Assessment of disability levels in patients with low back pain based on the type of lumbar spinal disorder.

BACKGROUND: Low back pain (LBP) is a common health condition and the leading cause of activity limitation and absenteeism in most parts of the world. One-fifth of patients with LBP develop chronic pain disability. OBJECTIVE: This study investigated the disability levels in patients with different types of lumbar spinal disorders. METHODS: A total of 528 patients visiting spine clinics between June 2017 and February 2018 were enrolled in this study. A demographic checklist, the patients' medical records, the Oswestry Disability Questionnaire, and the Visual Analog Scale (VAS) were used to collect the data. RESULTS: Non-specific LBP (29.5%) and discopathy (27%) were the most common final diagnoses. The obtained Oswestry Disability Index (ODI) was significantly higher in older patients, those with higher body mass index, more work experience, and smokers. Lower ODI was found in individuals with a history of regular exercise. Most individuals in all diagnostic groups were categorized into the high ODI group (p⩽ 0.001). CONCLUSION: In patients with lumbar spine lesions, ODI is significantly correlated with age, BMI, work experience, smoking, and the type of disorder (discopathy, spondylolysis, and spondylolisthesis). Regular exercise is associated with lower levels of disability.

Assessment of Changes in Lipids Metabolism in Patients with Degenerative Joints and Discs Diseases Subjected to Spa Therapy.

INTRODUCTION: High levels of total cholesterol, triglycerides, and, connected with them, lipoprotein fractions may result in atherosclerosis. There are various forms of therapy used to prevent cardiovascular diseases, such as balneophysiotherapy, the effectiveness of which is confirmed by numerous scientific publications. OBJECTIVE: The objective of this study was to assess the impact of balneophysiotherapeutic procedures on the systemic metabolism of lipids in patients suffering from osteoarthritis of the motor organ. MATERIAL AND METHODS: The study was conducted in the Health Resort Swieradów-Zdrój. Observation included patients undergoing radon water therapy. Before therapy and after 21 days of treatment, lipid profile was assessed with the use of standard colorimetric assay. Study group consisted of n=34 patients with degenerative joints and disc disease. The mean age of patients was 56.5l. The control group consisted of 17 people selected among the employees of the spa also suffering from osteoarthritis. The mean age was 54.2 years. RESULTS: The results of the study are based on a single, 21-day health resort stay period in April/May. A statistically significant increase in HDL cholesterol levels was observed in female patients having undergone health resort treatment (P<0.01). Statistically significant drops in LDL cholesterol and TG levels were observed in the control group (P<0.01). An increase in HDL levels was observed in the male and female control subjects, with P<0.05. CONCLUSIONS: (1) After the end of therapy, there were no changes in lipid metabolism in men, while in the group of women an increase in HDL level was observed. (2) In the control group, statistically significant changes in the field of lipid metabolism may be related to lifestyle changes as a result of educational activities conducted prior to the research. (3) Due to the divergent results, it is advisable to conduct randomized studies in a larger population. This trial is registered with NCT03274128.

The five-repetition sit-to-stand test: evaluation of a simple and objective tool for the assessment of degenerative pathologies of the lumbar spine.

OBJECTIVE: Recently, objective functional tests have generated interest since they can supplement an objective dimension to clinical assessment. The five-repetition sit-to-stand (5R-STS) test is a quick and objective tool that tests movements frequently used in everyday life. The aim of this prospective study was to evaluate the validity and reliability of the 5R-STS test in patients with degenerative pathologies of the lumbar spine. METHODS: Patients and healthy volunteers completed the standardized 5R-STS, Roland-Morris Disability Questionnaire (RMDQ), Oswestry Disability Index (ODI), visual analog scale (VAS) for back and leg pain, and EQ-5D for health-related quality of life (HRQOL). To assess convergent validity, the 5R-STS test times were correlated with these questionnaires. RESULTS: Overall, 157 patients and 80 volunteers were enrolled. Direct correlation with RMDQ (r = 0.49), ODI (r = 0.44), and VAS for back pain (r = 0.31) and indirect correlation with the EQ-5D index (r = -0.41) were observed (p < 0.001). The 5R-STS test showed no correlation with VAS for leg pain and EQ-5D VAS (p > 0.05). In 119 individuals, the 5R-STS test demonstrated excellent test-retest reliability with an intraclass correlation coefficient of 0.98. The upper limit of normal, distinguishing patients with and without objective functional impairment, was identified as 10.35 seconds. A severity stratification classified patients with test times of 10.5-15.2, 15.3-22.0, or greater than 22.0 seconds as having mild, moderate, or severe functional impairment, respectively. CONCLUSIONS: The 5R-STS test is a simple and effective tool to describe objective functional impairment. A patient able to perform the test in 10.4 seconds can be considered to have no relevant objective functional impairment. Clinical trial registration no.: NCT03303300 (clinicaltrials.gov).

Is L5-S1 motion segment different from the rest? A radiographic kinematic assessment of 72 patients with chronic low back pain.

PURPOSE: The relationship between biomechanical instability and degenerative changes in the lumbar spine in chronic low back pain (CLBP) patients remains controversial. The main objective of this retrospective radiographical study was to evaluate changes in kinematics at different lumbar levels (in particular the L5-S1 level) with progressive grades of disc degeneration and facet joint osteoarthritis in CLBP patients. METHODS: Using standing neutral and dynamic flexion/extension (Fx/Ex) radiographs of the lumbar spine, in vivo segmental kinematics at L1-L2 through L5-S1 were evaluated in 72 consecutive CLBP patients. Disc degeneration was quantified using changes in signal intensity and central disc height on mid-sagittal T2-weighted magnetic resonance (MR) scans. Additionally, the presence or absence of facet joint osteoarthritis was noted on T2-weighted axial MR scans. RESULTS: Disc degeneration and facet joint osteoarthritis occurred independent of each other at the L5-S1 level (p = 0.188), but an association was observed between the two at L4-L5 (p < 0.001) and L3-L4 (p < 0.05) levels. In the absence of facet joint osteoarthritis, the L5-S1 segment showed a greater range of motion (ROM) in Ex (3.3° ± 3.6°) and a smaller ROM in Fx (0.6° ± 4.2°) compared with the upper lumbar levels (p < 0.05), but the differences diminished in the presence of it. In the absence of facet joint osteoarthritis, no change in L5-S1 kinematics was observed with progressive disc degeneration, but in its presence, restabilisation of the L5-S1 segment was observed between mild and severe disc degeneration states. CONCLUSION: The L5-S1 motion segment exhibited unique degenerative and kinematic characteristics compared with the upper lumbar motion segments. Disc degeneration and facet joint osteoarthritis occurred independent of each other at the L5-S1 level, but not at the other lumbar levels. Severe disc degeneration in the presence of facet joint osteoarthritis biomechanically restabilised the L5-S1 motion segment.

Assessment of postural stability in patients with lumbar spine chronic disc disease.

PURPOSE: The pain, motor and sensory deficits are common symptoms of the lumbar disc disorder, and they can significantly affect human postural control. The aim of this study was to assess postural stability in patients with severe symptoms of lumbar spine disc disease qualifying them for surgical treatment and to compare them with a control group. METHODS: The study involved 103 subjects: 54 patients and 49 healthy subjects. Patient's mean age was 46.4 ± 11.3 years, mean body height 172.2 ± 10.3 cm, mean body mass 83.1 ± 18.9 kg, and mean body mass index (BMI) was 27.9 ± 5.2 kg m-2. The mean time of their recent pain episode was 9.7 ± 8.5 months. RESULTS: We found statistically significant differences between postural stability in patients with lumbar spine disc disease and the control group. The measurements taken with eyes closed, as compared with the clinical control group, revealed higher and statistically significant values of the mean amplitude of COP, mean amplitude of COP on sagittal plane, and maximal sway in sagittal plane parameters. The analysis of pressure value differences between the right and left lower limbs in both groups revealed statistical significance. In the study population the difference was significantly greater in comparison to the control group. The patients had significantly greater asymmetry of lower limb load. CONCLUSIONS: 1. Patients with lumbar spine discogenic pain had decreased postural control. 2. The patients had significant asymmetry in foot pressure resulting from pain radiating to a lower limb.

Efficacy and cost-effectiveness of intradiscal methylene blue injection for chronic discogenic low back pain: study protocol for a randomized controlled trial.

BACKGROUND: Low back pain (LBP) is a common health problem and a substantial part of LBP is presumed to be attributable to degeneration of the intervertebral disc. For patients suffering from intractable discogenic LBP, there are few evidence-based effective interventional treatment options available. In 2010, the results of a randomized controlled trial (RCT) were published concerning "intradiscal methylene blue injection" (IMBI), in which this intervention appeared to be very successful in relieving discogenic pain. Therefore, we decided to repeat this study to investigate whether we could replicate the published results. The results of our preliminary feasibility study gave reason to set up an RCT. The aim of this RCT is to evaluate if IMBI is a more effective treatment of discogenic low back pain as an intradiscal placebo intervention, and furthermore, to assess the cost-effectiveness of this intervention. METHODS/DESIGN: Consecutive discogenic low back pain patients referred to four specialized pain treatment facilities are being screened for eligibility. After a positive standardized provocation discography and informed consent, patients are randomized into two groups. The treatment group receives an intradiscal injection with methylene blue, lidocaine, and contrast, and the control group receives intradiscal isotonic saline with lidocaine and contrast. Main outcome measures are pain at the 6-month follow-up, patient's global impression of change, cost-effectiveness, quality of life, disability, and analgesic intake. DISCUSSION: The importance of this study is emphasized by the fact that for intractable discogenic low back pain patients, evidence-based effective pain treatments are rare. If this study establishes clinical success and cost-effectiveness, IMBI could become the "pain treatment of choice" for a selected group of patients with chronic discogenic low back pain for whom noninvasive treatment options have failed. TRIAL REGISTRATION: National Trial register NTR2547 Registered at 29 September 2010 and 31 March 2014.

Assessment of stress patterns on a spinal motion segment in healthy versus osteoporotic bony models with or without disc degeneration: a finite element analysis.

BACKGROUND CONTEXT: With an increasing prevalence of low back pain, physicians strive to optimize the treatment of patients with degenerated motion segments. There exists a consensus in literature that osteoporotic patients exhibit nonphysiologic loading patterns, while degenerated intervertebral discs (IVDs) are also believed to alter spine biomechanics. PURPOSE: To evaluate alterations occurring in lumbosacral spine biomechanics of an osteoporotic model, with or without IVD degeneration, when compared with a healthy spine segment. STUDY DESIGN: The investigation was based on finite element (FE) analysis of a patient-specific lumbosacral spine model. METHODS: A biorealistic model of a lumbosacral spine segment is introduced to determine the morbidity of disc degeneration and osteoporosis. The model was verified and validated for the purpose of the study and subjected to a dynamic FE analysis, considering anisotropic bone properties and solid ligamentous tissue. RESULTS: The yielded results merit high clinical interest. Osteoporosis resulted in a nonuniform increase of facet joint loading, which was even more pronounced in the scenario simulating a degenerated disc. The results also revealed an enslavement of intradiscal pressure to the disc state (in the degenerated and superior adjacent level). CONCLUSIONS: The investigation presented refined insight into the dynamic biomechanical response of a degenerated spine segment. The increase in the calculated occurring stresses was considered as critical in the motion segment adjacent and superior to the degenerated one. This suggests that prevalent trauma in a motion segment may be a symptomatic condition of a poorly treated formal pathology in the inferior spine level.

Fluoroscopic assessment of lumbar total disc replacement kinematics during walking.

STUDY DESIGN: Descriptive. OBJECTIVE: The purpose of this study was to determine the in vivo kinematics of functional spinal units, during gait, in individuals with a single-level lumbar total disc replacement (TDR). SUMMARY OF BACKGROUND DATA: TDR is a motion preservation technology that offers an alternative to spinal fusion for treatment of degenerative disc disease. The aim of TDRs is to replicate motion of the functional spinal units, which may protect adjacent intervertebral discs against accelerated degeneration. At present, there is limited understanding of the in vivo motion of TDRs, particularly during dynamic activities such as gait. Such information is important for understanding the wear characteristics of TDRs and furthering design rationale of future implants. METHODS: TDR motions were obtained from 24 participants who underwent implantation with single-level L4-L5 or L5-S1 CHARITÉ or In Motion TDRs. Video fluoroscopy was used to obtain measurements in the frontal and sagittal planes during fixed speed treadmill walking. RESULTS: The mean range of motion between the upper and lower lumbar TDR endplates during walking was 1.6° and 2.4° in the frontal and sagittal planes, respectively. These values were significantly different from zero and corresponded to 19% of the maximum static range of motion in each plane. CONCLUSION: Lumbar TDRs provide a degree of motion preservation at the operative level during moderate speed walking. The distribution of lumbar TDR motions during walking presented here will inform relevant standards for conducting standardized tests of lumbar TDRs, particularly wear assessments, and, hence, enable more realistic mechanical and computer-based wear simulations to be performed. LEVEL OF EVIDENCE: N/A.

Enhancing cell migration in shape-memory alginate-collagen composite scaffolds: In vitro and ex vivo assessment for intervertebral disc repair.

Lower lumbar disc disorders pose a significant problem in an aging society with substantial socioeconomic consequences. Both inner tissue (nucleus pulposus) and outer tissue (annulus fibrosus) of the intervertebral disc are affected by such debilitating disorders and can lead to disc herniation and lower back pain. In this study, we developed an alginate-collagen composite porous scaffold with shape-memory properties to fill defects occurring in annulus fibrosus tissue of degenerated intervertebral discs, which has the potential to be administered using minimal invasive surgery. In the first part of this work, we assessed how collagen incorporation on preformed alginate scaffolds influences the physical properties of the final composite scaffold. We also evaluated the ability of annulus fibrosus cells to attach, migrate, and proliferate on the composite alginate-collagen scaffolds compared to control scaffolds (alginate only). In vitro experiments, performed in intervertebral disc-like microenvironmental conditions (low glucose and low oxygen concentrations), revealed that for alginate only scaffolds, annulus fibrosus cells agglomerated in clusters with limited infiltration and migration capacity. In comparison, for alginate-collagen scaffolds, annulus fibrosus cells readily attached and colonized constructs, while preserving their typical fibroblastic-like cell morphology with spreading behavior and intense cytoskeleton expression. In a second part of this study, we investigated the effects of alginate-collagen scaffold when seeded with bone marrow derived mesenchymal stem cells. In vitro, we observed that alginate-collagen porous scaffolds supported cell proliferation and extracellular matrix deposition (collagen type I), with secretion amplified by the local release of transforming growth factor-ß3. In addition, when cultured in ex vivo organ defect model, alginate-collagen scaffolds maintained viability of transplanted mesenchymal stem cells for up to 5 weeks. Taken together, these findings illustrate the advantages of incorporating collagen as a means to enhance cell migration and proliferation in porous scaffolds which could be used to augment tissue repair strategies.

Biomechanical assessment of a novel L4/5 level interspinous implant using three dimensional finite element analysis.

OBJECTIVES: Range of motion (ROM) is often restricted by conventional spinal fusion surgery, while some complications also occurred after applying posterior dynamic devices in clinic. Therefore, new surgical implant options were necessitated. The biomechanical features of a novel interspinous implant were investigated using three dimensional (3D) finite element models (FEMs). MATERIALS AND METHODS: An "H-shaped" polyether ether ketone (PEEK) interspinous implant was designed to tightly fit the upper and lower spinous processes, featuring a hollow cylindrical portion which was implanted autologous bones to enhance fusion with spinous processes. A 3D FEM of the intact L3/S segment with mild disc degeneration in L4/5 (degenerated model) was developed and subjected to flexion-extension, lateral bending, and axial rotation either with or without the implanted prosthesis (implant model) in order to examine effects on ROM, intradiscal stress, and facet joint load. RESULTS: The whole lumbar ROM was altered slightly by implant insertion, and reduced end plate stress, nucleus stress, and facet joints load at the L4/5 level (implant location) were observed. L4/5 flexion-extension maximal end plate stress, nucleus stress, and facet joints load were 5.262 MPa, 0.1648 MPa, and 29.7 N, respectively, in the degenerated model and 2.323 MPa, 0.0892 MPa, and 5.4 N, respectively, in the implant model. End plate and nucleus stresses were partially alleviated at the L3/4 level. Slightly higher maximal von Mises stress in L3/4 and L5/S annuli were observed in the implant model. CONCLUSIONS: The proposed novel interspinous implant effectively restored stability without producing excessive ROM limitations, meriting further clinical evaluation. Furthermore, these findings provide a useful basis for wide application of FEM in a broad variety of spinal implant assessments.

Intervertebral disc creep behavior assessment through an open source finite element solver.

Degenerative Disc Disease (DDD) is one of the largest health problems faced worldwide, based on lost working time and associated costs. By means of this motivation, this work aims to evaluate a biomimetic Finite Element (FE) model of the Intervertebral Disc (IVD). Recent studies have emphasized the importance of an accurate biomechanical modeling of the IVD, as it is a highly complex multiphasic medium. Poroelastic models of the disc are mostly implemented in commercial finite element packages with limited access to the algorithms. Therefore, a novel poroelastic formulation implemented on a home-developed open source FE solver is briefly addressed throughout this paper. The combination of this formulation with biphasic osmotic swelling behavior is also taken into account. Numerical simulations were devoted to the analysis of the non-degenerated human lumbar IVD time-dependent behavior. The results of the tests performed for creep assessment were inside the scope of the experimental data, with a remarkable improvement of the numerical accuracy when compared with previously published results obtained with ABAQUS(®). In brief, this in-development open-source FE solver was validated with literature experimental data and aims to be a valuable tool to study the IVD biomechanics and DDD mechanisms.

Early versus late initiation of rehabilitation after lumbar spinal fusion: economic evaluation alongside a randomized controlled trial.

STUDY DESIGN: Economic evaluation conducted alongside a randomized controlled trial with 1-year follow-up. OBJECTIVE: To examine the cost-effectiveness of initiating rehabilitation 6 weeks after surgery as opposed to 12 weeks after surgery. SUMMARY OF BACKGROUND DATA: In a previously reported randomized controlled trial, we assessed the impact of timing of rehabilitation after a lumbar spinal fusion and found that a fast-track strategy led to poorer functional ability. Before making recommendations, it seems relevant to address the societal perspective including return to work, quality of life, and costs. METHODS: A cost-effectiveness analysis and a cost-utility analysis were conducted. Eighty-two patients undergoing instrumented lumbar spinal fusion due to degenerative disc disease or spondylolisthesis (grade I or II) were randomized to an identical protocol of 4 sessions of group-based rehabilitation and were instructed in home exercises focusing on active stability training. Outcome parameters included functional disability (Oswestry Disability Index) and quality-adjusted life years. Health care and productivity costs were estimated from national registries and reported in euros. Costs and effects were transformed into net benefit. Bootstrapping was used to estimate 95% confidence intervals (95% CI). RESULTS: The fast-track strategy tended to be costlier by €6869 (95% CI, -4640 to 18,378) while at the same time leading to significantly poorer outcomes of functional disability by -9 points (95% CI, -18 to -3) and a tendency for a reduced gain in quality-adjusted life years by -0.04 (95% CI, -0.13 to 0.01). The overall probability for the fast-track strategy being cost-effective does not reach 10% at conventional thresholds for cost-effectiveness. CONCLUSION: Initiating rehabilitation at 6 weeks as opposed to 12 weeks after surgery is on average more costly and less effective. The uncertainty of this result did not seem to be sensitive to methodological issues, and clinical managements who have already adapted fast-track rehabilitation strategies have reason to reconsider their choice. .

Hybrid dynamic stabilization: a biomechanical assessment of adjacent and supraadjacent levels of the lumbar spine.

OBJECT: The object of this study was to evaluate the effect of hybrid dynamic stabilization on adjacent levels of the lumbar spine. METHODS: Seven human spine specimens from T-12 to the sacrum were used. The following conditions were implemented: 1) intact spine; 2) fusion of L4-5 with bilateral pedicle screws and titanium rods; and 3) supplementation of the L4-5 fusion with pedicle screw dynamic stabilization constructs at L3-4, with the purpose of protecting the L3-4 level from excessive range of motion (ROM) and to create a smoother motion transition to the rest of the lumbar spine. An industrial robot was used to apply continuous pure moment (± 2 Nm) in flexion-extension with and without a follower load, lateral bending, and axial rotation. Intersegmental rotations of the fused, dynamically stabilized, and adjacent levels were measured and compared. RESULTS: In flexion-extension only, the rigid instrumentation at L4-5 caused a 78% decrease in the segment's ROM when compared with the intact specimen. To compensate, it caused an increase in motion at adjacent levels L1-2 (45.6%) and L2-3 (23.2%) only. The placement of the dynamic construct at L3-4 decreased the operated level's ROM by 80.4% (similar stability as the fusion at L4-5), when compared with the intact specimen, and caused a significant increase in motion at all tested adjacent levels. In flexion-extension with a follower load, instrumentation at L4-5 affected only a subadjacent level, L5-sacrum (52.0%), while causing a reduction in motion at the operated level (L4-5, -76.4%). The dynamic construct caused a significant increase in motion at the adjacent levels T12-L1 (44.9%), L1-2 (57.3%), and L5-sacrum (83.9%), while motion at the operated level (L3-4) was reduced by 76.7%. In lateral bending, instrumentation at L4-5 increased motion at only T12-L1 (22.8%). The dynamic construct at L3-4 caused an increase in motion at T12-L1 (69.9%), L1-2 (59.4%), L2-3 (44.7%), and L5-sacrum (43.7%). In axial rotation, only the placement of the dynamic construct at L3-4 caused a significant increase in motion of the adjacent levels L2-3 (25.1%) and L5-sacrum (31.4%). CONCLUSIONS: The dynamic stabilization system displayed stability characteristics similar to a solid, all-metal construct. Its addition of the supraadjacent level (L3-4) to the fusion (L4-5) did protect the adjacent level from excessive motion. However, it essentially transformed a 1-level lumbar fusion into a 2-level lumbar fusion, with exponential transfer of motion to the fewer remaining discs.

Biomechanical assessment of the effects of decompressive surgery in non-chondrodystrophic and chondrodystrophic canine multisegmented lumbar spines.

PURPOSE: Dogs are often used as an animal model in spinal research, but consideration should be given to the breed used as chondrodystrophic (CD) dog breeds always develop IVD degeneration at an early age, whereas non-chondrodystrophic (NCD) dog breeds may develop IVD degeneration, but only later in life. The aim of this study was to provide a mechanical characterization of the NCD [non-degenerated intervertebral discs (IVDs), rich in notochordal cells] and CD (degenerated IVDs, rich in chondrocyte-like cells) canine spine before and after decompressive surgery (nucleotomy). METHODS: The biomechanical properties of multisegmented lumbar spine specimens (T13-L5 and L5-Cd1) from 2-year-old NCD dogs (healthy) and CD dogs (early degeneration) were investigated in flexion/extension (FE), lateral bending (LB), and axial rotation (AR), in the native state and after nucleotomy of L2-L3 or dorsal laminectomy and nucleotomy of L7-S1. The range of motion (ROM), neutral zone (NZ), and NZ stiffness (NZS) of L1-L2, L2-L3, L6-L7, and L7-S1 were calculated. RESULTS: In native spines in both dog groups, the greatest mobility in FE was found at L7-S1, and the greatest mobility in LB at L2-L3. Surgery significantly increased the ROM and NZ, and significantly decreased the NZS in FE, LB, and AR in both breed groups. However, surgery at L2-L3 resulted in a significantly larger increase in NZ and decrease in NZS in the CD spines compared with the NCD spines, whereas surgery at L7-S1 induced a significantly larger increase in ROM and decrease in NZS in the NCD spines compared with the CD spines. CONCLUSIONS: Spinal biomechanics significantly differ between NCD and CD dogs and researchers should consider this aspect when using the dog as a model for spinal research.