Outcome assessment after spinal fusion: why and how?

Cross-cultural adaptation and psychometric testing of the Arabic version of the Modified Oswestry Low Back Pain Disability Questionnaire

Background

The Modified Low Back Pain Disability Questionnaire (MLBPDQ) is used for evaluating the functional disability in patients with low back pain (LBP). However, the measurement characteristics of the MLBPDQ among Arab patients are unknown. In this study, we aimed to translate and cross-culturally adapt the MLBPDQ into Arabic and evaluate its psychometric properties.

Methods

An Arabic version of the MLBPDQ was developed through forward translation, translation synthesis, and backward translation. Sixty-eight patients (55 males and 13 females) with a mean age 37.01 ± 7.57 years were recruited to assess its psychometric properties. Reliability was evaluated using internal consistency (Cronbach’s α), test retest reliability (utilizing intraclass correlation coefficient [ICC]), standard error of measurement (SEM), minimal detectable change at 95% confidence level (MDC_95%), and 95% limits of agreement (LOA). The construct validity was investigated by correlating the new translation with four other measures of LBP (using Spearman’s rho). Finally, receiver operating characteristic curve was constructed to compute the sensitivity, using the area under the curve (AUC), and the minimum important change (MIC). An alpha level of 0.05 was set for statistical tests and all the psychometric values were tested against a priori hypotheses.

Results

The culturally aligned MLBPDQ showed good internal consistency (Cronbach’s α = 0.85). The ICC, SEM, MDC_95%, and LOA between baseline and two days later were 0.98, 1.60, 4.43, and -4.23 to 7.70, respectively, while the values between baseline and 14 days later were 0.94, 2.77, 7.67, and -6.59 to 13.53, respectively. The scale also demonstrated moderate to excellent correlation (rho = 0.54–0.86) with the other four questionnaires. The AUC value of the Arabic-MLBPDQ was 0.68, and the MIC was 3 points.

Conclusion

The Arabic version of the MLBPDQ demonstrates adequate psychometric properties and can be used to assess disability level in patients with LBP in Arabic-speaking communities.

Lumbar Spinal Stenosis: Objective Measurement Scales and Ambulatory Status

Lumbar spinal stenosis (LSS) is one of the most common affecting the elderly population that may lead to loss of function and the inability to execute basic activities of daily living. While surgical decompression remains the standard of care, choosing an optimal management strategy is usually guided by a set of clinical, radiological, and measurement indices. However, to date, there is a major uncertainty and discrepancy regarding the methodology used. There is also inconsistent adoption of outcome measures across studies, which may result in huge limitations in predicting the efficacy and cost-effectiveness of different treatment paradigms. Herein, we review the various measurement indices used for outcome assessment among patients with LSS, and delineate the major advantages and disadvantages of each index. We call for the development of a single objective outcome measure that encompasses and addresses all issues encountered in this heterogeneous group of patients, including monitoring the patient's progression after treatment.

Avaliação da qualidade de vida em pacientes submetidos à cirurgia de estenose de canal lombar com mais de 60 anos

OBJETIVO: Avaliar as mudanças na qualidade de vida antes e após a cirurgia de artrodese lombar através dos questionários Owestry Disablity Index (ODI), Roland-Morris (RM) e Escala Analógica Visual (VAS). MÉTODOS: Foram avaliadas as mudanças nos questionários (ODI, RM e VAS) entre o pré-operatório, 1 semana, 1 mês, 2 meses, 6 meses, 1 ano e 2 anos após o procedimento cirúrgico. RESULTADOS: Foram estudados 38 pacientes com idade acima de 60 anos com acompanhamento de pelo menos dois anos. Houve uma melhora no ODI de 55,94%, 49,18 no RM e 39,48 no VAS. CONCLUSÃO: Os resultados mostram uma melhora nos índices analisados, apresentando índices semelhantes a estudos anteriores, apesar da discrepância entre os diversos estudos e à falta de dados referentes à nossa população.

Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients

INTRODUCTION

It is well known that during posterior stabilization of the spinal column conventionally open methods are predominantly used. However, in this study a minimally invasive method was chosen to decrease the morbidity of the operative access and to protect the paravertebral musculature, which serves as an important spine-stabilizing factor during posterior stabilization. The aims of this retrospective non-randomized case-control study were to compare the clinical and radiological results of minimally invasive on the one hand and conventionally open posterior surgery on the other with each other and to measure the loss of correction after purely posterior stabilization.

METHODS

Twenty-one consecutive non-randomized patients with thoracolumbar vertebral body fractures, which had been stabilized posteriorly without any intervertebral body fusion between 1996 and 1997, and without any neurological symptoms, were examined retrospectively more than 5 years after trauma. Eleven patients had been treated conventionally open and 10 patients minimally invasive. As methods of evaluation, the intra- and postoperative amount of blood loss, the X-ray time, the Hannover-Spine-Score, the SF-36 Health Questionnaire and radiological assessment of the bisegmental wedge and vertebral body angle were made use of.

RESULTS

The blood loss was significantly lower among those patients who had been operated in a minimally invasive way. The operating time, the time of X-ray exposure and the loss of correction were identical in both groups. The first year after implant removal, the loss of correction was the highest with 2.1 degrees for the body angle and 6.86 degrees for the bisegmental wedge angle. Neither in the Hannover-Spine-Score nor in the SF-36 Health Questionnaire did both groups show a difference. A correlation between the loss of correction and the clinical results could not be demonstrated.

CONCLUSION

The minimally invasive posterior stabilization leads to lower blood loss in comparison to the conventionally open method and can be carried out without any special effort limited to A-fractures without any neurological symptoms.

Pain regulation and health-related quality of life after thoracolumbar fractures of the spine

Fractures of the thoracolumbar spine rank among the severest injuries of the human skeleton. Especially in younger patients they often result from high-energy accidents. Recently, a shift in paradigm towards more aggressive treatment strategies including anterior procedures could be observed. However, so far only few data exist reflecting the quality of life (QoL) after such injuries. The aim of this study was to evaluate medium-term QoL and further to identify factors that influence the clinical outcome in patients with fractures of the thoracolumbar spine. Data of 906 patients who were treated during a 10-year period in our institution were evaluated retrospectively. Only patients with single-level traumatic injuries aged between 18 and 65 years without neurological deficits, concomitant injuries of other locations and internal comorbidities were included into the investigation (n = 204). Three different treatment groups (i.e. non-operative, dorsal and dorsoventral stabilisation) were compared to healthy controls as well as different pain populations. The QoL was assessed using established questionnaires (SF-36, HFAQ, VAS-Spinescore, PRQ, and PTSD). Sixty-five percent of the included patients (n = 133) were studied at an average follow-up of 5.3 +/- 1.7 years after injury. All treatment groups revealed an identical gender and age distribution. More severe and unstable injuries were found in the surgical groups associated with higher treatment costs and a longer inability to work. Compared to healthy controls, QoL was compromised to the same extent in all groups. Furthermore, all patients treated in this study did significantly better than low back pain individuals with regard to QoL and pain regulation parameters. In our study, patients with thoracolumbar spine fractures showed a reduced QoL compared to healthy controls. Thus, patients do not seem to regain their former QoL. However, the level of discomfort was comparably low in all groups, even in patients with more severe injuries requiring extensive surgery. Overall, outcome and QoL after traumatic fractures of the thoracolumbar spine rather seem to be determined by the severity of injury than by pain regulation or other psychosocial factors which is likely the case in low back pain disorders.

Functional outcomes of kyphoplasty for the treatment of osteoporotic and osteolytic vertebral compression fractures

INTRODUCTION

Vertebral body compression fractures secondary to osteoporosis or malignant osteolysis are an increasingly common problem. The primary purpose of our study was to assess functional outcomes of kyphoplasty for the treatment of osteoporotic and osteolytic vertebral compression fractures. Our secondary purpose was to compare such functional outcomes in patients with osteoporosis versus multiple myeloma.

METHODS

The 314 consecutive patients prospectively included in our study had progressive and painful compression fractures as a result of osteoporosis or multiple myeloma that were refractory to nonoperative modalities. Of those 314 patients, the 211 (67.2%) patients (155 with osteoporosis and 56 with multiple myeloma) who had complete preoperative and postoperative data formed our final study group. All patients tolerated the kyphoplasty procedure well (that is, there were no adverse events in terms of perioperative patient condition). Follow-up ranged from 1 to 235 weeks (mean 55.0 weeks). Functional outcomes were assessed by the SF-36 and Oswestry Disability Index at baseline and at follow-up examinations. Data were analyzed by Student's t-test and the level of significance was set at P<or=0.05.

RESULTS

The average Owestry Disability Index score decreased by 12.6 points (P<0.001) in the overall group, by 11.8 points (P<0.001) at short-term follow-up, and by 8.6 points (P<0.001) at long-term follow-up. All SF-36 sub-scores except for general health and role-emotional showed statistically significant improvement from baseline values at the same time points. There was no statistically significant difference with regard to functional outcome in the osteoporosis and multiple myeloma sub-groups.

CONCLUSIONS

Kyphoplasty provided a safe and effective treatment for pain and disability in patients with verterbral compression fractures secondary to osteoporosis and multiple myeloma. In addition, we found no statistically significant difference with regard to functional outcome between patients with osteoporosis and multiple myeloma.

The Oswestry Low Back Pain Disability Questionnaire. a two-year follow-up of spine surgery patients

BACKGROUND AND AIMS

So far there is no golden standard for the measurement of functional disability in spinal problems. The Oswestry index can be used to monitor the response to treatment and rehabilitation. It is based on a patient's subjective impression of his or her own state of disability. The purpose of this prospective study is to give a graphic presentation of the behaviour of the Oswestry index in different spine surgery groups.

MATERIAL AND METHODS

The material includes 193 discectomy and decompressive operations. 37 of these patients had been operated earlier. The patients were observed for two years after the index operation through the mail with the Oswestry questionnaire.

RESULTS

Before an operation the average Oswestry index corresponded to severe disability on average. After successful treatment the Oswestry index dropped by 20-40 points on average. The more complex the problem the higher the postoperative lines remained.

CONCLUSIONS

The results compared well with those of earlier studies. The graphs presented in this study may help the treating clinician to make conclusions on how his or her patients are doing on average after surgery.

The Oswestry Disability Index

STUDY DESIGN

The Oswestry Disability Index (ODI) has become one of the principal condition-specific outcome measures used in the management of spinal disorders. This review is based on publications using the ODI identified from the authors' personal databases, the Science Citation Index, and hand searches of Spine and current textbooks of spinal disorders.

OBJECTIVES

To review the versions of this instrument, document methods by which it has been validated, collate data from scores found in normal and back pain populations, provide curves for power calculations in studies using the ODI, and maintain the ODI as a gold standard outcome measure.

SUMMARY OF BACKGROUND DATA

It has now been 20 years since its original publication. More than 200 citations exist in the Science Citation Index. The authors have a large correspondence file relating to the ODI, that is cited in most of the large textbooks related to spinal disorders.

METHODS

All the published versions of the questionnaire were identified. A systematic review of this literature was made. The various reports of validation were collated and related to a version.

RESULTS

Four versions of the ODI are available in English and nine in other languages. Some published versions contain misprints, and many omit the scoring system. At least 114 studies contain usable data. These data provide both validation and standards for other users and indicate the power of the instrument for detecting change in sample populations.

CONCLUSIONS

The ODI remains a valid and vigorous measure and has been a worthwhile outcome measure. The process of using the ODI is reviewed and should be the subject of further research. The receiver operating characteristics should be explored in a population with higher self-report disabilities. The behavior of the instrument is incompletely understood, particularly in sensitivity to real change.