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Total Disc Replacement for Chronic Discogenic Low-Back Pain

A Cochrane Review. ABSTRACT: Study Design. Systematic literature review. Objective. To assess the effect of total disc replacement for chronic low back pain due to lumbar degenerative disc disease compared to fusion or other treatment options.Summary of Background Data. There is an increasing use in disc replacement devices for degenerative disc disease, but their effectiveness compared to other interventions such as fusion of the motion segment or conservative treatment remains unclear.Methods. A comprehensive search in CENTRAL, MEDLINE, EMBASE, BIOSIS ClinicalTrials.gov, and FDA trials register was conducted. Randomized controlled trials (RCT) comparing total disc replacement with any other intervention for degenerative disc disease were included. Risk of Bias was assessed using the criteria of the Cochrane Back Review Group. Quality of evidence was graded according to the GRADE approach. Two review authors independently selected studies, assessed risk of bias and extracted data. Results and upper bounds of confidence intervals were compared against predefined clinically relevant differences.Results. We included seven RCT's with a follow-up of 24 months. There is risk of bias in the included studies due to sponsoring and absence of any kind of blinding. One study compared disc replacement against rehabilitation and found a significant advantage in favor of surgery, which, however, did not reach the predefined threshold. Six studies compared disc replacement against fusion and found that the mean Improvement in VAS back pain was 5.2 mm higher (2 studies, 95% CI 0.2 to 10.3) with a low quality of evidence. The improvement of Oswestry score at 24 months in the disc replacement group was 4.3 points more than in the fusion group (5 studies; 95% CI 1.85 to 6.68) with a low quality of evidence. Both upper bounds of the confidence intervals were below the predefined clinically relevant difference. Conclusions. Although statistically significant, the differences in clinical improvement were not beyond generally accepted boundaries for clinical relevance. Prevention of adjacent level disease and/or facet joint degeneration was not properly assessed. Therefore, because we believe that harm and complications may occur after years, we believe that the spine surgery community should be prudent about adopting this technology on a large scale, despite the fact that total disc replacement seems to be effective in treating low back pain in selected patients, and in the short term is at least equivalent to fusion surgery. Jacobs WC et al. Spine (Phila Pa 1976). 2012 Sep 19.

Epidural steroids, etanercept, or saline in subacute sciatica

A multicenter, randomized trial. Epidural steroid injections may provide modest short-term pain relief for some adults with lumbosacral radiculopathy, but larger studies with longer follow-up are needed to confirm their benefits. Cohen SP et al. Ann Intern Med. 2012 Apr 17;156(8):551-9.

The role of classification of chronic low back pain

There currently are many classification systems for CLBP; some that are descriptive, some prognostic, and some that attempt to direct treatment. We recommend that no one classification system be adopted for all purposes. We further recommend that future efforts in developing a classification system focus on one that helps to direct both surgical and nonsurgical treatments.Fairbank J, Gwilym SE, France JC, Daffner SD, Dettori J, Hermsmeyer J, Andersson G. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S19-42. Review.

Puncture of a disc and application of nucleus pulposus induces disc herniation-like changes and osteophytes

An experimental study in rats. It has been observed that puncture of a lumbar disc may induce formation of a nodule on the surface of the disc and osteophytes. It is not known if this is based on the presence of a foreign tissue or specifically by the presence of nucleus pulposus or on the disc injury. In this study these mechanisms were separated by comparing disc puncture with application of nucleus pulposus without disc injury, with superficial disc injury without nucleus pulposus and with application of fat. Fifty rats underwent facetectomy of the left L4-5 facet. Ten additional rats were used as donor rats. The rats were exposed to disc puncture (n=10), application of homologous nucleus pulposus (n=10), application of homologous fat tissue (n=10), superficial disc injury (n=10) and ten rats served as control. After 3 weeks the rats were examined macroscopically regarding presence of disc nodules and osteophytes. A limited histological analysis was performed to obtain a microscopic overview of any observed changes. In rats with application of fat, superficial disc injury and in sham controls there were almost no changes observed. However, in rats with disc puncture and applied nucleus pulposus there were clear disc nodules and osteophytes noted. Microscopically the nodules comprised granulation tissue and the osteophytes cortical bone. In conclusion, the data indicate that the presence of nucleus pulposus is more likely to be responsible for the formation of disc nodules and osteophytes than disc injury or the presence of a foreign tissue. This may provide new insights in the mechanisms regarding the formation of disc herniations and osteophytes. Olmarker K. Open Orthop J. 2011 Apr 28;5:154-9.

Need for a national database on lumbar fusion surgery

INTRODUCTION: The indication for surgical technique in lumbar fusion is debated. The objective of this study was to analyse the indication and operative technique in lumbar surgery clinics in Denmark. MATERIAL AND METHODS: A cohort study based on a sample from four public and four private clinics in 2006 was used. RESULTS: There was no difference in patient demographics and diagnosis between public and private clinics. In 62% of the patient files, information was lacking. Considerations on indication and surgery did not differ from public to private clinics. A standard preoperative rehabilitation program was performed in 59% of the cases. Combined anterior and posterior fusion was performed in 37 cases, posterior instrumented fusion in 77 cases and posterior uninstrumented fusion in 105 cases, interspinous spacer was used in six cases and disc arthroplasty in 13 cases. CONCLUSION: Adequate evaluation of indication and choice of surgical technique in lumbar fusion based on patient files was not possible. We found no qualitative differences between public and private clinics. A national database is needed to monitor indication and choice of operative procedure. Ugeskr Laeger. 2010 Nov 22;172(47):3245-9. Rasmussen S et al.

A consensus approach toward the standardization of back pain definitions for use in prevalence studies

These definitions provide standards that may improve future comparisons of low back pain prevalence figures by person, place and time characteristics, and offer opportunities for statistical summaries. Dionne CE et al. Spine (Phila Pa 1976). 2008 Jan 1;33(1):95-103.

Surgery versus prolonged conservative treatment for sciatica

BACKGROUND: Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known. METHODS: We randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. The primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual-analogue scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups. RESULTS: Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiskectomy after a mean of 2.2 weeks. Of 142 patients designated for conservative treatment, 55 (39%) were treated surgically after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (P=0.13). Relief of leg pain was faster for patients assigned to early surgery (P<0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio, 1.97; 95% confidence interval, 1.72 to 2.22; P<0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%. CONCLUSIONS: The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. N Engl J Med. 2007 May 31;356(22):2245-56. Peul WC et al. Leiden-The Hague Spine Intervention Prognostic Study Group.

The management and outcome of spinal implant infections

BACKGROUND: Spinal implant infections provide unique diagnostic and therapeutic challenges. METHODS: We conducted a retrospective cohort study to evaluate risk factors for treatment failure in patients with early- and late-onset spinal implant infections at the Mayo Clinic (Rochester, MN) during 1994-2002. RESULTS: We identified 30 patients with early-onset spinal implant infection and 51 patients with late-onset spinal implant infection. Twenty-eight of 30 patients with early-onset infection were treated with debridement, implant retention, and antimicrobial therapy. The estimated 2-year cumulative probability of survival free of treatment failure for patients with early-onset infection was 71% (95% confidence interval [CI], 51%-85%). Thirty-two of 51 patients with late-onset infection were treated with implant removal. Their estimated 2-year cumulative probability of survival free of treatment failure was 84% (95% CI, 66%-93%). For patients with early-onset infections, receiving oral antimicrobial suppression therapy was associated with increased cumulative probability of survival (hazard ratio, 0.2; 95% CI, 0.1-0.7). For patients with late-onset infections, implant removal was associated with increased cumulative probability of survival (hazard ratio, 0.3; 95% CI, 0.1-0.7). CONCLUSIONS: Early-onset spinal implant infections are successfully treated with debridement, implant retention, and parenteral followed by oral suppressive antimicrobial therapy. Implant removal is associated with successful outcomes in late-onset infections. Clin Infect Dis. 2007 Apr 1;44(7):913-20. Epub 2007 Feb 14. Kowalski TJ, Berbari EF, Huddleston PM, Steckelberg JM, Mandrekar JN, Osmon DR.

Efficacy of tumor necrosis factor-alpha blockade for severe sciatica?

The domain of sciatica is at the edge of a mini revolution. For ten years evidence have been accumulating in favour of a local inflammation rather than a pathology resulling only from a nerve compression. This hypothesis has first been strengthened by the discovery of inflammatory mediators in human herniated discs and then by animal models. These models have demonstrated the impossibility for nerve root compression to produce sciatica in the absence of inflammation and the importance of proinflammatory cytokines in this pathology. TNF-alpha have been proved to be the most important inflammatory cytokine and TNF-alpha modulators has been most effective in the treatment of these models. Two pilot studies realized on humans seem to confirm these experimental data. A multicenter randomised, double-blind, placebo controlled study is being planed in Switzerland. Genevay S, Guerne PA, Gabay C. Rev Med Suisse Romande. 2004 Sep;124(9):543-5. Review. French.

Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration.

STUDY DESIGN: Single blind randomized study. OBJECTIVES: To compare the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. SUMMARY OF BACKGROUND DATA: To the authors' best knowledge, only one randomized study has evaluated the effectiveness of lumbar fusion. The Swedish Lumbar Spine Study reported that lumbar fusion was better than continuing physiotherapy and care by the family physician. PATIENTS AND METHODS: Sixty-four patients aged 25-60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4-L5 and/or L5-S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index. RESULTS: At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (-6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%. CONCLUSION: The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration randomized to cognitive intervention and exercises, or lumbar fusion. Spine (Phila Pa 1976). 2003 Sep 1;28(17):1913-21. Brox JI et al.

MR imaging and CT in osteoarthritis of the lumbar facet joints

With regard to osteoarthritis of the lumbar facet joints there is moderate to good agreement between MR imaging and CT. When differences of one grade are disregarded agreement is even excellent. Therefore, in the presence of an MR examination CT is not required for the assessment of facet joint degeneration. Weishaupt D, Zanetti M, Boos N, Hodler J. Skeletal Radiol. 1999 Apr;28(4):215-9.

The tissue origin of low back pain and sciatica

A report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. In an effort to define the origin of low back pain and sciatica, 193 patients were carefully studied using progressive local anesthesia. These patients had surgery for herniated discs, spinal stenoses, or both. Various tissues were stimulated during the performance of these lumbar spinal operations. This article discusses our observations and the results of that study. Kuslich SD, Ulstrom CL, Michael CJ. Orthop Clin North Am. 1991 Apr;22(2):181-79.

Oswestry Disability Index

Fairbank, J., Pynsent, P., Disney, S. 1980.

Incidence of lower extremity deep vein thrombosis in neurosurgical patients

Valladares JB, Hankinson J. In 100 patients who underwent major cranial or spinal operations, the incidence of lower extremity deep vein thrombosis was 29%. Of importance was the presence of known risk factors, particularly leg weakness and a long operation. The subject of deep vein thrombosis and its complications in neurosurgical disorders is reviewed and its prophylaxis is discussed. The administration of low dose heparin based on an epidemiological analysis of the risks involved would seem to be an effective method of prophylaxis. Neurosurgery. 1980 Feb;6(2):138-41.