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Torun E, Yuksel Y. The Relationship Between Craniocervical Morphology and the Presence and Level of Cervical Facet Joint Degeneration. J Comput Assist Tomogr 2024:00004728-990000000-00344. [PMID: 39095063 DOI: 10.1097/rct.0000000000001649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
OBJECTIVE To investigate the relationship between craniocervical morphology and the presence and level of cervical facet joint degeneration (FJD). METHODS A total of 108 consecutive female patients aged 45-55 years who had undergone neck + brain CT angiography were included in this retrospective sectional study. Only patients of a certain age and of the same gender were included in order to eliminate the differences that create a disposition to the development of spinal degeneration. The presence of facet joint (FJ) arthritis (grade ≥2 degeneration in at least one affected facet joint) and the grade of the facet joint degeneration for each patient were recorded. A total of 20 lengths and 3 angles of craniocervical morphology were measured. The differences between the individuals with and without FJ arthritis were investigated with the independent-sample t test, and the relationship between the FJD grade and craniocervical morphology was investigated using the Spearman correlation test. RESULTS Individuals with FJ arthritis were found to have longer Grabb-Oakes measurement, shorter FM AP length, lower ADI, lower EOP thickness, higher clivus length, higher crista gall-ATS distance, lower CCA angle, lower distance between the C1 vertebra lateral masses, and higher BAI than those without FJ arthritis (P ˂ 0.05). Besides, we found that the FJD grade increased as the Grabb-Oakes measurement increased, ADI distance decreased, FM AP length decreased, EOP thickness decreased, clivus length increased, basal angle increased, distance between the C1 vertebra lateral masses decreased, and BAI increased (P ˂ 0.05). CONCLUSIONS Differences in craniocervical morphology are statistically associated with degenerative processes that result in degenerative changes in the facet joint. Therefore, some morphological changes in craniocervical anatomy cause changes in the momentum and distribution of the load on the facet joints, predisposing the patient to facet arthropathy and osteoarthritis.
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Affiliation(s)
- Ebru Torun
- From the Department of Radiology, Faculty of Medicine, Alaaddin Keykubat University, Alanya, Turkey
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Shpigelman A, Shouval A, Koder I, Keret S, Slobodin G. Facet joint involvement in the inflammatory rheumatic disease. Joint Bone Spine 2024; 91:105674. [PMID: 38101697 DOI: 10.1016/j.jbspin.2023.105674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/12/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND The involvement of facet joints (FJ) in patients with inflammatory rheumatic disorders remains underexplored. This review aims to look at FJ disease from a rheumatologist's perspective, with the emphasis given to the clinical presentations and patterns of FJ engagement in axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), rheumatoid arthritis (RA), and crystal-related arthropathies, and discussion of challenges in studying FJ in rheumatic disease. METHODS A systematic PubMed search using the pertinent keywords was performed, relevant articles extracted, and the acquired data critically assessed, interpreted, and organized according to the authors' experience and judgment. RESULTS FJ involvement is common in patients with radiographic axSpA, occurs throughout the spine, but is more frequently seen in the thoracic segment. The existing data suggests that the FJ are primarily affected by the disease process, while altered spine biomechanics due to the presence of syndesmophytes at the same vertebral level contributes to the FJ fusion. Predominant involvement of FJ of the cervical spinal segment has been suggested in PsA; however, prevalence and clinical significance of FJ involvement in PsA is still markedly underexplored. RA-related FJ disease of the cervical spine in patients with poorly controlled RA is not uncommon and can be related to significant morbidity, while the burden of FJ involvement in the thoracic and lumbar spinal segments in RA is also underexplored. FJ disease is possible in the course of crystal-related arthropathies, but the high level of suspicion is a prerequisite for the timely diagnosis. CONCLUSIONS The involvement of FJ in the course of inflammatory rheumatic disease is not uncommon. Prospective studies are needed to understand the epidemiology and significance of FJ disease in inflammatory rheumatic conditions.
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Affiliation(s)
- Arsen Shpigelman
- Spine Unit, Department of Orthopedic Surgery, Lady Davis Carmel Medical Center, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Aniela Shouval
- Rheumatology Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Ilai Koder
- Spine Unit, Department of Orthopedic Surgery, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Shiri Keret
- Rheumatology Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Gleb Slobodin
- Rheumatology Unit, Bnai Zion Medical Center, Haifa, Israel.
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3
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Gupta A. Exosomes for the Management of Low Back Pain: A Review of Current Clinical Evidence. Cureus 2024; 16:e57539. [PMID: 38707134 PMCID: PMC11068073 DOI: 10.7759/cureus.57539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Low back pain affects millions of people, creating an enormous financial burden on the global healthcare system. Traditional treatment modalities are short-lived and have shortcomings. Recently, orthobiologics, including extracellular vesicles or exosomes derived from mesenchymal stem cells, have markedly increased for managing musculoskeletal conditions. Here, the primary aim is to review the outcomes of clinical studies using extracellular vesicles or exosomes for treating low back pain. Numerous databases (Scopus, PubMed, Web of Science, Embase, and Google Scholar) were searched using terms for the intervention 'exosomes' and the treatment 'low back pain' for studies published in English to March 18, 2024. Articles utilizing exosomes for the management of low back pain were included. Articles not utilizing exosomes, not explicitly stating the presence of exosomes in their formulation, or not targeting low back pain were excluded. Two articles that met our pre-defined criteria were included in this review. The results showed that administering extracellular vesicles or exosomes is safe and potentially effective in patients suffering from low back pain. Yet, more sufficiently powered, multi-center, prospective, randomized, and non-randomized trials with longer follow-up are essential to assess the long-term safety and efficacy of extracellular vesicles or exosomes derived from various sources and to support its routine clinical use for managing low back pain.
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Affiliation(s)
- Ashim Gupta
- Regenerative Medicine, Future Biologics, Lawrenceville, USA
- Regenerative Medicine, BioIntegrate, Lawrenceville, USA
- Orthopaedics, South Texas Orthopaedic Research Institute, Laredo, USA
- Regenerative Medicine and Orthopaedics, Regenerative Orthopaedics, Noida, IND
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Goto Y, Kato K, Yagi K, Kawaguchi Y, Yonezu H, Koshimae T, Waguri-Nagaya Y, Murakami H, Suzuki N. Transforming Growth Factor-β Induces Interleukin-6 Secretion from Human Ligamentum Flavum-Derived Cells through Partial Activation of p38 and p44/42 Mitogen-Activated Protein Kinases. Asian Spine J 2023; 17:997-1003. [PMID: 37946333 PMCID: PMC10764132 DOI: 10.31616/asj.2023.0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/03/2023] [Accepted: 04/23/2023] [Indexed: 11/12/2023] Open
Abstract
STUDY DESIGN This experimental study was performed using human ligamentum flavum-derived cells (HFCs). PURPOSE To investigate the intracellular signaling mechanism of interleukin-6 (IL-6) secretion in transforming growth factor-β (TGF- β)-stimulated HFCs. OVERVIEW OF LITERATURE Lumbar spinal stenosis (LSS) is a prevalent disease among the elderly, characterized by debilitating pain in the lower extremities. Although the number of patients with LSS has increased in recent years, the underlying pathomechanism remains unclear. Clinical examinations typically rely on magnetic resonance imaging to diagnose patients, revealing ligamentum flavum hypertrophy. Some studies have suggested an association between ligamentum flavum hypertrophy and inflammation/fibrosis, and expression of TGF-β and IL-6 has been observed in surgically obtained ligamentum flavum samples. However, direct evidence linking TGF-β and IL-6 expression in HFCs is lacking. METHODS HFCs were obtained from patients with LSS who had undergone decompression surgery. The cells were stimulated with TGF-β and pretreated with either the p38 mitogen-activated protein (MAP) kinase inhibitor SB203580 or the p44/42 MAP kinase inhibitor FR180204. IL-6 secretion in the cell culture medium and IL-6 messenger RNA (mRNA) expression levels were analyzed using an enzyme-linked immunoassay and real-time polymerase chain reaction, respectively. RESULTS TGF-β administration resulted in a dose- and time-dependent stimulation of IL-6 release. Treatment with SB203580 and FR180204 markedly suppressed TGF-β-induced IL-6 secretion from HFCs. Moreover, these inhibitors suppressed IL-6 mRNA expression in response to TGF-β stimulation. CONCLUSIONS Our findings indicate that TGF-β induces IL-6 protein secretion and gene expression in HFCs through the activation of p38 or p44/42 MAP kinases. These results suggest a potential association between IL-6-mediated inflammatory response and tissue hypertrophy in LSS, and we provide insights into molecular targets for therapeutic interventions targeting LSS-related inflammation through our analysis of the MAP kinase pathway using HFCs.
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Affiliation(s)
- Yuta Goto
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya,
Japan
| | - Kenji Kato
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya,
Japan
| | - Kiyoshi Yagi
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya,
Japan
| | - Yohei Kawaguchi
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya,
Japan
| | - Hiroki Yonezu
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya,
Japan
| | - Tomoko Koshimae
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya,
Japan
| | - Yuko Waguri-Nagaya
- Department of Orthopaedic Surgery, Nagoya City University East Medical Center, Nagoya,
Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya,
Japan
| | - Nobuyuki Suzuki
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya,
Japan
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Gupta A, Maffulli N. Amniotic membrane and/or umbilical cord tissue for treatment of facet joint syndrome: a narrative review. J Orthop Surg Res 2023; 18:744. [PMID: 37784162 PMCID: PMC10544465 DOI: 10.1186/s13018-023-04241-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/26/2023] [Indexed: 10/04/2023] Open
Abstract
Musculoskeletal spine disorders, especially low back pain, induce enormous amounts of stress and financial burden on individuals and healthcare systems throughout the world. Disorders of the facet joints in the lumbar spine are the most predominant cause of back pain, resulting in facet joint syndrome (FJS). Conventional treatments for FJS are short-lived and have limitations and side effects. Thus, safer and more effective alternatives that can reduce pain and improve patient-reported outcomes are needed. Recently, the utilization of biologics, including the ones derived from perinatal tissue such as amniotic membrane (AM) and umbilical cord (UC), has significantly increased for regenerative medicine applications. This manuscript summarizes the outcomes of preclinical and clinical studies utilizing AM and/or UC for FJS. We identified no preclinical studies and 3 retrospective studies utilizing the search terms "amniotic membrane" and/or "umbilical cord" and "facet joint syndrome". The administration of AM + UC is safe and potentially efficacious for patients with FJS. However, more preclinical studies and appropriately powered, multi-center, prospective non-randomized and randomized controlled studies with longer follow-up are warranted to further evaluate the efficacy of AM + UC to justify its clinical use.
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Affiliation(s)
- Ashim Gupta
- Regenerative Orthopaedics, Noida, India.
- Future Biologics, Lawrenceville, GA, USA.
- BioIntegrate, Lawrenceville, GA, USA.
- South Texas Orthopaedic Research Institute (STORI Inc.), Laredo, TX, USA.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Fisciano, Italy
- San Giovanni di Dio e Ruggi D'Aragona Hospital "Clinica Ortopedica" Department, Hospital of Salerno, Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, London, UK
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke On Trent, UK
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Shim JG, Ryu KH, Cho EA, Ahn JH, Park J, Lee HW, Kang S, Han SY, Lee SH. Association between body composition and chronic low back pain in Korean adults aged over 50 years: The Korea National Health and Nutrition Examination Survey (KNHANES) 2010-2011. Med Princ Pract 2023; 32:000533354. [PMID: 37549659 PMCID: PMC10659589 DOI: 10.1159/000533354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023] Open
Abstract
Background The relationship between overweight or obesity and low back pain (LBP) has previously been investigated. Several recent studies have focused on the relationship between other indicators of obesity, particularly indicators of fat and the risk of LBP. However, the results of body composition and LBP have been inconsistent. Methods All data for the present retrospective, cross-sectional study was extracted from the Korea National Health and Nutrition Examination Survey (KNHANES) versions V-1 and 2 conducted in 2010 and 2011 by the Korean Centers for Disease Control and Prevention. In KNHANES V-1 (2010) and V-2 (2011), those over 50 years of age completed the surveys on LBP, body weight, and body composition assessed using dual-energy X-ray absorptiometry (DXA) were included. The multivariable logistic regression analysis was used to examine the relationship between the presence of chronic LBP and body composition adjusting for confounders. Results We analyzed 3,579 persons who completed the question. In the multivariable analyses adjusting for age and sex, none of the variables, including fat mass and fat-free mass, remained positively or negatively associated with LBP. Additionally, when depression, smoking, alcohol intake, physical activity, diabetes mellitus, and fat or lean tissue mass were included in the multivariable logistic model, no significant associations were found between all measures of fat mass, fat-free mass, and LBP Conclusion This study is contrary to previous studies that concluded that there is a correlation between obesity and fat mass and LBP. LBP is not associated with increased levels of obesity and fat mass.
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Affiliation(s)
- Jae-Geum Shim
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyoung-Ho Ryu
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun-Ah Cho
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin Hee Ahn
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jiyeon Park
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyo-Won Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suji Kang
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - So Young Han
- Department of Ophthalmology, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, South Korea
| | - Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Jian S, Luo D, Wang Y, Xu W, Zhang H, Zhang L, Zhou X. MiR-337-3p confers protective effect on facet joint osteoarthritis by targeting SKP2 to inhibit DUSP1 ubiquitination and inactivate MAPK pathway. Cell Biol Toxicol 2023; 39:1099-1118. [PMID: 34697729 DOI: 10.1007/s10565-021-09665-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/29/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To probe the performance of miR-337-3p on the facet joint osteoarthritis (FJOA) and its underlying mechanism. METHODS qRT-PCR and Western blot were utilized to analyze the levels of miR-337-3p and DUSP1 in the synovial tissues from 36 FJOA patients and 10 healthy controls. The human synovial fibroblasts of FJOA were isolated and cultured followed by cell transfection. Then, cells were exposed to 10 ng/mL of IL-1β to induce inflammatory response of synovial fibroblasts. The alternation on cell biological function in cell models was determined. The binding of miR-337-3p and SKP2 was predicted by StarBase, TargetScan, DIANA-microT and miRmap, and further verified by RIP assay and dual-luciferase reporter assay. Co-IP experiment and ubiquitination assay were used to display the binding of SKP2 and DUSP1 as well as the ubiquitination and degradation of DUSP1. After that, the FJOA rat model was established and miR-337-3p mimic or negative control was given to rats by tail vein injection. The pathological changes of synovial tissues, synovitis score, and inflammation level in rats were assessed. RESULTS The low expressions of miR-337-3p and DUSP1 were noticed in the synovial tissues of FJOA patients and in IL-1β-induced synovial fibroblasts, and highly expressed p-p38 MAPK was noticed. Upregulation of miR-337-3p/DUSP1 or downregulation of SKP2 inhibited IL-1β-induced proliferation and inflammatory response of synovial fibroblasts. SKP2 was the target gene of miR-337-3p, and SKP2 induced the ubiquitination and degradation of DUSP1. MiR-337-3p exerted a protective effect on FJOA rats by alleviating damage of rat synovial tissues, promoting cell apoptosis and repressing inflammatory response. CONCLUSION MiR-337-3p plays a protective role in FJOA by negatively targeting SKP2 to suppress DUSP1 ubiquitination and inactivate the p38 MAPK pathway.
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Affiliation(s)
- Shengsheng Jian
- Department of Orthopedics, the Third Affiliated Hospital (the Affiliated Luohu Hospital) of Shenzhen University, Shenzhen, Guangdong, 518001, People's Republic of China
| | - Dixin Luo
- The Spine Department, Orthopaedic Center, Guangdong Second Provincial General Hospital, No. 466, Mid Xingang Road, Haizhu District, Guangzhou, Guangdong, 510317, People's Republic of China
| | - Yeyang Wang
- The Spine Department, Orthopaedic Center, Guangdong Second Provincial General Hospital, No. 466, Mid Xingang Road, Haizhu District, Guangzhou, Guangdong, 510317, People's Republic of China
| | - Wangyang Xu
- The Spine Department, Orthopaedic Center, Guangdong Second Provincial General Hospital, No. 466, Mid Xingang Road, Haizhu District, Guangzhou, Guangdong, 510317, People's Republic of China
| | - Hui Zhang
- The Spine Department, Orthopaedic Center, Guangdong Second Provincial General Hospital, No. 466, Mid Xingang Road, Haizhu District, Guangzhou, Guangdong, 510317, People's Republic of China
| | - Li Zhang
- The Spine Department, Orthopaedic Center, Guangdong Second Provincial General Hospital, No. 466, Mid Xingang Road, Haizhu District, Guangzhou, Guangdong, 510317, People's Republic of China
| | - Xiaozhong Zhou
- The Spine Department, Orthopaedic Center, Guangdong Second Provincial General Hospital, No. 466, Mid Xingang Road, Haizhu District, Guangzhou, Guangdong, 510317, People's Republic of China.
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Wong MJ, Rajarathinam M. Ultrasound-guided axial facet joint interventions for chronic spinal pain: A narrative review. Can J Pain 2023; 7:2193617. [PMID: 37214187 PMCID: PMC10193888 DOI: 10.1080/24740527.2023.2193617] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 05/24/2023]
Abstract
Background Axial facet joint interventions (e.g., medial branch block and radiofrequency ablation, facet joint intra-articular injection) are commonly performed for managing chronic spinal pain. Although traditionally performed with fluoroscopy or computed tomography (CT) guidance, ultrasound-guided techniques have also been developed for these interventions. Aims The aim of this study is to present contemporary ultrasound-guided techniques for facet joint interventions and synthesize data addressing their accuracy, safety, and efficacy. Methods The PubMed, MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials databases were systematically searched for studies of ultrasound-guided facet joint interventions with human subjects from November 1, 1992, to November 1, 2022. Additional sources were drawn from reference lists and citations of relevant studies. Results We found 48 studies assessing ultrasound-guided facet joint interventions. Ultrasound guidance for injection of the cervical facet joints and their innervating nerves had favorable accuracy (78%-100%), with lower procedural time compared to fluoroscopy or CT guidance and comparable pain relief. Accuracy with ultrasound-guided lumbar facet joint intra-articular injection (86%-100%) was more reliable than medial branch block (72%-97%); analgesia was comparable to fluoroscopy and CT guidance. In general, these procedures were more challenging for patients with obesity, and deeper structures were more difficult to accurately target (e.g., lower cervical levels, L5 dorsal ramus). Conclusions Ultrasound-guided facet joint interventions continue to evolve. Some technically challenging interventions may be impractical for widespread usage or require further technical refinement. The utility of ultrasound guidance with obesity and abnormal anatomy may be reduced.
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Affiliation(s)
- Michael J. Wong
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Manikandan Rajarathinam
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Karamian BA, Levy HA, Canseco JA, Goyal DKC, Divi SN, Lee JK, Kurd MF, Rihn JA, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Does Facet Distraction Affect Patient Outcomes After ACDF? Global Spine J 2023; 13:689-695. [PMID: 33759596 DOI: 10.1177/21925682211004244] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study is to determine if there is a correlation between the amount of facet distraction and postoperative patient-reported outcomes after ACDF. METHODS A retrospective cohort analysis of patients undergoing 1 to 3 level ACDF for degenerative pathologies at a single academic center was performed. Each patient received upright, lateral cervical spine x-rays at the immediate postoperative time point from which interfacet distance (facet distraction) was measured. Patient-reported outcome measures including NDI, PCS-12, MCS-12, VAS Neck, and VAS Arm pain scores were obtained preoperatively and at short-term (<3 months) and long-term (>1 year) follow-up. Receiver operating curves were generated to evaluate the possibility of a critical interfacet distraction distance. Univariate and multivariate analysis were performed to compare outcomes between groups based on the degree of facet distraction. RESULTS A total of 229 patients met the inclusion criteria. Receiver operating curves failed to yield a critical interfacet distraction distance associated with worse post-operative outcomes. Patients were instead grouped based on facet distraction distance below and above the third quartile (0.8mm-2.0 mm, 2.0mm-3.7 mm), with 173 and 56 patients in each respective group. Univariate analysis did not detect any statistically significant differences in outcome measures, recovery ratio, or % MCID achievement at short- and long-term follow-up between groups. Multivariate analysis also failed to demonstrate any significant differences between the facet distraction groups. CONCLUSION Increased interfacet distance did not correlate with increased neck pain or disability after an ACDF.
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Affiliation(s)
- Brian A Karamian
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Hannah A Levy
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose A Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Dhruv K C Goyal
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Srikanth N Divi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Joseph K Lee
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark F Kurd
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeffrey A Rihn
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alan S Hilibrand
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher K Kepler
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory D Schroeder
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Safety and Efficacy of Autologous Stem Cell Treatment for Facetogenic Chronic Back Pain. J Pers Med 2023; 13:jpm13030436. [PMID: 36983621 PMCID: PMC10058908 DOI: 10.3390/jpm13030436] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/14/2023] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
Background: Chronic back pain due to facet joint syndrome is a common and debilitating condition. Advances in regenerative medicine have shown that autologous unmodified adipose tissue-derived regenerative cells (ADRC) provide several beneficial effects. These regenerative cells can differentiate into various tissues and exhibit a strong anti-inflammatory potential. ADRCs can be obtained from a small amount of fatty tissue derived from the patient’s abdominal fat. Methods: We report long-term results of 37 patients (age 31–78 years, mean 62.5) suffering from “Facet Joint Syndrome” The pathology was confirmed by clinical, radiological examinations and fluoroscopically guided test injections. Then, liposuction was performed. An amount of 50–100 cc of fat was harvested. To recover stem cells from adipose tissue, we use the CE-certified Transpose RT™ system from InGeneron GmbH. The cells were then injected under fluoroscopic control in the periarticular fat. Follow-up examinations were performed at 1 week, 1 year, and 5 years. Results: Every patient reported improved VAS pain at any follow-up (1 week, 1 year, and 5 years) with ADRCs compared to the baseline. Conclusions: Our observational data indicate that facet joint syndrome patients treated with unmodified adipose tissue-derived regenerative cells experience improved the quality of life in the long term.
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Mechanisms behind the Development of Chronic Low Back Pain and Its Neurodegenerative Features. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010084. [PMID: 36676033 PMCID: PMC9862392 DOI: 10.3390/life13010084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/11/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
Chronic back pain is complex and there is no guarantee that treating its potential causes will cause the pain to go away. Therefore, rather than attempting to "cure" chronic pain, many clinicians, caregivers and researchers aim to help educate patients about their pain and try to help them live a better quality of life despite their condition. A systematic review has demonstrated that patient education has a large effect on pain and pain related disability when done in conjunction with treatments. Therefore, understanding and updating our current state of knowledge of the pathophysiology of back pain is important in educating patients as well as guiding the development of novel therapeutics. Growing evidence suggests that back pain causes morphological changes in the central nervous system and that these changes have significant overlap with those seen in common neurodegenerative disorders. These similarities in mechanisms may explain the associations between chronic low back pain and cognitive decline and brain fog. The neurodegenerative underpinnings of chronic low back pain demonstrate a new layer of understanding for this condition, which may help inspire new strategies in pain education and management, as well as potentially improve current treatment.
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12
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Ross A, Gambrill V, Main C. Clinical Outcomes of Amniotic Membrane/Umbilical Cord Particulate in Spinal Disorders: A Retrospective Study. J Pain Res 2022; 15:3971-3979. [PMID: 36561643 PMCID: PMC9767063 DOI: 10.2147/jpr.s375201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
Background Musculoskeletal spinal disorders significantly impact patient populations from everyday workers to military soldiers. Effective treatment is critical to minimize the time between injury and returning to work and daily activities. Injection of amniotic membrane/umbilical cord (AMUC) tissue has demonstrated great potential in reducing patients' pain and has become an increasingly popular treatment option for painful orthopedic disorders. Methods A single-center, retrospective study was conducted on patients diagnosed with musculoskeletal spinal disorders and subsequently treated with AMUC via epidural and facet injections. Demographics and outcomes related to pain were assessed. Pain was verbally reported by the patient on a scale of 0-10 where 0 indicated no pain and 10 indicated worst imaginable pain. Complications and adverse events were also reported. Results A total of 52 patients (average age 40.8 ± 9.6 years) were included in the analysis with diagnoses of spondylosis (n = 44), intervertebral disc degeneration (n = 31), radiculopathy (n = 18), stenosis (n = 2), or other conditions. The cohort's average baseline pain score was 4.9 ± 2.2 with a mean duration of symptoms for 54.2 months (range: 1-300 months). After AMUC injection, pain significantly decreased to 3.4 ± 2.3 at two weeks (p < 0.0001) and 3.5 ± 2.2 at 3-4 weeks (p = 0.0023). For the mean follow-up period of 10.6 ± 5.4 weeks, pain was reduced to 2.8 ± 2.1 (p < 0.0001 vs baseline). No significant complications or adverse events were reported. Conclusion Use of an injectable AMUC, such as CLARIX FLO, may alleviate pain in patients with painful spinal indications of various pathologies. This study provides further evidence of its safety and efficacy in epidural and facet injections. Further studies are warranted to verify these promising results.
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Affiliation(s)
| | | | - Chris Main
- Midwest Bone & Joint Center, Macon, MO, USA,Correspondence: Chris Main, Midwest Bone & Joint Center, Macon, MO, USA, Email
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13
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Du R, Xu G, Bai X, Li Z. Facet Joint Syndrome: Pathophysiology, Diagnosis, and Treatment. J Pain Res 2022; 15:3689-3710. [PMID: 36474960 PMCID: PMC9719706 DOI: 10.2147/jpr.s389602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/17/2022] [Indexed: 11/16/2023] Open
Abstract
Facet joint osteoarthritis (OA) is the most frequent form of facet joint syndrome. Medical history, referred pain patterns, physical examination, and diagnostic imaging studies (standard radiographs, magnetic resonance imaging, computed tomography and single-photon emission computed tomography) may suggest but not confirm lumbar facet joint (LFJ) syndrome as a source of low back pain (LBP). However, the diagnosis and treatment of facet joint syndrome is still controversial and needs further study. It is widely acknowledged that block with local anesthetic is perhaps the most effective method to establish a diagnosis of pain from LFJ. Particularly, there are different rates of success among different populations selected for diagnostic block with various positive criteria. Currently, in addition to conservative treatments for pain such as painkillers, functional exercises, and massage, there are many other methods, including block, denervation of the nerves that innervate the joints by radiofrequency, freezing or endoscopy, and injections. Due to the limited duration of pain relief from neurolysis of medial branch, many scholars have recently turned their targets to dorsal roots and LFJ capsules. Therefore, we reviewed the latest research progress of facet joint syndrome from diagnosis to treatment.
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Affiliation(s)
- Ruihuan Du
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Gang Xu
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Dalian, People’s Republic of China
| | - Xujue Bai
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Zhonghai Li
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Dalian, People’s Republic of China
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14
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Chua M, Salame K, Khashan M, Ofir D, Hochberg U, Ankory R, Lidar Z, Regev GJ. Facet overhang: A novel parameter in the pathophysiology of multifidus muscle atrophy. Clin Anat 2022; 35:1123-1129. [PMID: 35701879 PMCID: PMC9795881 DOI: 10.1002/ca.23923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/05/2022] [Accepted: 06/09/2022] [Indexed: 12/30/2022]
Abstract
The relationship between degenerative zygapophysial joint (facet) arthropathy and multifidus muscle atrophy has not been rigorously evaluated. The purpose of this study was to determine if specific morphological features of degenerative facet arthropathy are correlated with multifidus muscle atrophy. We retrospectively reviewed medical records and imaging studies of patients with lumbar spinal stenosis. Facet overhang, bridging osteophyte formation, facet effusion, and facet angles were evaluated by univariable and multivariable regression to identify independent associations with deep and superficial parts of the multifidus total cross-sectional area (tCSA), functional cross-sectional area (fnCSA), and fatty infiltration (FI). Facet overhang was classified as severe in 50 females (53.2%) versus 56 males (36.9%) (p = 0.030). Severity of facet overhang and female sex were independently associated with smaller deep part of the multifidus tCSA and fnCSA as well as higher FI, reflecting greater atrophy of the deep region compared to total muscle mass. In comparison, severe facet overhang (p < 0.001; OR = 3.47, 95% CI = 2.13-5.66) and female sex (p < 0.001; OR = 4.19, 95% CI = 2.58-6.79) were independently associated only with higher superficial part of the multifidus FI, reflecting muscle steatosis without significant lean muscle atrophy. In patients with degenerative lumbar spinal stenosis, facet overhang is an independent risk factor for deep part of the multifidus atrophy. Bridging osteophyte formation, facet effusion, and facet angles were not independently associated with deep part of the multifidus atrophy.
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Affiliation(s)
- Michelle Chua
- Department of NeurosurgeryTel‐Aviv Sourasky Medical CenterTel‐Aviv,Sackler Faculty of MedicineTel Aviv UniversityTel‐Aviv
| | - Khalil Salame
- Department of NeurosurgeryTel‐Aviv Sourasky Medical CenterTel‐Aviv,Sackler Faculty of MedicineTel Aviv UniversityTel‐Aviv
| | - Morsi Khashan
- Department of NeurosurgeryTel‐Aviv Sourasky Medical CenterTel‐Aviv,Sackler Faculty of MedicineTel Aviv UniversityTel‐Aviv
| | - Dror Ofir
- Department of NeurosurgeryTel‐Aviv Sourasky Medical CenterTel‐Aviv,Sackler Faculty of MedicineTel Aviv UniversityTel‐Aviv
| | - Uri Hochberg
- Department of NeurosurgeryTel‐Aviv Sourasky Medical CenterTel‐Aviv,Sackler Faculty of MedicineTel Aviv UniversityTel‐Aviv
| | - Ran Ankory
- Department of NeurosurgeryTel‐Aviv Sourasky Medical CenterTel‐Aviv,Sackler Faculty of MedicineTel Aviv UniversityTel‐Aviv
| | - Zvi Lidar
- Department of NeurosurgeryTel‐Aviv Sourasky Medical CenterTel‐Aviv,Sackler Faculty of MedicineTel Aviv UniversityTel‐Aviv
| | - Gilad J. Regev
- Department of NeurosurgeryTel‐Aviv Sourasky Medical CenterTel‐Aviv,Sackler Faculty of MedicineTel Aviv UniversityTel‐Aviv
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15
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Chung HY, Huang JX, Lee KH, Tsang HHL, Lau CS, Chan SCW. MRI lesions in SpA: a comparison with noninflammatory back pain using propensity score adjustment method. Ther Adv Musculoskelet Dis 2022; 14:1759720X221119250. [PMID: 36051632 PMCID: PMC9425894 DOI: 10.1177/1759720x221119250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/26/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Magnetic resonance imaging (MRI) is important in the management of axial spondyloarthritis (SpA). However, many MRI lesions are not exclusive to axial SpA. Further characterization of these lesions may lead to better clinical decisions. Objective: The objective of this study was to compare the frequency of individual spinal MRI lesions between axial SpA and noninflammatory back pain. The factors associated with individual lesions in participants with axial SpA were also determined. Design: This was a cross-sectional observational study. Methods: MRI lesions in 447 participants with axial SpA and 122 participants with noninflammatory back pain were compared using the propensity score adjustment method. Individual lesions included discovertebral lesions (DVL), Modic type 1 lesions, DVL without Modic type 1 lesions, facet joint lesions, costovertebral joint lesions, corner inflammatory lesions (CIL), and fatty corner lesions (FCL). The factors associated with the lesions were determined using regression analyses. Results: Among participants with axial SpA, 81.9% were HLA-B27-positive, 55.0% had radiographic axial SpA, and 60.5% had radiographic features of spinal damage (mSASSS >2). Almost half (48.6% in axial SpA versus 31.1% in noninflammatory back pain) had inflammatory lesions on spinal MRI. In propensity score matching with noninflammatory back pain, axial SpA had an increased occurrence of DVL without Modic type 1 lesion (OR = 3.43, p = 0.01), costovertebral lesion (OR = 11.89, p = 0.02), number of CIL (B = 1.19, p < 0.001), and number of FCL (B = 3.33, p < 0.001). Similar associations were found in the regression models in the radiographic axial SpA subgroup: DVL without Modic type 1 lesion (OR = 2.46, p = 0.001), costovertebral lesion (OR = 3.86, p < 0.001), number of CIL (B = 1.13, p < 0.001), and FCL (B = 2.29, p < 0.01). Conclusion: MRI lesions including DVL without Modic type 1, costovertebral joint lesions, CIL, and FCL were more specific in axial SpA.
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Affiliation(s)
- Ho Yin Chung
- Division of Rheumatology and Clinical Immunology, The University of Hong Kong, Hong Kong
| | - Jin Xian Huang
- Division of Rheumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Kam Ho Lee
- Department of Radiology, Queen Mary Hospital, Hong Kong
| | - Helen Hoi Lun Tsang
- Division of Rheumatology and Clinical Immunology, The University of Hong Kong, Hong Kong
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, The University of Hong Kong, Hong Kong
| | - Shirley Chiu Wai Chan
- Division of Rheumatology and Clinical Immunology, The University of Hong Kong, Queen Mary Hospital, 102 Pok Fu Lam Road, Hong Kong
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16
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The retrospective analysis of platelet-rich plasma and corticosteroid injection under epiduroscopic guidance for radiculopathy in operated or unoperated patients for lumbar disc herniation. Turk J Phys Med Rehabil 2022; 68:409-417. [DOI: 10.5606/tftrd.2022.9005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/13/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives: Epiduroscopy is a treatment method that can be applied to operated or non-operated patients with lumbar disc pathology. The aim of our study was to investigate and compare the efficacy of corticosteroid and platelet-rich plasma (PRP) therapy that we have injected in epidural and foraminal spaces under the guidance of epiduroscopy in the operated or unoperated patients with radicular pain.
Patients and methods: The retrospective study was conducted with 62 patients (40 females, 22 males; mean age: 48±12.3 years; range, 20 to 75 years) between January 2014 and September 2020. Of the patients, 32 were unoperated, whereas 30 were operated. All the patients had radicular pain. All the patients were evaluated by the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) at the start, on the 10th day, and at one and six months after the procedure by polyclinic control and by a phone call for their last follow-up.
Results: The VAS and ODI scores of patients treated with corticosteroid and PRP were decreased on the 10th day, at one and six months and the last follow-up, and this decrease was statistically significant.
Conclusion: Both PRP and corticosteroid injections were effective in pain scores during short-term and long-term follow-ups owing to the contribution of epiduroscopic intervention by allowing local administration of PRP or corticosteroids and analgesic agents as well as its mechanical adhesiolysis effect.
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17
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Zhang K, Gao L, Wang HX, Ye L, Shi YY, Yang WY, Li YN, Li Y. Interleukin-18 Inhibition Protects Against Intervertebral Disc Degeneration via the Inactivation of Caspase-3/9 Dependent Apoptotic Pathways. Immunol Invest 2022; 51:1895-1907. [PMID: 35921125 DOI: 10.1080/08820139.2022.2077113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The present study was designed to identify and understand the potential effectiveness of therapeutic target in intervertebral disc degeneration (IVDD) and its regulation mechanism. METHODS The role and mechanism of interleukin-18 (IL-18) in the disease were investigated. The IVDD degenerative nucleus pulposus (NP) tissues from the human and mouse models were used.A total of three groups of Male BALB/c mice were randomly made i.e control, IVDD, and IVDD+Ad-shIL-18 groups. After Ad-shIL-18 transfection, the expression of ECM synthesis related protein Aggrecan (ACAN) and Collagen II, apoptotic effector Caspases (Caspase-3, 8, 9, 12 and Cleaved-Caspase 3, 8, 9, 12), pro-apoptotic gene Bax and anti-apoptotic factors Bcl-2 in NP cells of the human were evaluated. RESULTS The results of our study revealed that the mRNA and protein expression levels of IL-18 were notably increased in the NP tissues of IVDD patients and mice models. In the IVDD mice model, Ad-sh-IL-18 treatment reversed the IVDD progression. The levels of Aggrecan and Collagen II, contributing to ECM degradation in NP cells, were also significantly increased. Additionally, Ad-sh-IL-18 could inhibit the NP cell's apoptosis via regulating the caspase-3/9 pathway. CONCLUSION The IL-18 knockdown via the caspase-3/9 pathway, might reduce the NP cell's death as well as the imbalance between catabolism and anabolism of ECM in IVDD.
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Affiliation(s)
- Kai Zhang
- Department of Spine Surgery, HanDan Central Hospital, Handan, Hebei, China
| | - Lei Gao
- Department of Bone Oncology, Second Hospital of Zhangjiakou, Zhangjiakou, Hebei, China
| | - Hai-Xu Wang
- Department of Orthopedics, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lei Ye
- Department of Infection Control, HanDan Central Hospital, Handan, Hebei, China
| | - Yan-Yan Shi
- Department of Spine Surgery, HanDan Central Hospital, Handan, Hebei, China
| | - Wu-Yan Yang
- Department of Spine Surgery, HanDan Central Hospital, Handan, Hebei, China
| | - Ya-Nan Li
- Department of Neurology, HanDan Central Hospital, Handan, Hebei, China
| | - Yan Li
- Department of Spine Surgery, HanDan Central Hospital, Handan, Hebei, China
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18
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Castellanos R. Injectable amniotic membrane/umbilical cord particulate for facet joint syndrome: A retrospective, single-center study. J Back Musculoskelet Rehabil 2022; 35:559-564. [PMID: 34511481 DOI: 10.3233/bmr-200330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Facet joint syndrome (FJS) pain is a significant contributor to back pain and has a high rate of opioid prescription. Unfortunately, there are a limited number of therapeutic options for these patients. OBJECTIVE To evaluate the safety and effectiveness of amniotic membrane/umbilical cord particulate (AM/UC) in managing FJS pain. METHODS A single-center, investigator-initiated, retrospective study was performed on consecutive patients with FJS pain who received intra- or peri-articular injection of AM/UC between July 1, 2018 and July 26, 2019. Primary outcome was change in Patient Global Impression of Change (PGIC) at 6 weeks, 3 months, 6 months, and 12 months to assess the self-reported percent improvement relative to baseline. Safety was assessed by AM/UC- and procedure-related complications. Paired t-tests were used to determine whether there is a statistically significant improvement of pain post-injection compared to baseline. RESULTS There were a total of 54 patients (69.7 ± 13.4 years; 31 female) presenting baseline pain score of 9.2 ± 1.0 despite prior treatments of activity modification (66.7%), NSAIDs (61.1%), opioids (37.0%), and physical therapy (35.2%). Mean GPIC improvement was 65.3%, 67.5%, 56.9%, and 56.7% among responders30, respectively. There were no complications. CONCLUSION This study supports the safety and effectiveness of AM/UC particulate injection in managing FJS pain.
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19
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Karamian BA, Levy HA, Boere P, Yalla GR, Canseco JA, Chang M, Divi SN, Fang T, Millhouse PW, Lendner M, Hilibrand AS, Vaccaro AR, Kepler CK, Markova DZ, Schroeder GD. Do Inflammatory Cytokines Affect Patient Outcomes After ACDF? Clin Spine Surg 2022; 35:137-143. [PMID: 35351842 DOI: 10.1097/bsd.0000000000001318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE The aim was to determine the relationship between serum inflammatory mediators, preoperative cervical spine disease severity, and clinical outcomes after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Given the role of the inflammatory cascade in spinal degenerative disease, it has been hypothesized that inflammatory markers may serve as a predictor of patient outcomes after surgery. MATERIALS AND METHODS All patients over age 18 who underwent ACDF for cervical spondylosis with associated radiculopathy and/or myelopathy between 2015 and 2017 from a single institution were prospectively recruited. Preoperative serum inflammatory markers including interleukin (IL)-6, IL-8, tumor necrosis factor-α, high-mobility group box-1 (HMGB1), and white blood cells were measured and correlated to patient demographics, surgical characteristics, duration of symptoms, previous opioid use, and preoperative and 1-year postoperative patient-reported outcomes measures (PROMs) including the neck disability index (NDI), visual analog scale neck pain, visual analog scale arm pain, and Physical and Mental Component Scores of the Short Form-12 (PCS and MCS, respectively) using spearman's rho coefficient. RESULTS A total of 77 patients were enrolled with follow-up PROMs available for 62% (n=48) of patients at a minimum of 1-year after ACDF. The absolute concentrations of IL-6 and tumor necrosis factor-α were found to be weakly correlated with one another (ρ=0.479). Preoperative symptoms lasting <1-year were weakly correlated with elevation in HMGB1 (ρ=0.421). All other patient demographics exhibited negligible correlation with the preoperative inflammatory markers. Lower preoperative PCS (ρ=0.355) and higher preoperative NDI (ρ=0.336) were weakly correlated with elevated HMGB1. Lower MCS (ρ=0.395) and higher NDI (ρ=0.317) preoperatively were weakly correlated with elevated white blood cells. Postoperative improvement in MCS (ρ=0.306) and MCS recovery ratio (ρ=0.321) exhibited a weakly positive correlation with IL-6. CONCLUSION Preoperative cytokine levels demonstrated minimal correlation with preoperative symptoms or clinical improvement, suggesting that profiling of patient cytokines has limited utility in predicting outcomes after ACDF. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Hannah A Levy
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Payton Boere
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Goutham R Yalla
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Michael Chang
- Department of Orthopaedic Surgery, Rothman Institute
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Srikanth N Divi
- Department of Orthopaedic Surgery, Rothman Institute
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Taolin Fang
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Paul W Millhouse
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Mayan Lendner
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Dessislava Z Markova
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
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20
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Factors Associated with Pain Intensity and Walking Disability After Lumbar Fusion: A Longitudinal Study. Spine (Phila Pa 1976) 2022; 47:597-606. [PMID: 35066535 DOI: 10.1097/brs.0000000000004324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective longitudinal study. OBJECTIVE To identify the preoperative factors associated with postoperative lumbar fusion recovery in back or leg pain, self-reported walking time, and gait speed over a 6-month period. SUMMARY OF BACKGROUND DATA The demand for lumbar fusion surgeries has significantly increased over the years. Yet, some patients report persistent postsurgical pain and poor functional outcomes. Unfortunately, the associated risk factors are not well understood. METHODS The study analyzed 232 subjects with mono- or bisegmental lumbar fusion surgery who underwent standardized assessment preoperatively and at 4, 12, and 24weeks postoperatively. Preoperative variables collected were demographic, clinical, and psychological variables. Back or leg pain was measured by the Numeric Pain Rating Scale. Walking disability was measured by self-reported walking time and performance-based fast gait speed. Risk factors of pain and walking disability over time were identified using ordinal and linear mixed-effects modeling. RESULTS At 6 months post-surgery, 17% of patients reported having moderate or severe back/leg pain and 24% were unable to walk longer than 30 minutes. Greater preoperative self-reported leg weakness frequency and body-mass-index (BMI) were strongly associated with greater pain and walking disability. Additionally, greater preoperative depression symptoms were associated with greater back/leg pain (adjusted odds ratio = 4.0) and shorter walking time (adjusted odds ratio = 2.7)-but not with slower gait speed (difference = 0.01 m/s). Old age and female gender were strongly associated with gait speed but not with self-reported walking time. CONCLUSION A sizable proportion of patients had poor pain and walking outcomes even at 6 months post-surgery. Preoperative leg weakness and BMI were consistent risk factors and patients with greater depression symptoms may have poorer self-reported outcomes. Although requiring validation, our study has identified potentially modifiable risk factors which may give clinicians an opportunity to provide early (preoperative) and targeted intervention strategies to optimize postoperative outcomes. UNLABELLED Level of Evidence: NA.
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21
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Piri R, Nøddeskou-Fink AH, Gerke O, Larsson M, Edenbrandt L, Enqvist O, Høilund-Carlsen PF, Stochkendahl MJ. PET/CT imaging of spinal inflammation and microcalcification in patients with low back pain: A pilot study on the quantification by artificial intelligence-based segmentation. Clin Physiol Funct Imaging 2022; 42:225-232. [PMID: 35319166 PMCID: PMC9322590 DOI: 10.1111/cpf.12751] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 03/11/2022] [Indexed: 12/29/2022]
Abstract
Background Current imaging modalities are often incapable of identifying nociceptive sources of low back pain (LBP). We aimed to characterize these by means of positron emission tomography/computed tomography (PET/CT) of the lumbar spine region applying tracers 18F‐fluorodeoxyglucose (FDG) and 18F‐sodium fluoride (NaF) targeting inflammation and active microcalcification, respectively. Methods Using artificial intelligence (AI)‐based quantification, we compared PET findings in two sex‐ and age‐matched groups, a case group of seven males and five females, mean age 45 ± 14 years, with ongoing LBP and a similar control group of 12 pain‐free individuals. PET/CT scans were segmented into three distinct volumes of interest (VOIs): lumbar vertebral bodies, facet joints and intervertebral discs. Maximum, mean and total standardized uptake values (SUVmax, SUVmean and SUVtotal) for FDG and NaF uptake in the 3 VOIs were measured and compared between groups. Holm–Bonferroni correction was applied to adjust for multiple testing. Results FDG uptake was slightly higher in most locations of the LBP group including higher SUVmean in the intervertebral discs (0.96 ± 0.34 vs. 0.69 ± 0.15). All NaF uptake values were higher in cases, including higher SUVmax in the intervertebral discs (11.63 ± 3.29 vs. 9.45 ± 1.32) and facet joints (14.98 ± 6.55 vs. 10.60 ± 2.97). Conclusion Observed intergroup differences suggest acute inflammation and microcalcification as possible nociceptive causes of LBP. AI‐based quantification of relevant lumbar VOIs in PET/CT scans of LBP patients and controls appears to be feasible. These promising, early findings warrant further investigation and confirmation.
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Affiliation(s)
- Reza Piri
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Lars Edenbrandt
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Physiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olof Enqvist
- Eigenvision AB, Malmö, Sweden.,Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Poul-Flemming Høilund-Carlsen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette J Stochkendahl
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark
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22
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Ye W, Wang Z, Zhu Y, Cai W. Analysis of Functional Outcomes and Risk Factors for Facet Joint Distraction During Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy. World Neurosurg 2022; 162:e301-e308. [PMID: 35259505 DOI: 10.1016/j.wneu.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to clarify functional outcomes of facet joint distraction (FJD) and identify specific risk factors for excessive FJD during single-level anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). METHODS This study retrospectively analyzed 100 patients who underwent single-level ACDF for CSM from January 2016 to May 2020. Anteroposterior and lateral radiographs were obtained before surgery and 12 months after surgery. Radiographic parameters including anterior intervertebral height (AIH), posterior intervertebral height, facet joint gap, cage posterior depth (CPD), upper vertebral length, cervical segmental Cobb angle (CSCA), C2-C7 Cobb angle, and C2-C7 sagittal vertical axis were analyzed. Functional outcomes were evaluated using the modified Japanese Orthopedic Association Score, visual analog scale (VAS), and Neck Disability Index (NDI). RESULTS Comparison between the appropriate FJD and excessive FJD groups showed statistically significant differences in the NDI, VAS, CPD, and ΔAIH (P < 0.05). Multivariate logistic regression analysis showed that independent factors associated with excessive FJD were as follows: a ΔAIH > 2.28 mm (odds ratio [OR] = 6.792, 95% confidence interval [CI] = 1.885-24.470, P = 0.003), CPD > 12.45 mm (OR = 5.876, 95% CI = 1.828-18.895, P = 0.003), and post-CSCA < 0° (OR = 6.251, 95% CI = 1.275-30.633, P = 0.024). Furthermore, receiver operating characteristic curve analysis for the multilevel logistic regression model produced an area under the curve of 0.783 (P < 0.001). CONCLUSION Patients with an FJD of >0.905 mm had worse NDI and VAS pain scores, but not a poorer modified Japanese Orthopedic Association Score recovery rate. Our findings suggested that a ΔAIH > 2.28 mm, CPD > 12.45 mm, and post-CSCA < 0° were independent risk factors for excessive FJD after single-level ACDF for CSM.
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Affiliation(s)
- Wu Ye
- Department of Orthopaedics, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhuanghui Wang
- Department of Orthopaedics, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yufeng Zhu
- Department of Orthopaedics, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Weihua Cai
- Department of Orthopaedics, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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Ruggiero E, Bonaccio M, Costanzo S, Esposito S, Di Castelnuovo A, Carpineta E, Cerletti C, Donati MB, Paolini S, Esposito V, de Gaetano G, Innocenzi G, Iacoviello L. Dietary factors and the risk of lumbar spinal stenosis: A case-control analysis from the PREFACE study. Nutr Metab Cardiovasc Dis 2022; 32:90-97. [PMID: 34802849 DOI: 10.1016/j.numecd.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS There is a lack of knowledge on the association of dietary factors and Lumbar Spinal Stenosis (LSS). We evaluated the association of a Mediterranean diet (MD), its major food components and ultra-processed food (UPF) with the risk of LSS. METHODS AND RESULTS Participants were recruited from the Neurosurgery Department of the IRCCS Neuromed, Italy. The study sample consisted of 156 cases of LSS, and 312 controls matched 1:2 for sex, age (±6 months) and physical activity, without a history or clinical evidence of LSS who were identified from the general population. Adherence to MD was assessed by the Mediterranean Diet Score based on 9 food groups. UPF was defined according to NOVA classification and calculated as the ratio (%) of UPF (g/d) on total food consumed (g/d). In multivariable-adjusted analysis, a 2-point increase in the MD score was not associated with LSS risk (OR: 1.02, 95% CI: 0.72-1.46). An increment of 10 g/d of fruits and nuts, cereals or fish led to lower odds of LSS (OR: 0.97, 95% CI: 0.95-0.99; OR: 0.88, 95% CI: 0.82-0.94; OR: 0.87, 95% CI: 0.76-0.99, respectively). Additionally, 1% increment in the consumption of UPF in the diet was independently associated with higher LSS risk (OR: 1.09, 95% CI: 1.04-1.14). CONCLUSION A diet rich in fruits, cereals, fish is associated with lower risk of LSS while a large dietary share of UPF increases the risk of this disease. Further studies with a prospective design and larger sample sizes are warranted.
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Affiliation(s)
- Emilia Ruggiero
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli, IS, Italy
| | - Marialaura Bonaccio
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli, IS, Italy
| | - Simona Costanzo
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli, IS, Italy
| | - Simona Esposito
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli, IS, Italy
| | | | | | - Chiara Cerletti
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli, IS, Italy
| | | | - Sergio Paolini
- Neurosurgery Department, IRCCS NEUROMED, Pozzilli, IS, Italy
| | | | - Giovanni de Gaetano
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli, IS, Italy
| | | | - Licia Iacoviello
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli, IS, Italy; Research Center in Epidemiology and Preventive Medicine (EPIMED), Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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Dwianingsih EK, Sakti YM, Magetsari R, Hutahaean DYP, Sakadewa GP, Lasmana PD, Budhiparama NC, Dwianingsih EK. Correlation of Tumor Necrosis Factor-α Expression with Pain Level in Degenerative Lumbar Canal Stenosis Patients. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Pain in degenerative lumbar canal stenosis is caused by osteoarthritis of a facet joint and intervertebral disc degeneration. Some inflammatory mediators such as tumor necrosis factor (TNF)-α are present in degenerative lumbar canal stenosis. This study aimed to evaluate the correlation of pain and functional pre-operative scores with the expression of TNF-α in nucleus pulposus, annulus fibrosus, and facet joint.
Methods: Patients diagnosed with degenerative lumbar canal stenosis and planned for surgical treatment were included in this study. Patients with history of fracture, neoplasm, and/or infection of the spine were excluded. Tissue samples were collected from the nucleus pulposus, annulus fibrosus, facet joint, flavum ligament and paraspinal muscles of the spine during the surgery. TNF-α expression was examined semi-quantitively and correlated with the axial and radicular pain that were measured using Visual Analog Score (VAS) score. The result was then statistically analyzed.
Results: The expression of TNF-α in the paraspinal muscle (6.30±14.20) was significantly higher compared to other locations. TNF-α expression in the facet joint group was significantly correlated with the intensity of low back pain measured by VAS score (r=0.893, p < 0.001), and pre-operative functional outcome based on Oswestry Disability Index (ODI) (r=0.948, p < 0.001).
Conclusion: TNF-α expression, especially in the facet joint, is significantly associated with the pain intensity and pre-operative ODI that allow pain reduction with less invasive treatment in lumbar canal stenosis patients.
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Chen F, Wu T, Bai C, Guo S, Huang W, Pan Y, Zhang H, Wu D, Fu Q, Chen Q, Li X, Li L. Serum apolipoprotein B/apolipoprotein A1 ratio in relation to intervertebral disk herniation: a cross-sectional frequency-matched case-control study. Lipids Health Dis 2021; 20:79. [PMID: 34325707 PMCID: PMC8320064 DOI: 10.1186/s12944-021-01502-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/12/2021] [Indexed: 12/04/2022] Open
Abstract
Study design This was a cross-sectional frequency-matched case–control study. Background and aim The serum lipid profile of lipoprotein(a) [Lp(a)] level and apolipoprotein B/apolipoprotein A1 ratio (Apo B/Apo A1) ratio were found to be more representative for serum lipid level and were recognized as the independent risk factors for various diseases. Although the blood levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were found to be associated with symptomatic intervertebral disk herniation (IDH), no studies to date have evaluated the association of Apo AI, Apo B, Lp(a), and Apo B/Apo AI levels with symptomatic IDH. This study aimed to assess the link between blood lipid levels and symptomatic IDH. Method The study included 1839 Chinese patients. Of these, 918 patients were diagnosed with IDH and enrolled in the experimental group. A control group of 921 patients underwent a physical examination during the same period. The serum lipid levels of TC, TG, LDL-C, HDL-C, Lp(a), Apo B, and Apo B/Apo AI were examined and analyzed. The control group comprised randomly selected patients who met the baseline levels of the aforementioned lipid molecules. Results Patients with IDH exhibited significantly higher TC, TG, LDL, Apo B, and Lp(a) levels than controls. The percentage of high TC, high TG, high LDL, high Apo B, and high Lp(a) were obviously higher in the IDH group than in the control group. However, hyperlipidemia had no relationship with the degenerated segment of the IDH (P = 0.201). The odds ratio (OR) for the incidence of IDH with elevated levels of LDL-C, TC, TG, Lp(a), Apo B, and Apo B/Apo AI was 1.583, 1.74, 1.62, 1.58, 1.49, and 1.39, respectively. The correlation analysis revealed the correlation between elevated LDL-C, TC, TG, Apo B, Lp(a), and incidence of IDH was significant (R2LDL = 0.017; R2TC = 0.004; R2TG = 0.015; R2Apo B = 0.004; R2Lp(a) = 0.021) (P < 0.05). Conclusion This study suggested that elevated levels of serum TC, TG, LDL, Apo B, Lp(a), and Apo B/Apo AI were associated with a higher risk of IDH. This study provided useful information to identify a population that might be at risk of developing IDH based on elevated lipid levels.
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Affiliation(s)
- Fei Chen
- Department of Cardiovascular, Pingxiang Hospital of Southern Medical University, Pingxiang, Jiangxi Province, 337055, China
| | - Tongde Wu
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, People's Republic of China
| | - Chong Bai
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, People's Republic of China
| | - Song Guo
- Department of Orthopedics, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | - Wenjun Huang
- Department of Cardiovascular, Pingxiang Hospital of Southern Medical University, Pingxiang, Jiangxi Province, 337055, China
| | - Yaqin Pan
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, People's Republic of China
| | - Huiying Zhang
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, People's Republic of China
| | - Desheng Wu
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, People's Republic of China
| | - Qiang Fu
- Department of Orthopedics, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | - Qi Chen
- Department of Cardiovascular, The Second Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, People's Republic of China.
| | - Xinhua Li
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, People's Republic of China. .,Department of Orthopedics, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China.
| | - Lijun Li
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 JiMo Road, Shanghai, 200120, People's Republic of China.
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Wang S, Zhu J, Sun K, Chen R, Cao J, You R, Liu A, Zhao F, Shi J. Clinical impact and imaging results after a modified procedure of ACDF: a prospective case-controlled study based on ninety cases with two-year follow-up. BMC Musculoskelet Disord 2021; 22:605. [PMID: 34217257 PMCID: PMC8254952 DOI: 10.1186/s12891-021-04229-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/07/2021] [Indexed: 11/18/2022] Open
Abstract
Study design This is a prospective case-controlled study. Background To analyze the postoperative axial pain and cage subsidence of patients presenting with cervical spondylotic myelopathy (CSM) after a modified procedure of ACDF (mACDF). Methods Ninety patients with CSM were prospectively collected from 2014 to 2018. The patients were divided into spread group and non-spread group (48:42 ratio) according to the cage placement with or without releasing the Caspar cervical retractor after decompression. Spread group received conventional ACDF and non-spread group received mACDF. Patients were followed-up for at least 24 months after surgery. Radiologic data, including height of intervertebral space and Cobb Angle, were collected. Nervous system function was obtained using JOA scores, and level of pain was assessed using VAS scores. Results A total of 90 patients were enrolled and the patients were divided into spread group (n = 48) and none-spread group(n = 42). Cage subsidence of (spread group vs none-spread group) was (0.82 ± 0.68 vs 0.58 ± 0.81) mm, (0.64 ± 0.77 vs 0.34 ± 0.46) mm, (0.48 ± 0.43 vs 0.25 ± 0.28) mm, and (0.45 ± 0.47 vs 0.17 ± 0.32) mm at 3 months, 6 months, 12 months and 24 months, respectively. The period exhibiting the most decrease of the height of intervertebral space was 3 months postoperatively. However, there was no statistical difference in the height of intervertebral space, JOA or VAS scores at the final follow-up between the two groups. Conclusions The mACDF can avoid excessive distraction by releasing the Caspar Cervical retractor, restore the “natural height” of cervical vertebra, relieve immediate pain after surgery, and prevent rapid Cage subsidence and the loss of cervical curvature.
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Affiliation(s)
- Shunmin Wang
- 910 Hospital of China Joint Logistics Support Force, 180 Garden Road, Fengze District, Quanzhou City, Fujian Province, China
| | - Jian Zhu
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, No.415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Kaiqiang Sun
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, No.415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Rongzi Chen
- 910 Hospital of China Joint Logistics Support Force, 180 Garden Road, Fengze District, Quanzhou City, Fujian Province, China
| | - Jie Cao
- 910 Hospital of China Joint Logistics Support Force, 180 Garden Road, Fengze District, Quanzhou City, Fujian Province, China
| | - Ruijin You
- 910 Hospital of China Joint Logistics Support Force, 180 Garden Road, Fengze District, Quanzhou City, Fujian Province, China
| | - Aigang Liu
- 910 Hospital of China Joint Logistics Support Force, 180 Garden Road, Fengze District, Quanzhou City, Fujian Province, China
| | - Feng Zhao
- 910 Hospital of China Joint Logistics Support Force, 180 Garden Road, Fengze District, Quanzhou City, Fujian Province, China.
| | - Jiangang Shi
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, No.415 Fengyang Road, Shanghai, 200003, People's Republic of China.
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Sainoh T, Orita S, Miyagi M, Suzuki-Narita M, Sakuma Y, Oikawa Y, Kubota G, Sato J, Shiga Y, Fujimoto K, Eguchi Y, Koda M, Aoki Y, Akazawa T, Furuya T, Nakamura J, Takahashi H, Maki S, Inoue M, Kinoshita H, Norimoto M, Sato T, Sato M, Suzuki M, Enomoto K, Takaoka H, Mizuki N, Hozumi T, Tsuchiya R, Kim G, Otagiri T, Mukaihata T, Hishiya T, Ohtori S, Inage K. Improvements in Intractable Lumbar and LowerExtremity Symptoms after Systemic Administration of Tocilizumab, an Anti-interleukin-6 Receptor Antibody. Asian Spine J 2021; 16:99-106. [PMID: 34015207 PMCID: PMC8873999 DOI: 10.31616/asj.2020.0283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/25/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design Prospective cohort study (open-label, single-arm, and non-blinded). Purpose This study aims to determine the effects of systemic administration of tocilizumab, an anti-interleukin-6 (IL-6) receptor antibody on refractory low back pain and leg symptoms. Overview of Literature IL-6 overexpression is associated with neuropathic pain pathogenesis, which is potentially followed by chronic low back pain, including leg pain and numbness. This finding suggest that inhibition of IL-6 at the site of pain or in the transmission pathway could provide novel therapeutic targets for chronic low back pain. Methods This prospective, single-arm study included 11 patients (eight men; mean age, 62.7 years) with ≥3-months’ chronic pain history due to lumbar disease. Subcutaneous TCZ injections were administered twice, at a 2-week interval. We evaluated low back pain, leg pain, and leg numbness using numeric rating scales and the Oswestry Disability Index (ODI; baseline and 6 months postinjection); serum IL-6 and tumor necrosis factor-α levels (baseline and 1 month postinjection); and clinical adverse events. Results Intractable symptoms reduced after TCZ administration. Low back pain improved for 6 months. Improvements in leg pain and numbness peaked at 4 and 1 month, respectively. Improvements in ODI were significant at 1 month and peaked at 4 months. Serum IL-6 was increased at 1 month. IL-6 responders (i.e., patients with IL-6 increases >10 pg/mL) showed particularly significant improvements in leg pain at 2 weeks, 1 month, and 2 months compared with nonresponders. We observed no apparent adverse events. Conclusions Systemic TCZ administration improved symptoms effectively for 6 months, with peak improvements at 1–4 months and no adverse events. Changing serum IL-6 levels correlated with leg pain improvements; further studies are warranted to elucidate the mechanistic connections between lumbar disorders and inflammatory cytokines.
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Affiliation(s)
- Takeshi Sainoh
- Department of Orthopaedic Surgery, Sainou Hospital, Toyama, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.,Center for Frontier Medical Engineering, Chiba University, Chiba, Japan
| | - Masayuki Miyagi
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Sagamihara, Japan
| | - Miyako Suzuki-Narita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.,Department of Environmental Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshihiro Sakuma
- Department of Orthopaedic Surgery, Kanazawa Hospital, Yokohama, Japan
| | - Yasuhiro Oikawa
- Department of Orthopaedic Surgery, Chiba Children's Hospital, Chiba, Japan
| | - Go Kubota
- Department of Orthopaedic Surgery, Chiba Prefectural Sawara Hospital, Katori, Japan
| | - Jun Sato
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuki Fujimoto
- Department of Orthopaedic Surgery, Kohnodai Hospital, Ichikawa, Japan
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masao Koda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Tsutomu Akazawa
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Junichi Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Satoshi Maki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masahiro Inoue
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
| | | | - Masaki Norimoto
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Takashi Sato
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masashi Sato
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masahiro Suzuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keigo Enomoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiromitsu Takaoka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Norichika Mizuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Hozumi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ryuto Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Geundong Kim
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takuma Otagiri
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomohito Mukaihata
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takahisa Hishiya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Wang Z, Liu Z, Wang ZW, Ding WY, Yang DL. Does cervical facet degeneration impact surgical outcomes and sagittal balance in patients with radiculopathy? BMC Surg 2021; 21:225. [PMID: 33941153 PMCID: PMC8091712 DOI: 10.1186/s12893-021-01227-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/26/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose In our present study, we aimed to investigate (1) whether cervical facet degeneration (FD) affects the clinical functional scores of patients with cervical radiculopathy after single-segment anterior cervical discectomy fusion (ACDF) and (2) whether FD affects the sagittal parameters of the cervical spine. Methods A total of 120 enrolled patients who underwent single-segment ACDF for radiculopathy with more than 2 years of follow-up were classified into two groups based on whether the preoperative mean FD was greater than or less than the mean FD grading score: mild FD group (mean score ≤ 2, n = 102) or severe FD group (mean score > 2, n = 48). Sagittal alignment changes and clinical functional scores were compared between the 2 groups. The relevant factors for FD were identified using multivariate logistic regression. Results Age, duration of symptoms, disc height and interfacet distance were independently associated with preoperative FD (age: P < 0.001; duration of symptoms: P = 0.020; disc height: P < 0.001; interfacet distance: P = 0.045). Compared with the mild FD group, the preoperative VAS (neck pain) score and NDI of the severe FD group were also higher, and the improvement of neck symptoms was better during the follow-up period. However, all clinical scores and radiographic parameters showed no significant differences during the 2-year follow-up. Additionally, no significant differences in the sagittal parameter changes were presented. Conclusion Patients with severe FD tended to experience more severe neck pain before surgery and greater improvement of neck symptoms at the follow-up visit. However, 2-year clinical efficacy and sagittal alignment after ACDF may not be markedly affected by preoperative FD severity. ACDF is considered to be a good choice for patients with radiculopathy, especially for patients with severe FD.
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Affiliation(s)
- Zheng Wang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Zhen Liu
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Zhi-Wei Wang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Wen-Yuan Ding
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Da-Long Yang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China.
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Ghaffari-Rafi A, Nosova K, Kim K, Goodarzi A. Intradural Disc Herniation in the Setting of Congenital Lumbar Spinal Stenosis. Neurochirurgie 2021; 68:335-341. [PMID: 33901524 DOI: 10.1016/j.neuchi.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/10/2021] [Accepted: 04/11/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Accounting for an estimated 1.10-1.76% of all lumbar herniations, lumbar intradural disc herniation (IDH) occurs primarily in males during the fourth to fifth decades of life. While not validated, congenital lumbar spinal stenosis (CLSS) is implicated as one precipitating factor for IDH. CASE REPORT We report 28-year-old Hispanic female with CLSS, severe obesity, and degenerative disk disease, with a history of minimally invasive surgical (MIS) decompression for a large paracentral L4-5 disc herniation at 25. After three years, the patient developed sudden burning dysesthesias in the L4-5 dermatomes bilaterally and temporary leg weakness. Lumbar magnetic resonance imaging exhibited severe L4-5 spinal stenosis, and the patient underwent repeat MIS decompression, which again provided her with adequate symptom resolution. However, 20 days postoperatively she developed cauda equina syndrome with anal dysfunction, and bilateral leg and foot weakness. Upon open surgical exploration we discovered a tense L4-5 dural protrusion. After a dorsal durotomy, a large IDH with a ventral dural tear was identified. Subsequent to adequate debulking of the IDH, the ventral tear was repaired, and an expansile duraplasty was performed. Overall, the patient's bladder and bowel function, pain, hypoesthesia, and motor strength all improved. Two weeks after surgery she presented with a lumbar pseudomeningocele that was managed conservatively. CONCLUSION This report not only highlights an atypical presentation of IDH and is the first case of CLSS linked with IDH, lending support to the hypothesis that CLSS can lead to IDH, but also provides a comprehensive review of IDHs.
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Affiliation(s)
- A Ghaffari-Rafi
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, 651, Ilalo street, 96813 Honolulu, HI, USA.
| | - K Nosova
- University of California, Davis, School of Medicine, Department of Neurological Surgery, Sacramento, CA, USA
| | - K Kim
- University of California, Davis, School of Medicine, Department of Neurological Surgery, Sacramento, CA, USA
| | - A Goodarzi
- University of California, Davis, School of Medicine, Department of Neurological Surgery, Sacramento, CA, USA
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Verheijen EJA, Munts AG, van Haagen OBHAM, de Vries D, Vleggeert-Lankamp CLA. The Outcome of Epidural Injections in Lumbar Radiculopathy Is Not Dependent on the Presence of Disc Herniation on Magnetic Resonance Imaging: Assessment of Short-Term and Long-Term Efficacy. World Neurosurg 2021; 148:e643-e649. [PMID: 33497827 DOI: 10.1016/j.wneu.2021.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Lumbar radiculopathy is a condition with major physical, social, and economic consequences. Despite its favorable prognosis, the burden can be significant. In this study, we aimed to determine the value of magnetic resonance imaging (MRI) and the efficacy of transforaminal epidural injections (TEIs) in patients with lumbar radiculopathy secondary to lumbar disc herniation (LDH) and other causes (non-LDH). METHODS Patients with lumbar radiculopathy were reviewed for radiologic diagnosis based on MRI. For patients receiving TEI therapy, response after 6-8 weeks (short-term) and 16 weeks (long-term), number of injections, subsequent surgery, and patient outcome were evaluated. Treatment response was assessed by patient-reported symptom relief and numeric rating scale pain scores. RESULTS Overall, 66% of MRI examinations showed a clinically relevant LDH. A total of 486 of 1824 patients received TEI, of whom one third did not show LDH. Of patients, 70% reported a short-term effect with significant pain reduction and 44% reported a long-term effect. No significant differences were observed between the LDH and non-LDH groups. Of patients, 59% required multiple injections and reported similar efficacy compared with patients treated with a single injection. CONCLUSIONS A considerable part of MRI examinations in patients with lumbar radiculopathy do not show a clinically relevant LDH. Regardless of the radiologic diagnosis, most patients treated with TEI benefit in both the short-term and the long-term after a single-injection or multiple-injection regime. Subsequent injections are advisable if the effect from the first injection is unsatisfactory or wears off. MRI examination before TEI therapy may be redundant, which allows for expedition of this treatment.
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Affiliation(s)
- Eduard J A Verheijen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.
| | | | | | - Dirk de Vries
- Department of Anaesthesiology, Spaarne Gasthuis, Haarlem, The Netherlands
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31
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Latini E, Curci ER, Nusca SM, Lacopo A, Musa F, Santoboni F, Trischitta D, Vetrano M, Vulpiani MC. Medical ozone therapy in facet joint syndrome: an overview of sonoanatomy, ultrasound-guided injection techniques and potential mechanism of action. Med Gas Res 2021; 11:145-151. [PMID: 34213496 PMCID: PMC8374461 DOI: 10.4103/2045-9912.318859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Facet joint osteoarthritis is the most prevalent source of facet joint pain and represents a significant cause of low back pain. Oxygen-ozone therapy has been shown to have positive results in acute and chronic spinal degeneration diseases and it could be a safe and efficacious alternative to traditional facet joint conservative treatments. This review article explains the interventional facet joint management with ultrasound-guided oxygen-ozone therapy, providing an anatomy/sonoanatomy overview of lumbar facet joints and summarizing the potential mechanism of action of oxygen-ozone in the treatment of facet joint osteoarthritis, not yet fully understood.
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Affiliation(s)
- Eleonora Latini
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Enrico Roberto Curci
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Sveva Maria Nusca
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Alessandra Lacopo
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Francesca Musa
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Flavia Santoboni
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Donatella Trischitta
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Mario Vetrano
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Maria Chiara Vulpiani
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
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32
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Bisson DG, Sheng K, Kocabas S, Krock E, Teles A, Saran N, Ouellet JA, Haglund L. Toll-like receptor involvement in adolescent scoliotic facet joint degeneration. J Cell Mol Med 2020; 24:11355-11365. [PMID: 32853438 PMCID: PMC7576299 DOI: 10.1111/jcmm.15733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/17/2020] [Indexed: 12/22/2022] Open
Abstract
Facet joint osteoarthritis is prevalent in young patients with adolescent idiopathic scoliosis (AIS) and might contribute to back pain. Toll-like receptors (TLR) have been linked to cartilaginous tissue degeneration but their involvement in facet joint osteoarthritis in AIS patients is still unknown. We compared baseline gene expression levels of TLRs -1, -2, -4, and -6 in scoliotic and non-scoliotic chondrocytes and found higher expression levels in scoliotic chondrocytes with significantly higher TLR2 levels. Furthermore, TLR expression correlated strongly and significantly with inflammatory and catabolic markers in scoliotic but not in non-scoliotic chondrocytes. TLR activation with a synthetic TLR2/6 agonist resulted in a robust induction and release of pro-inflammatory and catabolic factors which exacerbated proteoglycan loss in scoliotic but not in non-scoliotic cartilage. We also detected a higher abundance of alarmins including S100A8/9 and biglycan in scoliotic cartilage. Finally, the small-molecule antagonists Sparstolonin B and o-Vanillin reduced catabolism following induction with naturally occurring alarmins and the synthetic TLR2/6 agonist. The high baseline expression, robust responsiveness and strong and significant correlation with proteases and pro-inflammatory cytokines suggest that TLRs are key regulators of facet joint degeneration in AIS. Blocking their activity could therefore potentially modify disease progression.
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Affiliation(s)
- Daniel G Bisson
- Shriners Hospital for Children, Montreal, QC, Canada.,Orthopaedic Research Laboratory, Department of Orthopedic Surgery, McGill University, Montreal, QC, Canada
| | - Kai Sheng
- Shriners Hospital for Children, Montreal, QC, Canada.,Orthopaedic Research Laboratory, Department of Orthopedic Surgery, McGill University, Montreal, QC, Canada
| | - Semsi Kocabas
- Shriners Hospital for Children, Montreal, QC, Canada.,Orthopaedic Research Laboratory, Department of Orthopedic Surgery, McGill University, Montreal, QC, Canada
| | - Emerson Krock
- Orthopaedic Research Laboratory, Department of Orthopedic Surgery, McGill University, Montreal, QC, Canada
| | - Alisson Teles
- Shriners Hospital for Children, Montreal, QC, Canada
| | - Neil Saran
- Shriners Hospital for Children, Montreal, QC, Canada
| | - Jean A Ouellet
- Shriners Hospital for Children, Montreal, QC, Canada.,Orthopaedic Research Laboratory, Department of Orthopedic Surgery, McGill University, Montreal, QC, Canada
| | - Lisbet Haglund
- Shriners Hospital for Children, Montreal, QC, Canada.,Orthopaedic Research Laboratory, Department of Orthopedic Surgery, McGill University, Montreal, QC, Canada
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Lu Y, Pei S, Hou S. Development of a novel rat model of lumbar facet joint osteoarthritis induced by persistent compressive injury. Exp Ther Med 2020; 20:3740-3748. [PMID: 32855725 PMCID: PMC7444380 DOI: 10.3892/etm.2020.9117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 03/06/2020] [Indexed: 12/16/2022] Open
Abstract
The aim of the present study was to develop a novel animal model of lumbar facet joint osteoarthritis induced by persistent compressive injury. An intraspinal compression spring was randomly implanted into either the L4/5 or the L5/6 spinal segments of 40 Sprague Dawley (SD) rats to induce compression. Sham-operations were used in the other segment of the same rats as the control levels. The animals were sacrificed at 7, 14, 28, 42 and 56 days after surgery, prior to the radiological confirmation of the spring location. Degeneration of the lumbar facet joints was evaluated by macroscopic observation in addition to histological and immunohistological analyses. The results of this present study revealed the absence of spring dislocation during the entire observation period. Macroscopic and Osteoarthritis Research Society International scores of the compression levels were found to be higher in the compression levels compared with those noted in the control levels (P<0.05). In addition, interleukin-1β and tumor necrosis factor-α expression in the compression levels were increased over time compared with those recorded in the control levels. In conclusion, persistent compressive injury may induce degeneration of the lumbar facet joint. This novel animal model could serve as a useful tool for further studies into the mechanisms of action and potential treatment of lumbar facet joint osteoarthritis.
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Affiliation(s)
- You Lu
- Department of Orthopaedics, Chinese PLA Medical School, Beijing 100853, P.R. China.,Department of Orthopaedics, Sixth Medical Center of PLA General Hospital, Beijing 100048, P.R. China
| | - Shishen Pei
- Department of Orthopaedics, The Fourth People's Hospital of Hengshui City, Hengshui, Hebei 053000, P.R. China
| | - Shuxun Hou
- Department of Orthopaedics, Chinese PLA Medical School, Beijing 100853, P.R. China.,Department of Orthopaedics, Fourth Medical Center of PLA General Hospital, Beijing 100048, P.R. China
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34
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Is Facet Joint Distraction Associated with Functional Outcome in Patients with Cervical Spondylotic Radiculopathy Treated with Single-Segment Anterior Cervical Discectomy and Fusion? World Neurosurg 2020; 140:e53-e60. [DOI: 10.1016/j.wneu.2020.04.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 11/20/2022]
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35
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Sun C, Zhang H, Wang X, Liu X. Ligamentum flavum fibrosis and hypertrophy: Molecular pathways, cellular mechanisms, and future directions. FASEB J 2020; 34:9854-9868. [PMID: 32608536 DOI: 10.1096/fj.202000635r] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022]
Abstract
Hypertrophy of ligamentum flavum (LF), along with disk protrusion and facet joints degeneration, is associated with the development of lumbar spinal canal stenosis (LSCS). Of note, LF hypertrophy is deemed as an important cause of LSCS. Histologically, fibrosis is proved to be the main pathology of LF hypertrophy. Despite the numerous studies explored the mechanisms of LF fibrosis at the molecular and cellular levels, the exact mechanism remains unknown. It is suggested that pathophysiologic stimuli such as mechanical stress, aging, obesity, and some diseases are the causative factors. Then, many cytokines and growth factors secreted by LF cells and its surrounding tissues play different roles in activating the fibrotic response. Here, we summarize the current status of detailed knowledge available regarding the causative factors, pathology, molecular and cellular mechanisms implicated in LF fibrosis and hypertrophy, also focusing on the possible avenues for anti-fibrotic strategies.
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Affiliation(s)
- Chao Sun
- Department of Spine Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Han Zhang
- Department of Spine Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Xiang Wang
- Department of Spine Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Xinhui Liu
- Department of Spine Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
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36
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Özcan-Ekşi EE, Ekşi MŞ, Turgut VU, Canbolat Ç, Pamir MN. Reciprocal relationship between multifidus and psoas at L4-L5 level in women with low back pain. Br J Neurosurg 2020; 35:220-228. [PMID: 32576034 DOI: 10.1080/02688697.2020.1783434] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background Low back pain (LBP) may originate from different sources such as intervertebral disc degeneration (IVDD), end-plate and paraspinal muscle changes. Our aim is to explore the relevance of paraspinal muscles' fat-infiltration in women with LBP and its association with IVDD and Modic changes.Methods Consecutive female patients presenting with chronic LBP to the outpatient clinics were included. Patients were evaluated in terms of IVDD, vertebral end-plate changes, and fatty infiltration in the paraspinal muscles at all lumbar levels on lumbar spine magnetic resonance imaging (MRI). Visual Analogue Scale (VAS) scores were recorded using our prospectively collected database.Results Patients with higher VAS scores were significantly more likely to have more fatty infiltration in the multifidus and less fatty infiltration in the psoas at L4-L5 level when compared to those with lower VAS scores (69.1 vs. 31.8%, p = 0.003). To predict LBP, fatty infiltration in the multifidus and psoas had odds ratio (OR) of 4 (p = 0.010), and 0.3 (p = 0.013), respectively; whereas disc degeneration had an OR of 0.5 (p = 0.028).Conclusion This is the first clinical cross-sectional study suggested that women with chronic low back pain could have less fat-infiltrated psoas to compensate more fat-infiltrated multifidus at L4-L5 disc level.
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Affiliation(s)
- Emel Ece Özcan-Ekşi
- School of Medicine, Department of Physical Medicine and Rehabilitation, Bahçeşehir University, Istanbul, Turkey
| | - Murat Şakir Ekşi
- School of Medicine, Department of Neurosurgery, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Veli Umut Turgut
- Neurosurgery Clinic, Antalya Atatürk State Hospital, Antalya, Turkey
| | - Çağrı Canbolat
- Acıbadem Healthcare Group, Maslak Acıbadem Hospital, Neurosurgery Clinic, Istanbul, Turkey
| | - M Necmettin Pamir
- School of Medicine, Department of Neurosurgery, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
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37
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Tiwari P, Kaur H, Kaur H, Jha V, Singh N, Ashraf A. Prevalence of facet joint arthritis and its association with spinal pain in mountain population - A cross-sectional study. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:36-45. [PMID: 32549711 PMCID: PMC7274360 DOI: 10.4103/jcvjs.jcvjs_121_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/16/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction: People living in the mountains are subject to tough terrain and climbing biomechanics which lead to degeneration of the spine and Facet joint arthritis (FJA). Aims: The goal of present study was (1) to know the prevalence of facet joint arthritis on CT scans in mountain population in regard to (a) different levels in spine (b) age (c) sex (2) to know if there is any significant association between FJA and spinal pain at that corresponding level. Materials and Methods: Bilateral Facet joints of 210 participants (age range, 18 to 97 years) who underwent MDCT imaging for reasons other than spinal pain, were graded and statistically analysed with SPSS software in this study. FJA was defined as at least one joint affected by facet joint disease (grade 2). Results: In our study, Seventy two men (68.5%) and eighty four women (80%) had Facet Joint arthritis. The difference between men and women in the prevalence of FJA was not statistically significant (P = 0.058). The increasing age demonstrated a higher prevalence of facet joint arthritis with statistical significance (P = 0.000). In dorsal and lumbar spine region, there was a statistically significant difference in prevalence of FJA according to spinal level. The prevalence of FJA grade 2 in cervical and dorsal spine region was associated with spinal pain in both men (P = 0.000) and women (P = 0.000). However, no statistically significant association was found between FJA grade 2 and spinal pain in lumbar spine region in both males (P = 0.680) and females (P = 0.680) as well as in total population (P = 0.513). Conclusions: People residing and actually ambulating in the mountain regions and exposed to the terrain have higher prevalence of Facet joint arthritis as compared to general population and this may be an independent risk factor for development of facet joint arthritis. However, a statistically significant relation between FJA and spinal pain exists only in cervical and dorsal spine.
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Affiliation(s)
- Punit Tiwari
- Department of Orthopaedics, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India
| | - Harmeet Kaur
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bathinda, Punjab, India
| | - Harpreet Kaur
- Department of Community Medicine, Kalpana Chawla Government Medical College, Karnal, Haryana, India
| | - Vivek Jha
- Department of Orthopaedics, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India
| | - Navneet Singh
- Department of Orthopaedics, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India
| | - Arshad Ashraf
- Department of Orthopaedics, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India
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38
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Won HS, Yang M, Kim YD. Facet joint injections for management of low back pain: a clinically focused review. Anesth Pain Med (Seoul) 2020; 15:8-18. [PMID: 33329784 PMCID: PMC7713865 DOI: 10.17085/apm.2020.15.1.8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 11/17/2022] Open
Abstract
Lumbar facet joints have been implicated in chronic low back pain in up to 45% of patients with low back pain (LBP). Facet joint pain diagnosis and management are always challenging for pain physicians. Facet joint pain is not diagnosed by specific demographic features, pain characteristics, or physical findings, even though electrodiagnostic studies and imaging modalities are available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature. Treatment of chronic LBP arising due to facet joint includes intraarticular injections, medial branch blocks, and radiofrequency neurotomy. However, the evidence of their clinical efficacy is continuously under scrutiny. Pain physicians must have a detailed understanding of the spinal anatomy in order to perform safe and effective interventional procedures. This review outlines the important aspects of spinal anatomy as they relate to interventional pain management related to facet joint injections. Additionally, we provide a comprehensive review of the procedure and clinical evidence.
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Affiliation(s)
- Hyung-Sun Won
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Miyoung Yang
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea.,Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Yeon-Dong Kim
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea.,Department of Anesthesiology and Pain Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
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Zhu K, Su Q, Chen T, Zhang J, Yang M, Pan J, Wan W, Zhang A, Tan J. Association between lumbar disc herniation and facet joint osteoarthritis. BMC Musculoskelet Disord 2020; 21:56. [PMID: 31996194 PMCID: PMC6990568 DOI: 10.1186/s12891-020-3070-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 01/15/2020] [Indexed: 01/02/2023] Open
Abstract
Background This study was performed to investigate the association between lumbar disc herniation (LDH) and facet joint osteoarthritis (FJOA) using magnetic resonance imaging (MRI). Methods Between March 2012 and September 2018, a total of 441 segments from 394 patients with LDH were included in the study. LDH was classified according to the Michigan State University (MSU) classification, in which the degree of LDH is divided into 3 levels (expressed as 1, 2, and 3) and the location of LDH is divided into 4 zones (described as A, AB, B, and C). Bilateral FJOA was graded from 0 to 3 using the criteria introduced by Weishaupt et al., and bilateral facet orientations were measured on axial MRI slices. A mixed-effects ordinal logistic regression model was utilized to determine the potential factors that may be associated with FJOA, including sex, age, body mass index (BMI), segment, facet orientation and tropism, and the degree and location of LDH. Results In general, the prevalence of FJOA (grade ≥ 2) was 66.2% in LDH segments. For both the left and right sides, the degree of LDH was associated with the severity of FJOA (p < 0.01). Age and BMI were also associated with the severity of left and right FJOA (p = 0.002 and p < 0.001 for age, p < 0.001 and p = 0.003 for BMI, respectively), while segment, facet orientation, and facet tropism were not (p > 0.05 for all). Notably, MSU-B LDH was associated with greater odds of having more severe FJOA on the herniation side (left: p < 0.001, odds ratio (OR) = 2.714, 95% confidence interval (CI) = 1.583~4.650; right: p = 0.003, OR = 2.615, 95% CI = 1.405~4.870). However, other locations of LDH were not associated with the severity of FJOA (p > 0.05 for all). Conclusions Both the degree of LDH and MSU-B LDH are associated with the severity of FJOA. The association between LDH and FJOA highlights the complexity of the etiology of FJOA.
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Affiliation(s)
- Kai Zhu
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, No.150 Jimo Road, Shanghai, 200120, China
| | - Qihang Su
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, No.150 Jimo Road, Shanghai, 200120, China
| | - Tao Chen
- Department of Orthopedics, Shanghai Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Shanghai, 200092, China
| | - Jinbiao Zhang
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, No.150 Jimo Road, Shanghai, 200120, China
| | - Mingjie Yang
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, No.150 Jimo Road, Shanghai, 200120, China
| | - Jie Pan
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, No.150 Jimo Road, Shanghai, 200120, China
| | - Weiping Wan
- Department of Radiology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China
| | - Aihong Zhang
- Department of Medical Statistics, Tongji University School of Medicine, No.1239 Siping Road, Shanghai, 200092, China.
| | - Jun Tan
- Department of Orthopedics, Shanghai East Hospital, Tongji University School of Medicine, No.150 Jimo Road, Shanghai, 200120, China. .,Department of Orthopedics, Pinghu Second People's Hospital, Pinghu, 314200, China.
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40
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Wei P, Xu Y, Yao Q, Wang L. Randomized trial of 3-drug combination for lumbar nerve root epidural injections with a TNF-α inhibitor in treatment of lumbar stenosis. Br J Neurosurg 2020; 34:168-171. [PMID: 31955619 DOI: 10.1080/02688697.2020.1713990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Peiran Wei
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yan Xu
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Qingqiang Yao
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Liming Wang
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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41
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Campos WK, Linhares MN, Sarda J, Santos ARS, Lin K, Latini A, Walz R. Predictors of Pain Recurrence After Lumbar Facet Joint Injections. Front Neurosci 2019; 13:958. [PMID: 31619946 PMCID: PMC6763569 DOI: 10.3389/fnins.2019.00958] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/26/2019] [Indexed: 01/22/2023] Open
Abstract
Introduction Facet joint injections (FJIs) of anesthetic and corticosteroids are useful for the diagnosis and treatment of low back pain (LBP). In the current study, we evaluated the efficacy of FJI on LBP treatment and the predictive variables of pain recurrence after FJI. Methods We included and followed prospectively forty-three consecutive patients with chronic LBP treated with FJI. Clinical assessments were carried out at a baseline 1 week before FJIs and after a 6-month follow-up visit using the visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) for disability-specific measure and MacNab criteria for global effectiveness, and compared through analysis using paired-samples “t” tests. Multiple cox-regression analysis was used to identify the presurgical variables independently associated with pain recurrence anytime during the follow-up. In addition to the demographic, clinical, and surgical data, we also analyzed psychometric scales: Pain Catastrophizing Scale (PCS), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI). Results After a 6-month follow-up, thirty-two patients (74.4%) showed a clinically significant reduction of pain and twenty-seven (62.8%) reported a clinically significant improvement of disability. Presurgical catastrophizing (PCS score ≥ 5, adjusted HR 4.4, CI 95% 1.7–11.3, p = 0.002) and smoking (Adjusted HR 12.5, CI 95% 1.1–138.9, p = 0.04) remains associated with pain recurrence. Conclusion FJI reduces LBP and disability of patients with unresponsive LBP. Pain-related cognitive and behavioral factors determined by pain catastrophizing and smoking were independently associated with pain recurrence after lumbar FJI. The results support the need of a multidisciplinary approach for presurgical evaluation of patients with chronic pain.
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Affiliation(s)
- Wuilker Knoner Campos
- Functional Neurosurgery Division, Department of Neurosurgery, Baia Sul Medical Center, Florianópolis, Brazil.,Neuron Institute, Baia Sul Medical Center, Florianópolis, Brazil.,Neurosurgery Division, Hospital Governador Celso Ramos, Florianópolis, Brazil.,Center for Applied Neuroscience (CeNAp), University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Marcelo Neves Linhares
- Functional Neurosurgery Division, Department of Neurosurgery, Baia Sul Medical Center, Florianópolis, Brazil.,Neuron Institute, Baia Sul Medical Center, Florianópolis, Brazil.,Neurosurgery Division, Hospital Governador Celso Ramos, Florianópolis, Brazil.,Center for Applied Neuroscience (CeNAp), University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, Brazil.,Department of Surgery, Neurosurgery Division, HU, UFSC, Florianópolis, Brazil
| | - Jamir Sarda
- Department of Psychology and Master Program of Health and Work, Univali, Itajaí, Brazil
| | | | - Kátia Lin
- Center for Applied Neuroscience (CeNAp), University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, Brazil.,Department of Internal Medicine, Neurology Division, HU, UFSC, Florianópolis, Brazil
| | - Alexandra Latini
- Center for Applied Neuroscience (CeNAp), University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, Brazil.,Laboratory of Bioenergetics and Oxidative Stress, Department of Biochemistry, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Roger Walz
- Center for Applied Neuroscience (CeNAp), University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, Brazil.,Department of Internal Medicine, Neurology Division, HU, UFSC, Florianópolis, Brazil
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Controlled immobilization-traction based on intervertebral stability is conducive to the regeneration or repair of the degenerative disc: an in vivo study on the rat coccygeal model. Spine J 2019; 19:920-930. [PMID: 30399448 DOI: 10.1016/j.spinee.2018.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Previous studies have shown the potential for intervertebral disc tissue regeneration is very limited. While in vivo and in vitro studies have shown that traction can restore disc height and internal pressure, in many clinical studies it was shown that axial mechanical traction for the treatment of low back pain is ineffective. PURPOSE The aim of this study was to identify how the disc could be distracted, how to define the state of traction, and to further examine the feasibility of regenerating or restoring the degenerative disc by means of traction. STUDY DESIGN A macro- and microlevel structural analysis of degenerative discs of rat tail before and after controlled immobilization-traction. METHODS In this study, 49 6-month-old male Sprague-Dawley rats were randomly assigned to one of seven groups. Group A was the sham control group in which caudal vertebrae were instrumented with K-wires only. In Group B (model group), caudal vertebrae were immobilized using a custom-made external device to fix four caudal vertebrae (Co7-Co10) and Co8-Co9 underwent 4 weeks of compression to induce moderate disc degeneration. In Group C, vertebrae Co8-Co9 underwent 4 weeks of compression to induce moderate disc degeneration, followed by removal of the external apparatus. Rats in the other four groups (Groups D-G), Co8-Co9 underwent 4 weeks of compression to induce moderate disc degeneration followed by 2 weeks, 4 weeks, 6 weeks, and 8 weeks of distraction, respectively. Caudal vertebrae were harvested and disc height, T2 signal intensity of the discs, disc morphology, total glycosaminoglycan content of the nucleus pulposus and the structure of the Co8-Co9 end plate were evaluated. RESULTS After 4 weeks of compression, the intervertebral height and T2 signal intensity of Co8-Co9 vertebrae of rats in Groups B to G were significantly reduced compared with Group A (sham group, all p<.0001). Histological scores of rats in Group B averaged 10.14 and the total glycosaminoglycan (GAG) of nucleus pulposus averaged 238.21μg GAG/ng DNA. The bony end plate structure showed significant changes in comparison with the control Group. After 2 weeks to 8 weeks of traction, the disc space and T2 signal intensity of Co8-Co9 vertebrae in Group E were significantly recovered compared to that of rats in Group B (p<.0001), and the intervertebral height of the Co8-Co9 in Group D, Group F, and Group G when compared with Group B (p<.0001). Meanwhile, the T2 signal intensity of Co8-Co9 in Group D, F, and G when compared with Group B (p<.001). Histological scores dropped from an average of 10.14 in Group B to 5.57 in Group E, and 5.86 in Group F (all p<.0001). Furthermore, the total GAG content of the nucleus pulposus increased from an average of 238.21μg GAG/ng DNA in Group B to 601.02μg GAG/ng DNA in Group E (p<.0001). The number of pores of end plates in rats in Groups D and E both were significantly increased when compared to that of rats in Group B (Groups D vs Groups B, p<.05; Groups E vs Groups B, p<.0001). CONCLUSIONS A mechanical degenerative model was successfully established by using a custom-made device. We demonstrated that disc degeneration is a cascade of biochemical, mechanical, and structural changes mediated by cells in an abnormal mechanical environment. Not all levels of disc degeneration can be regenerated or repaired. Regeneration or recovery of disc degeneration requires specific conditions. Based on the immobilization-traction mode, the cascade cycle of disc degeneration is interrupted. Traction of 2 to 6 weeks is a sensitive period for regeneration of the degenerative disc. Moreover, the duration and extent of the traction loading must be moderately controllable, and beyond the limits that can lead to significant degeneration. These data may help improve our understanding of the pathogenesis of clinical disc degeneration and how to optimize the use of traction devices for possible regeneration.
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Liu S, Yang DL, Zhao RY, Yang SD, Ma L, Wang H, Ding WY. Prevalence and risk factors of axial neck pain in patients undergoing multilevel anterior cervical decompression with fusion surgery. J Orthop Surg Res 2019; 14:94. [PMID: 30947714 PMCID: PMC6450001 DOI: 10.1186/s13018-019-1132-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/15/2019] [Indexed: 01/10/2023] Open
Abstract
Objectives The aim of this study was to explore the prevalence and risk factors for axial neck pain in patients undergoing multilevel anterior cervical decompression with fusion surgery. Methods In this study, 88 patients, who underwent multilevel anterior cervical decompression with fusion surgery from January 2012 to January 2017, were retrospectively reviewed. Based on the postoperative axial neck pain, the patients were classified into two groups: axial pain group and no axial pain group. The patients were followed up 3 weeks, 3 months, and 1 year after cervical anterior surgery for the early- and long-term clinical evaluation. The possible effect factors included demographic variables (age, sex, BMI, smoking, drinking, heart disease, hypertension, diabetes, preoperative kyphosis, preoperative axial neck pain, preoperative JOA scores, and ODI) and surgery-related variables (surgical option, vertebral lesions, spinal canal stenosis rate, superior fusion segment, presence of intramedullary high signal intensity). Results The prevalence of axial neck pain was 27.3% (24 cases of 88). Our results showed that preoperative axial neck pain (62% vs 23%, P < 0.001) and preoperative kyphosis (42% vs 21.9%, P < 0.001) were risk factors for axial pain after multilevel anterior cervical surgery. Additionally, for patients with preoperative cervical kyphosis, compared to no axial pain group, the axial neck group was significantly more likely to exist a higher preoperative angle of C2–7 (13.31 ± 2.33 vs 7.33 ± 2.56, P < 0.001) and a higher correction range for kyphosis (20.24 ± 4.12 vs 12.34 ± 3.12, P < 0.001). However, for all the patients with postoperative axial symptoms, the improvement rate of axial pain was significantly higher for patients without cervical kyphosis at the early-term follow-up (3 weeks) (P = 0.032), no significant differences were found at the medium-term (P = 0.554) and long-term follow-up (P = 0.902), and improvements of clinical symptom have no obvious difference at the last follow-up. Conclusions Overall, preoperative axial neck pain and kyphosis could predict axial neck pain for patients undergoing multilevel anterior cervical decompression with fusion surgery, and recovery of cervical kyphosis may contribute to the long-term recovery of neural function, but may also suffer from risk of short-term axial pain, which could be reduced through moderate cervical curvature recovery.
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Affiliation(s)
- Sen Liu
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Da-Long Yang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Ruo-Yu Zhao
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Si-Dong Yang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Lei Ma
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Hui Wang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Wen-Yuan Ding
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China. .,Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China.
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Valimahomed AK, Haffey PR, Urman RD, Kaye AD, Yong RJ. Regenerative Techniques for Neuraxial Back Pain: a Systematic Review. Curr Pain Headache Rep 2019; 23:20. [DOI: 10.1007/s11916-019-0758-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Bennett DS. Cryopreserved amniotic membrane and umbilical cord particulate for managing pain caused by facet joint syndrome: A case series. Medicine (Baltimore) 2019; 98:e14745. [PMID: 30855467 PMCID: PMC6417546 DOI: 10.1097/md.0000000000014745] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Treatment of back pain due to facet joint syndrome has been a challenge for physicians since its recognition ∼80 years ago. Intra-articular injections of steroids, local anesthetics, and phenol have been widely adopted despite their known shortcomings. Recently, intra-articular injection of amniotic membrane-umbilical cord (AMUC) has been utilized in various orthopedic indications, including those involving synovial joints, due to its reported anti-inflammatory properties. Herein, use of AMUC for facet joint syndrome was evaluated.A single-center case series was conducted on patients presenting with pain caused by facet joint syndrome, confirmed by single blocking anesthetic injection and treated using a single intra-articular injection of 50 mg particulate AMUC (CLARIX FLO) suspended in preservative-free saline. Patient reported back pain severity (numerical scale 0-10) and opioid use were compared between baseline and 6 months following treatment.A total of 9 patients (7 males, 2 females), average age 52.1 ± 15.9 years, were included. Five patients with cervical pain had a history of trauma, 1 patient had suffered lumbar facet injury and 3 had degenerative lumbar facet osteoarthritis. All patients had severe pain prior to injection (8.2 ± 0.8) and 4 (44%) were taking opioids (>100 morphine milligram equivalents). Six-month post-treatment, average pain had decreased to 0.4 ± 0.7 (P <.05). All patients had ceased use of prescription pain medications, including opioids. No adverse events, repeat procedures, or complications were reported.Intra-articular injection of AMUC appears to be promising for managing facet pain and mitigating opioid use. Further investigation with larger sample size is warranted.
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Sugimoto K, Nakamura T, Tokunaga T, Uehara Y, Okada T, Taniwaki T, Fujimoto T, Oike Y, Nakamura E. Angiopoietin-Like Protein 2 Induces Synovial Inflammation in the Facet Joint Leading to Degenerative Changes via Interleukin-6 Secretion. Asian Spine J 2019; 13:368-376. [PMID: 30685956 PMCID: PMC6547404 DOI: 10.31616/asj.2018.0178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/11/2018] [Indexed: 11/23/2022] Open
Abstract
Study Design Experimental human study. Purpose To determine whether angiopoietin-like protein 2 (ANGPTL2) is highly expressed in the hyperplastic facet joint (FJ) synovium and whether it activates interleukin-6 (IL-6) secretion in FJ synoviocytes. Overview of Literature Mechanical stress-induced synovitis is partially, but significantly, responsible for degenerative and subsequently osteoarthritic changes in the FJ tissues in patients with lumbar spinal stenosis (LSS). However, the underlying molecular mechanism remains unclear. IL-6 is highly expressed in degenerative FJ synovial tissue and is responsible for local chronic inflammation. ANGPTL2, an inflammatory and mechanically induced mediator, promotes the expression of IL-6 in many cells. Methods FJ tissues were harvested from five patients who had undergone lumbar surgery. Immunohistochemistry for ANGPTL2, IL-6, and cell markers was performed in the FJ tissue samples. After cultured synoviocytes from the FJ tissues were subjected to mechanical stress, ANGPTL2 expression and secretion were measured quantitatively using real-time quantitative reverse-transcription–polymerase chain reaction and enzyme-linked immunosorbent assay (ELISA), respectively. Following ANGPTL2 administration in the FJ synoviocytes, anti-nuclear factor-κB (NF-κB) activation was investigated using immunocytochemistry, and IL-6 expression and secretion were assayed quantitatively with or without NF-κB inhibitor. Moreover, we assessed whether ANGPTL2-induced IL-6 modulates leucocyte recruitment in the degenerative process by focusing on the monocyte chemoattractant protein-1 (MCP-1) expression. Results ANGPTL2 and IL-6 were highly expressed in the hyperplastic FJ synovium samples. ANGPTL2 was co-expressed in both, fibroblast-like and macrophage-like synoviocytes. Further, the expression and secretion of ANGPTL2 in the FJ synoviocytes increased in response to stimulation by mechanical stretching. ANGPTL2 protein promoted the nuclear translocation of NF-κB and induced IL-6 expression and secretion in the FJ synoviocytes. This effect was reversed following treatment with NF-κB inhibitor. Furthermore, ANGPTL2-induced IL-6 upregulated the MCP-1 expression in the FJ synoviocytes. Conclusions Mechanical stress-induced ANGPTL2 promotes chronic inflammation in the FJ synovium by activating IL-6 secretion, leading to FJ degeneration and subsequent LSS.
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Affiliation(s)
- Kazuki Sugimoto
- Department of Orthopaedics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Takayuki Nakamura
- Department of Orthopaedics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Takuya Tokunaga
- Department of Orthopaedics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yusuke Uehara
- Department of Orthopaedics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Tatsuya Okada
- Department of Orthopaedics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Takuya Taniwaki
- Department of Orthopaedics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Toru Fujimoto
- Department of Orthopaedics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yuichi Oike
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Eiichi Nakamura
- Department of Orthopaedics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
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Abstract
ABSTRACT Objective: Facet joints are true synovial joints, which derive their nerve supply from the sinuvertebral or recurrent nerve of Luschka as well as the posterior primary division of the corresponding spinal nerve. Diagnosis of low-back pain originating in the facet joints is difficult, and has traditionally relied upon invasive tests. To aid in the clinical diagnosis of this condition, the senior author described a new clinical sign. The following research project was designed to test the utility of this sign in the diagnosis of lumbar facet joint pain. Methods: We conducted a prospective evaluation of patients suspected of having low back pain secondary to facet joint involvement (Lumbar Facet joint Pain Syndrome – LFPS) during a twelve month observation period; candidate patients were evaluated clinically using the new diagnostic sign, which was then compared to findings on radionuclide bone scans and diagnostic medial branch blocks. Contingency table analysis was performed to calculate the sensitivity, specificity, positive and negative predictive values and accuracy of the new clinical sign. Results: Contingency table analysis showed the following operating characteristics for the new diagnostic sign: Sensitivity: 70.37%, Specificity: 50%, Positive predictive value: 90.47%, Negative predictive value: 20% and accuracy 67.7%. Conclusions: Although the new clinical sign failed to show the same operating characteristics as the ones originally described, it has high sensitivity coupled with a good positive predictive value. We consider that although the sign by itself is not diagnostic of lumbar facet joint pain, its presence should alert the clinician to the diagnosis and the possibility of requiring additional testing. Level of Evidence III; Case control studyg.
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Chowdhury SK, Byrne RM, Zhou Y, Zhang X. Lumbar Facet Joint Kinematics and Load Effects During Dynamic Lifting. HUMAN FACTORS 2018; 60:1130-1145. [PMID: 30074402 DOI: 10.1177/0018720818790719] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To examine the lumbar facet joint kinematics in vivo during dynamic lifting and the effects of the load lifted. BACKGROUND Although extensive efforts have been dedicated to investigating the risk factors of low back pain (LBP) associated with load handling in the workplace, the biomechanics of lumbar facet joints during such activities is not well understood. METHOD Fourteen healthy participants performed a load-lifting task while a dynamic stereo-radiography system captured their lumbar motion continuously. Data from 11 participants were included for subsequent analysis. A randomized block design was employed to study the load effect (4.5 kg, 9.0 kg, and 13.5 kg) on bilateral facet joint motions at approximately 60°, 40°, 20°, and 0° trunk-flexion postures. The facet orientations were also examined. RESULTS Significant load effects were found for the flexion and lateral bending and superior-inferior translation of the facet joints. The L5-S1 displayed greater lateral bending and twisting, which was due to its more posterolateral orientation than the L2-L3, L3-L4, and L4-L5 facet joints. The left-right asymmetry in facet orientation was observed, most prominently at L3-L4 and L5-S1 facet joints. CONCLUSION The lumbar facet joint kinematics are affected by the magnitude of the lifted load and are dependent on the orientations of articulating adjacent facets. APPLICATION This study provided new insights into the role of lumbar facet joints in vivo during lifting. Alterations in the facet joint kinematics due to vigorous functional demand can be one of the primary but overlooked mechanical factors in the causation of LBP.
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Affiliation(s)
- Suman K Chowdhury
- Texas A&M University, College Station, USA
- Texas A&M University, College Station, USA
| | - Ryan M Byrne
- University of Pittsburgh, Pennsylvania, USA
- Texas A&M University, College Station, USA
| | - Yu Zhou
- Texas A&M University, College Station, USA
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Vier C, Bracht MA, Neves ML, Junkes-Cunha M, Santos ARS. Effects of spinal manipulation and pain education on pain in patients with chronic low back pain: a protocol of randomized sham-controlled trial. Integr Med Res 2018; 7:271-278. [PMID: 30271716 PMCID: PMC6160616 DOI: 10.1016/j.imr.2018.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/27/2018] [Accepted: 04/30/2018] [Indexed: 02/05/2023] Open
Abstract
Background Low back pain (LBP) has more than doubled in the last 20 years, probably influenced by biopsychosocial factors. Noninvasive treatments have been applied in individuals with chronic nonspecific LBP as spinal manipulation and pain education. However, the neurophysiological effects of these treatments are not clear. The aim of this research is to verify the pain control, functional and neurophysiological effects of spinal manipulation, and pain education in individuals with chronic nonspecific LBP. Methods This research is an assessor and subject blinded, 2-arm, randomized sham-controlled trial and will be conducted at Governador Celso Ramos Hospital, Florianópolis, Brazil. One hundred and twenty-eight individuals with chronic nonspecific LBP will be recruited for this study. Individuals will be randomly allocated into one of the two groups: (1) spinal manipulation plus pain education or (2) sham treatment plus pain education. Each group will be received two sessions per week over six weeks of treatment. The measures will be applied at baseline, six weeks, and three months after randomization. The primary outcome will be a pain intensity at six weeks postrandomization. Secondary outcomes will be pressure pain threshold, disability, fear and avoidance beliefs, kinesiophobia, risk of poor prognosis, quality of life, and inflammatory biomarkers. Discussion Evidence has shown that psychosocial factors are more involved in chronic pain than we thought a few years ago. Then, studies investigating both functional and neurophysiological effects of these interventions to evaluate the effectiveness of treatment and what else is happening at the cellular level in nervous system are needed.
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Affiliation(s)
- Clécio Vier
- Graduate Program in Neurosciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil.,Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil
| | - Marcelo Anderson Bracht
- Graduate Program in Neurosciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil.,Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil
| | - Marcos Lisboa Neves
- Graduate Program in Neurosciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil.,Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil
| | - Maíra Junkes-Cunha
- Graduate Program in Neurosciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil.,Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil
| | - Adair Roberto Soares Santos
- Graduate Program in Neurosciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil.,Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Trindade, Florianópolis, Brazil
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Exploration of the Inter-Relationships Between Obesity, Physical Inactivity, Inflammation, and Low Back Pain. Spine (Phila Pa 1976) 2018; 43:1218-1224. [PMID: 29419713 DOI: 10.1097/brs.0000000000002582] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis wherein 103 patients were considered, and 76 patients were included: 49 were classified as chronic non-specific low back pain (CNSLBP) (Study group) and 27 had identifiable cases of specific chronic low back pain (LBP) (Control group). OBJECTIVE Elucidate markers of systemic inflammation in patients with CNSLBP. SUMMARY OF BACKGROUND DATA Mechanisms of LBP are poorly understood. Pro-inflammatory cytokines are increased in obesity and involved with pain modulation; we previously proposed a theoretical model of their mediating role in LBP. METHODS Demographic information was acquired via questionnaire, chart review, and blood test data. Univariate analysis identified factors associated with CNSLBP and markers of systemic inflammation. A receiver operating curve and Youden Index were used to select optimal cut-off points for elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Multivariable logistic regression analysis calculated the adjusted strength of relationship between factors that were proposed in our theoretical model for CNSLBP. RESULTS Unadjusted CRP was significantly correlated with ESR (R = 0.63, P < 0.0001) and body mass index (BMI) (R = 0.38, P = 0.0015). Physically inactive patients had significantly higher CRP (6.1 vs. 1.2, P = 0.0050). ESR was significantly correlated with number of comorbidities (R = 0.34, P = 0.0047), BMI (R = 0.38, P = 0.0014), and age (R = 0.36, P = 0.0026). Physically inactive patients (10.4 vs. 3.6, P = 0.0001) and females (11.2 vs. 6.4, P = 0.0422) had significantly higher ESR. Adjusted analyses indicated significant relationships between physical inactivity and markers of systemic inflammation (adjusted odds ratios for ESR and CRP: 15.9, P = 0.0380; 15.2, P = 0.0272, respectively), and between elevated CRP and CNSLBP (adjusted odds ratio: 8.0, P = 0.0126). CONCLUSION Systemic inflammation may act as a mediator for physical inactivity and obesity in the pathogenesis of CNSLBP. LEVEL OF EVIDENCE 2.
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