively and was comparable to the results of conventional surgery via screws and cages. Iatrogenic hypomobilization caused significant reductions in facet joint space and intervertebral disc height of segments at index and adjacent level. Restabilized segments after iatrogenic hypermobilzation also significantly decreased facet joint space and disc height at index level, but revealed no influence on adjacent segments.

INTERPRETATION

These findings in the sheep model question the necessity of costly instrumentation and suggest the alternative possibility of stimulating the reparative capacity of the body in human lumbar spine fusion surgery.

Decompression Versus Decompression and Fusion for Degenerative Lumbar Stenosis in a Workers' Compensation Setting

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to compare outcomes in Workers' compensation (WC) subjects receiving decompression alone versus decompression and fusion for the indication of degenerative spinal stenosis (DLS) without deformity or instability.

SUMMARY OF BACKGROUND DATA

The use of a fusion procedure during lumbar decompression for DLS alone remains controversial. We hypothesize that WC subjects receiving fusion and decompression will return to work less and incur greater medical costs than subjects receiving decompression alone.

METHODS

Three hundred sixty-four Ohio WC subjects were identified who underwent primary decompression (DC) or primary decompression and fusion (DC + F) for DLS alone between 1993 and 2013. Our primary outcome was if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for more than 6 months. A number of secondary outcomes were collected and analyzed.

RESULTS

The DC cohort had a significantly higher RTW rate [36% (83/227) vs. 25% (54/212); P = 0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that fusion with operative decompression remained a significant negative predictor of RTW status (P = 0.04; odds ratio: 0.58, 95% confidence interval: 0.34-0.99). Within the DC cohort, the rate of postoperative instability and subsequent fusion was 8%. Furthermore, subjects who received an adjunctive fusion cost of the Ohio BWC on average, $46,115 more in costs accrued over 3 years after their index surgery compared with subjects who received a decompression alone.

CONCLUSION

Overall, fusion with decompression had a significantly negative impact on clinical outcomes in WC subjects with DLS. These results demonstrate the high risk of postoperative morbidity associated with fusion procedures and underscore the need to strongly reevaluate the use of fusion for DLS without instability in the WC population.

LEVEL OF EVIDENCE

3.

Effectiveness and safety of moxibustion treatment for non-specific lower back pain: protocol for a systematic review

INTRODUCTION

Many patients experience acute lower back pain that becomes chronic pain. The proportion of patients using complementary and alternative medicine to treat lower back is increasing. Even though several moxibustion clinical trials for lower back pain have been conducted, the effectiveness and safety of moxibustion intervention is controversial. The purpose of this study protocol for a systematic review is to evaluate the effectiveness and safety of moxibustion treatment for non-specific lower back pain patients.

METHODS AND ANALYSIS

We will conduct an electronic search of several databases from their inception to May 2017, including Embase, PubMed, Cochrane Central Register of Controlled Trial, Allied and Complementary Medicine Database, Wanfang Database, Chongqing VIP Chinese Science and Technology Periodical Database, China National Knowledge Infrastructure Database, Korean Medical Database, Korean Studies Information Service System, National Discovery for Science Leaders, Oriental Medicine Advanced Searching Integrated System, the Korea Institute of Science and Technology, and KoreaMed. Randomised controlled trials investigating any type of moxibustion treatment will be included. The primary outcome will be pain intensity and functional status/disability due to lower back pain. The secondary outcome will be a global measurement of recovery or improvement, work-related outcomes, radiographic improvement of structure, quality of life, and adverse events (presence or absence). Risk ratio or mean differences with a 95% confidence interval will be used to show the effect of moxibustion therapy when it is possible to conduct a meta-analysis.

ETHICS AND DISSEMINATION

This review will be published in a peer-reviewed journal and will be presented at an international academic conference for dissemination. Our results will provide current evidence of the effectiveness and safety of moxibustion treatment in non-specific lower back pain patients, and thus will be beneficial to patients, practitioners, and policymakers.

TRIAL REGISTRATION NUMBER

CRD42016047468 in PROSPERO 2016.

Study-protocol for a randomized controlled trial comparing clinical and radiological results after three different posterior decompression techniques for lumbar spinal stenosis: the Spinal Stenosis Trial (SST) (part of the NORDSTEN Study)

Background

There are several posterior decompression techniques for lumbar spinal stenosis (LSS). There is a trend towards performing less invasive surgical procedures, but no multicentre randomized controlled trials have evaluated the relative efficacy of these techniques at short and long-term.

Method/design

A multicentre randomized controlled trial [the Spinal Stenosis Trial (SST) (part of the NORDSTEN study)] including 465 patients aged 18–80 years with neurogenic claudication or radiating pain and MRI findings indicating lumbar spinal stenosis without spondylolisthesis is performed to compare three posterior decompression techniques: unilateral laminotomy with crossover, bilateral laminotomy and spinous process osteotomy. The primary outcome is change in Oswestry Disability Index (ODI 2 years postoperatively). Secondary outcomes are change in EQ-5D, Zurich Claudication Questionnaire, and Numeric Rating Scale for leg-pain and back-pain. Also recorded were Global Perceived Effect score, complications, length of hospital stay, reoperation rate 2 years postoperatively, difference in recurrence of symptoms or postoperative instability, and MRI change in the dural sac area. Further, a 5 and 10 years follow-up is planned with the same outcome measures.

Discussion

Newer and less invasive techniques are increasingly favoured in surgery for LSS. This trial will compare the clinical and radiological results of three different techniques, and may contribute to better clinical decision making in the surgical treatment of LSS.

Trial registration

ClinicalTrials.gov reference: NCT02007083 (November 22, 2013).

Management of degenerative lumbar spinal stenosis: an evidence-based review

Lumbar spinal stenosis has become one of the most disabling pathologies in the elderly population.Some additional conditions such as foraminal stenosis or degenerative spondylosis with a history of back pain and leg pain must be considered before treatment.A completely appropriate protocol and unified management of spinal stenosis have not yet been well defined.The objective of this literature review is to provide evidence-based recommendations reflected in the highest-quality clinical literature available to address key clinical questions surrounding the management of degenerative lumbar spinal stenosis. Cite this article: Covaro A, Vilà-Canet G, García de Frutos A, Ubierna MT, Ciccolo F, Caceres E. Management of degenerative lumbar spinal stenosis: an evidence-based review article. EFORT Open Rev 2016;1:267-274. DOI: 10.1302/2058-5241.1.000030.

[Lumbar disc herniation: Natural history, role of physical examination, timing of surgery, treatment options and conflicts of interests]

INTRODUCTION

Indication for surgery in lumbar disc herniation (LDH) varies widely depending on the geographical area.

DEVELOPMENT

A literature review is presented on the natural history, role of physical examination, timing of surgery, evidence-based treatment, and conflicts of interests in LDH. Surgery is shown to provide significant faster relief of pain compared to conservative therapy, although the effect fades after a year. There is no treatment modality better than the rest in terms of pain control and neurological recovery, nor is there a surgical technique clearly superior to simple discectomy. The lack of sound scientific evidence on the surgical indication may contribute to its great geographical variability.

CONCLUSIONS

Since LDH has a favourable natural history, neuroimaging and surgery should not be considered until after a 6-week period. It is necessary to specify and respect the surgical indications for LDH, avoiding conflicts of interests.

PREPARE: Pre-surgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial protocol

BACKGROUND

Current guidelines for the management of patients with specific low back pain pathology suggest non-surgical intervention as first-line treatment, but there is insufficient evidence to make recommendations of the content in the non-surgical intervention. Opinions regarding the dose of non-surgical intervention that should be trialled prior to decision making about surgery intervention vary. The aim of the present study is to investigate if physiotherapy administrated before surgery improves function, pain and health in patients with degenerative lumbar spine disorder scheduled for surgery. The patients are followed over two years. A secondary aim is to study what factors predict short and long term outcomes.

METHODS

This study is a single blinded, 2-arm, randomized controlled trial with follow-up after the completion of pre-surgery intervention as well as 3, 12 and 24 months post-surgery. The study will recruit men and women, 25 to 80 years of age, scheduled for surgery due to; disc herniation, spinal stenosis, spondylolisthesis or degenerative disc disease. A total of 202 patients will be randomly allocated to a pre-surgery physiotherapy intervention or a waiting list group for 9 weeks. The waiting-list group will receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. The pre-surgery physiotherapy group will receive physiotherapy 2 times per week, consisting of a stratified classification treatment, based on assessment findings. One of the following treatments will be selected; a) Specific exercises and mobilization, b) Motor control exercises or c) Traction. The pre-surgery physiotherapy group will also be prescribed a tailor-made general supervised exercise program. The physiotherapist will use a behavioral approach aimed at reducing patient fear avoidance and increasing activity levels. They will also receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. Primary outcome measure is Oswestry Disability Index. Secondary outcome measures are the visual analogue scale for back and leg pain, pain drawing, health related quality of life, Hospital anxiety and depression scale, Fear avoidance beliefs questionnaire, Self-efficacy scale and Work Ability Index.

DISCUSSION

The study findings will help improve the treatment of patients with degenerative lumbar spine disorder scheduled for surgery.

TRIAL REGISTRATION

ClinicalTrials.gov reference: NCT02454400 (Trial registration date: August 31st 2015) and has been registered on ClinicalTrials.gov, identifier: NCT02454400 .

Does surgical technique influence clinical outcome after lumbar spinal stenosis decompression? A comparative effectiveness study from the Norwegian Registry for Spine Surgery

INTRODUCTION

The aim of this study was to compare the clinical outcome of spinal process osteotomy with two other midline-retaining methods, bilateral laminotomy and unilateral laminotomy with crossover, among patients undergoing surgery for lumbar spinal stenosis.

METHODS

This cohort study was based on data from the Norwegian Registry for Spine Surgery (NORspine). Patients were operated on between 2009 and 2013 at 31 Norwegian hospitals. The patients completed questionnaires at admission for surgery, and after 3 and 12 months. The Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were duration of surgery and hospital stay, Numeric Rating Scale (NRS) for back pain and leg pain, and EQ-5D and EQ-VAS. The patients were classified into one of three treatment groups according to the surgery they had received, and a propensity score was utilized to minimize bias. The three treatment groups were divided into subgroups based on Propensity Scores, and the statistical analyses were performed with and within the Propensity Score stratified subgroups.

RESULTS

103 patients had spinal process osteotomy, 966 patients had bilateral laminotomy, and 462 patients had unilateral laminotomy with crossover. Baseline clinical scores were similar in the three groups. There were no differences in improvement after 3 and 12 months between treatment groups. At 12 months, mean ODI improvement was 15.2 (SD 16.7) after spinous process osteotomy, 16.9 (SD 17.0) after bilateral laminotomy, and 16.7 (SD 16.9) after unilateral laminotomy with crossover. There were no differences in the secondary clinical outcomes or complication rates. Mean duration of surgery was greatest for spinal process osteotomy (p < 0.05). Length of stay was 2.1 days (SD 2.1) in the bilateral laminotomy group, 3.5 (SD 2.4) days for unilateral laminotomy, and 6.9 days (SD 4.1) for spinous process osteotomy group (p < 0.05).

CONCLUSION

In a propensity scored matched cohort, there were no differences in the clinical outcome 12 months after surgery for lumbar spinal stenosis performed using the three different posterior decompression techniques. Bilateral laminotomy had shortest duration of surgery and shortest length of hospital stay. Surgical technique does not seem to affect clinical outcome after three different midline-retaining posterior decompression techniques.

Factors associated with lumbar fusion surgery: a case-control study

PURPOSE

The objective of this study is to identify the demographic and payer factors that are associated with lumbar fusion surgery.

METHODS

A case-control study was conducted utilizing a population of 38,092 patients from the 2010 Florida Agency for Health Care Administration (AHCA), USA hospital discharge data. The case population included 16,236 records with any of five ICD-9-CM principal procedure codes for initial lumbar fusion. The control group was comprised of 21,856 patients who were admitted for the same principal diagnoses as the cases, but who did not have initial fusion surgery. Logistic regression was used to analyze the association of age, gender, race and principal payer type with initial lumbar fusions. The interaction between age and payer was also examined, as payer type may moderate the association between age and lumbar fusion surgery.

RESULTS

Gender, race, principal payer and age were all found to be significantly associated with lumbar fusion surgery. The interaction of payer and age was also found to be significant. Being female was significantly associated with having a fusion (OR = 1.11, 95 % CI 1.07-1.16). The association between age and receiving surgery was greatest for the less than 20 age group (OR = 10.43, 95 % CI 8.74-12.45). Employees and dependents of Federal government agencies (Tricare, etc.) and patients with commercial insurance were significantly associated with surgery (OR = 1.48, 95 % CI 1.29-1.70 and OR = 1.12, 95 % CI 1.04-1.20, respectively). Patients insured through Medicaid (a social health care program for those with low incomes and limited resources), and the uninsured were negatively associated with surgery (OR = 0.53, 95 % CI 0.47-0.60 and OR = 0.52, 95 % CI 0.46-0.58, respectively).

CONCLUSIONS

Lumbar fusion surgery is not recommended in clinical practice guidelines for the top four principal diagnoses in this study. Yet, patients covered by certain types of insurance were found to be significantly associated with fusion surgery.

Limitations of A Measurement Tool to Assess Systematic Reviews (AMSTAR) and suggestions for improvement

A Measurement Tool to Assess Systematic Reviews (AMSTAR) is a commonly used tool to assess the quality of systematic reviews; however, modifications are needed to improve its usability, reliability, and validity. In this commentary, we summarize our experience and the experiences of others who have used AMSTAR and provide suggestions for its improvement. We propose that AMSTAR should modify a number of individual items and their instructions and responses to make them more congruent with an assessment of the methodologic quality of systematic reviews. We recommend adding new items and modifying existing items to assess the quality of the body of evidence and to address subgroup and sensitivity analyses. More detailed instructions are needed for scoring individual items across multiple reviewers, and we recommend that a total score should not be calculated. These suggestions need to be empirically tested prior to implementation.

Degenerative disease of the lumbar spine

In the last 25 years, scientific research has brought about drastic changes in the concept of low back pain and its management. Most imaging findings, including degenerative changes, reflect anatomic peculiarities or the normal aging process and turn out to be clinically irrelevant; imaging tests have proven useful only when systemic disease is suspected or when surgery is indicated for persistent spinal cord or nerve root compression. The radiologic report should indicate the key points of nerve compression, bypassing inconsequential findings. Many treatments have proven inefficacious, and some have proven counterproductive, but they continue to be prescribed because patients want them and there are financial incentives for doing them. Following the guidelines that have proven effective for clinical management improves clinical outcomes, reduces iatrogenic complications, and decreases unjustified and wasteful healthcare expenditures.

Multipotent Mesenchymal Stem Cell Treatment for Discogenic Low Back Pain and Disc Degeneration

Low back pain with resultant loss of function, decreased productivity, and high economic costs is burdensome for both the individual and the society. Evidence suggests that intervertebral disc pathology is a major contributor to spine-related pain and degeneration. When commonly used conservative therapies fail, traditional percutaneous or surgical options may be beneficial for pain relief but are suboptimal because of their inability to alter disc microenvironment catabolism, restore disc tissue, and/or preserve native spine biomechanics. Percutaneously injected Multipotent Mesenchymal Stem Cell (MSC) therapy has recently gained clinical interest for its potential to revolutionarily treat disc-generated (discogenic) pain and associated disc degeneration. Unlike previous therapies to date, MSCs may uniquely offer the ability to improve discogenic pain and provide more sustained improvement by reducing disc microenvironment catabolism and regenerating disc tissue. Consistent treatment success has the potential to create a paradigm shift with regards to the treatment of discogenic pain and disc degeneration.

Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: a systematic review with meta-analysis

BACKGROUND

Lumbar disc herniation has a prevalence of up to 58% in the athletic population. Lumbar discectomy is a common surgical procedure to alleviate pain and disability in athletes. We systematically reviewed the current clinical evidence regarding athlete return to sport (RTS) following lumbar discectomy compared to conservative treatment.

METHODS

A computer-assisted literature search of MEDLINE, CINAHL, Web of Science, PEDro, OVID and PubMed databases (from inception to August 2015) was utilised using keywords related to lumbar disc herniation and surgery. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Methodological quality of individual studies was assessed using the Downs and Black scale (0-16 points).

RESULTS

The search strategy revealed 14 articles. Downs and Black quality scores were generally low with no articles in this review earning a high-quality rating, only 5 articles earning a moderate quality rating and 9 of the 14 articles earning a low-quality rating. The pooled RTS for surgical intervention of all included studies was 81% (95% CI 76% to 86%) with significant heterogeneity (I(2)=63.4%, p<0.001) although pooled estimates report only 59% RTS at same level. Pooled analysis showed no difference in RTS rate between surgical (84% (95% CI 77% to 90%)) and conservative intervention (76% (95% CI 56% to 92%); p=0.33).

CONCLUSIONS

Studies comparing surgical versus conservative treatment found no significant difference between groups regarding RTS. Not all athletes that RTS return at the level of participation they performed at prior to surgery. Owing to the heterogeneity and low methodological quality of included studies, rates of RTS cannot be accurately determined.

Lower urinary tract dysfunction in patients with peripheral nervous system lesions

The prevalence of lower urinary tract (LUT) dysfunction in peripheral nervous system (PNS) disorders is larger than in comparable control populations. This is particularly true for polyneuropathies with autonomic nervous system involvement, and for localized lesions with LUT innervation. LUT symptoms may be the guide to the diagnosis of processes localized in the lumbosacral spinal canal (as in cauda equina syndrome), and in the pelvis. Typical LUT dysfunctions (LUTD) caused by PNS involvement include bladder and sphincter hypoactivity with poor emptying, and incontinence. Paradoxically, bladder overactivity may also occur in pure PNS lesions. The acute cauda equina syndrome is an emergency requiring magnetic resonance imaging and surgery; in chronic neurogenic LUTD due to PNS involvement, the diagnosis of the lesion may be clarified by clinical neurophysiologic testing. Other important causes of neurogenic LUT dysfunction are perineoabdominal and pelvic surgeries. Surgeons are devising nerve-sparing techniques to prevent such major and often persistent complications in patients who are otherwise cured of the underlying disease. LUTD significantly affects the quality of life in patients and may lead to recurring urinary infections and upper urinary tract involvement. Thorough assessment of LUT function by urodynamics may be necessary in patients who are not improved by simple conservative measures.