Should age be a contraindication for degenerative lumbar surgery?

INTRODUCTION AND PURPOSE: The purpose of this study was to evaluate and compare disability, quality of life and satisfaction outcomes between young people and elderly who were operated on for degenerative lumbar disease. MATERIAL AND METHODS: A database of 263 patients undergoing lumbar surgery for degenerative conditions was collected. There were 74 patients who were 65 years old or above and 189 who were below 65 who had complete preoperative and 2-year postoperative HRQOL data measures: ODI, SF-36 and COMI. RESULTS: There were no significant differences in the outcomes between the two age groups (p > 0.05). An improvement from baseline in all quality of life measures in the two age groups was observed. A median improvement of 6.0 points was found in the ODI in the younger patients versus 12.0 in older ones. A median improvement in the SF36 physical component score of 6.95 was seen in the younger group while improvement was reported at 6.36 points in patients over 65. The SF36 mental component score improved by 4.48 points and 4.96 points, respectively. COMI improved a median of 1.2 points in both groups. In terms of satisfaction, 66.9 % of the younger patients were pleased or very pleased whereas this was found to be 59.7 % for the older group. CONCLUSION: Older patients can see substantial clinical improvement after degenerative lumbar disease surgery similar to that obtained in younger patients in terms of quality of life and satisfaction. The improvement in terms of the disability is greater for older patients. Thus, age should not be a contraindication for this procedure.

Predictors of blood transfusion in patients undergoing elective surgery for degenerative conditions of the spine.

BACKGROUND: The requirement of blood in the surgery of degenerative conditions of lumbar spine is around 10 %. Preoperative autologous blood donation is an effective method that is used in surgeries with an important blood loss. This is an expensive method because of the great number of predonated blood units not used in the postoperative period (around 70 % in our practice). OBJECTIVE: To know the risk factors associated with transfusion in the postoperative period in patients who undergo surgeries of degenerative conditions of the lumbar spine. METHODS: We designed a retrospective study of 142 cases of patients operated for degenerative conditions of the lumbar spine (not including simple disk hernia or adult degenerative scoliosis). RESULTS: Female sex, age >60 years, preoperative ASA score 3 and preoperative hemoglobin ≤136 g/L are the risk factors related to the need of blood transfusion in the postoperative period. After application of a statistical study, female sex and preoperative ASA score 3 were the most important variables to explain transfusional risk. A woman with ASA score 3 has a 61 % foretold probability to be transfused in the postoperative period, while a man with ASA < 3, only 1.1 %. For this reason, application of this method to patients with these risk factors is more cost-effective. CONCLUSIONS: Females, ASA 3, preoperative hemoglobin ≤136 g/L and age older than 60 years increase the risk to be transfused in the postoperative period for degenerative conditions of the spine.

Effect of IL-1beta, PGE(2), and TGF-beta1 on the expression of OPG and RANKL in normal and osteoporotic primary human osteoblasts.

The RANKL/RANK/OPG pathway is essential for bone remodeling regulation. Many hormones and cytokines are involved in regulating gene expression in most of the pathway components. Moreover, any deregulation of this pathway can alter bone metabolism, resulting in loss or gain of bone mass. Whether osteoblasts from osteoporotic and nonosteoporotic patients respond differently to cytokines is unknown. The aim of this study was to compare the effect of interleukin (IL)-1beta, proftaglandin E(2) (PGE(2)), and transforming growth factor-beta1 (TGF-beta1) treatments on OPG and RANKL gene expression in normal (n = 11) and osteoporotic (n = 8) primary osteoblasts. OPG and RANKL mRNA levels of primary human osteoblastic (hOB) cell cultures were assessed by real-time PCR. In all cultures, OPG mRNA increased significantly in response to IL-1beta treatment and decreased in response to TGF-beta1 whereas PGE(2) treatment had no effect. RANKL mRNA levels were significantly increased by all treatments. Differences in OPG and RANKL responses were observed between osteoporotic and nonosteoporotic hOB: in osteoporotic hOB, the OPG response to IL-1beta treatment was up to three times lower (P = 0.009), whereas that of RANKL response to TGF-beta1 was five times higher (P = 0.002) after 8 h of treatment, as compared with those in nonosteoporotic hOBs. In conclusion, osteoporotic hOB cells showed an anomalous response under cytokine stimulation, consistent with an enhanced osteoclastogenesis resulting in high levels of bone resorption.

Cervical paravertebral osteolipoma: case report and literature review.

Lipomas are the most frequent soft tissue tumors. Osteolipomas are a rare variant that can be difficult to diagnose. We report the case of a 66-year-old man consulting with a tumor of 2 years development in the right paravertebral cervical region. Neurologically, the patient had no sign of myelopathy or neurological focality. Magnetic resonance imaging showed a mass with a lipid component and calcifications inside within the right paravertebral musculature with a possible origin in the right C3 posterior root. A computed tomography scan and guided biopsy were performed, revealing hematic material and small bone spicules with no apparent neoplastic element. The tumor was totally removed, including the right C3 posterior branch, and was confirmed to be an osteolipoma on biopsy. The patient remains asymptomatic at 6-month follow-up. The osteolipoma is a benign tumor of soft tissue, characterized by lipoma areas with mature bone tissue differentiation, and even with hematopoietic marrow.

Symptomatic vertebral artery stenosis secondary to cervical spondylolisthesis.

STUDY DESIGN: Case report. OBJECTIVE: To present a rare case of vertebrobasilar insufficiency (VBI) syndrome secondary to the C6 level isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: VBI associated with voluntary head movements is known as the bow hunter syndrome. It may manifest in temporary symptoms of dizziness, syncope, nausea, or motor and sensory deficits in certain head positions. The present syndrome is rare and difficult to diagnose. The authors describe a VBI case caused by vertebral artery compression due to the C6 level isthmic spondylolisthesis (to date, the authors have not found any other similar case described in the literature). METHODS: The patient was a 27-year-old male with a 12-month history of vertigo and dizziness in relation to head movements. These problems interfered with his day-to-day activities.With other causes of neurological and cardiac origin dismissed, the patient was sent for an orthopedic evaluation.Radiological imaging showed spondylolisys, spondylolisthesis, and spina bifida between the facets of the C6 and C7. Dynamic radiographies evidenced C6 and C7 cervical instability.Angio-MRI indicated an anomalous trajectory of the right vertebral artery at the C6 level upon entering the foramen transversarium. However, there were no signs of stenosis. Dynamic angiography confirmed partial stenosis of the right vertebral artery upon rightward head rotation. The substantial suspicion of positional VBI after rejecting other diagnoses and the significant disability of the patient led to treating the patient with anterior cervical arthrodesis at the C6-C7 level. RESULTS: The patient was symptom free for more than 15 months' monitoring and returned to all his daily work and life activities. CONCLUSION: Isthmic spondylolisthesis must be considered as a cause within VBI. Surgery presents good results.

Usefulness of the core outcome measures index in daily clinical practice for assessing patients with degenerative lumbar disease.

Introduction. Outcome evaluation is an important aspect of the treatment of patients with degenerative lumbar disease. We evaluated the usefulness of the Core Outcome Measures Index (COMI) in assessing people affected by degenerative lumbar disease in daily clinical practice. Methods. We evaluated 221 patients who had completed preoperatively and 2 years after surgery VAS pain, Short Form-36 (SF-36), Oswestry Disability Index (ODI) and COMI. We calculated the change of scores and its sensitivity to change. The internal consistency of the COMI items and the correlation between the COMI scores and the scores of the other measurements were assessed. Results. Statistically significant differences were observed between the mean scores of the preoperative and 2 years questionnaires for nearly all measurements. COMI showed a good internal consistency, except for the preoperative pain subscale. The sensitivity to change was high for the total COMI and its pain and well-being subscales and moderate for the rest. The COMI demonstrated strong correlation with the other measurements. Conclusions. The COMI is a useful tool for assessing the patient-based outcome in the studied population. Given its simplicity, good correlation with the SF-36 and ODI and its good sensitivity to change, it could replace more cumbersome instruments in daily clinical practice.

The visual analog scale and a five-item verbal rating scale are not interchangeable for back pain assessment in lumbar spine disorders.

STUDY DESIGN: Prospective study of patients with chronic back pain from lumbar spine disorders. OBJECTIVE: To evaluate the degree of interchangeability of a 100-mm visual analog scale (VAS) and a 5-point verbal rating scale (VRS) for the assessment of pain intensity. SUMMARY OF BACKGROUND DATA: The fact that VAS and Likert scales are highly intercorrelated does not mean that both types of scales can be used interchangeably. METHODS.: A total of 151 patients (mean age, 52 ± 14.6 years) undergoing elective spine surgery completed a 100-mm VAS and a discrete 5-category VRS corresponding to the first item question of the core set ("How severe was your back pain in the last week?"). Pain intensity on the VAS was rated using the same question than for the VRS. The level of order-consistency (monotonic agreement), disordered pairs (D), percentage of agreement, and systematic disagreement (relative position), and relative concentration ([RC]) were estimated. VAS assessments were transformed into a discrete 5-category, with the cut-off VAS positions being defined by quintiles and equidistantly. RESULTS: For VAS defined equidistantly, monotonic agreement was 0.840, D was 0.080, and the percentage of identical pairs was 53%. The corresponding figures for VAS defined by quintiles were 0.809, 0.096, and 27.8%. Inconsistencies between the VAS and the VRS scales were also demonstrated by the marginal distributions, with PR values of -0.005 (95% confidence interval [CI], -0.011 to -0.002) and RC values of 0.144 (95% CI, 0.137-0.152) for VAS defined equidistantly, and PR values of 0.391 (95% CI, 0.384-0.397) and RC values of 0.265 (95% CI, 0.255-0.275) for VAS defined by quintiles. CONCLUSION: The order-consistency level was low with overlapping of pain records between the 2 scales, indicating that VAS and VRS are not interchangeable and, therefore, a results obtained with the use of each scale cannot be compared.

A haplotype-based analysis of the LRP5 gene in relation to osteoporosis phenotypes in Spanish postmenopausal women.

LRP5 encodes the low-density lipoprotein receptor-related protein 5, a transmembrane protein involved in Wnt signaling. LRP5 is an important regulator of osteoblast growth and differentiation, affecting bone mass in vertebrates. Whether common variations in LRP5 are associated with normal BMD variation or osteoporotic phenotypes is of great relevance. We used a haplotype-based approach to search for common disease-associated variants in LRP5 in a cohort of 964 Spanish postmenopausal women. Twenty-four SNPs were selected, covering the LRP5 region, including the missense changes p.V667M and p.A1330V. The SNPs were genotyped and evaluated for association with BMD at the lumbar spine (LS) or femoral neck (FN) and with osteoporotic fracture, at single SNP and haplotype levels, by regression methods. Association with LS BMD was found for SNP 1, rs312009, located in the 5'-flanking region (p = 0.011, recessive model). SNP 6, rs2508836, in intron 1, was also associated with BMD, both at LS (p = 0.025, additive model) and FN (p = 0.031, recessive model). Two polymorphisms were associated with fracture: SNP 11, rs729635, in intron 1, and SNP 15, rs643892, in intron 5 (p = 0.007 additive model and p = 0.019 recessive model, respectively). Haplotype analyses did not provide additional information, except for haplotype "GC" of the block located at the 3'end of the gene. This haplotype spans intron 22 and the 3' untranslated region and was associated with FN BMD (p = 0.029, one copy of the haplotype versus none). In silico analyses showed that SNP 1 (rs312009) lies in a putative RUNX2 binding site. Electro-mobility shift assays confirmed RUNX2 binding to this site.