Stress hormone response to instrumented elective lumbar spine fusion surgery.

PURPOSE: To understand the systemic effect of major spine surgery, we investigated stress, anabolic and catabolic hormonal levels and their association with interleukin 6 (IL-6) in patients undergoing elective lumbar spine fusion surgery. METHODS: Blood samples were collected preoperatively, and at 1, 3, 42, 90 days postoperatively (POD) from 49 patients who underwent elective lumbar spine fusion surgery. RESULTS: Serum concentration of cortisol was below the preoperative value at POD 1 but did not differ from the baseline values thereafter. Adrenocorticotropic hormone (ACTH) decreased at PODs 1 and 3. Testosterone decreased at PODs 1 and 3 in men, and at POD 3 in women. Sex hormone-binding globulin decreased at PODs 1 and 3 in both genders. No changes were observed in free testosterone or growth hormone concentrations. Insulin-like growth factor 1 increased significantly above the preoperative level at PODs 42 and 90 in women, and at POD 42 in men. IL-6 was significantly elevated at PODs 1 and 3. Increases in IL-6 from the preoperative level to POD 1 correlated significantly with decreases of cortisol at POD 1 but not with ACTH. CONCLUSIONS: There were only short-term stress hormonal changes after elective lumbar spine fusion surgery. Cortisol changes after elective lumbar spine surgery are transient and might be partly cytokine induced and non-ACTH driven since there was association between cortisol and IL-6 but not with ACTH and IL-6.

Benefits of lumbar spine fusion surgery reach 10 years with various surgical indications.

Background Context: Lumbar spine fusion (LSF) surgery is a viable form of treatment for several spinal disorders. Treatment effects are preferably to be endorsed in real-life settings. Methods: This prospective study evaluated the 10-year outcomes of LSF. A population-based series of elective LSFs performed at 2 spine centers between January 2008 and June 2012 were enrolled. Surgeries for tumor, acute fracture, or infection, neuromuscular scoliosis, or postoperative conditions were excluded. The following patient-reported outcome measures (PROMs) were collected at baseline, and 1, 2, 5, and 10 years postsurgery: VAS for back and leg pain, ODI, SF-36. Longitudinal measures of PROMs were analyzed using mixed-effects models. Results: A total of 683 patients met the inclusion criteria, and 630 (92%) of them completed baseline and at least 1 follow-up PROMs, and they constituted the study population. Mean age was 61 (SD 12) years, 69% women. According to surgical indication, patients were stratified into degenerative spondylolisthesis (DS, n=332, 53%), spinal stenosis (SS, n=102, 16%), isthmic spondylolisthesis (IS, n=97, 15%), degenerative disc disease (DDD, n=52, 8%), and deformity (DF, n=47, 7%).All diagnostic cohorts demonstrated significant improvement at 1 year, followed by a partial loss of benefits by 10 years. ODI baselines and changes at 1 and 10 years were: (DS) 45, -21, and -14; (SS) 51, -24, and -13; (IS) 41, -24, and -20; (DDD) 50, -20, and -20; and (DF) 50, -21, and -16, respectively. Comparable patterns were seen in pain scores. Significant HRQoL achievements were recorded in all cohorts, greatest in physical domains, but also substantial in mental aspects of HRQoL. Conclusions: Benefits of LSF were partially lost but still meaningful at 10 years of surgery. Long-term benefits seemed milder with degenerative conditions, reflecting the progress of the ongoing spinal degeneration. Benefits were most overt in pain and physical function measures.

The Finnish spine register (FinSpine): development, design, validation and utility.

PURPOSE: Our aim was to develop a nationwide, computer-based, Spine Register (FinSpine) for monitoring surgical activity, quality of surgery, long-term outcomes, and effectiveness of treatment. In this paper, we describe our experiences in the development and implementation of the register. METHODS: The register was developed by a steering group, consisting of orthopedic surgeons and neurosurgeons from the whole country. We strived to develop a register which would be in active use by spine surgeons and enable collection of Patient Reported Outcome and Experience Measures (PROMs and PREMs) automatically and prospectively. We are actively promoting the use of the register in order to gain a nationwide coverage and achieve high response-rates from both surgeons and patients. RESULTS: The use of FinSpine started in 2016 and it has been granted continuous funding from the Finnish Institute for Health and Welfare from the 1st of January 2023 onwards. Currently the register is used by 19/23 (83%) public hospitals and the use is expanding to private hospitals as well. The response-rate of surgeons is currently 80%. The response-rate of patients is on average 56% but reaches up to 90% in hospitals using register-coordinators. CONCLUSION: The use of FinSpine is increasing. By gaining a larger coverage and completeness, the data can be used for research purposes which we believe will influence decision making and ultimately improve the outcomes and quality of life of the patients. Comparison with other national spine registers is possible, since FinSpine includes similar baseline characteristics and outcome measures (e.g., ODI, EQ-5D, VAS).

Mechanical complications and reoperations after adult spinal deformity surgery: a clinical analysis with the GAP score.

PURPOSE: Adult spinal deformity (ASD) surgery is prone to postoperative complications, leading to high reoperation rates. The global alignment and proportion (GAP) score is a novel method to predict mechanical complications (MC) based on the optimal parameters related to individual pelvic incidence. The aim of this study was to determine the cut-off point and the predictive value of the GAP score for those MCs that require reoperation. A secondary aim was to investigate the cumulative incidence of MCs requiring reoperation during a long follow-up period. METHODS: In total, 144 ASD patients were operated at our institution due to marked symptomatic spinal deformity between 2008 and 2020. The cut-off point and the predictive value of the GAP score for the MCs that required reoperation and the cumulative incidence of reoperated MCs after index surgery were determined. RESULTS: A total of 142 patients were included in the analysis. The risk for having an MC that required reoperation was significantly lower when the postoperative GAP score was < 5 (HR = 3.55, 95% CI: 1.40-9.02). The discriminative power of the GAP score to predict MCs that require reoperation was good with an AUC of 0.70 (95% CI: 0.58-0.81). The cumulative incidence of reoperated MCs was 18%. CONCLUSION: The GAP score was associated with the risk for MCs that require reoperation. The best predictive value for surgically treated MC was with the GAP score [Formula: see text] 5. The cumulative incidence of the reoperated MCs was 18%.

Disability, Health-Related Quality of Life and Mortality in Lumbar Spine Fusion Patients-A 5-Year Follow-Up and Comparison With a Population Sample.

STUDY DESIGN: Prospective follow-up study. OBJECTIVES: We aimed to assess the effect of lumbar spine fusion (LSF) on disability, health-related quality of life and mortality in a 5-year follow-up, and to compare these results with the general population. METHODS: 523 consecutive LSF operations were included in a prospective follow-up. Disability was assessed by the Oswestry Disability Index (ODI), and HRQoL by the 36-item Short Form (SF-36) questionnaire using the physical and mental summary scores (PCS and MCS). The patients were compared with an age-, sex-, and residential area matched general population cohort. RESULTS: The preoperative ODI in the patients was 46 (SD 16), and the change at 5 years was -26 (95% CI: -24 to -28), p < 0.001. In the population, ODI (baseline 13, SD 16) remained unchanged. The preoperative PCS in the patients was 27 (SD 7), in the population 45 (SD 11), and the increase in the patients at 5 years was 8 (95% CI: 7 to 9), p < 0.001. The patients did not reach the population in ODI or PCS. The baseline MCS in the patients was 47 (SD 13), and the change at 5 years 4 (95% CI: 3 to 7), p < 0.001. MCS of the females reached the population at 5-year follow-up. When analyzing short and long fusions separately, comparable changes were seen in both subgroups. There was no difference in mortality between the patients (3.4%) and the population (4.8%), hazard ratio (HR) 0.86. CONCLUSIONS: Although the patients who had undergone LSF benefited from surgery still at 5 years, they never reached the physical level of the population.

Influence of Depressive Symptoms on the Outcome of Lumbar Spine Fusion-A 5-year Follow-up Study.

STUDY DESIGN: Prospective follow-up study. OBJECTIVE: The aim of this study was to assess whether depressive symptoms change the outcome of lumbar spine fusion (LSF) surgery at a 5-year follow-up. SUMMARY OF BACKGROUND DATA: Previous reports of the influence of depressive symptoms on the results of spine surgery are controversial, but the patient characteristics and indications for surgery varied widely between the studies. The influence of depressive symptoms on the 5-year outcome of LSF has not been studied. METHODS: The study was based on data from a local LSF database from two hospitals comprising 392 consecutive patients (mean age 61 years, 277 women) who underwent an instrumented LSF and fulfilled the 5-year follow-up. At the 5-year follow-up, the patients were compared with a control group from the general population (n = 477, age-, sex-, and residential area-matched) extracted from Official Statistics of Finland. The prevalence of depressive symptoms was evaluated using the Depression Scale (DEPS; 0-30) and disability was evaluated by the Oswestry Disability Index (ODI; 0-100%). A DEPS score ≥12 was considered to indicate depressive symptoms. RESULTS: Before surgery, 35% of the patients had depressive symptoms. The proportion diminished to 13% at 3 months postoperatively and increased to 24% at 5 years. In the population, the prevalence was 11% at baseline and 10% at the 5-year follow-up. The preoperative ODI was 54 in the patients with depressive symptoms, and it was 41 in the patients with no depressive symptoms. The changes at 5-year follow-up were -20 and -18, correspondingly. The same congruence was preserved when analyzing short and long fusions separately. These changes were statistically and clinically significant. In the control population, the ODI remained around 24 in depressive people and 10 in nondepressive people. CONCLUSION: Our data suggest that patients with and without depressive symptoms may benefit equally well from LSF. LEVEL OF EVIDENCE: 3.

National trends in lumbar spine decompression and fusion surgery in Finland, 1997-2018.

Background and purpose - During recent years, spine surgery techniques have advanced, the population has become older, and multiple high-quality randomized controlled trials that support surgical treatment for degenerative spinal stenosis and spondylolisthesis have been published. We assess the incidence and trends in spine fusion and decompression surgery in Finland between 1997 and 2018.Patients and methods - We used nationwide data from the Finnish nationwide National Hospital Discharge Register. The study population covered all patients aged 20 years or over in Finland (5.5 million inhabitants) during a 22-year period from 1997 through 2018. All patients who underwent spinal decompression were included. Patients with both decompression and fusion codes were analyzed as fusions.Results - 76,673 lumbar spine decompressions and fusions were performed during the study period. The incidence of lumbar spine decompressions increased from 33 (95% CI 23-45) per 100,000 person-years in 1997 to 77 (CI 61-95) per 100,000 person-years in 2018. The incidence of lumbar spine fusions increased from 9 (CI 5-17) per 100,000 person-years in 1997 to 30 (CI 21-43) per 100,000 person-years in 2018. The increase in incidence of lumbar spinal fusions was highest among women aged over 75 years, with a 4-fold increase.Interpretation - The incidence of lumbar spine fusions and decompressions increased between 1997 and 2018 in Finland. These findings may be the result of the emergence of advanced surgical techniques but may also be the result of an aging population and increased evidence supporting the surgical treatment of various spinal pathologies.

30-Day Recurrence, Readmission Rate, and Clinical Outcome After Emergency Lumbar Discectomy.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To investigate the 30-day recurrence rate after emergency lumbar discectomy. Secondary aims were to investigate the factors affecting the 30-day recurrence and readmission rates and clinical outcome. SUMMARY OF BACKGROUND DATA: Excluding cauda equine syndrome (CES) due to massive intervertebral disc herniation, emergency surgery for lumbar disc herniation (LDH) is rarely required. The operation may, however, be performed for other reasons such as persistent or progressive motor paresis associated with radiculopathy or uncontrolled pain. Literature on these topics is scarce. METHODS: All patients admitted for inpatient care after a visit to the emergency department (ED) due to acute low back pain and who had subsequently undergone an emergency lumbar discectomy during the 4-year study period were included in the study. Patients attending the ED who subsequently had a delayed discectomy formed the control group. Recurrence and readmission rates were analyzed and clinical outcome at 30 days post-surgery was assessed with the Oswestry Disability Index (ODI) and the visual analog pain scale (VAS). RESULTS: One hundred thirty patients were admitted to the hospital after visiting the ED and underwent an emergency discectomy after a median of 1.0 days from admittance. Six patients in the study group [4.6% (95% CI: 2.1-9.7)] had recurrent LDH and nine patients in total [6.9% (95% CI: 3.9-12.6)] were readmitted within 30 days. None of the baseline variables clearly predicted recurrence. Mean ODI difference between the study group and controls was 8.1 (95% CI: -6.7-23.2). BMI and surgery by a non-spine surgeon were associated with higher ODI values. CONCLUSION: An emergency discectomy is associated with a higher rate than expected of both recurrent LDHs and 30-day readmissions. Surgeon experience and patient-related factors had minor effects on the 30-day clinical outcome. LEVEL OF EVIDENCE: 4.

Specific spinal pathologies in adult patients with an acute or subacute atraumatic low back pain in the emergency department.

PURPOSE: The primary aim in the evaluation of patients presenting with acute or subacute low back pain (LBP) is to exclude a possible specific spinal pathology. Literature on the population-based incidences of these pathologies is scarce. The aim of our study was to investigate the population-based incidence of specific spinal pathologies as a cause of atraumatic acute or subacute LBP. METHODS: From our institutional database, we identified all patients with a relevant LBP-related ICD-10 code during a visit to our emergency department (ED) in a level II/III teaching hospital between January 2012 and December 2014. Patients with a possible specific spinal pathology (cauda equina syndrome, spondylodiscitis, vertebral fracture, and cancer) were assessed in detail. RESULTS: A total of 900 visits were due to atraumatic low back pain. Of these 284 (31.6%) were due to nonspecific LBP, and 583 (64.8%) due to radicular pain suggesting nerve root compression. In 33 (3.7%) cases, the LBP was caused by a specific spinal pathology. The annual incidences per 100,000 were 0.60 for CES, 2.1 for spondylodiscitis, 0.76 for cancer and 1.2 for compression fracture. CONCLUSIONS: The incidences of specific spinal pathologies were low. Given that LBP is a very common symptom, it is not surprising that the accuracy of red flag symptoms is poor. Each patient should be considered individually, and we advocate a low threshold for referral and advanced imaging in cases where a specific spinal pathology is suspected.

Effectiveness of postoperative home-exercise compared with usual care on kinesiophobia and physical activity in spondylolisthesis: A randomized controlled trial.

OBJECTIVE: To study the effectiveness of a 12-month exercise therapy on kinesiophobia and physical activity in patients with spondylolisthesis after lumbar spine fusion. DESIGN: Randomized controlled trial. SUBJECTS: Patients (n = 98) with spondylolisthesis who had undergone lumbar spine fusion. METHODS: All patients (mean age 59 years) had received lumbar spine fusion surgery and identical postoperative instructions. Three months postoperatively, they were randomized into an exercise group (n = 48) or usual care group (n = 50). The exercise group received 12-month progressive home-based training with regular booster sessions, and the usual care group a single session of physiotherapy instruction. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK) and physical activity by the International Physical Activity Questionnaire (IPAQ) preoperatively, 3 months after lumbar spine fusion, and at the end of the 12-month intervention. RESULTS: Before the intervention, the median (first quartile; third quartile) of TSK was 32.5 (29.0; 37.0) in the exercise group and 30.0 (25.8; 36.0) in the usual care group, changing to 30.0 (25; 36) in the exercise group and to 30.5 (24; 36.3) in the usual care group (between-group p = 0.17). IPAQ metabolic equivalent minutes per week increased from 1,863 (1,040; 3,042) to 3,190 (1,634; 6,485) in the exercise group and from 2,569 (1,501; 4,075) to 3,590 (1,634; 6,484) in the usual care group (between-group p = 0.92). CONCLUSION: Progressive 12-month home-exercise starting 3 months postoperatively was not superior to usual care in decreasing kinesiophobia or increasing physical activity in spondylolisthesis.

Quality of life and disability: can they be improved by active postoperative rehabilitation after spinal fusion surgery in patients with spondylolisthesis? A randomised controlled trial with 12-month follow-up.

PURPOSE: The aim of the study was to investigate the effectiveness of the postoperative 12-month exercise program compared to usual care on disability and health-related quality of life (HRQoL) in patients after lumbar spine fusion surgery (LSF). METHODS: Altogether, 98 patients with isthmic (31) or degenerative (67) spondylolisthesis were randomised to exercise therapy group (EG) (n = 48) or usual care group (UCG) (n = 50) 3 months after LSF. EG patients had home-based progressive strength and aerobic training program for 12 months. UCG patients received only oral and written instructions of exercises. Oswestry Disability Index (ODI) and HRQoL (RAND-36) were evaluated at the time of randomization, at the end of the intervention and 1 year after intervention. RESULTS: The mean ODI score decreased from 24 (12) to 18 (14) in the EG and from 18 (12) to 13 (11) in the UCG during intervention (between-groups p = 0.69). At 1-year follow-up, 25 % of the EG and 28 % of the UCG had an ODI score ≥20. No between-group differences in HRQoL change were found at any time point. The mean (95 % CI) physical functioning dimension of the HRQoL improved by 10.0 (4.6-15.3) in the EG and by 7.8 (2.5-13.0) in the UCG. In addition, the role physical score improved by 20.0 (7.7-32.3) in the EG and by 16.4 (4.4-28.4) in the UCG during the intervention. CONCLUSIONS: The exercise intervention did not have an impact on disability or HRQoL beyond the improvement achieved by usual care. However, disability remained at least moderate in considerable proportion of patients.

Changes in health utility, disability, and health-related quality of life in patients after spinal fusion: a 2-year follow-up study.

STUDY DESIGN: Prospective longitudinal database study. OBJECTIVE: To evaluate changes in health utility, disability, and health-related quality of life (HRQOL) in patients undergoing spinal fusion. SUMMARY OF BACKGROUND DATA: Recently, measuring disability, HRQOL, and health utility has become important when defining the value of surgical interventions. METHODS: Data of spinal fusion patients from a prospective longitudinal database were analyzed. Health utility was captured by SF-6D (six dimensional health state classification from the 36-dimensional Short Form Health Survey) score, disability by Oswestry Disability Index, and HRQOL by the 36-Item Short Form Health Survey. The changes in these scores were compared between the groups during the 2-year follow-up. RESULTS: Altogether 242 patients were stratified into 5 groups according to the surgical indication: degenerative spondylolisthesis (n = 140), isthmic spondylolisthesis (n = 39), spinal stenosis (n = 23), disc pathology (n = 15), and postoperative conditions (n = 25). The mean age varied from 48 years in isthmic spondylolisthesis group to 66 years in the groups with degenerative spondylolisthesis or spinal stenosis. Preoperatively, the surgical indication subgroups differed significantly from each other according to utility, disability, and the physical component summary score of the HRQOL. Isthmic spondylolisthesis group had the best and the group of postoperative conditions the worst preoperative values. Nevertheless, the SF-6D, the Oswestry Disability Index, and the physical component summary in all diagnostic groups had improved significantly already by 3 months of follow-up, and the improvement remained stable until 2 years of follow-up. Interestingly, the biggest improvement in Oswestry Disability Index (-27), physical component summary (13) and SF-6D (0.19) was found in a group with disc pathology. The mental component summary score values were similar preoperatively (P = 85), and the improvement in the mental component summary was significant in the groups with degenerative olisthesis, spinal stenosis, and postoperative conditions. CONCLUSION: The 5 surgical indication groups showed significantly different scores preoperatively in health utility, disability, and the physical aspect of HRQOL. At 2 years, however, all groups benefitted from the fusion surgery significantly. LEVEL OF EVIDENCE: 3.

Disability and health-related quality of life in patients undergoing spinal fusion: a comparison with a general population sample.

BACKGROUND: The aim of the present study was to compare one-year-follow-up data on disability and health-related quality of life (HRQoL) between spinal fusion patients and age- and sex-matched general population. METHODS: The data on fusion patients were collected prospectively using a spinal fusion data base in two Finnish hospitals. A general population sample matched for age, sex and residential area was drawn from the Finnish Population Register. All participants completed a questionnaire and the main outcome measures were the Oswestry Disability Index (ODI) and the Short Form-36 questionnaire (SF-36). RESULTS: Altogether 252 (69% females) fusion patients and 682 (67% females) population sample subjects participated in the study. In general population the mean ODI was 15 (SD 17) in females and 9 (SD 13) in males. The corresponding preoperative ODI values were 47 (SD16) and 40 (SD 15) and one year follow-up values 22 (SD 17) and 23 (SD 20). In both sexes the ODI decreased significantly after surgery but remained higher than in the general population, p < 0.001. The physical component summary score (PCS) of the SF-36 was lower in the patients than general population sample both preoperatively and at one-year follow-up (p < 0.001). The mental component summary score (MCS) was lower preoperatively (p < 0.001), but reached the general population level after one year in both men (p = 0.42) and women (p = 0.61). CONCLUSIONS: Disability and HRQoL improved significantly after spinal fusion surgery during a one- year follow-up. However, the patients did not reach the level of the general population in the ODI or in the physical component of HRQoL at that time, although in the mental component the difference disappeared.

The early changes in trunk muscle strength and disability following lumbar spine fusion.

PURPOSE: To analyze trunk muscle function pre- and postoperatively in patients undergoing lumbar spine fusion. Associations between changes in trunk muscle strength and disability were also studied. METHOD: A total of 114 patients undergoing lumbar spine fusion participated in the study. The flexion and extension strength of the trunk was measured preoperatively and 3 months after surgery using a strain-gauge dynamometer. Disability and pain during the past week was evaluated with the Oswestry disability index (ODI) and visual analog scale (VAS), respectively. RESULTS: Preoperative trunk extension and flexion strength levels were 319 N and 436 N in males, respectively, and 160 N and 214 N in females, respectively. In females 3 months postoperatively, the trunk extension strength increased by 39 N (p < 0.001) and flexion by 38N (p < 0.001), whereas it remained unchanged in males. The preoperative extension/flexion strength ratio was 0.79 in females and 0.76 in males. Three months postoperatively, the strength ratio decreased to 0.66 in males (p = 0.02). The mean ODI improved by 47% and back pain decreased by 65% (both p < 0.001). The changes in the ODI correlated with changes in trunk extension (r = -0.38) and flexion (r = -0.43) strength. CONCLUSIONS: Patients undergoing lumbar spine fusion had low trunk muscle strength and strength imbalance. Back fusion surgery leads to considerable relief of pain and disability, but patients still have low trunk extension and flexion strength levels 3 months postoperatively. Therefore, there is need for a proper progressive strength training protocols to normalize back function.

Decreased disability is associated with improved perceived quality of life following spinal fusion.

PURPOSE: To assess the disability and relationship between functional status and health related quality of life (HRQoL) in patients in the early recovery phase following spinal fusion. METHODS: This is a prospective cohort study. Since 2008 data of spinal fusion patients have been collected prospectively in two Finnish hospitals. In August 2009, complete data of 173 patients were available. The measurement tool of disability was the Oswestry Disability Index (ODI) and it was also examined in the framework of International Classification of Functioning, Disability and Health (ICF) using body functions and structures, activities and participation components. RESULTS: Preoperatively the mean total ODI was 45 (SD17) and mean (95% confidence interval) change to 3 months postoperatively was -19 (-22 to -17). When the ODI was linked to the ICF, there was a 55% improvement in the body structure and functions component and a 44% improvement in both the activities and the participation components. However, 25% of the patients still had the total ODI score over 40 three months postoperatively. Preoperatively, the mean (95% CI) Physical Component Summary Score (PCS) of the Short Form 36-questionnaire (SF-36) was 27 (26 to 28) and the mean Mental Component Summary Score (MCS) of SF-36 was 47 (45 to 49). Postoperatively the improvement was 9 (95% CI: 8 to 11) in PCS and 6 (95% CI: 4 to 7) in MCS (p < 0.001). CONCLUSIONS: Spinal fusion is successful in the early recovery period in terms of reduction of pain and disability. The significant changes in the ODI were seen in all three components of the ICF model. In addition, improvement in functioning was significantly related to positive change in HRQoL. Still there is a subgroup of patients having marked disability needing more intensive rehabilitation and follow-ups.

Randomized controlled trial of postoperative exercise rehabilitation program after lumbar spine fusion: study protocol.

BACKGROUND: Lumbar spine fusion (LSF) effectively decreases pain and disability in specific spinal disorders; however, the disability rate following surgery remains high. This, combined with the fact that in Western countries the number of LSF surgeries is increasing rapidly it is important to develop rehabilitation interventions that improve outcomes. METHODS/DESIGN: In the present RCT-study we aim to assess the effectiveness of a combined back-specific and aerobic exercise intervention for patients after LSF surgery. One hundred patients will be randomly allocated to a 12-month exercise intervention arm or a usual care arm. The exercise intervention will start three months after surgery and consist of six individual guidance sessions with a physiotherapist and a home-based exercise program. The primary outcome measures are low back pain, lower extremity pain, disability and quality of life. Secondary outcomes are back function and kinesiophobia. Exercise adherence will also be evaluated. The outcome measurements will be assessed at baseline (3 months postoperatively), at the end of the exercise intervention period (15 months postoperatively), and after a 1-year follow-up. DISCUSSION: The present RCT will evaluate the effectiveness of a long-term rehabilitation program after LSF. To our knowledge this will be the first study to evaluate a combination of strength training, control of the neutral lumbar spine position and aerobic training principles in rehabilitation after LSF. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT00834015.

Reliability and validity study of the Finnish version 2.0 of the oswestry disability index.

STUDY DESIGN: Prospective clinical validation study. OBJECTIVE: The aims of this study were to translate into Finnish and culturally adapt and study the psycho-metric properties of the Oswestry Disability Index (ODI) version 2.0. SUMMARY OF BACKGROUND DATA: The ODI is one of the most commonly reported back-specific disability questionnaires. It is widely used both in clinical work and in medical studies. To date, no validated Finnish version of the ODI version 2.0 has been reported. METHODS: The ODI version 2.0 was translated into the Finnish language. A total of 115 patients with back pain, referred by the primary care physician to the outpatient clinic of the department of physical medicine and rehabilitation, were recruited for this study. The patients answered a questionnaire package that included the Finnish ODI 2.0, Back Pain Questionnaire for Visual Analogue Assessment (Million-VAS), Visual Analogue Scales of back and leg pain (VASback, VASleg), the Depressions Scale, and a question on their subjectively perceived health. The package was administered twice; 2 weeks before and at the arrival to the clinic. RESULTS: Reproducibility of the ODI was 0.90 (95% confidence interval [CI] = 0.85-0.94) and the internal consistency was 0.86 (95% CI = 0.81-0.90). Factor analysis showed that the ODI was loaded on 2 factors, which explained 51% of the total variance. In testing convergent validity ODI correlated with Million-VAS, r = 0.75 (95% CI = 0.64-0.84); VASback, r = 0.48 (95% CI = 0.32-0.62); and VAS leg, r = 0.41 (95% CI = 0.23-0.57). CONCLUSION: The Finnish ODI version 2.0 proved to be a valid and reliable instrument that showed psychometric properties comparable with the original English version. Therefore, it can be used in assessing the disability among Finnish-speaking patients with back pain for both clinical and scientific purposes.