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.

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%.

Comparison of magnetic resonance imaging findings among sciatica patients classified as centralizers or non-centralizers.

OBJECTIVE: To compare if the degenerative findings from MRI differ between the sciatica patients classified as centralizers (CEN) and non-centralizers (Non-CEN) according to the McKenzie Method of mechanical diagnosis and therapy. STUDY DESIGN: A cross-sectional study. METHODS: Patients (N = 100) referred to a spine clinic of a single tertiary hospital for specialist consultation for sciatica. The McKenzie-based assessment was performed by the mechanical diagnosis and therapy-trained physiotherapists. Clinical data and prevalence of lumbar MRI findings were compared between the groups. RESULTS: There was no significant difference in leg pain intensity between the groups. The Non-CEN had significantly more intense back pain, mean 56 (SD 30) and were more disabled 44 (SD 15) compared to the CEN mean 41 (SD 25) and mean 31 (11), measured with a visual analogue scale (0-100), and the Oswestry Disability Index (0-100), respectively. The CEN had more severe degenerative findings on MRI than the Non-CEN: vertebral end-plate changes were 63% and 43%; mean Pfirrmann's disc degeneration lumbar summary score was 12.8, and 10.6; and severity score of total damage was 12.0 and 10.1, respectively. There were differences neither in disc contour changes nor nerve root stenosis on MRI. CONCLUSIONS: Sciatica patients classified as non-centralizers had significantly more severe back pain, and were significantly more disabled than centralizers, who instead had more severe degenerative findings on MRI. Thus, classification to non-centralizers by the McKenzie method seems not predict higher incidence of degenerative findings on MRI compared to centralizers.

Psychometric Properties of the Scoliosis Research Society Questionnaire (Version 22r) Domains Among Adults With Spinal Deformity: A Rasch Measurement Theory Analysis.

OBJECTIVE: Adult spinal deformity (ASD) have lower health-related quality of life (HRQoL) compared to the general population. Applying Rasch measurement theory (RMT), this study tested the revised Scoliosis Research Society-22 (SRS-22r) HRQoL instrument among symptomatic adult patients with degenerative spinal disorders and varying degrees of ASD. METHODS: SRS-22r data from 637 outpatient spine clinic patients with degenerative spine conditions were investigated for unidimensionality, item/scale fit, differential item functioning (DIF), scale coverage/targeting, and person separation index (PSI) using RMT. RESULTS: Unidimensionality of the SRS-22r was not supported for either the total score or for 3 of its 5 domains. Item fit was acceptable for 11/22 items. The individual domains showed good coverage despite the degree of structural disorders. Ordered thresholds were achieved by merging response categories in some of the items. DIF towards age or sex was found in 11/22 items and in some domain items. The PSI exceeded 0.7 for the SRS-22r total score. CONCLUSION: The individual domain scores of the SRS-22r perform better than the total score providing good coverage and targeting among patients with ASD. Refinements of items and domains may improve the structural validity of the instrument to meet the criteria for measuring ASD patients, even when multidimensionality persists.

Effectiveness of a 12-month home-based exercise program on trunk muscle strength and spine function after lumbar spine fusion surgery: a randomized controlled trial.

MATERIALS AND METHODS: Three months postoperatively, 98 patients were randomized either to the exercise group (EG), with a progressive 12-month home-based exercise program, or to usual care group (UCG), with one guidance session for light home-exercises. Maximal trunk muscle strength was measured by a strain-gauge dynamometer and trunk extensor endurance was measured by Biering-Sørensen's test at baseline and after the intervention. RESULTS: The mean change in extension strength during the intervention was 75 N in EG and 58 N in UCG. Flexion strength improved 50 N in UCG and 45 N in EG. Trunk extension/flexion strength ratio changed from 0.90 to 1.02 in EG and from 0.98 to 1.00 in UCG. In EG, Biering-Sørensen's test improved by 17 s, and in UCG, it improved by 24 s. No statistically significant between-group differences were found in any variables. Median exercise frequency in EG decreased from 2.5×/week during the first two intervention months to 1.7×/week during the last two intervention months. CONCLUSIONS: Twelve-month progressive exercise program was equally effective as usual care in improving trunk muscle strength. Home exercise adherence decreased, which may have influenced the strength changes.Implications for rehabilitationThe 12-month home-based exercise program was equally as effective as usual care after lumbar spine fusion (LSF) in improving trunk muscle strength, however, the back-specific exercises led to better trunk muscle strength balance in exercise group only.The adherence to the home based exercise program is a challenge; therefore, different techniques could be implemented to provide purposeful support for each individual in their long-term exercising.It is important to recognize those who need more individualized rehabilitation in recovery of the spine function, while others may manage with subtle intervention after LSF.

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.

Further validation of the Scoliosis Research Society (SRS-30) questionnaire among adult patients with degenerative spinal disorder.

PURPOSE: The Scoliosis Research Society (SRS-30) questionnaire proved valid in measuring health-related quality of life (HRQoL) in adult patients with spinal deformity or degenerative disease. This study further assesses the validity of the SRS-30 by comparing its results with other HRQoL instruments, such as Oswestry disability index (ODI) and the RAND-36, among unselected adult patients with degenerative spinal disorder. MATERIALS AND METHODS: 628 consecutive patients completed the SRS-30, the ODI, the pain visual analog scale (VAS), and RAND-36 questionnaires. Using a 9 mm minimal important difference threshold of the VAS, patients were divided into three groups of symptom location: back pain (n = 226), lower extremity pain (n = 161), and combination of both (n = 241). Statistical and illustrative tests using beta coefficients, Rasch measurement analytics, and score distributions were used for analysis. RESULTS: The SRS-30 functioned well for all three subgroups. There were small differences in convergent validity of the SRS-30 compared to the ODI and the RAND-36 between the three subgroups. The SRS-30 performed similarly in different pain groups independent of age, gender, or deformity severity. The scale displayed good coverage and targeting for all three subgroups. CONCLUSIONS: The SRS-30 proved to provide valid HRQoL scores for all adult patients with degenerative spinal disorders. Implications for Rehabilitation Degenerative spinal conditions associated with spinal deformities are common in patients over 60 years. Low back pain is globally the leading cause of disability. The applicability of the Scoliosis Research Society (SRS-30) questionnaire has not been tested in relation to different pain origins. The SRS-30 proved to provide valid health-related quality of life assessment among patients with degenerative spinal disease independent of pain location. The SRS-30 questionnaire can be used to assess the level of disability and rehabilitation of patients with degenerative spinal disease.

Rasch validation of the Depression Scale among patients with low back pain.

BACKGROUND: The Depression Scale (DEPS) is a commonly used screening tool for major depression in studies investigating low back pain, yet it has not been validated for patients with back-specific problems. OBJECTIVE: To assess the psychometric properties of the DEPS in patients with degenerative spinal disease. METHODS: Six hundred and thirty-seven patients with a degenerative spinal disease completed the DEPS instrument. The Rasch Measurement Theory was applied to analyze the measurement properties of the DEPS. The main hypothesis-driven approach was whether the DEPS would meet relevant psychometric criteria for assessing depressive symptoms among patients with degenerative spinal disease. RESULTS: The Mean (SD) DEPS score was 9.2 (6.6). Scale minimum or maximum points among participants were 2.4% and 0.8%, respectively. Cronbach's alpha for internal consistency was 0.92. Person Separation Index for reliability was 0.88. All items had ordered thresholds and seven of the 10 items had good item fit. Unidimensionality of the DEPS was supported (proportion of significant t-tests, 4.5%). CONCLUSIONS: This study supports the validity of the DEPS for screening depressive symptoms in patients with degenerative spinal disease.

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.

Mortality and comorbidity after non-operatively managed, low-energy pelvic fracture in patients over age 70: a comparison with an age-matched femoral neck fracture cohort and general population.

BACKGROUND: Research on mortality and comorbidity associated with pelvic fractures in older patients is scarce. We aimed to determine the short- and long-term mortality rates of older patients with a pelvic ring fracture compared with both an age-matched cohort of patients with a femoral neck fracture and a general population, and to investigate 30- and 60-day readmission rates after pelvic fracture. METHODS: This was a retrospective cohort study done in an emergency department of a level II/III trauma center. All patients aged over 70 years diagnosed with a pelvic or acetabular fracture between January 2010 and December 2016 in our ED were identified. Two reference populations were used: patients operated due to femoral neck fracture in our institution between 2007 and 2008 and a general population aged 70 years or more. RESULTS: Two hundred nineteen patients were identified. 30- and 90-day mortality was 7.3 and 11.4%, respectively. Compared to the general population, a pelvic fracture was associated with an 8.5-fold (95% CI: 5.2-13.9) and 11.0-fold (95% CI: 5.4-22.3) 90-day mortality risk in females and males, respectively. We could not observe a difference in the risk of 90-day mortality between femoral neck fracture patients and patients with a pelvic fracture. Within 30 days, 28 (12.8%) pelvic fracture patients were readmitted for in-patient care in our hospital. CONCLUSIONS: The mortality of older patients with pelvic ring fractures resembles that after hip fracture. Although older patients with a pelvic ring fracture rarely require operative treatment, the severity of the injury should not be considered as a class apart from hip fracture.

Assessment of Construct Validity of the Oswestry Disability Index and the Scoliosis Research Society-30 Questionnaire (SRS-30) in Patients With Degenerative Spinal Disease.

STUDY DESIGN: Observational cohort study. OBJECTIVES: To measure and compare the structural validity of the Oswestry Disability Index (ODI) and the Scoliosis Research Society-30 (SRS-30) questionnaire in an adult population with prolonged degenerative thoracolumbar disease. SUMMARY OF BACKGROUND DATA: The ODI and the SRS-30 are commonly used patient-reported outcome instruments to assess back-specific disability and symptoms related to scoliosis. Still, these instruments have not been validated for degenerative spinal disease with different stages of deformity. METHODS: Altogether, 637 consecutive adult patients with degenerative spinal pathologies were included. The patients completed the ODI (version 2.0), the 23 preoperative items of the SRS-30, a general health survey, the Kasari Frequency Intensity Time (FIT) index, the Depression Scale (DEPS), the RAND-36, and visual analog scales for leg and back pain instruments. Psychometric statistical and illustrative analyses were conducted. Deformity groups were analyzed to assess how well the two instruments reflect deformity-related back problems. RESULTS: Both instruments reflected good coverage and targeting. Correlation between the ODI and the SRS-30 was high (r = 0.70; p < .001). Both measures could distinguish between different general health states. The SRS-30 strongly reflected mental state and social well-being. The SRS-30 was less sensitive for pain and function. Furthermore, the principal component of pain/function explained more variance in the SRS-30 compared with the ODI score. The ODI was more sensitive for variance of disability among different age and deformity groups. CONCLUSIONS: Both the ODI and the the SRS-30 provide valid scores in evaluating health-related quality of life and/or level of disability among patients with prolonged degenerative thoracolumbar disease. The ODI has slightly higher correlation with physical functioning. The SRS-30 seems to be better when evaluating the emotional and psychological functions. LEVEL OF EVIDENCE: Level III.

Increased interleukin-6 and C-reactive protein levels after instrumented lumbar spine fusion in older patients.

PURPOSE: Interleukin 6 (IL-6) and the acute phase C-reactive protein (CRP) blood concentrations after lumbar spine fusion may be affected by age. The purpose of this prospective observational study was to assess postoperative serum levels of pro-inflammatory IL-6 and CRP after instrumented lumbar spine fusion surgery. We hypothesized that older patients would have increased levels of IL-6 and CRP after surgery. METHODS: IL-6 and high-sensitive CRP biochemical marker levels were measured before instrumented spinal fusion, and postoperatively at 1 and 3 days, 6 weeks, and 3 months. The 49 patients in this sample were divided into two groups: age ≤ 60 years ( n = 23) and age > 60 years ( n = 26). RESULTS: Acute changes in IL-6 high-sensitivity and CRP from preoperative levels to postoperative day (POD) 1 increased with age. Mean (95% CI) difference between the age-groups in changes of IL-6 at PODs 1 and 3 was 45 pg/ml (10-83, p = 0.014) and 20 pg/ml (5-36, p = 0.021), respectively. Mean (95% CI) difference between groups in changes of CRP at PODs 1 and 3 was 9.6 mg/l (-3.5 to 22.7, p = 0.47) and 24.8 mg/l (-17 to 67, p = 0.33), respectively. Both groups had decreased IL-6 and CRP levels at 6 weeks after surgery compared to the preoperative level. CONCLUSIONS: Elevation of IL-6 and CRP is stronger in patients over 60 years old after instrumented lumbar spinal fusion. The CRP and IL-6 are sensitive markers for acute postoperative inflammation. Even high acute CRP values do not necessarily indicate postoperative infection.

Trunk Muscle Strength After Lumbar Spine Fusion: A 12-Month Follow-up.

OBJECTIVE: The aim of this study was to investigate changes in trunk muscle strength 12 months after lumbar spine fusion (LSF) compared to preoperative strength. METHODS: A total of 194 patients (mean±standard deviation [SD] age, 61±21 years) who underwent LSF participated in this prospective longitudinal study. Physical measurements of the participants were made before surgery and 12 months postoperatively. Isometric trunk extension and flexion strength was measured using a strain-gauge dynamometer in the standing position. Strength changes were calculated. Regression analysis was performed to explore which factors predicted strength levels at 12 months postoperatively. RESULTS: The preoperative mean±SD extension strength was 205±144 N, which increased to 258±142 N (p<0.001) at the 12-month follow-up. Flexion strength increased from 295±172 N to 364±164 N (p<0.001). The preoperative extension/flexion strength ratio was 0.75±0.38 and remained similar (0.73±0.26) at 12 months postoperatively (p=0.39). CONCLUSION: Although trunk muscle strength increased by 26% for extension and 23% for flexion at the 12-month postoperative follow-up, both values remained objectively low. In addition, flexion strength remained higher than extension strength, which indicates an imbalance between those muscle groups. Age, severe back pain, and low trunk muscle strength before surgery predicted low trunk muscle strength at 1 year after spinal fusion.

Spinopelvic Parameters and Sagittal Alignment of Symptomatic Degenerative Adult Spinal Disorder Patients With 6 Lumbar Vertebrae.

STUDY DESIGN: This was a cross-sectional, observational study. OBJECTIVE: The main objectives of this study were to observe the prevalence of a true L6 among patients with symptomatic adult spinal degeneration, and to evaluate similarities of their radiographic spinopelvic parameters to L5 patients. SUMMARY OF BACKGROUND DATA: Spinopelvic parameter values used for diagnosis and surgical planning are different between individuals with 5 or 6 lumbar vertebrae. The difference has not been studied in patients with symptomatic spinal degenerative conditions. MATERIALS AND METHODS: A total of 775 consecutive symptomatic patients with degenerative spinal disorders were classified as having 5 or 6 lumbar vertebrae in full spine radiographs. Pelvic incidence minus lumbar lordosis (PI-LL), sagittal vertical axis (SVA), pelvic tilt, and T1 pelvic angle were measured in 3 groups: sacral (L5 and L6s) and L6 upper endplate (L6e). Oswestry Disability Index (ODI) was obtained. RESULTS: In total, 715 (92.3%) patients had L5 and 60 (7.7%) had L6. LL values were comparable between the L5 and L6s (P=0.355) and SVA between all groups (P=0.869). Only SVA had excellent concordance correlation (ρc=0.91) between the L6s and L6e groups. PI-LL had significantly different values (P<0.001 all groups) and distributions between L5 and L6s (P=0.038), and L6s and L6e (P<0.001) groups. In patients with severe disability (ODI>40%) the parameters that deteriorate with increasing degeneration (pelvic tilt, T1 pelvic angle, SVA, LL, PI-LL) were not significantly different between L5 and L6s groups unlike patients with ODI<40% while PI remained similarly different (P<0.001). PI and LL had a multivariate relationship in L6 patients computable as regression model equation: PI (sacrum)=-0.92×LL (L6e)+0.91×LL (sacrum) +1.11×PI (L6e)+10.81 (R=0.88). CONCULSIONS: L6 variant is fairly common. The radiographic L6 parameters were different from L5 except for SVA and values of patients with severe disability measured from sacrum. PI and LL have a mathematic relationship in L6 patients. The cutoff values for radiographic modifiers need further studies combining radiology and clinical outcome. LEVEL OF EVIDENCE: Level III.

Intra- and Interrater Reliability of Sagittal Spinopelvic Parameters on Full-Spine Radiographs in Adults With Symptomatic Spinal Disorders.

OBJECTIVE: To evaluate the intra- and interrater reliability (I-IR) of sagittal spinopelvic parameters from digital full-spine plain radiographs with basic software tools in an unselected adult population with degenerative spinal complaints who were evaluated for surgery. METHODS: Forty-nine adult full-spine digital radiographs were measured twice by 3 independent observers, including an experienced spine surgeon, an experienced radiologist, and a resident orthopedic surgeon. Clinical picture archiving and communication system workstations and software tools were used and landmarks were set manually. The I-IR of the sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), and thoracic kyphosis in T4-T12 (TK) were assessed. RESULTS: The intrarater intraclass correlation coefficient (ICC) scores varied from 0.82 to 0.99. The interrater ICC scores ranged from 0.78 to 0.99. The intrarater standard error of measurement (SEM) values for SS, PT, PI, and TK varied from 0.8° to 5.0°, and the interrater SEM values ranged from 2.5° to 6.2°, depending on the parameter and the reading round. The I-IR SEM values for SVA varied from 2.2 to 5.7 mm and from 4.6 to 5.0 mm, respectively. Kappa values were >0.88 for all readers. The intrarater variability was the smallest for the most experienced rater. CONCLUSION: The I-IR of measuring sagittal spinopelvic parameters on digital full-spine images with basic software tools was high. Parameters consisting of several anatomic landmarks were more liable to error. Rater experience had a positive influence on reliability and repeatability. Reader experience should be assessed before accepting measurements for surgical planning and the interpretation of surgical correction during postoperative follow-up.

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.

Spinopelvic Changes Based on the Simplified SRS-Schwab Adult Spinal Deformity Classification: Relationships With Disability and Health-Related Quality of Life in Adult Patients With Prolonged Degenerative Spinal Disorders.

STUDY DESIGN: Cross-sectional, observational study. OBJECTIVE: To study the occurrence of sagittal malalignment, the adaptability of a simplified sagittal modifiers grading of the Scoliosis Research Society (SRS)-Schwab adult spinal deformity (ASD) classification, and the deformity-specific SRS questionnaire version 30 (SRS-30) in an unselected adult cohort with symptomatic degenerative spinal disorders. SUMMARY OF BACKGROUND DATA: The sagittal modifiers of the SRS-Schwab ASD classification correlate with health-related quality of life (HRQoL) measures in patients with ASD. The deformities and disabilities caused by sagittal malalignment in patients with common degenerative spinal disorders of multiple etiologies are rarely studied. A simplified and categorizing version of the SRS-Schwab ASD classification in relation to the Oswestry Disability Index (ODI) and the SRS-30 outcomes has not yet been developed. METHODS: We recruited 874 consecutive patients with degenerative spinal disorders between March 2013 and February 2014. Full spine radiographs were taken and the patients divided into sagittal deformity severity groups: mild or none, moderate, and marked deformity. Participants completed the ODI, SRS-30, and a general health questionnaire. RESULTS: We included 637 patients in the analysis. The severity of sagittal deformity was mild or none in 407 (63.9%) patients, moderate in 159 (25.0%), and marked in 71 (11.1%). Linearity across the modifier grades and deformity classes was found for ODI total score (P = 0.033), and the function/activity (P = 0.004) and self-image/appearance (P = 0.030) domains of the SRS-30. Age, body mass index, duration of symptoms, and the use of painkillers increased while physical activity, working, and educational status decreased significantly with deformity severity. CONCLUSION: Sagittal spinopelvic malalignment is significantly related to deterioration of the ODI and the SRS-30 in symptomatic adults with degenerative spinal disorders. The SRS-Schwab classification sagittal modifiers categorized into three groups is a practical tool to detect various clinically significant grades of deformity in a cohort with no recognized ASD. LEVEL OF EVIDENCE: 3.

Reliability and Validity Study of the Finnish Adaptation of Scoliosis Research Society Questionnaire Version SRS-30.

STUDY DESIGN: A prospective clinical study to test and adapt a Finnish version of the Scoliosis Research Society 30 (SRS-30) questionnaire. OBJECTIVE: The aim of this study was to perform cross-cultural adaptation and evaluate the validity of the adapted Finnish version of the SRS-30 questionnaire. SUMMARY OF BACKGROUND DATA: The SRS-30 questionnaire has proved to be a valid instrument in evaluating health-related quality of life (HRQoL) in adolescent and adult population with spine deformities in the United States. Multinational availability requires cross-cultural and linguistic adaptation and validation of the instrument. METHODS: The SRS-30 was translated into Finnish using accepted methods for translation of quality-of-life questionnaires. A total of 274 adult patients with degenerative radiographic sagittal spinal disorder answered the questionnaire with sociodemographic data, RAND 36-item health survey questionnaire (RAND Corp. Health, Santa Monica, CA, US), Oswestry disability index, DEPS depression scale, and Visual Analog Scale (VAS) back and leg pain scales within 2 weeks' interval. The cohort included patients with and without previous spine surgery. Internal consistency and validity were tested with Cronbach α, intraclass correlation (ICC), standard error of measurement, and Spearman correlation coefficient with 95% confidence intervals (CIs). RESULTS: The internal consistency of SRS-30 was good in both surgery and nonsurgery groups, with Cronbach α 0.853 (95% CI, 0.670 to 0.960) and 0.885 (95% CI, 0.854 to 0.911), respectively. The test-retest reproducibility ICC of the SRS-30 total and subscore domains of patients with stable symptoms was 0.905 (95% CI, 0.870-0.930) and 0.904 (95% CI, 0.871-0.929), respectively. The questionnaire had discriminative validity in the pain, self-image, and satisfaction with management domains compared with other questionnaires. CONCLUSION: The SRS-30 questionnaire proved to be valid and applicable in evaluating HRQoL in Finnish adult spinal deformity patients. It has two domains related to deformity that are not covered by other generally used questionnaires. LEVEL OF EVIDENCE: 3.

Effect of Obesity and Being Overweight on Disability and Pain After Lumbar Fusion: An Analysis of 805 Patients.

STUDY DESIGN: Prospective follow-up study. OBJECTIVE: To investigate the influence of obesity and being overweight on disability and pain of patients undergoing lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: Although spinal fusion surgery has been shown to relieve symptoms in several spinal disorders, the influence of obesity on the results remains controversial. METHODS: Since January 1, 2008, all patients undergoing lumbar fusion in two hospitals have been invited to participate in a prospective follow-up database. At the end of 2014, the preoperative and 1-year follow-up data of 805 patients were available. Disability was evaluated using the Oswestry Disability Index and back and leg pain by the visual analogue scale. In addition, the working status, smoking, physical activity, duration of symptoms, and indication for surgery were captured. According to the World Health Organization classification of preoperative body mass index, patients were divided into three groups: normal weight (<25.0 kg/m), overweight (25.0-29.9 kg/m), and obese (≥30.0 kg/m). RESULTS: Of the 805 patients, 204 (25.3%) were normal weight, 365 (45.3%) were overweight, and 236 (29.3%) were obese. The patients in the obese group exercised significantly less per week (P < 0.001). Preoperatively, the body mass index groups did not differ with regard to disability and pain. At the 1-year follow-up, the change in the Oswestry Disability Index was -25 in normal, -24 in overweight, and -23 in obese patients (P = 0.013), and disability was severe in 14.7% of the normal group, 17.0% of the overweight group, and 24.2% of the obese group (P = 0.0052). Back and leg pain improved more in the normal weight group compared with the overweight or obese groups (P < 0.05). CONCLUSION: Although lumbar spine fusion is also effective in obese patients, the present large follow-up study demonstrates that their outcome results are slightly poorer than patients with normal weight at 1 year after surgery. LEVEL OF EVIDENCE: 3.

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.