[Spondylolisthesis]. / Spondylolisthese.

Spondylolisthesis is a frequent disease that is found in 20% of the adult population and is particularly accompanied by lumbar back pain. Degenerative spondylolisthesis develops in adulthood and is most often found in the L4/5 segment, in contrast to nondegenerative spondylolisthesis which is most often situated in the L5/S1 segment. Prior to every treatment the heterogeneous disease pattern has to be classified according to the severity grade of the olisthesis and to the Spinal Deformity Study Group (SDSG) classification. High-grade spondylolisthesis should preferably be surgically treated and low-grade spondylolisthesis should preferably be treated conservatively. In approximately 50% of all recently acquired spondylolistheses healing of the lysis can be achieved by a consequently carried out conservative treatment.

Radiographic analysis of dynamic lumbar motion during the five-repetition sit-to-stand test in degenerative lumbar spondylolisthesis.

BACKGROUND: To investigate the mechanisms of low back pain triggered by the five-repetition sit-to-stand test (5R-STS test) in degenerative lumbar spondylolisthesis (DLS) from radiographic perspective, as well as to determine the most useful diagnostic modalities in the evaluation of segmental instability. METHODS: We retrospectively performed a study of 78 patients (23 men and 55 women) with symptomatic DLS at L4/5 in our institution between April 2020 and December 2021. Each patient was assessed by using the 5R-STS test and received a series of radiographs including the upright standing, normal sitting, standing flexion-extension radiographs, and supine sagittal MR images. Enrolled patients were divided into two groups based on the 5R-STS test score: severe group and mild group. Translational and angular motion was determined by comparing normal sitting radiograph (N) with upright standing radiograph (U) (Combined, NU), flexion/extension radiographs (FE) as well as normal sitting radiograph (N) with a supine sagittal MR image (sMR) (Combined, N-sMR). RESULTS: Overall, 78 patients were enrolled, and there were 31(39.7%) patients in group S and 47(60.3%) patients in group M, with an average age of 60.7 ± 8.4 years. The normal sitting radiograph demonstrated the maximum slip percentage (SP) and the highest kyphotic angle both in group S and group M. Compared with group M, group S revealed significantly higher SP in the normal sitting position (24.1 vs 19.6; p = 0.002). The lumbar slip angular in group S with a sitting position was significantly higher than that in group M (-5.2 vs -1.3; p < 0.001). All patients in group S had objective functional impairment (OFI) and 28 patients of them were diagnosed with lumbar instability by using the combination of normal sitting radiograph (N) and supine sagittal MR image (sMR) (Combined, N-sMR). CONCLUSION: DLS patients with positive sign of the 5R-STS test is a distinct subgroup associated with lumbar instability. The modality of the combination of normal sitting radiograph (N) and supine sagittal MR image (sMR) had a significant advantage in terms of the ability to identify segmental instability.

Initial classification of low back and leg pain based on objective functional testing: a pilot study of machine learning applied to diagnostics.

OBJECTIVE: The five-repetition sit-to-stand (5R-STS) test was designed to capture objective functional impairment and thus provided an adjunctive dimension in patient assessment. The clinical interpretability and confounders of the 5R-STS remain poorly understood. In clinical use, it became apparent that 5R-STS performance may differ between patients with lumbar disk herniation (LDH), lumbar spinal stenosis (LSS) with or without low-grade spondylolisthesis, and chronic low back pain (CLBP). We seek to evaluate the extent of diagnostic information contained within 5R-STS testing. METHODS: Patients were classified into gold standard diagnostic categories based on history, physical examination, and imaging. Crude and adjusted comparisons of 5R-STS performance were carried out among the three diagnostic categories. Subsequently, a machine learning algorithm was trained to classify patients into the three categories using only 5R-STS test time and patient age, gender, height, and weight. RESULTS: From two prospective studies, 262 patients were included. Significant differences in crude and adjusted test times were observed among the three diagnostic categories. At internal validation, classification accuracy was 96.2% (95% CI 87.099.5%). Classification sensitivity was 95.7%, 100%, and 100% for LDH, LSS, and CLBP, respectively. Similarly, classification specificity was 100%, 95.7%, and 100% for the three diagnostic categories. CONCLUSION: 5R-STS performance differs according to the etiology of back and leg pain, even after adjustment for demographic covariates. In combination with machine learning algorithms, OFI can be used to infer the etiology of spinal back and leg pain with accuracy comparable to other diagnostic tests used in clinical examination. These slides can be retrieved under Electronic Supplementary Material.

Decompression alone versus decompression with instrumental fusion the NORDSTEN degenerative spondylolisthesis trial (NORDSTEN-DS); study protocol for a randomized controlled trial.

BACKGROUND: Fusion in addition to decompression has become the standard treatment for lumbar spinal stenosis with degenerative spondylolisthesis (DS). The evidence for performing fusion among these patients is conflicting and there is a need for further investigation through studies of high quality. The present protocol describes an ongoing study with the primary aim of comparing the outcome between decompression alone and decompression with instrumented fusion. The secondary aim is to investigate whether predictors can be used to choose the best treatment for an individual. The trial, named the NORDSTEN-DS trial, is one of three studies in the Norwegian Degenerative Spinal Stenosis (NORDSTEN) study. METHODS: The NORDSTEN-DS trial is a block-randomized, controlled, multicenter, non-inferiority study with two parallel groups. The surgeons at the 15 participating hospitals decide whether a patient is eligible or not according to the inclusion and exclusion criteria. Participating patients are randomized to either a midline preserving decompression or a decompression followed by an instrumental fusion. Primary endpoint is the percentage of patients with an improvement in Oswestry Disability Index version 2.0 of more than 30% from baseline to 2-year follow-up. Secondary outcome measurements are the Zürich Claudication Questionnaire, Numeric Rating Scale for back and leg pain, Euroqol 5 dimensions questionnaire, Global perceived effect scale, complications and several radiological parameters. Analysis and interpretation of results will also be conducted after 5 and 10 years. CONCLUSION: The NORDSTEN/DS trial has the potential to provide Level 1 evidence of whether decompression alone should be advocated as the preferred method or not. Further on the study will investigate whether predictors exist and if they can be used to make the appropriate choice for surgical treatment for this patient group. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02051374 . First Posted: January 31, 2014. Last Update Posted: February 14, 2018.

Comparison of the French and CARDS classifications for lumbar degenerative spondylolisthesis: reliability and validity.

BACKGROUND: The aim of this study was to compare the reliability and validity of the CARDS and French classification systems for lumbar DS. METHODS: Between May 2013 and December 2016, 158 consecutive patients diagnosed with single-level lumbar DS were included in this study, and all underwent lumbar fusion. All patients underwent long-cassette standing anterioposterior and lateral radiographs of the spine preoperatively and postoperatively. The images were graded according to the CARDS and French classification systems by two orthopedic spinal surgeons and two orthopedic spinal fellows, independently. Clinical outcome measures used were the visual analog scale, Oswestry Disability Index, and the 36-Item Short Form Health Survey. Clinical data were collected before surgery and 1 year after surgery. RESULTS: A total of 146 patients were finally included in this study and followed up for at least 1 year. When grading using the CARDS system, the κ values for inter- and intraobserver reliability were 0.837 and 0.869, respectively, representing perfect agreement. The interobserver κ value for the French classification was 0.693 and the intraobserver κ value was 0.743, both representing substantial agreement. CARDS Type D patients have higher preoperative back pain scores and better improvement after surgery compared with non-Type D patients. Mean back and leg pain was worse in French Type 5 patients, while the most significant improvement was also seen in Type 5 patients after surgery. CONCLUSIONS: Both CARDS and French classification systems have acceptable reliability and validity. The CARDS system is easier to utilize and has better reliability. LEVEL OF EVIDENCE: IV.

Follow-up score, change score or percentage change score for determining clinical important outcome following surgery? An observational study from the Norwegian registry for Spine surgery evaluating patient reported outcome measures in lumbar spinal stenosis and lumbar degenerative spondylolisthesis.

BACKGROUND: Assessment of outcomes for spinal surgeries is challenging, and an ideal measurement that reflects all aspects of importance for the patients does not exist. Oswestry Disability Index (ODI), EuroQol (EQ-5D) and Numeric Rating Scales (NRS) for leg pain and for back pain are commonly used patients reported outcome measurements (PROMs). Reporting the proportion of individuals with an outcome of clinical importance is recommended. Knowledge of the ability of PROMs to identify clearly improved patients is essential. The purpose of this study was to search cut-off criteria for PROMs that best reflect an improvement considered by the patients to be of clinical importance. METHODS: The Global Perceived Effect scale was utilized to evaluate a clinically important outcome 12 months after surgery. The cut-offs for the PROMs that most accurately distinguish those who reported 'completely recovered' or 'much improved' from those who reported 'slightly improved', unchanged', 'slightly worse', 'much worse', or 'worse than ever' were estimated. For each PROM, we evaluated three candidate response parameters: the (raw) follow-up score, the (numerical) change score, and the percentage change score. RESULTS: We analysed 3859 patients with Lumbar Spinal Stenosis [(LSS); mean age 66; female gender 50%] and 617 patients with Lumbar Degenerative Spondylolisthesis [(LDS); mean age 67; 72% female gender]. The accuracy of identifying 'completely recovered' and 'much better' patients was generally high, but lower for EQ-5D than for the other PROMs. For all PROMs the accuracy was lower for the change score than for the follow-up score and the percentage change score, especially among patients with low and high PROM scores at baseline. The optimal threshold for a clinically important outcome was ≤24 for ODI, ≥0.69 for EQ-5D, ≤3 for NRS leg pain, and ≤ 4 for NRS back pain, and, for the percentage change score, ≥30% for ODI, ≥40% for NRS leg pain, and ≥ 33% for NRS back pain. The estimated cut-offs were similar for LSS and for LDS. CONCLUSION: For estimating a 'success' rate assessed by a PROM, we recommend using the follow-up score or the percentage change score. These scores reflected a clinically important outcome better than the change score.

Predictive model for long-term patient satisfaction after surgery for grade I degenerative lumbar spondylolisthesis: insights from the Quality Outcomes Database.

OBJECTIVESince the enactment of the Affordable Care Act in 2010, providers and hospitals have increasingly prioritized patient-centered outcomes such as patient satisfaction in an effort to adapt the "value"-based healthcare model. In the current study, the authors queried a prospectively maintained multiinstitutional spine registry to construct a predictive model for long-term patient satisfaction among patients undergoing surgery for Meyerding grade I lumbar spondylolisthesis.METHODSThe authors queried the Quality Outcomes Database for patients undergoing surgery for grade I lumbar spondylolisthesis between July 1, 2014, and June 30, 2016. The primary outcome of interest for the current study was patient satisfaction as measured by the North American Spine Surgery patient satisfaction index, which is measured on a scale of 1-4, with 1 indicating most satisfied and 4 indicating least satisfied. In order to identify predictors of higher satisfaction, the authors fitted a multivariable proportional odds logistic regression model for ≥ 2 years of patient satisfaction after adjusting for an array of clinical and patient-specific factors. The absolute importance of each covariate in the model was computed using an importance metric defined as Wald chi-square penalized by the predictor degrees of freedom.RESULTSA total of 502 patients, out of a cohort of 608 patients (82.5%) with grade I lumbar spondylolisthesis, undergoing either 1- or 2-level decompression (22.5%, n = 113) or 1-level decompression and fusion (77.5%, n = 389), met the inclusion criteria; of these, 82.1% (n = 412) were satisfied after 2 years. On univariate analysis, satisfied patients were more likely to be employed and working (41.7%, n = 172, vs 24.4%, n = 22; overall p = 0.001), more likely to present with predominant leg pain (23.1%, n = 95, vs 11.1%, n = 10; overall p = 0.02) but more likely to present with lower Numeric Rating Scale score for leg pain (median and IQR score: 7 [5-9] vs 8 [6-9]; p = 0.05). Multivariable proportional odds logistic regression revealed that older age (OR 1.57, 95% CI 1.09-2.76; p = 0.009), preoperative active employment (OR 2.06, 95% CI 1.27-3.67; p = 0.015), and fusion surgery (OR 2.3, 95% CI 1.30-4.06; p = 0.002) were the most important predictors of achieving satisfaction with surgical outcome.CONCLUSIONSCurrent findings from a large multiinstitutional study indicate that most patients undergoing surgery for grade I lumbar spondylolisthesis achieved long-term satisfaction. Moreover, the authors found that older age, preoperative active employment, and fusion surgery are associated with higher odds of achieving satisfaction.

Age-related changes in axial and sagittal orientation of the facet joints: Comparison with changes in degenerative spondylolisthesis.

BACKGROUND: Despite facet joints being three-dimensional structures, previous computed tomography and magnetic resonance imaging studies have evaluated facet joint orientation in only the axial plane. Facet joint orientation in the sagittal plane has rarely been studied using these imaging techniques. The aim of this study was to elucidate facet joint orientation in both the axial and sagittal planes on computed tomography. METHODS: A total of 568 patients (343 men, 225 women) (excluding orthopedic outpatients) for whom abdominal and pelvic computed tomography scans were obtained at our hospital between September 2010 and October 2012 were included. Mean age was 63 (range 21-90) years. Patients were divided into a degenerative spondylolisthesis group (67 patients; 30 men, 37 women) and a control group (313 patients; 313 men, 188 women). Facet joint orientation was evaluated in the control group according to patient age (≤50, 51-60, 61-70, or ≥71 years). The findings in the control group were then compared with those in the degenerative spondylolisthesis group. The orientation of the lumbar facet joints at each level was measured in the axial and sagittal planes on computed tomography images. RESULTS: Facet joint angles decreased with age at L4/5 and L5/S1 in women in the axial plane and at L4/5 in men and L3/4 and L4/5 in women in the sagittal plane. The variation in facet joint angle was greatest at L4/5 in women. Patients with degenerative spondylolisthesis showed more sagittally and horizontally oriented facet joints in the axial and sagittal planes; facet tropism showed an association with degenerative spondylolisthesis in the axial plane. CONCLUSIONS: The axial and sagittal orientation of facet joints in the lower lumbar vertebra, especially L4/5, was negatively correlated with age. This finding could help to explain why older people are more prone to degenerative spondylolisthesis.

Increased risk of symptomatic progression of instability following decompression for lumbar canal stenosis in patients receiving chronic glucocorticoids therapy.

BACKGROUND: Lumbar decompression surgery is a commonly used treatment for degenerative lumbar spinal stenosis; however, some patients develop symptomatic spinal instability following decompression surgery. The objective of this study was to reveal risk factors for delayed instability following decompression surgery for lumbar spinal stenosis. METHODS: One hundred ten patients who underwent single-level lumbar decompression between 2008 and 2014 were retrospectively reviewed. Surgical indication for decompression surgery was symptomatic lumbar canal stenosis without spondylolisthesis or with minimum spondylolisthesis (less than 4 mm translation). Patients with gross segmental motion (>10° in disc angle, >2 mm translation) on flexion-extension lumbar radiographs were excluded. Age, sex, body mass index, smoking history, diabetes mellitus, autoimmune connective tissue diseases including rheumatoid arthritis, and the use of glucocorticoids were investigated. Radiographic measurements included disc angle, disc height, slippage, facet angle, segmental motion (flexion-extension), lumbar alignment, facet effusion, and disc degeneration. Data were analyzed using multivariate forward selection stepwise logistic regression, chi-square tests, and Student t-test. RESULTS: Six of 110 patients (5.5%) developed symptomatic spinal instability at the operative level and underwent spinal fusion surgery at an average of 2.1 years postoperatively. Autoimmune connective tissue disorders and chronic use of glucocorticoids were associated with the occurrence of symptomatic spinal instability requiring spine fusion surgery, while there was no significant difference in radiographic parameters and demographic factors excluding autoimmune connective tissue diseases between reoperation and non-reoperation groups. CONCLUSIONS: Patients with autoimmune connective tissue disorders receiving chronic glucocorticoid therapy are more likely to develop symptomatic spinal instability following decompression surgery for lumbar canal stenosis without or with minimal spondylolisthesis.

Evaluating low back pain in adolescents.

Low back pain in adolescents is a common complaint in primary care. With an average prevalence rate of 40%, adolescent low back pain correlates with greater healthcare use, higher incidences of adult back pain, and negative effects on overall well-being. A thorough history and physical examination can increase early detection and accurate diagnosis while ensuring the judicious use of diagnostic modalities. Although underlying serious pathology is rare in adolescents with low back pain, clinicians should recognize specific signs and symptoms that necessitate urgent evaluation and intervention. This article emphasizes the value of using a thorough history and physical examination to guide the initial diagnostic workup and to enhance the early detection and accurate diagnosis of adolescents who present with low back pain.

Defining the minimum clinically important difference for grade I degenerative lumbar spondylolisthesis: insights from the Quality Outcomes Database.

OBJECTIVE Patient-reported outcomes (PROs) play a pivotal role in defining the value of surgical interventions for spinal disease. The concept of minimum clinically important difference (MCID) is considered the new standard for determining the effectiveness of a given treatment and describing patient satisfaction in response to that treatment. The purpose of this study was to determine the MCID associated with surgical treatment for degenerative lumbar spondylolisthesis. METHODS The authors queried the Quality Outcomes Database registry from July 2014 through December 2015 for patients who underwent posterior lumbar surgery for grade I degenerative spondylolisthesis. Recorded PROs included scores on the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for leg pain (NRS-LP) and back pain (NRS-BP). Anchor-based (using the North American Spine Society satisfaction scale) and distribution-based (half a standard deviation, small Cohen's effect size, standard error of measurement, and minimum detectable change [MDC]) methods were used to calculate the MCID for each PRO. RESULTS A total of 441 patients (80 who underwent laminectomies alone and 361 who underwent fusion procedures) from 11 participating sites were included in the analysis. The changes in functional outcome scores between baseline and the 1-year postoperative evaluation were as follows: 23.5 ± 17.4 points for ODI, 0.24 ± 0.23 for EQ-5D, 4.1 ± 3.5 for NRS-LP, and 3.7 ± 3.2 for NRS-BP. The different calculation methods generated a range of MCID values for each PRO: 3.3-26.5 points for ODI, 0.04-0.3 points for EQ-5D, 0.6-4.5 points for NRS-LP, and 0.5-4.2 points for NRS-BP. The MDC approach appeared to be the most appropriate for calculating MCID because it provided a threshold greater than the measurement error and was closest to the average change difference between the satisfied and not-satisfied patients. On subgroup analysis, the MCID thresholds for laminectomy-alone patients were comparable to those for the patients who underwent arthrodesis as well as for the entire cohort. CONCLUSIONS The MCID for PROs was highly variable depending on the calculation technique. The MDC seems to be a statistically and clinically sound method for defining the appropriate MCID value for patients with grade I degenerative lumbar spondylolisthesis. Based on this method, the MCID values are 14.3 points for ODI, 0.2 points for EQ-5D, 1.7 points for NRS-LP, and 1.6 points for NRS-BP.

A new classification system for degenerative spondylolisthesis of the lumbar spine.

PURPOSE: There is no consensus for a comprehensive analysis of degenerative spondylolisthesis of the lumbar spine (DSLS). A new classification system for DSLS based on sagittal alignment was proposed. Its clinical relevance was explored. METHODS: Health-related quality-of-life scales (HRQOLs) and clinical parameters were collected: SF-12, ODI, and low back and leg pain visual analog scales (BP-VAS, LP-VAS). Radiographic analysis included Meyerding grading and sagittal parameters: segmental lordosis (SL), L1-S1 lumbar lordosis (LL), T1-T12 thoracic kyphosis (TK), pelvic incidence (PI), pelvic tilt (PT), and sagittal vertical axis (SVA). Patients were classified according to three main types-1A: preserved LL and SL; 1B: preserved LL and reduced SL (≤5°); 2A: PI-LL ≥10° without pelvic compensation (PT < 25°); 2B: PI-LL ≥10° with pelvic compensation (PT ≥ 25°); type 3: global sagittal malalignment (SVA ≥40 mm). RESULTS: 166 patients (119 F: 47 M) suffering from DSLS were included. Mean age was 67.1 ± 11 years. DSLS demographics were, respectively: type 1A: 73 patients, type 1B: 3, type 2A: 8, type 2B: 22, and type 3: 60. Meyerding grading was: grade 1 (n = 124); grade 2 (n = 24). Affected levels were: L4-L5 (n = 121), L3-L4 (n = 34), L2-L3 (n = 6), and L5-S1 (n = 5). Mean sagittal parameter values were: PI: 59.3° ± 11.9°; PT: 24.3° ± 7.6°; SVA: 29.1 ± 42.2 mm; SL: 18.2° ± 8.1°. DSLS types were correlated with age, ODI and SF-12 PCS (ρ = 0.34, p < 0.05; ρ = 0.33, p < 0.05; ρ = -0.20, and p = 0.01, respectively). CONCLUSION: This classification was consistent with age and HRQOLs and could be a preoperative assessment tool. Its therapeutic impact has yet to be validated. LEVEL OF EVIDENCE: 4.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews.

BACKGROUND: Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization. METHODS: A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR. RESULTS: Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making. CONCLUSIONS: This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

A cost-utility analysis of Dynesys dynamic stabilization versus instrumented fusion for the treatment of degenerative lumbar spine diseases.

BACKGROUND: Symptomatic chronic low back and leg pain resulting from lumbar spine degenerative disorders is highly prevalent in China, and for some patients, surgery is the final option for improvement. Several techniques for spinal non-fusion have been introduced to reduce the side-effects of fusion methods and hasten postoperative recovery. In this study, the authors have evaluated the cost-effectiveness of Dynesys posterior dynamic stabilization system (DY) compared with lumbar fusion techniques in the treatment of single-level degenerative lumbar spinal conditions. METHODS: A total of 221 patients undergoing single-level elective primary surgery for degenerative lumbar pathology were included. 2-Year postoperative health outcomes of Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36) and EuroQol-5 Dimensions (EQ-5D) questionnaires were recorded. 2-Year back-related medical resource use, missed work, and health-state values (Quality-adjusted life-year [QALY]) were assessed. Cost-effectiveness was determined by the incremental cost per QALY gained. RESULTS: At each follow-up point, both cohorts were associated with significant improvements in VAS scores, ODI, SF-36 scores and EQ-5D QALY scores, which persisted at the 2-year evaluation. The 2-year total mean cost per patient were significantly lower for Dynesys system ($20,150) compared to fusion techniques ($25,581, $27,862 and $27,314, respectively) (P < 0.001). Using EQ-5D, the mean cumulative 2-year QALYs gained were statistically equivalent between the four groups (0.28, 0.27, 0.30 and 0.30 units, respectively) (P = 0.74). Results indicate that patients implanted with the DY system derive lower total costs and more utility, on average, than those treated with fusion. CONCLUSIONS: The Dynesys dynamic stabilization system is cost effective compared to instrumented lumbar fusion for treatment of single-level degenerative lumbar disorders. It is not possible to state whether DY or lumbar fusion is more cost-effective after 2 years.

[Injuries of the upper cervical spine : Update on diagnostics and management]. / Verletzungen der oberen Halswirbelsäule : Update zu Diagnostik und Management.

Injuries to the upper cervical spine represent a diagnostic and therapeutic challenge to the treating surgeon due to the complex anatomical relationships and biomechanical features. In this further education article the diagnostic principles, established classifications and therapeutic recommendations as well as injury-specific characteristics of bony and ligamentous injuries to the upper cervical spine (C0-C2) are presented.

Responsiveness and minimum important change of the Oswestry Disability Index in Italian subjects with symptomatic lumbar spondylolisthesis.

BACKGROUND: This study aims to investigate the responsiveness and the minimum important change of the Italian version of the Oswestry Disability Index (ODI-I) in subjects with symptomatic specific low back pain associated with lumbar spondylolisthesis (SPL). MATERIALS AND METHODS: One hundred and fifty-one patients with symptomatic SPL completed the ODI-I, a 0-100 numerical rating scale (NRS), and performed the prone and supine bridge tests. The global perception of effectiveness was measured with a 7-point Likert scale. Responsiveness was assessed by distribution methods (minimum detectable change [MDC], effect size [ES], standardized response mean [SRM]) and anchor-based methods (ROC curves). RESULTS: The MDC was 4.23, the ES was 0.95 and the SRM was 1.25. ROC analysis revealed an area under the curve of 0.76 indicating moderate discriminating capacity. The best cut-off point for the dichotomous outcome was 7.5 (sensitivity 90.3%, specificity 56.7%). . CONCLUSIONS: The ODI-I proved to be responsive in detecting changes after conservative treatment in subjects with lumbar SPL. LEVEL OF EVIDENCE: II.

Prevalence of spinal pathology in patients presenting for lumbar MRI as referred from general practice.

BACKGROUND: The use of magnetic resonance imaging (MRI) as initial imaging for back pain has increased in general practice. However, few data are available on the characteristics of these referred patients. The objective of this study was to describe the baseline characteristics and MRI findings of patients presenting for a lumbar MRI examination as referred by their GP. METHODS: Patients presenting for a lumbar MRI examination as referred by their GP were recruited at the MRI Center. The MRI radiology reports were scored for the presence of disc bulging, disc herniation, nerve root compression, spinal stenosis, spondylolisthesis and serious pathologies. Information on patients' characteristics, characteristics of the complaints and red flags were derived from questionnaires. Cross-sectional differences between patients with and without specific MRI findings were analyzed. RESULTS: A total of 683 low back pain (LBP) patients were included; mean age was 49.9 (range 19-80) years and 53% was male. Mean back pain severity score was 6.6 (SD 2.0) and 67% of the patients reported having chronic LBP. In total, 374 patients (55%) reported sciatica complaints for at least 6 weeks. Of all MRI reports, 69% mentioned signs of nerve root compression. Serious pathologies were reported in 3% of the patients. In total, 94% of patients had abnormal MRI findings. CONCLUSIONS: Almost all patients presenting for a lumbar MRI examination as referred by their GP had abnormal MRI findings. In total, 55% of the patients reported persistent sciatica in which imaging is recommended according to international guidelines.

The added prognostic value of MRI findings for recovery in patients with low back pain in primary care: a 1-year follow-up cohort study.

PURPOSE: Information on the prognostic value of MRI findings in low back pain patients in primary care is lacking. The objective of this study is to investigate the added prognostic value of baseline MRI findings over known prognostic factors for recovery at 12-month follow-up in patients with low back pain referred to MRI by their general practitioner. METHODS: Patients referred by their general practitioner for MRI of the lumbar spine were recruited at the MRI Center. The questionnaires at baseline and at 3 and 12-months follow-up included potential clinical predictors from history taking and the outcome recovery. The MRI radiology reports were scored. Analysis was performed in 3 steps: derivation of a predictive model including characteristics of the patients and back pain only (history taking), including reported MRI findings only, and the addition of reported MRI findings to the characteristics of the patients and back pain. RESULTS: At 12-months follow-up 53% of the patients reported recovery (n = 683). Lower age, better attitude/beliefs regarding back pain, acute back pain, presence of neurological symptoms of the leg(s), and presence of non-continuous back pain were significantly associated with recovery at 12-months follow-up: area under the curve (AUC) 0.77. Addition of the MRI findings resulted in an AUC of 0.78. CONCLUSIONS: At 12-months follow-up, only 53% of these patients with low back pain referred for MRI in general practice reported recovery. Five clinic baseline characteristics were associated with recovery at 12-months follow-up; adding the MRI findings did not result in a stronger prediction of recovery.

Pedicle screw fixation and posterior fusion for lumbar degenerative diseases: effects on individual paraspinal muscles and lower back pain; a single-center, prospective study.

BACKGROUND: To the best of our knowledge, there have been no reports on the points at which the denervated multifidus and erector spinae muscles become reinnervated after pedicle screw fixation and posterior fusion in patients with lumbar degenerative diseases. Our study was designed to confirm reinnervation of denervated paraspinal muscles following pedicle screw fixation and posterior fusion and to confirm alleviation of the patients' lower back pain (LBP). METHODS: In this prospective study, we enrolled 67 patients who had undergone pedicle screw fixation and posterior fusion. The surgery had alleviated their leg pain, but the patients complained of LBP at the L3-5 level 3 months after the surgery. The patients were divided into two groups (I and II) according to the level at which pain was experienced. Paraspinal mapping scores were recorded preoperatively and 3, 6, 12, and 18 months postoperatively. Oswestry Disability Index and visual analogue scale scores were determined. Regression analyses using a general linear model and a mixed model were performed. RESULTS: Pedicle screw fixation and posterior fusion significantly denervated the multifidus and erector spinae not only in the surgical segment, but also in adjacent segments. Group I patients displayed reinnervation in the denervated erector spinae and multifidus muscles at 12 and 18 months, respectively. In contrast, group II showed reinnervation only in of the denervated erector spinae of the upper segment at 18 months, with no other areas of reinnervation. Postoperative LBP was significantly diminished at 12 months in group I and at 18 months in group II. There was also significantly less LBP at 6 months (prior to reinnervation of the paraspinal muscles). CONCLUSIONS: The denervated multifidus and erector spinae muscles at L4-5, which had been denervated using pedicle screw fixation and posterior fusion, were significantly reinnervated at 18 months postoperatively, whereas patients with denervation at L3-5 had only a tendency to be reinnervated at follow-up. Postoperative LBP in these patients was significantly diminished at the follow-up visits.

Biomechanical evaluation of fixation strength among different sizes of pedicle screws using the cortical bone trajectory: what is the ideal screw size for optimal fixation?

BACKGROUND: The cortical bone trajectory (CBT) has attracted attention as a new minimally invasive technique for lumbar instrumentation by minimizing soft-tissue dissection. Biomechanical studies have demonstrated the superior fixation capacity of CBT; however, there is little consensus on the selection of screw size, and no biomechanical study has elucidated the most suitable screw size for CBT. The purpose of the present study was to evaluate the effect of screw size on fixation strength and to clarify the ideal size for optimal fixation using CBT. METHOD: A total of 720 analyses on CBT screws with various diameters (4.5-6.5 mm) and lengths (25-40 mm) in simulations of 20 different lumbar vertebrae (mean age: 62.1 ± 20.0 years, 8 males and 12 females) were performed using a finite element method. First, the fixation strength of a single screw was evaluated by measuring the axial pullout strength. Next, the vertebral fixation strength of a paired-screw construct was examined by applying forces simulating flexion, extension, lateral bending, and axial rotation to the vertebra. Lastly, the equivalent stress value of the bone-screw interface was calculated. RESULTS: Larger-diameter screws increased the pullout strength and vertebral fixation strength and decreased the equivalent stress around the screws; however, there were no statistically significant differences between 5.5-mm and 6.5-mm screws. The screw diameter was a factor more strongly affecting the fixation strength of CBT than the screw fit within the pedicle (%fill). Longer screws significantly increased the pullout strength and vertebral fixation strength in axial rotation. The amount of screw length within the vertebral body (%length) was more important than the actual screw length, contributing to the vertebral fixation strength and distribution of stress loaded to the vertebra. CONCLUSIONS: The fixation strength of CBT screws varied depending on screw size. The ideal screw size for CBT is a diameter larger than 5.5 mm and length longer than 35 mm, and the screw should be placed sufficiently deep into the vertebral body.