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Naidu RK, Tran OV, Schatman ME. Longitudinal Analysis of the Care Pathway of Patients with Lumbar Spinal Stenosis in the US. J Pain Res 2024; 17:1979-1987. [PMID: 38854929 PMCID: PMC11162185 DOI: 10.2147/jpr.s454887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/19/2024] [Indexed: 06/11/2024] Open
Abstract
Background Evidence regarding the frequency and timing of treatment for lumbar spinal stenosis (LSS) fails to offer clear consensus. We describe the LSS care journey from initial diagnosis to first surgical intervention. Methods Using Medicare claims database from 2009 through 2020, we identified patients who were diagnosed with LSS. The use and timing of conservative and surgical treatments during the entire follow-up from the initial diagnosis were reported. Results Of the 143,849 patients identified, 68% received conservative care within 8.4 months and 25.3% received a surgical or minimally invasive intervention over 5.7 years following initial diagnosis, with 12.6% undergoing open decompression alone, 10.2% undergoing open decompression with fusion, and 5.1% undergoing fusion surgery alone. Fewer than 1% were provided with interspinous spacers or a percutaneous image-guided lumbar decompression. Conclusion Approximately three-quarters of patients in the study received no surgical or non-invasive interventions for approximately six years following diagnosis with LSS.
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Affiliation(s)
- Ramana K Naidu
- Pain Management, Marin Health Medical Center, Greenbrae, CA, USA
| | - Oth V Tran
- Health Economics & Outcomes Research, Boston Scientific, Marlborough, MA, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA
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Toivonen LA, Häkkinen A, Pekkanen L, Kyrölä K, Kautiainen H, Neva MH. Benefits of lumbar spine fusion surgery reach 10 years with various surgical indications. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100276. [PMID: 37840551 PMCID: PMC10570578 DOI: 10.1016/j.xnsj.2023.100276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/28/2023] [Accepted: 09/02/2023] [Indexed: 10/17/2023]
Abstract
Background Context Lumbar spine fusion (LSF) surgery is a viable form of treatment for several spinal disorders. Treatment effects are preferably to be endorsed in real-life settings. Methods This prospective study evaluated the 10-year outcomes of LSF. A population-based series of elective LSFs performed at 2 spine centers between January 2008 and June 2012 were enrolled. Surgeries for tumor, acute fracture, or infection, neuromuscular scoliosis, or postoperative conditions were excluded. The following patient-reported outcome measures (PROMs) were collected at baseline, and 1, 2, 5, and 10 years postsurgery: VAS for back and leg pain, ODI, SF-36. Longitudinal measures of PROMs were analyzed using mixed-effects models. Results A total of 683 patients met the inclusion criteria, and 630 (92%) of them completed baseline and at least 1 follow-up PROMs, and they constituted the study population. Mean age was 61 (SD 12) years, 69% women. According to surgical indication, patients were stratified into degenerative spondylolisthesis (DS, n=332, 53%), spinal stenosis (SS, n=102, 16%), isthmic spondylolisthesis (IS, n=97, 15%), degenerative disc disease (DDD, n=52, 8%), and deformity (DF, n=47, 7%).All diagnostic cohorts demonstrated significant improvement at 1 year, followed by a partial loss of benefits by 10 years. ODI baselines and changes at 1 and 10 years were: (DS) 45, -21, and -14; (SS) 51, -24, and -13; (IS) 41, -24, and -20; (DDD) 50, -20, and -20; and (DF) 50, -21, and -16, respectively. Comparable patterns were seen in pain scores. Significant HRQoL achievements were recorded in all cohorts, greatest in physical domains, but also substantial in mental aspects of HRQoL. Conclusions Benefits of LSF were partially lost but still meaningful at 10 years of surgery. Long-term benefits seemed milder with degenerative conditions, reflecting the progress of the ongoing spinal degeneration. Benefits were most overt in pain and physical function measures.
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Affiliation(s)
- Leevi A. Toivonen
- Department of Orthopedics and Traumatology, Tampere University Hospital, Elämänaukio 2, PB 272, Tampere, 33101, Finland
| | - Arja Häkkinen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Seminaarinkatu 15, Jyväskylä, 40014, Finland
| | - Liisa Pekkanen
- Department of Surgery, Central Finland Healthcare District, Hoitajantie 3, Jyväskylä, 40620, Finland
| | - Kati Kyrölä
- Department of Surgery, Central Finland Healthcare District, Hoitajantie 3, Jyväskylä, 40620, Finland
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio University Hospital, Yliopistonranta 8, Kuopio, 70210, Finland
- Folkhälsan Research Center, Topeliuksenkatu 20, Helsinki, 00250, Finland
| | - Marko H. Neva
- Department of Orthopedics and Traumatology, Tampere University Hospital, Elämänaukio 2, PB 272, Tampere, 33101, Finland
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Griffiths F, Srikesavan C, Ward L, Boniface G, Williamson E, Lamb SE. Longitudinal qualitative study of living with neurogenic claudication. BMJ Open 2022; 12:e060128. [PMID: 36104131 PMCID: PMC9476140 DOI: 10.1136/bmjopen-2021-060128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Neurogenic claudication (NC) causes pain and reduced mobility, particularly in older people, and can negatively affect mental and social well-being, so limiting successful ageing. This qualitative study explored how people with NC changed over 12 months. DESIGN A longitudinal qualitative study using semi-structured interviews. SETTING Participants were recruited from a UK clinical trial of a physiotherapy intervention for NC. PARTICIPANTS Interviews were undertaken at baseline, 1 month after receiving any intervention and at 12 months. We analysed 30 sets of three interviews. RESULTS Interview data were summarised for each time point into biopsychosocial domains: pain, mobility and activities of daily living, psychological impact, and social and recreational participation. Through comparative analysis we explored participant trajectories over time.Progressive improvement in at least one domain was experienced by 13 participants, but there was variability in trajectories with early improvements that remained the same, transient changes and no change also commonly observed.Eleven participants described co-present improvement trajectories in all domains. Three participants described co-present improvement in all domains except participation; one had never stopped their participation and two had unattainable expectations. Five participants described co-present improvement in one domain and deterioration in another and 14 participants described co-present no change in one domain and change in another.There was evidence of interaction between domains; for example, improved mobility led to improved participation and for some participants, specific factors influenced change. Of the 15 participants who experienced improved participation, 10 reported improvements in all other domains and five participants did not; for two, pain did not prevent participation, one used a walking aid and two had a positive psychological outlook. CONCLUSION The daily lived experiences of older adults with NC are variable and include interaction between biopsychosocial domains. Therapist understanding of these trajectories and their interactions may help to provide personalised therapy TRIAL REGISTRATION NUMBER: ISRCTN12698674.
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Affiliation(s)
- Frances Griffiths
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Lesley Ward
- Department of Sport, Exercise & Rehabilitation, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Graham Boniface
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Esther Williamson
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
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Efficacy and characteristics of physiotherapy interventions in patients with lumbar spinal stenosis: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1370-1390. [PMID: 35511368 DOI: 10.1007/s00586-022-07222-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 12/15/2021] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To determine the efficacy of physiotherapy approaches used in the treatment of LSS and compare their delivery characteristics. METHODS A systematic search was conducted using MEDLINE/PubMed, EMBASE, Scopus, PEDro, CINAHL and Web of Science databases, from inception until March 2021. Inclusion criteria were clinical diagnosis of LSS confirmed through imaging techniques, RCTs written in English comparing physiotherapy interventions among them or versus placebo or usual care without restrictions on treatment and follow-up duration, outcomes related to pain, physical function, disability and quality of life. Two independent reviewers assessed records for eligibility and methodological quality (PEDro scale) and extracted participants' characteristics, interventions details and outcome measures at each timepoint. Pooled or un-pooled findings were reported as mean difference with 95% confidence interval, depending on heterogeneity. Evidence quality was rated using the GRADE approach. RESULTS Twelve studies (944 patients, mean PEDro score 7.6, range 5-9) were included. Three weeks of weight-supported walking improved pain and disability, while 8 weeks of aquatic exercises improved pain and walking tolerance (very low evidence). Six weeks of cycling reduced disability compared to weight-supported walking (low evidence). Six weeks of manual therapy plus exercise was not superior to supervised exercises (low evidence), but improved pain, walking tolerance, disability and quality of life compared to home/group exercises (moderate to very low evidence). Very low evidence supported 2 weeks of electromagnetic fields, whereas TENS (low evidence) and ultrasounds (very low evidence) revealed no effects. CONCLUSIONS These findings may assist clinicians in delivering effective physiotherapy interventions in LSS patients.
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Diwan S, Sayed D, Deer TR, Salomons A, Liang K. An Algorithmic Approach to Treating Lumbar Spinal Stenosis: An Evidenced-Based Approach. PAIN MEDICINE 2020; 20:S23-S31. [PMID: 31808532 PMCID: PMC7101167 DOI: 10.1093/pm/pnz133] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Lumbar spinal stenosis (LSS) can lead to compression of the neural and vascular elements and is becoming more common due to degenerative changes that occur because of aging processes. Symptoms may manifest as pain and discomfort that radiates to the lower leg, thigh, and/or buttocks. The traditional treatment algorithm for LSS consists of conservative management (physical therapy, medication, education, exercise), often followed by epidural steroid injections (ESIs), and when nonsurgical treatment has failed, open decompression surgery with or without fusion is considered. In this review, the variables that should be considered during the management of patients with LSS are discussed, and the role of each treatment option to provide optimal care is evaluated. RESULTS This review leads to the creation of an evidence-based practical algorithm to aid clinicians in the management of patients with LSS. Special emphasis is directed at minimally invasive surgery, which should be taken into consideration when conservative management and ESI have failed.
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Affiliation(s)
- Sudhir Diwan
- Advanced Spine on Park Avenue, New York, NY 10022.,Albert Einstein College of Medicine, Pain Attending, Lenox Hill Hospital, New York, NY
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas
| | - Timothy R Deer
- The Center for Pain Relief, Spine and Nerve Centers of the Virginias, Charleston, West Virginia, USA
| | | | - Kevin Liang
- Milestone Research Organization, San Diego, California, USA
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Zileli M, Crostelli M, Grimaldi M, Mazza O, Anania C, Fornari M, Costa F. Natural Course and Diagnosis of Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations. World Neurosurg X 2020; 7:100073. [PMID: 32613187 PMCID: PMC7322797 DOI: 10.1016/j.wnsx.2020.100073] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/13/2020] [Indexed: 11/26/2022] Open
Abstract
Lumbar spinal stenosis (LSS) is defined as a degenerative disorder showing a narrowing of the spinal canal. The diagnosis is straightforward in cases with typical neurogenic claudication symptoms and unequivocal imaging findings. However, not all patients present with typical symptoms, and there is obviously no correlation between the severity of stenosis and clinical complaint. The radiologic diagnosis of LSS is widely discussed in the literature. The best diagnostic test for the diagnosis of LSS is magnetic resonance imaging (MRI). However, canal diameter measurements have not gained much consensus from radiologists, whereas qualitative measures, such as cerebrospinal fluid space obliteration, have achieved greater consensus. Instability can best be defined by standing lateral radiograms and flexion-extension radiograms. For cases showing typical neurogenic claudication symptoms and unequivocal imaging findings, the diagnosis is straightforward. However, not all patients present with typical symptoms, and there is obviously no correlation between the severity of stenosis (computed tomography and MRI) and clinical complaint. In fact, recent MRI studies have shown that mild-to-moderate stenosis can also be found in asymptomatic individuals. Routine electrophysiological tests such as lower extremity electromyography, nerve conduction studies, F-wave, and H-reflex are not helpful in the diagnosis and outcome prediction of LSS. The electrophysiological recordings are complementary to the neurologic examination and can provide confirmatory information in less obvious clinical complaints. However, in the absence of reliable evidence, imaging studies should be considered as a first-line diagnostic test in the diagnosis of degenerative LSS.
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Key Words
- CT, Computed tomography
- Canal diameter
- Central stenosis
- DSEP, Dermatomal somatosensory evoked potential
- EMG, Electromyography
- Electrophysiological recordings
- Foraminal stenosis
- IONM, Intraoperative neurophysiological monitoring
- Intraoperative neurophysiological monitoring
- LS, Likert scale
- LSS, Lumbar spinal stenosis
- Lumbar spinal stenosis
- MEP, Motor evoked potential
- MRI, Magnetic resonance imaging
- Motor evoked potentials
- NASS, North American Spine Society
- Natural course
- SSEP, Somatosensory evoked potential
- Somatosensory evoked potentials
- VAS, Visual analog scale
- WFNS, World Federation of Neurosurgical Societies
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Affiliation(s)
- Mehmet Zileli
- Neurosurgery Department, Ege University, Bornova, Izmir, Turkey
| | - Marco Crostelli
- Spine Surgery Unit, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | - Osvaldo Mazza
- Spine Surgery Unit, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Carla Anania
- Neurosurgery Department, Humanitas Clinical and Research Hospital, Milan, Italy
| | - Maurizio Fornari
- Neurosurgery Department, Humanitas Clinical and Research Hospital, Milan, Italy
| | - Francesco Costa
- Neurosurgery Department, Humanitas Clinical and Research Hospital, Milan, Italy
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7
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Cushnie D, Thomas K, Jacobs WB, Cho RKH, Soroceanu A, Ahn H, Attabib N, Bailey CS, Fisher CG, Glennie RA, Hall H, Jarzem P, Johnson MG, Manson NA, Nataraj A, Paquet J, Rampersaud YR, Phan P, Casha S. Effect of preoperative symptom duration on outcome in lumbar spinal stenosis: a Canadian Spine Outcomes and Research Network registry study. Spine J 2019; 19:1470-1477. [PMID: 31121258 DOI: 10.1016/j.spinee.2019.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/10/2019] [Accepted: 05/14/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar degenerative stenosis is one of the most common spine pathologies for which surgical intervention is indicated. There is some evidence that a prolonged duration of neurological compression could lead to a failure of surgery to alleviate symptoms. PURPOSE Determination of whether longer symptom duration was associated with worse postoperative disability outcomes after decompressive surgery for lumbar degenerative stenosis. STUDY DESIGN/SETTING The Canadian Spine Outcomes and Research Network (CSORN) prospective database includes pre- and postoperative data from 18 tertiary care hospitals. PATIENT SAMPLE The CSORN database was queried for all cases of degenerative lumbar stenosis receiving surgical decompression for neurogenic claudication or radiculopathy. Patients with tumor, infection, fracture, or previous surgery were excluded. Patients were divided into groups based on symptom duration (<6 weeks, 6-12 weeks, 3-6 months, 6-12 months, 1-2 years, and >2 years). OUTCOME MEASURES Change between preoperative and 12-month postoperative Oswestry Disability Index (ODI) was compared between symptom duration groups. Secondary outcomes included SF12 physical component score (PCS), and numeric rating scales for leg and back pain. Outcomes were also assessed at 3 months and 24 months postoperatively. METHODS Change in ODI, and secondary outcome measures, were compared between different symptom duration groups. Multiple regression analysis was used to identify factors interacting with symptom duration to predict change in ODI. RESULTS Four hundred and seventy-eight cases of lumbar stenosis with 12-month postoperative data were identified. Longer symptom duration correlated with less improvement in ODI (p<.001). Patients with >1 year of symptoms were less likely to achieve a Minimal Clinically Significant Difference in ODI (54.4% vs. 66.1%; p=.03) and were more likely to experience no improvement or worse disability, postoperatively (22.1% vs. 11.3%; p=.008). Similar results were found at 3- and 24-month timepoints. Smaller postoperative improvements in SF12 PCS and leg pain scales were also correlated with longer symptom duration (p<.05). CONCLUSIONS Multicenter registry data provides important real-world evidence to guide consent, surgical planning, and health resource management. Longer symptom duration was found to correlate with less improvement in pain and disability after lumbar stenosis surgery suggesting that these patients may benefit from earlier treatment.
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Affiliation(s)
- Duncan Cushnie
- University of Calgary, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada.
| | - Kenneth Thomas
- University of Calgary, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada
| | - W Bradley Jacobs
- University of Calgary, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada
| | - Roger K H Cho
- University of Calgary, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada
| | - Alex Soroceanu
- University of Calgary, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada
| | - Henry Ahn
- University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, Toronto, Ontario, Canada
| | | | | | - Charles G Fisher
- University of British Columbia, Vancouver, British Columbia, Canada; Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | - Peter Jarzem
- McGill Scoliosis & Spine Group, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Michael G Johnson
- Winnipeg Spine Program Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Neil A Manson
- Dalhousie University, Halifax, Nova Scotia, Canada; Canada East Spine Centre, Saint John, New Brunswick, Canada
| | | | - Jerome Paquet
- CHU de Québec-Université Laval, Laval, Quebec, Canada
| | - Y Raja Rampersaud
- University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada; Arthritis Program, Krembil Research Institute, Toronto, Ontario, Canada
| | - Philippe Phan
- University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Steven Casha
- University of Calgary, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada
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Abstract
PURPOSE OF REVIEW Our review of current literature within the past 12-24 months for the treatment of lumbar spinals stenosis (LSS) serves to update providers on recent advances and comparisons regarding therapy spanning lifestyle modification, pharmacologic therapy, minimally invasive interventions, and surgical interventions. RECENT FINDINGS Current literature supporting the inclusion of physical therapy and gabapentin/pregabalin within an initial treatment regimen have been positive. A recent randomized, double-blinded clinical trial of adding calcitonin to epidural steroid injections have shown improvement in pain and function up to 1 year. The minimally invasive lumbar decompression (mild) procedure is showing ongoing beneficial results in pain and function. Spinal cord stimulation (SCS) may have a role for select patients with lumbar spinal stenosis. Finally, the benefits of surgical treatment versus nonsurgical treatment is ultimately inconclusive because of the nature of data collection, inconsistencies with the clinical definition of LSS, and a lack of standardized treatment guidelines. SUMMARY Our review of current research demonstrates there is a positive role for the current conservative therapies, with favorable results for interventions such as minimally invasive decompression and SCS. Pharmacologic interventions such as systemic prostaglandin analogues and epidural agents such as calcitonin demonstrate early promise, but need to undergo additional safety testing and confirmatory trials. Further long-term research with validated, objective measurements for the aforementioned treatments are needed to draw any definitive conclusions for clinical practice.
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Amudong A, Muheremu A, Abudourexiti T. Hypertrophy of the ligamentum flavum and expression of transforming growth factor beta. J Int Med Res 2017. [PMID: 28635357 PMCID: PMC5805210 DOI: 10.1177/0300060517711308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Objective To explore the relationship between cellular apoptosis and hypertrophy of the
ligamentum flavum in the lumbar region. Methods Thirty patients with lumbar spinal stenosis were evaluated. Hypertrophy of
the ligamentum flavum was present in 15 patients and absent in 15.
Hematoxylin–eosin staining and transforming growth factor beta (TGF-β)
immunohistochemical testing were applied to compare these two groups. Results Derangement of fibrous alignment, fibrocartilage changes, and infiltration of
inflammatory cells were observed in the patients with hypertrophy of the
ligamentum flavum, while fibrous alignment was normal and few inflammatory
cells were observed in patients without hypertrophy. Immunohistochemical
studies showed positive expression of TGF-β in patients with hypertrophy,
while expression was negative in patients without hypertrophy. The
integrated optical density was 2.6556708 in the hypertrophy group and
23104671 in the normal controls. Conclusions Expression of TGF-β was closely related to hypertrophy of the ligamentum
flavum. Appropriate application of the TGF-β expression level can be used to
predict progression of hypertrophy of the ligamentum flavum.
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Affiliation(s)
- Aierken Amudong
- Department of Spine Surgery, Sixth Affiliated Hospital of Xinjiang Medical University, Xinjiang Urumqi, China
| | - Aikeremujiang Muheremu
- Department of Spine Surgery, Sixth Affiliated Hospital of Xinjiang Medical University, Xinjiang Urumqi, China
| | - Tuerhongjiang Abudourexiti
- Department of Spine Surgery, Sixth Affiliated Hospital of Xinjiang Medical University, Xinjiang Urumqi, China
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