The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI) randomized controlled trial protocol

Evaluating the causal relationship between five modifiable factors and the risk of spinal stenosis: a multivariable Mendelian randomization analysis

Background

Spinal stenosis is a neurological disorder related to the compression of the spinal cord or nerve roots, and its incidence increases yearly. We aimed to use Mendelian randomization (MR) to investigate the causal relationship between several modifiable risk factors and the risk of spinal stenosis.

Methods

We obtained genome-wide association study summary data of large-sample projects (more than 100,000 individuals) from public databases. The data were associated with traits, including years of schooling (educational attainment) from the IEU OpenGWAS Project, smoking behavior (never vs. initiation) from the IEU OpenGWAS Project, body mass index (BMI) from the UK Biobank, length of mobile phone use from the UK Biobank, time spent watching television (TV) from the UK Biobank, and spinal stenosis from FinnGen biobank. Spinal stenosis was used as the outcome, whereas the other four traits were used as exposures. Inverse variance weighted (IVW) regressions were used as a primary to estimate the causal-effect size. Several sensitive analyses (including consistency, heterogenicity, and pleiotropy analyses) were conducted to test the stability and reliability of causal estimates.

Results

Univariable MR analyses showed that genetically predicted higher educational attainment (IVW; odds ratio (OR) = 0.606; 95% confidence interval (CI): 0.507-0.724; P = 3.37 × 10^-8) and never smoking (IVW; OR = 1.388; 95% CI [1.135-1.697]; P = 0.001) were negatively correlated with the risk of spinal stenosis. Meanwhile, a higher BMI (IVW; OR = 1.569; 95% CI [1.403-1.754]; P = 2.35 × 10^-8), longer time spent using a mobile phone (IVW; OR = 1.895; 95% CI [1.306-2.750]; P = 0.001), and watching TV (IVW; OR = 1.776; 95% CI [1.245-2.532]; P = 0.002) were positively associated with the risk of spinal stenosis. Multivariable MR analysis indicated that educational attainment (IVW; OR = 0.670; 95% CI [0.465-0.967]; P = 0.032) and BMI (IVW; OR = 1.365; 95% CI [1.179-1.580]; P = 3.12 × 10^-5) were independently causally related to the risk of spinal stenosis.

Conclusion

Our findings supported the potential causal associations of the five factors (educational attainment, smoking behavior, BMI, length of mobile phone use, and watching TV) with the risk for spinal stenosis. While replication studies are essential, these findings may provide a new perspective on prevention and intervention strategies directed toward spinal stenosis.

Effectiveness of a 6-week specific rehabilitation program combining education and exercises on walking capacity in patients with lumbar spinal stenosis with neurogenic claudication: a randomized controlled clinical trial protocol

BACKGROUND

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is a leading cause of disability which is intimately related to a decrease in walking capacity. Walking limitation has negative physical and mental impacts on patients. Recent guidelines recommend the use of conservative treatment options such as exercises before considering surgery. Unfortunately, dedicated healthcare resources for the conservative management of patients with LSS causing NC are uncommon. Thus, it is important to develop accessible and specific rehabilitation programs aimed at improving patients' self-management, especially with regard to walking capacity. The aim of this study is to evaluate the effectiveness of a 6-week specific rehabilitation program combining education and exercises on walking capacity in patients with LSS causing NC.

METHODS/DESIGN

This is a prospective randomized controlled parallel-group clinical trial. Sixty-six patients with LSS causing NC will be recruited from identified clinics and local advertisements. The intervention group will receive standardized education and specific exercises while the control group will only receive a standardized education. The program in both groups will last for 6 weeks with 5 evaluation time points (baseline, week 2, week 4, week 6, and week 12). The primary outcome will be walking capacity measured with the Self-Paced Walking Test, and the secondary outcomes will be back and leg pain intensity, LSS-related disability, self-efficacy, level of physical activity, anxiety, depression, gait pattern characteristics, balance, and global perceived change.

DISCUSSION

This study will assess the effectiveness of a 6-week specific rehabilitation program combining education and exercises on walking capacity in patients with LSS causing NC. By measuring objective gait pattern characteristics, the study will also provide new information about the impact of NC on gait pattern that could eventually improve the evaluation and the management of LSS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05513326 . Registered on August 22, 2022.

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

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

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence). PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

Lumbar spinal stenosis: symptoms, diagnosis and treatment (meta-analysis of literature data)

Lumbar spinal stenosis is a disease in which degenerated discs, ligamentum flavum, facet joints, while aging, lead to a narrowing of the space around the neurovascular structures of the spine. This article presents a meta-analysis of literature data on epidemiology, causes, pathogenesis, diagnosis and various types of treatment of lumbar spinal stenosis.

Objective measurement of function following lumbar spinal stenosis decompression reveals improved functional capacity with stagnant real-life physical activity

BACKGROUND CONTEXT

Lumbar spinal stenosis (LSS) is a prevalent and costly condition associated with significant dysfunction. Alleviation of pain and improvement of function are the primary goals of surgical intervention. Although prior studies have measured subjective improvements in function after surgery, few have examined objective markers of functional improvement.

PURPOSE

We aimed to objectively measure and quantify changes in physical capacity and physical performance following surgical decompression of LSS.

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

Thirty-eight patients with LSS determined by the treating surgeon's clinical and imaging evaluation, and who were scheduled for surgical treatment, were consecutively recruited at two academic medical facilities, with 28 providing valid data for analysis at baseline and 6 months after surgery.

OUTCOME MEASURES

Before surgery and at 6 months after surgery, participants provided 7 days of real-life physical activity (performance) using ActiGraph accelerometers; completed two objective functional capacity measures, the Short Physical Performance Battery and Self-Paced Walking Test; and completed three subjective functional outcome questionnaires, Oswestry Disability Index, Spinal Stenosis Symptom Questionnaire, and Short-Form 36.

METHODS

Physical activity, as measured by continuous activity monitoring, was analyzed as previously described according to the 2008 American Physical Activity Guidelines. Paired t tests were performed to assess for postsurgical changes in all questionnaire outcomes and all objective functional capacity measures. Chi-square analysis was used to categorically assess whether patients were more likely to meet these physical activity recommendations after surgery.

RESULTS

Participants were 70.1 years old (±8.9) with 17 females (60.7%) and an average body mass index of 28.4 (±6.2). All subjective measures (Oswestry Disability Index, Spinal Stenosis Symptom Questionnaire, and Short-Form 36) improved significantly at 6 months after surgery, as did objective functional measures of capacity including balance, gait speed, and ambulation distance (Short Physical Performance Battery, Self-Paced Walking Test). However, objectively measured performance (real-life physical activity) did not change following surgery. Although fewer participants qualified as inactive (54% vs. 71%), and more (11% vs. 4%) met the physical activity guideline recommendations at the 6-month follow-up, these differences were not statistically significant (p=.22) CONCLUSIONS: This is the first study, of which we are aware, to objectively evaluate changes in postsurgical performance (real-life physical activity) in people with LSS. We found that at 6 months after surgery for LSS, participants demonstrated significant improvements in self-reported function and objectively measured physical capacity, but not physical performance as measured by continuous activity monitoring. This lack of improvement in performance, despite improvements in self-reported function and objective capacity, suggests a role for postoperative rehabilitation focused specifically on increasing performance after surgery in the LSS population.

Objective measurement of free-living physical activity (performance) in lumbar spinal stenosis: are physical activity guidelines being met?

BACKGROUND

Research suggests that people with lumbar spinal stenosis (LSS) would benefit from increased physical activity. Yet, to date, we do not have disease-specific activity guidelines for LSS, and the nature of free-living physical activity (performance) in LSS remains unknown. LSS care providers could endorse the 2008 United States Physical Activity Guidelines; however, we do not know if this is realistic. The goal of the present study was to determine the proportion of individuals with LSS meeting the 2008 Guidelines. A secondary goal was to better understand the nature of physical performance in this population.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

People from the Lumbar Spinal Stenosis Accelerometry Database, all of whom have both radiographic and clinical LSS and are seeking various treatments for their symptoms.

OUTCOME MEASURES

Seven-day accelerometry (functional outcome) and demographics (self-reported).

METHODS

For the present study, we analyzed only baseline data that were obtained before any new treatments. Patients with at least 4 valid days of baseline accelerometry data were included. We determined the proportion of individuals with LSS meeting the 2008 US Physical Activity Guidelines of at least 150 minutes of moderate-vigorous (MV) physical activity per week in bouts of 10 minutes or more. We also used the novel Physical Performance analysis designed by our group to determine time spent in varying intensities of activity. There are no conflicts of interest to disclose.

RESULTS

We analyzed data from 75 individuals with a mean age of 68 (SD 9), 37% of whom were male. Three people (4%) were considered Meeting Guidelines (at least 150 MV minutes/week), and 56 (75%) were considered Inactive with not even 1 MV minute/week. With the 10-minute bout requirement removed, 10 of 75 (13%) achieved the 150-minute threshold. The average time spent in sedentary activity was 82%, and of time spent in nonsedentary activity, 99.6% was in the light activity range.

CONCLUSIONS

In conclusion, the present study confirms that people with symptomatic LSS, neurogenic claudication, walking limitations, and LSS-related disability are extremely sedentary and are not meeting guidelines for physical activity. There is an urgent need for interventions aimed at reducing sedentary behavior and increasing the overall level of physical activity in LSS, not only to improve function but also to prevent diseases of inactivity. The present study suggests that reducing sedentary time, increasing time spent in light intensity activity, and increasing time spent in higher intensities of light activity may be appropriate as initial goals for exercise interventions in people with symptomatic LSS and neurogenic claudication, transitioning to moderate activity when appropriate. Results of the present study also demonstrate the importance of employing disease-specific measures for assessment of performance in LSS, and highlight the potential value of these methods for developing targeted and realistic goals for physical activity. Physical activity goals could be personalized using objective assessment of performance with accelerometry. The present study is one step toward a personalized medicine approach for people with LSS, focusing on increasing physical function.

Synthetic meshes in the treatment of postoperative fascial dehiscence of the spine

BACKGROUND

A fascial dehiscence after spinal instrumentation is usually located at the mechanically stressed interscapular thoracic spine and often causes cosmetic impairment and pain. However, therapy options remain barely discussed. Synthetic meshes have been successfully used in the treatment of abdominal hernias.

OBJECTIVE

It was hypothesized that synthetic meshes are a successful treatment option for spinal fascial dehiscence.

METHODS

This retrospective study of a prospective database investigated all consecutive patients who received a synthetic mesh for a fascial dehiscence of the spine between 2010 and 2014 after prior spinal instrumentation. Primary outcomes were healing of the fascial dehiscence, recurrence, infection, revision, subjective satisfaction on a visual analog scale (VAS), and the Oswestry Disability Index (ODI). Among others, secondary outcomes consisted of seroma formation and return to work. The evaluated risk factors consisted of the body mass index (BMI), outer abdominal fat (OAF), back tissue, smoking, immunomodulatory therapy, preoperative radiation dose, and instrumented levels.

RESULTS

Sixteen patients with a mean follow up of 24 months were included. Every fascial dehiscence successfully healed with the synthetic mesh and there were no recurrences, infections or revisions. The mean subjective satisfaction level was VAS 7.3 and the mean ODI was 26%. Five (31%) patients had a seroma postoperatively, but did not show any differences in the outcome (e.g. ODI of 28%). In the patient group < 65 years (n = 12), all but two patients, who had work restrictions due to other diseases, regained at least some capacity to work. Worse ODI scores were found for patients with increased BMI, OAF, back tissue, cortisone therapy, instrumented levels, preoperative radiation dose, and for smokers.

CONCLUSION

Synthetic meshes are a successful treatment option for spinal fascial dehiscence, even seemingly in patients with a higher risk profile such as obese and immunocompromised patients as well as in revision procedures. They are associated with respectable cosmetic results, pain relief and clinical outcome. Postoperatively, it is recommended to leave drains for more than five to seven days in order to avoid seroma formation and to avoid weight training for six weeks. Further prospective, comparative studies are recommended.

Management of lumbar spinal stenosis

Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.

Obesity and chronic pain: systematic review of prevalence and implications for pain practice

The combination of obesity and pain may worsen a patient's functional status and quality of life more than each condition in isolation. We systematically searched PubMed/MEDLINE and the Cochrane databases for all reports published on obesity and pain. The prevalence of combined obesity and pain was substantial. Good evidence shows that weight reduction can alleviate pain and diminish pain-related functional impairment. However, inadequate pain control can be a barrier to effective lifestyle modification and rehabilitation. This article examines specific pain management approaches for obese patients and reviews novel interventional techniques for treatment of obesity. The infrastructure for simultaneous treatment of obesity and pain already exists in pain medicine (eg, patient education, behavioral medicine approaches, physical rehabilitation, medications, and interventional treatment). Screening for obesity, pain-related disability, and behavioral disorders as well as monitoring of functional performance should become routine in pain medicine practices. Such an approach requires additional physician and staff training. Further research should focus on better understanding the interplay between these 2 very common conditions and the development of effective treatment strategies.

Impact of obesity on complications, infection, and patient-reported outcomes in adult spinal deformity surgery

OBJECT

Adult spinal deformity (ASD) surgery is known for its high complication rate. This study examined the impact of obesity on complication rates, infection, and patient-reported outcomes in patients undergoing surgery for ASD.

METHODS

This study was a retrospective review of a multicenter prospective database of patients with ASD who were treated surgically. Patients with available 2-year follow-up data were included. Obesity was defined as having a body mass index (BMI) ≥ 30 kg/m2. Data collected included complications (total, minor, major, implant-related, radiographic, infection, revision surgery, and neurological injury), estimated blood loss (EBL), operating room (OR) time, length of stay (LOS), and patient-reported questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], and Scoliosis Research Society [SRS]) at baseline and at 6 weeks, 1 year, and 2 years postoperatively. The impact of obesity was studied using multivariate modeling, accounting for confounders.

RESULTS

Of 241 patients who satisfied inclusion criteria, 175 patients were nonobese and 66 were obese. Regression models showed that obese patients had a higher overall incidence of major complications (IRR 1.54, p = 0.02) and wound infections (odds ratio 4.88, p = 0.02). Obesity did not increase the number of minor complications (p = 0.62), radiographic complications (p = 0.62), neurological complications (p = 0.861), or need for revision surgery (p = 0.846). Obesity was not significantly correlated with OR time (p = 0.23), LOS (p = 0.9), or EBL (p = 0.98). Both groups experienced significant improvement overtime, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001).

CONCLUSIONS

This study revealed that obese patients have an increased risk of complications following ASD correction. Despite these increased complications, obese patients do benefit from surgical intervention; however, their improvement in health-related quality of life (HRQL) is less than that of nonobese patients.

The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI): development and pilot

BACKGROUND CONTEXT

Owing to mobility limitations, people with lumbar spinal stenosis (LSS) are at risk for diseases of inactivity, including obesity. Therefore, weight management in LSS is critical. Body mass index is the strongest predictor of function in LSS, suggesting that weight loss may promote physical activity and provide a unique treatment option. We propose a lifestyle modification approach of physical activity and nutrition education, delivered through an e-health platform.

PURPOSE

The purpose of this study was to develop and pilot an e-health intervention aimed at increasing physical activity and decreasing fat mass in people with LSS.

STUDY DESIGN

The study design was based on intervention development and pilot.

PATIENT SAMPLE

Ten overweight or obese individuals with LSS were confirmed clinically and on imaging.

OUTCOME MEASURES

Self-reported measures were food record, Short-Form 36 (SF-36), pain scales, Swiss Spinal Stenosis Symptom and Physical Function Scales, Oswestry Disability Index (ODI), Pain Catastrophizing Questionnaire, Tampa Scale for Kinesiophobia, Center for Epidemiologic Studies(Depression) Scale, Behavioral Regular in Exercise Questionnaire, and Regulation for Eating Behavior Scale and physiologic measures were dual-energy X-ray absorptiometry (DXA), blood draw, 7-day accelerometry, self-paced walking test, and balance test.

METHODS

The e-health platform was developed.

INTERVENTION

during Week 1, participants received a pedometer and a personalized consultation with a dietitian and an exercise physiologist. For 12 weeks, participants logged on to the e-health Web site to access personal step goals, nutrition education videos, and a discussion board. Follow-up occurred at Week 13.

RESULTS

Nine participants had a mean age of 67.5±6.7 years (60% women). Significant improvements were observed for fat mass (DXA), trunk fat mass, symptom severity (Swiss Symptom Scale), energy intake, maximum continuous activity (accelerometry), and mental health (SF-36) (p<.05). Nonsignificant improvements were observed for waist circumference, pain, ODI, and obesity biomarkers. Seventy percent lost weight, 50% increased walking capacity, and 60% increased quality of life. The mean increase in steps was 15%.

CONCLUSIONS

The spinal stenosis pedometer and nutrition lifestyle intervention was shown to be feasible, attractive to participants, and effective in this small sample. This intervention provides people with LSS the opportunity to participate in their own health management, potentially improving access to care. Efficacy is currently being assessed in a randomized trial.