The influence of sagittal instability factors on clinical lumbar spinal symptoms

Outcomes and Vertebral Osteophytes and Bulging Intervertebral Discs Occupancy as a Decision-Making Tool for Surgical Success in Patients Undergoing Microendoscopic Foraminotomy for Lumbar Foraminal Stenosis

OBJECTIVE

The objective of this study was to determine the long-term outcomes of microendoscopic foraminotomy in treating lumbar foraminal stenosis and identify the optimal extent of decompression that yields improved results and fewer complications.

METHODS

A retrospective cohort study reviewed the medical records of 95 consecutive patients who underwent microendoscopic foraminotomy for lumbar foraminal stenosis. Clinical outcomes were assessed using the Japanese Orthopaedic Association scoring system and visual analog scale for low back and leg pain. Surgical success was determined by meeting significant improvement thresholds for back and leg pain at 2 years postoperatively. Multiple regression analysis identified factors associated with improved pain scores. Receiver operating characteristic curve analysis determined the cut-off values for successful surgeries.

RESULTS

Significant improvements were observed in Japanese Orthopaedic Association and visual analog scale scores for back and leg pain 2 years postoperatively compared with preoperative scores (P < 0.0001) and sustained over a ≥5-year follow-up period. Reoperation rates were low and did not significantly increase over time. Multiple regression analysis identified occupancy of the vertebral osteophytes and bulging intervertebral discs (O/D complex) as surgical success predictors. A 45.0% O/D complex occupancy cutoff value was determined, displaying high sensitivity and specificity for predicting surgical success.

CONCLUSIONS

This study provides evidence supporting the long-term efficacy of microendoscopic foraminotomy for lumbar foraminal stenosis and predicting surgical success. The 45.0% O/D complex occupancy cut-off value can guide patient selection and outcome prediction. These insights contribute to informed surgical decision-making and underscore the importance of evaluating the O/D complex in preoperative planning and predicting outcomes.

Myofascial and discogenic origins of lumbar pain: A critical review

The purpose of this three-part narrative review is to examine the anatomy of, and the research which supports, either the lumbar myofascia or intervertebral disc (IVD) as principal sources of our patient's low back pain. A comprehensive understanding of anatomical lumbar pain generators in combination with the current treatment-based classification system will further improve and enhance clinical decision-making skills. Section I reviews the anatomy of the spinal myofascia, myofascial sources of lumbar pain, and imaging of myofascial tissues. Part II reviews the anatomy of the IVD, examines the IVD as a potential lumbar pain generator, and includes detailed discussion on Nerve Growth Factor, Inflammatory Cytokines, Vertebral End Plates and Modic change, Annular tears, and Discogenic instability. Part III looks at the history of myofascial pain, lab-based research and myofascial pain, and various levels of discogenic pain provocation research including animal, laboratory and human subjects. Our review concludes with author recommendations on developing a comprehensive understanding of altered stress concentrations affecting the posterior annulus fibrosis, neo-innervation of the IVD, inflammatory cytokines, discogenic instability, and how this knowledge can complement use of the Treatment-Based Classification System.

Comprehensive comparison of three techniques for the treatment of adjacent segment degeneration after lumbar fusion

Purpose

Adjacent segment degeneration (ASD) following lumbar fusion is technically challenging for spine surgeons. Posterolateral open fusion surgery with pedicle screw fixation is an effective way to treat symptomatic ASD with favorable clinical outcomes; however, it is associated with an increased morbidity rate. Therefore, minimally invasive spine surgery is advocated. This study was designed to compare clinical outcomes among patients with symptomatic ASD who underwent percutaneous transforaminal endoscopic discectomy (PTED) with the transforaminal approach, posterior lumbar interbody fusion (PLIF) with cortical bone trajectory screw fixation (CBT-PLIF), and PLIF with traditional trajectory screw fixation (TT-PLIF).

Methods

A retrospective study was conductedon 46 patients (26 men and 20 women; average age 60.8 ± 6.78 years) with symptomatic ASD. The patients were treated with three approaches. The operation time, incision length, time to return to work, complications, and the like were compared among three groups. Intervertebral disc (IVD) space height, angular motion, and vertebral slippage were obtained to assess spine biomechanical stability following surgery. The visual analog scale (VAS) score and Oswestry disability index were evaluated at preoperation and 1-week, 3-month, and the latest follow-ups. Clinical global outcomes were also estimated using modified MacNab criteria.

Results

The operation time, incision length, intraoperative blood loss, and time to return to work for the PTED group were significantly decreased compared with those for the other two groups (P &lt; 0.05). The radiological indicators in the CBT-PLIF group and TT-PLIF group had better biomechanical stability compared with those in the PTED groups at the latest follow-up (P &lt; 0.05). The back pain VAS score in the CBT-PLIF group was significantly decreased compared with those in the other two groups at the latest follow-up (P &lt; 0.05). The good-to-excellent rate was 82.35% in the PTED group, 88.89% in the CBT-PLIF group, and 85.00% in the TT-PLIF group. No serious complications were encountered. Two patients experienced dysesthesia in the PTED group; screw malposition was found in one patient in the CBT-PLIF group. One case with a dural matter tear was observed in the TT-PLIF group.

Conclusion

All three approaches can treat patients with symptomatic ASD efficiently and safely. Functional recovery was more accelerated in the PTED group compared with the other approaches in the short term; CBT-PLIF and TT-PLIF can provide superior biomechanical stability to the lumbosacral spine following decompression compared with PTED; however, compared with TT-PLIF, CBT-PLIF can significantly reduce back pain caused by iatrogenic muscle injury and improve functional recovery. Therefore, superior clinical outcomes were achieved in the CBT-PLIF group compared with the PTED and TT-PLIF groups in the long term.

The effect of sagittal alignment, coronal balance, and segmental stability on preoperative patient-reported outcomes in patients with degenerative lumbar spondylolisthesis

OBJECTIVE

The aim of this study was to investigate the association between spinal alignment and preoperative patient-reported outcomes (PROs) in patients with degenerative lumbar spondylolisthesis (DLS) and to identify the independent risk factors for worse preoperative PROs.

METHODS

In total, 101 patients suffering from DLS were retrospectively studied within a single medical center. Age, sex, height, weight, and body mass index were uniformly recorded. PRO-related indicators include the Oswestry Disability Index (ODI), the Japanese Orthopedic Association's (JOA) score, and the visual analog scale (VAS) for back and leg pain. Sagittal alignment, coronal balance, and stability of the L4/5 level were evaluated through whole-spine anteroposterior and lateral radiographs and dynamic lumbar X-ray.

RESULTS

Increasing age (P = 0.005), higher sagittal vertical axis (SVA) (P < 0.001), and global coronal imbalance (GCI) (P = 0.023) were independent risk factors for higher ODI. Patients with GCI had lower JOA scores (P = 0.001) than those with balanced coronal alignment. Unstable spondylolisthesis (P < 0.001) and GCI (P = 0.009) were two vital predictors of VAS-back pain. Increasing age (P = 0.031), local coronal imbalance (LCI) (P < 0.001), and GCI (P < 0.001) were associated with higher VAS-leg pain. Moreover, patients with coronal imbalance also exhibited significant sagittal malalignment based on the subgroup analysis.

CONCLUSION

DLS patients with higher SVA, unstable spondylolistheses, a combination of LCI/GCI, or increasing age were predisposed to have more severe subjective symptoms before surgery.

Transforaminal Epidural Steroid Injection for Patients with Lumbosacral Disc Herniation in the Absence of Spine Magnetic Resonance Imaging - Is Better Really the Enemy of the Best?

Purpose

This study aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) in patients with lumbosacral disc herniation by comparing its effect between those diagnosed by clinical evaluation and plain radiography only (X-ray group) and those by additional magnetic resonance imaging (MRI) (MRI group). Additionally, we investigated the accuracy of the preliminary clinical assumption in the X-ray group using confirmative post-injection MRI.

Patients and Methods

We retrospectively recruited 367 patients with back and radicular pain due to lumbosacral disc herniation from a single pain clinic. Among them, 201 and 166 patients were categorized into the X-ray and MRI groups, respectively. In the X-ray group, the pathological level assumed initially by clinical evaluation and plain radiography concurred with that confirmed later on post-injection MRI in 139 patients (corresponding group); the remaining 62 patients lacked this concurrence (non-corresponding group). The NRS scores and Macnab criteria results were compared between the X-ray and MRI groups as well as the corresponding and non-corresponding groups.

Results

Both the X-ray and MRI groups showed significant reductions in the NRS scores at 2 and 10 weeks post-injection when compared with the pretreatment scores. However, no significant difference was noted between the groups in terms of the magnitude of clinical improvement assessed by successful reduction in the NRS or Macnab scores. Furthermore, similar results were obtained in the comparison between the corresponding and non-corresponding groups of the X-ray group.

Conclusion

TFESI guarantees favorable clinical outcomes even in the absence of confirmative MRI in patients with back and radicular pain. The preemptive application of this procedure could be prioritized and justified in patients suspected of lumbosacral disc herniation based on clinical evaluation and plain radiography only without the preceding MRI verification.

A High Body Mass Index and the Vacuum Phenomenon Upregulate Pain-Related Molecules in Human Degenerated Intervertebral Discs

Animal studies suggest that pain-related-molecule upregulation in degenerated intervertebral discs (IVDs) potentially leads to low back pain (LBP). We hypothesized that IVD mechanical stress and axial loading contribute to discogenic LBP’s pathomechanism. This study aimed to elucidate the relationships among the clinical findings, radiographical findings, and pain-related-molecule expression in human degenerated IVDs. We harvested degenerated-IVD samples from 35 patients during spinal interbody fusion surgery. Pain-related molecules including tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-6, calcitonin gene-related peptide (CGRP), microsomal prostaglandin E synthase-1 (mPGES1), and nerve growth factor (NGF) were determined. We also recorded preoperative clinical findings including body mass index (BMI), Oswestry Disability Index (ODI), and radiographical findings including the vacuum phenomenon (VP) and spinal instability. Furthermore, we compared pain-related-molecule expression between the VP (−) and (+) groups. BMI was significantly correlated with the ODI, CGRP, and mPGES-1 levels. In the VP (+) group, mPGES-1 levels were significantly higher than in the VP (−) group. Additionally, CGRP and mPGES-1 were significantly correlated. Axial loading and mechanical stress correlated with CGRP and mPGES-1 expression and not with inflammatory cytokine or NGF expression. Therefore, axial loading and mechanical stress upregulate CGRP and mPGES-1 in human degenerated IVDs, potentially leading to chronic discogenic LBP.

A real-time 3D electromagnetic navigation system for percutaneous transforaminal endoscopic discectomy in patients with lumbar disc herniation: a retrospective study

BACKGROUND

In this study, we present a novel electromagnetic navigation (EMN) system for percutaneous transforaminal endoscopic discectomy (PTED) procedure. The objective of this study was to investigate the safety and effectiveness of the PTED with the assistance of the EMN system and compare it with the conventional PTED with the assistance of fluoroscopic guidance (C-arm).

METHODS

The clinical data of 79 patients (32 in EMN group and 47 in C-arm group) undergoing PTED for lumbar disc herniation (LDH) from January to September of 2019 were analyzed retrospectively. The radiation time, puncture time, operation time, visual analog scale (VAS), Oswestry disability index (ODI), modified MacNab criteria, and radiological parameters were recorded in both groups.

RESULTS

Radiation time, puncture time, and operation time were significantly reduced in the EMN group compared with the C-arm group (P < 0.05). Compared with the C-arm group, a steeper learning curve was observed in the EMN group. There were no significant differences between the two groups regarding VAS and ODI scores at different time points (P > 0.05). The satisfaction rates of the EMN and C-arm groups were 90.63 and 87.23%, respectively, but no significant difference was found between the two groups (P > 0.05). There was no significant difference regarding translation and angular motion between the two groups at preoperation and postoperation (P > 0.05).

CONCLUSIONS

The EMN system can be applied to facilitate the PETD procedure. It can significantly reduce the intraoperative radiation time, puncture time, and operation time, and reshape the learning curve of PTED. Due to limitations of a retrospective study, results may need validation with larger prospective randomized clinical trials.

Research progress of diagnosing methodology for lumbar segmental instability: A narrative review

OBJECTIVE

Lumbar segmental instability (LSI) is due to a pathologic movement of the vertebral body on the vertebra below and often causes clinical symptoms. The study was to achieve the research progress of diagnosing methodology for lumbar segmental instability and help clinicians make treatment choices.

METHODS

The data for this study were collected from the MEDLINE, Springer, Web of Science, PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Evidence Based Medicine Reviews, VIP, and CNKI. The search terms were integrated as follows: "(∗lumbar instability∗ OR ∗lumbar spondylolisthesis∗) and (∗image∗ or ∗diagnosis∗)". Studies without clear radiographic instable criteria, case reports, letter, and basic research were excluded.

RESULT

In total, 39 articles published met our inclusion criteria. The various modalities were used to diagnosis LSI in these studies included radiographs, facet joint degeneration and physical examination tests.

CONCLUSION

Overall, there have been a variety of researches to develop the diagnosing methodology for LSI, and many have been successful, although no consensus has been reached yet. However, it is believed that the diagnosis of LSI will become easier and more accurate in the near future.

Lumbar Intervertebral Kinematics During an Unstable Sitting Task and Its Association With Standing-Induced Low Back Pain

People developing transient low back pain during standing have altered control of their spine and hips during standing tasks, but the transfer of these responses to other tasks has not been assessed. This study used video fluoroscopy to assess lumbar spine intervertebral kinematics of people who do and do not develop standing-induced low back pain during a seated chair-tilting task. A total of 9 females and 8 males were categorized as pain developers (5 females and 3 males) or nonpain developers (4 females and 5 males) using a 2-hour standing exposure; pain developers reported transient low back pain and nonpain developers did not. Participants were imaged with sagittal plane fluoroscopy at 25 Hz while cyclically tilting their pelvises anteriorly and posteriorly on an unstable chair. Intervertebral angles, relative contributions, and anterior-posterior translations were measured for the L3/L4, L4/L5, and L5/S1 joints and compared between sexes, pain groups, joints, and tilting directions. Female pain developers experienced more extension in their L5/S1 joints in both tilting directions compared with female nonpain developers, a finding not present in males. The specificity in intervertebral kinematics to sex-pain group combinations suggests that these subgroups of pain developers and nonpain developers may implement different control strategies.

The Influence of Posture on Instability Evaluation Using Flexion-Extension X-Ray Imaging in Lumbar Spondylolisthesis

Study Design

Prospective clinical study.

Purpose

To determine the optimal posture for instability evaluation using flexion–extension X-ray imaging in patients with lumbar spondylolisthesis.

Overview of Literature

Currently, flexion–extension X-ray imaging is the most practical approach for the evaluation of lumbar instability. In flexion–extension X-ray imaging, achievement of the greatest segmental motion with flexion–extension movement is necessary. However, to our knowledge, currently, there is no standardized posture for determining lumbar instability.

Methods

Twenty-three individuals with lumbar spondylosis related to the fourth vertebra underwent flexion–extension X-ray imaging in different postures (standing, sitting, and lateral decubitus positions), lumbar magnetic resonance imaging (MRI), and low back pain Visual Analog Scale (VAS) evaluation on the same day. Intervertebral angle, percent slippage, and intervertebral disc area ratio for different postures during flexion and extension were compared using Tukey’s method. The effect of low back pain and the association between MRI facet effusion and these measurements were investigated according to posture.

Results

The percent slippage during extension (p=0.036), change in the percent slippage between flexion and extension (p=0.004), and change in the intervertebral angle (p=0.042) were significantly different between the sitting and lateral decubitus positions. There were also significant differences between the standing and lateral decubitus positions in the change in intervertebral angle (p=0.010). In patients with VAS score <40, there were significant differences in the intervertebral angle (p=0.011) between the standing and lateral decubitus positions, percent slippage (p=0.048), and intervertebral disk ratio (p=0.008) between the sitting and lateral decubitus positions. We found no relationship between MRI facet effusion and posture in terms of instability.

Conclusions

In this study, intervertebral instability was best evaluated in the lateral decubitus position when using flexion–extension X-ray imaging for patients with fourth lumbar vertebral spondylolisthesis.

Center of rotation locations during lumbar spine movements: a scoping review protocol

OBJECTIVE

The objective of this review is to identify and map current literature describing the center of rotation locations and migration paths during lumbar spine movements.

INTRODUCTION

Altered lumber spine kinematics has been associated with pain and injury. Intervertebral segments' center of rotations, the point around which spinal segments rotate, are important for determining the features of lumbar spine kinematics and the potential for increased injury risk during movements. Although many studies have investigated the center of rotations of humans' lumbar spine, no review has summarized and organized the state of the science related to center of rotation locations and migration paths of the lumbar spine during lumbar spine movements.

INCLUSION CRITERIA

This review will consider studies that include human lumbar spines of any age and condition (e.g. heathy, pathological) during lumbar spine movements. Quantitative study designs, including clinical, observational, laboratory biomechanical experimental studies, mathematical and computer modeling studies will be considered. Only studies published in English will be included, and there will be no limit on dates of publication.

METHODS

PubMed, MEDLINE, Embase, the Cochrane Library Controlled Register of Trials, CINAHL, ACM Digital Library, Compendex, Inspec, Web of Science, Scopus, Google Scholar, and dissertation and theses repositories will be searched. After title and abstract screening of identified references, two independent reviewers will screen the full-text of identified studies and extract data. Data will be summarized and categorized, and a comprehensive narrative summary will be presented with the respective results.

Image-Based Markers Predict Dynamic Instability in Lumbar Degenerative Spondylolisthesis

Objective

To identify possible radiographic predictors markers of dynamic instability including disc height (DH), disc degeneration, and spondylosis in the setting of degenerative spondylolisthesis (DS).

Methods

A retrospective review with prospectively collected data was performed on 125 patients with L4–5 DS who underwent decompression and fusion. Patients were divided into groups with dynamic instability and those without. Radiographs of the lumbar spine in neutral, flexion, and extension were used to determine degree of slip, DH, translational motion, angular motion, spondylotic changes, and lumbar lordosis. Magnetic resonance imaging (MRI) scans were reviewed to assess disc degeneration.

Results

Thirty-one percent of the patients met criteria for dynamic instability. Significant correlations (p < 0.05) were found between preserved DH and dynamic instability; increased spondylotic changes and decreased translational motion; as well as advanced MRI-based disc degeneration scores with decreased angular motion, respectively. Six radiographic parameters were utilized to create a predictive model for dynamic instability, and a receiver operating characteristic curve was able to validate the predictive model (area = 0.891, standard error = 0.034, p < 0.001).

Conclusion

In DS patients, preserved DH was significantly related to dynamic instability. This finding may represent a greater potential for slip progression over time in these patients. In contrast, disc degeneration on MRI, and spondylotic changes were inversely related to dynamic instability and may represent restabilization mechanisms that decrease the chance of future slip progression in DS.

Comparison of Segmental Mobility in Lumbar Extension Radiographs between a New Technique ("Fulcrum Bending Position") and Conventional Standing Position in Spondylolisthesis Patients

Study Design

Cross-sectional study.

Purpose

This was carried out to evaluate the benefit of a ‘fulcrum bending position’ compared with the standing position for evaluation of sagittal translation and sagittal rotation in symptomatic patients with spondylolisthesis.

Overview of Literature

In lumbar X-ray, the standing position is the most common position used in determining abnormalities in lumbar movement. Lack of standardized method is one of the pitfalls in this technique. We hypothesized that the new technique, that is, fulcrum bending position, may reveal a higher translation and rotation in spondylolisthesis patients.

Methods

The extension lumbar radiographs of 36 patients with low-grade spondylolisthesis were included in the analysis and measurement. Sagittal translation and sagittal rotation were measured in both the routine standing position and in our new technique, the fulcrum bending position, which involves taking lateral cross-table images in the supine position wherein the patient lies on a cylindrical pipe to achieve maximum passive back extension by the fulcrum principle.

Results

Results of the measurement of sagittal translation in both positions revealed that compared with the extension standing position, the fulcrum bending position achieved a statistically significant increase of 1.57 mm in translation of the vertebra position (95% confidence interval [CI], 0.52–2.61; p=0.004). The measurement of sagittal rotation in both positions revealed that when compared with the extension standing position, the fulcrum bending position achieved a statistically significant increase of 3.47° in the rotation of the vertebra (95% CI, 1.64–5.30; p<0.001).

Conclusions

For evaluation of both sagittal translation and sagittal rotation in symptomatic patients with spondylolisthesis, compared with the extension standing position, the fulcrum bending position can achieve an increased change in magnitude. Our technique, that is, the fulcrum bending position, may offer an alternative method in the detection or exclusion of pathological mobility in patients with spondylolisthesis.

Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate

SYNOPSIS

Although biomechanics plays a role in the development and perhaps the persistent or recurrent nature of low back pain (LBP), whether biomechanics alone can provide the basis for intervention is debated. Biomechanics, which refers to the mechanics of the body, including its neuromuscular control, has been studied extensively in LBP. But, can gains be made in understanding LBP by research focused on this component of biology in the multifactorial biopsychosocial problem of LBP? This commentary considers whether biomechanics research has the potential to advance treatment of LBP, and how likely it is that this research will lead to better treatment strategies. A point-counterpoint format is taken to present both sides of the argument. First, the challenges faced by an approach that considers biomechanics in isolation are presented. Next, we describe 3 models that place substantial emphasis on biomechanical factors. Finally, reactions to each point are presented as a foundation for further research and clinical practice to progress understanding of the place for biomechanics in guiding treatment of LBP. J Orthop Sports Phys Ther 2019;49(6):425-436. Epub 15 May 2019. doi:10.2519/jospt.2019.8825.

Quantifying Range of Motion and Stress Patterns at the Transitional Lumbosacral Junction: Pilot Study Using a Computational Model for Load-Bearing at Accessory L5-S1 Articulation

Background

Symptomatic or asymptomatic transitional anomalies at the lumbosacral junction are common occurrences in the population. Lumbosacral (L5-S1) accessory articulations are the most common presentations of transitional anomalies at this region. Such anatomical alterations are believed to be associated with biomechanical changes of load-bearing and movement restrictions leading to low back pain. This study attempts to use computational models of a normal and a lumbosacral transitional vertebrae (LSTV) accessory articulation to analyze and compare the range of motion and loading patterns at the lumbosacral articulations.

Methods

Three-dimensional Finite Element computational models of normal and accessory L5-S1 articulated sacrum were created. These models were tested for range of motion and stress patterns generated at the lumbosacral articulations using similar loading and motion simulation to elicit different moments/excursions at the lumbosacral junctions.

Results

Compared to the normal variant, the transitional model exhibited different range of motion and divergent patterns of stress generation at the lumbosacral and accessory articulations with equal and physiological magnitudes of loading applied to both the models.

Conclusions

The finite element modeling approach can be used for biomechanical investigations in LSTV variants. However, larger sample studies with different LSTV models may be required to statistically compare movement and loading patterns at LSTV-affected lumbosacral and sacroiliac junctions, and to recommend definitive treatment strategies in these situations.

Surgical Intervention for Osteoporotic Vertebral Burst Fractures in Middle-low Lumbar Spine with Special Reference to Postoperative Complications Affecting Surgical Outcomes

The purpose of this study was to investigate the clinical and radiological features of osteoporotic burst fractures affecting levels below the second lumbar (middle-low lumbar) vertebrae, and to clarify the appropriate surgical procedure to avoid postoperative complications. Thirty-eight consecutive patients (nine male, 29 female; mean age: 74.8 years; range: 60-86 years) with burst fractures affecting the middle-low lumbar vertebrae who underwent posterior-instrumented fusion were included. Using the Magerl classification system, these fractures were classified into three types: 16 patients with superior incomplete burst fracture (superior-type), 11 patients with inferior incomplete burst fracture (inferior-type) and 11 patients with complete burst fracture (complete-type). The clinical features were investigated for each type, and postoperative complications such as postoperative vertebral collapse (PVC) and instrumentation failure were assessed after a mean follow-up period of 3.1 years (range: 1-8.1 years). All patients suffered from severe leg pain by radiculopathy, except one with superior-type fracture who exhibited cauda equina syndrome. Nineteen of 27 patients with superior- or inferior-type fracture were found to have spondylolisthesis due to segmental instability. Although postoperative neurological status improved significantly, lumbar lordosis and segmental lordosis at the fused level deteriorated from the postoperative period to the final follow-up due to postoperative complications caused mainly by PVC (29%) and instrument failure (37%). Posterior-instrumented fusion led to a good clinical outcome; however, a higher incidence of postoperative complications due to bone fragility was inevitable. Therefore, short-segment instrument and fusion with some augumentation techniqus, together with strong osteoporotic medications may be required to avoid such complications.

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

Relationships between lumbar inter-vertebral motion and lordosis in healthy adult males: a cross sectional cohort study

Background

Intervertebral motion impairment is widely thought to be related to chronic back disability, however, the movements of inter-vertebral pairs are not independent of each other and motion may also be related to morphology. Furthermore, maximum intervertebral range of motion (IV-RoMmax) is difficult to measure accurately in living subjects. The purpose of this study was to explore possible relationships between (IV-RoMmax) and lordosis, initial attainment rate and IV-RoMmax at other levels during weight-bearing flexion using quantitative fluoroscopy (QF).

Methods

Continuous QF motion sequences were recorded during controlled active sagittal flexion of 60° in 18 males (mean age 27.6 SD 4.4) with no history of low back pain in the previous year. IV-RoMmax, lordotic angle, and initial attainment rate at all inter-vertebral levels from L2-S1 were extracted. Relationships between IV-RoMmax and the other variables were explored using correlation coefficients, and simple linear regression was used to determine the effects of any significant relationships. Within and between observer repeatability of IV-RoMmax and initial attainment rate measurements were assessed in a sub-set of ten participants, using the intra-class correlation coefficient (ICC) and standard error of measurement (SEM).

Results

QF measurements were highly repeatable, the lowest ICC for IV-RoMmax, being 0.94 (0.80–0.99) and highest SEM (0.76°). For initial attainment rate the lowest ICC was 0.84 (0.49–0.96) and the highest SEM (0.036). The results also demonstrated significant positive and negative correlations between IV-RoMmax and IV-RoMmax at other lumbar levels (r = −0.64–0.65), lordosis (r = −0.52–0.54), and initial attainment rate (r = −0.64–0.73). Simple linear regression analysis of all significant relationships showed that these predict between 28 and 42 % of the variance in IV-RoMmax.

Conclusions

This study found weak to moderate effects of individual kinematic variables and lumbar lordosis on IV-RoMmax at other intervertebral levels. These effects, when combined, may be important when such levels are being considered by healthcare professionals as potential sources of pain generation. Multivariate investigations in larger samples are warranted.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0975-1) contains supplementary material, which is available to authorized users.

Attainment rate as a surrogate indicator of the intervertebral neutral zone length in lateral bending: an in vitro proof of concept study

Background

Lumbar segmental instability is often considered to be a cause of chronic low back pain. However, defining its measurement has been largely limited to laboratory studies. These have characterised segmental stability as the intrinsic resistance of spine specimens to initial bending moments by quantifying the dynamic neutral zone. However these measurements have been impossible to obtain in vivo without invasive procedures, preventing the assessment of intervertebral stability in patients. Quantitative fluoroscopy (QF), measures the initial velocity of the attainment of intervertebral rotational motion in patients, which may to some extent be representative of the dynamic neutral zone. This study sought to explore the possible relationship between the dynamic neutral zone and intervertebral rotational attainment rate as measured with (QF) in an in vitro preparation. The purpose was to find out if further work into this concept is worth pursuing.

Method

This study used passive recumbent QF in a multi-segmental porcine model. This assessed the intrinsic intervertebral responses to a minimal coronal plane bending moment as measured with a digital force guage. Bending moments about each intervertebral joint were calculated and correlated with the rate at which global motion was attained at each intervertebral segment in the first 10° of global motion where the intervertebral joint was rotating.

Results

Unlike previous studies of single segment specimens, a neutral zone was found to exist during lateral bending. The initial attainment rates for left and right lateral flexion were comparable to previously published in vivo values for healthy controls. Substantial and highly significant levels of correlation between initial attainment rate and neutral zone were found for left (Rho = 0.75, P = 0.0002) and combined left-right bending (Rho = 0.72, P = 0.0001) and moderate ones for right alone (Rho = 0.55, P = 0.0012).

Conclusions

This study found good correlation between the initial intervertebral attainment rate and the dynamic neutral zone, thereby opening the possibility to detect segmental instability from clinical studies. However the results must be treated with caution. Further studies with multiple specimens and adding sagittal plane motion are warranted.

Hidden spondylolisthesis: unrecognized cause of low back pain? Prospective study about the use of dynamic projections in standing and recumbent position for the individuation of lumbar instability

INTRODUCTION

Dynamic X-rays (DXR) are widely recognized as an effective method to detect lumbar instability (LI). They are usually performed with the patient in standing position (SDXR). In our opinion, standing position inhibits micromovements of the lumbar segment interested by the listhesis, thanks to paravertebral muscles antalgic contraction and augmented tone. We aim to demonstrate that DXR in recumbent position (RDXR), reducing the action of paravertebral muscles, can discover hypermovements not evidenced in SDXR.

METHODS

Between January 2011 and January 2013, we studied 200 consecutive patients with lumbar degenerative disease with MRI, SDXR, and RDXR. We aimed to find a correlation between low back or radicular pain and the presence of a spondylolisthesis not showed by the SDXR, but showed by the RDXR.

RESULTS

We analysed 200 patients: of the 133 not pathologic in SDXR, 43 patients (32.3 %) showed an hypermovement in RDXR (p = 0.0001) without any significant correlation between hidden listhesis and age, sex, or level involved.

CONCLUSIONS

The aim of our study is to determine whether in patients with lumbalgy without evidence of listhesis in SDXR, pain can be attributed to a faccettal syndrome or to a spondylolisthesis. Consequence of pain is augmented muscular tone of the paravertebral musculature, particularly in standing position. Augmented muscular tone tries to inhibit the pain generator, attempting to limit the slippage of the involved segment. In patients examined in RDXR, the tone of paravertebral musculature is reduced, showing the hidden spondylolisthesis.

The effects of anterior vacuum disc on surgical outcomes of degenerative versus spondylolytic spondylolisthesis: at a minimum two-year follow-up

Background

The vacuum phenomenon within the intervertebral disc usually represents disc degeneration. There are no reports in the English literature that focus on the effect of an anterior vacuum disc on surgical outcome of same-segment spondylolisthesis.

Methods

Patients with degenerative spondylolisthesis (DS) or isthmic spondylolisthesis (IS) who underwent a spinal surgery between January 2005 and December 2006 were reviewed. Patients who met certain criteria, including (1) only mono-segment spondylolisthesis, (2) gas air within the disc space of the spondylolisthesis segment on preoperative radiographs, (3) having received posterior decompression, posterior pedicle screw fixation, and posterolateral fusion, and (4) at least 12 months of follow-up radiographs available to define the posterolateral fusion rate, were enrolled into the study. Four radiographic parameters (disc height, translation, intradiscal angle, segmental angle) were assessed. Two-year postoperative radiographs were used to determine whether the posterolateral segment was fused or not. Clinical outcome and complications during the follow-up period were documented.

Results

Incidence of the disc vacuum phenomenon was significantly higher in the IS group than in the DS group (p < 0.001). The IS group had more listhesis and a narrower disc height on preoperative static radiographs; however, the DS group had a more prominent angle and listhesis change in preoperative dynamic variables. The posterolateral fusion rate was significantly higher in the IS group (p = 0.019). The preoperative Oswestry Disability Index (ODI) score, the final ODI, and the ODI difference were similar between groups. More excellent and good results were seen in the IS group. Besides, better final ODI and results were seen in the bilateral fusion group than in the nonfusion group.

Conclusion

The disc vacuum phenomenon is not equal to anterior instability absolutely. Determination of stability or instability in a vacuum disc should be considered by a combination of dynamic radiographs. In the present study, vacuum discs in the DS group showed more instability and a higher posterolateral pseudoarthrosis rate.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-329) contains supplementary material, which is available to authorized users.

A randomized clinical trial comparing extensible and inextensible lumbosacral orthoses and standard care alone in the management of lower back pain

STUDY DESIGN

Single blinded, randomized clinical trial for the evaluation of lumbosacral orthoses (LSOs) in the management of lower back pain (LBP).

OBJECTIVE

To evaluate the effects of two types of LSOs on self-rated disability in patients with LBP.

SUMMARY OF BACKGROUND DATA

LSOs are commonly used for the management of LBP, but their effectiveness may vary because of design. An inextensible LSO (iLSO) reduces trunk motion and increases trunk stiffness, whereas an extensible LSO (eLSO) does not.

METHODS

A total of 98 participants with LBP were randomized to 3 groups: (1) standard care (SC) group, which included medication and physical therapy (n = 29), (2) SC with eLSO (eLSO group) (n = 32), and (3) SC with iLSO (iLSO group) (n = 37). Outcome measures were evaluated before and after 2 weeks of treatment: modified Oswestry Disability Index (ODI), Patient Specific Activity Scale, pain ratings, and Fear Avoidance Beliefs Questionnaire.

RESULTS

There were no statistically significant differences between groups at baseline. Compared with the SC alone, iLSO group showed greater improvement on the ODI scores (P = 0.01) but not the eLSO group. The ODI scores improved by a mean of 2.4 (95% confidence interval [CI], 2.2-7.1), 8.1 (95% CI, 2.8-13.4), and 14.0 (95% CI, 8.2-19.8) points for SC, eLSO, and iLSO groups, respectively. Individuals wearing the iLSO had 4.7 times higher odds of achieving 50% or greater improvement in the ODI scores than those assigned to SC (95% CI, 1.2-18.5, P = 0.03). Both the eLSO and iLSO groups had a greater improvement in the Patient Specific Activity Scale scores than the SC group (P = .05 and P = 0.01, respectively), but the change did not meet the minimal clinically important difference. Pain ratings improved for all 3 groups, with no statistical difference between them. Finally, no significant differences across groups were found for the Fear Avoidance Beliefs Questionnaire.

CONCLUSION

An iLSO led to greater improvement in ODI scores than SC and an eLSO. We surmise that the likely mechanism responsible for this difference in outcome was the added trunk stiffness and motion restriction by the iLSO.

LEVEL OF EVIDENCE

2.

Dynamic motion characteristics of the lower lumbar spine: implication to lumbar pathology and surgical treatment

PURPOSE

Many studies have reported on the segmental motion range of the lumbar spine using various in vitro and in vivo experimental designs. However, the in vivo weightbearing dynamic motion characteristics of the L4-5 and L5-S1 motion segments are still not clearly described in literature. This study investigated in vivo motion of the lumbar spine during a weight-lifting activity.

METHODS

Ten asymptomatic subjects (M/F: 5/5; age: 40-60 years) were recruited. The lumbar segment of each subject was MRI-scanned to construct 3D models of the L2-S1 vertebrae. The lumbar spine was then imaged using a dual fluoroscopic imaging system as the subject performed a weight-lifting activity from a lumbar flexion position (45°) to maximal extension position. The 3D vertebral models and the fluoroscopic images were used to reproduce the in vivo vertebral positions along the motion path. The relative translations and rotations of each motion segment were analyzed.

RESULTS

All vertebral motion segments, L2-3, L3-4, L4-5 and L5-S1, rotated similarly during the lifting motion. L4-5 showed the largest anterior-posterior (AP) translation with 2.9 ± 1.5 mm and was significantly larger than L5-S1 (p < 0.05). L5-S1 showed the largest proximal-distal (PD) translation with 2.8 ± 0.9 mm and was significantly larger than all other motion segments (p < 0.05).

CONCLUSIONS

The lower lumbar motion segments L4-5 and L5-S1 showed larger AP and PD translations, respectively, than the higher vertebral motion segments during the weight-lifting motion. The data provide insight into the physiological motion characteristics of the lumbar spine and potential mechanical mechanisms of lumbar disease development.

Radiographic evaluation of ventral instability in lumbar spondylolisthesis: do we need extension radiographs in routine exams?

PURPOSE

To determine the usefulness of acquiring extension radiographs for the evaluation of the degree of spondylolisthesis.

METHODS

Routine radiographs of the lumbar spine were retrospectively evaluated in 87 patients (mean-age 63, range 32-86) by two independent radiologists. All patients received radiographs in standing neutral, flexion and extension position. Vertebral body depth, sagittal translational displacement and lordosis angle were measured and slip percentage (SP) was calculated on standing neutral, flexion and extension radiographs. Statistical analysis was performed with a two-sided t test. Inter- and intraobserver reliability was assessed using the kappa-coefficient.

RESULTS

There was no statistically significant SP-difference between neutral standing and extension images. Ventral instability was diagnosed in 25-34 % (cut-off >8 % SP-difference) for neutral versus flexion comparison. The detection rate of flexion-extension radiographs representing the extremes of motion was lower with 15-22 %. Inter- and intraobserver reliability was good to excellent.

CONCLUSION

Slip percentage in routine standing extension radiography ultimately does not differ from that obtained in a static neutral standing view. Extension radiography may therefore be omitted in a routine work-up of ventral instability in lumbar spondylolisthesis.

Grade three disc degeneration is a critical stage for anterior spondylolisthesis in lumbar spine

INTRODUCTION

Little is known about when and how progressive spondylolisthesis occurs. In this report segmental motion related to age and disc degeneration at L4/5 disc was investigated.

MATERIALS AND METHODS

637 patients with low back and/or leg pain underwent radiologic and MRI examinations simultaneously. Because 190 patients with conditions which might impede accurate measurement were excluded, 447 patients, comprising 268 men and 179 women, were included; age range, was 10-86 (mean: 53) years. Three radiologic parameters slip in neutral position (mm), sagittal translation (mm), and segmental angulation (degrees) were examined at the L4/5 segment. On T2-weighted MRI, severity of disc degeneration at L4/5 was classified by Pfirrmann's criteria, grade 1-5.

RESULTS

Results showed stage of disc degeneration that progressed according to aging with significant differences except for between grades 4 and 5. Amount of anterior slip was small among grades 1 to 3; however, it greatly increased between grades 3 and 4 and between grades 4 and 5, suggesting that grade 3 disc degeneration has a potential risk of future progression of anterior slip. This finding may also suggest that once significant slip occurs, it will progress to the final grade. Furthermore, the grade 3 degeneration group exhibited large amounts of motion in both angulation and translation, suggesting it was the most unstable group.

CONCLUSION

Our results with radiography and MRI indicate that grade 3 disc degeneration is a critical stage for the progression of lumbar spondylolisthesis at L4/5 segment.

Dysfunctional segmental motion treated with dynamic stabilization in the lumbar spine

OBJECTIVE

To determine the suitability of the application of dynamic stabilization (DS) as a nonfusion technique to address dysfunctional segmental motion (DSM) in the lumbar spine.

METHODS

Over a 1-year period, 25 patients were treated with the same assessment and surgical protocol. Inclusion criteria were clinical presentation of DSM with or without stenosis. On preoperative and postoperative plain anteroposterior, lateral, and lateral flexion-extension radiographs, anterior and posterior disc height (DH); anteroposterior diameter of the disc; and global, segmental, apical segment, and below level lordotic angles (LAs) were measured.

RESULTS

The study included 9 women and 16 men with a mean age of 43.48 years ± 7.6. On average, patients had symptoms for 38.04 months ± 29.6, and mean follow-up was 12.36 months ± 3.46. The average height of anterior, posterior, and mean intervertebral discs increased significantly (P = 0.002, P = 0.003, and P < 0.0001). There were no significant differences between the preoperative and postoperative global, segmental, apical segment, and below segment LAs in flexion, extension, and neutral positions. At mid-term follow-up, no patients showed new signs of degeneration at the adjacent motion segment.

CONCLUSIONS

Overall, the limited radiologic data advocate DS as a nonfusion technique in the treatment of DSM in the lumbar spine. Long-term follow-up is essential, however, to investigate the long-term efficacy of DS in the surgical treatment of DSM.

The analysis of segmental mobility with different lumbar radiographs in symptomatic patients with a spondylolisthesis

PURPOSE

Lumbar flexion-extension radiographs in standing position (SFE) are the most commonly used imaging method to evaluate segmental mobility. Many surgeons use SFE to disclose abnormal vertebral motion and base their decision for surgical fusion on its results. We tested the hypothesis that imaging in standing and recumbent position (SRP) reveals a higher sagittal translation (ST) and sagittal rotation (SR) in symptomatic patients than with SFE.

MATERIALS AND METHODS

We analysed images of 100 symptomatic patients with a low-grade spondylolisthesis that underwent surgical fusion. To determine the ST and SR in SRP, we compared the images taken in the recumbent position in the CT with images taken in the standing position during the routine plain radiography.

RESULTS

The measurement of ST revealed an absolute value of 2.3 ± 1.5 mm in SFE and 4.0 ± 2.0 mm in SRP and differed significantly (p = 0.001). The analysis of the relative value showed an ST of 5.9 ± 3.9% in SFE and 7.8 ± 5.4% in SRP (p = 0.008). The assessment of ST in flexion and in a recumbent position (FRP) revealed the highest ST (4.6 ± 2.5 mm or 9.2 ± 5.7%). Comparison of SR showed the highest rotation in SFE (6.1° ± 3.8°), however, compared to SRP (5.4° ± 3.3°), it missed the level of significance (p = 0.051).

CONCLUSIONS

For evaluation of ST in symptomatic patients with spondylolisthesis SRP appears to be more suitable than SFE, while a pathological SR is better revealed in SFE. The analysis of SRP might offer a complementary method to detect or exclude pathological mobility in more cases.

Intimate relationship between instability and degenerative signs at L4/5 segment examined by flexion-extension radiography

Relationship between lumbar disc degeneration and segmental instability has remained controversial. Using instability factors that found close relations with symptoms in flexion-extension radiographic study, their relationship with degenerative findings was examined. More than (≥) 3 mm slip in neutral position (SN), ≥3 mm translation (ST), and ≥10° angulation (SA) at L4/5 segment were defined as instability factors and were applied on 447 patients who had low back and/or leg pain and satisfied inclusion criteria for accurate measurements. Radiologic findings for degeneration were disc height including three groups with different disc heights divided by mean ± 1 standard deviation, length of the anterior spur formation, presence of vacuum phenomenon, and endplate sclerosis. As results, group with SN factor was the oldest in age and the lowest in disc height; in contrast, group with SA was the youngest in age and the highest in disc height. The group with ST showed a mid-standing position in both age and disc height. These findings indicate that instability factors are intimately related to age and disc height. The three different disc height groups showed more anterior slip according to the progression of the disc height diminution. Presence of the apparent spur formation and/or vacuum phenomenon had an intimate relationship with the ST factor. Disc height was the most important in the examined parameters and showed an intimate relationship with age and instability factors. Although the etiology is still unknown, clinical common knowledge, that a diminution of disc height with progressive degeneration had a close relation with anterior vertebral slippage, was firstly confirmed. This study allows comprehensive understanding of segmental instability and is useful for considering surgical indications.