Relationship of disc degeneration after pubertal growth spurt to future low back pain: a longitudinal cohort study.

PURPOSE: In this longitudinal cohort study, we investigated the relationship of disc degeneration (DD) after pubertal growth spurt to future low back pain (LBP). METHODS: A group of healthy volunteers underwent a semi-structured interview about LBP without trauma and a 1.5T lumbar MRI at ages 18 and 34. A Pfirrmann Summary Score (PSS) was calculated by adding up the Pfirrmann grades of the three lowest lumbar discs of each subject (range 3-15). The relationship of PSS at age 18 to LBP at age 34 was analyzed. RESULTS: Forty-one participants had full data at both time points. Mean PSS at age 18 was 6.8 (SD 1.1) and 5.6 (SD 1.2) for participants with or without LBP at age 34, respectively (p = 0.009). The OR (95% CI) of PSS at age 18 for LBP at age 34 was 5.46 (1.22 to 24.47) when adjusted for sex, BMI, smoking and physical activity. All participants but one with PSS greater than 6 at age 18 reported LBP at age 34. CONCLUSION: This is the first study to suggest that DD may be associated with future LBP and the critical time frame seems to be the pubertal growth spurt. Every 1-point increase in Pfirrmann grade at age 18 increased the risk of LBP 5.5-fold at age 34 when adjusted for sex, BMI, smoking and physical activity at age 34. All participants but one with at least one disc with Pfirrmann grade 3 or higher at age 18 reported LBP at age 34.

Reliability of T2-weighted signal intensity-based quantitative measurements and visual grading of lumbar disc degeneration on MRI.

BACKGROUND: Decrease in signal intensity (SI) of the nucleus pulposus (NP) on T2-weighted (T2W) images, a sign of disc degeneration (DD), is usually graded based on an observer's image interpretation. No gold standard for quantitative assessment of NP SI exists to date. PURPOSE: To compare different quantitative methods and visual gradings of lumbar DD and to evaluate the ability of the quantitative methods to differentiate DD grades. MATERIAL AND METHODS: The mean SI of 95 lumbar discs was measured from sagittal T2W images using three regions of interest (ROI): the whole disc, ellipsoid ROI on the NP, and targeted ROI on the most homogenous, brightest area of the NP. SI values were adjusted with cerebrospinal fluid (CSF) SI and compared with vertebral bone SI-adjusted values. DD was evaluated with Pfirrmann grading and visual grading of NP SI. Intra- and inter-observer agreements and relationships between measurements and visual gradings were assessed. RESULTS: Repeatability of all measurements was excellent. All measurements had a strong correlation with Pfirrmann grading and visual NP SI grading, and the CSF SI-adjusted values had a stronger correlation than the vertebral bone SI-adjusted values. The SI values obtained with the targeted ROI had the most significant differences between visual DD grades. CONCLUSION: Quantitative measurement of the NP SI provides a reliable method for evaluating lumbar DD. Targeted selection of the NP structures included in the measurement offers the best differentiation of DD grades. A reliable quantitative method for DD evaluation is needed for the development of machine-learning-based DD classification.

ISSLS prize in clinical science 2022: accelerated disc degeneration after pubertal growth spurt differentiates adults with low back pain from their asymptomatic peers.

PURPOSE: In this prospective observational cohort study, the development of lumbar intervertebral discs (LIVD) on magnetic resonance imaging (MRI) was investigated from childhood to adulthood with emphasis on the possible association of disc degeneration (DD) to low back pain (LBP). METHODS: In 2021, 89 subjects who were enrolled in 1994 in a longitudinal study with lumbar spine MRI at ages 8, 11 and 18 were invited to participate in a long-term follow-up comprising a clinical examination, selected patient-reported outcome measures and a lumbar spine MRI. We assessed all MRIs (three lowest LIVDs) with the Pfirrmann summary score, and the ratio of signal intensity of nucleus pulposus to signal intensity of cerebrospinal fluid (SINDL). We further analyzed whether disc changes at any age were associated with self-reported LBP at age 34. RESULTS: Of the 48 subjects in the follow-up, 35 reported LBP at age 34. The Pfirrmann summary score significantly increased with age (p < 0.001). Subjects reporting LBP at age 34 demonstrated statistically significantly higher summary scores at age 18 and 34 compared to asymptomatic subjects (p = 0.004 at age 18, and p = 0.039 at age 34). SINDL significantly decreased with age (p < 0.001 for all levels separately), but no significant differences between subjects with or without LBP at age 34 were noticed. CONCLUSION: Subjects with LBP at age 34 had more widespread or severe DD already at age 18 compared to those without LBP.

Increased preoperative knowledge reduces surgery-related anxiety: a randomised clinical trial in 100 spinal stenosis patients.

PURPOSE: To assess the impact of preoperative knowledge on anxiety, health-related quality of life (HRQoL), disability, and pain in surgically treated spinal stenosis patients. METHODS: One hundred patients were randomised into an intervention group (IG, n = 50) or control group (CG, n = 50). Both groups received routine preoperative patient education. IG additionally underwent a feedback session based on a knowledge test. Primary outcome measure was anxiety at the time of surgery. HRQoL, disability, and pain constituted the secondary outcome measures during a 6-month follow-up. RESULTS: In IG, a significant reduction in anxiety was noted after the intervention, whereas in CG, anxiety reduced only after the surgery. In both groups, a significant improvement in HRQoL, disability, and pain was noticed at the 6-month follow-up, but there were no between-group differences. CONCLUSIONS: Higher knowledge level may reduce preoperative anxiety but does not seem to affect the self-reported clinical outcomes of surgery.

Bodily growth and the intervertebral disc: a longitudinal MRI study in healthy adolescents.

BACKGROUND CONTEXT: Low back pain (LBP) among children and adolescents is a growing global concern. Disc degeneration (DD) is considered a significant factor in the clinical symptom of LBP. Both LBP and DD become more prevalent as adolescents transition into emerging adulthood. However, the relationship between growth during the pubertal growth spurt and the morphology of lumbar discs has yet to be elucidated. PURPOSE: This study aimed to assess the relationship between bodily growth during the pubertal growth spurt and the morphology of lumbar discs at age 18. STUDY DESIGN: This study was a prospective longitudinal cohort study. PATIENT SAMPLE: A randomly selected cohort of healthy children was examined at ages 8, 11, and 18. Participants with complete data sets (semi-structured interview, anthropometric measurements and lumbar spine MRI) at age 11 and 18 were included in this analysis (n=59). OUTCOME MEASURES: The morphological characteristics of lumbar discs were evaluated on MRI. Anthropometric measures including height, sitting height and weight were obtained to calculate the Body Surface Area (BSA) and the Body Mass Index (BMI). METHODS: The morphology of the lumbar discs was evaluated on T2-weighted mid-sagittal MRI using the Pfirrmann classification. A disc with a Pfirrmann grade of 3 or higher was considered degenerated at age 18. The relationship between relative growth between ages 11 and 18 (adjusted to sex and baseline values) and DD at age 18 was assessed. To analyze the relationship between the relative increase in BSA and DD, the participants were categorized into three equal-sized categories (tertiles). For all other anthropometric measures, the analysis was based on the relative increase in each measure between ages 11 and 18. RESULTS: In the highest tertile of relative increase in BSA (≥43%), 76% of participants had at least 1 disc with a Pfirrmann grade 3 or higher at age 18 while only 10% and 21% of participants in the lowest and medium tertiles had DD, respectively. The sex- and baseline-adjusted odds ratio (OR) for DD at age 18 for every additional 10% increase in BSA was 1.08 (1.02-1.15). The sex- and baseline-adjusted OR (95% CI) for DD at age 18 was 10.5 (1.60-68.7) and 7.92 (1.19-52.72) with every additional 10% increase in height and sitting height, respectively. For every additional 10% increase in weight, the adjusted OR for DD at age 18 was 1.51 (1.12-2.04) and for BMI 1.05 (1.01-1.09). CONCLUSIONS: More relative growth between ages 11 and 18 is significantly associated with the occurrence of DD in emerging adulthood. Among the measures investigated, height and sitting height are nonmodifiable. Maintaining an ideal body weight during the pubertal growth spurt may be beneficial for the health of the lumbar discs.

The intervertebral disc during growth: Signal intensity changes on magnetic resonance imaging and their relevance to low back pain.

Life-time prevalence of low back pain (LBP) in children and adolescents varies from 7% to 72%. Disc changes on magnetic resonance imaging (MRI) have been reported in up to 44% of children with earliest observations around pre-puberty. In this longitudinal cohort study, our objective was to determine the natural history of disc changes from childhood to early adulthood, and the possible association of these changes to LBP. Healthy 8-year-old schoolchildren were recruited for this longitudinal study consisting of a semi-structured interview, a clinical examination, and an MRI investigation at the age of 8-9 (Y8), 11-12 (Y12) and 18-19 (Y19) years. The interview inquired about LBP without trauma. T2-weighted sagittal MRI of the lumbar spine was acquired. Life-long prevalence of LBP was determined, and the disc signal intensity (SI) at the three lowest lumbar levels was assessed both visually using the Schneiderman classification (Bright-Speckled-Dark), and digitally using the disc to cerebrospinal fluid -SI ratio. Possible associations between SI changes and LBP were analyzed. Ninety-four of 208 eligible children were included at Y8 in 1994, 13 and 23 participants were lost to follow-up at Y12 and Y19, respectively. Prevalence of LBP increased after the pubertal growth spurt reaching 54% at Y19. On MRI, 18%, 10% and 38% of participants had disc SI changes at Y8, Y12 and Y19, respectively. No significant associations between self-reported LBP and either qualitative or quantitative disc SI changes were observed at any age. Life-time prevalence of LBP reached 54% by early adulthood. Disc SI changes on MRI traditionally labeled as degenerative were seen earlier than previously reported. Changes in disc SI were not associated with the presence of LBP in childhood, adolescence or early adulthood.

Spinal Stenosis Patients' Visual and Verbal Description of the Comprehension of Their Surgery.

BACKGROUND: Spine surgery patients have difficulty comprehending the patient education aimed at preparing for surgery. PURPOSE: To assess the effect of a specific preoperative education approach (Knowledge Test Feedback Intervention, KTFI) on patients' verbal and visual understanding of their surgery. METHODS: In this randomized controlled trial, the intervention group (n = 50) went through the KTFI and routine education, whereas the control group (n = 50) received only routine patient education. Written description of the surgical procedure and drawing of incision were used as outcome measures at baseline, at hospitalization, at discharge, and 3 and 6 months after surgery. RESULTS: At baseline, half of the participants showed verbal and visual understanding of their surgery. During follow-up, understanding improved significantly with no statistically significant differences between the groups. CONCLUSION: Spinal stenosis patients' understanding of their surgical procedure is imperfect. Patient educators need to ensure patient learning by evaluating comprehension outcomes.

The Knowledge Test Feedback Intervention (KTFI) increases knowledge level of spinal stenosis patients before operation-A randomized controlled follow-up trial.

OBJECTIVE: To assess the impact of a preoperative educational intervention on the knowledge level of patients with spinal stenosis. METHODS: One hundred spinal stenosis patients were randomized into a preoperative educational intervention group (IG, n=50) or a control group (CG, n=50). All the patients received routine preoperative education. In addition, the IG went through an empowering telephone discourse based on a knowledge test performed before admission to hospital. Data on patients' knowledge level were collected at baseline (after the treatment decision), admission to hospital, discharge from hospital and at 3 and 6 months follow-up. RESULTS: At baseline, there was no difference in the knowledge level of the study groups. At admission, the knowledge level was significantly higher in five of six dimension of empowering knowledge in the IG compared to the CG. During follow-up, the knowledge level within the study groups remained stable. CONCLUSION: A preoperative KTFI significantly increased the patients' knowledge level in most dimensions of empowering knowledge. PRACTICE IMPLICATION: KTFI is an effective method of preoperative education in patients with spinal stenosis.

Adjacent level disk disease--is it really a fusion disease?

Adjacent segment degeneration (ASD) is a relatively common phenomenon after spinal fusion surgery. Whether ASD is a consequence of the previous fusion or an individual's predisposition to continued degeneration remains unsolved to date. This article summarizes the existing biomechanical and clinical literature on the causes and clinical impact of ASD, as well as possible risk factors. Further, the theoretical advantage of motion-preserving technologies that aim to preserve the adjacent segment is discussed.

Effectiveness of spinal fusion versus structured rehabilitation in chronic low back pain patients with and without isthmic spondylolisthesis: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: To determine if the presence of isthmic spondylolisthesis modifies the effect of treatment (fusion vs. multidimensional supervised rehabilitation) in patients with chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: Results of spinal surgery for CLBP are variable. It is unclear whether patients with CLBP and isthmic spondylolisthesis have more success with surgery versus a multidimensional supervised rehabilitation program when compared with those with CLBP but without spondylolisthesis. METHODS: A systematic search was conducted in MEDLINE and the Cochrane Collaboration Library for articles published through January 2011. Randomized controlled trials (RCTs) were included that compared spine fusion versus multidimensional supervised rehabilitation in patients with and without isthmic spondylolisthesis. Standardized mean differences (SMDs) and risk differences were calculated for common outcomes, and then compared to determine potential heterogeneity of treatment effect. The final strength of the body of literature was expressed as "high," "moderate," or "low" confidence that the evidence reflects the true effect. RESULTS: No studies were found that directly compared the two subgroups. Three RCTs compared fusion with supervised nonoperative care in patients with CLBP without isthmic spondylolisthesis; one RCT evaluated these treatments in patients with isthmic spondylolisthesis. There were study differences in patient characteristics, type of fusion, the nature of the rehabilitation, outcomes assessed, and length of follow-up. The SMDs for pain in favor of fusion were modest at 2 years for those without isthmic spondylolisthesis, but large in favor of fusion for those with isthmic spondylolisthesis compared with rehabilitation. Similarly, the SMDs for function in patients without isthmic spondylolisthesis compared with rehabilitation was small at 2 years, but appreciably higher in favor of fusion in patients with isthmic spondylolisthesis. CONCLUSION: The overall strength of evidence evaluating whether the presence of isthmic spondylolisthesis modifies the effect of fusion compared with rehabilitation patients with CLBP is "low." Fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed nonoperative treatment. CLINICAL RECOMMENDATIONS: We recommend considering fusion for patients with isthmic spondylolisthesis and lower back pain who have failed nonoperative treatment. RECOMMENDATION: Weak.

Three-dimensional motion patterns during active bending in patients with chronic low back pain.

STUDY DESIGN: The three-dimensional motion patterns of chronic low back pain (LBP) patients were studied during active motions. OBJECTIVE: To evaluate whether the motion patterns of coupling and asymmetry in chronic LBP patients differ from those in the normal population according to previous literature. SUMMARY OF BACKGROUND DATA: There exists little data that correlates vertebral motion with LBP symptoms despite extensive research. Several studies have suggested that patterns of motion are sensitive indicators of spinal pathology, including coupled motion patterns and asymmetry of motion. METHODS: In this study, 34 chronic LBP patients enrolled for an external fixation test performed active bending maneuvers, during which the three-dimensional intervertebral motions were measured continuously with an optoelectronic camera via markers attached to the percutaneous transpedicular screws. If a solid connection between each marker carrier and vertebrae was verified, the three-dimensional rotations of the vertebrae were analyzed with special reference to motion asymmetries and patterns of coupled motion. All data were compared to the normal values in the literature since the methodology is not possible in asymptomatic control subjects. RESULTS: Seven patients were removed from the analysis because of a loose screw-bone interface. In the remaining patients, three distinct patterns of motion were observed in each direction of movement. Significant differences in the extension-flexion ratio, the lateral bending asymmetry, and the coupled axial rotation-lateral bending ratio were found between the chronic LBP group and the normal literature values. CONCLUSIONS: Chronic LBP patients exhibited motion patterns altered from those of the normal population. Specific differences were observed in coupled axial rotation during lateral bending movement, in the symmetry between flexion and extension, and in the symmetry be tween right and left lateral bending.

Is there a connection between the clinical response after an external fixation test or a subsequent lumbar fusion and the pre-test intervertebral kinematics?

STUDY DESIGN: Evaluation of a possible correlation of clinical symptoms of chronic low back pain (LBP) patients before and after application of external spinal fixation (ESF) with three-dimensional motion patterns. OBJECTIVE: To determine whether the intervertebral kinematics in chronic LBP patients correlate with pain relief after stabilization of the suspected painful segments. SUMMARY OF BACKGROUND DATA: Chronic LBP is a complex clinical entity with mechanical, biochemical, and psychosocial components. Although clinically controversial, ESF has been shown to reduce intervertebral motion, and thus, it provides a mechanism to investigate the mechanical aspect of LBP. METHODS: Thirty-four chronic LBP patients were tested with ESF of the suspected painful segments. The subjective pain relief experienced by the patients during the test and 2 years after spinal fusion surgery was determined, along with the Oswestry Disability Index. Before removal of ESF, the three-dimensional intervertebral kinematics of the painful segments (specifically range of motion, coupling patterns, and motion asymmetries) were analyzed with a precision optoelectronic camera system during active trunk motions. A series of linear correlations were performed between the clinical measures and the motion parameters. RESULTS: The subjective pain relief during the ESF test was nominally, but not significantly, associated with lateral bending asymmetry ( = 0.22) and "abnormal" axial rotation-lateral bending coupling ( = 0.13). The improvement in the Oswestry Disability Index both post-test and at 2 years after lumbar fusion surgery was significantly correlated with the extension range of motion ( = 0.049 and = 0.036, respectively) and the extension-to-flexion range of motion ratio ( = 0.035 and = 0.044, respectively). CONCLUSIONS: The "abnormal" motion patterns of chronic LBP patients did not correlate with subjective pain relief after ESF of the suspected symptomatic levels or with the midterm outcome of subsequent lumbar fusion surgery. The results suggest that preserved motion of the symptomatic segments before surgery is positively correlated with the clinical result of the subsequent spinal fusion in case of a positive ESF test result.

Three-dimensional stabilization provided by the external spinal fixator compared to two internal fixation devices: a biomechanical in vitro flexibility study.

We performed an in vitro study to investigate the stabilization (i.e. motion reduction) provided by the external spinal fixator (ESF), and to compare the three configurations of the ESF with two internal fixation techniques. Six human cadaveric lumbar spine specimens (L3-S1) were subjected to multidirectional flexibility testing in six configurations: (1) intact, (2) ESF in neutral, (3) ESF in distraction, (4) ESF in compression, (5) translaminar facet screw fixation, and (6) internal transpedicular fixation. Both the ESF and the internal fixation systems stabilized the specimens from L4 to S1. In each testing configuration, pure bending moments of flexion-extension, bilateral axial rotation, and bilateral lateral bending were applied to the uppermost vertebra stepwise to a maximum of 10 Nm. The rigid body motion between the vertebrae was measured using an optoelectronic camera system, and custom software was used to calculate the intervertebral rotations. For each applied motion in all testing configurations, the total range of motion (ROM) of L4-S1 is reported. All three ESF configurations stabilized the spine significantly when compared to the intact specimen. The ESF in compression provided significantly more stabilization in flexion-extension than the two other ESF configurations, but no other significant differences were found between the three ESF modes. In flexion-extension the ESF stabilized the spine significantly when compared with the two internal fixation devices. Only in bilateral lateral bending was the ESF inferior to internal transpedicular fixation in providing stabilization. The results of the present study suggest that the ESF provides a high degree of stabilization for preoperative assessment of selected low back pain patients. Whether other non-mechanical factors affect the pain relief experienced by the patients remains unknown.