Evidence for surgery in degenerative lumbar spine disorders. Best Pract Res Clin Rheumatol. 2013;27:673-684. [PMID: 24315148 DOI: 10.1016/j.berh.2013.09.009]

Pacific Spine and Pain Society (PSPS) Evidence Review of Surgical Treatments for Lumbar Degenerative Spinal Disease: A Narrative Review

INTRODUCTION

Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments.

METHODS

The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria.

RESULTS

The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis.

CONCLUSIONS

There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes.

Screening patients requiring secondary lumbar surgery for degenerative lumbar spine diseases: a nationwide sample cohort study

This study aims to identify healthcare costs indicators predicting secondary surgery for degenerative lumbar spine disease (DLSD), which significantly impacts healthcare budgets. Analyzing data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database of Republic of Korea (ROK), the study included 3881 patients who had surgery for lumbar disc herniation (LDH), lumbar spinal stenosis without spondylolisthesis (LSS without SPL), lumbar spinal stenosis with spondylolisthesis (LSS with SPL), and spondylolysis (SP) from 2006 to 2008. Patients were categorized into two groups: those undergoing secondary surgery (S-group) and those not (NS-group). Surgical and interim costs were compared, with S-group having higher secondary surgery costs ($1829.59 vs $1618.40 in NS-group, P = 0.002) and higher interim costs ($30.03; 1.86% of initial surgery costs vs $16.09; 0.99% of initial surgery costs in NS-group, P < 0.0001). The same trend was observed in LDH, LSS without SPL, and LSS with SPL (P < 0.0001). Monitoring interim costs trends post-initial surgery can effectively identify patients requiring secondary surgery.

Design principles in mechanically adaptable biomaterials for repairing annulus fibrosus rupture: A review

Annulus fibrosus (AF) plays a crucial role in the biomechanical loading of intervertebral disc (IVD). AF is difficult to self-heal when the annulus tears develop, because AF has a unique intricate structure and biologic milieu in vivo. Tissue engineering is promising for repairing AF rupture, but construction of suitable mechanical matching devices or scaffolds is still a grand challenge. To deeply know the varied forces involved in the movement of the native annulus is highly beneficial for designing biomimetic scaffolds to recreate the AF function. In this review, we overview six freedom degrees of forces and adhesion strength on AF tissue. Then, we summarize the mechanical modalities to simulate related forces on AF and to assess the characteristics of biomaterials. We finally outline some current advanced techniques to develop mechanically adaptable biomaterials for AF rupture repair.

Efficacy of Repeat Percutaneous Endoscopic Lumbar Decompression for Reoperation of Lumbar Spinal Stenosis: A Retrospective Study

Purpose

To evaluate the efficacy of repeat percutaneous endoscopic lumbar decompression (PELD) in lumbar spinal stenosis (LSS) reoperation.

Patients and Methods

This study included patients with LSS who relapsed following treatment with PELD therapy between March 2017 and March 2020. Visual analog scale (VAS) scores and Oswestry Disability Index (ODI) were analyzed preoperatively, postoperatively at 3, 6, 12, and 24 months, and at final follow-up. The modified MacNab criteria were used to assess clinical effects. All complications were recorded.

Results

At a mean follow-up of 3 years, 24 patients with LSS who underwent repeat PELD were identified. The patients' mean operative time was 122.3±29.2 min, blood loss was 12.5±5.3 mL, and mean hospital stay was 7.0±1.9 days. VAS leg-pain score improved from 6.1±1.0 to 2.0±1.2 (P<0.001), VAS back-pain score improved from 6.2±0.8 to 2.1±1.1 (P<0.001), and ODI improved from 68.9±6.0 to 20.9±5.6 (P <0.001). According to the modified MacNab criteria, the good-to-excellent rate was 83.3%. Postoperative complications, including hematoma, nerve root injury, and dural injury, developed in four patients.

Conclusion

Repeat PELD for reoperation in patients with LSS has a good clinical effect, and is recommended in routine clinical practice. Careful intraoperative manipulation is recommended to prevent complications.

Surgery for Lumbar Spinal Stenosis in Patients With Mild Leg Pain Levels Is Associated With Unsatisfactory Outcome

STUDY DESIGN

Prospective register cohort study.

OBJECTIVES

The indication for surgery in patients with lumbar spinal stenosis (LSS) is considered to be leg pain and neurogenic claudication (NC). Nevertheless, a significant part of patients operated for LSS have mild leg pain levels defined as leg pain ≤minimally important clinical difference (MICD). Information is lacking on how to inform these patients about the probable outcome of surgery. The objective was to report the outcome of surgery for LSS in patients with a mild preoperative level of leg pain.

METHODS

A total of 2559 patients operated upon for LSS with preoperative leg pain ≤3 NRS (Numerical Rating Scale) were evaluated for outcome at the 1-year follow-up. NRS for back pain, the Oswestry Disability Index (ODI), and the EuroQol (EQ-5D) were used.

RESULTS

In the period 2007 to 2017, we identified 3239 patients (14%) who had mild leg pain (≤3 on the NRS). In this cohort, leg pain increased 0.40 (0.56-0.37) and back pain decreased 1.0 (0.95-1.2) at the 1-year follow up. ODI decreased 11.1 (10.2-11.4) and the EQ-5D increased 0.15 (0.17-0.14). A total of 31% reached successful outcome in terms of back pain, 43% in terms of ODI and 48% in terms of EQ-5D. 63% of the patients were satisfied with the outcome.

CONCLUSION

A minority of patients with mild leg pain levels operated upon for LSS attain MICD for back pain, ODI, and EQ-5D. The results from this study can aid the surgeon in the shared decision-making process before surgery.

The application of decellularized nucleus pulposus matrix/chitosan with transforming growth factor β3 for nucleus pulposus tissue engineering

Low back pain caused by intervertebral disc degeneration has become a global problem that seriously affects public health. The application of nucleus pulposus tissue engineering to disc degeneration has attracted increasing attention. A scaffold is important for nucleus pulposus tissue engineering, which provides a three-dimensional growth space with an appropriate biomechanical and biochemical microenvironment for seed cell differentiation and proliferation. In this study, a decellularized nucleus pulposus matrix/chitosan (DNPM/chitosan) hydrogel scaffold was prepared with crosslinker genipin. Nucleus pulposus stem cells (NPSCs) were cultured in hybrid hydrogels with or without transforming growth factor-β3 (TGF-β3) and then cell morphology, proliferation, and nucleus pulposus-related gene expression were analyzed. TGF-β3 was successfully incorporated into the DNPM/chitosan hydrogel and NPSCs grew well on both kinds of hydrogel. Moreover, gene expression of collagen-I, collagen-II, and aggrecan was enhanced in the DNPM/chitosan hydrogel with TGF-β3. These results indicate that the DNPM/chitosan hybrid hydrogel is a promising candidate scaffold for nucleus pulposus tissue engineering.

Physician-Related Variability in the Outcomes of an Invasive Treatment for Neck and Back Pain: A Multi-Level Analysis of Data Gathered in Routine Clinical Practice

Neuro-reflexotherapy (NRT) is a proven effective, invasive treatment for neck and back pain. To assess physician-related variability in results, data from post-implementation surveillance of 9023 patients treated within the Spanish National Health Service by 12 physicians were analyzed. Separate multi-level logistic regression models were developed for spinal pain (SP), referred pain (RP), and disability. The models included all patient-related variables predicting response to NRT and physician-related variables. The Intraclass Correlation Coefficient (ICC) and the Median Odds Ratio (MOR) were calculated. Adjusted MOR (95% CI) was 1.70 (1.47; 2.09) for SP, 1.60 (1.38; 1.99) for RP, and 1.65 (1.42; 2.03) for disability. Adjusted ICC (95%CI) values were 0.08 (0.05; 0.15) for SP, 0.07 (0.03; 0.14) for RP, and 0.08 (0.04; 0.14) for disability. In the sensitivity analysis, in which the 6920 patients treated during the physicians’ training period were excluded, adjusted MOR was 1.38 (1.17; 1.98) for SP, 1.37 (1.12; 2.31) for RP, and 1.25 (1.09; 1.79) for disability, while ICCs were 0.03 (0.01; 0.14) for SP, 0.03 (0.00; 0.19) for RP, and 0.02 (0.00; 0.10) for disability. In conclusion, the variability in results obtained by different NRT-certified specialists is reasonable. This suggests that current training standards are appropriate.

Characterization and cytocompatibility of 3D porous biomimetic scaffold derived from rabbit nucleus pulposus tissue in vitro

Intervertebral disc (IVD) degeneration is one of the most important causes of lower back pain. Tissue engineering provides a new method for the experimental treatment of degenerative disc diseases. This study aims to develop a natural, acellular, 3D interconnected porous scaffold derived from the extracellular matrix (ECM) of nucleus pulposus. The nucleus pulposus (NP) was decellularized by sequential detergent-nuclease methods, including physical crushing, freeze-drying and cross-linking. These 3D porous scaffolds were fabricated with a high porosity of (81.28 ± 4.10)%, an ideal pore size with appropriate mechanical properties. Rabbit bone marrow mesenchymal stem cells (rBMSCs) were seeded and cultured on the scaffolds. And the mechanical tests showed the compressive elastic modulus of the scaffolds cultured for 4 weeks reached 0.12 MPa, which was better than that of the scaffolds cultured for 2 weeks (0.07 MPa) and that of the control group (0.04 MPa). Scanning electron microscopy (SEM), histological assays, molecular biology assays revealed that the scaffolds could provide an appropriate microstructure and environment for the adhesion, proliferation, migration and secretion of seeded cells in vitro. As assays like histology, immunohistochemistry and the real-time qRT-PCR showed, NP-like tissues were preliminarily formed. In conclusion, the 3D porous scaffold derived from NP ECM is a potential biomaterial for the regeneration of NP tissues. A natural, acellular, 3D interconnected porous scaffold derived from the extracellular matrix (ECM) of nucleus pulposus was developed by sequential detergent-nuclease and freeze-drying method, which can reduce the damage of protein activity to the minimum. It is very similar to the composition and internal environment of the natural nucleus pulposus, because it derived from the natural nucleus pulposus. Scanning electron microscopy (SEM), histological assays, molecular biology assays revealed that the scaffolds could provide an appropriate microstructure and environment for the adhesion, proliferation, migration, and secretion of seeded cells in vitro.

Outcome analysis of lumbar endoscopic unilateral laminotomy for bilateral decompression in patients with degenerative lumbar central canal stenosis

BACKGROUND CONTEXT

Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS).

PURPOSE

To investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC).

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

One-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study.

OUTCOME MEASURES

Operative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events.

METHODS

A comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications.

RESULTS

The study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods.

CONCLUSIONS

LE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS.

Advances of Naturally Derived and Synthetic Hydrogels for Intervertebral Disk Regeneration

Intervertebral disk (IVD) degeneration is associated with most cases of cervical and lumbar spine pathologies, amongst which chronic low back pain has become the primary cause for loss of quality-adjusted life years. Biomaterials science and tissue engineering have made significant progress in the replacement, repair and regeneration of IVD tissue, wherein hydrogel has been recognized as an ideal biomaterial to promote IVD regeneration in recent years. Aspects such as ease of use, mechanical properties, regenerative capacity, and their applicability as carriers for regenerative and anti-degenerative factors determine their suitability for IVD regeneration. This current review provides an overview of naturally derived and synthetic hydrogels that are related to their clinical applications for IVD regeneration. Although each type has its own unique advantages, it rarely becomes a standard product in truly clinical practice, and a more rational design is proposed for future use of biomaterials for IVD regeneration. This review aims to provide a starting point and inspiration for future research work on development of novel biomaterials and biotechnology.

1,4-Dihydropyridine (DHP) suppresses against oxidative stress in nucleus pulposus via activating sirtuin-1

Intervertebral disc degeneration (IVDD) is a major cause of many spinal diseases characterized mainly by nucleus pulposus degradation. 1,4-dihydropyridine (DHP), a new activator of sirtuin-1 (sirt1), has been reported to have anti-oxidative effects. The aim of this study is to investigate the effect of DHP on nucleus pulposus (NP) cells in vitro. NP cells were pretreated with IL-1β to establish a degenerated model, and then treated with DHP alone or DHP combined with selisistat (an inhibitor of sirt1). ROS level was analyzed by flow cytometry. Production of IL-6 and TNF-α were evaluated by the enzyme-linked immunosorbent assay (ELISA). The mRNA and protein expression were measured by quantitative real-time polymerase chain reaction (qRT-PCR) and Western blot respectively. Immunofluorescence was used to assess the expression of collagen-II and sirt1. We found that DHP inhibited IL-1β-induced upregulation of ROS, TNF-α, IL-6, MMP-3, ADAMTS-5. Besides, DHP remarkably increased the sirt1 and anti-oxidative protein SOD-1 level. Furthermore, DHP significantly protected the IL-1β-induced degradation of collagen-II and aggrecan. However, the inhibitory effect of DHP was obvious abolished by selisistat, suggesting that DHP exerts these effects in NP cells through activating sirt1. Taken together, we found that DHP inhibited the ROS, inflammatory response and ECM degradation through activating Sirt1 in human NP cells.

Can patient-reported profiles avoid unnecessary referral to a spine surgeon? An observational study to further develop the Nijmegen Decision Tool for Chronic Low Back Pain

INTRODUCTION

Chronic Low Back Pain (CLBP) is a heterogeneous condition with lack of diagnostic clarity. Therapeutic interventions show small effects. To improve outcomes by targeting interventions it is recommended to develop a triage system to surgical and non-surgical treatments based on treatment outcomes. The objective of the current study was to develop and internally validate prognostic models based on pre-treatment patient-reported profiles that identify patients who either respond or do not respond to two frequently performed treatments (lumbar spine surgery and multidisciplinary pain management program).

METHODS

A consecutive cohort study in a secondary referral spine center was performed. The study followed the recommendations of the PROGRESS framework and was registered in the Dutch Trial Register (NTR5946). Data of forty-seven potential pre-consultation (baseline) indicators predicting 'response' or 'non-response' at one-year follow-up for the two treatments were obtained to develop and validate four multivariable logistic regression models. The source population consisted of 3,410 referred CLBP-patients. Two treatment cohorts were defined: elective 'spine surgery' (n = 217 [6.4%]) and multidisciplinary bio-psychosocial 'pain management program' (n = 171 [5.0%]). Main inclusion criteria were age ≥18, CLBP (≥6 months), and not responding to primary care treatment. The primary outcome was functional ability: 'response' (Oswestry Disability Index [ODI] ≤22) and 'non-response' (ODI ≥41).

RESULTS

Baseline indicators predictive of treatment outcome were: degree of disability (all models), ≥2 previous spine surgeries, psychosocial complaints, age (onset <20 or >50), and patient expectations of treatment outcomes. The explained variances were low for the models predicting response and non-response to pain management program (R2 respectively 23% and 26%) and modest for surgery (R2 30% and 39%). The overall performance was acceptable (c-index; 0.72-0.83), the model predicting non-response to surgery performed best (R2 = 39%; c-index = 0.83).

CONCLUSION

This study was the first to identify different patient-reported profiles that predict response to different treatments for CLBP. The model predicting 'non-response' to elective lumbar spine surgery performed remarkably well, suggesting that referrals of these patients to a spine surgeon could be avoided. After external validation, the patient-reported profiles could potentially enhance timely patient triage to the right secondary care specialist and improve decision-making between clinican and patient. This could lead to improved treatment outcomes, which results in a more efficient use of healthcare resources.

A UK-based pilot study of current surgical practice and implant preferences in lumbar fusion surgery

Lumbar fusion surgery is an established procedure for the treatment of low back pain. Despite the wide set of alternative fusion techniques and existing devices, uniform guidelines are not available yet and common surgical trends are scarcely investigated.The purpose of this UK-based study was to provide a descriptive portrait of current surgeons' practice and implant preferences in lumbar fusion surgery.A UK-based in-person survey was designed for this study and submitted to a group of consultant spinal surgeons (n = 32). Fifteeen queries were addressed based on different aspects of surgeons' practice: lumbar fusion techniques, implant preferences, and bone grafting procedures. Answers were analyzed by means of descriptive statistics.Thirty-two consultant spinal surgeons completed the survey. There was clear consistency on the relevance of a patient-centered management (82.3%), along with a considerable variability of practice on the preferred fusion approach. Fixation surgery was found to be largely adopted (96.0%) and favored over stand-alone cages. With regards to the materials, titanium cages were the most used (54.3%). The geometry of the implants influenced the choice of lumbar cages (81.3%). Specifically, parallel-shape cages were mostly avoided (89.2%) and hyperlordotic cages were preferred at the lower lumbar levels. However, there was no design for lumbar cages which was consistently favored. Autograft bone graft surgeries were the most common (60.0%). Amongst the synthetic options, hydroxyapatite-based bone graft substitutes (76.7%) in injectable paste form (80.8%) were preferred.Current lumbar fusion practice is variable and patient-oriented. Findings from this study highlight the need for large-scale investigative surveys and clinical studies aimed to set specific guidelines for certain pathologies or patient categories.

Spinal Surgeons' Opinions on Pre- and Postoperative Rehabilitation in Patients Undergoing Lumbar Spinal Fusion Surgery: A Survey-Based Study in the Netherlands and Sweden

STUDY DESIGN

A cross-sectional survey in the Netherlands and Sweden.

OBJECTIVE

To investigate Dutch and Swedish spinal surgeons' opinions on spinal fusion pre- and postoperative rehabilitation.

SUMMARY OF BACKGROUND DATA

Lumbar spinal fusion surgery is increasingly provided in patients with chronic low back pain. No guidelines however exist for pre- and postoperative rehabilitation and it is unknown what opinions spinal surgeons currently have about pre- and postoperative rehabilitation.

METHODS

A survey was circulated to Dutch and Swedish spinal surgeons. Reminders were sent after 4 and 8/9 weeks. Data of completed questionnaires of orthopedic- and neurosurgeons currently performing lumbar spinal fusion were included for analysis. Analysis comprised a range of descriptive summaries (numerical, graphical, and tabular).

RESULTS

Surveys of 34 Dutch and 48 Swedish surgeons were analyzed. Surgeons provided preoperative information on postoperative mobilization. Spinal fusion techniques varied, but technique did not influence postoperative treatment. Swedish surgeons recommended slightly faster mobilization than Dutch (direct vs. 1-day postoperative), and more activities the first day (sitting, standing, walking). Stair climbing was the most reported discharge criterion; however, time point to start varied. More Swedish surgeons referred to postoperative physiotherapy than Dutch (88% vs. 44%). Time-point to start home activities varied from 1 week to more than 6 months. Pain increase was allowed for less than 24 hours (The Netherlands 81%, Sweden 92%).

CONCLUSION

Findings reflect variability in lumbar spinal fusion rehabilitation in two European countries, especially in postoperative phase. The study proposes many new research topics and acts as starting point for future research valuable for the spinal community.

LEVEL OF EVIDENCE

3.

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.

Lumbar spinal stenosis: symptoms, diagnosis and treatment (meta-analysis of literature data)

Lumbar spinal stenosis is a disease in which degenerated discs, ligamentum flavum, facet joints, while aging, lead to a narrowing of the space around the neurovascular structures of the spine. This article presents a meta-analysis of literature data on epidemiology, causes, pathogenesis, diagnosis and various types of treatment of lumbar spinal stenosis.

Survey of integrative lumbar spinal stenosis treatment in Korean medicine doctors: preliminary data for clinical practice guidelines

BACKGROUND

Considering that large variations exist amongst practitioners in lumbar disorder management and the significant costs that lumbar disorders incur, determining clinical practice patterns to provide preliminary data for standardization should be given higher priority. Lumbar spinal stenosis (LSS) is commonly treated using integrative non-surgical methods by Korean medicine doctors (KMDs) in Korea, and this is the first study to assess current Korean medicine practice trends for LSS.

METHODS

A survey on KMD diagnosis, treatment, prognosis and decision-making in LSS treatment was developed in a 3-step procedure of preliminary drafting, revision based on extramural expert opinion, and final editing. The survey was conducted at the internal conference of a spine-specialty Korean medicine hospital on January 25th, 2015.

RESULTS

The response rate was high at 79.19% (n = 118/149). Participants replied that they treated 7.3 ± 6.8 LSS patients/day using a multimodal treatment method consisting of acupuncture, pharmacopuncture, herbal medicine, Chuna manipulation, and electroacupuncture. Acupuncture mainly used Ashi points and MSAT, and pharmacopuncture mainly Shinbaro solution. The most frequently prescribed herbal medicine was Chungpa-jun, and the most commonly applied Chuna techniques were sidelying lumbar extension dysfunction correction technique, and prone lumbosacral joint distraction method. Radiological findings were mainly referred to for diagnosis, and clinical symptoms, age, radiological findings, and medical history were regarded to be important for prognosis. Participants replied that 7.8 ± 3.3 weeks were required for 50% reduction in pain, and 16.1 ± 7.7 weeks for 80% reduction.

CONCLUSIONS

These results suggest that KMDs in Korea combine a conventional approach to LSS and a Korean medicine approach to low back pain for integration of empirical- and evidence-based diagnosis and treatment. The findings may contribute in bridging the divide between evidence and clinical practice guidelines for Korean medicine treatment of LSS and real-world clinical practice in future research.

Neuropathic Pain Related with Spinal Disorders: A Systematic Review

Systematic literature review. To review the evidence from high-quality studies regarding the treatment of neuropathic pain originating specifically from spinal disorders. In general, treatment guidelines for neuropathic pain cover all its various causes, including medical disease, peripheral neuropathy, and cancer. However, the natural history of neuropathic pain originating from spinal disorders may differ from that of the pain originating from other causes or lesions. An expert research librarian used terms related to neuropathic pain and spinal disorders, disc herniation, stenosis, and spinal cord injury to search in MEDLINE, Embase, and Cochrane CENTRAL for primary research from January 2000 to October 2015. Among 2,313 potential studies of interest, 25 randomized controlled trials (RCTs) and 21 systematic reviews (SRs) were included in the analysis. The selection was decided based on the agreement of two orthopedic surgeons. There was a lack of evidence about medication for radiculopathy arising from disc herniation and stenosis, but intervention procedures, including epidural block, showed positive efficacy in radiculopathy and also limited efficacy in spinal stenosis. There was some evidence based on the short-term follow-up regarding surgery being superior to conservative treatments for radiculopathy and stenosis. There was limited evidence regarding the efficacy of pharmacological and electric or magnetic stimulation therapies for neuropathic pain after spinal cord injury. This review of RCTs and SRs with high-quality evidence found some evidence regarding the efficacy of various treatment modalities for neuropathic pain related specifically to spinal disorders. However, there is a need for much more supportive evidence.

Lumbar herniated disc: spontaneous regression

BACKGROUND

Low back pain is a frequent condition that results in substantial disability and causes admission of patients to neurosurgery clinics. To evaluate and present the therapeutic outcomes in lumbar disc hernia (LDH) patients treated by means of a conservative approach, consisting of bed rest and medical therapy.

METHODS

This retrospective cohort was carried out in the neurosurgery departments of hospitals in Kahramanmaraş city and 23 patients diagnosed with LDH at the levels of L3-L4, L4-L5 or L5-S1 were enrolled.

RESULTS

The average age was 38.4 ± 8.0 and the chief complaint was low back pain and sciatica radiating to one or both lower extremities. Conservative treatment was administered. Neurological examination findings, durations of treatment and intervals until symptomatic recovery were recorded. Laségue tests and neurosensory examination revealed that mild neurological deficits existed in 16 of our patients. Previously, 5 patients had received physiotherapy and 7 patients had been on medical treatment. The number of patients with LDH at the level of L3-L4, L4-L5, and L5-S1 were 1, 13, and 9, respectively. All patients reported that they had benefit from medical treatment and bed rest, and radiologic improvement was observed simultaneously on MRI scans. The average duration until symptomatic recovery and/or regression of LDH symptoms was 13.6 ± 5.4 months (range: 5-22).

CONCLUSIONS

It should be kept in mind that lumbar disc hernias could regress with medical treatment and rest without surgery, and there should be an awareness that these patients could recover radiologically. This condition must be taken into account during decision making for surgical intervention in LDH patients devoid of indications for emergent surgery.

An Inflammatory Nucleus Pulposus Tissue Culture Model to Test Molecular Regenerative Therapies: Validation with Epigallocatechin 3-Gallate

Organ cultures are practical tools to investigate regenerative strategies for the intervertebral disc. However, most existing organ culture systems induce severe tissue degradation with only limited representation of the in vivo processes. The objective of this study was to develop a space- and cost-efficient tissue culture model, which represents degenerative processes of the nucleus pulposus (NP). Intact bovine NPs were cultured in a previously developed system using Dyneema jackets. Degenerative changes in the NP tissue were induced either by the direct injection of chondroitinase ABC (1-20 U/mL) or by the diffusion of interleukin-1 beta (IL-1β) and tumor necrosis factor alpha (TNF-α) (both 100 ng/mL) from the culture media. Extracellular matrix composition (collagens, proteoglycans, water, and DNA) and the expression of inflammatory and catabolic genes were analyzed. The anti-inflammatory and anti-catabolic compound epigallocatechin 3-gallate (EGCG, 10 µM) was employed to assess the relevance of the degenerative NP model. Although a single injection of chondroitinase ABC reduced the proteoglycan content in the NPs, it did not activate cellular responses. On the other hand, IL-1β and TNF-α significantly increased the mRNA expression of inflammatory mediators IL-6, IL-8, inducible nitric oxide synthase (iNOS), prostaglandin-endoperoxide synthase 2 (PTGS2) and matrix metalloproteinases (MMP1, MMP3, and MMP13). The cytokine-induced gene expression in the NPs was ameliorated with EGCG. This study provides a proof of concept that inflammatory NP cultures, with appropriate containment, can be useful for the discovery and evaluation of molecular therapeutic strategies against early degenerative disc disease.

Conservative Care in Lumbar Spine Surgery Trials: A Descriptive Literature Review

OBJECTIVE

To evaluate the degree to which conservative care and failure were specifically defined in studies comparing nonoperative treatment versus surgery for low back pain (LBP) conditions in adults.

DATA SOURCES

A comprehensive literature search was conducted by an experienced librarian using MEDLINE (PubMed), Embase, Google Scholar, and CENTRAL from January 2003 to June 2014. Endnote bibliographic management application was used to remove duplicates and organize the citations.

STUDY SELECTION

Prospective, randomized, or cohort trials comparing surgery versus conservative intervention for patients with LBP conditions. Study selection was conducted by 2 independent reviewers.

DATA EXTRACTION

Three independent reviewers extracted data from each article using a structured data extraction form. Data extracted included type of study, participant characteristics, sample size, description, and duration of conservative care and whether failed conservative care criterion was defined.

DATA SYNTHESIS

A total of 852 unique records were screened for eligibility; of those, 72 articles were identified for further full-text review. Thirty-four full texts were excluded based on the exclusion criteria, and 38 articles, representing 20 unique studies, were included for qualitative synthesis. Fifteen of the 20 studies defined the duration of conservative care. Only 3 studies defined the dosage of physical therapy sessions, including total number of visits and visit duration. Two studies described medication usage, including the duration and type. No studies specifically defined what constituted failed conservative therapy.

CONCLUSIONS

This literature review suggests conservative care is poorly defined in randomized trials, which can lead to ambiguity of research procedures and unclear guidelines for clinicians. Future studies should increase transparency and explicitly define conservative care.

Computed Tomography Findings Associated with Clinical Outcome After Dynamic Posterior Stabilization of the Lumbar Spine

OBJECTIVE

To evaluate whether preoperative multirow detector computed tomography (MDCT) findings were associated with clinical outcome 24 months after dynamic stabilization for painful degenerative lumbar spine disease.

METHODS

Preoperative MDCT examinations of 63 patients (66 ± 11.7 years; 60% women) treated with a dynamic screw rod system for painful degenerative segmental instability with/without spinal stenosis were assessed for quantitative and qualitative parameters defining degenerative changes of the thoracolumbar spine, including grades of disc herniation, degenerative spondylolisthesis, vertebral body sclerosis, cross-sectional area of the spinal canal at disc level, intervertebral disc height, ancillary bone mineral density, and anteroposterior diameter of intervertebral foramina. Clinical performance was assessed at baseline and 24 months with quantitative scales, including the Oswestry Disability Index and Short-Form 36 physical component summary. For statistical analysis classification and regression trees, linear regression and nonparametric tests were used.

RESULTS

Clinical scores improved substantially over 24 months compared with preoperative values (delta Oswestry Disability Index -32.1 ± 17.2, delta Short-Form 36 physical component summary 4.9 ± 2.3). Physical component summary improvement was significantly better in patients with lower grades of disc herniation (P < 0.001) and/or spondylolisthesis (P = 0.011), lower cross-sectional area of the spinal canal (P = 0.043), high intervertebral disc height (P = 0.006), and high grades of vertebral body sclerosis (P = 0.002). Patients with high bone mineral density and initially low diameter of intervertebral foramina showed a significantly better improvement of Oswestry Disability Index (P < 0.05).

CONCLUSIONS

Clinical improvement after dynamic stabilization was significantly associated with 7 independent baseline imaging findings. Preoperative evaluation of these MDCT parameters may improve therapy selection for patients with degenerative lumbar spine disease.

Evidence base and future research directions in the management of low back pain

Low back pain (LBP) is a prevalent and costly condition. Awareness of valid and reliable patient history taking, physical examination and clinical testing is important for diagnostic accuracy. Stratified care which targets treatment to patient subgroups based on key characteristics is reliant upon accurate diagnostics. Models of stratified care that can potentially improve treatment effects include prognostic risk profiling for persistent LBP, likely response to specific treatment based on clinical prediction models or suspected underlying causal mechanisms. The focus of this editorial is to highlight current research status and future directions for LBP diagnostics and stratified care.

Repeated 3.0 Tesla Magnetic Resonance Imaging After Clinically Successful Lumbar Disc Surgery

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To describe the naturally occurring magnetic resonance imaging (MRI) findings after successful microsurgical removal of lumbar disc herniation with repeated MRI examinations.

SUMMARY OF BACKGROUND DATA

The interpretation of MRI after spinal surgery may be particularly challenging and image findings do not always correlate to clinical findings. Early postoperative MRI has limited value in the evaluation of patients after surgery for lumbar disc herniation.

METHODS

Prospective study of 30 successfully operated patients, which underwent 3.0 T MRI within 24 h after surgery for lumbar disc herniation and repeated at 6 weeks and 3 months postoperatively. Postoperative image findings (nerve root enhancement, nerve root thickening, displacement or compression of the nerve root, and residual mass size and signal) were assessed quantitatively. Inter-rater reliability was tested.

RESULTS

Inter-rater reliability between neuroradiologists was moderate for assessed MRI variables. In the immediate postoperative phase, compression or dislocation of the nerve root at the operated level was common. A residual mass at the operated level was seen in 80%, 47%, and 33% after 24 h, 6 weeks, and 3 months, respectively. Postoperative dislocation or compression of the nerve root from residual masses was seen in 67%, 24%, and 14% after 24 h, 6 weeks, and 3 months, respectively. A residual mass with a higher signal than muscle on T2-weighted images was seen in 80%, 30%, and 17% after 24 h, 6 weeks, and 3 months, respectively.

CONCLUSION

A residual mass with compression or dislocation of the nerve root at the operated level, that disappears over 3 months, is a common MRI finding in patients successfully operated for symptomatic lumbar disc herniation. An expectant approach instead of early reoperations may perhaps be preferred in patients with residual pain and root compression due to residual masses with high T2-signal since these often seem to resolve spontaneously.

LEVEL OF EVIDENCE

3.

Management of lumbar spinal stenosis

Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.

Influence of different fusion techniques in lumbar spine over the adjacent segments: A 3D finite element study

The most conventional technique to treat the intervertebral disc degeneration consists on fusing the affected segment with a posterior screw fixation and sometimes with the insertion of a cage in the intersomatic space. However, this kind of surgeries had controversial results in the adjacent discs. The aim of this work was to prove the stabilization of the spine and the decompression of the disc and to analyze the influence over the adjacent segments. With this purpose, four different models were built and simulated under different loading conditions. The stabilization of the spine was ensured by the screw fixation which reduced dramatically the relative motion in the affected segment. On the other hand, the pore pressure showed a high fall in the operated models proving the decompression of the neural structures. In the adjacent segments, the ROM increased up to 50% in the upper disc and 70% in the lower one. The pore pressure and principal stresses also increased after both surgeries. The observed results suggested that the fusion procedure could trigger a cascade degeneration effect over the adjacent discs, while it is also seen that cage insertion helps to maintain disc height in a better way than screw fixation only.

Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study

OBJECTIVE

To evaluate whether an epidural steroid injection or gabapentin is a better treatment for lumbosacral radiculopathy.

DESIGN

A multicenter randomized study conducted between 2011 and 2014. Computer generated randomization was stratified by site. Patients and evaluating physicians were blinded to treatment outcomes.

SETTINGS

Eight military, Veterans Administration, and civilian hospitals.

PARTICIPANTS

145 people with lumbosacral radicular pain secondary to herniated disc or spinal stenosis for less than four years in duration and in whom leg pain is as severe or more severe than back pain.

INTERVENTIONS

Participants received either epidural steroid injection plus placebo pills or sham injection plus gabapentin.

MAIN OUTCOME MEASURES

Average leg pain one and three months after the injection on a 0-10 numerical rating scale. A positive outcome was defined as a ≥ 2 point decrease in leg pain coupled with a positive global perceived effect. All patients had one month follow-up visits; patients whose condition improved remained blinded for their three month visit.

RESULTS

There were no significant differences for the primary outcome measure at one month (mean pain score 3.3 (SD 2.6) and mean change from baseline -2.2 (SD 2.4) in epidural steroid injection group versus 3.7 (SD 2.6) and -1.7 (SD 2.6) in gabapentin group; adjusted difference 0.4, 95% confidence interval -0.3 to 1.2; P=0.25) and three months (mean pain score 3.4 (SD 2.7) and mean change from baseline -2.0 (SD 2.6) versus 3.7 (SD 2.8) and -1.6 (SD 2.7), respectively; adjusted difference 0.3, -0.5 to 1.2; P=0.43). Among secondary outcomes, one month after treatment those who received epidural steroid injection had greater reductions in worst leg pain (-3.0, SD 2.8) than those treated with gabapentin (-2.0, SD 2.9; P=0.04) and were more likely to experience a positive successful outcome (66% v 46%; number needed to treat=5.0, 95% confidence interval 2.8 to 27.0; P=0.02). At three months, there were no significant differences between treatments.

CONCLUSIONS

Although epidural steroid injection might provide greater benefit than gabapentin for some outcome measures, the differences are modest and are transient for most people.Trial registration ClinicalTrials.gov Identifier: NCT01495923.

Transarticular laser discal fragmentectomy. A new minimally invasive surgical approach for challenging disc herniations in the elderly

This report describes two elderly patients with large disc fragments extruded into lumbar radicular recesses not treatable by any conventional conservative, minimally invasive or surgical approach. Direct access to the disc fragments was obtained crossing the articular zygapophyseal cavity instead of the interlaminar space and spinal canal, using a small needle through which a laser fibre was inserted to deliver energy for tissue ablation. The procedures obtained regression of both symptoms and the bulk of the fragments at early and late clinical and MR follow-ups.

The Nijmegen decision tool for chronic low back pain. Development of a clinical decision tool for secondary or tertiary spine care specialists

BACKGROUND

In Western Europe, low back pain has the greatest burden of all diseases. When back pain persists, different medical specialists are involved and a lack of consensus exists among these specialists for medical decision-making in Chronic Low Back Pain (CLBP).

OBJECTIVE

To develop a decision tool for secondary or tertiary spine care specialists to decide which patients with CLBP should be seen by a spine surgeon or by other non-surgical medical specialists.

METHODS

A Delphi study was performed to identify indicators predicting the outcome of interventions. In the preparatory stage evidence from international guidelines and literature were summarized. Eligible studies were reviews and longitudinal studies. Inclusion criteria: surgical or non-surgical interventions and persistence of complaints, CLBP-patients aged 18-65 years, reported baseline measures of predictive indicators, and one or more reported outcomes had to assess functional status, quality of life, pain intensity, employment status or a composite score. Subsequently, a three-round Delphi procedure, to reach consensus on candidate indicators, was performed among a multidisciplinary panel of 29 CLBP-professionals (>five years CLBP-experience). The pre-set threshold for general agreement was ≥70%. The final indicator set was used to develop a clinical decision tool.

RESULTS

A draft list with 53 candidate indicators (38 with conclusive evidence and 15 with inconclusive evidence) was included for the Delphi study. Consensus was reached to include 47 indicators. A first version of the decision tool was developed, consisting of a web-based screening questionnaire and a provisional decision algorithm.

CONCLUSIONS

This is the first clinical decision tool based on current scientific evidence and formal multidisciplinary consensus that helps referring the patient for consultation to a spine surgeon or a non-surgical spine care specialist. We expect that this tool considerably helps in clinical decision-making spine care, thereby improving efficient use of scarce sources and the outcomes of spinal interventions.