Evaluating a targeted person-centred pain management intervention programme in lumbar spine surgery - a controlled segment-specific before-and-after interventional design.

BACKGROUND: Postoperative pain management in lumbar spine surgery care remains a challenge. The aim of this study was to evaluate the impact of a person-centred postoperative pain management intervention programme on lumbar spine surgery patients on postoperative pain, shared decision-making, and satisfaction with postoperative pain management. METHODS: The study was performed with a controlled before-and-after interventional design in an orthopaedic unit at a university hospital. Person-centred pain management for patients undergoing spine surgery was developed in co-creation by a multi-professional team and implemented throughout the care pathway. The usual care group (pre-intervention) served as a comparison to the intervention group. Pain intensity, shared decision-making in pain management, and patient satisfaction with results of pain management, served as patient-reported measures, collected using the International Pain Outcomes questionnaire and analysed using descriptive statistics. RESULTS: The intervention showed no benefit for patients' pain and satisfaction, while shared decision-making in pain management was significant lower in the intervention group than in the conventional group. The per-protocol analysis showed no significant differences between groups. CONCLUSION: The initial assumption of the study, that the implementation of a co-created structured person-centred care pathway would improve patient-reported outcomes, was not confirmed. The periodically low fidelity to the intervention due to organizational constraints (due to sub-optimal organizational conditions and managerial support) may have affected the results.

Nighttime versus Fulltime Brace Treatment for Adolescent Idiopathic Scoliosis: Which Brace to Choose? A Retrospective Study on 358 Patients.

The purpose of this study is to retrospectively compare the effectiveness of fulltime Boston Brace (BB) and Providence Nighttime Brace (PNB) treatments in moderate scoliotic curves (20-40°) at a single institution and to carry out analyses for different subgroups. Inclusion criteria: idiopathic scoliosis, age ≥ 10 years, curve 20-40°, Risser ≤ 3 or Sanders stage ≤ 6 and curve apex below T6 vertebra. Exclusion criteria: incomplete radiological or clinical follow-up and previous treatment. The primary outcome was failure according to the SRS outcome assessment: increase in main curve > 5° and/or increase in main curve beyond 45° and/or surgery. The subgroup analyses were secondary outcomes. In total, 249 patients in the PNB and 109 in the BB groups were included. The BB showed a higher success rate compared to the PNB (59% and 46%, respectively) in both crude and adjusted comparisons (p = 0.029 and p = 0.007, respectively). The subgroup analyses showed higher success rates in pre-menarchal females, thoracic curves and curves > 30° in the BB group compared to the PNB group. Based on the findings, fulltime braces should be the treatment of choice for more immature patients and patients with larger and thoracic curves while nighttime braces might be sufficient for post-menarchal females and patients with lumbar and smaller curves.

Detailed MRI evaluation of the spine: a 2-year follow-up study of young individuals reporting different training doses.

OBJECTIVE: To characterize the discs and vertebrae in detail over time in a group of adolescent individuals with varying training doses using magnetic resonance imaging (MRI). METHOD: Thirty-five students were recruited from regular high schools (n=13) as well as schools with athlete competitive skiing programmes (n = 22). The thoraco-lumbar spine of all individuals was examined at baseline and at 2-year follow-up using the same 1.5T scanner and imaging protocol. The individuals were grouped based on their reported training dose: low-to-normal training dose (≤5 h/week, n = 11, mean age 16.5 ± 0.5 years) and high training dose (>5 h/week, n = 24, mean age 17.2 ± 0.6 years.) RESULTS: At baseline, the signal intensity in the discs and vertebrae were significantly lower in individuals reporting high compared to low-to-normal training dose. The vertebral signal changed significantly over the 2-year period in both groups. However, only individuals reporting low-to-normal training dose displayed an overall disc signal change. Interestingly, the regional analysis displayed at baseline high annular signals in the more training-active individuals followed by a reduction over the two-year period. CONCLUSION: This study suggests that disc degeneration is manifested earlier in individuals reporting a higher training dose. Over a 2-year period, however, the degeneration process did not accelerate further. Also, a significant difference in the vertebral signal, at baseline and follow-up as well as over time, could be seen between groups of individuals reporting high versus low-to-normal training dose.

Full-Endoscopic Lumbar Discectomy vs Standard Discectomy: A Noninferiority Study on Clinically Relevant Changes.

BACKGROUND: Surgery for lumbar disc herniation (LDH) has had a remarkable technological development during the past 20 years. Microscopic discectomy has traditionally been the gold standard method to treat symptomatic LDH before the introduction of full-endoscopic lumbar discectomy (FELD). The FELD procedure allows unsurpassed magnification and visualization and is currently the most minimally invasive surgical technique. In this study, FELD was compared with standard surgery for LDH, with a focus on medically relevant changes in patient-reported outcome measures (PROMs). PURPOSE: The purpose of this study was to investigate whether FELD is noninferior to other surgical methods for LDH surgery in the most common PROMs, including postoperative leg pain and disability, while still reaching the necessary thresholds for relevant clinical and medical improvements. METHODS: Patients undergoing a FELD procedure at the Sahlgrenska University Hospital, Gothenburg, Sweden, between 2013 to 2018 were included. A total of 80 (41 men and 39 women) patients were enrolled. The FELD patients were matched 1:5 to controls from the Swedish spine register (Swespine) who had a standard microscopic or mini-open discectomy surgery. PROMs, including the Oswestry Disability Index (ODI) and the Numerical Rating Scale (NRS), as well as the patient acceptable symptom states (PASS) and the minimal important change (MIC), were used to compare the efficacy of the 2 surgical approaches. RESULTS: The FELD group achieved medically relevant and significant improvements noninferior to standard surgery within the predefined thresholds of MIC and PASS. No differences could be found in disability measured by ODI FELD -28.4 (SD 19.2) vs standard surgery -28.7 (SD 18.9) or leg pain NRSLeg FELD -4.35 (SD 2.93) vs standard surgery -4.99 (SD 3.12). All intragroup score changes were significant. CONCLUSIONS: The FELD results are not inferior to standard surgery 1 year postoperatively after LDH surgery. There were no medically significant differences regarding MIC achieved or final PASS in any of the measured PROMs, including leg pain, back pain, or disability (ODI) between the surgical methods. CLINICAL RELEVANCE: The present study highlights that FELD is noninferior to standard surgery in clinically relevant PROMs.

Revision Spinal Surgery at a University Hospital: Incidence, Causes, and Microbiological Agents in Infected Patients.

BACKGROUND: The number of spinal surgeries performed worldwide have significantly increased over the past decade. However, to the best of our knowledge, there are no national or international studies that report the overall picture of complications following spinal surgery. This article sought to identify the incidence and causes of reoperations in patients undergoing spinal surgery, as well as the average time from index surgery to reoperation. Furthermore, the purpose was to identify the microbiological agents present in cultures from infected patients. METHODS: This was a retrospective cohort study that used a university hospital's medical records as the data source. The study population comprised 2110 patients who underwent spinal surgery during a 40-month period between 2015 and 2018. All suspected reoperations were verified manually. Additional data collected for reoperations included cause, time from index surgery, and laboratory results from cultures. Descriptive analysis was used. RESULTS: The incidence of reoperations during the study period was 11% (n = 232). The most common cause of reoperation was infection (28%, n = 65), followed by implant-related causes (19%, n = 44) and hemorrhage/hematoma (15%, n = 34). The time between index surgery and reoperation varied, but half of all reoperations occurred within 30 days. Coagulase-negative staphylococci were the most common type of bacteria (positive cultures in 39% of infected patients). CONCLUSION: The number of reoperations in the studied hospital were high during the study period. Infections accounted for a large percentage of reoperations, suggesting that effective preventive measures might significantly reduce the total number of reoperations. CLINICAL RELEVANCE: Postoperative infection causing reoperations after spinal surgeries is a large problem, and finding effective preventive measures should be a priority for caregivers.

No Significant Change in MRI Abnormalities or Back Pain Prevalence in the Thoraco-Lumbar Spine of Young Elite Skiers Over a 2-Year Follow-Up.

Background: Young athletes are at increasing risk for spinal column injuries due to overloading the spine with excessive sports activities, with potential development of complications later in life. Purpose: The purpose of this 2-year follow-up study of young elite skiers and non-athletes was to investigate any potential change in the thoraco-lumbar findings on MRI and to outline any change in back pain prevalence with continuing sporting activity and age. Study Design: Longitudinal cross-sectional study. Methods: MRI of the thoraco-lumbar spine was performed on 30 skiers (mean age 20 years, female 43%) and 16 non-athletes (mean age 19, female 75%), available for the 2-year follow-up. The intervertebral discs were evaluated for signal, height, bulge/herniation, and additionally according to Pfirrmann classification, and the endplates were graded according to endplate defect score. Any of the following disc findings was defined as disc degenerative change: reduced signal, reduced height, bulge, or herniation. All participants answered a specific back pain questionnaire. Results: No significant difference in spinal column abnormalities, nor back pain, was found between baseline and 2-year follow-up in neither skiers nor controls. There was significantly higher prevalence of disc degenerative changes in skiers (73%) than in non-athletes (44%, p=0.05). Skiers (63%) had significantly more Pfirrmann grade ≥3 discs compared to non-athletes (25%) (p=0.03). There was no significant difference in number of endplates with score ≥4 between skiers and non-athletes (50% vs 38%, p=0.40) nor in lifetime prevalence of back pain between skiers (46%) and non-athletes (40%). Conclusion: There was no significant change over time of the spinal column MRI abnormalities, nor back pain prevalence, during a 2-year follow-up of skiers and non-athletes. Young skiers had significantly higher prevalence of spine abnormalities compared with non-athletes. There was no significant difference of the back pain lifetime prevalence in skiers compared with non-athletes.

The impact of implementing a person-centred pain management intervention on resistance to change and organizational culture.

BACKGROUND: Resistance to change and organizational culture are essential factors to consider in change management in health care settings. Implementation of structural change remains a challenge. There is a lack of studies providing information on the impact of implementation processes on the organization. The aim of this study was to describe the impact of implementing a systematic change process concerning postoperative person-centred pain management on resistance to change and organizational culture in an orthopaedic spine surgery unit. METHODS: The study was set in an orthopaedic spine surgery unit at a university hospital. Person-centred bundles of care for postoperative pain management of spine surgery patients were developed in co-creation by a multi-professional expert group and implemented throughout the care pathway. The intervention was underpinned by theories on organizational culture and inspired by principles of person-centred care. Quantitative data were collected using the Resistance to Change Scale and the Organizational Culture Assessment Instrument and analysed using descriptive statistics. RESULTS: The findings showed a low resistance to change decreasing during the study. The organizational culture shifted from a result-oriented to a formalized and structured culture after the implementation. The culture preferred by the staff was team-oriented and participation-focused throughout the study. The discrepancy between the current and preferred cultures remained extensive over time. CONCLUSION: It is challenging to describe the influence of the development and implementation of a postoperative pain management program on organizational culture as well as in terms of resistance to change, in a complex health care setting. In the current study the unit was under organizational strain during the implementation. Albeit, the important discrepancy between the current and preferred organizational culture could imply that structural changes aren't enough when implementing person-centred pain management structures and needs to be combined with relational aspects of change.

Association of extended duration of sciatic leg pain with worse outcome after lumbar disc herniation surgery: a register study in 6216 patients.

OBJECTIVE: Sciatica is the hallmark symptom of a lumbar disc herniation (LDH). Up to 90% of LDH patients recover within 12 weeks regardless of treatment. With continued deteriorating symptoms and low patient quality of life, most surgeons recommend surgical discectomy. However, there is not yet a clear consensus regarding the proper timing of surgery. The aim of this study was to evaluate how the duration of preoperative leg pain (sciatic neuralgia) is associated with patient-reported levels of postoperative leg pain reduction and other patient-reported outcome measures (PROMs) in a prospectively collected data set from a large national cohort. METHODS: All patients aged 18-65 years undergoing a lumbar discectomy during 2013-2016 and registered in Swespine (the Swedish national spine registry) with 1 year of postoperative follow-up data were included in the study (n = 6216). The patients were stratified into 4 groups according to preoperative pain duration: < 3, 3-12, 12-24, or > 24 months. Patient results assessed with the numeric rating scale (NRS) for leg pain (rated from 0 to 10), global assessment of leg pain, EQ-5D, Oswestry Disability Index (ODI), and patient satisfaction with the final surgical outcome were analyzed and compared with preoperative values and between groups. RESULTS: A significant improvement was seen 1 year postoperatively regardless of preoperative pain duration (change in NRS score: mean -4.83, 95% CI -4.73 to -4.93 in the entire cohort). The largest decrease in leg pain NRS score (mean -5.59, 95% CI -5.85 to -5.33) was seen in the operated group with the shortest sciatica duration (< 3 months). The patients with a leg pain duration in excess of 12 months had a significantly higher risk of having unchanged radiating leg pain 1 year postoperatively compared with those with < 12-month leg pain duration at the time of surgery (OR 2.41, 95% CI 1.81-3.21, p < 0.0001). CONCLUSIONS: Patients with the shortest leg pain duration (< 3 months) reported superior outcomes in all measured parameters. More significantly, using a 12-month pain duration as a cutoff, patients who had a lumbar discectomy with a preoperative symptom duration < 12 months experienced a larger reduction in leg pain and were more satisfied with their surgical outcome and perception of postoperative leg pain than those with > 12 months of sciatic leg pain.

Intradiscal Injection of Iron-Labeled Autologous Mesenchymal Stromal Cells in Patients With Chronic Low Back Pain: A Feasibility Study With 2 Years Follow-Up.

PURPOSE: Degeneration of the intervertebral disc is considered to be central in pain pathogenesis in patients suffering from chronic low back pain (LBP). In recent years, the injection of mesenchymal stromal cells (MSCs) into the disc to arrest or reverse the degenerative process has been proposed as an alternative therapy. The aim of the present study was to investigate the feasibility of using iron-labeled MSCs for intradiscal injection in patients with long-standing LBP. METHODS: Ten patients (7 men, 3 women, mean age 40 years, range 26-53) with chronic LBP and confirmed disc degeneration on magnetic resonance imaging (MRI) were recruited from the waiting list for planned surgery. Injection of autologous, expanded, and iron-labeled bone marrow-derived MSCs (BM-MSCs) into 1 or 2 disc levels was undertaken. Follow-up consisted of monitoring of adverse events, regular MRI examinations, and collection of patient-reported outcome measures (PROMs) for a minimum of 2 years. RESULTS: No complications could be detected, neither clinically nor on MRI. No statistically significant improvement was seen for PROMs on a group level up to 2 years postinjection. Three of 10 patients opted to proceed with the initially planned surgery within the first year and 2 more within 3 years postinjection. CONCLUSION: Results from this pilot cohort study show that injection of autologous expanded iron-labeled BM-MSCs is a safe procedure, in accordance with the existing body of evidence. The clinical result warrants further larger studies. LEVEL OF EVIDENCE: 4 for therapeutic studies.

Hip pain and its correlation with cam morphology in young skiers-a minimum of 5 years follow-up.

BACKGROUND: There is conflicting evidence regarding the association between cam morphological changes and hip pain, and it remains unclear who with cam morphology will develop hip pain and who will not. This study aimed to investigate the correlation between cam morphology, hip pain, and activity level at a 5-year follow-up in young Alpine and Mogul skiers. METHOD: All students (n = 76) at Åre Ski National Sports High School were invited and accepted participation in this prospective study at baseline. Magnetic resonance imaging (MRI) of both hips was conducted to evaluate the presence of cam morphology (α-angle ≥ 55°) and its size alongside the reporting of hip pain, type, and frequency of training by the Back and hip questionnaire, at baseline. After 5 years, the skiers were invited to complete a shortened version of the same questionnaire. RESULTS: A total of 60 skiers (80%) completed the follow-up questionnaire, of which 53 had concomitant MRI data. Cam morphology was present in 25 skiers (47.2%, 39 hips). Hip pain at baseline and at follow-up was reported in 17 (28.3%) and 22 (36.7%) skiers, respectively. No correlations were found between the activity level, the frequency, and the size of cam morphology and hip pain, except for the right hip α-angle at 1 o'clock and hip pain in skiers with cam morphology at baseline (rs = 0.49; P = 0.03) and at follow-up (rs = 0.47; P = 0.04). A total of 73.3% skiers had retired, of which 48% reported this was due to injuries. CONCLUSION: Hip pain was not shown to be correlated, or had a low correlation, with activity level and the presence and size of cam morphology in young skiers on a 5-year follow-up. Based on these results, cam morphology or activity level did not affect hip pain to develop during 5 years of follow-up in young skiers. Furthermore, this study highlights that almost 75% of young elite skiers had retired from their elite career with almost 50% reporting that this was due to injuries sustained from skiing.

Successful Introduction of Full-Endoscopic Lumbar Interlaminar Discectomy in Sweden.

BACKGROUND: The introduction of full-endoscopic lumbar discectomy (FELD) procedures has made it possible to challenge microscopic discectomy as the gold standard method to treat lumbar disc herniations. PURPOSE: The aim of the present study is to investigate the introductory-phase postoperative clinical improvement for FELD patients regarding leg pain, patient-reported outcome measurements (PROMs), complications, reoperations, and learning curve analysis. METHODS: All patients who underwent FELD at Sahlgrenska University Hospital, Sweden, were prospectively included during 2013- 2017. A total of 92 patients were enrolled and followed up for 1 year. The characteristics of the study population, degree of leg pain, complications, learning curve, and PROMs were retrieved from patient records and the National Quality Register for Spine Surgery (Swespine). RESULTS: The postoperative results demonstrated major improvements; leg pain measured by a numerical rating scale (0-10) decreased from 7.4 ± 2.25 to 2.76 ± 2.70, with a mean improvement of -4.54, (-3.62-5.46) 95% confidence interval (CI). The Oswestry Disability Index decreased by 30.48 (-36.27-23.73) with a 95% CI, and the EuroQol-5D increased by 0.39 (0.21-0.57) 95% CI. An assessment of the final surgical result showed that 91.6% ranked their general situation as better or much better. Specifically, regarding postoperative leg pain, 87% regarded their leg pain as completely gone, much better, or somewhat better, while 13% regarded their leg pain as unchanged or worse. A learning curve analysis showed that for every 10th FELD procedure performed; the duration of surgery decreased by 2 minutes. CONCLUSIONS: In our study, the introduction of FELD as a safe, quick procedure for the treatment of lumbar disc herniations can yield significant gains in patient-reported outcome measurements and pain reduction. The rate of recurrence and complications is comparable to that of standard surgery.

Human Levels of MMP-1 in Degenerated Disks Can Be Mitigated by Signaling Peptides from Mesenchymal Stem Cells.

Degradation of extracellular matrix (ECM) in intervertebral disks (IVDs) during IVD degeneration plays a vital role in low back pain (LBP). In healthy IVDs, synthesis and degradation of ECM are kept in balance by matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs. MMPs are enzymes responsible for ECM degradation, and their expression levels are known to increase in degenerated disks. However, the exact pathophysiological concentration of MMP-1 in the degenerated disks of patients with chronic LBP has not been reported previously. Factors secreted by human mesenchymal stem cells (hMSCs) have shown positive results in cell therapy of degenerated disks. The aim of this study was to investigate the pathophysiological MMP-1 concentration (in ng/mL) in degenerated disk tissue and to evaluate if conditioned media (CM) from hMSCs could mitigate the effects of MMP-1 at the detected levels in a 3D in vitro disk cell (DC) pellet model. Tissue levels of MMP-1 were quantified in disk tissue collected from 6 chronic LBP patients undergoing surgery. DC pellet cultures were performed to investigate the effects of MMP-1 alone and the effects of conditioned media (CM) in the presence of MMP-1. MMP-1 was introduced in the pellets on day 14 at concentrations of 5, 50, or 100 ng/mL. The pellets were harvested on day 28 and evaluated for cell viability, proliferation, and ECM production. The mean concentration of MMP-1 in disk tissue was 151 ng/mL. Results from pellet cultures demonstrated a higher number of viable cells, glycosaminoglycan production, and ECM accumulation in the CM group even in the presence of MMP-1 compared to the controls. However, the level decreased with increasing MMP-1 concentration. The results demonstrated that CM has the ability to mitigate matrix degradation property of MMP-1 up to 50 ng/mL suggesting that CM could potentially be used to treat early stages of disk degeneration.

Low rate of high-level athletes maintained a return to pre-injury sports two years after arthroscopic treatment for femoroacetabular impingement syndrome.

PURPOSE: The aim was to investigate the rate of athletes still active at their pre-injury sports level two years after arthroscopic treatment for femoroacetabular impingement syndrome (FAIS), and examine this between different sports and gender, and its correlation to patient-reported outcome measures (PROMs). METHOD: High-level athletes planned for arthroscopic treatment for FAIS were included prospectively in a Swedish hip arthroscopy registry between 2011 and 2017, and 717 met the inclusion criteria. Self-reported sporting activity was recorded preoperatively. The subjects answered PROMs, including the HSAS, iHOT-12 and HAGOS pre- and postoperatively. RESULTS: A total of 551 athletes (median age 26, interquartile range 20-34 years; 23% women) had completed follow-up PROMs, at mean 23.4 ± 7.2 months postoperatively. In total, 135 (24.5%) were active at their pre-injury level of sports at follow-up (RTSpre). Athletes ≤30 years at time of surgery (n = 366; median age 22 years) had higher rate of RTSpre (31.4%) compared with athletes > 30 years (n = 185; median age 40 years) (10.8%; p < 0.001). All athletes had improvements in iHOT-12 and HAGOS, two years postoperatively (p < 0.001), while RTSpre athletes reported significantly better PROMs, pre- and postoperatively, and had greater improvements two years postoperatively, compared with athletes not active at pre-injury level. CONCLUSION: Only 25% of all high-level athletes and 31% of athletes ≤30 years were still active at their pre-injury sports level two years after arthroscopic treatment for FAIS. Athletes still active had significantly and clinically greater improvement regarding hip symptoms, function and quality of life, as compared with athletes not active at pre-injury level, two years postoperatively.

Low lordosis is a common finding in young lumbar disc herniation patients.

PURPOSE: The sagittal alignment of the lumbar spine and pelvis can be classified into several subtypes. It has been suggested that the risk of developing certain pathologies, such as a lumbar disc herniation (LDH) is affected by spinal sagittal profiles. The main aim of this study was to investigate the sagittal profile in young patients surgically treated for a lumbar disc herniation and if a discectomy would alter the sagittal parameters. METHODS: Sixteen active young patients (mean age 18.3 ± 3.2 SD) with a lumbar disc herniation having a discectomy were included. A classification according to Roussouly of the sagittal parameters was made by two senior spinal surgeons, both pre-operatively and post-operatively on radiographs. The distribution of sagittal parameters and spinopelvic profiles were analysed and compared to a previous established healthy normal population. RESULTS: This series of active young patients with LDH exhibited a low lumbar lordosis dominance, with Roussouly sagittal profiles type 1 and type 2 accounting for more than 75% of the examined patients. An analysis of the erect radiographs revealed no significant changes in the post-operative sagittal profile. CONCLUSIONS: This study showed that sagittal spinal alignment according to Roussouly in a young population with LDH is skewed compared with a normal population cohort. Furthermore, the lack of post-operative correction is suggestive of a non-ephemeral response to a LDH. Roussouly type 2 spinal sagittal profile may be a risk factor in young individuals suffering a disc herniation.

A model for evaluation of the electric activity and oxygenation in the erector spinae muscle during isometric loading adapted for spine patients.

BACKGROUND: Simultaneous measurement of electromyography (EMG) and local muscle oxygenation is proposed in an isometric loading model adjusted for patients that have undergone spinal surgery. METHODS: Twelve patients with degenerative lumbar spinal stenosis (DLSS) were included. They were subjected to a test protocol before and after surgery. The protocol consisted of two parts, a dynamic and an isometric Ito loading with a time frame of 60 s and accompanying rest of 120 s. The Ito test was repeated three times. EMG was measured bilaterally at the L4 level and L2 and was recorded using surface electrodes and collected (Biopac Systems Inc.). EMG signal was expressed as RMS and median frequency (MF). Muscle tissue oxygen saturation (MrSO2) was monitored using a near-infrared spectroscopy (NIRS) device (INVOS® 5100C Oxymeter). Two NIRS sensors were positioned bilaterally at the L4 level. The intensity of the leg and back pain and perceived exertion before, during, and after the test was evaluated with a visual analogue scale (VAS) and Borg RPE-scale, respectively. RESULTS: All patients were able to perform and complete the test protocol pre- and postoperatively. A consistency of lower median and range values was noted in the sensors of EMG1 (15.3 µV, range 4.5-30.7 µV) and EMG2 (13.6 µV, range 4.0-46.5 µV) that were positioned lateral to NIRS sensors at L4 compared with EMG3 (18.9 µV, range 6.5-50.0 µV) and EMG4 (20.4 µV, range 7.5-49.0 µV) at L2. Right and left side of the erector spinae exhibited a similar electrical activity behaviour over time during Ito test (60 s). Regional MrSO2 decreased over time during loading and returned to the baseline level during recovery on both left and right side. Both low back and leg pain was significantly reduced postoperatively. CONCLUSION: Simultaneous measurement of surface EMG and NIRS seems to be a promising tool for objective assessment of paraspinal muscle function in terms of muscular activity and local muscle oxygenation changes in response to isometric trunk extension in patients that have undergone laminectomy for spinal stenosis.

Healthcare practitioners' experiences of postoperative pain management in lumbar spine surgery care-A qualitative study.

AIMS AND OBJECTIVE: To explore and describe healthcare practitioners' experiences of postoperative pain management to patients undergoing planned lumbar spine surgery by identifying the healthcare practitioners' behaviours, attitudes and strategies. BACKGROUND: Poorly managed postoperative pain continues to cause suffering and prolong hospital care and may affect individual and team practitioners' strategies and attitudes. The impact of these strategies and attitudes needs greater understanding. DESIGN: Descriptive qualitative study. METHODS: In-depth interviews were conducted at a university hospital in Sweden during January-March 2016 with 9 healthcare practitioners (ages: 29-61 years; gender: male 3 and female 6; professions: medical doctor 3, registered nurse 3 and physiotherapist 3; professional experience: 1.5 months to 25 years). The interviews were analysed using Braun and Clarke's thematic analysis. The study adhered to the Consolidated Criteria for Reporting Qualitative Research COREQ. RESULTS: The interviews revealed healthcare practitioners' attitudes and strategies. Three themes were identified: (a) Connecting with the person was recognised as the key component in postoperative pain management; (b) Professionalism: a balancing act, accentuated health care practitioners' duality in being both vulnerable and strong in delicate care situations; and (c) Collaboration: being constantly responsive, the necessity for healthcare practitioners to be constantly responsive to their environment. CONCLUSIONS: The findings pinpoint the need for healthcare organisations to build structures enabling practitioners to deliver adequate pain management in acknowledging the practitioners' delicate situation when facing patients in pain. RELEVANCE TO CLINICAL PRACTICE: Given the global need for postoperative pain management, our findings have international relevance. Preconceived expectations on specific pain need to be depicted and postoperative pain taken seriously to protect the patient as well as the healthcare practitioners.

Resolving anterior hip pain in a young male footballer following arthroscopic surgery for Femoroacetabular Impingement Syndrome: A case report.

BACKGROUND: There appear to be limited studies available regarding the conservative management of patients following hip joint arthroscopic surgery, or investigating reasons for which patients still report hip and groin pain post surgery. OBJECTIVES: Treatment was applied to restore spino-pelvic mechanics and to reduce soft tissue restrictions in hip joint motion. Neuromuscular movement control and work capacity exercises were encouraged to support the integrity of the hip joint and spino-pelvic complex. CLINICAL FEATURES: A 22-year-old male footballer, (height 190cm and weight 82kg) presented reporting an eighteen-month history of hip and groin pain, having previously undergone bilateral arthroscopic surgery twelve months earlier for Femoroacetabular Impingement Syndrome. Strength measurements were recorded using the MicroFET 2 Wireless Digital Handheld Dynamometer. Trunk muscular endurance was evaluated with Sorenson test. RESULTS: Five treatment consultations over a five-week period resulted in pain reduction, (Visual Analogue Scale 8/10 to 0/10). Improvement in range of motion, right hip flexion (70-100°) and left (80-100°), right internal rotation (30-45°) and left (40-45°). Improvement in strength, specifically right hip flexion (0.29-0.43Nm/kg, 48%) and right hip abduction (0.35-0.46Nm/kg, 31%). Improvement in trunk muscular endurance increased 41% from 170 seconds to 240 seconds. CONCLUSION: This case report supports the rationale that the post arthroscopic management of Femoroacetabular Impingement Syndrome, should include both treatment to address spino-pelvic restrictions, if appropriate, combined with exercises that specifically target hip flexor strength. However, a larger randomized study would provide a clearer understanding for the management of this particular subset of patients.

Good 5-year outcomes after arthroscopic treatment for femoroacetabular impingement syndrome.

PURPOSE: The purpose of the present study was to evaluate the outcome of arthroscopic treatment for femoroacetabular impingement (FAI) syndrome 5 years post-surgery using patient-reported outcome scores (PROMs) validated for a young and active population with hip complaints. METHODS: Patients were prospectively included in the study. A total of 184 patients [males = 110 (59.8%), females = 74 (40.2%)], with mean age 38.0, underwent arthroscopic treatment for FAI syndrome and were analysed. Preoperatively and at the 5-year follow-up, patients completed a set of self-administered web-based PROMs consisting of the International Hip Outcome Tool (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), the Hip Sports Activity Scale (HSAS), the EuroQoL-5 Dimension Questionnaire (EQ-5D), the EQ-Visual Analogue Scale (VAS) and the VAS for overall hip function and overall satisfaction. The Wilcoxon signed rank test was used to compare preoperative PROM values with those obtained at the 5-year follow-up. RESULTS: A comparison of preoperative PROM scores and those obtained at the 5-year follow-up revealed statistically significant improvements for all outcome scores (p < 0.05), except for the HSAS score, which were unchanged; iHOT-12 (42.9 vs 67.2), HAGOS different subscales (50.2 vs 69.6, 55.7 vs 76.1, 59.2 vs 72.3, 41.1 vs 66.4, 30.8 vs 60.2, 31.6 vs 60.4), EQ-5D (0.570 vs 0.742), EQ-VAS (66.6 vs 74.4), HSAS (3.13 vs 3.17) and VAS for overall hip function (47.9 vs 69.2). At the 5-year follow-up, 154 patients reported that they were satisfied with surgery (84.6%). Survivorship at the 5-year follow-up was 86.4%. CONCLUSION: Arthroscopic treatment for FAI syndrome yields good patient-reported outcome at the 5-year follow-up. LEVEL OF EVIDENCE: II.

Young elite Alpine and Mogul skiers have a higher prevalence of cam morphology than non-athletes.

PURPOSE: To investigate the prevalence of cam morphology in (1) a group of young elite Mogul and Alpine skiers compared with non-athletes and (2) between the sexes. METHOD: The hip joints of 87 subjects [n = 61 young elite skiers (29 females and 32 males) and n = 26 non-athletes (17 females and 9 males)] were examined using MRI, for measurements of the presence of cam morphology (α-angle ≥ 55). RESULTS: The skiers had a significantly higher prevalence of cam morphology compared with the non-athletes (49% vs 19%, p = 0.009). A significant difference (p < 0.001) was also found between females and males, where 22% of the females and 61% of the males had cam morphology. Among the skiers, there was also a significant difference (p < 0.001) between the sexes, where 28% of the females and 68% of the males had cam morphology. This difference between the sexes was not found in the non-athletic group. No significant differences were found between Mogul and Alpine skiers. CONCLUSION: Young male elite skiers have a higher prevalence of cam morphology of the hips compared with non-athletes. LEVEL OF EVIDENCE: II.

BMP-3 Promotes Matrix Production in Co-cultured Stem Cells and Disc Cells from Low Back Pain Patients.

Low back pain is one of the most common disorders and believed to be due to intervertebral disc degeneration. Transplantation of human mesenchymal stem cells (hMSCs) is suggested as potential treatment option. Bone morphogenetic growth factor 3 (BMP-3) promotes chondrogenesis and is proven effective in enhancing chondrogenesis in hMSCs pretreated with interleukin-1 beta (IL-1ß) in hydrogel model. Three-dimensional co-cultures of hMSCs and disc cells (DCs) have previously been demonstrated to result in increased proteoglycan production. The aim was to study the effects of BMP-3 on hMSCs, DCs, as well as hMSCs and DCs in co-culture in a pellet system, both as single treatment and after pretreatment of IL-1ß. Cell pellet cultures with hMSCs, DCs, and co-culture (1:1 ratio) were performed and stimulated with BMP-3 at 1 or 10 ng/mL concentrations. For pretreatment (PRE-T), cell pellets were first stimulated with IL-1ß, for 24 h, and then BMP-3. The pellets were harvested on day 7, 14, and 28. Results demonstrated that BMP-3 stimulation at 10 ng/mL promoted cell viability, proteoglycan accumulation, as well as chondrogenesis in all pellet groups compared to 1 ng/mL. Cellular proliferation and chondrogenic differentiation of hMSCs were best promoted by PRE-T at 10 ng/mL, whereas BMP-3 best enhanced chondrogenesis in DC and co-culture pellets at the same concentration. Impact Statement Current therapies for low back pain include pain modulation and surgery, which do not tackle the underlying cellular mechanisms of the degenerated intervertebral discs (IVDs). To develop an understanding of the degeneration process and to further reverse its course, the effects of growth factor and cytokine on the native cells of the IVDs were investigated, revealing the potency of bone morphogenetic growth factor 3 on disc cells (DCs) and combined culture of mesenchymal stem cells and DCs. These results may impact future strategies in development of cell therapies that could directly influence the IVD degeneration process, which might alter the treatment models of today.