Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials

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.

Long-Term Follow-Up of a Person-Centered Prehabilitation Program Based on Cognitive-Behavioral Physical Therapy for Patients Scheduled for Lumbar Fusion

OBJECTIVE

Long-term follow-ups of prehabilitation programs for lumbar spine surgery are lacking, and more comprehensive evaluations are needed. In the current study, we evaluated the long-term effects of a prehabilitation program compared with conventional care in relation to lumbar fusion surgery in patients with degenerative disc disease.

METHODS

Patients (n = 118) receiving lumbar fusion surgery were included in a multicenter randomized controlled trial, involving 1 university hospital and 2 spine clinics. The intervention was a person-centered prehabilitation program based on cognitive-behavioral physical therapy that targeted psychological presurgical risk factors, physical activity, and overall health. The control group received conventional preoperative care. Patient-reported outcome measures (PROMs) included assessments at 8 time-points: low back disability (primary outcome), back pain intensity, leg pain intensity, pain catastrophizing, fear of movement, anxiety and depressive mood, health-related quality of life, and patient-specific functioning. Physical activity and physical capacity were assessed at 5 time points. Linear mixed models were used to analyze the effects of the intervention.

RESULTS

There were no significant differences between groups at the 12- and 24-month follow-ups for any outcome, except for the One Leg Stand test 1 year following surgery, in favor of the control group. There were significant improvements for both groups, from baseline to the 12- and 24-month follow-ups for all physical capacity test and patient-reported outcome measures, except for leg pain and self-efficacy for exercise.

CONCLUSION

No long-term effects were found for the prehabilitation program compared to conventional care. Physical activity did not improve over time, despite significantly improved self-reported functioning and physical capacity measurements.

IMPACT

These findings have implications for the current understanding of the long-term effects of prehabilitation and suggest that future research should focus on programs promoting physical activity both before and after lumbar spine surgery to decrease the risk of long-term adverse health outcomes.

Lumbar spine fusion surgery versus best conservative care for patients with severe, persistent low back pain

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians' views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Methods

An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials.

Results

There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%).

Conclusion

This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK.

Psychophysiologic symptom relief therapy for chronic back pain: hypothesis and trial rationale

Chronic pain syndromes affect over one-third of the US adult population and often lead to significant disability and a reduced quality of life. Despite their high prevalence, causal links between chronic pain syndromes and anatomic abnormalities are often not apparent. Most current chronic pain treatments provide modest, if any, relief. Thus, there is a pressing need to understand the causal mechanisms implicated in chronic pain as a means to develop more targeted interventions for improvement in clinical outcomes and reduction in morbidity and financial burden. In the present manuscript, we summarize the current literature on treatment for chronic pain, and hypothesize that non-specific chronic back pain (without a clear organic etiology, such as tumors, infections or fractures) is of psychophysiologic origin. Based on this hypothesis, we developed Psychophysiologic Symptom Relief Therapy (PSRT), a novel pain reduction intervention for understanding and treating chronic pain. In this manuscript, we provide the rationale for PSRT, which we have tested in a pilot trial with a subsequent larger randomized trial underway. In the proposed trial, we will evaluate whether non-specific chronic back pain can be treated by addressing the underlying stressors and psychological underpinnings without specific physical interventions.

Impact of Supine versus Prone Positioning on Segmental Lumbar Lordosis in Patients Undergoing ALIF Followed by PSF: A Comparative Study

Background: Anterior lumbar interbody fusion (ALIF) and posterior spinal fusion (PSF) play pivotal roles in restoring lumbar lordosis in spinal surgery. There is an ongoing debate between combined single-position surgery and traditional prone-position PSF for optimizing segmental lumbar lordosis. Methods: This retrospective study analyzed 59 patients who underwent ALIF in the supine position followed by PSF in the prone position at a single institution. Cobb angles were measured preoperatively, post-ALIF, and post-PSF using X-ray imaging. One-way repeated measures ANOVA and post-hoc analyses with Bonferroni adjustment were employed to compare mean Cobb angles at different time points. Cohen's d effect sizes were calculated to assess the magnitude of changes. Sample size calculations were performed to ensure statistical power. Results: The mean segmental Cobb angle significantly increased from preoperative (32.2 ± 13.8 degrees) to post-ALIF (42.2 ± 14.3 degrees, Cohen's d: -0.71, p < 0.0001) and post-PSF (43.6 ± 14.6 degrees, Cohen's d: -0.80, p < 0.0001). There was no significant difference between Cobb angles after ALIF and after PSF (Cohen's d: -0.10, p = 0.14). The findings remained consistent when Cobb angles were analyzed separately for single-screw and double-screw ALIF constructs. Conclusions: Both supine ALIF and prone PSF significantly increased segmental lumbar lordosis compared to preoperative measurements. The negligible difference between post-ALIF and post-PSF lordosis suggests that supine ALIF followed by prone PSF can be an effective approach, providing flexibility in surgical positioning without compromising lordosis improvement.

A comprehensive review of cell transplantation and platelet-rich plasma therapy for the treatment of disc degeneration-related back and neck pain: A systematic evidence-based analysis

Low back pain (LBP) and neck pain predominate as the primary causes of disability. Cell- and platelet-rich plasma (PRP) products are potential therapies with clinical trials and reviews promoting their efficacy. Nonetheless, they frequently disregard the clinical significance of reported improvements. In this systematic review, the effectuated improvements in pain, disability, quality of life (QoL), and radiographic images are comprehensively described and scored on their clinical significance. An electronic database literature search was conducted on July 2023 for in-human assessment of cell or PRP products to alleviate discogenic pain. Papers were screened on quantitative pain, disability, QoL, radiographic improvements, and safety outcomes. Risk of bias was assessed through MINORS and Cochrane Source of Bias tools. Reported outcomes were obtained, calculated, and assessed to meet minimal clinically important difference (MCID) standards. From 7623 screened papers, a total of 80 articles met the eligibility criteria, presenting 68 specific studies. These presented at least 1974 treated patients. Overall, cell/PRP injections could alleviate pain and disability, resulting in MCID for pain and disability in up to a 2-year follow-up, similar to those observed in patients undergoing spinal fusion. Included trials predominantly presented high levels of bias, involved heterogeneous study designs, and only a minimal number of randomized controlled trials. Nonetheless, a clear clinically significant impact was observed for cell- and PRP-treated cohorts with overall good safety profiles. These results highlight a strong therapeutic potential but also underline the need for future cost-effectiveness assessments to determine the benefits of cell/PRP treatments.

Physical therapist-led interventions based on the biopsychosocial model provide improvement in disability and pain for spinal disorders: A systematic review and meta-analysis

OBJECTIVE

To summarize the effects of physical therapist-led interventions based on the biopsychosocial (BPS) model in spinal disorders compared to interventions with no BPS model through a systematic review and meta-analysis of randomized-controlled trials. TYPE: Systematic review and meta-analysis.

LITERATURE SURVEY

We searched the Web of Science, CENTRAL, MEDLINE, PsycINFO, CINAHL, and PEDro up to October 27, 2022.

METHODOLOGY

Pain intensity and disability were primary outcomes and psychological factors were secondary outcomes in spinal disorders. The included intervention was physical therapist-led interventions based on the BPS model. The control group received no physiotherapy intervention for BPS. Pooled effects were analyzed as standardized mean differences (SMDs) and 95% confidence intervals (CIs), and the random-effects model was used for the meta-analysis. The subgroup analysis was divided into low back pain group and neck pain group. Another subgroup analysis was conducted only of the groups that had received training of the BPS model.

SYNTHESIS

Fifty-seven studies with 5471 participants met the inclusion criteria. For pain intensity, there was a statistically significant effect for the BPS model led by physical therapists in the short, medium, and long terms. The SMDs with 95% CIs were -0.44 (-0.62, -0.27), -0.24 (-0.37, -0.12), and -0.17 (-0.28, -0.06), respectively. Outcomes were clinically significant, except in the long term. For disability, there was a statistically significant effect in the short, medium, and long terms. The SMDs with 95% CIs were -0.48 (-0.69, -0.27), -0.44 (-0.64, -0.25), and -0.37 (-0.58, -0.15), respectively. All periods were clinically significant. The quality of the evidence was low for all of the main outcomes for all of the terms.

CONCLUSION

Physical therapist-led interventions based on the BPS model effectively improve pain intensity and disability in patients with spinal disorders based on low-quality evidence.

The relationship between changes in pain intensity and functional disability in persistent disabling low back pain during a course of cognitive functional therapy

OBJECTIVES

Pain relief and reduced disability are both common treatment targets for persistent disabling low back pain (LBP). Cross-sectional studies show a moderate relationship between functional disability and pain intensity, but little is known about the relationship between changes in pain intensity and functional disability over multiple time points. The objective of this study was to investigate the associations between changes in functional disability and pain intensity and whether changes occurred simultaneously or differentially during a course of cognitive functional therapy for people with persistent disabling LBP.

METHODS

Self-reported measures of pain intensity and patient-specific functional disability were collected prior to each treatment session from 40 participants during a 12-week intervention period. Linear mixed modeling was used to assess simultaneous and lagged associations between pain intensity and functional disability over time. Sensitivity analysis using nonparametric subject-specific methods (simulation modeling analysis) was also performed.

RESULTS

Thirty-five participants had sufficient data for analysis. Using the linear mixed-model approach, there was evidence of a moderate and simultaneous association between pain intensity and functional disability over time (regression coefficient = 0.56, 95% confidence interval: 0.44-0.68, p < 0.001). Simulation modeling analysis supported weak to mostly strong associations and supported for simultaneous change in pain and disability for the majority of participants (22 of 35, 64%).

CONCLUSION

Changes in pain intensity and functional disability were moderately related across the intervention. Visual inspection of graphs indicated a very close relationship in some individuals and a decoupling of pain intensity and functional disability in others. The changes in pain intensity and functional disability seem to occur simultaneously in most individuals.

Preoperative conservative treatment is insufficiently described in clinical trials of lumbar fusion: a scoping review

PURPOSE

To identify how pre-surgical conservative care is characterized and reported in randomized controlled trials of adults undergoing elective lumbar fusion, including duration and type of treatment.

METHODS

The study design is a scoping review. Data sources include PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). All randomized controlled trials published in English between January 1, 2005, and February 15, 2022, assessing lumbar fusion as the intervention were included in this review.

RESULTS

Of 166 studies, 62.0% reported a failure in conservative care prior to lumbar fusion, but only 15.1% detailed the type of specific conservative care received. None of the trials provided sufficient details to understand the nature of the pre-surgical conservative treatment, such as frequency, recency/timing, or dosage of conservative interventions.

CONCLUSION

Although roughly two-thirds of trials reported that patients failed conservative care prior to receiving a lumbar fusion, few studies named the conservative intervention provided and no studies provided any details regarding dosing or recency of care. This lack of information creates ambiguity in the surgical decision-making process, setting the assumption that all patients received adequate conservative care prior to surgery. Details about pre-surgical conservative care should be disclosed to allow for appropriate clinical application, decision-making, and interpretation of treatment effects.

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.

Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis

PURPOSE

To evaluate the effectiveness of rehabilitation strategies on disability, pain, pain-related fear, and return-to-work in patients undergoing lumbar fusion surgery for degenerative conditions or adult isthmic spondylolisthesis.

METHODS

Six electronic databases were systematically searched for randomized controlled trials (RCTs) evaluating the effect of rehabilitation (unimodal or multimodal). The estimated effect size was calculated for interventions with homogeneous content using a random-effects model. Certainty of evidence was assessed by GRADE.

RESULTS

In total, 18 RCTs, including 1402 unique patients, compared specific rehabilitation to other rehabilitation strategies or usual care. Most described indications were degenerative disc disease and spondylolisthesis. All rehabilitation interventions were delivered in the postoperative period, and six of them also included a preoperative component. Intervention dose and intensity varied between studies (ranging from one session to daily sessions for one month). Usual care consisted mostly of information and postoperative mobilization. At short term, low quality of evidence shows that exercise therapy was more effective for reducing disability and pain than usual care (standardized mean difference [95% CI]: -0.41 [-0.71; -0.10] and -0.36 [-0.65; -0.08], four and five studies, respectively). Multimodal rehabilitation consisted mostly of exercise therapy combined with cognitive behavioral training, and was more effective in reducing disability and pain-related fear than exercise therapy alone (-0.31 [-0.49; -0.13] and -0.64 [-1.11; -0.17], six and four studies, respectively). Effects disappeared beyond one year. Rehabilitation showed a positive tendency towards a higher return-to-work rate (pooled relative risk [95% CI]: 1.30 [0.99; 1.69], four studies).

CONCLUSION

There is low-quality evidence showing that both exercise therapy and multimodal rehabilitation are effective for improving outcomes up to six months after lumbar fusion, with multimodal rehabilitation providing additional benefits over exercise alone in reducing disability and pain-related fear. Additional high-quality studies are needed to demonstrate the effectiveness of rehabilitation strategies in the long term and for work-related outcomes.

Association of patient engagement strategies with utilisation and spending for musculoskeletal problems in the USA: a cross-sectional analysis of Medicare patients and physician practices

OBJECTIVE

Musculoskeletal problems like hip and knee osteoarthritis and low-back pain are preference sensitive conditions. Patient engagement strategies (PES), such as shared decision-making and motivational interviewing, can help align patients' preferences with treatment options and potentially reduce spending. We assess the association of physician practice-level adoption of PES with utilisation and spending.

DESIGN

Cross-sectional study in which patients were matched across low, moderate and high levels of PES via coarsened exact matching.

SETTING

Primary and secondary care in 2190 physician practices.

PARTICIPANTS

39 336 hip, 48 362 knee and 67 940 low-back patients who were Medicare beneficiaries were matched to the 2017-2018 National Survey of Healthcare Organizations and Systems.

PRIMARY AND SECONDARY OUTCOME MEASURES

Total hip replacement (THR), total knee replacement (TKR), 1-2 level posterior lumbar fusion (LF), total annual spending, components of total annual spending.

RESULTS

Total annual spending for patients with musculoskeletal problems did not differ for practices with low versus moderate PES, low versus high PES or moderate versus high PES, but spending was significantly lower in some categories for practices with relatively higher PES adoption. For hospital-owned and health system-owned practices, the ORs of receiving LF were 0.632 (95% CI 0.396 to 1.009) for patients attributed to practices with high PES compared with patients attributed to practices with moderate PES. For independent practices, the odds of receiving THR were 1.403 (95% CI 1.035 to 1.902) for patients attributed to practices with moderate PES compared with patients attributed to practices with low PES.

CONCLUSIONS

Practice-level adoption of PES for patients with musculoskeletal problems was generally not associated with total spending. PES, however, may steer patients toward evidence-based treatments. Opportunities for overall spending reduction exist as indicated by the variation in the subcomponents of total spending by PES adoption.

Lumbar spinal fusion surgery outcomes in a cohort of injured workers in the Victorian workers' compensation system

BACKGROUND

Lumbar spinal fusion (LSF) outcomes for workers' compensation patients are worse than for the general population. The objectives were to examine the long-term work capacity, opioid prescription and mental health outcomes of injured workers who have undergone LSF surgery in Victoria, Australia, and to identify demographic and pre- and post-operative characteristics associated with these outcomes.

METHODS

Retrospective study of 874 injured workers receiving elective LSF from 2008 to 2016 in the Victorian workers' compensation system. WorkSafe Victoria's claims data were used to infer outcomes for recovery. Association of demographics, pre-surgery and surgery variables with outcomes were modelled using multivariate multinomial logistic regression analyses.

RESULTS

Twenty-four months after LSF surgery, 282 (32.3%) of the 874 injured workers had substantial work capacity, 388 (44.4%) were prescribed opioids, and 330 (37.8%) were receiving mental health treatment. Opioid prescription and limited work capacity before surgery were independent strong predictors of opioid prescription, reduced work capacity and mental health treatment 24 months after LSF. Pre-operative mental health treatment was associated with the use of mental health treatment at 24 months. Other predictors for poor outcomes included a greater than 12-month duration from injury to surgery, LSF re-operation and common law or impairment benefit lodgement before surgery.

CONCLUSION

An association between pre-operative factors and post-operative outcomes after LSF in a Victorian workers' compensation population was identified, suggesting that pre-operative status may influence outcomes and should be considered in LSF decisions. The high opioid use indicates that opioid management before and after surgery needs urgent review.

Prognostic factors for outcome following lumbar spine fusion surgery: a systematic review and narrative synthesis

PURPOSE

The objective of this study was to identify and evaluate the value of prognostic factors related to disability, pain and quality of life (QoL) for adult patients undergoing lumbar spine fusion surgery (LSFS).

METHODS

Two reviewers independently searched the literature, assessed eligibility, extracted data and assessed risk of bias and certainty of evidence. Key electronic databases were searched [PubMed, CINAHL, EMBASE, MEDLINE, PEDro and ZETOC] using pre-defined terms [e.g. LSFS] to 20/9/2020; with additional searching of journals, reference lists and unpublished literature. Prospective cohort studies with ≥ 12-month follow-up after LSFS were included. Narrative synthesis was based on recommendations by Cochrane Consumers and Communication Review Group. The GRADE tool enabled assessment of certainty of evidence. Prognostic factors and outcome were analysed and summarised when examined in ≥ 2 studies and when results pointed in the same direction in ≥ 75% of studies.

RESULTS

Sixteen studies (n =  8388, 2 low and 14 high risk of bias) were included with 39 prognostic factors identified. There is low certainty evidence that higher pre-operative severity of leg pain predicts greater improvement of leg pain and that pre-operative working predicts less post-operative disability both at 1-2-year follow-up. Other found associations were of very low certainty evidence.

CONCLUSION

No moderate to high certainty evidence exists. Use of leg pain and pre-operative working may be valuable predictors of outcome to inform clinical decision-making and advice regarding LSFS surgery. There is need for adequately powered low-risk-of-bias prospective observational studies to further investigate candidate prognostic factors.

Effects of a Remotely Delivered Cognitive Behavioral Coaching Program on the Self-Rated Functional Disability of Participants with Low Back Pain

PURPOSE

A remotely delivered cognitive behavioral coaching (CBC) program was offered as a service benefit for commercial health plan members with low back pain (LBP). This study describes changes in self-rated functional disability in a sample of plan members participating in the program (N=423).

METHODS

Independent measures included demographics, length of program enrollment, total CBC sessions, and baseline self-reported patient activation and presenteeism levels. Participants rated their functional disability level due to LBP using the Oswestry Disability Index (ODI). Dependent outcomes quantified change in participant functional disability rating (final ODI score minus baseline ODI score). Nonparametric tests compare differences between groups and within-group ODI score change. Two generalized linear models test for associations between independent variables and the ODI change score.

RESULTS

A significant difference between baseline and final ODI scores was observed at the overall program level (p<.001) and within all independent variable categories of interest. Over 68% of total participants (n=289) reported improved functional ability from baseline to final (decrease in ODI score). Participants who completed more CBC sessions demonstrated significantly greater improvement in functional ability (p=.038) compared to those who completed fewer sessions. Participants aged 55 and older were significantly more likely to show deterioration in functional ability from baseline to final (p=.021).

CONCLUSION

Outcomes suggest that program participation can influence self-rated functional disability in the management of LBP.

Final Long-Term Reporting from a Randomized Controlled IDE Trial for Lumbar Artificial Discs in Single-Level Degenerative Disc Disease: 7-Year Results

BACKGROUND

This study compared 7-year safety and efficacy outcomes of activL and ProDisc-L lumbar total disc replacements in patients with symptomatic, single-level lumbar degenerative disc disease (DDD). The objectives are to report 7-year outcomes of the trial, evaluate the outcomes for patients lost to follow-up, and determine whether early outcomes predict long-term outcomes.

METHODS

This was a prospective, multicenter, randomized, controlled investigational device exemption study. Eligible patients with symptomatic, single-level lumbar DDD had failed ≥6 months of nonsurgical management. Patients (N = 283) were randomized to receive activL (n = 218) or ProDisc-L (n = 65). At 7 years, data were available from 206 patients (activL, 160; ProDisc-L, 46). Logistic regression models were fit to predict 7-year outcomes for patients lost to follow-up after 2 years.

RESULTS

At 7 years, the activL group was noninferior to the ProDisc-L group on the primary composite endpoint (P = .0369). Both groups showed significant reductions in back/leg pain severity and improvements in disability index and quality-of-life relative to baseline (P < .0001). In both groups, opioid use was significantly reduced at 7 years (0%) relative to baseline (P < .01), and the overall reoperation rates were low (4.6%). activL patients showed a significantly better range of motion (ROM) for flexion-extension rotation than ProDisc-L patients (P = .0334). A significantly higher proportion of activL patients did not report serious adverse events (activL, 62%; ProDisc-L, 43%; P = .011). Predictive modeling indicated that >70% of patients (depending on outcome) lost to follow-up after 2 years would show clinically significant improvement at 7 years if improvements were achieved at 2 years.

CONCLUSIONS

The benefits of activL and ProDisc-L are maintained after 7 years, with significant improvements from baseline observed in pain, function, and opioid use. activL is more effective at preserving ROM than ProDisc-L and has a more favorable safety profile. Improvements in other primary and secondary outcomes were similar between both disc designs.

LEVEL OF EVIDENCE

1.

Long-term follow-up of patients with chronic musculoskeletal pain attending interdisciplinary pain rehabilitation: outcomes and predictive factors

The long-term outcomes of interdisciplinary pain rehabilitation (IPR) in patients with chronic musculoskeletal pain (CMP) and its predictors has been studied to a limited extent. In this historical cohort study, functioning, satisfaction with life domains, and pain were assessed at baseline, discharge, and at 6-15 years follow-up. At follow-up, most patients (77%) rated the effects of the IPR as temporarily or persistently positive. The gains in functioning, satisfaction with life domains, and pain made during IPR remained for 6-15 years after the IPR. Patients who were single, retired, or not in work, and those having higher pain and lower functioning at baseline, had lower functioning at follow-up, while patients with traumatic pain disorders had higher functioning at follow-up. Gains made during IPR, particularly gains in social and mental functioning and in pain predicted functioning at follow-up. Treatments and events between discharge and follow-up also influenced the long-term outcome. In conclusion, on average, outcomes achieved during IPR persisted at long-term follow-up. Predictors of a better long-term outcome were mainly baseline characteristics.

Bone morphogenic protein-2 signaling in human disc degeneration and correlation to the Pfirrmann MRI grading system

BACKGROUND CONTEXT

Back and neck pain secondary to disc degeneration is a major public health burden. There is a need for therapeutic treatments to restore intervertebral disc (IVD) composition and function.

PURPOSE

To quantify ALK3, BMP-2, pSMAD1/5/8 and MMP-13 expression in IVD specimens collected from patients undergoing surgery for disc degeneration, to correlate ALK3, BMP-2, pSMAD1/5/8 and MMP-13 expression in IVD specimens to the 5-level Pfirrmann MRI grading system, and to compare ALK3, BMP-2, pSMAD1/5/8 and MMP-13 expression between cervical and lumbar degenerative disc specimens.

STUDY DESIGN

An immunohistochemical study assessing ALK3, BMP-2, pSMAD1/5/8, and MMP-13 expression levels in human control and degenerative IVD specimens.

METHODS

Human IVD specimens were collected from surgical patients who underwent discectomy and interbody fusion at our institution between 1/2015 and 8/2017. Each patient underwent MRI prior to surgery. The degree of disc degeneration was measured according to the 5-level Pfirrmann MRI grading system. Patients were categorized into either the 1) control group (Pfirrmann grades I-II) or 2) degenerative group (Pfirrmann grades III-V). Histology slides of the collected IVD specimens were prepared and immunohistochemical staining was performed to assess ALK3, BMP-2, pSMAD1/5/8, and MMP-13 expression levels in the control and degenerative specimens. Expression levels were also correlated to the Pfirrmann criteria. Lastly, the degenerative specimens were stratified according to their vertebral level and expression levels between the degenerative lumbar and cervical discs were compared.

RESULTS

Fifty-two patients were enrolled; however, 2 control and 2 degenerative patients were excluded due to incomplete data sets. Of the remaining 48 patients, there were 12 control and 36 degenerative specimens. Degenerative specimens had increased expression levels of BMP-2 (p=.0006) and pSMAD1/5/8 (p<.0001). Pfirrmann grade 3 (p=.0365) and grade 4 (p=.0008) discs had significantly higher BMP-2 expression as compared to grade 2 discs. Pfirrmann grade 4 discs had higher pSMAD1/5/8 expression as compared to grade 2 discs (p<.0001). There were no differences in ALK3 or MMP-13 expression between the control and degenerative discs (p>.05). Stratifying the degenerative specimens according to their vertebral level showed no significant differences in expression levels between the lumbar and cervical discs (p>.05).

CONCLUSIONS

BMP-2 and pSMAD1/5/8 signaling activity was significantly upregulated in the human degenerative specimens, while ALK3 and MMP-13 expression were not significantly changed. The expression levels of BMP-2 and pSMAD1/5/8 correlate positively with the degree of disc degeneration measured according to the Pfirrmann MRI grading system.

CLINICAL SIGNIFICANCE

BMP-SMAD signaling represents a promising therapeutic target to restore IVD composition and function in the setting of disc degeneration.

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.

Allogeneic mesenchymal precursor cells treatment for chronic low back pain associated with degenerative disc disease: a prospective randomized, placebo-controlled 36-month study of safety and efficacy

BACKGROUND CONTEXT PURPOSE

Evaluate the safety and efficacy of a single intradiscal injection of STRO-3+ adult allogeneic mesenchymal precursor cells (MPCs) combined with hyaluronic acid (HA) in subjects with chronic low back pain (CLBP) associated with degenerative disc disease (DDD) through 36-month follow-up.

STUDY DESIGN/SETTING

A multicenter, randomized, controlled study conducted at 13 clinical sites (12 in the United States and 1 in Australia).

SUBJECT SAMPLE

A total of 100 subjects with chronic low back pain associated with moderate DDD (modified Pfirrmann score of 3-6) at one level from L1 to S1 for at least 6 months and failing 3 months of conservative treatment, including physical therapy were randomized in a 3:3:2:2 ratio to receive 6 million MPCs with HA, 18 million MPCs with HA, HA vehicle control, or saline control (placebo) treatment.

OUTCOME MEASURES

Subjects were clinically and radiographically evaluated at 1, 3, 6, 12, 24, and 36 months postinjection. Subject-reported outcomes including adverse events, LBP on a Visual Analog Scale (VAS), Oswestry Disability Index (ODI), SF-36 and Work Productivity and Activity Index were collected.

METHODS

Clinical and radiographic measures were collected at each visit. All randomized subjects were included in the safety assessments and analyzed based on the treatment received. Safety assessments included assessments of AEs, physical and radiographic examinations and laboratory testing. Efficacy assessments evaluated changes in VAS, ODI, and modified Pfirrmann (MP) scores between all active and control groups, respectively. Assessments included least squares mean (Mean), LS mean change from baseline (Mean Change) and responder analyses in order to assess the clinical significance of observed changes from baseline. The population for efficacy assessments was adjusted for the confounding effects of post-treatment interventions (PTIs). This study was conducted under an FDA Investigational New Drug application sponsored and funded by Mesoblast.

RESULTS

There were significant differences between the control and MPC groups for improvement in VAS and ODI. The PTI-corrected VAS and ODI Means and Mean Change analyses; the proportion of subjects with VAS ≥30% and ≥50% improvement from baseline; absolute VAS score ≤20; and ODI reduction ≥10 and ≥15 points from baseline showed MPC therapy superior to controls at various time points through 36 months. Additionally, the proportion of subjects achieving the minimally important change and clinically significant change composite endpoints for the MPC groups was also superior compared with controls at various time points from baseline to 36 months. There were no significant differences in change in MP score from baseline across the groups. There were also no statistically significant differences in change in modified MP score at the level above or below the level treated between study arms. Both the procedure and treatment were well tolerated and there were no clinical symptoms of immune reaction to allogeneic MPCs. There was a low rate of Treatment Emergent Adverse Events (TEAEs) and Serious Adverse Events, and the rates of these events in the MPC groups were not significantly different from the control groups. One TEAE of severe back pain was possibly related to study agent and one TEAE of implantation site infection was considered to be related to the study procedure.

CONCLUSIONS

Results provide evidence that intradiscal injection of MPCs could be a safe, effective, durable, and minimally invasive therapy for subjects who have CLBP associated with moderate DDD.

Does Capacitively Coupled Electric Fields Stimulation Improve Clinical Outcomes After Instrumented Spinal Fusion? A Multicentered Randomized, Prospective, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Lumbar spinal fusion (LSF) is used to treat lumbar degenerative disorders. Methods to improve the functional recovery of patients undergoing LSF is one of the main goals in daily clinical practice. The objective of this study is to assess whether biophysical stimulation with capacitively coupled electric fields (CCEF) can be used as adjuvant therapy to enhance clinical outcome in LSF-treated patients.

METHODS

Forty-two patients undergoing LSF were assessed and randomly allocated to either the active or to the placebo group. Follow-up visits were performed at 1, 3, 6, and 12 months after surgery; long-term follow-up was performed at year 10. Visual analogue scale (VAS), the Oswestry Disability Index (ODI), and the 36-item Short Form Health Survey (SF-36) questionnaire were recorded.

RESULTS

This study demonstrates a significant improvement in CCEF-treated patients at 6 and 12 months' follow-up for SF-36, and at 12 months' follow-up for ODI values. Based on SF-36 and ODI scores, we reported a significantly higher percentage of successful treatments at 12 months in the active compared with the placebo group. Moreover, in a subset of patients at 10 years' follow-up, a significant difference was reported in VAS and ODI scores between groups.

CONCLUSIONS

The results demonstrate that 3 months of CCEF treatment immediately after surgery is effective in reducing ODI and improving SF-36 score, and that these benefits can be maintained up to 12 months. In a subset of patients, these positive outcomes are retained up to 10 years.

LEVEL OF EVIDENCE

I.

CLINICAL RELEVANCE

This study suggests that CCEF stimulation can be used as an adjunct to LSF for spine diseases, for increasing overall quality of life and improving patients' functional recovery. CCEF is safe and well tolerated, compatible with activities of daily living.

Patients' perspective on cognitive behavioural therapy after surgical treatment of endometriosis: a qualitative study

RESEARCH QUESTION

Would adding cognitive behavioural therapy (CBT) to the treatment of endometriosis improve the quality of life of patients suffering from endometriosis-associated pain? The aim of this study was to identify if patients believed CBT should be added to endometriosis treatment and which form of CBT they would prefer: face-to-face individual or group, or web-based individual, sessions.

DESIGN

Between November 2019 and January 2020, semi-structured focus groups were conducted using an interview guide to ensure all topics were discussed. Data collection was continued until saturation was obtained. The focus groups were transcribed word for word and openly encoded. Finally, themes were formulated.

RESULTS

All participating women believed CBT should be offered to patients undergoing endometriosis surgery. They believed it could be an asset to improve quality of life. Participants preferred either in-person individual or group therapy. They stressed the importance of being offered a custom-made treatment plan, individually tailored to the different needs of different patients.

CONCLUSION

This study has shown that patients with endometriosis believe that CBT should be added to the standard treatment regimen of endometriosis in either group or individual face-to-face sessions, because they expect that CBT will improve their quality of life after surgery.

Patient journey following lumbar spinal fusion surgery (FuJourn): A multicentre exploration of the immediate post-operative period using qualitative patient diaries

The aim of this study was to capture and understand the immediate recovery journey of patients following lumbar spinal fusion surgery and explore the interacting constructs that shape their journey. A qualitative study using Interpretive Phenomenological Analysis (IPA) approach. A purposive sample of 43 adult patients (≥16 years) undergoing ≤4 level instrumented fusion for back and/or leg pain of degenerative cause, were recruited pre-surgery from 4 UK spinal surgery centres. Patients completed a weekly diary expressed in their own words for the first 4 weeks following surgery to capture their life as lived. Diary content was based on previous research findings and recorded progress, recovery, motivation, symptoms, medications, healthcare appointments, rehabilitation, positive/negative thoughts, and significant moments; comparing to the previous week. To maximise completion and data quality, diaries could be completed in paper form, word document, as online survey or as audio recording. Strategies to enhance diary adherence included a weekly prompt. A framework analysis for individual diaries and then across participants (deductive and inductive components) captured emergent themes. Trustworthiness was enhanced by strategies including reflexivity, attention to negative cases and use of critical co-investigators. Twenty-eight participants (15 female; n = 18 (64.3%) aged 45-64) contributed weekly diaries (12 withdrew post-surgery, 3 did not follow through with surgery). Adherence with diaries was 89.8%. Participants provided diverse and vivid descriptions of recovery experiences. Three distinct recovery trajectories were identified: meaningful recovery (engagement in physical and functional activities to return to functionality/mobility); progressive recovery (small but meaningful improvement in physical ability with increasing confidence); and disruptive recovery (limited purpose for meaningful recovery). Important interacting constructs shaped participants' recovery including their pain experience and self-efficacy. This is the first account of immediate recovery trajectories from patients' perspectives. Recognition of a patient's trajectory may inform patient-centred recovery, follow-up and rehabilitation to improve patient outcomes.

Development of a Multivariate Prediction Model for Successful Oswestry Disability Index Changes in L5/S1 Anterior Lumbar Interbody Fusion for Degenerative Disc Disease

OBJECTIVE

Lower back pain associated with degenerative disc disease (DDD) is a leading cause of disability worldwide. Anterior lumbar interbody fusion (ALIF) has been shown to be effective for treating refractory DDD, but it remains unclear which patients may benefit most from the procedure. This study aims to develop a predictive model for clinical success in L5/S1 ALIF for DDD.

METHODS

A retrospective cohort study of 68 patients with refractory DDD who underwent L5/S1 ALIF was performed. Clinical success was defined as an improvement in Oswestry Disability Index (ODI) of 20 points postoperatively. Exploratory analyses were performed on 16 preoperative clinical and radiographic parameters, followed by a multivariate logistic regression. Evaluation of the predictive model was performed.

RESULTS

After exploratory analyses, 4 parameters were suitable for inclusion in the multivariate model. Workers' compensation status (odds ratio [OR], 0.02; 95% confidence interval [CI], 0.001-0.262; P = 0.004) and preoperative ODI (OR, 1.13; 95% CI, 1.05-1.23; P = 0.002) were statistically significant parameters. Furthermore, posterior disc height and disc depth contributed significantly to the model variance (OR, 0.69, 95% CI, 0.44-1.09 and OR, 0.97, 95% CI, 0.81-1.15, respectively). The model had a sensitivity of 81.5%, specificity of 83.3%, C-statistic of 0.921, and a calibration plot similar to the 45° reference line.

CONCLUSIONS

This analysis confirms workers' compensation and low preoperative ODI as risk factors for successful L5/S1 ALIF performed for DDD. It also identifies novel prognostic factors, namely posterior disc height and disc depth. This model can aid in patient counseling and selection in the management of L5/S1 DDD.

Mid-Term and Long-Term Clinical and Radiological Outcomes of a Carbon I/F Stand-Alone Cage in Anterior Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The current study was undertaken to determine the midterm and long-term radiological outcomes, complications and functional status of patients who underwent a single-level anterior interbody lumbar fusion (ALIF) procedure.

SUMMARY OF BACKGROUND DATA

Low back pain affects 70%-90% of the general population at some point in their life, and in general, the majority are best treated by nonsurgical therapy. However, a lumbar fusion can be considered in selected cases. In previous decades, lumbar interbody fusion procedures have gained popularity. Despite the approach used, stand-alone interbody fusion is becoming less popular due to poor fusion rates. When studying ALIF procedures, the addition of instrumentation results in higher fusion rates. Nevertheless, long-term follow-up can give either unexpected or similar insights into certain procedures that should be available in the current literature. Therefore, the current study was undertaken to determine the midterm and long-term radiological outcomes, complications, and functional status of patients who underwent a single-level ALIF procedure.

METHODS

A cohort of 50 patients was studied following stand-alone ALIF for midterm and long-term follow-up of 6.6 years and 19.7 years, respectively. Primary outcome measurements were disability using the Oswestry Disability Index (ODI) score and pain scores using the visual analog scale, and the MOS 36-item Short-Form Health Survey (SF-36) was used to evaluate the quality of life. In addition, radiographic assessment was performed to indicate the number of solid fusions.

RESULTS

After a mean of 19.7 years, we had a loss to follow-up of 34%. Functional measurements revealed an ODI of 41 for both time points and an SF-36 physical component score around 41.4 and 40.8 for the midterm and long-term follow-up, respectively. The mental component of the SF-36 was 48.7 and 49.9, respectively. The assessment of interbody fusion revealed only 66% and 70% solid fusion after 6.6 years and 19.7 years, respectively.

CONCLUSIONS

In concordance with previous studies, the outcome of midterm and long-term results in this study showed that the I/F cage in ALIF procedures is a safe treatment option for single-level interbody fusion. The radiological results corroborate literature regarding stand-alone interbody fusion, and additional instrumentation is likely to increase fusion rates. However, functional measurements reveal that the postsurgical situation remains likely worse than patients in a healthy Dutch population but possibly better that in a back pain population.

Definitions of unfavorable surgical outcomes and their risk factors based on disability score after spine surgery for lumbar spinal stenosis

Background

Risk factors for unfavorable surgical outcomes are dependent on the definitions of the unfavorable surgical outcomes. The aims of this study were to compare risk factors for each unfavorable surgical outcome according to two different definitions of “unfavorable” surgical outcomes after surgery for lumbar spinal stenosis (LSS) as well as compare the clinical course from the preoperative period to 3 years postoperatively between cases with favorable and unfavorable outcomes according to the two different definitions.

Methods

Overall, 295 patients who underwent spine surgery for LSS and a follow-up evaluation at 3 years postoperatively were enrolled and divided into favorable and unfavorable groups, based on two different definitions for unfavorable surgical outcomes, as evaluated at 12 months postoperatively: the patient-reported outcome (PRO) and minimal clinically important difference (MCID) methods. In the PRO method, patients with a postoperative Oswestry Disability Index (ODI) score > 22 were considered as having an “unfavorable” outcome, whereas in the MCID method, those with a postoperative ODI score that changed < 12.8 points from the preoperative value were classified as having an “unfavorable” outcome. As a primary outcome, risk factors for unfavorable surgical outcomes according to each definition were investigated at 12 months postoperatively.

Results

In the PRO method, female sex (P = 0.011; odds ratio (OR): 2.340), elementary school attainment (vs. university attainment; P = 0.035; OR: 2.875), and higher preoperative ODI score (P = 0.028; OR: 2.340) were associated with higher odds for an unfavorable surgical outcome. In the MCID method, a higher preoperative ODI score was associated with higher odds (P <  0.001; OR: 0.920) of a favorable surgical outcome. In the PRO method, the favorable outcome group demonstrated significantly lower visual analog scale for back and leg pain and lower ODI scores than the unfavorable outcome group at 3 years postoperatively, whereas in the MCID method, clinical outcomes were not different between the two groups at 3 years postoperatively.

Conclusion

A higher preoperative ODI score may be a risk factor for postoperative ODI > 22 after surgery for LSS. It may also be associated with higher odds for improvements in the ODI score of > 12.8.

Standalone oblique lateral interbody fusion vs. combined with percutaneous pedicle screw in spondylolisthesis

Background

To compare standalone oblique lateral interbody fusion (OLIF) vs. OLIF combined with posterior bilateral percutaneous pedicle screw fixation (OLIF combined) for the treatment of lumbar spondylolisthesis.

Methods

This was a retrospective study of patients who underwent standalone OLIF or combined OLIF between 07/2014 and 08/2017 at two hospitals in China. Direct decompressions were not performed. Visual analog scale (VAS), Oswestry Disability Index (ODI), satisfaction rate, anterior/posterior disc heights (DH), foraminal height (FH), foraminal width (FW), cage subsidence, cage retropulsion, fusion rate, and complications were analyzed. All imaging examinations were read independently by two physicians and the mean measurements were used for analysis.

Results

A total of 73 patients were included: 32 with standalone OLIF and 41 with combined OLIF. The total complication rate was 25.0% with standalone OLIF and 26.8% with combined OLIF. There were no differences in VAS and ODI scores by 2 years of follow-up, but the scores were better with standalone OLIF at 1 week and 3 months (P < 0.05). PDH and FW was smaller in the combined OLIF group compared with the standalone OLIF group before and after surgery (all P < 0.05). There were significant differences in FH before surgery and at 1 week and 3 months between the two groups (all P < 0.05), but the difference disappeared by 2 years (P = 0.111). Cage subsidence occurred in 7.3% (3/41) and 7.3% (3/41) of the patients at 3 and 24 months, respectively, in the combined OLIF group, compared with 6.3% (2/32) and 15.6% (5/32), respectively, in the standalone OLIF group at the same time points (P = 0.287). There was no cage retropulsion in both groups at 2 years. The fusion rate was 85.4%(35/41) in the combined OLIF group and 84.4% (27/32) in the standalone OLIF group at 3 months(P = 0.669). At 24 months, the fusion rate was 100.0% in the combined OLIF group and 93.8% (30/32) in the standalone OLIF group (P = 0.066).

Conclusion

Standalone OLIF may achieve equivalent clinical and radiological outcomes than OLIF combined with fixation for spondylolisthesis. The rate of complications was similar between the two groups. Patients who are osteoporotic might be better undergoing combined rather than standalone OLIF. The possibilty of proof lies within a future prospective study, preferably an RCT.

[Diagnostics and therapy of back pain: what is advisable? What should be avoided and why is it still done?]

Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X‑rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.

Costs Associated with the Treatment of Low Back Disorders: A Comparison of Surgeons and Physiatrists

BACKGROUND

Spine care is costly and subject to wide variability. Defining costs and patterns of care for different specialties is critical to improving value.

OBJECTIVE

Determine costs, utilization, and differences therein for nonoperative and operative specialists in treating low back disorders. We hypothesized costs associated with nonoperative specialists would be lower.

DESIGN

Retrospective cohort.

SETTING

Medicare Limited Data Set (5% sample), 2011 to 2014.

PARTICIPANTS

A total of 170 011 patients saw a primary care provider for a low back disorder between 1 July 2011, and 1 January 2013. Excluding those seen for a low back disorder in the preceding 6 months, final cohorts totaled 11 829 patients subsequently evaluated by a physiatrist (specialist in physical medicine and rehabilitation; 3183 patients) or surgeon (orthopedic or neurosurgeon; 8646 patients) within the following 6 months.

MAIN OUTCOME MEASURES

Total Medicare expenditures, spine-specific costs, spine surgical rates over 24 months.

RESULTS

Cohorts had comparable demographics, initial diagnoses, and baseline mean per-member per-month (PMPM) total spending. Mean 2-year spine-specific spending was $3978 for the physiatrist cohort and $7387 for the surgeon cohort. Comparatively, the physiatrist cohort had lower total mean 2-year spine-specific spending (-$3409; 95% confidence interval [CI] -$3824 to -$2994), mean PMPM total spending (-$122/mo; CI -$184 to -$60), and surgical rate (7.8% vs. 18.9%, risk ratio [RR] = 0.41; CI 0.36-0.47). Surgery predominantly drove cost differential. Mean PMPM total spending for both cohorts remained elevated at 24 months compared to baseline mean spending (physiatrist: +$293; CI $447 to $138; surgeon: +$325; CI $425 to $225).

CONCLUSIONS

Following a new episode of a low back disorder, substantial costs were seen for those subsequently evaluated by a physiatrist or surgeon. Costs were considerably lower for those first seen by a physiatrist. Patients in both cohorts displayed long-term increases in health care costs. Our data suggest that early engagement in nonoperative care, when appropriate, may improve value.

Everyday life with chronic back pain: a qualitative study among Turkish immigrants in Denmark

BACKGROUND

Chronic back pain has a major physical and psycho-social impact. There have been few subjective assessments of everyday life in relation to migration and ethnicity. Through a descriptive and qualitative cross-cultural design, the aim was to develop an in-depth understanding of how Turkish immigrants experience living with back pain.

METHODS

We conducted a qualitative study based on interviews with Turkish immigrants suffering from CBP recruited from a rheumatology outpatient clinic. The analysis was based on Giorgi's phenomenological analysis.

RESULTS

Eleven Turkish participants with chronic back pain (mean age 47.6) were recruited. Three essences resulted from the analysis: "Overwhelming and prevailing pain" - reflecting pain taking control of everyday life, "Being distressed in community life" - encompassing how pain causes changes in social roles, and "Looking for a way out of pain" - referring to feeling lost when being treated in the healthcare system, finding pain-management strategies and returning to Turkey for assistance.

CONCLUSION

Chronic back pain has a significant influence on daily life. Pain changes the feeling of identity relating to close relationships and in the Labor market. Most participants' proficiency in Danish language skills posed a challenge for the existing treatment paradigm, in which information is crucial for successful rehabilitation.IMPLICATIONS FOR REHABILITATIONTo improve access to both info on chronic back pain and its treatment, it is crucial that rehabilitation be offered in a range of languages.Proficiency in Danish varies greatly among immigrants, despite years of stay in Denmark. Engaging a professional interpreter early on in the rehabilitation program might improve patient compliance to the preferred treatment regimen.Including a peer-to-peer educational approach in parts of the rehabilitation program might be beneficial, as some immigrants remain skeptical towards the health care system in Denmark.

Spondylodiscitis due to Cutibacterium acnes following lumbosacral intradiscal biologic therapy: a case report

A 40-year-old woman with a history of chronic low back pain underwent a fluoroscopically guided intradiscal platelet-rich plasma injection (PRP) at the L5-S1 level. She subsequently developed progressive low back pain, night sweats and decreased ability to ambulate. Laboratory work-up revealed elevated acute phase reactants and imaging revealed L5-S1 intervertebral disc and vertebral end-plate abnormalities highly suggestive of spondylodiscitis. Computed tomography-guided aspiration and biopsy cultures grew Cutibacterium acnes and the patient was subsequently treated with intravenous antibiotics without surgical management. To the best of our knowledge, this is the first published case of lumbar spondylodiscitis following an intradiscal PRP injection, and brings to the forefront several clinically relevant issues including the antimicrobial effects of PRP, the role of C. acnes in spine infections and the ideal treatment protocol for intradiscal biologics in order to minimize morbidity and optimize functional outcomes.

Disability, emotional distress and well-being among patients with lumbar spondylolisthesis

AIM AND OBJECTIVE

To explore the disability, emotional distress and well-being of patients with lumbar spondylolisthesis.

BACKGROUND

Few studies have investigated the correlations between disability, emotional distress and well-being of patients with lumbar spondylolisthesis.

DESIGN

This study used a cross-sectional research design.

METHODS

Participants were 133 patients aged over 50 years who were experiencing lumbar spondylolisthesis. The research instruments included a demographic information questionnaire; the Numeric Rating Scale (NRS); the Charlson Comorbidity Index (CCI); the Chinese versions of the Oswestry Disability Index (ODI), State-Trait Anxiety Inventory-State (STAI-S) and Center for Epidemiological Study-Depression (CES-D); and the Psychological Well-being (PWB) Scale. Emotional distress was measured by the STAI-S and CES-D. Pearson's correlations coefficient, multiple linear regression and a mediating effect model were introduced to explore correlations between the variables and predictors of psychological well-being, and details of the methods are reported in coherence to STROBE criteria.

RESULTS

Eighty-six participants (64.6%) had moderate and severe anxiety, and 42 (31.6%) experienced depression. Participants reported medium to high levels of well-being; "satisfaction with interpersonal relationships" was rated the highest and "physical and mental health" the lowest. Disability, depression and anxiety had significant negative correlations with well-being. Depression and anxiety mediated the relationship between disability and well-being. Moreover, depression, family support, educational background and anxiety were predictors of well-being, accounting for 39.1% of the total variance.

CONCLUSIONS

Disability and emotional distress among patients with lumbar spondylolisthesis had a negative impact on well-being. Anxiety and depression were closely correlated with and substantially influenced well-being.

RELEVANCE TO CLINICAL PRACTICE

Health professionals will enhance the understanding of important factors influencing well-being among patients with lumbar spondylolisthesis. This study suggests the conduct of depression and anxiety evaluations at outpatient clinics and prior to surgery, so that clinicians will be aware of the emotional distress status of patients with lumbar spondylolisthesis and, therefore, enhance their well-being.

Abstracts of low back pain trials are poorly reported, contain spin of information and are inconsistent with the full text: An overview study

OBJECTIVE

To investigate trials abstracts evaluating treatments for low back pain with regards to completeness of reporting, spin (i.e., interpretation of study results that overemphasizes the beneficial effects of the intervention), and inconsistencies in data with the full text.

DATA SOURCES

The search was performed on Physiotherapy Evidence Database (PEDro) in February 2016.

STUDY SELECTION

This is an overview study of a random sample of 200 low back pain trials published between 2010 and 2015. The languages of publication were restricted to English, Spanish and Portuguese.

DATA EXTRACTION

Completeness of reporting was assessed using the CONSORT for Abstracts checklist (CONSORT-A). Spin was assessed using a SPIN-checklist. Consistency between abstract and full text were assessed by applying the assessment tools to both the abstract and full text of each trial and calculating inconsistencies in the summary score (paired t test) and agreement in the classification of each item (Kappa statistics). Methodological quality was analyzed using the total PEDro score.

DATA SYNTHESIS

The mean number of fully reported items for abstracts using the CONSORT-A was 5.1 (SD 2.4) out of 15 points and the mean number of items with spin was 4.9 (SD 2.6) out of 7 points. Abstract and full text scores were statistically inconsistent (P=0.01). There was slight to moderate agreement between items of the CONSORT-A in the abstracts and full text (mean Kappa 0.20 SD 0.13) and fair to moderate agreement for items of the SPIN-checklist (mean Kappa 0.47 SD 0.09).

CONCLUSIONS

The abstracts were incomplete, with spin and inconsistent with the full text. We advise health care professionals to avoid making clinical decisions based solely upon abstracts. Journal editors, reviewers and authors are jointly responsible for improving abstracts, which could be guided by amended editorial policies.

Clinical experiences with a PEEK-based dynamic instrumentation device in lumbar spinal surgery: 2 years and no more

Background

Dynamic spine implants were developed to prevent adjacent segment degeneration (ASD) and adjacent segment disease (ASDi). Purpose of this study was to investigate the clinical and radiological outcomes of “topping off” devices following lumbar spinal fusion procedure using a PEEK-based dynamic rod system. Moreover, this study focused on the hypothesis that “topping off” devices can prevent ASD.

Methods

This prospective nonrandomized study included patients with indication for single-level lumbar fusion and radiological signs of ASD without instability. The exclusion criteria were previous lumbar spine surgery and no sign of disc degeneration in the adjacent segment according to magnetic resonance imaging. All patients were treated with single-level lumbar interbody fusion and dynamic stabilization of the cranial adjacent segment. Patients underwent a clinical examination and radiographs preoperatively and at 1 and 2 years after surgery. Analyses were performed on clinical data collected with the German Spine Registry using the core outcome measure index (COMI) and visual analogue scale (VAS) scores for back and leg pain.

Results

A total of 22 patients (6 male and 16 female) with an average age of 57.6 years were included in the study; 20 patients completed the follow-up (FU). The average COMI score was 9.0 preoperatively, 4.2 at the 1-year FU, and 4.7 at the 2-year FU. The average preoperative VAS scores for back and leg pain were 7.7 and 7.1, respectively. At the 1-year FU, the scores were 4.25 for back pain and 2.2 for leg pain, and at the 2-year FU, the scores were 4.7 for back pain and 2.3 for leg pain. At FU, failure of the dynamic topping off implant material was verified in four cases, and ASD of the segment cranial to the topping off was confirmed in three cases.

Conclusions

These results demonstrate significant improvements in clinical outcomes and pain reduction after lumbar spinal fusion with topping off at 2 years after surgery. However, the implant failed due to the high rate of implant failure and the development of ASD in the segment cranial to the dynamic stabilized segment.

Development and validation of two clinical prediction models to inform clinical decision-making for lumbar spinal fusion surgery for degenerative disorders and rehabilitation following surgery: protocol for a prospective observational study

INTRODUCTION

Potential predictors of poor outcome will be measured at baseline: (1) preoperatively to develop a clinical prediction model to predict which patients are likely to have favourable outcome following lumbar spinal fusion surgery (LSFS) and (2) postoperatively to predict which patients are likely to have favourable long-term outcomes (to inform rehabilitation).

METHODS AND ANALYSIS

Prospective observational study with a defined episode inception of the point of surgery. Electronic data will be collected through the British Spine Registry and will include patient-reported outcome measures (eg, Fear-Avoidance Beliefs Questionnaire) and data items (eg, smoking status). Consecutive patients (≥18 years) undergoing LSFS for back and/or leg pain of degenerative cause will be recruited.

EXCLUSION CRITERIA

LSFS for spinal fracture, inflammatory disease, malignancy, infection, deformity and revision surgery. 1000 participants will be recruited (n=600 prediction model development, n=400 internal validation derived model; planning 10 events per candidate prognostic factor). The outcome being predicted is an individual's absolute risk of poor outcome (disability and pain) at 6 weeks (objective 1) and 12 months postsurgery (objective 2). Disability and pain will be measured using the Oswestry Disability Index (ODI), and severity of pain in the previous week with a Numerical Rating Scale (NRS 0-10), respectively. Good outcome is defined as a change of 1.7 on the NRS for pain, and a change of 14.3 on the ODI. Both linear and logistic (to dichotomise outcome into low and high risk) multivariable regression models will be fitted and mean differences or ORs for each candidate predictive factor reported. Internal validation of the derived model will use a further set of British Spine Registry data. External validation will be geographical using two spinal registries in The Netherlands and Switzerland.

ETHICS AND DISSEMINATION

Ethical approval (University of Birmingham ERN_17-0446A). Dissemination through peer-reviewed journals and conferences.

Identifying subsets of patients with single-level degenerative disc disease for lumbar fusion: the value of prognostic tests in surgical decision making

BACKGROUND CONTEXT

Fusion surgery for degenerative disc disease (DDD) has become a standard of care, albeit not without controversy. Outcomes are inconsistent and a superiority over conservative treatment is debatable. Proper patient selection is key to clinical success, and a comprehensive understanding of prognostic tests does not currently exist.

PURPOSE

This study aimed to investigate the value of prognostic tests and sociodemographic factors in predicting outcomes following lumbar fusion surgery for DDD.

STUDY DESIGN

This is a retrospective analysis of prospectively collected data.

PATIENT SAMPLE

We included patients who underwent fusion surgery for DDD between 2010 and 2016.

OUTCOME MEASURES

The outcome measures included pre- and postoperative visual analog scale and Oswestry Disability Index scores.

MATERIALS AND METHODS

Prospectively collected patient data were reviewed for preoperative tests, perioperative data, and clinical outcomes. Prognostic tests used were discography, pantaloon cast test (PCT), Modic changes, and a summary of physical symptoms, coined "loading factor." By means of multivariate stepwise regression, prognostic factors that were useful in predicting outcomes were identified.

RESULTS

A total of 91 patients fit the inclusion criteria, with a mean follow-up of 33±16 months. Discography, Modic changes, and loading factor were of no value for predicting outcome scores (p>.05). A positive PCT predicted improved outcomes in back pain severity, but only in patients without prior surgery (p=.02). Demographic factors that showed a consistent reduction in back pain were female sex (p=.021) and no prior surgery at index level (p=.009). No other sociodemographic factors were of predictive value (p>.05).

CONCLUSIONS

In patients without prior surgery, the PCT appears to be the most promising prognostic tool. Other prognostic selection tools such as discography and Modic changes yield disappointing results. In this study, female patients and those without prior spine surgery appear to be most likely to benefit from fusion surgery for DDD.

Interdisciplinary Cognitive-Behavioral Therapy as Part of Lumbar Spinal Fusion Surgery Rehabilitation: Experience of Patients With Chronic Low Back Pain

Supplemental Digital Content is Available in the Text.

BACKGROUND:

Patients receiving lumbar spinal fusion surgery often have persisting postoperative pain negatively affecting their daily life. These patients may be helped by interdisciplinary cognitive-behavioral therapy which is recognized as an effective intervention for improving beneficial pain coping behavior, thereby facilitating the rehabilitation process of patients with chronic pain.

PURPOSE:

The purpose of this study was to describe the lived experience of patients recovering from lumbar spinal fusion surgery and to explore potential similarities and disparities in pain coping behavior between receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy.

METHODS:

We conducted semistructured interviews with 10 patients; 5 receiving cognitive-behavioral therapy in connection with their lumbar spinal fusion surgery and 5 receiving usual care. We conducted a phenomenological analysis to reach our first aim and then conducted a comparative content analysis to reach our second aim.

RESULTS:

Patients' postoperative experience was characterized by the need to adapt to the limitations imposed by back discomfort (coexisting with the back), need for recognition and support from others regarding their pain, a relatively long rehabilitation period during which they “awaited the result of surgery”, and ambivalence toward analgesics. The patients in both groups had similar negative perception of analgesics and tended to abstain from them to avoid addiction. Coping behavior apparently differed among receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy. Receivers prevented or minimized pain by resting before pain onset, whereas nonreceivers awaited pain onset before resting.

CONCLUSION:

The postoperative experience entailed ambivalence, causing uncertainty, worry and insecurity. This ambivalence was relieved when others recognized the patient's pain and offered support. Cognitive-behavioral therapy as part of rehabilitation may have encouraged beneficial pain coping behavior by altering patients' pain perception and coping behavior, thereby reducing adverse effects of pain.

Accumulated Spinal Axial Biomechanical Loading Induces Degeneration in Intervertebral Disc of Mice Lumbar Spine

OBJECTIVE

To investigate the effect of accumulated spinal axial biomechanical loading on mice lumbar disc and the feasibility of applying this method to establish a mice intervertebral disc degeneration model using a custom-made hot plate cage. In previous studies, we observed that the motion pattern of mice was greatly similar to that of humans when they were standing and jumping on their lower limbs. There is little data to demonstrate whether or not accumulated spinal axial biomechanical loading could induce intervertebral disc degeneration in vivo.

METHODS

Twenty-four 0-week-old mice were randomly divided into model 1-month and 3-month groups, and control 1-month and 3-month groups (n = 6 per group). The model groups was transferred into the custom-made hot plate cage three times per day for modeling. The control group was kept in a regular cage. The intervertebral disc samples of the L₃ -L₅ were harvested for histologic, molecular, and immunohistochemical studies after modeling for 1 and 3 months.

RESULTS

Accumulated spinal axial biomechanical loading affects the histologic, molecular, and immunohistochemical changes of mice L_3- L₅ intervertebral discs. Decreased height of disc and endplate, fissures of annulus fibrosus, and ossification of cartilage endplate were found in morphological studies. Immunohistochemical studies of the protein level showed a similar expression of type II collagen at 1 month, but a slightly decreased expression at 3 months, and an increased expression level of type X collagen and matrix metalloproteinase 13 (MMP13). Molecular studies showed that ColIIa1 and aggrecan mRNA expression levels were slightly increased at 1 month (P > 0.05), but then decreased slightly (P > 0.05). ColXa1, ADAMTS-5, and MMP-13 expression levels werer increased both at 1 and 3 months (P < 0.05). In addition, increased expression of Runx2 was observed.

CONCLUSION

Accumulated spinal axial loading provided by a custom-made hot plate accelerated mice lumbar disc and especially endplate degeneration. However, this method requires further development to establish a lumbar disc degeneration model.

Five-Year Reoperation Rates of 2-Level Lumbar Total Disk Replacement Versus Fusion: Results of a Prospective, Randomized Clinical Trial

STUDY DESIGN

Long-term analysis of prospective randomized clinical trial data.

SUMMARY OF BACKGROUND DATA

Lumbar total disk replacement (TDR) has been found to have equivalent or superior clinical outcomes compared with fusion and decreased radiographic incidence of adjacent level degeneration in single-level cases.

OBJECTIVE

The purpose of this particular analysis was to determine the incidence and risk factors for secondary surgery in patients treated with TDR or circumferential fusion at 2 contiguous levels of the lumbar spine.

METHODS

A total of 229 patients were treated and randomized to receive either TDR or circumferential fusion to treat degenerative disk disease at 2 contiguous levels between L3 and S1 (TDR, n=161; fusion, n=68).

RESULTS

Overall, at final 5-year follow-up, 9.6% of subjects underwent a secondary surgery in this study. The overall rate of adjacent segment disease was 3.5% (8/229). At 5 years, the percentage of subjects undergoing secondary surgeries was significantly lower in the TDR group versus fusion (5.6% vs. 19.1%, P=0.0027).Most secondary surgeries (65%, 17/26) occurred at the index levels. Index level secondary surgeries were most common in the fusion cohort (16.2%, 11/68 subjects) versus TDR (3.1%, 5/161 subjects, P=0.0009). There no statistically significant difference in the adjacent level reoperation rate between TDR (2.5%, 4/161) and fusion (5.9%, 4/68). The most common reason for index levels reoperation was instrumentation removal (n=9). Excluding the instrumentation removals, there was not a significant difference between the treatments in index level reoperations or in reoperations overall.

CONCLUSIONS

There were significantly fewer reoperations in TDR patients compared with fusion patients. However, most of the secondary surgeries were instrumentation removal in the fusion cohort. Discounting the instrumentation removals, there was no significant difference in reoperations between TDR and fusion. These results are indicative that lumbar TDR is noninferior to fusion.

The Global Spine Care Initiative: a narrative review of psychological and social issues in back pain in low- and middle-income communities

PURPOSE

The purpose of this review was to describe psychological and social factors associated with low back pain that could be applied in spine care programs in medically underserved areas and low- and middle-income countries.

METHODS

We performed a narrative review of cohort, cross-sectional, qualitative and mixed methods studies investigating adults with low back pain using Medline and PubMed were searched from January 2000 to June 2015. Eligible studies had at least one of the following outcomes: psychological, social, psychosocial, or cultural/ethnicity factors. Studies met the following criteria: (1) English language, (2) published in peer-reviewed journal, (3) adults with spinal disorders, (4) included treatment, symptom management or prevention.

RESULTS

Out of 58 studies, 29 were included in this review. There are few studies that have evaluated psychological and social factors associated with back pain in low- and middle-income communities, therefore, adapting recommendations from other regions may be needed until further studies can be achieved.

CONCLUSION

Psychological and social factors are important components to addressing low back pain and health care providers play an important role in empowering patients to take control of their spinal health outcomes. Patients should be included in negotiating their spinal treatment and establishing treatment goals through careful listening, reassurance, and information providing by the health care provider. Instruments need to be developed for people with low literacy in medically underserved areas and low- and middle-income countries, especially where psychological and social factors may be difficult to detect and are poorly addressed. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: a summary of guidelines on invasive interventions for the management of persistent and disabling spinal pain in low- and middle-income communities

PURPOSE

The purpose of this study was to synthesize recommendations on the use of common elective surgical and interventional procedures for individuals with persistent and disabling non-radicular/axial with or without myelopathy, radicular back pain, cervical myelopathy, symptomatic spinal stenosis, and fractures due to osteoporosis. This review was to inform a clinical care pathway on the patient presentations where surgical interventions could reasonably be considered.

METHODS

We synthesized recommendations from six evidence-based clinical practice guidelines and one appropriate use criteria guidance for the surgical and interventional management of persistent and disabling spine pain.

RESULTS

Lower priority surgery/conditions include fusion for lumbar/non-radicular neck pain and higher priority surgery/conditions include discectomy/decompressive surgery for cervical or lumbar radiculopathy, cervical myelopathy, and lumbar spinal stenosis. Epidural steroid injections are less expensive than most surgeries with fewer harms; however, benefits are small and short lived. Vertebroplasty should be considered over kyphoplasty as an option for patients with severe pain and disability due to osteoporotic vertebral compression fracture.

CONCLUSION

Elective surgery and interventional procedures could be limited in medically underserved areas and low- and middle-income countries due to a lack of resources and surgeons and thus surgical and interventional procedures should be prioritized within these settings. There are non-invasive alternatives that produce similar outcomes and are a recommended option where surgical procedures are not available. These slides can be retrieved under Electronic Supplementary Material.

Patient journey following lumbar spinal fusion surgery (LSFS): protocol for a multicentre qualitative analysis of the patient rehabilitation experience (FuJourn)

INTRODUCTION

There has been a 65% increase in lumbar spinal fusion surgery (LSFS) worldwide over the last 13 years, with costs of £26 million to the UK National Health Service annually. Patient dissatisfaction with outcome and persistent pain and disability incurs further costs. Three trials provide low-quality evidence for the role of physiotherapy. Our UK surveys investigating physiotherapy/surgeon practice concluded rehabilitation should be tailored to the individual patient owing to considerable clinical heterogeneity. This study will explore the perceptions of patients who undergo LSFS to inform precision rehabilitation.

METHODS AND ANALYSIS

A qualitative study, using interpretive phenomenological analysis, will recruit a purposive sample (n=40) to ensure patterns of similarity and difference in their journeys can be explored. In-depth semistructured interviews will be undertaken following discharge from hospital and at 12 months postsurgery. Patients' preoperative and postoperative experiences, underlying attitudes and beliefs towards the surgical intervention, facilitators and barriers to recovery, adherence to advice and physiotherapy, experiences of rehabilitation and return to normal function/activity/work will be explored. A 12-month patient diary will provide real time access to patient data, capturing a weekly record of life as lived, including symptoms, medication, experiences of stages of recovery, rehabilitation adherence, healthcare professional appointments, attitudes, their feelings and experiences throughout their journey. Data will be analysed in a number of stages in accordance with interpretive phenomenological analysis, supported using NVivo software. Analysis of the first interviews and patient diaries will afford a rich density of data to build an overall understanding of the patients' lived experiences, informing the 12-month interview. Strategies (eg, reflexivity) will ensure trustworthiness.

ETHICS AND DISSEMINATION

The study has ethical approval (IRAS 223283). Findings will ensure that patient-driven data inform precision rehabilitation by understanding the patient journey. Findings will be disseminated through peer-reviewed journals and conferences.

Total disc replacement versus multidisciplinary rehabilitation in patients with chronic low back pain and degenerative discs: 8-year follow-up of a randomized controlled multicenter trial

BACKGROUND CONTEXT

Lumbar total disc replacement (TDR) is a treatment option for selected patients with chronic low back pain (LBP) that is non-responsive to conservative treatment. The long-term results of disc replacement compared with multidisciplinary rehabilitation (MDR) have not been reported previously.

PURPOSE

We aimed to assess the long-term relative efficacy of lumbar TDR compared with MDR.

DESIGN

We undertook a multicenter randomized controlled trial at five university hospitals in Norway.

PATIENT SAMPLE

The sample consisted of 173 patients aged 25-55 years with chronic LBP and localized degenerative changes in the lumbar intervertebral discs.

OUTCOME MEASURES

The primary outcome was self-reported physical function (Oswestry Disability Index [ODI]) at 8-year follow-up in the intention-to-treat population. Secondary outcomes included self-reported LBP (visual analogue scale [VAS]), quality of life (EuroQol [EQ-5D]), emotional distress (Hopkins Symptom Checklist [HSCL-25]), occupational status, patient satisfaction, drug use, complications, and additional back surgery.

METHODS

Patients were randomly assigned to lumbar TDR or MDR. Self-reported outcome measures were collected 8 years after treatment. The study was powered to detect a difference of 10 ODI points between the groups. The study has not been funded by the industry.

RESULTS

A total of 605 patients were screened for eligibility, of whom 173 were randomly assigned treatment. Seventy-seven patients (90%) randomized to surgery and 74 patients (85%) randomized to rehabilitation responded at 8-year follow-up. Mean improvement in the ODI was 20.0 points (95% confidence interval [CI] 16.4-23.6, p≤.0001) in the surgery group and 14.4 points (95% CI 10.7-18.1, p≤.0001) in the rehabilitation group. Mean difference between the groups at 8-year follow-up was 6.1 points (95% CI 1.2-11.0, p=.02). Mean difference in favor of surgery on secondary outcomes were 9.9 points on VAS (95% CI 0.6-19.2, p=.04) and 0.16 points on HSCL-25 (95% CI 0.01-0.32, p=.04). There were 18 patients (24%) in the surgery group and 4 patients (6%) in the rehabilitation group who reported full recovery (p=.002). There were no significant differences between the groups in EQ-5D, occupational status, satisfaction with care, or drug use. In the per protocol analysis, the mean difference between groups was 8.1 ODI points (95% CI 2.3-13.9, p=.01) in favor of surgery. Forty-three of 61 patients (70%) in the surgery group and 26 of 52 patients (50%) in the rehabilitation group had a clinically important improvement (15 ODI points or more) from baseline (p=.03). The proportion of patients with a clinically important deterioration (six ODI points or more) was not significantly different between the groups. Twenty-one patients (24%) randomized to rehabilitation had crossed over and had undergone back surgery since inclusion, whereas 12 patients (14%) randomized to surgery had undergone additional back surgery. One serious adverse event after disc replacement is registered (<1%).

CONCLUSIONS

Substantial long-term improvement can be expected after both disc replacement and MDR. The difference between groups is statistically significant in favor of surgery, but smaller than the prespecified clinically important difference of 10 ODI points that the study was designed to detect. Future research should aim to improve selection criteria for disc replacement and MDR.