Association between paraspinal muscle morphology, clinical symptoms and functional status in patients with lumbar spinal stenosis.

PURPOSE: Lumbar spinal stenosis (LSS) is a disabling condition associated with narrowing of the spinal canal or vertebral foramina. Paraspinal muscle atrophy and fatty infiltration have been reported in patients with chronic LBP and disc herniation. However, very few imaging studies have examined paraspinal muscle morphology and composition in patients with LSS. The purpose of this study was to investigate the association of paraspinal muscle size, composition and asymmetry with functional status in patients with LSS. METHODS: Thirty-six patients diagnosed with LSS at L4-L5 with neurogenic claudication were included. Paraspinal muscle measurements were obtained from axial T2-weighted MR images, bilaterally, at the level of the superior and inferior vertebral endplates of L5. Muscle measurements of interest included: total cross-sectional area (CSA), functional CSA (FCSA), the ratio of FCSA to CSA (FCSA/CSA) as an indicator of muscle composition, and relative % asymmetry in muscle CSA. The association between muscle parameters and other patient characteristics with function as indicated from Oswestry Disability Index (ODI) scores and pain interference status was investigated. RESULTS: Greater multifidus muscle fatty infiltration (e.g., lower FCSA/CSA) and lower psoas relative CSA were associated with lower function (higher ODI and pain interference scores) in univariable and multivariable analyses. There was no association between the different muscle parameters and stenosis severity or back or leg pain duration or severity. CONCLUSIONS: Our findings suggest an association of multifidus muscle fatty infiltration and psoas muscle size with functional status in patients diagnosed with LSS. Future prospective studies are needed to evaluate whether such muscle parameters are associated with prognosis and functional recovery following surgical treatment.

Paraspinal muscle asymmetry and fat infiltration in patients with symptomatic disc herniation.

PURPOSE: To investigate asymmetry in size and composition of the multifidus and erector spinae in patients with posterolateral disc herniation and concordant radicular symptoms, and determine whether symptom duration is associated with degree of asymmetry. METHODS: Thirty-three patients diagnosed with posterolateral disc herniation at L4-L5 verified on imaging and concordant leg pain were included. Multifidus and erector spinae cross-sectional area (CSA), functional cross-sectional area (FCSA, fat-free area), signal intensity and ratio of FCSA to total CSA were measured bilaterally from T 2-weighted axial magnetic resonance imaging (MRI) at L3-L4, L4-L5, L5-S1 and S1 levels. RESULTS: No side-to-side differences in multifidus CSA, FCSA, and ratio of FCSA/CSA reached statistical significance at any spinal level. The multifidus signal intensity at L5-S1 was significantly greater (more fatty infiltration) on the side of the disc herniation. The erector spinae FCSA (lean muscle mass) at L5-S1 was found to be significantly smaller on the side of the herniation and the ratio of FCSA/CSA was smaller (more fatty infiltration) on the side of the herniation at L4-L5 and L5-S1. The degree of muscle asymmetry was not associated with symptoms duration. CONCLUSIONS: There was no significant asymmetry of the multifidus at spinal level above, same or level below the disc herniation. Instead, variations in muscle composition were observed, with greater fat infiltration on the side and at spinal levels adjacent to the disc herniation. Muscle asymmetry was not correlated with symptom duration.

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.

Longevity of elastin in human intervertebral disc as probed by the racemization of aspartic acid.

BACKGROUND: Aging and degeneration of human intervertebral disc (IVD) are associated with biochemical changes, including racemization and glycation. These changes can only be counteracted by protein turnover. Little is known about the longevity of IVD elastin in health or disease. Yet, such knowledge is important for a quantitative understanding of tissue synthesis and degradation. METHODS: We have measured the accumulation of d-Asp and pentosidine in IVD elastin. Samples representing a broad range of ages (28-82years) and degeneration grades (1-5) were analyzed. RESULTS: d/l-Asp for elastin increased linearly with age from 3.2% (early 30s) to 14.8% (early 80s) for normal tissue (grades 1-2) and from 1.7% (late 20s) to 6.0% (until the mid 50s) for degenerate tissue (grades 3-5) with accumulation rates of 16.2±3.1×10(-4) and 11.7±3.8×10(-4)year(-1), respectively; no significant difference was found between these values (p<0.05). Above the mid 50s, a decrease in d-Asp accumulation was recorded in the degenerate tissue. d-Asp accumulation correlated well with pentosidine content for elastin from healthy and degenerate tissues combined. We conclude that IVD elastin is metabolically-stable and long-lived in both healthy and degenerate human IVDs, with signs of new synthesis in the latter. The correlation of d-Asp with pentosidine content suggests that both these agents may be used as markers in the overall aging process of IVD. GENERAL SIGNIFICANCE: Accumulation of modified IVD elastin argues for its longevity and may have a negative impact on its role in disc function. Weak signs of newly synthesized molecules may act to counteract this effect in degenerate tissue.

Reliability and validity study on the Hungarian versions of the oswestry disability index and the Quebec back pain disability scale.

PURPOSE: Patient-reported outcome measurements (PROMs) are widely used in spine care. The development of reliable and valid National versions of spine-related disability questionnaires is strongly recommended from both the clinical and scientific points-of-view. The aims of this study were to adapt and validate the Oswestry Disability Index (ODI) and the Quebec back pain disability scale (QDS) for use with the Hungarian language. METHODS: After translating and culturally adapting the ODI and QDS, 133 patients with lumbar degenerative spinal disorder filled in the questionnaire booklet twice within 2 weeks. Subjects completed the Hungarian versions of the two PROMs as well as the WHOQoL-BREF validated as a general life quality questionnaire and Visual Analogue Scale of pain. Internal consistency, reliability and construct validity of the questionnaires were determined, as were the standard error of measurement (SEM) and minimal detectable change (MDC) scores. RESULTS: The Hungarian ODI consisted of one factor that showed good internal consistency (Cronbach-α 0.890). The QDS showed a four-factor structure with Cronbach-α values between 0.788 and 0.917. No significant floor or ceiling effects were observed. The test-retest analysis showed excellent reliability of the Hungarian ODI and QDS. The intraclass correlation coefficients (ICC) were 0.927 and 0.923, respectively. SEM values of 4.8 and 5.2 resulted in a MDC of 13 and 14 points in the Hungarian ODI and QDS, respectively. The correlation coefficient (r) between pain and ODI was 0.680 (p < 0.001) and the correlation between the ODI and the physical subscale of WHOQoL was also very good (r = -0.705, p < 0.001). The QDS total score and its four subscales correlated significantly with pain and with the physical subscale of WHOQoL (r > 0.4, p < 0.001). The level of disability measured by the Hungarian ODI and QDS was significantly higher in the surgical subgroup than in non-surgically treated patients (p < 0.001). CONCLUSIONS: Translation and cultural adaptation of the ODI and QDS were successful. Hungarian versions of the ODI and QDS proved to be reliable, valid PROMs confirming that they can be used in future clinical and scientific work with Hungarian-speaking spine patients.

Sacral tumors and management.

The evaluation and complex treatments of sacral tumors require a multidisciplinary approach. Because of the complex anatomy conditions and biomechanics of the lumbo-pelvic junction, surgical treatment of sacral neoplasms is one of the most challenging fields in spine. Here, diagnostic process and surgical and nonsurgical treatment options for sacral tumors are summarized based on the literature and on the authors' own experiences.

Validation of the Hungarian version of the Roland-Morris disability questionnaire.

PURPOSE: To create a cross-culturally adapted and clinically valid Hungarian version of the Roland-Morris Disability Questionnaire (RMQ). METHODS: After the translation and cross-cultural adaptation process, a total of 133 patients were included into the quality measurement study. Validity and reliability domains of the Hungarian RMQ were tested following the COSMIN guideline. Differences between clinically different patient groups were measured. Correlations of the RMQ with the Oswestry Disability Index (ODI), the World Health Organization Quality of Life-BREF assessment (WHOQoL) and pain were also calculated. To assess the reliability dimension, internal consistency (Cronbach's α) was determined and the test-retest method was used to calculate the interclass correlation coefficient (ICC), the standard error of measurement (SEM) and the minimal detectable change (MDC). RESULTS: Patients indicated for surgery or having neurological deficit had significantly higher RMQ scores. RMQ strongly correlated with pain (r = 0.61), ODI (r = 0.81) and physical subscale of WHOQoL (r = -0.7). Reliability of the Hungarian RMQ was expressed with a Cronbach's α of 0.87, ICC of 0.91 (p < 0.001) and SEM and MDC as 1.71 and 4.74 points, respectively. CONCLUSIONS: Translation and cross-cultural adaptation process of the RMQ into Hungarian language was successful resulting in a reliable and valid measurement tool with good psychometric properties. Implications for Rehabilitation Low back pain (LBP) related disability is a big health, social and economical problem in industrial countries. Correct evaluation of spine related disability can be performed using valid and reliable national versions of condition specific patient reported questionnaires such as the Roland-Morris Disability Questionnaire (RMQ). After the cross-cultural adaptation and validation of the Hungarian RMQ, it can be reliably used for the evaluation of LBP patients and for their follow-up during a rehabilitation process.

Long-term outcomes in primary spinal osteochondroma: a multicenter study of 27 patients.

OBJECT Clinical outcomes in patients with primary spinal osteochondromas are limited to small series and sporadic case reports. The authors present data on the first long-term investigation of spinal osteochondroma cases. METHODS An international, multicenter ambispective study on primary spinal osteochondroma was performed. Patients were included if they were diagnosed with an osteochondroma of the spine and received surgical treatment between October 1996 and June 2012 with at least 1 follow-up. Perioperative prognostic variables, including patient age, tumor size, spinal level, and resection, were analyzed in reference to long-term local recurrence and survival. Tumor resections were compared using Enneking appropriate (EA) or Enneking inappropriate surgical margins. RESULTS Osteochondromas were diagnosed in 27 patients at an average age of 37 years. Twenty-two lesions were found in the mobile spine (cervical, thoracic, or lumbar) and 5 in the fixed spine (sacrum). Twenty-three cases (88%) were benign tumors (Enneking tumor Stages 1-3), whereas 3 (12%) exhibited malignant changes (Enneking tumor Stages IA-IIB). Sixteen patients (62%) underwent en bloc treatment-that is, wide or marginal resection-and 10 (38%) underwent intralesional resection. Twenty-four operations (92%) followed EA margins. No one received adjuvant therapy. Two patients (8%) experienced recurrences: one in the fixed spine and one in the mobile spine. Both recurrences occurred in latent Stage 1 tumors following en bloc resection. No osteochondroma-related deaths were observed. CONCLUSIONS In the present study, most patients underwent en bloc resection and were treated as EA cases. Both recurrences occurred in the Stage 1 tumor cohort. Therefore, although benign in character, osteochondromas still require careful management and thorough follow-up.

Surgical treatment of primary malignant tumors of the sacrum.

OBJECTIVES: The objective of the authors was to provide an up-to-date review about the epidemiology, diagnosis, and surgical management of the malignant primary sacral tumors. METHODS: A PubMed search was conducted using a combination of the following items: (('Spinal Neoplasms'[Mesh]) AND 'Sacrum'[Mesh]) NOT ('Metastasis' OR 'Metastases' OR 'Benign'). The literature review and the author's own surgical experiences were used to assess the current treatment strategies of the malignant sacral tumors. RESULTS: Twenty case series were identified, which studies discuss in detail the surgical strategies, the postoperative complications, the functional and oncologic outcome, and the recurrence-free and disease-specific survival of this rare patient category. DISCUSSION: Sacral tumors are rare pathologies. Their management generates a complex medical problem, as they usually are diagnosed in advanced stages with extended dimensions involving the sacral nerves and surrounding organs. The evaluation and complex treatment of these rare tumors require a multidisciplinary approach, optimally at institutions with comprehensive care and experience. Although conventional oncologic therapeutic methods should be used as neoadjuvant or adjuvant therapies in certain histological types, en bloc resection with wide surgical margins is essential for long-term local oncologic control. This is often technically difficult to achieve, as just a few centers in the world perform sacral tumor surgeries on a regular basis, and have enough wide experience. Therefore international cooperation and organization of multicenter tumor registries are essential to develop evidence based treatment protocols.

Surgical resection and reconstruction after resection of tumors involving the sacropelvic region.

OBJECTIVES: Surgical management of tumors in the sacropelvic region is a challenging field of spine surgery because of the region's complex local anatomy and biomechanics. Recent developments in anesthesia and intensive care have allowed us to perform extended surgeries focused on the en bloc resection of sacropelvic tumors. Various techniques for the resection and for the reconstruction were published in the last decade. METHODS: Sacropelvic tumor resection techniques and methods for the biomechanical and soft-tissue reconstruction are reviewed in this paper. RESULTS: The literature data is based on case reports and case-series. Several different techniques were developed for the lumbopelvic stabilization after sacropelvic tumor resection according to three different reconstruction principles (spinopelvic fixation (SPF), posterior pelvic ring fixation (PRF), and anterior spinal column fixation (ACF)); however, long-term follow-up data and comparative studies of the different techniques are still missing. Soft-tissue reconstruction can be performed according to an algorithm depending on the surgical approach, but relatively high complication rates are reported with all reconstruction strategies. The clinical outcome of such surgeries should ideally be evaluated in three dimensions; surgical-, oncological-, and functional outcomes. The last and most important step of the presurgical planning procedure is a careful presentation of the surgical goals and risks to the patient, who must provide a fully informed consent before surgery can proceed. DISCUSSION: Sacropelvic tumors are rare conditions. In the last decade, growing evidence was published on resection and reconstruction techniques for these tumors; however, experience at most medical centers is limited due to the low numbers of cases. The formation of international expert groups and the initiation of multicenter studies are strongly encouraged to produce a high level of evidence in this special field of spine surgery.

An evidence-based medicine model for rare and often neglected neoplastic conditions.

OBJECT: The National Institutes of Health recommends strategies to obtain evidence for the treatment of rare conditions such as primary tumors of the spine (PTSs). These tumors have a low incidence and are pathologically heterogeneous, and treatment approaches are diverse. Appropriate evidence-based care is imperative. Failure to follow validated oncological principles may lead to unnecessary mortality and profound morbidity. This paper outlines a scientific model that provides significant evidence guiding the treatment of PTSs. METHODS: A four-stage approach was used: 1) planning: data from large-volume centers were reviewed to provide insight; 2) recruitment: centers were enrolled and provided the necessary infrastructure; 3) retrospective stage: existing medical records were reviewed and completed with survival data; and 4) prospective stage: prospective data collection has been implemented. The AOSpine Knowledge Forum Tumor designed six modules: demographic, clinical, diagnostic, therapeutic, local recurrence, survival, and perioperative morbidity data fields and provided funding. RESULTS: It took 18 months to implement Stages 1-3, while Stage 4 is ongoing. A total of 1495 tumor cases were captured and diagnosed as one of 18 PTS histotypes. In addition, a PTS biobank network has been created to link clinical data with tumor pathology and molecular analysis. CONCLUSIONS: This scientific model has not only aggregated a large amount of PTS data, but has also established an international collaborative network of spine oncology centers. Access to large volumes of data will generate further research to guide and enhance PTS clinical management. This model could be applied to other rare neoplastic conditions. Clinical trial registration no.: NCT01643174 (ClinicalTrials.gov).

Timing of surgery and radiotherapy in the management of metastatic spine disease: a systematic review.

The last decade has witnessed a dramatic change in management of metastatic spine disease, with an increased role for surgery and emerging use of stereotactic radiotherapy, often in combination. Patients may be treated with radiotherapy followed by surgery, or have surgery and then adjuvant radiotherapy. In both cases, the surgeon and oncologist need to select the optimal timing for surgery and radiotherapy to minimize wound complications while obtaining maximum oncolytic effects. The purpose of this review was to determine the optimal timing of surgery and radiotherapy in patients surgically treated for spinal metastases. A systematic review utilizing Medline, Embase, Paper First, Web of Science, Google Scholar, and the Cochrane Database of Systematic Reviews was performed. References were screened to further identify relevant studies and basic science literature reviewed. A total of 46 reports discussing the timing of surgery after radiotherapy, describing experience in 5836 patients, were identified. Only one retrospective study addressed the research question and suggested that surgery within seven days of radiation increases the rate of postoperative wound complications. Timing of adjuvant radiotherapy following surgery was addressed in 51 reports describing 7090 patients. None of the studies specifically answered the research question. The time interval between radiotherapy and surgery was reported as 5-21 days in nine studies. Based on this systematic review together with the understanding of general principles of wound healing and effects of radiation on wound healing, the optimal radiotherapy-surgery/surgery-radiotherapy time interval should be at least one week to minimize wound complications.

Reliability analysis of the epidural spinal cord compression scale.

OBJECTIVE: The evolution of imaging techniques, along with highly effective radiation options has changed the way metastatic epidural tumors are treated. While high-grade epidural spinal cord compression (ESCC) frequently serves as an indication for surgical decompression, no consensus exists in the literature about the precise definition of this term. The advancement of the treatment paradigms in patients with metastatic tumors for the spine requires a clear grading scheme of ESCC. The degree of ESCC often serves as a major determinant in the decision to operate or irradiate. The purpose of this study was to determine the reliability and validity of a 6-point, MR imaging-based grading system for ESCC. METHODS: To determine the reliability of the grading scale, a survey was distributed to 7 spine surgeons who participate in the Spine Oncology Study Group. The MR images of 25 cervical or thoracic spinal tumors were distributed consisting of 1 sagittal image and 3 axial images at the identical level including T1-weighted, T2-weighted, and Gd-enhanced T1-weighted images. The survey was administered 3 times at 2-week intervals. The inter- and intrarater reliability was assessed. RESULTS: The inter- and intrarater reliability ranged from good to excellent when surgeons were asked to rate the degree of spinal cord compression using T2-weighted axial images. The T2-weighted images were superior indicators of ESCC compared with T1-weighted images with and without Gd. CONCLUSIONS: The ESCC scale provides a valid and reliable instrument that may be used to describe the degree of ESCC based on T2-weighted MR images. This scale accounts for recent advances in the treatment of spinal metastases and may be used to provide an ESCC classification scheme for multicenter clinical trial and outcome studies.