Comparison of the patient-derived modified Japanese Orthopaedic Association scale and the European myelopathy score

PURPOSE

To compare the patient-derived modified Japanese Orthopaedic Association (P-mJOA) scale with the European myelopathy score (EMS) for the assessment of patients with degenerative cervical myelopathy (DCM).

METHODS

In this register-based cohort study with prospectively collected data, included patients were surgically treated for DCM and had reported both P-mJOA and EMS scores at baseline, 1-year follow-up, and/or 2-year follow-up to the Swedish Spine Register. P-mJOA and EMS scores were defined as severe (P-mJOA 0-11 and EMS 5-8), moderate (P-mJOA 12-14 and EMS 9-12), or mild (P-mJOA 15-18 and EMS 13-18). P-mJOA and EMS mean scores were compared, and agreement was evaluated with Spearman's rank correlation coefficient (ρ), the intraclass correlation coefficient (ICC), and kappa (κ) statistics.

RESULTS

Included patients (n = 714, mean age 63.2 years, 42.2% female) completed 937 pairs of the P-mJOA and the EMS. The mean P-mJOA and EMS scores were 13.9 ± 3.0 and 14.5 ± 2.7, respectively (mean difference -0.61 [95% CI -0.72 to -0.51; p < 0.001]). Spearman's ρ was 0.84 (p < 0.001), and intra-rater agreement measured with ICC was 0.83 (p < 0.001). Agreement of severity level measured with unweighted and weighted κ was fair (κ = 0.22 [p < 0.001]; κ = 0.34 [p < 0.001], respectively). Severity levels were significantly higher using the P-mJOA (p < 0.001).

CONCLUSION

The P-mJOA and the EMS had similar mean scores, and intra-rater agreement was high, whereas severity levels only demonstrated fair agreement. The EMS has a lower sensitivity for detecting severe myelopathy but shows an increasing agreement with the P-mJOA for milder disease severity. A larger interval to define severe myelopathy with the EMS is recommended.

Dizziness and balance outcomes after two different postoperative rehabilitation approaches following neck surgery: analyses of a multicenter randomized controlled trial

BACKGROUND

Dizziness and balance problems are common symptoms in patients with cervical radiculopathy.

OBJECTIVE

To evaluate the effect of neck surgery postoperatively combined with either structured rehabilitation or standard approach in patients with cervical radiculopathy and dizziness and/or balance problems, and investigate factors influencing dizziness and balance at 6-month follow-up.

METHODS

Individuals (n = 149) with cervical radiculopathy and dizziness and/or balance problems were randomized preoperatively to structured postoperative rehabilitation or standard postoperative approach. Outcomes were intensity of dizziness and subjective balance, and clinical measures of balance.

RESULTS

Self-reported measures improved at three months (p ˂ 0.001 to p = .007) and the standing balance at six months (p = .008). No between-group differences. Baseline values, neck pain, and physical activity level explained 23-39% of the variance in 6-month outcomes for self-reported measures. Baseline values and physical activity level explained 71% of the variance in walking balance, and lower baseline scores were significantly associated with standing balance impairments (OR 0.876).

CONCLUSION

Patients improved significantly in dizziness and subjective balance intensity shortly after surgery, and in standing balance at 6 months, independent of postoperative rehabilitation. Neck pain, physical activity, and neck muscle function influenced dizziness and balance, although preoperative values and neck pain were of most importance for 6-month outcomes.

Neurological outcomes after surgery and postoperative rehabilitation for cervical radiculopathy due to disc disease: a 2-year-follow-up of a randomized clinical trial

Reports on neurological outcomes in patients with cervical radiculopathy (CR) undergoing surgery and postoperative rehabilitation are important to inform prognosis. This 2-year-follow-up of a randomized clinical trial aimed to compare secondary neurological outcomes between structured postoperative rehabilitation and a standard approach after surgery for CR. A secondary aim was to increase knowledge about recovery of neurological impairments in relation to patient-reported neck disability. Neurological outcomes included assessment of sensibility, motor function, arm reflexes and the Spurling test. A total of 153 and 135 participants (> 70% response rate) completed the clinical examination. Between-group differences, changes over time, and associations between persistent neurological impairments and the Neck Disability Index were investigated. No between-group differences were reported (p > 0.07), and neurological impairments in sensibility, motor function, and a positive Spurling test decreased over time in both groups (p < 0.04). Persistent impairments in sensibility and reflex arm were most frequent at follow-up, whereas, a persistent positive Spurling test, and impairments in motor function were associated with higher NDI score. Neurological outcomes improved over time in patients undergoing surgery for CR with no between-group differences., However, persistent neurological impairments were common, and associated with poorer outcome for patient-reported neck disability.Clinical registration: clinicaltrial.gov NCT01547611, 08/03/2012, Title: Outcome of physiotherapy after surgery for cervical disc disease: a prospective multi-centre trial.

Comparison of posterior muscle-preserving selective laminectomy and laminectomy with fusion for treating cervical spondylotic myelopathy: study protocol for a randomized controlled trial

BACKGROUND

Cervical spondylotic myelopathy (CSM) is the predominant cause of spinal cord dysfunction in the elderly. The patients are often frail and susceptible to complications. Posterior surgical techniques involving non-fusion are complicated by postlaminectomy kyphosis and instrumented fusion techniques by distal junction kyphosis, pseudarthrosis, or implant failure. The optimal surgical approach is still a matter of controversy. Since anterior and posterior fusion techniques have been compared without presenting any superiority, the objective of this study is to compare stand-alone laminectomy with laminectomy and fusion to determine which treatment has the lowest frequency of reoperations.

METHODS

This is a multicenter randomized, controlled, parallel-group non-inferiority trial. A total of 300 adult patients are allocated in a ratio of 1:1. The primary endpoint is reoperation for any reason at 5 years of follow-up. Sample size and power calculation were performed by estimating the reoperation rate after laminectomy to 3.5% and after laminectomy with fusion to 7.4% based on the data from the Swedish spine registry (Swespine) on patients with CSM. Secondary outcomes are the patient-derived Japanese Orthopaedic Association (P-mJOA) score, Neck Disability Index (NDI), European Quality of Life Five Dimensions (EQ-5D), Numeric Rating Scale (NRS) for neck and arm pain, Hospital Anxiety and Depression Scale (HADS), development of kyphosis measured as the cervical sagittal vertical axis (cSVA), and death. Clinical and radiological follow-up is performed at 3, 12, 24, and 60 months after surgery. The main inclusion criterium is 1-4 levels of CSM in the subaxial spine, C3-C7. The REDcap software will be used for safe data management. Data will be analyzed according to the modified intention to treat (mITT) population, defined as randomized patients who are still alive without having emigrated or left the study after 2 and 5 years.

DISCUSSION

This will be the first randomized controlled trial comparing two of the most common surgical treatments for CSM: the posterior muscle-preserving selective laminectomy and posterior laminectomy with instrumented fusion. The results of the myelopathy randomized controlled (MyRanC) study will provide surgical treatment recommendations for CSM. This may result in improvements in surgical treatment and clinical practice regarding CSM.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04936074 . Registered on 23 June 2021.

Determining the level of cervical radiculopathy: Agreement between visual inspection of pain drawings and magnetic resonance imaging

BACKGROUND AND AIMS

Pain drawings are commonly used in the clinical assessment of people with cervical radiculopathy. This study aimed to assess (1) the agreement of clinical interpretation of pain drawings and MRI findings in identifying the affected level of cervical radiculopathy, (2) the agreement of these predictions based on the pain drawing among four clinicians from two different professions (i.e., physiotherapy and surgery) and (3) the topographical pain distribution of people presenting with cervical radiculopathy (C4-C7).

METHODS

Ninety-eight pain drawings were obtained from a baseline assessment of participants in a randomized clinical trial, in which single-level cervical radiculopathy was determined using MRI. Four experienced clinicians independently rated each pain drawing, attributing the pain distribution to a single nerve root (C4-C7). A post hoc analysis was performed to assess agreement.

OUTCOME MEASURES

Percentage agreement and kappa values were used to assess the level of agreement. Topographic pain frequency maps were created for each cervical radiculopathy level as determined by MRI.

RESULTS

The radiculopathy level determined from the pain drawings showed poor overall agreement with MRI (mean = 35.7%, K = -0.007 to 0.139). The inter-clinician agreement ranged from fair to moderate (K = 0.212-0.446). Topographic frequency maps revealed that pain distributions were widespread and overlapped markedly between patients presenting with different levels cervical radiculopathy.

CONCLUSION

This study revealed a lack of agreement between the segmental level affected determined from the patient's pain drawing and the affected level as identified on MRI. The large overlap of pain and non-dermatomal distribution of pain reported by patients likely contributed to this result.

Work Ability After Anterior Cervical Decompression and Fusion Followed by a Structured Postoperative Rehabilitation: Secondary Outcomes of a Prospective Randomized Controlled Multi-Centre Trial with a 2-year Follow-up

Purpose Information on work ability after ACDF and postoperative rehabilitation is lacking. The aim of the present study is therefore to investigate the work ability benefits of a structured postoperative treatment (SPT) over a standard care approach (SA) in patients who underwent anterior cervical decompression and fusion (ACDF) for cervical radiculopathy and factors important to the 2-year outcome. Methods Secondary outcome and prediction model of a prospective randomized controlled multi-centre study with a 2-year follow-up (clinicaltrials.gov NCT01547611). The Work Ability Index (WAI) and Work Ability Score (WAS) were measured at baseline and up to 2 years after ACDF in 154 patients of working age who underwent SPT or SA after surgery. Predictive factors for the WAI at 2 years were analysed. Results Both WAI and WAS significantly improved with SPT and SA (p < 0.001), without any between-group differences. Thoughts of being able to work within the next 6 months, Neck Disability Index (NDI), and work-related neck load explained 59% of the variance in WAI at the 2-year follow-up after ACDF. Conclusions Patients improved over time without group differences, suggesting the improvement to be surgery related. Expectation to work within the next 6 months, self-reported neck functioning and work-related neck load were important to work ability and are central factors to ask early after ACDF, to identifying further interventions promoting return to work.

Artificial disc replacement and adjacent-segment pathology: 10-year outcomes of a randomized trial

OBJECTIVE

Artificial disc replacement (ADR) is designed to preserve motion and thus protect against adjacent-segment pathology (ASP) and act as an alternative treatment to fusion surgery. The question remains, how well do ADR devices perform after 10 years of follow-up compared with fusion surgery in terms of patient satisfaction, sustainability, and protection against ASP?

METHODS

This was the 10-year follow-up study of 153 participants who underwent ADR or fusion surgery after anterior decompression due to cervical degenerative radiculopathy (ISRCTN registration no. 44347115). Scores on the Neck Disability Index (NDI), EQ-5D, and visual analog scale for neck and arm pain were obtained from the Swedish Spine Registry and analyzed using ANCOVA. Information about secondary surgical procedures was collected from medical records and presented as Kaplan-Meier curves. MRI and flexion-extension radiography were performed, and ASP was graded according to the Miyazaki classification system.

RESULTS

Ten participants were lost to follow-up, which left 143 participants (80 underwent ADR and 65 underwent anterior cervical discectomy and fusion). There were no differences between groups in terms of patient-reported outcome measures (10-year difference in NDI scores 1.7 points, 95% CI -5.1 to 8.5, p = 0.61). Nineteen (24%) participants in the ADR group compared with 9 (14%) in the fusion group underwent secondary surgical procedures. The higher reoperation rate of the ADR group was mainly due to 11 female participants with device loosening. The rates of reoperation due to ASP were similar between groups, which was confirmed with MRI assessment of ASP that also showed no differences between the groups (p = 0.21).

CONCLUSIONS

This was the first 10-year follow-up study to compare ADR with fusion surgery and to provide MRI information for the assessment of ASP. The authors found no benefit of ADR over fusion surgery after anterior decompression for cervical degenerative radiculopathy.

Larger pain extent is associated with greater pain intensity and disability but not with general health status or psychosocial features in patients with cervical radiculopathy

Pain as a result of cervical radiculopathy (CR) can be widespread, nondermatomal and individually specific, but the association between pain extent and other clinical features has never been explored. The objective of this study is to investigate whether pain extent relates to clinical variables including pain intensity in addition to health indicators including disability, general health, depression, somatic anxiety, coping strategies or self-efficacy.An observational cohort study was conducted. Participants were recruited from 4 hospital spinal centres in Sweden. Pain extent was quantified from the pain drawings of 190 individuals with cervical disc disease, verified with magnetic resonance imaging (MRI) and compatible with clinical findings (examined by a neurosurgeon), that show cervical nerve root compression. Pain extent was evaluated in relation to neck pain, arm pain, and headache intensity. Multiple linear regression analysis were then used to verify whether pain extent was associated with other health indicators including disability, health-related quality of life, depression, somatic anxiety, coping strategies and self-efficacy.Pain extent was directly related to neck, arm and headache pain intensity (all P < .01). Multiple linear regression revealed that pain extent was significantly associated only to the level of perceived disability (P < .01).Increased pain extent in people with CR is associated with higher headache, neck and arm pain intensity, and disability but not measures of general health, depression, somatic anxiety, coping strategies or self-efficacy.

Sagittal Alignment After Laminectomy Without Fusion as Treatment for Cervical Spondylotic Myelopathy: Follow-up of Minimum 4 Years Postoperatively

OBJECTIVES

The aims of this study were to evaluate the incidence of sagittal malalignment including kyphosis following cervical laminectomy without fusion as treatment for cervical spondylotic myelopathy and to assess any correlation between malalignment and clinical outcome.

STUDY DESIGN

Retrospective cohort study.

METHODS

In all, 60 patients were followed up with conventional radiography at an average of 8 years postoperatively. The cervical lordosis (C2-C7 Cobb angle), C2-C7 sagittal vertical axis (cSVA) and C7 slope were measured on both preoperative and postoperative images. Patients completed a questionnaire covering Neck Disability Index (NDI), visual analogue scale for neck pain, and general health (EQ-5D).

RESULTS

Mean C2-C7 Cobb angle was 8.6° (SD 9.0) preoperatively, 3.4° (10.7) postoperatively and 9.6° (14.5) at follow-up. Ultimately, 3 patients showed >20° cervical kyphosis. Mean cSVA was 16.3 mm (SD 10.2) preoperatively, 20.6 mm (11.8) postoperatively, and 31.6 mm (11.8) at follow-up. Mean C7 slope was 20.4° (SD 8.9) preoperatively, 18.4° (9.4) postoperatively, and 32.6° (10.2) at follow-up. The preoperative to follow-up increase in cSVA and C7 slope was statistically significant (both P < .0001), but not for cervical lordosis. The preoperative to follow-up change in cSVA correlated moderately with preoperative cSVA (r = 0.43, P = .002), as did the corresponding findings regarding C7 slope (r = 0.52, P = .0001). A comparison of radiographic measurements with clinical outcome showed no strong correlations.

CONCLUSIONS

No preoperative to follow-up change in cervical lordosis was found in this group; 5.0% developed >20° kyphosis. No clear correlation between sagittal alignment and clinical outcome was shown.

Artificial disc replacement versus fusion in patients with cervical degenerative disc disease and radiculopathy: a randomized controlled trial with 5-year outcomes

In BriefIn this study the authors compare cervical arthroplasty with fusion surgery in a randomized controlled trial using patient-reported outcome measures and MRI after 5 years of follow-up. Because the main purpose of arthroplasties is to prevent adjacent-segment pathology, it is important to investigate if that is actually realized in practice.

Postoperative structured rehabilitation in patients undergoing surgery for cervical radiculopathy: a 2-year follow-up of a randomized controlled trial

OBJECTIVE

Information about postoperative rehabilitation for cervical radiculopathy (CR) is scarce. The aim of this study was to investigate the additional benefits of structured postoperative rehabilitation (SPT), which was performed in all patients, compared with a pragmatic standard postoperative approach (SA), in which rehabilitation was used as needed and patients sought physiotherapy on their own without a referral, in patients with MRI evidence of disc herniation and concomitant clinical signs who underwent surgery for CR.

METHODS

Patients (n = 202) were randomized to receive SPT or SA. Included key variables in the present study were primary and selected secondary outcomes of a prospective randomized controlled multicenter study. The main outcome was the Neck Disability Index (NDI) score. The NDI score, pain variables, self-efficacy, and health-related quality of life were investigated at baseline and 3, 6, 12, and 24 months postoperatively.

RESULTS

SPT provided no additional benefits over SA (p = 0.08 to p = 0.99) at the postoperative 2-year follow-up. Both groups improved over time (p < 0.0001), with no reported adverse effects.

CONCLUSIONS

One can conclude that SPT offered no additional benefits over SA; however, patients tolerated postoperative neck exercises without any negative side effects. These findings are important for the development of future active and neck-specific postoperative rehabilitation interventions for patients with CR.Clinical trial registration no.: NCT01547611 (clinicaltrials.gov).

Physiotherapy after anterior cervical spine surgery for cervical disc disease: study protocol of a prospective randomised study to compare internet-based neck-specific exercise with prescribed physical activity

INTRODUCTION

Patients suffering from remaining disability after anterior cervical decompression and fusion (ACDF) surgery for cervical disc disease may be prescribed physical activity (PPA) or neck-specific exercises (NSEs). Currently, we lack data for the success of either approach. There is also a knowledge gap concerning the use of internet-based care for cervical disc disease. The scarcity of these data, and the high proportion of patients with various degrees of incapacity following ACDF, warrant increased efforts to investigate and improve cost-effective rehabilitation. The objective is to compare the effectiveness of a structured, internet-based NSE programme, versus PPA following ACDF surgery.

METHODS AND ANALYSIS

This is a prospective, randomised, multicentre study that includes 140 patients with remaining disability (≥30% on the Neck Disability Index, NDI) following ACDF for radiculopathy due to cervical disc disease. Patient recruitment occurs following attendance at routine clinical appointments, scheduled at 3 months postsurgery. Patients are then randomised to one of two groups (70 patients/group) for a 3-month treatment programme/period of either internet-based NSE or PPA. Questionnaires on background data, pain and discomfort, physical and mental capacity, satisfaction with care, and health and workplace factors are completed, along with physical measures of neck-related function conducted by independent test leaders blinded to randomisation. Measures are collected at inclusion, after the 3-month treatments (end of treatment) and at a 2-year follow-up. Radiography will be completed at the 2-year follow-up. Preoperative data will be collected from the Swedish Spine Registry. Data on healthcare consumption, drug use and sick leave will be requested from the relevant national registers.

ETHICAL CONSIDERATIONS

This study was approved by the Regional Ethical Review Board in Linköping Ref. 2016/283-31 and 2017/91- 32. The scientists are independent with no commercial ties. Patients are recruited after providing written informed consent. Patient data are presented at group level such that no connection to any individual can be made. All data are anonymised when reported, and subject to the Swedish Official Secrets Health Acts. The test leaders are independent and blinded for randomisation. Exercises, both general and neck-specific, have been used extensively in clinical practice and we anticipate no harm from their implementation other than a risk of muscle soreness. Both randomisation groups will receive care that is expected to relieve pain, although the group receiving NSE is expected to demonstrate a greater and more cost-effective improvement versu s the PPA group. Any significant harm or unintended effects in each group will be collected by the test leaders. All questionnaires and test materials are coded by the research group, with code lists stored in locked, fireproof file cabinets, housed at the university in a room with controlled (card-based) access. Only individuals in receipt of a unique website address posted by the researchers can access the programme; patients can neither communicate with each other nor with caregivers via the programme.Study participation might lead to improved rehabilitation versus non-participation, and might therefore be of benefit. The results of this study should also contribute to more effective and flexible rehabilitation, shorter waiting times, lower costs and the possibility to implement our findings on a wider level.

DISSEMINATION

If effective, the protocols used in this study can be implemented in existing healthcare structures. The results of the study will be presented in scientific journals and popular science magazines of relevance to health. The findings will also be presented at local, regional, national and international conferences and meetings, as well as in the education of university students and at public lectures. Information about the results will be communicated to the general population in cooperation with patient organisations and the media.

TRIAL REGISTRATION

NCT03036007.

Artificial disc replacement versus fusion in patients with cervical degenerative disc disease with radiculopathy: 5-year outcomes from the National Swedish Spine Register

OBJECTIVE

The long-term efficacy of artificial disc replacement (ADR) surgery compared with fusion after decompression for the treatment of cervical degenerative disc disease and radiculopathy has not previously been investigated in a population-based setting.

METHODS

All patients with cervical degenerative disc disease and radiculopathy who were in the national Swedish Spine Registry (Swespine) beginning in January 1, 2006, were eligible for the study. Follow-up information was obtained up to November 15, 2017. The authors compared, using propensity score matching, patients treated with anterior decompression and insertion of an ADR with patients who underwent anterior decompression combined with fusion surgery. The primary outcome was the Neck Disability Index (NDI), a patient-reported function score ranging from 0% to 100%, with higher scores indicating greater disability and a minimum clinically important difference of > 15%.

RESULTS

A total of 3998 patients (2018:1980 women/men) met the inclusion criteria, of whom 204 had undergone arthroplasty and 3794 had undergone fusion. After propensity score matching, 185 patients with a mean age of 49.7 years remained in each group. Scores on the NDI were approximately halved in both groups after 5 years, but without a significant mean difference in NDI (3.0%; 95% CI −8.4 to 2.4; p = 0.28) between the groups. There were no differences between the groups in EuroQol–5 Dimensions or in pain scores for the neck and arm.

CONCLUSIONS

In patients with cervical degenerative disc disease and radiculopathy, decompression plus ADR surgery did not result in a clinically important difference in outcomes after 5 years, compared with decompression and fusion surgery.

Risk factors for neck pain among forklift truck operators: a retrospective cohort study

BACKGROUND

No previous research has been performed into neck pain among forklift operators. This is a common complaint among these workers, who number around 150,000 in Sweden and six million in Europe. The aim of the study was to examine long-term exposure to unnatural neck positions among forklift operators as a risk factor for neck pain.

METHODS

A retrospective cohort study was conducted of all eligible employees at a high-level warehouse. Forklift operators and office workers answered an 18-page questionnaire comprising questions about joint pain, work tasks, work postures and year of start for all items. By using person years in the exposed and less-exposed groups before start of neck pain we were able to calculate Incident Rate ratios for various exposures.

RESULTS

Forty nine percent of the forklift operators reported having experienced neck pain compared to 30 % of office workers. Being a forklift operator was associated with an increased risk of neck pain (OR = 5.1, 95% CI 1.4-18.2). Holding the head in an unnatural position resulted in significantly increased risks for neck pain, irrespective of type of position. The risks for neck pain remained after taking other ergonomic exposures and psychosocial aspects into consideration.

CONCLUSIONS

This is the first published study showing that forklift operators have an increased risk of neck pain. The results are therefore of significance for improving work schedules, the adjustment of work tasks for these workers and the design of the vehicles.

Structured postoperative physiotherapy in patients with cervical radiculopathy: 6-month outcomes of a randomized clinical trial

OBJECTIVE Structured physiotherapy has been suggested as treatment before as well as after surgery to improve clinical outcomes in patients with cervical radiculopathy (CR), but randomized clinical trials to inform evidence-based clinical guidelines for the treatment of patients with CR after surgery are lacking. The aim of this study was to compare the results of structured postoperative physiotherapy combining neck-specific exercises with a behavioral approach to a standard postoperative approach in patients who had undergone surgery for cervical disc disease with CR at 6 months after surgery. METHODS Patients with cervical disc disease and persistent CR who were scheduled for surgery were randomized preoperatively to structured postoperative physiotherapy (n = 101) or a standard postoperative approach (n = 100). The latter included pragmatic physiotherapy in accordance with the usual Swedish postoperative care. Outcome measures included patient-reported neck disability as measured with the Neck Disability Index (NDI), intensity and frequency of neck and arm pain, global outcome of treatment, and expectation fulfillment, as well as enablement. RESULTS Patients who received structured postoperative physiotherapy reported greater expectation fulfillment (p = 0.01), and those who attended at least 50% of the treatment sessions reported less neck pain frequency (p = 0.05), greater expectation fulfillment (p = 0.001), and greater enablement (p = 0.04) compared with patients who received the standard postoperative approach. No other difference between treatment groups was found (p > 0.15). The NDI and neck and arm pain intensity were improved in both groups at 6 months after surgery (p < 0.001). Additional use of postoperative physiotherapy was reported by 61% of the patients who received the standard postoperative approach. CONCLUSIONS The results from this first randomized clinical trial of postoperative physiotherapy showed only minor additional benefit of structured postoperative physiotherapy compared with standard postoperative approach 6 months postoperatively in patients who underwent surgery for cervical disc disease with CR. Patients who received structured postoperative physiotherapy reported higher expectation fulfillment, and many patients in the standard postoperative approach group perceived a need for additional treatments after surgery, suggesting that patients with CR are in need of further postoperative support. The results confirm that neck-specific exercises are tolerated postoperatively by patients with CR, but more studies of postoperative physiotherapy are needed to inform clinical guidelines for this patient group. Clinical trial registration no.: NCT01547611 (clinicaltrials.gov).

A 5- to 8-year randomized study on the treatment of cervical radiculopathy: anterior cervical decompression and fusion plus physiotherapy versus physiotherapy alone

OBJECTIVE

The aim of this study was to evaluate the 5- to 8-year outcome of anterior cervical decompression and fusion (ACDF) combined with a structured physiotherapy program as compared with that following the same physiotherapy program alone in patients with cervical radiculopathy. No previous prospective randomized studies with a follow-up of more than 2 years have compared outcomes of surgical versus nonsurgical intervention for cervical radiculopathy.

METHODS

Fifty-nine patients were randomized to ACDF surgery with postoperative physiotherapy (30 patients) or to structured physiotherapy alone (29 patients). The physiotherapy program included general and specific exercises as well as pain coping strategies. Outcome measures included neck disability (Neck Disability Index [NDI]), neck and arm pain intensity (visual analog scale [VAS]), health state (EQ-5D questionnaire), and a patient global assessment. Patients were followed up for 5–8 years.

RESULTS

After 5–8 years, the NDI was reduced by a mean score% of 21 (95% CI 14–28) in the surgical group and 11% (95% CI 4%–18%) in the nonsurgical group (p = 0.03). Neck pain was reduced by a mean score of 39 mm (95% CI 26–53 mm) compared with 19 mm (95% CI 7–30 mm; p = 0.01), and arm pain was reduced by a mean score of 33 mm (95% CI 18–49 mm) compared with 19 mm (95% CI 7–32 mm; p = 0.1), respectively. The EQ-5D had a mean respective increase of 0.29 (95% CI 0.13–0.45) compared with 0.14 (95% CI 0.01–0.27; p = 0.12). Ninety-three percent of patients in the surgical group rated their symptoms as “better” or “much better” compared with 62% in the nonsurgical group (p = 0.005). Both treatment groups experienced significant improvement over baseline for all outcome measures.

CONCLUSIONS

In this prospective randomized study of 5- to 8-year outcomes of surgical versus nonsurgical treatment in patients with cervical radiculopathy, ACDF combined with physiotherapy reduced neck disability and neck pain more effectively than physiotherapy alone. Self-rating by patients as regards treatment outcome was also superior in the surgery group. No significant differences were seen between the 2 patient groups as regards arm pain and health outcome.

The Discover artificial disc replacement versus fusion in cervical radiculopathy--a randomized controlled outcome trial with 2-year follow-up

BACKGROUND CONTEXT

Several previous studies comparing artificial disc replacement (ADR) and fusion have been conducted with cautiously positive results in favor of ADR. This study is not, in contrast to most previous studies, an investigational device exemption study required by the Food and Drug Administration for approval to market the product in the United States. This study was partially funded with unrestricted institutional research grants by the company marketing the artificial disc used in this study.

PURPOSE

To compare outcomes between the concepts of an artificial disc to treatment with anterior cervical decompression and fusion (ACDF) and to register complications associated to the two treatments during a follow-up time of 2 years.

STUDY DESIGN/SETTING

This is a randomized controlled multicenter trial, including three spine centers in Sweden.

PATIENT SAMPLE

The study included patients seeking care for cervical radiculopathy who fulfilled inclusion criteria. In total, 153 patients were included.

OUTCOME MEASURES

Self-assessment with Neck Disability Index (NDI) as a primary outcome variable and EQ-5D and visual analog scale as secondary outcome variables.

METHODS

Patients were randomly allocated to either treatment with the Depuy Discover artificial disc or fusion with iliac crest bone graft and plating. Randomization was blinded to both patient and caregivers until time for implantation. Adverse events, complications, and revision surgery were registered as well as loss of follow-up.

RESULTS

Data were available in 137 (91%) of the included and initially treated patients. Both groups improved significantly after surgery. NDI changed from 63.1 to 39.8 in an intention-to-treat analysis. No statistically significant difference between the ADR and the ACDF groups could be demonstrated with NDI values of 39.1 and 40.1, respectively. Nor in secondary outcome measures (EQ-5D and visual analog scale) could any statistically significant differences be demonstrated between the groups. Nine patients in the ADR group and three in the fusion group underwent secondary surgery because of various reasons. Two patients in each group underwent secondary surgery because of adjacent segment pathology. Complication rates were not statistically significant between groups.

CONCLUSIONS

Artificial disc replacement did not result in better outcome compared to fusion measured with NDI 2 years after surgery.

Outcome of physiotherapy after surgery for cervical disc disease: a prospective randomised multi-centre trial

BACKGROUND

Many patients with cervical disc disease require leave from work, due to long-lasting, complex symptoms, including chronic pain and reduced levels of physical and psychological function. Surgery on a few segmental levels might be expected to resolve disc-specific pain and reduce neurological deficits, but not the non-specific neck pain and the frequent illness. No study has investigated whether post-surgery physiotherapy might improve the outcome of surgery. The main purpose of this study was to evaluate whether a well-structured rehabilitation programme might add benefit to the customary post-surgical treatment for cervical disc disease, with respect to function, disability, work capability, and cost effectiveness.

METHODS/DESIGN

This study was designed as a prospective, randomised, controlled, multi-centre study. An independent, blinded investigator will compare two alternatives of rehabilitation. We will include 200 patients of working age, with cervical disc disease confirmed by clinical findings and symptoms of cervical nerve root compression. After providing informed consent, study participants will be randomised to one of two alternative physiotherapy regimes; (A) customary treatment (information and advice on a specialist clinic); or (B) customary treatment plus active physiotherapy. Physiotherapy will follow a standardised, structured programme of neck-specific exercises combined with a behavioural approach. All patients will be evaluated both clinically and subjectively (with questionnaires) before surgery and at 6 weeks, 3 months, 6 months, 12 months, and 24 months after surgery. The main outcome variable will be neck-specific disability. Cost-effectiveness will also be calculated.

DISCUSSION

We anticipate that the results of this study will provide evidence to support physiotherapeutic rehabilitation applied after surgery for cervical radiculopathy due to cervical disc disease.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01547611.

Clinical and radiological evaluation of Trabecular Metal and the Smith-Robinson technique in anterior cervical fusion for degenerative disease: a prospective, randomized, controlled study with 2-year follow-up

A prospective, randomized, controlled study was carried out to compare the radiological and clinical outcomes after anterior cervical decompression and fusion (ACDF) with Trabecular Metal (TM) to the traditional Smith-Robinson (SR) procedure with autograft. The clinical results of cervical fusion with autograft from the iliac crest are typically satisfactory, but implications from the donor site are frequently reported. Alternative materials for cervical body interfusion have shown lower fusion rates. Trabecular Metal is a porous tantalum biomaterial with structure and mechanical properties similar to that of trabecular bone and with proven osteoconductivity. As much as 80 consecutive patients planned for ACDF were randomized for fusion with either TM or tricortical autograft from the iliac crest (SR) after discectomy and decompression. Digitized plain radiographic images of 78 (98%) patients were obtained preoperatively and at 2-year follow-up and were subsequently evaluated by two senior radiologists. Fusion/non-fusion was classified by visual evaluation of the A-P and lateral views in forced flexion/extension of the cervical spine and by measuring the mobility between the fused vertebrae. MRI of 20 TM cases at 2 years was successfully used to assess the decompression of the neural structures, but was not helpful in determining fusion/non-fusion. Pain intensity in the neck, arms and pelvis/hip were rated by patients on a visual analog scale (VAS) and neck function was rated using the Neck Disability Index (NDI) the day before surgery and 4, 12 and 24 months postoperatively. Follow-ups at 12 and 24 months were performed by an unbiased observer, when patients also assessed their global outcome. Fusion rate in the SR group was 92%, and in the TM group 69% (P < 0.05). The accuracy of the measurements was calculated to be 2.4 degrees . Operating time was shorter for fusion with TM compared with autograft; mean times were 100 min (SD 18) and 123 min (SD 23), respectively (P = 0.001). The patients' global assessments of their neck and arm symptoms 2 years postoperatively for the TM group were rated as 79% much better or better after fusion with TM and 75% using autograft. Pain scores and NDI scores were significantly improved in both groups when compared with baseline at all follow-ups, except for neck pain at 1 year for the TM group. There was no statistically significant difference in clinical outcomes between fusion techniques or between patients who appeared radiologically fused or non-fused. There was no difference in pelvic/hip pain between patients operated on with or without autograft. In our study, Trabecular Metal showed a lower fusion rate than the Smith-Robinson technique with autograft after single-level anterior cervical fusion without plating. There was no difference in clinical outcomes between the groups. The operative time was shorter with Trabecular Metal implants.

Automatic fitting procedures for EPR spectra of disordered systems: matrix diagonalization and perturbation methods applied to fluorocarbon radicals

Two types of automatic fitting procedures for EPR spectra of disordered systems have been developed, one based on matrix diagonalization of a general spin Hamiltonian, the other on 2nd order perturbation theory. The first program is based on a previous Fortran code complemented with a newly written interface in Java to provide user-friendly in and output. The second is intended for the special case of free radicals with several relatively weakly interacting nuclei, in which case the general method becomes slow. A least squares' fitting procedure utilizing analytical or numerical derivatives of the theoretically calculated spectrum with respect to the g- and hyperfine structure (hfs) tensors was used to refine those parameters in both cases. 'Rigid limit' ESR spectra from radicals in organic matrices and in polymers, previously studied experimentally at low temperature, were analyzed by both methods. Fluorocarbon anion radicals could be simulated, quite accurately with the exact method, whereas automatic fitting on, e.g. the c-C(4)F(8)(-) anion radical is only feasible with the 2nd order approximative treatment. Initial values for the (19)F hfs tensors estimated by DFT calculations were quite close to the final. For neutral radicals of the type XCF(2)CF(2)* the refinement of the hfs tensors by the exact method worked better than the approximate. The reasons are discussed. The ability of the fitting procedures to recover the correct magnetic parameters of disordered systems was investigated by fittings to synthetic spectra with known hfs tensors. The exact and the approximate methods are concluded to be complementary, one being general, but limited to relatively small systems, the other being a special treatment, suited for S=1/2 systems with several moderately large hfs.

Reduced pain after surgery for cervical disc protrusion/stenosis: a 2 year clinical follow-up

PURPOSE

To follow the clinical outcome after surgery for cervical radiculopathy caused by degenerative cervical disc disease and to compare it with the outcome after conservative treatment.

METHOD

Forty-three patients all awaiting surgery were studied prospectively. A control group of 39 conservatively treated patients were chosen, matched for gender and age. All patients rated their Sickness Impact Profile (SIP) and pain (VAS) and were clinically examined by unbiased observers initially and after 3, 9 and 24 months.

RESULTS

Long-lasting pain reduction was noted both in the neck and in the arm for the operated patients, as well as improved sensory function and reduction of reflex disturbances. Their SIP showed a temporary improvement in the overall index, in the psychosocial dimension, in sleep/rest and home management, but only mobility remained improved. Among the operated patients referred directly to us, there was an improvement in SIP at the final follow-up. The control group's SIP indicated only a temporary improvement in sleep/rest.

CONCLUSIONS

Surgically treated patients experienced pain reduction which was partially maintained for at least 24 months. A sustained improvement in the health status measured by SIP was observed only among operated patients that were not referred via the social insurance offices.

Outcome of surgery for cervical radiculopathy evaluated by determination of trapezius muscle microcirculation and electromyography

Surgery for cervical radiculopathy was evaluated in 27 patients after anterior Cloward procedure (19 patients) or posterior decompression (eight patients). In addition, we examined 10 conservatively treated patients. Each patient was studied prospectively with regards to the effects on microcirculation in the local trapezius muscle during a fatiguing series of stepwise increased contractions. The right and left muscles were simultaneously examined pre-operatively and postoperatively after 9 months using laser-Doppler flowmetry and simultaneous surface electromyography (EMG). Preoperatively, a reduced microcirculation was found in the most painful side compared with the opposite side. This is in accordance with earlier reports on patients with chronic neurogenic neck pain, who also show reduced muscle tension on EMG. Postoperatively, the muscle blood flow became increased, but only in patients operated on via a posterior approach. A tendency at increased EMG-amplitude and reduced mean power frequency of the EMG was noted. These EMG signs of muscle fatigue suggest increased ability to exhaust the trapezius muscle postoperatively. The observed postoperative changes were consistently more frequent in the less painful side. We conclude from these objective measurements showing only a tendency at increased microcirculation and muscle tension postoperatively, that the effect on the trapezius muscle is limited.

Psychiatric nurses' conceptions of how a group supervision programme in nursing care influences their professional competence: a 4-year follow-up study

AIM

The aim of the study was to describe, after 4 years, psychiatric nurses' conceptions of how a 2-year group supervision programme within nursing care had influenced their professional competence.

BACKGROUND

The intention of group supervision in nursing care is to understand nurses' experiences within real care settings and to structure these in a professional and personal context.

METHODS

Ten psychiatric nurses participated in a 2-year group supervision programme. They were interviewed 4 years after the group supervision was ended. Data were analysed according to the phenomenographic method.

FINDINGS

Six description categories emerged: a feeling of job satisfaction; gaining knowledge and competence; gaining a sense of security in nursing situations; a feeling of personal development; realizing the value of supervision; and a sense of professional solidarity.

CONCLUSIONS

The findings of the 4-year follow-up showed that a group supervision programme in nursing care had lasting influences on the psychiatric nurses' professional competence in the form of a pronounced professional identity and an integrated nursing care perspective. Group supervision contributes to maintaining the strength and energy needed to carry on working, which makes continuing supervision necessary.

IMPLICATIONS

An important research implication could be to investigate the type of knowledge that ought to be developed within group supervision in nursing care.

Rigid fusion after cloward operation for cervical disc disease using autograft, allograft, or xenograft: a randomized study with radiostereometric and clinical follow-up assessment

STUDY DESIGN

In this study, 43 patients scheduled for a single-level cervical Cloward procedure for disc disease were randomized prospectively to fusion with autograft, allograft, or xenograft.

OBJECTIVE

To outline any differences in fusion over time in terms of final mobility and clinical outcome between the three bone grafts.

SUMMARY OF BACKGROUND DATA

Fusion is used to relieve pain from a spinal segment. The bovine xenograft gives a fibrous fusion in contrast to the solid bone fusion obtained with autograft from the iliac crest, but no definite differences in clinical outcome have been shown previously after surgery at a single level.

METHODS

By use of radiostereometric analysis, 33 patients were observed after 6, 12, and 24 to 50 (mean, 37) months. All 43 patients underwent clinical examination, which involved pain rating before and after surgery, with a final follow-up assessment by an unbiased observer.

RESULTS

Mobility could be demonstrated in 9 patients after 1 year and in 6 patients at the final follow-up assessment, without pain, and with no difference between bone grafts. The patients who received autograft experienced a greater reduction of pain than the patients treated with xenograft.

CONCLUSIONS

Most of the patients healed with a rigid fusion no matter which graft was used, but the healing process took longer than expected. The clinical results were not influenced by whether mobility could be demonstrated. There was a tendency toward better clinical results in the patients treated with autograft.

Methods for determining the accuracy of radiostereometric analysis (RSA)

The problem of determining the noise level in any measuring system remains urgent. Radiostereometric analysis (RSA) is a radiographic system of unique accuracy which has applications in areas where minute motions or no motion at all occurs. Examples are micromotion between endoprostheses and bone and in fracture healing. We have determined the accuracy of the RSA system as applied to a clinical series of spinal fusions, where the conditions for RSA were not optimal. Using the usual test-retest methodology on a phantom, we showed that its accuracy can be grossly overestimated in the individual case. We found considerable variations in the accuracy in the individual case, depending on the rigid-body configuration. The overall accuracy, expressed as 3-D "vectors" for rotation and translation, respectively, correlated with the condition number, a method for characterizing the marker configuration. Indeed, the condition number explained as much as 92% of the variation in overall rotation. This condition number, however, cannot be used to analyze the accuracy of one degree of freedom of rotation alone. Mathematical simulation of the accuracy in the individual case of the individual dimension, using in-house software, showed that the accuracy (95% confidence) varied between 0.4 and 4.6 degrees of rotation about the transverse axis, corresponding to a clinical stress series of extension and flexion.

The Pharmaceutical Benefits Scheme and the shifting paradigm of welfare policy

This paper describes the design and operation of the Pharmaceutical Benefits Scheme and then proceeds with an analysis of current policy deliberations which identifies an extension of the market as predominant trend. The paper demonstrates that the conditions which historically sustained the scheme are now present to a lesser extent. The Pharmaceutical Benefits Scheme has functioned as a universalist welfare program which conferred onto the Commonwealth Department of Health substantial powers vis-à-vis drug suppliers and professional groups. This position of dominance has been eroded, with challenges to established arrangements arising, in particular, from the enhanced bargaining position of business and wider pressures operating on the Keynesian welfare state.

Sodium ion diffusion through liposome membranes containing cerebroside

Na+ efflux from liposomes (small unilamellar vesicles, SUV) of various compositions was studied, using 22Na+ and 3H-labelled stachyose in simultaneous dual isotope measurements, stachyose being used as a measure of liposome disintegration. Dialysis was utilised to separate liposomes from extra-liposomal activity. Liposomes were made from egg lecithin and sphingomyelin and from mixtures of egg lecithin, sphingomyelin, cerebroside, sulphatide and cholesterol. All mixtures produced more leaky and less stable SUVs than pure lecithin and pure sphingomyelin. The incorporation of cerebroside is significantly smaller than that of the phospholipids including sphingomyelin. It was found that membranes containing cerebroside had a significantly higher Na+ permeability than membranes without cerebroside.

A new instrument for measuring surface pressure

A new instrument for surface pressure measurements using a floating-foil technique has been constructed. The instrument makes use of a probe in the form of a thin foil suspended at the gas/liquid or liquid/liquid interface tension. The present instrument has a dynamic range of 0.1-70 mN/m and a sensitivity better than 0.1 mN/m. Its speed of response is 50 ms but much faster measurements are possible. Measurements on behenic acid and cholesterol films on water and on a cerebroside film at a heptane/water interface are presented.

Accommodation of hydroxyl groups and their hydrogen bond system in a hydrocarbon matrix

From data of a single crystal analysis of 12-D-hydroxyoctadecanoic acid methyl ester principles for the incorporation of hydroxyl groups into a hydrocarbon chain matrix can be deduced. In the crystalline compound infinite hydrogen bond systems are accommodated in an orthorhombic perpendicular chain arrangement. The orthorhombic perpendicular hydrocarbon subcell is expanded towards a hexagonal packing pattern, allowing more space and optimal geometry for the hydrogen bond system. The arrangement of the bond system in the orthorhombic perpendicular subcell requires that hydrogen bonded carbon chains carry alternatingly hydroxyl groups with opposite configuration. For the enantiomeric compound this requirement is met by a head to tail packing of molecules in a single layer arrangement. The corresponding racemates on the other hand pack head to head in double layers as confirmed by X-ray powder and IR studies. In monolayers both enantiomers and racemates behave identically. The hydrogen bonding of the hydroxyl groups apparently leads to the formation of lipid clusters, in which the geometric conditions for both a close packing of hydrocarbon chains and the formation of an extensive hydrogen bond system do not exist.

Molecular arrangements of sphingolipids. The monolayer behaviour of ceramides

A series of synthetic ceramides have been studied at the air-water interface by recording the surface pressue-area isotherms at continuous compression. Ceramides that contain a 4,5-trans-double bond in the long chain base were found to condense into a close-packed arrangement with vertical chains already at a very low surface pressure. The corresponding saturated compounds adopt a similar close packed arrangement only at high surface pressue. At 30 dynes/cm, a lateral pressure representative of biological membranes, the area per molecule and compressibility was further found to depend on the number and configuration of the hydroxyl groups. The presence of a 2-D-hydroxyl group in the fatty acid generally promotes the condensation. A similar effect is observed if the long chain base contains a 4-D-hydroxyl group. Cis-double bonds or methyl branches in the fatty acid chain, which increase the space requirement, limit the lateral interaction of the polar group. However the 15-cis-double bond of nervonic acid can be accomodated without any distortion of the close-packing arrangement.

Surface balance study of the interaction between microorganisms and lipid monolayer at the air/water interface

Using the surface balance technique, we have compared the interaction between Acholeplasma laidlawii and some marine bacteria towards different types of monolayered lipid films. Cells from A. laidlawii and Serratia marinorubra penetrate the film, whereas cells from Psuedomonas fluorescens form a layer underneath the film. The forces that bind microorganisms to the air/water interface are not strong enough to scatter a condensed monolayer but increase the strength of loosely packed monolayers.