BACKGROUND CONTEXT: Sex life and sexual function maybe affected by low back pain (LBP). Sexual dysfunction after anterior lumbar fusion is reported in both men and women, but focus is mainly on impaired male biological function (retrograde ejaculation) as this may cause infertility. This has led to concern as to whether anterior surgery should be employed in men, at least in younger age groups. PURPOSE: To investigate how chronic low back pain (CLBP) of assumed discogenic origin affects sex life and sexual function in patients considered for surgical treatment, whether this is affected by surgical treatment (total disc replacement [TDR] or posterolateral fusion [PLF]/posterior lumbar interbody fusion [PLIF]), and if so, are there differences between the surgical procedures undertaken. STUDY DESIGN: A randomized controlled trial comparing TDR and instrumented lumbar spine fusion, performed either as a PLF or PLIF. PATIENT SAMPLE: One hundred fifty-two patients were included in this randomized controlled trial to compare the effect on CLBP of either TDR via an anterior retroperitoneal approach or instrumented posterior lumbar fusion, PLF or PLIF. OUTCOME MEASURES: Global assessment of back pain, back pain (visual analog scale [VAS] 0-100), function (Oswestry Disability Index [ODI] 0-100), quality of life (EQ5D [EuroQol] 0-1), and answers on specific sexual function. METHODS: Outcome was assessed using data from the Swedish Spine Register (SweSpine). In ODI, one question, ODI 8, reflects the impact of back pain on sex life. This question was analyzed separately. Patients also answered a gender-specific questionnaire preoperatively and at the 2-year follow-up to determine any sexual dysfunction regarding erection, orgasm, and ejaculation. Followup was at 1 and 2 years. RESULTS: Before surgery, 34% reported that their sex life caused some extra LBP, and an additional 30% that their sex life was severely restricted by LBP. After surgery, sex life improved in both groups, with a strong correlation to a reduction of LBP. The gender-specific questionnaire used to measure sexual function after 2 years revealed no negative effect of TDR or Fusion in men regarding erection or retrograde ejaculation. However, 26% of all men in the Fusion group, compared with 3% in the TDR group, reported postoperative deterioration in the ability to achieve orgasm, despite a reduction of LBP CONCLUSIONS: Impairment of sex life appears to be related to CLBP. An improvement in sex life after TDR or lumbar fusion was positively correlated to a reduction in LBP. Total disc replacement in this study, performed through an anterior retroperitoneal approach, was not associated with greater sexual dysfunction compared with instrumented lumbar fusion performed either as a PLF or as a PLIF. Sexual function, expressed as orgasm, deteriorated in men in the Fusion group postoperatively, in spite of this group reporting less LBP after 2 years.

Study Design. Comparison of X-ray measurements in a randomized controlled trial between instrumented posterior fusion (N=72) and total disc replacement (TDR) (N=80) for chronic low back pain assumed to be discogenic. Results were compared to clinical outcome.

Objective. To see if surgical goals for respective treatments had been reached, if clinical outcome was related to this, and if differences in disc height and adjacent segment motion patterns between groups occurred.

Summary of Background Data. Fusion is considered the “gold standard” in surgical treatment of degenerated disc disease, though the resulting stiffness may induce degeneration in adjacent segments. TDR aims to restore and maintain mobility by replacing a painful disc. Little is known about the degree and quality of mobility in artificial discs in vivo, and whether maintained mobility reduces stress on adjacent segments.

Methods. Flexion-extension X-rays were analyzed pre- and two years postoperatively using Distortion Compensated Roentgen Analysis (DCRA) at treated and adjacent levels, mobility following fusion and TDR was estimated. Changes in disc height and changes in mobility patterns in adjacent segments were compared. The results were compared with clinical outcome regarding back pain.

Results. 78% of fused patients had no mobility whereas 89% of TDR-patients were mobile, but with less than normal mobility. The fulfilment of surgical goals was not correlated to clinical outcome. Fused segments were lower and TDR-segments were higher than normal. There were minor differences, there being more translation or flexion-extension at adjacent levels in the fusion group than in the TDR group.

Conclusions. This very accurate X-ray method (DCRA) indicates that surgical goals were reached in most patients. This however, was not correlated to outcome. Differences between the groups in postoperative disc height and motion patterns at adjacent segments may lead to differences in outcome in the long-term perspective, but this was not detectable after two years.

The study design includes a prospective, randomised controlled study comparing total disc replacement (TDR) with posterior fusion. The main objective of this study is to compare TDR with lumbar spinal fusion, in terms of clinical outcome, in patients referred to a spine clinic for surgical evaluation. Fusion is effective for treating chronic low back pain (LBP), but has drawbacks, such as stiffness and possibly adjacent level degradation. Motion-preserving options have emerged, of which TDR is frequently used because of these drawbacks. How the results of TDR compare to fusion, however, is uncertain. One hundred and fifty-two patients with a mean age of 40 years (21-55) were included: 90 were women, and 80 underwent TDR. The patients had not responded to a conservative treatment programme and suffered from predominantly LBP, with varying degrees of leg pain. Diagnosis was based on clinical examination, radiographs, MRI, and in unclear cases, diagnostic injections. Outcome measures were global assessment (GA), VAS for back and leg pain, Oswestry Disability Index, SF36 and EQ5D at 1 and 2 years. Follow-up rate was 100%, at both 1 and 2 years. All outcome variables improved in both groups between preoperative and follow-up assessment. The primary outcome measure, GA, revealed that 30% in the TDR group and 15% in the fusion group were totally pain-free at 2 years (P = 0.031). TDR patients had reached maximum recovery in virtually all variables at 1 year, with significant differences compared to the fusion group. The fusion patients continued to improve and at 2 years had results similar to TDR patients apart from numbers of pain-free. Complications and reoperations were similar in both groups, but pedicle screw removal as additive surgery, was frequent in the fusion group. One year after surgery, TDR was superior to spinal fusion in clinical outcome, but this difference had diminished by 2 years, apart from (VAS for back pain and) numbers of pain-free. The long-term benefits have yet to be examined.

Study Design. Cross-sectional study. Objective. To investigate the presence and magnitude of anterior spinal overgrowth in neuromuscular scoliosis and compare this with the same measurements in idiopathic scoliosis and healthy spines. Summary of Background Data. Anterior spinal overgrowth has been described as a potential driver for the onset and progression of adolescent idiopathic scoliosis (AIS). Whether this anterior overgrowth is specific for AIS or also present in nonidiopathic scoliosis has not been reported. Methods. Supine computed tomography (CT) scans of thirty AIS patients (thoracic Cobb 21-81 degrees), thirty neuromuscular (NM) scoliotic patients (thoracic Cobb 19-101 degrees) and 30 nonscoliotic controls were used. The difference in length in per cents between the anterior and posterior side {[(Delta A-P)/P] * 100%, abbreviated to A-P%} of each vertebral body and intervertebral disc, and between the anterior side of the spine and the spinal canal (A-C%) were determined. Results. The A-P% of the thoracic curves did not differ between the AIS (+1.2 perpendicular to 2.2%) and NM patients (+0.9 +/- 4.1%, P = 0.663), both did differ, however, from the same measurements in controls (-3.0 +/- 1.6%; Pamp;lt; 0.001) and correlated linearly with the Cobb angle (AIS r = 0.678, NM r = 0.687). Additional anterior length was caused by anterior elongation of the discs (AIS: A-P% disc +17.5 +/- 12.7% vs. A-P% body - 2.5 +/- 2.6%; Pamp;lt; 0.001, NM: A-P% disc + 19.1 +/- 18.0% vs. A-P% body -3.5 +/- 5.1%; Pamp;lt; 0.001). The A-C% T1-S1 in AIS and NM patients were similar (+ 7.9 +/- 1.8% and + 8.7 +/- 4.0%, P = 0.273), but differed from the controls (+4.2 +/- 3.3%; Pamp;lt; 0.001). Conclusion. So called anterior overgrowth has been postulated as a possible cause for idiopathic scoliosis, but apparently it occurs in scoliosis with a known origin as well. This suggests that it is part of a more generalized scoliotic mechanism, rather than its cause. The fact that the intervertebral discs contribute more to this increased anterior length than the vertebral bodies suggests an adaptation to altered loading, rather than a primary growth disturbance.

Purpose

The pelvic incidence (PI) is used to describe the sagittal spino-pelvic alignment. In previous studies, radiographs were used, leading to less accuracy in establishing the three-dimensional (3D) spino-pelvic parameters. The purpose of this study is to analyze the differences in the 3D sagittal spino-pelvic alignment in adolescent idiopathic scoliosis (AIS) subjects and non-scoliotic controls.

Methods

Thirty-seven female AIS patients that underwent preoperative supine low-dose computed tomography imaging of the spine, hips and pelvis as part of their general workup were included and compared to 44 non-scoliotic age-matched female controls. A previously validated computerized method was used to measure the PI in 3D, as the angle between the line orthogonal to the inclination of the sacral endplate and the line connecting the center of the sacral endplate with the hip axis.

Results

The PI was on average 46.8° ± 12.4° in AIS patients and 41.3° ± 11.4° in controls (p = 0.025), with a higher PI in Lenke type 5 curves (50.6° ± 16.2°) as compared to controls (p = 0.042), whereas the Lenke type 1 curves (45.9° ± 12.2°) did not differ from controls (p = 0.141).

Conclusion

Lenke type 5 curves show a significantly higher PI than controls, whereas the Lenke type 1 curves did not differ from controls. This suggests a role of pelvic morphology and spino-pelvic alignment in the pathogenesis of idiopathic scoliosis. Further longitudinal studies should explore the exact role of the PI in the initiation and progression of different AIS types.

In scoliosis, kypholordos and wedge properties of the vertebrae should be involved in determining how stress is distributed in the vertebral column. The impact is logically expected to be maximal at the apex.

Background and purpose - Routine outcome measurement has been shown to improve performance in several fields of healthcare. National spine surgery registries have been initiated in 5 Nordic countries. However, there is no agreement on which outcomes are essential to measure for adolescent and young adult patients with a spinal deformity. The aim of this study was to develop a core outcome set (COS) that will facilitate benchmarking within and between the 5 countries of the Nordic Spinal Deformity Society (NSDS) and other registries worldwide. Material and methods - From August 2015 to September 2016, 7 representatives (panelists) of the national spinal surgery registries from each of the NSDS countries participated in a modified Delphi study. With a systematic literature review as a basis and the International Classification of Functioning, Disability and Health framework as guidance, 4 consensus rounds were held. Consensus was defined as agreement between at least 5 of the 7 representatives. Data were analyzed qualitatively and quantitatively. Results - Consensus was reached on the inclusion of 13 core outcome domains: "satisfaction with overall outcome of surgery", "satisfaction with cosmetic result of surgery", "pain interference", physical functioning", "health-related quality of life", "recreation and leisure", "pulmonary fatigue", "change in deformity", "selfimage", "pain intensity", "physical function", "complications", and "re-operation". Panelists agreed that the SRS-22r, EQ-5D, and a pulmonary fatigue questionnaire (yet to be developed) are the most appropriate set of patient-reported measurement instruments that cover these outcome domains. Interpretation - We have identified a COS for a large subgroup of spinal deformity patients for implementation and validation in the NSDS countries. This is the first study to further develop a COS in a global perspective.

Reliable measurements of spinal deformities in idiopathic scoliosis are vital, since they are used for assessing the degree of scoliosis, deciding upon treatment and monitoring the progression of the disease. However, commonly used two dimensional methods (e.g. the Cobb angle) do not fully capture the three dimensional deformity at hand in scoliosis, of which axial vertebral rotation (AVR) is considered to be of great importance. There are manual methods for measuring the AVR, but they are often time-consuming and related with a high intra- and inter-observer variability. In this paper, we present a fully automatic method for estimating the AVR in images from computed tomography. The proposed method is evaluated on four scoliotic patients with 17 vertebrae each and compared with manual measurements performed by three observers using the standard method by Aaro-Dahlborn. The comparison shows that the difference in measured AVR between automatic and manual measurements are on the same level as the inter-observer difference. This is further supported by a high intraclass correlation coefficient (0.971-0.979), obtained when comparing the automatic measurements with the manual measurements of each observer. Hence, the provided results and the computational performance, only requiring approximately 10 to 15 s for processing an entire volume, demonstrate the potential clinical value of the proposed method.

When low back pain becomes chronic, surgery is sometimes performed. The gold standard today is lumbar fusion (FUS), using a variety of procedures. Total disc replacement (TDR) aimed at motion preservation is increasing in popularity. This randomized controlled health economic study assesses the cost-effectiveness of TDR (Charité/Prodisc/Maverick) compared with instrumented FUS (posterior lumbar fusion (PLF)/posterior lumbar interbody fusion (PLIF). Social and healthcare perspectives after two years are reported. In all, 152 patients were randomized to either TDR (n=80) or FUS (n=72). Cost to society, (total mean cost/patient, Swedish kronor=SEK, standard deviation) for TDR was SEK 599,560 (400,272), and for FUS SEK 685,919 (422,903) (ns). TDR was significantly less costly from a healthcare perspective, SEK 22,996 (43,055- -1,202). Number of days on sick leave among those who returned to work was 185 (146) in the TDR group, and 252 (189) in the FUS group (ns). Using EQ-5D, the total gain in quality adjusted life years (QALYs) over two years was 0.41 units for TDR and 0.40 units for FUS (ns). Based on EQ-5D, the incremental cost effectiveness ratio (ICER) of using TDR instead of FUS was difficult to analyze due to the “non-difference” in treatment outcome, which is why cost/QALY could not be defined. Using cost-effectiveness probabilistic analysis, the net benefit with CI) was found to be SEK 91,359 (-73,643 – 249,114) (ns).

Conclusion: It is not possible to state whether TDR or FUS is more cost-effective after two years. Since disc replacement and lumbar fusion are based on different conceptual approaches, it is important to follow these results over time.

Study Design. A cost-effectiveness study was performed from the societal and health care perspectives. Objective. To evaluate the costs-effectiveness of lumbar fusion for chronic low back pain (CLBP) during a 2-year follow-up. Summary of Background Data. A full economic evaluation comparing costs related to treatment effects in patients with CLBP is lacking. Patients and Methods. A total of 284 of 294 patients with CLBP for at least 2 years were randomized to either lumbar fusion or a nonsurgical control group. Costs for the health care sector ( direct costs), and costs associated with production losses ( indirect costs) were calculated. Societal total costs were identified as the sum of direct and indirect costs. Treatment effects were measured using patient global assessment of improvement, back pain ( VAS), functional disability (Owestry), and return to work. Results. The societal total cost per patient ( standard deviations) in the surgical group was significantly higher than in the nonsurgical group: Swedish kroner (SEK) 704,000 ( 254,000) vs. SEK 636,000 ( 208,000). The cost per patient for the health care sector was significantly higher for the surgical group, SEK 123,000 ( 60,100) vs. 65,200 ( 38,400) for the control group. All treatment effects were significantly better after surgery. The incremental cost-effectiveness ratio ( ICER), illustrating the extra cost per extra effect unit gained by using fusion instead of nonsurgical treatment, were for improvement: SEK 2,600 ( 600 - 5,900), for back pain: SEK 5,200 ( 1,100 - 11,500), for Oswestry: SEK 11,300 ( 1,200 - 48,000), and for return to work: SEK 4,100 ( 100 21,400). Conclusion. For both the society and the health care sectors, the 2-year costs for lumbar fusion was significantly higher compared with nonsurgical treatment but all treatment effects were significantly in favor of surgery. The probability of lumbar fusion being cost-effective increased with the value put on extra effect units gained by using surgery.

In a prospective study, 23 consecutive girls with Rett syndrome and neuromuscular scoliosis were evaluated for functioning at a long-term follow-up. The patients had mostly improved, which was confirmed by their parents. Rett syndrome is associated with neuromuscular scoliosis and has a typically long C-shaped thoracolumbar kyphoscoliosis. Prospective long-term follow-up studies related to these patients total situation are sparse. Most studies focus on the Cobb angle of the scoliosis, whereas parents are mainly concerned about the girls continued functioning. Twenty-three patients with Rett syndrome and neuromuscular scoliosis were evaluated preoperatively from 1993 to 2002. At follow-up, 19 patients remained in the study. Three patients died (not due to surgery), and one patient could not participate because it was too far to travel. Mean follow-up time was 74 months (range 49-99 months). The assessments comprised the sitting balance, seating supports in wheelchair, weight distribution, time used for rest, care given, and angle of scoliosis. Follow-up questionnaires and two-open-ended questions about the positive and negative effects of surgery were sent to parents. Sitting balance, number of seating supports in wheelchair, weight distribution, time used for rest, and the Cobb angle had all improved after surgery. The parents assessed improvement in seating position, daily activities, time used for rest, and cosmetic appearance. We can conclude that the stabilized spine resulted in sufficient strength to keep the body upright with the possibility of looking around at the surroundings more easily. The girls got better seating position with less need for seating adaptations in the wheelchair and with reduced time needed for resting during the day. Finally we can conclude that the indication for surgery is to get a better posture which lead to less risk of pressure sores, and that un upright position lead to better possibility to easily breath with fewer episodes of pneumonia and a better general health as result. The evidence of positive surgical effects for girls with Rett syndrome is of great importance in indication for surgery in the decision-making process.

Background

A screening block followed by a confrrmatory block using different anesthetic agent is a common method used to identify the zygapophysial joint (ZJ) as a tissue origin of LBP. While previous studies have identified potentially valuable clinical tests, identification of patients unlikely to respond to the initial screeuing block is desirable.

Purpose

To estimate the predictive power of specific clinical findings in relation to screening ZJ blocks.

Study Design

A prospective blioded study carried was out in a private radiology clinic specializing in the diagnosis of spinal pain.

Patient sample

Chronic LBP patients received screening ZJ blocks (N=151) with 120 patients included in the analysis after exclusions.

Outcome Measures

Pre and post procedure pain intensity was measured using a standardized VAS. A 95% reduction in pain following ZJ block was defmed as a positive response.

Methods

Patients completed pain drawings, psychosocial distress and disability questionnaires. Thereafter they received a clinical examination and screening lumbar zygapophysial blocks. History, demographic and clinical variables were evaluated in logistic regression models with sensitivity, specificity and likelihood ratios being calculated for potentially useful variables.

Results 

A positive screeulng ZJ block was reported by 10.8% of patients. Sensivity of the extension rotation test was 100% and specificity 22%. No positive responders reported centralization or peripheralization of pain. The best predictors of a positive response to ZJ block were: age over 55 (odds ratio 3.55, p=0.06); report that walking (odds ratio 4.79, p=0.02) and sitting (odds ratio 4.27, p=0.04) were the best activities for pain.

Conclusions 

A negative extension rotation test, centralization or peripheralization can rule out ZJ mediated pain. Age over 55 and report of walking and sitting being the best activities for pain, are associated with a positive response to screening ZJ blocks.

Background: Only controlled intra-articular zygapophyseal joint (ZJ) injections or medial branch blocks can diagnose ZJ-mediated low back pain. The low prevalence of ZJ pain implies that identification of clinical predictors of a positive response to a screening block is needed. Purpose: To estimate the predictive power of clinical findings in relation to pain reduction after screening ZJ blocks. Study design: As part of a wider prospective blinded study investigating diagnostic accuracy of clinical variables, a secondary analysis was carried out to seek evidence of variables potentially valuable as predictors of screening ZJ block outcomes. Patient sample: Chronic low back pain patients received screening ZJ blocks (n=151) with 120 patients included in the analysis after exclusions. Outcome measures: Pain intensity was measured using a 100-mm visual analog scale, and responses were categorized according to 75% through 95% or more pain reduction in 5% increments. Methods: Patients completed pain drawings, questionnaires, and a clinical examination before screening lumbar ZJ blocks. History, demographic and clinical variables were evaluated in cross tabulation and regression analyses with diagnostic accuracy values calculated for variables and variable clusters in relation to different pain reduction standards. Results: At the 75% pain reduction standard, 24.5% responded to screening ZJ blocks and 10.8% responded at the 95% standard. The centralization phenomenon is not associated with pain reduction using any standard. No variables were useful predictors of post-ZJ block pain reduction of less than 90%. Seven clinical findings were associated with 95% pain reduction after blocks. Five useful clinical prediction rules (CPRs) were found for ruling out a 95% pain reduction (100% sensitivity), and one CPR had a likelihood ratio of 9.7, producing a fivefold improvement in posttest probability. Conclusions: A negative extension rotation test, the centralization phenomenon, and four CPRs effectively rule out pain ablation after screening ZJ block. One CPR generates a fivefold improvement in posttest probability of a negative or positive response to ZJ block. © 2006 Elsevier Inc. All rights reserved.

Background: The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70% of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine single tests in relation to single reference standards, yet in clinical practice, clinicians use multiple tests and select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards. Methods: We compared blinded clinical diagnoses with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiotherapists examined consecutive patients with chronic lumbopelvic pain and/or referred LES scheduled to receive the reference standard examinations. When diagnoses were in complete agreement regardless of complexity, "exact" agreement was recorded. When the clinical diagnosis was included within the reference standard diagnoses, "clinical agreement" was recorded. The proportional chance criterion (PCC) statistic was used to estimate agreement on multiple diagnostic possibilities because it accounts for the prevalence of individual categories in the sample. The kappa statistic was used to estimate agreement on six pathoanatomic diagnoses. Results: In a sample of chronic LBP patients (n = 216) with high levels of disability and distress, 67% received a patho-anatomic diagnosis based on available reference standards, and 10% had more than one tissue origin of pain identified. For 27 diagnostic categories and combinations, chance clinical agreement (PCC) was estimated at 13%. "Exact" agreement between clinical and reference standard diagnoses was 32% and "clinical agreement" 51%. For six pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33% with actual agreement 56%. There was no overlap of 95% confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatomic categories produced a kappa of 0.31. Conclusion: Clinical diagnoses agree with reference standards diagnoses more often than chance. Using available reference standards, most patients can have a tissue source of pain identified. © 2005 Laslett et al, licensee BioMed Central Ltd.

Background

The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70% of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine tests in relation to single reference standards, yet in clinical practice, clinicians select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards.

Methods

We compared blinded clinical diagnoses with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiotherapists examined consecutive patients with chronic lumbopelvic pain and/or referred LES scheduled to receive the reference standard examinations. When diagnoses were in complete agreement regardless of complexity, "exact" agreement was recorded. When the clinical diagnosis was included within the reference standard diagnoses, "clinical agreement" was recorded. The proportional chance criterion (PCC) statistic was used to estimate agreement on multiple diagnostic possibilities because it accounts for the prevalence of individual categories in the sample. The kappa statistic was used to estimate agreement on six pathoanatomic diagnoses.

Results

In a sample of chronic LBP patients (n=216) with high levels of disability and distress, 67% received a patho-anatomic diagnosis based on available reference standards, and 10% had more than one tissue origin of pain identified. For 27 diagnostic categories and combinations, chance clinical agreement (PCC) was estimated at 13.3%. "Exact" agreement between clinical and reference standard diagnoses was 31.9% and "clinical agreement" 51.4%. For six pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33.5% with actual agreement 56.2%. There was no overlap of 95% confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatornic categories produced a kappa of 0.31 (0.18, 0.44).

Conclusions

Clinical diagnoses agree with reference standards diagnoses more often than chance. Using available reference standards, most patients can have a tissue source of pain identified.

Background Context

Surgery because of disc herniation or spinal stenosis results mostly in large improvement in the short-term, but mild to moderate improvements for pain and disability at long-term follow-up. Prehabilitation has been defined as augmenting functional capacity before surgery, which may have beneficial effect on outcome after surgery.

Purpose

The aim was to study if presurgery physiotherapy improves function, pain, and health in patients with degenerative lumbar spine disorder scheduled for surgery.

Study Design

A single-blinded, two-arm, randomized controlled trial (RCT).

Patient Sample

A total of 197 patients were consecutively included at a spine clinic. The inclusion criteria were patients scheduled for surgery because of disc herniation, spinal stenosis, spondylolisthesis, or degenerative disc disease (DDD), 25–80 years of age.

Outcome Measures

Primary outcome was Oswestry Disability Index (ODI). Secondary outcomes were pain intensity, anxiety, depression, self-efficacy, fear avoidance, physical activity, and treatment effect.

Methods

Patients were randomized to either presurgery physiotherapy or standardized information, with follow-up after the presurgery intervention as well as 3 and 12 months post surgery. The study was funded by regional research funds for US$77,342. No conflict of interest is declared.

Results

The presurgery physiotherapy group had better ODI, visual analog scale (VAS) back pain, EuroQol-5D (EQ-5D), EQ-VAS, Fear Avoidance Belief Questionnaire-Physical Activity (FABQ-PA), Self-Efficacy Scale (SES), and Hospital Anxiety and Depression Scale (HADS) depression scores and activity level compared with the waiting-list group after the presurgery intervention. The improvements were small, but larger than the study-specific minimal clinical important change (MCIC) in VAS back and leg pain, EQ-5D, and FABQ-PA, and almost in line with MCIC in ODI and Physical Component Summary (PCS) in the physiotherapy group. Post surgery, the only difference between the groups was higher activity level in the physiotherapy group compared with the waiting-list group.

Conclusions

Presurgery physiotherapy decreases pain, risk of avoidance behavior, and worsening of psychological well-being, and improves quality of life and physical activity levels before surgery compared with waiting-list controls. These results were maintained only for activity levelspost surgery. Still, presurgery selection, content, dosage of exercises, and importance of being active in a presurgery physiotherapy intervention is of interest to study further to improve long-term outcome.

Background: Current guidelines for the management of patients with specific low back pain pathology suggest non-surgical intervention as first-line treatment, but there is insufficient evidence to make recommendations of the content in the non-surgical intervention. Opinions regarding the dose of non-surgical intervention that should be trialled prior to decision making about surgery intervention vary. The aim of the present study is to investigate if physiotherapy administrated before surgery improves function, pain and health in patients with degenerative lumbar spine disorder scheduled for surgery. The patients are followed over two years. A secondary aim is to study what factors predict short and long term outcomes. Methods: This study is a single blinded, 2-arm, randomized controlled trial with follow-up after the completion of pre-surgery intervention as well as 3, 12 and 24 months post-surgery. The study will recruit men and women, 25 to 80 years of age, scheduled for surgery due to; disc herniation, spinal stenosis, spondylolisthesis or degenerative disc disease. A total of 202 patients will be randomly allocated to a pre-surgery physiotherapy intervention or a waiting list group for 9 weeks. The waiting-list group will receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. The pre-surgery physiotherapy group will receive physiotherapy 2 times per week, consisting of a stratified classification treatment, based on assessment findings. One of the following treatments will be selected; a) Specific exercises and mobilization, b) Motor control exercises or c) Traction. The pre-surgery physiotherapy group will also be prescribed a tailor-made general supervised exercise program. The physiotherapist will use a behavioral approach aimed at reducing patient fear avoidance and increasing activity levels. They will also receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. Primary outcome measure is Oswestry Disability Index. Secondary outcome measures are the visual analogue scale for back and leg pain, pain drawing, health related quality of life, Hospital anxiety and depression scale, Fear avoidance beliefs questionnaire, Self-efficacy scale and Work Ability Index. Discussion: The study findings will help improve the treatment of patients with degenerative lumbar spine disorder scheduled for surgery.

Background: Somatosensory profiling in affected and non-affected body regions can strengthen our insight regarding the underlying pain mechanisms, which can be valuable in treatment decision making and to improve outcomes, in patients with degenerative lumbar spine disorders pre-surgery. The aim was to describe somatosensory profiles in patients with degenerative lumbar spine disorders, to identify the proportion with altered somatosensory profile, and to analyze demographic characteristics, self-reported function, pain, and health pre- and 3 months post-surgery. Methods: In this prospective cohort study in a Spine Clinic, 105 patients scheduled for surgery for spinal stenosis, disc herniation, degenerative disc disease, or spondylolisthesis were consecutively recruited. Exclusion criteria were; indication for acute surgery or previous surgery at the same spinal level or severe grade of pathology. Quantitative sensory testing (QST) and self-reported function, pain, and health was measured pre- and 3 months post-surgery. The somatosensory profile included cold detection threshold, warmth detection threshold, cold pain threshold, heat pain threshold and pressure pain threshold in affected and non-affected body regions. Results: On a group level, the patients somatosensory profiles were within the 95% confidence interval (CI) from normative reference data means. On an individual level, an altered somatosensory profile was defined as having two or more body regions (including a non-affected region) with QST values outside of normal ranges for reference data. The 23 patients (22%) with altered somatosensory profiles, with mostly loss of function, were older (P = 0.031), more often female (P = 0.005), had higher back and leg pain (P = 0.016, 0.020), lower mental health component summary score (SF 36 MCS) (P = 0.004) and larger pain distribution (P = 0.047), compared to others in the cohort. Post-surgery there was a tendency to worse pain, function and health in the group with altered somatosensory profile pre-surgery. Conclusions: On a group level, patients with degenerative lumbar spine disorders scheduled for surgery were within normal range for the QST measurements compared to reference values. On an individual level, an altered somatosensory profile outside of normal range in both affected and non-affected body regions occurred in 22% of patients, which may indicate disturbed somatosensory function. Those patients had mostly loss of sensory function and had worse self-reported outcome pre-surgery, compared to the rest of the cohort. Future prospective studies are needed to further examine whether these dimensions can be useful in predicting post-surgery outcome and guide need of additional treatments.

PURPOSE: To investigate the association between pain sensitivity in the hand pre-surgery, and patient-reported outcomes (PROs) in function, pain and health pre- and post-surgery in patients with disc herniation or spinal stenosis.

METHODS: This is a prospective cohort study with 82 patients. Associations between pressure-, cold- and heat pain threshold (PPT, CPT, HPT) in the hand pre-surgery and Oswestry, VAS pain, EQ-5D, HADS, and Self-Efficacy Scale, pre- and three months post-surgery; were investigated with linear regression.

RESULTS: Patients with disc herniation more sensitive to pressure pain pre-surgery showed lower function and self-efficacy, and higher anxiety and depression pre-surgery, and lower function, and self-efficacy, and higher pain post-surgery. Results for cold pain were similar. In patients with spinal stenosis few associations with PROs were found and none for HPT and PROs.

CONCLUSIONS: Altered pain response in pressure- and cold pain in the hand, as a sign of widespread pain pre-surgery had associations with higher pain, lower function and self-efficacy post-surgery in patients with disc herniation.

BACKGROUND CONTENT: Questionnaires for measuring the functional status of patients with low back pain (LBP) focus on disability and present responses for each question in a predetermined, fixed relationship between "can do/difficulties and pain." Their design does not permit a separation of the two. PURPOSE: To present the development of The Assessment of Pain and Occupational Performance (POP) and to evaluate validity and reliability. STUDY DESIGN: A prospective, consecutive study of patients investigated by use of the POP. PATIENT SAMPLE: A total of 220 patients participated in the study. METHODS: In a cross-sectional study including 53 patients with chronic musculoskeletal pain, empirical tests of content and construct validity established the definitive version of the POP. The POP focuses on performance of activities. It is a disease-specific, discriminative assessment instrument designed for patients with back pain (BP) and LBP. Based on a semi-structured interview the POP investigates each of 36 activities in two dimensions, with separate, defined scales from "normally healthy" to "extremes" for level of activity (x-scale) and pain intensity (y-scale). The final scores are expressed in percent, 0% to 100%. Patients with chronic LBP (CLBP) (n=142) were allocated to the specific (S) group, that is, patients with specific LBP problems (n=97) or to the nonspecific (NS) group, that is, those with NS BP (n=45). The ability of the POP to differentiate between the two known groups was evaluated. Construct-convergent validity between the POP and the Oswestry Disability Index (ODI) was carried out for the S group. Inter-rater reliability was established between six pairs of raters who examined 25 patients recruited from primary health care, the P-LBP group. RESULTS: In construct known group validity, the median, the interquartile range, and the Mann-Whitney U test showed that the S group had a significantly higher level of activity (p<.001) combined with worse pain (p=.001) compared with the NS group. There were significant differences between the two groups in performing activities in the forward bending position (10 items) and in the upright standing position (9 items). The result of Spearman rank order correlation showed a strong relationship between the ODI and the POP for level of activity (r=0.70, p

Objective: The study had a descriptive, longitudinal design and evaluated occupational performance and pain intensity in daily occupations for patients with low back pain (LBP), assessed preoperatively, and at six and 12 months after surgery and rehabilitation. Methods: Patients were assessed by surgeons and occupational therapists (OTs) to determine whether surgery was required. The OTs used the Assessment of Pain and Occupational Performance (POP) instrument. The POP measures 36 occupations in two dimensions: occupational performance and pain intensity. Patients with specific LBP (n = 97) were included. Results: Preoperatively, 23 occupations showed lower performance and "severe pain". At six months, 27 occupations were performed "without restriction" (p = n.s. -less than 0.001) and without pain or with "mild pain" (p less than 0.001). A comparison of preoperative values with those at 12 months showed that 35 occupations were significantly changed on both scales, and 31 occupations were performed "without restriction" (p less than 0.01-less than 0.001) and "without pain" (p less than 0.001). Conclusions: The results indicate significant improvements between baseline, six months, and 12 months. Moreover, when occupational performance and pain intensity were separately identified, it was shown that patients had regained their performance at an ordinary level without pain. This underlines the added value of differentiating between disability and pain.

To assess whether the clinical knowledge of the treating surgeon had any effect on the reliability of the pain-drawing evaluation, drawings from 50 low-back pain patients were evaluated by the treating surgeon and by three colleagues who had no clinical knowledge of the patient. The evaluation was repeated after 10 days. The treating surgeons were also blinded to clinical data. The kappa value in the evaluation when the surgeon had clinical knowledge of the patient was lower (0.29 (95% CI 0.13–0.45)) than the kappa value in the evaluations made without clinical knowledge (0.60 (CI 0.45–0.75)). The differences observed in interobserver reliability between open and blind evaluations suggest that clinical knowledge of a patient influences the evaluation of the pain drawings.

Objective - To study the incidence of self-reported hack pain in a general population and to identify risk factors for sick leave and factors associated with recovery from back pain.

Population - A cross-sectional sample (n=1344) of a general adult population.

Setting - In a semi-urban Swedish county.

Design - One-year prospective study of a single cohort.

Main outcome measures - The incidence of back pain, risk factors for sick leave, factors predisposing for recovery.

Results - The incidence of back pain was 24 % (95% C.I. 22% to 27%). 79% of the pain episodes lasted less than two months. History of previous back pain predisposed to developing new episodes of back pain, while stress at work combined with low work satisfaction were associated factors. Factors predisposing to recovery were young age, skilled work, and living in the countryside. Unskilled work, pain debut at work, previous history and back pain at the start of the study were factors predisposing to sick listing for back pain. Long-term sick leave was predisposed by previous history of back pain and ongoing back pain at the start of the study.

OBJECTIVES: To investigate the prevalence of back pain in a general population aged between 20 and 59 years.

POPULATION: A representative sample of 2000 individuals from Ostergotland County, Sweden (population 400,000).

STUDY DESIGN: Cross-sectional study using a questionnaire including the pain drawing.

RESULTS: The observed point prevalence was 28% (95% confidence interval 26-31%). The adjusted prevalence taking into account the non-responders was 23% (21-25%). Lumbar pain with radiation was reported by 40%, while 4% had only cervical pain with radiation. Twelve per cent were on sick-leave due to back pain. Activity of daily life was affected mainly in the group of men aged 40-59 and only in household tasks. The back problems did not affect social activity.

CONCLUSIONS: The prevalence of back problems in the vocational ages was found to be 23%. Only small parts of a pain population are on sick-leave or have changed working tasks because of back problems. The distribution of pain in most cases is combined with radiation to extremities and not isolated to a single region. The combination of different localisations shows the pain problem to be more than just a "low back" problem.

Factors important for avoiding back disorders in different age-groups have seldom been compared and studied over time. We therefore set out to study age-related differences in socio-economic and work-related factors associated with the absence of back disorders in a 5-year comparative cohort study using a mailed questionnaire. Two subgroups (aged 25-34 and 54-59 years) derived from a representative sample of the Swedish population were followed at baseline, 1 year and 5 years. Questions were asked about the duration of back pain episodes, relapses, work changes and work satisfaction. A work adaptability, partnership, growth, affection, resolve (APGAR) score was included in the final questionnaire. Multivariate logistic regression was used to identify factors predicting the absence of back disorders. Absence of physically heavy work predicted an absence of back disorders [odds ratio (OR), 2.86, 95% confidence interval (CI), 1.3-6.3] in the older group. In the younger age-group, the absence of stressful work predicted absence of back disorders (OR, 2.0, 95% CI, 1.1-3.6). Thirty-seven per cent of the younger age-group and 43% of the older age-group did not experience any back pain episodes during the study period. The exploratory work APGAR scores indicated that back disorders were only associated with lower work satisfaction in the older group. The analyses point out the importance of avoiding perceived psychological stress in the young and avoiding perceived physically heavy work in the older age-group for avoiding back disorders. The results suggest a need for different programmes at workplaces to avoid back disorders depending on the age of the employees concerned.

Objective - To investigate whether physical examination findings can be used in predicting recovery from back pain and new episodes of sick leave.

Design - One-year prospective study of a single cohort.

Settings - Semi-rural Swedish county.

Population - A cross-section of a general population with back pain (207 women, 176 men) between 20 and 59 years of age.

Main outcome measures - Cumulative incidence of sick leave due to back pain, cumulative incidence of sick leave due to back pain > 30 days, incidence of recovery from back pain.

Results - For recovery from pain, the absence of tenderness in the trapezius muscle (OR 0.33, CI 0.1-0.5) was predictive. New sick leave was predicted by tenderness in the trapezius muscle (OR 2.67, CI 1.5-4.9), and had a tendency to be associated with a flattened lumbar lordosis and a restricted cervical range of motion. For long-term sick leave, the same findings and also observation of scoliosis (OR 3.44, CI 1.1-10.5) were predictive.

Conclusion - There are subgroups with back pain predisposed to development of more persistent symptoms and a higher risk for sick-listing.

Back pain contributes to a large number of disability pensions. The process toward disability is not well understood. In a 10-year (1988-1998) prospective study of a single cohort (n=1902) representative of the general adult population in a semi-nrban Swedish county, the incidence of disability pensions based on back pain was studied. Socio-demographic and work-related risk factors for disability pension were analysed.

Eigbt percent of respondents to a baseline survey (n=1344) and 10% of the non-respondents (n=558) were granted full-time disability pension on back pain diagnosis during the 10-year period. Age over 40, low professional status, primary sick leave because of back pain and the perception of work tasks as unsatisfying were found to predict disability.

Disability pension granted due to back pain appears to have a variation over time and is affected by both social insurance and work-related factors.

During the past 15 years, wheelchair development has focused on driving properties. Back pain, however, is a problem among wheelchair users. Thirty-one wheelchair users, mean age 46 years (range 21–79), (3 women and 28 men), with spinal cord injuries were studied with regard to back pain and spinal deformity. Sixteen subjects had tetraplegia and 15 had paraplegia; median time since injury was 11 years (range 2–37). Pain was assessed using pain drawings, visual analogue scale and questionnaire. Spinal deformity was examined using X-ray, weight distribution, 3D magnetic motion tracker, photographs and physical examination. Some degree of back pain was found in 84% of the patients. Most patients could modify their pain by changing their sitting posture or by rest in bed, and had some kind of spinal deformity that might be related to neurological injury and sitting posture. Further wheelchair research considering the ergonomics of both driving and sitting seems important.

Study design: Cross-sectional.

Objectives: To describe the consequences of shoulder pain on activity and participation in spinal cord-injured paraplegic wheelchair users. To describe the prevalence and type of shoulder pain.

Setting: Two spinal cord injury (SCI) centres in Sweden.

Methods: All subjects with paraplegia due to an SCI of more than 1 year living in the counties of Uppsala and Linköping, Sweden were contacted by mail and asked to fill in a questionnaire (89 subjects). Those of the responding 56 subjects with current shoulder pain were asked to participate in further examination and interviews. A physiotherapist examined 13 subjects with shoulder pain in order to describe type and site of impairment. To describe consequences of shoulder pain on activity and participation, the Constant Murley Scale (CMS), the Wheelchair Users Shoulder Pain Index (WUSPI) the Klein & Bell adl-index and the Canadian Occupational Performance Measure (COPM) were used.

Results: Out of all respondents, 21 had shoulder pain (37.5%). Data from 13 of those subjects were used in the description of type and consequences of shoulder pain. Findings of muscular atrophy, pain, impingement and tendinits were described. We found no difference in ADL-performance with, respectively without, shoulder pain (P=0.08) using the Klein & Bell adl-index. No correlation was found between the various descriptions of impairment, activity limitations and participation restriction (P>0.08). All together 52 problems with occupational performance due to shoulder pain were identified using the COPM. Of these, 54% were related to self-care activities.

Conclusion: The consequences of shoulder pain in paraplegic wheelchair users are mostly related to wheelchair activities. Since the wheelchair use itself presumably cause shoulder problems, this will become a vicious circle. More research is needed in order to reduce shoulder problems in wheelchair users.

The aim of this study was to analyse the consequences of a change in rear-wheel position on mobility and seating ergonomic aspects. Twelve randomly selected paraplegic wheelchair users were tested iu two different activities, treadmill propulsion and computer work, in two different seating positions. The change in wheel position did affect chair ergonomics with respect to weight distribution and seat-inclination. These changes did have an effect on push frequency and stroke angle during treadmill, propulsion. We found no consistent effect on mechanical efficiency, estimated exertion, breathlessness or seating quality in this group. Nor did we find any consistent significant effect on pelvic position or under-seat pressure. There are effects from wheelchair adaptation, but these seem to be individual. With the knowledge of risk factors related to seating posture in mind, future research concerning effects of wheelchair adaptation has to be performed with considerations for individual changes.

This study analyzed the effect of rear-wheel position on seating comfort and mobility efficiency. Twelve randomly selected paraplegic wheelchair users participated in the study. Wheelchairs were tested in two rear-wheel positions while the users operated the wheelchair on a treadmill and while they worked on a computer. Propulsion efficiency, seating comfort, and propulsion qualities were registered at different loads during the treadmill session. During the computer session, pelvic position, estimated seating comfort, and estimated activity performance were measured. The change in rear-wheel position affected wheelchair ergonomics with respect to weight distribution (p < 0.0001) and seat inclination angle (position I = 5° and position II = 12°). These changes had a significant effect on push frequency (p < 0.05) and stroke angle (p < 0.05) during wheelchair propulsion. We found no consistent effect on mechanical efficiency, estimated exertion, breathlessness, seating comfort, estimated propulsion qualities, pelvic position, or activity performance.

To evaluate long-term clinical results of lumbar total disc replacement (TDR) compared with posterior lumbar fusion. less thanbrgreater than less thanbrgreater thanThis prospective randomized controlled trial comprised 152 patients; 80 were randomized to TDR and 72 to fusion. All patients had chronic low back pain (CLBP) and had not responded to nonsurgical treatment. Primary outcome measure was global assessment of back pain (GA), secondary outcome measures were back and leg pain, Oswestry Disability Index (ODI), EQ5D, and SF-36. All measures were collected from SweSpine (Swedish national register for spinal surgery) at 1, 2, and 5 years. Follow-up rate at 5 years was 99.3 %. less thanbrgreater than less thanbrgreater thanBoth groups showed clinical improvement at 5-year follow-up. For GA, 38 % (30/80) in the TDR group were totally pain free vs. 15 % (11/71) in the fusion group (p andlt; 0.003). Back pain and improvement of back pain were better in the TDR group: VAS back pain at 5 years 23 +/- A 29 vs. 31 +/- A 27, p = 0.009, and VAS improvement of back pain at 5 years 40 +/- A 32 vs. 28 +/- A 32, p = 0.022. ODI and improvement in ODI were also better in the TDR group: ODI at 5 years 17 +/- A 19 vs. 23 + 17, p = 0.02 and ODI improvement at 5 years 25 +/- A 18 vs. 18 +/- A 19 (p = 0.02). There was no difference in complications and reoperations between the two groups. less thanbrgreater than less thanbrgreater thanGlobal assessment of low back pain differed between the two surgical groups at all follow-up occasions. Significant differences between groups concerning back pain, pain improvement, and ODI were present at 1 year and disappeared at 2 years, but reappeared at the 5-year follow-up.

OBJECTIVES: The limiting factors with regard to power output available for wheelchair ambulation have not been identified. The aim of the present study was to correlate power output during wheelchair driving with (i) power output and oxygen uptake during arm crank ergometry and (ii) arm muscle strength.

METHODS: Eleven disabled men were examined for maximal power output (POmax) during wheelchair driving on a treadmill and during arm crank ergometry. Oxygen uptake (VO2) was recorded at submaximal and maximal arm crank ergometry in all men and during submaximal wheelchair driving on a treadmill in four men. Power output during wheelchair driving on a treadmill was measured. Static and dynamic elbow muscle strength was measured isokinetically.

RESULTS: POmax was significantly lower (P < 0.001) for wheelchair driving (109 (31) W; mean (SD)) than for arm ergometry (163 (49) W). There was a significant correlation between POmax for arm crank ergometry and wheelchair driving (r = 0.73). There was no correlation between POmax and elbow strength. The mechanical efficiency was constant for the different levels on the arm crank ergometry test. The submaximal testing showed a consistently lower mechanical efficiency for wheelchair driving than for arm crank ergometry.

CONCLUSIONS: It is suggested that the lower level of power output for wheelchair driving is fully explained by the lower mechanical efficiency. Any improvement in power output available for ambulation must be based on wheelchair ergonomics.

Rapid urban population growth is a striking feature for most cities in developing countries. Such demographic change, compounded by political power structures, industrialisation and culture, pose big institutional challenges in coping with urban environments. Already today, the government and local authorities in urban centres face great difficulties in coming to grips with environmental decay. For example, there is a widening gap between public service demands, and what is being supplied by the government and environmental legislation, is poorly implemented.

Riding on the tidal wave of doubts about state-led development, Non-Governmental Organisations (NG0s) are under way to play the role of new development wizards. The NGO-sector has been attributed a plethora of capacities from various sources, such as donors, governments and the NGO-sector itself. NG0s' role in various aspects of development ranges from more tangible comparative advantages in the field of service provision to the poor, to an ability to independently restructure political and social life and formulate alternative pathways to development. Currently, a new role - partners in development - has been ascribed the NGO-sector. Both in international, national and local contexts partnership and increased cooperation between NG0s and the state have been envisaged as a new development model. This study looks into the possibilities of forming such a partnership. From the perspective of NGO-state relationships the study critically assesses NGO abilities in the area of urban environmental issues and their role in restructuring local political life.

Many NGO analysts seem to have paid little attention to the fact that organised environmental activism does not take place in a vacuum, The impact of such activism and the possibility of forming NGO-state partnerships is dependent on sociopolitical structures which influence societal dynamics at local and national levels. This study draws on patron-client theories where patterns of reciprocal exchanges, asymmetry, dependence and personalised relations mark important features in understanding relational patterns between NG0s and the state. It is built on field research in a local urban context. The city of Chennai formerly called Madras) marks the geographical area of interest. Five environmental NG0s were depicted and researched.

Mini Patients with Lenke type 1 idiopathic scoliosis can be effectively managed surgically with an anterior or posterior approach. However, each approach has specific advantages and challenges, as described in this study, which must be considered before treating each patient.

Study Design. Retrospective study.

Objective. To describe surgical results in two and three dimensions and patient-reported outcomes of scoliosis treatment for Lenke type 1 idiopathic curves with an open anterior or posterior approach.

Summary of Background Data. Different surgical techniques have been described to prevent curve progression and to restore spinal alignment in idiopathic scoliosis. The spine can be accessed via an anterior or a posterior approach. However, the surgical outcomes, especially in three dimensions, for different surgical approaches remain unclear.

Methods. Cohorts of Lenke curve type 1 idiopathic scoliosis patients, after anterior or posterior spinal fusion were recruited, to measure curve characteristics on conventional radiographs, before and after surgery and after 2 years follow-up, whereas the vertebral axial rotation, true mid-sagittal anterior–posterior height ratio of individual structures, and spinal height differences were measured on 3D reconstructions of the pre- and postoperative supine low-dose computed tomography (CT) scans. Additionally, the intraoperative parameters were described and the patients completed the SRS-22 and EQ-5D-3L questionnaire postoperatively.

Results. Fifty-three patients with Lenke curve type 1 idiopathic scoliosis (26 in the anterior cohort and 27 in the posterior cohort) were analyzed. Fewer vertebrae were instrumented in the anterior cohort compared with the posterior cohort (P < 0.001), with less surgery time and lower intraoperative blood loss (P < 0.001). The Cobb angle correction of the primary thoracic curve directly after surgery was 57 ± 12% in the anterior cohort and 73 ± 12% in the posterior cohort (P < 0.001) and 55 ± 13% and 66 ± 12% (P = 0.001) at 2 years follow-up. Postoperative 3D alignment restoration and questionnaires showed no significant differences between the cohorts.

Conclusion. This study suggests that Lenke type 1 curves can be effectively managed surgically with either an open anterior or posterior approach. Each approach, however, has specific advantages and challenges, as described in this study, which must be considered before treating each patient.

Level of evidence: 3

Study Design

Retrospective study.

Objectives

To investigate parameters of axial vertebral deformation in patients with scoliosis compared to a control group, and to determine whether these parameters correlated with the severity of spine curvature, measured as the Cobb angle.

Summary of Background Data

Adolescent idiopathic scoliosis (AIS) is the most common type of spinal deformity. Many studies have investigated vertebral deformation, in terms of wedging and pedicle deformations, but few studies have investigated actual structural changes within vertebrae.

Methods

This study included 20 patients with AIS (Lenke 1–3, mean age: 15.6 years, range: 11–20). We compared preoperative low-dose computed tomography(CT) examinations of patients with AIS to those of a control group matched for age and sex. The control individuals had no spinal deformity, but they were admitted to the emergency department for trauma CTs. We measured the Cobb angles and the axial vertebral rotation (AVR), axial vertebral bodyasymmetry (AVBA), and frontal vertebral body rotation (FVBR) for the superior end, inferior end, and apical vertebrae, with in-house–developed software. Correlations between entities were investigated with the Pearson correlation test.

Results

The average Cobb angles were 49.3° and 1.3° for the scoliotic and control groups, respectively. The patient and control groups showed significant differences in the AVRs of all three vertebra levels (p < .01), the AVBAs of the superior end and apical vertebrae (p < .008), and the FVBR of the apical vertebra (p = .011). Correlations were only found between the AVBA and FVBR in the superior end vertebra (r = 0.728, p < .001) and in the apical vertebra (r = 0.713, p < .001).

Conclusions

Compared with controls, patients with scoliosis showed clear morphologic differences in the midaxial plane vertebrae. Differences in AVR, AVBA, and FVBR were most pronounced at the apical vertebra. The FVBR provided valuable additional information about the internal rotation and deformation of vertebrae.

Level of Evidence

Level III.

Background: Scoliosis is traditionally evaluated by measuring the Cobb angle in radiograph images taken while the patient is standing. However, low-dose computed tomography (CT) images, which are taken while the patient is in a supine position, provide new opportunities to evaluate scoliosis. Few studies have investigated how the patient's position, standing or supine, affects measurements. The purpose of this study was to compare the Cobb angle in images from patients while standing versus supine.less thanbr /greater thanMaterial/methods: A total of 128 consecutive patients (97 females and 21 males; mean age 15.5 [11-26] years) with late-onset scoliosis requiring corrective surgery were enrolled. One observer evaluated the type of curve (Lenke classification) and measured the Cobb angle in whole-spine radiography (standing) and scout images from low-dose CT (supine) were taken on the same day.less thanbr /greater thanResults: For all primary curves, the mean Cobb angle was 59 (SD 12) while standing and 48 (SD 12) while in the supine position, with a mean difference of 11 (SD 5). The correlation between primary standing and supine images had an r value of 0.899 (95% CI 0.860-0.928) and an intra-class correlation coefficient value of 0.969. The correlation between the difference in standing and supine images from primary and secondary curves had an r value of 0.340 (95% CI 0.177-0.484).less thanbr /greater thanConclusions: We found a strong correlation between the Cobb angle in images obtained while the patient was standing versus supine for primary and secondary curves. This study is only applicable for patients with severe curves requiring surgical treatment. It enables additional studies based on low-dose CT.

Background: Objective data on the incidence and pattern of adverse events after orthopaedic surgical procedures remain scarce, secondary to the reluctance for encompassing reporting of surgical complications. The aim of this study was to analyze the nature of adverse events after orthopaedic surgery reported to a national database for patient claims in Sweden.

Methods: In this retrospective review data from two Swedish national databases during a 4-year period were analyzed. We used the "County Councils' Mutual Insurance Company", a national no-fault insurance system for patient claims, and the "National Patient Register at the National Board of Health and Welfare".

Results: A total of 6,029 patient claims filed after orthopaedic surgery were assessed during the study period. Of those, 3,336 (55%) were determined to be adverse events, which received financial compensation. Hospital-acquired infections and sepsis were the most common causes of adverse events (n = 741; 22%). The surgical procedure that caused the highest rate of adverse events was "decompression of spinal cord and nerve roots" (code ABC**), with 168 adverse events of 17,507 hospitals discharges (1%). One in five (36 of 168; 21.4%) injured patient was seriously disabled or died.

Conclusions: We conclude that patients undergoing spinal surgery run the highest risk of being severely injured and that these patients also experienced a high degree of serious disability. The most common adverse event was related to hospital acquired infections. Claims data obtained in a no-fault system have a high potential for identifying adverse events and learning from them.

Background and purpose: Our knowledge of complications and adverse events in spinal surgery is limited, especially concerning incidence and consequences. We therefore investigated adverse events in spine surgery in Sweden by comparing patient claims data from the County Councils' Mutual Insurance Company register with data from the National Swedish Spine Register (Swespine).

Methods: We analyzed patient claims (n = 182) to the insurance company after spine surgery performed between 2003 and 2005. The medical records of the patients filing these claims were reviewed and compared with Swespine data for the same period.

Results: Two-thirds (119/182, 65%) of patients who claimed economic compensation from the insurance company were registered in Swespine. Of the 210 complications associated with these 182 claims, only 74 were listed in Swespine. The most common causes of compensated injuries (n = 139) were dural lesions (n = 40) and wound infections (n = 30). Clinical outcome based on global assessment, leg pain, disability, and quality of health was worse for patients who claimed economic compensation than for the total group of Swespine patients.

Interpretation: We found considerable under-reporting of complications in Swespine. Dural lesions and infections were not well recorded, although they were important reasons for problems and contributed to high levels of disability. By analyzing data from more than one source, we obtained a better understanding of the patterns of adverse events and outcomes after spine surgery.