The impact of four common lumbar spine diagnoses upon overall health status

The Dietary Intake of Polyphenols Is Associated with a Lower Risk of Severe Lumbar Spinal Stenosis: A Case-Control Analysis from the PREFACE Study

Polyphenols are naturally occurring compounds endowed with antioxidant and anti-inflammatory properties. We sought to examine the association of dietary polyphenols with the risk of severe lumbar spinal stenosis (LSS), a condition possibly characterized by a high inflammatory component. A case-control study included 156 patients with LSS and indication to surgery and 312 controls, matched (1:2) for sex, age (±6 months), and physical activity. The polyphenol intake was calculated by matching food consumption data from a 188-item food frequency questionnaire with the Phenol-Explorer database regarding the polyphenol content of each reported food. In a multivariable-adjusted logistic regression analysis including lifestyles, sociodemographic factors, and the Mediterranean Diet Score, a 1-standard deviation (SD) increase in dietary polyphenols intake was associated with lower odds of LSS (Odds ratio [OR] = 0.65; 95% CI: 0.47-0.89). Analyses of different polyphenol classes showed that a per 1-SD in the consumption of flavonoids and stilbenes was related to lower LSS risk (OR = 0.57; 95% CI: 0.42-0.78; OR = 0.40; 95% CI: 0.27-0.61, respectively). Further adjustment for the total dietary antioxidant capacity did not modify the strength of these associations. A diet rich in polyphenols is independently associated with a lower risk of severe LSS, possibly through mechanisms that include the anti-inflammatory potential of these bioactive compounds.

Cost-effectiveness of 4 mg dibotermin alfa/absorbable collagen sponge versus iliac crest bone graft for lumbar degenerative disc disease in the United Kingdom

AIMS

To develop a model to evaluate the cost-effectiveness of 4 mg dibotermin alfa/absorbable collagen sponge (ACS) versus iliac crest bone graft (ICBG) in patients with lumbar degenerative disc disease in the United Kingdom.

MATERIALS & METHODS

A Markov decision-analytic model was constructed to calculate costs and quality-adjusted life-years over a 4-year time horizon in each treatment group, from a United Kingdom National Health Service perspective. An individual patient data meta-analysis was undertaken to synthesize data from four randomized controlled trials and two single-arm studies concerning health-related quality of life and procedural resource use. Current cost data from the United Kingdom were then applied to determine the overall mean cost per patient in each group. One-way and probabilistic sensitivity analyses were undertaken to explore the impact of parameter uncertainty.

RESULTS

The model predicted 4-year discounted cost savings of £192 per patient treated with dibotermin alfa/ACS, compared with ICBG, and a gain of 0.0114 QALYs per patient over the same time period. Sensitivity analyses indicated that the results were most sensitive to variability in the differences in health-related quality of life and secondary surgery rate, with dibotermin alfa/ACS having a 60% probability of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY gained.

LIMITATIONS

There is uncertainty in the difference in cost and QALYs between the two groups. However, comprehensive sensitivity analyses were undertaken to explore this and present the results in a transparent manner.

CONCLUSIONS

Our results provide an economic case for the use of 4 mg dibotermin alfa/ACS versus iliac crest bone graft, with additional health benefits predicted at reduced overall cost.

Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis

PURPOSE

To estimate the prevalence of degenerative lumbar spinal stenosis (LSS) in adults, identified by clinical symptoms and/or radiological criteria.

METHODS

Systematic review of the literature. Pooled prevalence estimates by care setting and clinical or radiological diagnostic criteria were calculated and plotted [PROSPERO ID: CRD42018109640].

RESULTS

In total, 41 papers reporting on 55 study samples were included. The overall risk of bias was considered high in two-thirds of the papers. The mean prevalence, based on a clinical diagnosis of LSS in the general population, was 11% (95% CI 4-18%), 25% (95% CI 19-32%) in patients from primary care, 29% (95% CI 22-36%) in patients from secondary care and 39% (95% CI 39-39%) in patients from mixed primary and secondary care. Evaluating the presence of LSS based on radiological diagnosis, the pooled prevalence was 11% (95% CI 5-18%) in the asymptomatic population, 38% (95% CI - 10 to 85%) in the general population, 15% (95% CI 13-18%) in patients from primary care, 32% (95% CI 22-41%) in patients from secondary care and 21% (95% CI 16-26%) in a mixed population from primary and secondary care.

CONCLUSIONS

The mean prevalence estimates based on clinical diagnoses vary between 11 and 39%, and the estimates based on radiological diagnoses similarly vary between 11 and 38%. The results are based on studies with high risk of bias, and the pooled prevalence estimates should therefore be interpreted with caution. With an growing elderly population, there is a need for future low risk-of-bias research clarifying clinical and radiological diagnostic criteria of lumbar spinal stenosis. These slides can be retrieved under Electronic Supplementary Material.

Lumbar Spine Fusion Patients See Similar Improvements in Physical Activity Level to Non-Spine Fusion Patients Following Total Hip Arthroplasty

BACKGROUND

The impact of prior lumbar spinal fusion on the change in physical activity level following total hip arthroplasty (THA) has not been thoroughly examined. Therefore, we sought to compare the change in physical activity level following THA for patients with and without a history of lumbar spine fusion.

METHODS

Patients who underwent primary elective THA were identified using an integrated healthcare system's Total Joint Replacement Registry (2010-2013). Prior lumbar spine fusion was identified using the healthcare system's Spine Registry. Physical activity was self-reported by patients and measured in min/wk. Generalized linear models were used to evaluate the association between prior spine fusion and the change in physical activity from 1 year pre-THA to 1-2 years post-THA.

RESULTS

Of 11,416 THAs, 90 (0.8%) had a history of lumbar spinal fusion. Patients with a prior lumbar fusion had a median physical activity level of 28 min/wk prior to THA compared to 45 min/wk in the patients with no history of lumbar spinal fusion. One year after THA, patients with a history of lumbar spinal fusion reported a median of 120 min/wk of physical activity compared to 150 min/wk for patients without a history of lumbar spinal fusion. The difference in physical activity level change between groups was not statistically significant (estimate = -23.1, 95% confidence interval -62.1 to 15.9, P = .246).

CONCLUSION

Patients with prior lumbar fusion were found to have lower self-reported physical activity levels than patients without spine fusion both before and after THA surgery. However, both groups saw the same degree of improvement in physical activity level following THA. These findings may help in counseling patients who have had a prior lumbar spine fusion and in setting appropriate expectations prior to THA.

Factors affecting health-related quality of life one year after lumbar spinal fusion

OBJECTIVE

To identify preoperative factors that affect the medical outcome study 36-item short form health survey (SF-36) score 1 year after lumbar spinal fusion.

METHODS

Participants were selected from among 624 patients who underwent lumbar spinal fusion between April 1, 2009 and March 31, 2011 who were followed up for 1 year or more. The SF-36 version 2 was used to evaluate HRQOL. The following preoperative parameters were investigated: sex, age, body mass index (BMI), employment status (other than home-making), living with other family members, smoking, orthopedic disorder in another part of the body (other than lumbar spinal disease), history of lumbar spinal surgery, bladder function, and leg muscle strength.

RESULTS

94 patients were included. None of the independent preoperative factors exhibited a high degree of correlation, and the absence of multicollinearity was confirmed before further analysis was performed. The first canonical variates were age and leg muscle strength, which had a major effect on physical functioning, role physical, and role emotional 1 year after surgery, and the second canonical variates were employment status, sex, and orthopedic disorder in another part of the body, which had a major effect on general health 1 year after surgery.

CONCLUSIONS

The SF-36 score 1 year after lumbar spinal fusion was affected by the preoperative factors of age, leg muscle strength, living with other family members, employment status, sex, and orthopedic disorders in another part of the body.

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: assessment of functional outcome following lumbar fusion

Assessment of functional patient-reported outcome following lumbar spinal fusion continues to be essential for comparing the effectiveness of different treatments for patients presenting with degenerative disease of the lumbar spine. When assessing functional outcome in patients being treated with lumbar spinal fusion, a reliable, valid, and responsive outcomes instrument such as the Oswestry Disability Index should be used. The SF-36 and the SF-12 have emerged as dominant measures of general health-related quality of life. Research has established the minimum clinically important difference for major functional outcomes measures, and this should be considered when assessing clinical outcome. The results of recent studies suggest that a patient's pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome.

Lumbar spinal stenosis has a negative impact on quality of life compared with other comorbidities: an epidemiological cross-sectional study of 1862 community-dwelling individuals

Lumbar spinal stenosis (LSS) is common in the elderly. However, there have been few reports on its impact on quality of life (QoL) in community-dwelling individuals. The purpose of this study was to clarify how symptomatic LSS affects QoL at the community level. A total of 1862 people (697 males and 1165 females, most subjects were between 40 and 85 y.o.) agreed to participate and were interviewed. The presence of symptomatic LSS was assessed by a specially designed questionnaire. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) was also administered. In addition, the presence of comorbid conditions that affect QoL, such as osteoarthritis of the knee and hip, cardiovascular disease, cerebrovascular disease, or respiratory disease, was also analyzed. The prevalence of symptomatic LSS gradually increased with age. Furthermore, the presence of symptomatic LSS had a strong negative effect on all 8 physical and mental domains and the physical component summary (PCS) (OR: 1.547–2.544) but not the mental component summary (MCS). In comparison with comorbid conditions, LSS had a much stronger negative impact on health-related QoL (HR-QoL). The current study confirmed that the presence of symptomatic LSS might have a strong negative influence on HR-QoL in the community setting.

Clinical interpretation of outcome measures generated from a lumbar computerized adaptive test

BACKGROUND

A computerized adaptive test (CAT) provides a way of efficiently estimating functional status in people with specific impairments.

OBJECTIVE

The purpose of this study was to describe meaningful interpretations of functional status (FS) estimated using a lumbar CAT developed using items from the Back Pain Functional Scale (BPFS) and selected physical functioning items. Design and Setting This was a prospective longitudinal cohort study of 17,439 patients with lumbar spine impairments in 377 outpatient rehabilitation clinics in 30 states. Outcome Measures Patient self-reports of functional status were assessed using a lumbar CAT (0-100 scale).

METHODS

Outcome data were interpreted using 4 methods. First, the standard error of the estimate was used to construct a 95% confidence interval for each CAT estimated score. Second, percentile ranks of FS scores were presented. Third, 2 threshold approaches were used to define individual patient-level change: minimal detectable change (MDC) and clinically important change. Fourth, a functional staging model, the Back Pain Function Classification System (BPFCS), was developed and applied.

RESULTS

On average, precision of a single score was estimated by FS score+/-4. Based on score distribution, 25th, 50th and 75th percentile ranks corresponded to intake FS scores of 44, 51, and 59, and discharge FS scores of 54, 62, and 74, respectively. An MDC(95) value of 8 or more represented statistically reliable change. Receiver operating characteristic analyses supported that changes in FS scores of 5 or more represented minimal clinically important improvement. The BPFCS appeared clinically logical and provided insight for clinical interpretation of patient progress.

LIMITATIONS

The BPFCS should be assessed for validity using prospective designs.

CONCLUSIONS

Results may improve clinical interpretation of CAT-generated outcome measures and assist clinicians using patient-reported outcomes during physical therapist practice.

Correlations between quality of life and psychological factors in patients with chronic neck pain

The purpose of this study was to investigate health-related quality of life (HRQOL) and associated factors in patients with chronic neck pain (CNP). The HRQOL of patients with CNP was assessed by the Short Form-36 questionnaire in this cross-sectional study. To evaluate the psychological factors related to HRQOL, the Eysenck Personality Questionnaire, Chinese Health Questionnaire, and Beck Anxiety Inventory were used. The scores for the eight subscales of Short Form-36 were all lower than the Taiwanese age-matched normative values (p < 0.001). The two most strongly affected subscales were the role-physical subscale and the bodily pain subscale; both scores were below half the score of the age-/sex-matched normative values. The physical components summary score, a summary measure, was moderately correlated with age (rho = -0.43), education level (rho = 0.37) and Beck Anxiety Inventory score (rho = -0.36). The mental components summary score was moderately to highly correlated with the Chinese Health Questionnaire score (rho = -0.72), the neuroticism domain of Eysenck Personality Questionnaire (rho = -0.52) and Beck Anxiety Inventory score (rho = -0.41). The HRQOL of patients with CNP was worse than that of normal subjects across all domains. Furthermore, patients with a neurotic personality, minor psychiatric morbidity and higher anxiety status showed poor mental health, as measured by the Short Form-36. We found that patients with CNP had multiple physical and mental health problems in terms of. The mental health of patients with CNP was strongly associated with various psychological factors. Comprehensive assessment of the physical and mental functioning of patients with CNP can improve the management and care of these patients.

Clinical outcome of deep wound infection after instrumented posterior spinal fusion: a matched cohort analysis

STUDY DESIGN

Retrospective case control study.

OBJECTIVE

Determine the impact of infection on clinical outcome in patients undergoing posterior spinal fusion surgery.

SUMMARY OF BACKGROUND DATA

The outcome of patients treated for infection after spinal surgery is not well established because of variability in cohort identification, definition of infection, outcomes instrument, use of a control group, and/or sample size.

METHODS

Thirty-two patients were included. Sixteen patients ("infection group") met inclusion criteria of deep wound infection after spinal fusion with posterior segmental instrumentation (including combined approach). A 1:1 matched cohort ("control group") was created based on primary or revision status, length of fusion, diagnosis, and age. Postoperative patient outcomes were evaluated using the physical components of SF-36 v2.0 with minimum 2-year follow-up.

RESULTS

No significant difference in the Physical Function, Role Physical, Bodily Pain, and General Health domains was detected between the infection group and control group. Mean follow-up was 62 months. Mean Physical Component Summary was 41.4 in the infection group and 44.3 in the control group (P = 0.6). Infection occurred early in 12 patients and late in 4 patients. Most common organisms isolated were Staphylococcus epidermidis, Enterococcus sp., and Staphylococcus aureus. Multiple debridements were significantly associated with polymicrobial infections and later pseudarthrosis requiring reoperation.

CONCLUSION

An aggressive approach to deep wound infection emphasizing early irrigation and debridement allowed preservation of instrumentation and successful fusion in most cases. At the conclusion of treatment, patients can expect a medium-term clinical outcome similar to patients in whom this complication did not occur.

Prevalence and risk factors associated with low back pain among health care providers in a Kuwait hospital

STUDY DESIGN

A cross-sectional survey among health professionals working in a Kuwait hospital.

OBJECTIVE

To investigate the prevalence and factors associated with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The literature suggests that health professionals are exposed to occupational risk factors that predispose them to developing LBP. These rates are not well established in Middle Eastern countries such as Kuwait.

METHODS

A self-administered survey was conducted with health professionals in an urban orthopedic hospital.

RESULTS

The response rate to the survey was 60% (n = 344). Lifetime prevalence of LBP in the sample was 70.9%, and point prevalence of LBP was 21.5%. Factors associated with acute LBP included direct patient contact (P = 0.015), performing patient lifts and/or transfers (P = 0.016), low job satisfaction (P = 0.039), and poor self-reported health status (P = 0.019). The prevalence ratio (PR) of reporting acute LBP was also found to increase as a function of the number of daily lifts/transfers performed (PR: 1.4; 95% CI: 1.27 to 1.70). Other factors generally associated with LBP, such as age, sex, professional experience, smoking and exercise, were not found to be significantly associated with LBP in this study.

CONCLUSION

No causal relationships can be inferred using these cross-sectional data. However, results suggest that direct patient contact that includes lifting and/or transferring patients may be an important risk factor. Further research is warranted to evaluate effectiveness of back education and prevention programs among hospital staff in Kuwait.

Disc displacement patterns in lumbar anterior spondylolisthesis: contribution to foraminal stenosis

PURPOSE

To describe the particular disc displacement pattern seen at MRI in patients with spondylolisthesis, and its potential contribution to foraminal stenosis.

METHODS

38 patients with symptomatic lumbar anterior spondylolisthesis and 38 sex and aged matched control patients with herniated disc disease, at corresponding disc space levels, were included for study. In each case note was made of the presence, absence and direction of disc displacement and also the presence and location of neural contact with the displaced disc.

RESULTS

In 33 of 38 (86.8%) patients in the spondylolisthesis group, the vertical disc displacement was upward. In the control group only 3 patients (7.8%) had upward vertical disc displacement. 19 patients (53%) from the spondylolisthesis group had exit foraminal nerve root contact, compared to 7 patients (18.4%) from the control group. 27 control patients (71%) had contact within the lateral recess, compared to only 6 patients (17%) with spondylolisthesis. Differences for upward displacement were significant (p<0.05).

CONCLUSION

Disc displacement in patients with spondylolisthesis is predominately in a cephalad and lateral direction. Although this disc displacement pattern can occur in patients without spondylolisthesis, its incidence is much greater in the subset of patients with concomitant spondylolisthesis. In the setting of acquired osseous narrowing of the exit foramen, this described pattern of disc displacement superiorly and laterally in spondylolisthesis increases the susceptibility of spondylolisthesis patients to radicular symptoms and accounts for the exiting nerve root being more commonly affected than the traversing nerve root.

Lumbale Spinalkanalstenose

Lumbal spinal stenosis is gaining more and more clinical relevance because of changing population structure and increasing demand on lifequality in the elderly. Current treatment recommendations are based on clinical experience, expert opinions and single studies rather than on proven evidence. The radiologic degree of stenosis does not correlate with the patients' clinical situation. It is not the main factor indicating surgery but rather the typical history and spinal claudication. Symptomatic patients with light to moderate complaints should undergo multimodal conservative treatment. Epidural injections, delordosating physiotherapy and medication are useful. In patients with severe symptomatic stenosis surgery is indicated after a conservative treatment of 3 months. Relevant pareses or a cauda equina syndrome are absolute indications for surgery. The general aim is to decompress sufficiently while maintaining or restoring segmental stability. A laminectomy is not necessarily required. In patients with accompanying degenerative Meyerding grade I-II spondylolisthesis or instability in functional radiographs, fusion or dynamic stabilisation are recommended in addition to decompression, depending on the patient's age and activity level.