Sunphysio

December 8, 2010 in General Research, Research Lower Back Pain by Francdore

Predicators of outcome after Anterior Cervical Dsicectomy and Fusion: A Multivariate Analysis – (Spine; January 2009 – Volume 34 – Issue 2 Pg 161-166 )

Identifying prognostic factors is important to aid surgical decision-making and counselling of patients. Recent randomised control trial of disc arthroplasty devices have established a large cohort of patients treated with fusion and 2 year outcomes that allow analysis of prognostic factors.

Methods:
The patient cohort was the fusion control patients (n=488) from 2 randomised controlled studies of disc replacements. Surgical indicators were recalcitrant single- level subaxial radiculopathy of myelopathy. The surgery included anterior discectomy and fusion with allograft and plate. Patients were assessed by neck and arm pain, neck disability index (NDI), SF-36, neurologic examination and return to work. Overall clinical success was defined based on meeting all 4 of these criteria: >15-point improvement in NDI; maintained or improved neurologic examination; no serious adverse event related to the procedure; and no revision of the plate or graft. Patient’s outcomes were recorded at 3, 6, 12 and 24 months, with 77% follow up at 24 months. The outcome variables for this analysis were overall improvement in NDI. We studied the relationship between each of the outcome variablesand 26 potential important variables including demographics, medical conclusions, socio-economic factors and disease state. Two statistical models were used to explore the association between outocme variables and baseline measures: multivariate logistical regression of the full model with every prognostic variable included and the model with the variables selected by the stepwise selection procedure.

Results:
In the full-model logistic analysis for overall success, worker’s compensation and weak narcotic use were negative predicators, while higher preoperative NDI score and normal sensory function were positive predicators. For NDI success, only the preoperative NDI scores (higher disability predictive of improvement) appeared to have strong influence on the outcome. In the stepwise regression model, preoperative normal sensorey function was a positive predicator and worker’s compensation a negative predicators of overall clinical success. Greaer age, higher peroperative NDI score and gainful employment were positive predicators and spinal litigation was a negative predicator of NDI success.

Conclusion:
We found that important predicators of outcome were work status, sensory function, involvement in litigation and higher disability scores.

in General Research, Research Lower Back Pain by Francdore

Recurrance Rate of Lumbar Disc Herniation after Open Discectomy in Active young man – (Spine; January 2009 – Volume 34 – Issue 1 Pg 24-29 )

There are a few reports on the reoccurrence rate of lumbar disc herniation in young adults, even though this age group shows a higher incidence of disc herniation than the other age groups. In addition, most of the studies on the recurrence rate of disc herniation have reported percentages without regard to the effect of the time course.

Methods:
Medical records were retrospectively reviewed and phone call surveys were undertaken for 241 patients aged from 20 to 39 who had undergone open discectomies over a period of 14 years. A diagnosis of recurrrence was based on the development of new symptoms and magnetic resonance imaging showing compatible lesions in the same segments as the initial diagnosis. The recurrance rate was calculated using a survival analysis based on the Kaplan-Meler product-limit method and the log-rank test was used to evaluate the effect of patient age, level of occurrence, and type of herniated disc on the recurrence rate.

Results:
The overall recurrence rate was 7.1% (17 patients) at a mean follow-up of 8.55 years, and the the cumulative survival rate was 91.5% at a follow-up of 14 years. Survival analysis estimated a higher rate of recurrence at longer follow-up, although there was no recurrence after the ninth year from the primary surgery. The recurrence rate was significantly higher for protruded discs compared to other types.

Conclusion:
Survival analysis provides a more accurate estimation of true recurrence rate. Protruded discs are more likely to show recurrence than other types.

in General Research, Research Lower Back Pain by Francdore

Comparison of Magentic Resonance Imaging and Computed Tomography in predicting Facet: Arthrosis in the Cervical Spine (Spine; January 2009 – Volume 34 – Issue 1 Pg 65-68 )

Comparison of Magentic Resonance Imaging and Computed Tomography in predicting Facet: Arthrosis in the Cervical Spine (Spine; January 2009 – Volume 34 – Issue 1 Pg 65-68 )

In the Food and Drug Administration investigational Device Exemption trials of cervical disc arthroplasty (CDA), the presence of facet arthrosis on CT was a contra-indication to the insertion of a CDA. Most surgeons routinely obtain an MRI, but not necessarily a CT before performing surgery in the cervical spine. We sought to determine if the MRI alone is adequate to assess for the presence of Facet Arthrosis,

Methods:
Three experienced spine surgeons retrospectively evaluated CT scans and MRI’s of the same patients, obtained within 30 days of each other in a blinded, random fashion. Reviewers graded each of the MRI and CT scans as normal or abnormal on 3 seperate occasions and if the Facet wa abnormal, each reviewer graded the degree of arthrosis. The radiologist’s evaluation for each study was compared with our results.

Results:
Of 594 Facets analysed, 43.1% were categorised as normal on CT, and of those, MRI concordance was only 63.7% with moderate / substantial inter-method agreement. Furthermore, MRI was concordant only 15.9% of the time in patients with Ankylosed Facet joints on CT. CT inter-rater reliability showed substantial agreement for diagnoses of both normal and Ankylosis and fair agreement for lesser degrees of facet arthrosis. MRI inter-rater reliability showed fair/moderate agreement in normal and ankylosed segments and only slight agreement with lesser degrees of facet arthrosis. CT intra-rater reliability showed substantial agreement in normal or ankylosed joints, but only fair agreement for all other categories; MRI showed only fair agreement.

Conclusion:
The ability of MRI to adequately determine the presence of amount or Facet Arthrosis is not reliable. Additionally, for abnormal facets, MRI was not reliable in adequately determining the degree of arthrosis. Our data suggests that Computed Tomography remains necessary in diagnosing Facet Arthrosis before CDA.

in General Research, Research Lower Back Pain by Francdore

Effectiveness of Steroid Injection in treating patients with moderate to severe degree
of Carpal Tunnel Syndrome (The Clinical Journal of Pain; February 2009 – Volume 25 – Issue 2 Pg 111-115 )

Objectives:
This study is to assess the effectiveness of steroid injections to improve the clinical and electordiagnostic (EDX) parameters associated with moderate and severe Carpal Tunnel Syndrome (CTS). The study will also evaluate the correlation between EDX and clinical assessment scores.

Methods:
Patients with moderate or severe CTS identified by EDX were recruited. A visual analog scale, the Boston Carpal Tunnel Syndrome Questionnaire, and EDX procedures were all used during patients’ pr-etreatment. These tests were repeated at 4 and 8 week after patients received a 20 mg injection of Triamcinolonein the carpel tunnel to evaluate the changes and the correlation between the clinical and EDX parameters.

Results:
Although moderate and severe CTS showed significant improvement in clinical parameters at 4 weeks and 2 months, EDX parameters of moderate CTS were significantly improved at 4 weeks but diminished at 8 weeks. Those with severe CTS were not significantly improved at either 4 or 8 weeks. There was no correlation between clinical and EDX results for both groups.

Discussion:
Steroid injection is an effective mothod to improve clinical scales but has limited ability to restore nerve conductionin moderate or severe CTS. Because there is no correlation between clinical and EDX parameters, we should consider both clinical and neurophysiologic tests to assess CTS.

in General Research, Research Lower Back Pain by Francdore

The Deficit of Pain inhibitions in Fibromyalgia is more pronounced in patients with Comobid Depressive Symptoms (The Clinical Journal of Pain; February 2009 – Volume 25 – Issue 2 Pg 123-127 )

Background:
On pathophysiologic grounds, fibromyalgia (FM) is characterised by a deficit in diffuse noxious inhibitory controls (DNIC), but the role of depressive symptoms on these mechanisms had not been investigated. We hypothosized that the deficit in pain inhibition would be more pronounced in FM patients with depressive symptoms (FM+D), relative to patients without such symptoms (FM-D).

Methods:
Fifty two women diagnosed with FM (American College of Rheumatology criteria) and 10 healthy women participated in this study. Thermal stimuli were used to measure pain thresholds and DNIC efficacy. Clinical pain was measured using visual analog scales.

Results:
We found that the amplitude of DNIC was smaller in FM+D patients, relative to the FM-D group; and that daily pain (unpleasantness) was higher in the FM+D group, relative to FM-D patients.

Discussion:
We found that FM+D patients have a more pronounced deficit in pain inhibition as well as increased clinical pain. As such, these results show the usefulness of combining psychologic factors and psychophysical measures to identify subgroups of FM patients. These results may have implicationsfor future treatment of FM patients with and without comorbid depressive symptoms.

in General Research, Research Lower Back Pain by Francdore

Work Disability After Whiplash: A Prospective Cohort Study
( Spine; 1 February 2009 – Volume 34 – Issue 3 Pg 262-267 )

Previous studies on work disability related to whiplash are very heterogeneous, and show a wide variability in terms of results. A relationship has been suggested between poor recovery from or persistent work disability after whiplash and female gender, older age, marital status, heavy manual work, self-employment, prior psychological problems, subjective complaints of poor concentration, pain catastrophysing and kinesiophobia.

Methods:
Individuals with neck complaints after involvement in traffic accidents, who initiated compensation claim procedures with a Dutch insurance company (n=879), were sent questionnaires (Q1) concerning the accident, the injuries that they had sustained, their complaints at that time and questions regarding work and disability. The course of complaints and work disability at 6 (Q2) and 12 months (Q3) after the accident.

Results:
A total of 58.8% of the population with neck complaints studied was work-disabled after the accident. Age and impaired concentration complains after 1 month were found to be related to work disability at 1 year, independant of physical complaints and work characteristics.

Conclusion:
Age and concentration complaints were important independant predicators of long-lasting work disability, whereas no evidence emereged to indicate that the degree of manual labour (blue or white collar work) or educational level was involved in persistant work disability in post-whiplash syndrome. The current results suggest that work disability could benefit most from interventions related to recovery from coginitive complaints and less from physically related intervention.

in General Research, Research Lower Back Pain by Francdore

Injection Therapy for Subacute and Chronic Low Back Pain: An updated Cochrane Review (Spine; January 2009 – Volume 34 – Issue 1 Pg 49-59 )

The effectiveness of injection therapy for low back pain is stil debatable. Heterogeneity of target tissue, pharmacological agent and dosage, generally found in RCT’s, point to the need for clinically valid comparisons in a literature synthesis.

Methods:
We updated the search of the earlier systematic review and searched the Cochrane Central Register of Controlled Trials, Medline and Embase databases up to March 2007 for relevant trials reported in English, French, German, Dutch and Nordic languages. We also screened references from trials indentified. RCT’s on the effects of injection therapy involving epidural, facet or local sites for subacute or chronic low back pain were included. Studies tha compared the effects of intradiscal injections, prolotherapy or ozone therapy with other treatments were excluded unless injection therapy with another pharmaceutical agent (no placebo treatments) was part of one of the treatment arms. Studies about injections in sacropiac joints and studies evaluating the effects of epidural steroids for radicular pain were also excluded.

Results:
Eighteen trials (1179 participants) were included in this review. The injection sites varied epidural sites and facet joints (i.e.intra-articular injections, peri-articular injections and nerve blocks) to local sites (i.e. tender and trigger points). The drugs that were studied consisted of corticosteroids, local anesthetics, and a variety of other drugs. The methodologic quality of the trials was limited with 10 of 18 trials rated as having a high methodologic quality. Statistically pooling was not possible because of clinical hetrogenecated that there is no strong evidence for or against the use of any type of injection therapy.

Conclusion:
There is insufficient evidence to support the use of injection therapy in sub-acute and chronic low back pain. However, it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy.

in General Research, Research Lower Back Pain by Francdore

Graded Execise for Recurrent Low-Back Pain: A Randomised, Controlled Trial with
6-, 12- and 36 month follow-ups ( Spine; 1 February 2009 – Volume 34 – Issue 3 Pg 221-228 )

Exercise therapy is recommended and widely used as treatment for LBP. Although
stabilising exercises are reportedly effective in the management of certain subgroups of
LBP, such intervention protocols have not yet been evaluated in relation to a more general
exercise regimen in patients with recurrent LBP, all at work.

Method:
Seventy one patients recruited consecutively (36 Men, 35 Women) with recurrent nonspecific LBP
seeking care at an outpatient physiotherapy clinic were randomised into 2 treatment groups;
graded exercise intervention or daily walks. The primary outcome was perceived disability and pain at 12 month follow-up. Secondary outcomes included physical health, fear-avoidance and self-efficacy beliefs.

Results:
Of the particpants, 83% provided data at the 12 month follow-upand 79% at 36 months. At 12 months, between-group comparison showed a reduction in perceived disability in favor of the exercise group, whereas such an effect for pain emerged only immediately post-intervention. Ratings of physcial health and sel-efficacy beliefs also improved in the exercise group over the long term, though no changes were observed for fear-avoidance beliefs.

in General Research, Research Lower Back Pain by Francdore

Effectiveness of a Lumbar Belt in Subacute Lower Back pain: An Open, Multicentric
and Randomised Clinical Study ( Spine; 1 February 2009 – Volume 34, Issue 3 pg 215-220)

There is limited evidence of efficiency of lumbar supports for treatment of lower
back pain. There is also a lack of the methodology in the studies reported on the efficiency
of this device.

Methods:
This study is randomised, multicentric and controlled with 2 groups: a patient group treated with a lumbar belt (BWG) and a control group (CG). The main criteria of clinical evaluation were the physical restoration assessed with the Eifel scale, the pain assessed by a visual analogic scale, the main economical criteria was the overall cost of associated medical treatments.

Results:
One hundred of ninety seven patients have participated. The results show a higher decrease in Eifel score in BWG then CG between days 0 -90. Respectively significant reduction in visual analogic scale was also noticed. Pharmagologic consumption decreased at D90.

Conclusion:
Lumbar belt wearing is consequent in subacute LBP to improve significantly the function status, the pain level and the pharmacologic consumption. This study may be useful to underline the interest of lumbar support as a complementary and non-pharmacologic treatment beside the classic medication use in low back pain treatment.

in General Research, Research Lower Back Pain by Francdore

This past month an interesting, but maybe not surprising article was published on
the current state of affairs in treatin Lower Back Pain (LBP). Although many authors
were involved, one cannot help notice the name of Dr. Richard Deyo, MD an epedemiologist
well known to ruffle some feathers, especially those of surgeons when he points out the over-
utilisation of Imaging and surgical procedures. This article reports on ever-increasing
expenditure in Medicare populations:

• 629% increase in Medicare expediture for epidural steriod injections
• 423% increase in expediture for opioids for back pain
• 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries
• 220% increase in spinal fusion surgery rate