Fulcrum to Generate Maximum Extension of the Spine and Hip-Proposing A New Strategy using EOS Imaging for Patient-specific Assessment of Degenerated Lumbar Spines.

STUDY DESIGN: A retrospective, radiographic comparative study conducted in a single academic institution. OBJECTIVE: This study aims to compare fulcrum extension with conventional extension imaging to determine maximum "hip lordosis" (HL), an important novel patient-specific parameter in spinal realignment surgery, as well as understand the extension capabilities of the lower lumbar spine, which together, are key contributors to whole-body balancing. SUMMARY OF BACKGROUND DATA: Recent literature recognizes the hip as an important contributor to whole-body lordosis beyond a compensator for spinal imbalance. METHODS: Patients >45 years' old with mechanical low back pain due to degenerative spinal conditions were included and grouped based on the imaging performed-fulcrum or conventional extension. All imaging was performed using EOS under standardized instructions and visual aids. Radiographic parameters include global lumbar angle (GLA), inflexion-S1 (Inf-S1) angle, segmental lumbar angles, pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), femoral alignment angle (FAA), HL and spinocoxa angle (SCA). Unpaired t test was used to compare between radiographic parameters. RESULTS: One hundred patients (40 males and 60 females, mean age 63.0 years) underwent either fulcrum or conventional extension EOS® imaging. Both groups had comparable baseline radiographic parameters. Fulcrum extension gave a larger mean GLA (-60.7° vs. -48.5°, P = 0.001), Inf-S1 angle (-58.8° vs. -48.8°, P = 0.003), SCA (-36.5° vs. -24.8°, P < 0.001), L4/5 and L5/S1 lordosis (-20.7° vs. -17.7°, P = 0.041, and -22.3° vs. -17.1°, P = 0.018, respectively), compared to conventional extension. PI, SS, PT, FAA, and HL were similar between both extension postures. CONCLUSION: Fulcrum extension, compared to conventional extension, is better at generating lordosis in the lower lumbar spine, thus improving preoperative assessment of stiffness or instability of the lumbar spine. Both extension methods were equally effective at determining the patient-specific maximum HL to assess the flexibility and compensation occurring at the hip, potentially guiding surgical management of patients with degenerative spines.Level of Evidence: 3.

The Effect of Including Benchmark Prevalence Data of Common Imaging Findings in Spine Image Reports on Health Care Utilization Among Adults Undergoing Spine Imaging: A Stepped-Wedge Randomized Clinical Trial.

Importance: Lumbar spine imaging frequently reveals findings that may seem alarming but are likely unrelated to pain. Prior work has suggested that inserting data on the prevalence of imaging findings among asymptomatic individuals into spine imaging reports may reduce unnecessary subsequent interventions. Objective: To evaluate the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions. Design, Setting, and Participants: This stepped-wedge, pragmatic randomized clinical trial included 250 401 adult participants receiving care from 98 primary care clinics at 4 large health systems in the United States. Participants had imaging of their backs between October 2013 and September 2016 without having had spine imaging in the prior year. Data analysis was conducted from November 2018 to October 2019. Interventions: Either standard lumbar spine imaging reports (control group) or reports containing age-appropriate prevalence data for common imaging findings in individuals without back pain (intervention group). Main Outcomes and Measures: Health care utilization was measured in spine-related relative value units (RVUs) within 365 days of index imaging. The number of subsequent opioid prescriptions written by a primary care clinician was a secondary outcome, and prespecified subgroup analyses examined results by imaging modality. Results: We enrolled 250 401 participants (of whom 238 886 [95.4%] met eligibility for this analysis, with 137 373 [57.5%] women and 105 497 [44.2%] aged >60 years) from 3278 primary care clinicians. A total of 117 455 patients (49.2%) were randomized to the control group, and 121 431 patients (50.8%) were randomized to the intervention group. There was no significant difference in cumulative spine-related RVUs comparing intervention and control conditions through 365 days. The adjusted median (interquartile range) RVU for the control group was 3.56 (2.71-5.12) compared with 3.53 (2.68-5.08) for the intervention group (difference, -0.7%; 95% CI, -2.9% to 1.5%; P = .54). Rates of subsequent RVUs did not differ between groups by specific clinical findings in the report but did differ by type of index imaging (eg, computed tomography: difference, -29.3%; 95% CI, -42.1% to -13.5%; magnetic resonance imaging: difference, -3.4%; 95% CI, -8.3% to 1.8%). We observed a small but significant decrease in the likelihood of opioid prescribing from a study clinician within 1 year of the intervention (odds ratio, 0.95; 95% CI, 0.91 to 1.00; P = .04). Conclusions and Relevance: In this study, inserting benchmark prevalence information in lumbar spine imaging reports did not decrease subsequent spine-related RVUs but did reduce subsequent opioid prescriptions. The intervention text is simple, inexpensive, and easily implemented. Trial Registration: ClinicalTrials.gov Identifier: NCT02015455.

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.

Delirium After Spine Surgery in Older Adults: Incidence, Risk Factors, and Outcomes.

OBJECTIVES: To characterize the incidence, risk factors, and consequences of delirium in older adults undergoing spine surgery. DESIGN: Prospective observational study. SETTING: Academic medical center. PARTICIPANTS: Individuals aged 70 and older undergoing spine surgery (N = 89). MEASUREMENTS: Postoperative delirium and delirium severity were assessed using validated methods, including the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit, Delirium Rating Scale-Revised-98, and chart review. Hospital-based outcomes were obtained from the medical record and hospital charges from data reported to the state. RESULTS: Thirty-six participants (40.5%) developed delirium after spine surgery, with 17 (47.2%) having purely hypoactive features. Independent predictors of delirium were lower baseline cognition, higher average baseline pain, more intravenous fluid administered, and baseline antidepressant medication. In adjusted models, the development of delirium was independently associated with higher quintile of length of stay (odds ratio (OR) = 3.66, 95% confidence interval (CI) = 1.48-9.04, P = .005), higher quintile of hospital charges (OR = 3.49, 95% CI = 1.35-9.00, P = .01), and lower odds of discharge to home (OR = 0.22, 95% CI = 0.07-0.69, P = .009). Severity of delirium was associated with higher quintile of hospital charges and lower odds of discharge to home. CONCLUSION: Delirium is common after spine surgery in older adults, and baseline pain is an independent risk factor. Delirium is associated with longer stay, higher charges, and lower odds of discharge to home. Thus, prevention of delirium after spine surgery may be an important quality improvement goal.

Dynamic balance assessment during gait in spinal pathologies - a literature review.

UNLABELLED: The role of the spine as a gait stabilizer is essential. Dynamic assessment, while walking, might provide complementary data to improve spinal deformity management. The aim of this paper was to review spine dynamic behavior and the various methods that have been used to assess gait dynamic balance in order to explore the consequences of spinal deformities while walking. A review was performed by obtaining publications from five electronic databases. All papers reporting pathological or non-pathological spine dynamic behavior during gait and dynamic balance assessment methods were included. Sixty articles were selected. Results varied widely according to pathologies, study conditions, and balance assessment techniques. Three methods assessing dynamic stability during gait were identified: local-orbital dynamic stability, tri-axial accelerometry, and dynamic stability margin. Data from conventional gait analysis techniques were established essentially for scoliosis and low back pain, but they do not assess specific consequences on gait dynamic balance. Three techniques investigate gait dynamic balance and have been validated in normal subjects. Further investigations need to be performed for validation in spinal pathologies as well as the value for clinical practice. LEVEL OF EVIDENCE: Level IV.

Establishing the content validity of palpatory examination for the assessment of the lumbar spine using ultrasonography: a pilot study.

CONTEXT: Practitioners of manipulative medicine have long sought to prove the intra- and interexaminer reliability of palpatory examinations in assessing somatic dysfunction. However, decades of research have yet to achieve the level of reproducibility needed to satisfy evidence-based criteria. OBJECTIVES: To examine the content validity of segmental motion evaluations using ultrasonographic measurements and to investigate the implication of these results for understanding the effects of an osteopathic manipulative treatment technique--high-velocity, low-amplitude (HVLA)--applied to somatic dysfunction in the lumbar spine. METHODS: A repeated-measures design was used, with the ultrasonographer blinded to the findings for each participant. The study was divided into 2 phases: (1) palpatory and ultrasonographic examination with no treatment and (2) palpatory and ultrasonographic examination with HVLA treatment. During phase 1, measurements were taken of tissue depth corresponding to bony landmarks of the dysfunctional vertebrae. Dysfunction was identified by means of palpatory examination and captured in sequential (ie, test-retest) ultrasonographic images. Content validity of somatic dysfunction was addressed by comparing palpatory examination with ultrasonographic data. During phase 2, the same protocol for tissue depth measurements was applied to the pre- and posttreatment images for comparison. RESULTS: Twelve young, healthy, asymptomatic students with no contraindications to HVLA treatment were recruited at Kansas City University of Medicine and Biosciences. The test-retest reliability, as determined by a Pearson correlation coefficient, was 0.997. For all participants, objectively identified side of dysfunction correlated with palpatory evaluation of segmental motion. A within-subjects analysis of variance was performed on the raw data, corrected for lumbar lordosis, showing statistical significance for main effect for side of measurement (P<.001) and interaction of side and time (P<.001), and showed no statistically significant effect for time (P=.259). CONCLUSION: Ultrasonography is a reliable instrument for the assessment of somatic dysfunction of the lumbar spine. The data also establish the content validity of palpatory examinations. In addition, this study provides the first objective evidence, to our knowledge, of the effect of a thrusting manipulative treatment on dysfunctional lumbar vertebrae.

SF-6D values stratified by specific diagnostic indication.

STUDY DESIGN: Longitudinal cohort. OBJECTIVE: To present Oswestry Disability Index scores and SF-6D utility values among patients with different diagnostic etiologies who underwent fusion surgery. SUMMARY OF BACKGROUND DATA: Several studies have increased our understanding of health-related quality-of-life measures in patients with low back pain. With rising health care costs, cost-utility analysis is increasingly used by decision makers. Thus, clinicians and researchers need to understand the psychometrics and clinical importance of health state utility values in patients with spine disorders. METHODS: A total of 1104 patients who had decompression and lumbar fusion with complete data to compute the SF-6D score at baseline and 2-year follow-up were identified. Primary surgical cases were classified as disc pathology (n = 200), spondylolisthesis (n = 288), instability (n = 43), stenosis (n = 134), or scoliosis (n = 44). Revision cases were classified as nonunion (n = 94), adjacent-level degeneration (n = 98), or postdiscectomy revision (n = 203). Baseline SF-6D and change in SF-6D scores at 2 years were compared among the groups as well as primary versus revision cases. RESULTS: There were 674 women and 430 men. The mean age at surgery was 56.65 ± 12.7 years. There were 220 (19.9%) smokers. The worst mean baseline SF-6D score was in patients with nonunion (0.492), followed by disc pathology (0.493), adjacent-level degeneration (0.494), postdiscectomy revision (0.499), stenosis (0.504), instability (0.512), spondylolisthesis (0.520), and scoliosis (0.530). There was a statistically significant difference in baseline SF-6D score among the different groups (P = 0.002). The mean change in SF-6D score was greatest in patients with stenosis (0.088), followed by spondylolisthesis (0.085), scoliosis (0.076), disc pathology (0.076), instability (0.073), postdiscectomy revision (0.070), adjacent-level degeneration (0.066), and nonunion (0.050). There was no statistically significant difference in change in SF-6D score among the different groups (P = 0.096). However, revision cases had statistically significantly smaller gains in SF-6D score (0.064) than primary cases (0.082, P = 0.012). CONCLUSION: Patients with lumbar degenerative disorders have health state values similar to patients with chronic renal disease, Crohn's disease, or coronary artery disease. Health state values of patients with different indications for surgery differ at baseline and after surgery. Revision cases have worse baseline SF-6D scores and less improvement in scores at 2 years after surgery than primary cases. Further studies are needed to gain a greater understanding of health state utility values in patients with lumbar degenerative disorders.

Validation of a noninvasive dynamic spinal stiffness assessment methodology in an animal model of intervertebral disc degeneration.

STUDY DESIGN: An experimental in vivo ovine model of intervertebral disc degeneration was used to quantify the dynamic motion response of the lumbar spine. OBJECTIVE: The purpose of this study was to: (1) compare invasively measured lumbar vertebral bone acceleration responses to noninvasive displacement responses, and (2) determine the effects of a single level degenerative intervertebral disc lesion on these responses. SUMMARY OF BACKGROUND DATA: Biomechanical techniques have been established to quantify vertebral motion responses, yet their invasiveness limits their use in a clinical setting. METHODS: Twenty-five Merino sheep were examined; 15 with surgically induced disc degeneration at L1-L2 and 10 controls. Triaxial accelerometers were rigidly fixed to the L1 and L2 spinous processes and dorsoventral (DV) mechanical excitation (20-80 N, 100 milliseconds) was applied to L3 using a spinal dynamometer. Peak force and displacement and peak-peak acceleration responses were computed for each trial and a least squares regression analysis assessed the correlation between L3 displacement and adjacent (L2) segment acceleration responses. An analysis of covariance (ANCOVA) was performed to test the homogeneity of slopes derived from the regression analysis and to assess the mean differences. RESULTS: A significant, positive, linear correlation was found between the DV displacement of L3 and the DV acceleration measured at L2 for both normal (R = 0.482, P < 0.001) and degenerated disc groups (R = 0.831, P < 0.001). The L3 DV displacement was significantly lower (ANCOVA, P < 0.001) for the degenerated group (mean: 10.39 mm) in comparison to the normal group (mean: 9.07 mm). Mean peak-peak L2-L1 DV acceleration transfer was also significantly reduced from 12.40 m/s to 5.50 m/s in the degenerated animal group (ANCOVA, P < 0.001). CONCLUSION: The findings indicate that noninvasive displacement measurements of the prone-lying animal can be used to estimate the segmental and intersegmental motions in both normal and pathologic spines.

Interobserver reliability and intraobserver reproducibility of powers ratio for assessment of atlanto-occipital junction: comparison of plain radiography and computed tomography.

Powers ratio, as assessed on plain radiographs or computed tomography (CT) images, appears to have clinical and prognostic value. To date, the validation of this assessment tool has been limited to a small number of observers at a single site. No study has examined the intraobserver reproducibility and interobserver reliability of the Powers ratio measurement on plain radiographs or CT images among a large cohort of spine surgeons. This type of validation is critical to allow for the broader use of the Powers ratio methodology in research studies and clinical applications. Plain radiographs and spiral CT images of the cervical spine of 32 patients were assessed, and the Powers ratio was determined by five spine surgeons. Each surgeon performed three readings, 7 months apart. In the first round of measurements, the observers used only the Powers' method of instruction. The second and third measurement sets were obtained after an interactive teaching session on the methodology. The order of the images was altered for the second and third set of measurements. The coefficient of variation (Cv) was calculated to determine the intraobserver repeatability and interobserver reliability for each imaging technique. A Bland-Altman plot was then used to assess the agreement between the two imaging techniques. For interobserver reliability, the mean Cv of the Powers ratio was 9.09 and 4.31% for plain radiographs and CT, respectively. The Cv mean value for intraobserver reproducibility averaged 4.95% (range 1.39-9.08) when CT scans were used and 14.17% (range 7.54-34.30) when plain radiographs were used. For intraobserver reproducibility, the lowest and highest Cv mean value of five raters was 1.39 and 9.08% using CT scans and 7.54 and 34.3% using plain radiographs. The Bland-Altman plot, demonstrated that the two methods were in close agreement on the -0.8 and 0.89% interval for limits of agreement (bias +/- 1.96sigma). The intraobserver reproducibility and interobserver reliability of Powers ratio measurement was acceptable (<5%) with CT scans but not with plain radiographs. However, despite the statistically inferior reliability and repeatability, the Bland-Altman plot analysis showed that given the -0.8 and 0.89% limits of agreement, the two methods may be used interchangeably in clinical practice.

Spinal motion palpation: a comparison of studies that assessed intersegmental end feel vs excursion.

OBJECTIVE: Spinal motion palpation (MP) is a procedure used to detect intersegmental hypomobility/hypermobility. Different means of assessing intersegmental mobility are described, assessing either excursion of the segments (quantity of movement) or end feel (quality of motion when stressed against the paraphysiological space). The objective of this review was to classify and compare studies based on method of MP used, considering that some studies may have used both methods. METHODS: Four databases were searched: MEDLINE-PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature databases for the years 1965 through January 2007. Retrieved citations were independently screened for inclusion by 2 of the authors consistent with the inclusion and exclusion criteria. Included studies were appraised for quality, and data were extracted and recorded in tables. RESULTS: The search strategy generated 415 citations, and 29 were harvested from reference lists. After removing articles that did not meet the inclusion criteria, 44 were considered relevant and appraised for quality. Fifteen studies focused on MP excursion, 24 focused on end feel, and 5 used both. Eight studies reported high levels of reproducibility (kappa = >or=0.4), although 4 were not of acceptable quality, and 2 were only marginally acceptable. When only high-quality studies were considered, 3 of 24 end-feel studies reported good reliability compared with 1 of 15 excursion studies. There was no statistical support for a difference between the 2 groupings. CONCLUSIONS: A difference in reported reliability was observed when the method of MP varied, although it was not statistically significant. There was no support in the literature for the advantage of one MP method over the other.

What comprises a good outcome in spinal surgery? A preliminary survey among spine surgeons of the SSE and European spine patients.

Standardized and validated self-administered outcome-instruments are broadly used in spinal surgery. Despite a plethora of articles on outcome research, no systematic evaluation is available on what actually comprises a good outcome in spinal surgery from the patients' and surgeons' perspective, respectively. However, this is a prerequisite for improving outcome instruments. In performing a cross-sectional survey among spine patients from different European regions and spine surgeons of the SSE, the study attempted (1) to identify the most important domains determining a good outcome from a patients' as well as a surgeon's perspective, and (2) to explore regional differences in the identified domains. For this purpose, a structured interview was performed among 30 spine surgeons of the SSE and 353 spine surgery patients (representing Northern, Central and Southern Europe) to investigate their criteria for a good outcome. A qualitative and descriptive approach was used to evaluate the data. Results revealed a high agreement on what comprises a good outcome among surgeons and patients, respectively. The main parameters determining good outcome were achieving the patients' expectations/satisfaction, pain relief, improvement of disability and social reintegration. Younger patients more often expected a complete pain relief, an improved work capacity, and better social life participation. Patients in southern Europe more often wanted to improve work capacity compared to those from central and northern European countries. No substantial differences were found when patients' and surgeons' perspective were compared. However, age and differences in national social security and health care system ("black flags") have an impact on what is considered a good outcome in spinal surgery.

Neurologic complications of lumbar pedicle subtraction osteotomy: a 10-year assessment.

STUDY DESIGN: Clinical, radiographic, and outcomes assessment focusing on neurologic complications in patients undergoing pedicle subtraction osteotomy (PSO). Clinical data were collected prospectively. Radiographic analysis was performed retrospectively. OBJECTIVE: To evaluate intraoperative and postoperative neurologic deficits following lumbar PSOs in order to determine risk factors, treatment strategies, and patient outcome. SUMMARY OF BACKGROUND DATA: Although technically demanding, PSOs have been increasingly used to restore lumbar lordosis and correct sagittal deformity. Although some reports have commented on various complications of the procedure, to our knowledge, there have been no studies focusing on neurologic complications of the osteotomy. METHODS: An analysis of 108 consecutive patients with an average age of 54.8 +/- 14.0 years and treated with a lumbar PSO at 1 institution over a 10-year period (1995-2005) was performed. Medical records, radiographs, and neuromonitoring data were analyzed. Clinical outcome was assessed using the Oswestry Disability Index and the Scoliosis Research Society (SRS)-24 instruments. RESULTS: A total of 108 PSOs were performed. Following surgery, lumbar lordosis increased from -17.1 degrees +/- 19.3 degrees to -49.3 degrees +/- 14.7 degrees (P < 0.000), and sagittal balance improved from 131 +/- 73 mm to 23 +/- 48 mm (P < 0.000). Intraoperative and postoperative deficits (defined as motor loss of 2 grades or more or loss of bowel/bladder control) were seen in 12 patients (11.1%) and were permanent in 3 patients (2.8%). With time motor function improved by 1 grade in 2 patients and all 3 were able to ambulate. Intraoperative neuromonitoring did not detect the deficits. In 9 patients, additional surgical intervention consisted of central enlargement and further decompression. Deficits were thought to be due to a combination of subluxation, residual dorsal impingement, and dural buckling. CONCLUSION: Intraoperative or postoperative neurologic deficits are relatively common following a PSO; however, in a majority of cases, deficits are not likely to be permanent.

A review of 1985 Volvo Award winner in clinical science: objective assessment of spine function following industrial injury: a prospective study with comparison group and 1-year follow-up.

It is now 2 decades since Mayer et al published their Volvo Award-winning paper entitled "Objective assessment of spine function following industrial injury: a prospective study with comparison group and one-year follow-up." Their landmark paper reported that return to work rates of patients that underwent a "functional restoration" treatment program were double that of a comparative group of patients that were denied treatment by their insurers. These results were considered extraordinary and inspired both debate and enthusiasm. Our goal is to review this landmark study, report on its strengths and weaknesses, and review the studies that have attempted to replicate this work in other settings. We also highlight its contribution to our current knowledge about the treatment of back pain and disability. The major weaknesses of the paper of Mayer et al are the possibility of selection bias in the development of their cohort of patients and the lack of a true randomized controlled study design. These factors may have inflated the rates of return to work. Regardless, their reported results were robust, and cannot be easily dismissed. During the last 20 years, this treatment model has received considerable study worldwide, and it is generally agreed that it is superior to standard care for reducing work absence in patients with chronic low back pain. Additionally, the concepts underlying functional restoration have been found to be highly relevant to patients with chronic low back pain, medical providers, and disability systems and continue to gain acceptance and integration into the care of patients throughout the industrialized world.

Radiologic assessment of all unfused lumbar segments 7.5 years after instrumented posterior spinal fusion.

STUDY DESIGN: Prospective observational single-cohort study. OBJECTIVE: To analyze long-term radiographic changes in all unfused lumbar segments after instrumented posterolateral lumbar fusion. SUMMARY OF BACKGROUND DATA: Adjacent segment degeneration (ASD) after lumbar fusion may be a consequence of biomechanical stress or result from constitutional factors. Most studies analyzing ASD only investigate the motion segments immediately above and below the fusion. None compares adjacent segments to all the other unfused segments after instrumented posterior fusion. METHODS: Using the distortion-compensated roentgen analysis method, disc height, dorsoventral displacement, and lordosis were measured in 212 unfused segments from 62 patients, on digitized standing radiographs taken before fusion surgery and after a mean follow-up of 7.5 years (range, 4-11 years). The effect of covariables, such as age, length of follow-up, fusion level, number of fused segments, and sagittal and spinopelvic parameters on the preoperative to follow-up changes, were analyzed using a repeated-measurement model. RESULTS: No changes were observed at the segments located below the fusion. All the unfused segments above the fusion showed the same significant loss of disc height. Loss of disc height did not depend on fusion parameters, correlated weakly with age and length of follow-up, and correlated highly across adjacent unfused segments. CONCLUSIONS: After posterior lumbar instrumented fusion, radiographic changes suggesting disc degeneration appear homogeneously at several levels cephalad to fusion and seem to be determined by individual characteristics.

The (cost-)effectiveness of a lifestyle physical activity intervention in addition to a work style intervention on the recovery from neck and upper limb symptoms in computer workers.

BACKGROUND: Neck and upper limb symptoms are frequently reported by computer workers. Work style interventions are most commonly used to reduce work-related neck and upper limb symptoms but lifestyle physical activity interventions are becoming more popular to enhance workers health and reduce work-related symptoms. A combined approach targeting work style and lifestyle physical activity seems promising, but little is known on the effectiveness of such combined interventions. METHODS/DESIGN: The RSI@Work study is a randomised controlled trial that aims to assess the added value of a lifestyle physical activity intervention in addition to a work style intervention to reduce neck and upper limb symptoms in computer workers. Computer workers from seven Dutch companies with frequent or long-term neck and upper limb symptoms in the preceding six months and/or the last two weeks are randomised into three groups: (1) work style group, (2) work style and physical activity group, or (3) control group. The work style intervention consists of six group meetings in a six month period that take place at the workplace, during work time, and under the supervision of a specially trained counsellor. The goal of this intervention is to stimulate workplace adjustment and to improve body posture, the number and quality of breaks and coping behaviour with regard to high work demands. In the combined (work style and physical activity) intervention the additional goal is to increase moderate to heavy physical activity. The control group receives usual care. Primary outcome measures are degree of recovery, pain intensity, disability, number of days with neck and upper limb symptoms, and number of months without neck and upper limb symptoms. Outcome measures will be assessed at baseline and six and 12 months after randomisation. Cost-effectiveness of the group meetings will be assessed using an employer's perspective. DISCUSSION: This study will be one of the first to assess the added value of a lifestyle physical activity intervention in addition to a work style intervention in reducing neck and upper limb symptoms of computer workers. The results of the study are expected in 2007.

Lumbar segmental instability: a criterion-related validity study of manual therapy assessment.

BACKGROUND: Musculoskeletal physiotherapists routinely assess lumbar segmental motion during the clinical examination of a patient with low back pain. The validity of manual assessment of segmental motion has not, however, been adequately investigated. METHODS: In this prospective, multi-centre, pragmatic, diagnostic validity study, 138 consecutive patients with recurrent or chronic low back pain (R/CLBP) were recruited. Physiotherapists with post-graduate training in manual therapy performed passive accessory intervertebral motion tests (PAIVMs) and passive physiological intervertebral motion tests (PPIVMs). Consenting patients were referred for flexion-extension radiographs. Sagittal angular rotation and sagittal translation of each lumbar spinal motion segment was measured from these radiographs, and compared to a reference range derived from a study of 30 asymptomatic volunteers. Motion beyond two standard deviations from the reference mean was considered diagnostic of rotational lumbar segmental instability (LSI) and translational LSI. Accuracy and validity of the clinical assessments were expressed using sensitivity, specificity, and likelihood ratio statistics with 95% confidence intervals (CI). RESULTS: Only translation LSI was found to be significantly associated with R/CLBP (p < 0.05). PAIVMs were specific for the diagnosis of translation LSI (specificity 89%, CI 83-93%), but showed poor sensitivity (29%, CI 14-50%). A positive test results in a likelihood ratio (LR+) of 2.52 (95% CI 1.15-5.53). Flexion PPIVMs were highly specific for the diagnosis of translation LSI (specificity 99.5%; CI 97-100%), but showed very poor sensitivity (5%; CI 1-22%). Likelihood ratio statistics for flexion PPIVMs were not statistically significant. Extension PPIVMs performed better than flexion PPIVMs, with slightly higher sensitivity (16%; CI 6-38%) resulting in a likelihood ratio for a positive test of 7.1 (95% CI 1.7 to 29.2) for translation LSI. CONCLUSION: This study provides the first evidence reporting the concurrent validity of manual tests for the detection of abnormal sagittal planar motion. PAIVMs and PPIVMs are highly specific, but not sensitive, for the detection of translation LSI. Likelihood ratios resulting from positive test results were only moderate. This research indicates that manual clinical examination procedures have moderate validity for detecting segmental motion abnormality.

Outcome assessment in lumbar spine surgery.

BACKGROUND: There is no consensus regarding outcomes assessment in spine patients. When using Health-Related Quality of Life (HRQoL) in assessing outcomes of treatment, normative data for different diagnoses are needed to allow comparisons between existing and future studies. The most used generic instrument for HRQoL evaluation in spine pathologies is SF-36. There is no standard definition of important differences in spine surgery patients and no standard reference for minimal clinically important difference. OBJECTIVE: The overall aim of this thesis was to increase understanding of some aspects of outcome measurement in patients operated on for lumbar spine problems using existing prospective data available at the spine section of the Orthopedics Department of the University of Lund, and, moreover, to explore potentials and weaknesses in the methodology of retrospectively analysis of prospectively collected observational data. METHODS: A systematic web-search and review of the literature and a retrospective analysis of prospective cohort data collected within the data collection protocol in use by the Swedish Spine Register. Since 1993 all persons undergoing elective lumbar surgery at the spine section of the Orthopedics Department of the University of Lund were included in the prospective registration protocol either in its first version (1993-1997), which was the source of data for paper III, or in its revised version after 1998. Initial information at baseline (the day before surgery) included age, sex, smoking habits, duration of preoperative back and leg pain in months, duration of preoperative sickleave in months, number of previous operations, patient's working status, diagnostic techniques pre- and postoperatively VAS scores analgesic intake, walking distance. Postoperatively, change in leg and back pain, respectively, was recorded on a 5-point Likert Scale as compared to preoperative status, patient satisfaction was recorded on a 3-point Likert Scale. RESULTS: The number of proposed outcomes, outcome scores, outcome instruments is incredibly high: no new HRQoL instruments specific for LBP are needed. The data collection protocol of the Swedish Spine Register studied can reliably detect postoperative improvements between large groups of patients such as in a Register. Pain intensity measured on the VAS correlates significantly to other indicators of perceived pain, but correlation is not as strong as it could be if they were all measuring the same construct. HRQoL as measured by SF-36 in patients scheduled for lumbar spine surgery showed a pronounced reduction compared to normal and LBP population. The use of norm-based scoring for SF-36 can help interpretation and simplify graphic representation of the findings. SF-36 outcomes 1-year after surgery for lumbar spine disorders are improved, although other factors or natural history could contribute to this improvement. The global effect of spine surgery in our sample is quite similar to effect sizes of very successful orthopedic interventions. The use of standardised outcome measures allows international comparisons, although caution should be used in the interpretation of differences. CONCLUSIONS: Without the need of additional expensive data collection and using limited economic resources an increased understanding of some aspects of outcome measurement in patients operated on for lumbar spine problems has been achieved. Reference values and more speculative data (such as effect sizes and MCIDs) have been presented. The ecological methodology has been presented and discussed: with a clear respect for its limitations, it could be used to obtain relevant information also in other clinical fields.

Assessment of gait and balance in patients with spinal diseases using the leg reposition test.

We devised a new leg reposition test, to assess gait and balance in patients with spinal diseases. This study included 344 patients who were scheduled to undergo spine surgery; 14 (4.1%) patients showed positive results. These 14 patients had worse gait status than leg reposition test-negative patients both preoperatively and postoperatively. The leg reposition test is a simple procedure, and requires no specialized equipment. This study showed that the leg reposition test has a strong relation with gait status, and therefore a high clinical significance regarding the assessment of preoperative gait and balance and prediction of postoperative gait status.

The development of a comorbidity index with physical function as the outcome.

BACKGROUND AND OBJECTIVES: Physical function is an important measure of success of many medical and surgical interventions. Ability to adjust for comorbid disease is essential in health services research and epidemiologic studies. Current indices have primarily been developed with mortality as the outcome, and are not sensitive enough when the outcome is physical function. The objective of this study was to develop a self-administered Functional Comorbidity Index with physical function as the outcome. METHODS: The index was developed using two databases: a cross-sectional, simple random sample of 9,423 Canadian adults and a sample of 28,349 US adults seeking treatment for spine ailments. The primary outcome measure was the SF-36 physical function (PF) subscale. RESULTS: The Functional Comorbidity Index, an 18-item list of diagnoses, showed stronger association with physical function (model R(2) = 0.29) compared with the Charlson (model R(2) = 0.18), and Kaplan-Feinstein (model R(2) = 0.07) indices. The Functional Comorbidity Index correctly classified patients into high and low function, in 77% of cases. CONCLUSION: This new index contains diagnoses such as arthritis not found on indices used to predict mortality, and the FCI explained more variance in PF scores compared to indices designed to predict mortality.