Correction to: Association of vitamin D receptor gene polymorphisms with disc degeneration.

Unfortunately, the following reference was missed out in the original publication.

Association of vitamin D receptor gene polymorphisms with disc degeneration.

PURPOSE: Numerous candidate genes and single-nucleotide polymorphisms (SNPs) have been identified in the background of lumbar disc degeneration (LDD). However, in most of these underpowered studies, definitions of LDD are inconsistent; moreover, many of the findings have not been replicated and are contradictory. Our aim was to characterize LDD by well-defined phenotypes and possible endophenotypes and analyse the association between these and candidate vitamin D receptor (VDR) gene polymorphisms on a large (N = 1426) dataset. METHODS: Seven candidate VDR SNPs were genotyped. Individual association, haplotype and gene-gene interaction analyses were performed. All degenerative endophenotypes were significantly associated with one or more candidate VDR gene variants. RESULTS: Haplotype analyses confirmed the association between the 3'-end VDR variants (BsmI, ApaI, TaqI) and Modic changes as well as the relationship of 5'-end variants (Cdx2, A1012G) with endplate defects. We also found significant interactions between the 3'- and 5'-end regulatory regions and endplate defects. Based on our results, VDR and its gene variants are highly associated with specific degenerative LDD endophenotypes. CONCLUSION: Understanding relationships between phenotype and gene variants is crucial for describing the pathways leading to the multifactorial, polygenic degeneration process and LDD-related conditions. These slides can be retrieved under Electronic Supplementary Material.

Risk factors of non-specific spinal pain in childhood.

PURPOSE: Non-specific spinal pain can occur at all ages and current evidence suggests that pediatric non-specific spinal pain is predictive for adult spinal conditions. A 5-year long, prospective cohort study was conducted to identify the lifestyle and environmental factors leading to non-specific spinal pain in childhood. MATERIALS AND METHODS: Data were collected from school children aged 7-16 years, who were randomly selected from three different geographic regions in Hungary. The risk factors were measured with a newly developed patient-reported questionnaire (PRQ). The quality of the instrument was assessed by the reliability with the test-retest method. Test (N = 952) and validity (N = 897) datasets were randomly formed. Risk factors were identified with uni- and multivariate logistic regression models and the predictive performance of the final model was evaluated using the receiver operating characteristic (ROC) method. RESULTS: The final model was built up by seven risk factors for spinal pain for days; age > 12 years, learning or watching TV for more than 2 h/day, uncomfortable school-desk, sleeping problems, general discomfort and positive familiar medical history (χ2 = 101.07; df = 8; p < 0.001). The probabilistic performance was confirmed with ROC analysis on the test and validation cohorts (AUC = 0.76; 0.71). A simplified risk scoring system showed increasing possibility for non-specific spinal pain depending on the number of the identified risk factors (χ2 = 65.0; df = 4; p < 0.001). CONCLUSION: Seven significant risk factors of non-specific spinal pain in childhood were identified using the new, easy to use and reliable PRQ which makes it possible to stratify the children according to their individual risk. These slides can be retrieved under Electronic Supplementary Material.

Primary prevention of disc degeneration-related symptoms.

INTRODUCTION: It has been shown previously that a history of low back pain often begins in childhood or adulthood. Indeed, the prevalence of severe back symptoms among schoolchildren is not insignificant. Possibilities for the primary prevention of intervertebral disc degeneration-related conditions are poorly reported in the literature despite the assumed socio-economical impact of the prevention of these conditions. METHODS: In this review, the authors have collated published data on the prevalence and risk factors of childhood low back pain as well as the structure and results of published primary prevention programs. RESULTS: The prevalence of self-reported low back pain is 7-65% among children and it increases with age. Several lifestyle factors have been reported as significant risk factors for back pain, many of which are related to the schools. Current educational primary prevention programs in schools show no clear or long-term stable effect. CONCLUSION: Considering the growing evidence about the importance of normal and bad posture, an exercise-based posture correction program is suggested as a school-based primary prevention of disc degeneration-related symptoms. Further, prospective randomized studies with more than 20 years follow-up, however, are strongly required to confirm it.

Impact of Patient-specific Factors and Spinopelvic Alignment on the Development of Adjacent Segment Degeneration After Short-segment Lumbar Fusion.

STUDY DESIGN: Prospective cross-sectional cohort study. OBJECTIVES: The main purpose of this study was to evaluate the association between demographical, surgery-related and morphologic parameters, and the development or progress of adjacent segment degeneration (ASD) after short-segment lumbar fusions. SUMMARY OF BACKGROUND DATA: ASD is a major long-term complication after lumbar fusions. Possible risk factors are related to the patients' demographics, spinopelvic anatomy, or preoperative lumbar intervertebral disk conditions, but the role of these parameters is still not clear. METHODS: A prospective cross-sectional study of 100 patients who underwent 1- or 2-level open lumbar transforaminal interbody fusions due to a lumbar degenerative pathology was conducted. Demographical, radiologic findings, and magnetic resonance imaging features were analyzed to identify factors associated with ASD in 5-year follow-up. RESULTS: ASD patients showed higher level of pain ( P =0.004) and disability ( P =0.020) at follow-up. In univariate analysis, older age ( P =0.007), upper-level lumbar fusion ( P =0.007), lower L4-S1 lordosis ( P =0.039), pelvic incidence-lumbar lordosis mismatch ( P =0.021), Pfirrmann grade III or higher disk degeneration ( P =0.002), and the presence of disk bulge/protrusion ( P =0.007) were associated with ASD. In multivariate analysis, the presence of major degenerative sign (disk degeneration and/or disk bulge) was the significant predictor for developing ASD (odds ratio: 3.85, P =0.006). CONCLUSION: By examining the role of different patient- and procedure-specific factors, we found that preoperative major degenerative signs at the adjacent segment increase the risk of ASD causing significantly worse outcome after short-segment lumbar fusion. On the basis of our results, adjacent disk conditions should be considered carefully during surgical planning.

Outcome of group physical therapy treatment for non-specific low back pain patients can be predicted with the cross-culturally adapted and validated Hungarian version STarT back screening tool.

PURPOSE: The STarT Back Tool was developed to identify the specific modifiable prognostic factors for non-specific low back pain and to classify the patients into risk groups; low, medium and high risk of chronicity. Applied therapeutic approaches often involve group physical therapy. The aim of this study was the cross-cultural adaptation and validation of the Hungarian version of the STarT Back Tool and to investigate the predictive ability for global treatment outcome. MATERIALS AND METHODS: A prospective cohort study (N = 133) was carried out involving non-specific low back pain patients. Internal consistency, construct validity, reliability and prognostic discriminative ability have been investigated. After 3 months of treatment global outcome was evaluated. RESULTS: A 2-factor structure was found, with moderate internal consistency (Cronbach α = 0.89 for the total and psychosocial subscale 0.62). Between the Hungarian STarT Back Tool, the Oswestry Disability Index, leg pain, low back pain, Tampa Scale for Kinesiophobia, Fear Avoidance Beliefs Questionnaire and the physical subscale of the quality of life questionnaire, significant good to excellent- correlation was found (r > 0.41). The test-retest analysis showed excellent reliability (Intraclass Correlation Coefficient = 0.93) with standard error measurement being 0.49 (minimal detectable change = 1.37). The Area Under the Curve for baseline STarT Back Tool scores was 0.7 and 0.8 for global treatment outcome and distress, respectively. The Area Under the Curve for global treatment outcome versus STarT risk groups proved to be 0.76 representing adequate discriminative ability. CONCLUSION: The successful cross-cultural adaptation was followed by the validity analysis and as a result the Hungarian version of the STarT Back Tool proved to be a reliable and valid tool in the identification of risk groups of chronicity for patients with low back pain. Patients allocated to the high-risk group were more likely experiencing poor outcome at 3 months follow up, thus it can be used to predict outcome if treated with group physical therapy.Implication for rehabilitationLow back pain is a multifactorial disease where physical and psychosocial risk factors play a role in the development and prognosis of the disease.The STarT-H can be considered as a reliable, valid measurement tool in the identification of risk groups of chronicity for patients with low back pain.Clinical relevance of the STarT-H is that it can be used to stratify patients into risk groups of chronicity in different Hungarian speaking healthcare settings.According to our findings the STarT-H can also be applied to predict global treatment outcome in low back pain patients if treated with group physical therapy.

Global Treatment Outcome after Surgical Site Infection in Elective Degenerative Lumbar Spinal Operations.

Background: Surgical site infection (SSI) is a serious complication after routine lumbar spinal operations, and its effect on global treatment outcome (GTO) is less reported. The aim of the current study was to measure the impact of SSI on outcome, which was evaluated with patient reported outcome measures (PROMs) and patients' subjective judgment (GTO). Methods: A total of 910 patients underwent primary a single- or two-level lumbar decompression or instrumented fusion surgical procedure. Patients completed Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Core Outcome Measurement Index (COMI) at baseline and at two-year follow-up. The rate of improvement in PROMs was measured for the total cohort and the group of patients with SSI. Patients evaluated GTO on a five-point Likert scale. This study was approved by the Scientific and Research Ethics Committee of the Medical Research Council (number: 29970-3/2015/EKU) and the Institutional Review Board. Results: Regardless of the presence of SSI, significant improvement was measured in all PROMs without any difference in the rate of change between the clinical subgroups (non-SSI vs. SSI, dODI: p = 0.370, dCOMI: p = 0.383, dVAS: p = 0.793). In the total cohort, 87.3% of patients reported good outcome (N% = 87.3%). After an SSI, however, more patients (25.7%) reported poor outcome compared with those without the complication (chi-square test: value = 5.66; df = 1; p = 0.017; odds ratio = 2.49). Conclusions: Patients with successfully treated SSI can expect as good objective clinical result as patients without SSI while the subjective treatment outcome can be worse. The GTO could also be improved in complicated cases, however, with more extensive peri-operative patient education and information considering the patients' expectations, too.