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Background Chronic low back pain (CLBP) is a common issue among the working-age population. Sleeping position may affect CLBP, with the prone position commonly suggested to be avoided. This study aims to examine the relationship between preferred and avoided sleeping positions and to explore the frequency of increased pain in various sleeping positions among patients with nonspecific CLBP and pain and disability levels. Methods This cross-sectional study included all adult patients referred for specialist consultation for CLBP at the outpatient clinic of the Central Hospital of Central Finland's spine department. Pain intensity was measured using a visual analog scale (VAS), and disability was assessed with the Oswestry Disability Index (ODI). Patients completed a questionnaire detailing the main sleeping positions and positions avoided due to low back pain (LBP). Results The study enrolled 375 consecutive patients, with a mean age of 51 ± 17 years; 64% (n=240) were female. The mean VAS score was 63 ± 24, and the mean Oswestry Index was 38 ± 18%. The majority of patients (87%, n=327) reported sleeping in a side-lying position, followed by supine (47%, n=176) and prone (22%, n=82) positions. A negative correlation was found between age and the preference for sleeping in the prone position. No significant gender differences in sleep positions were observed (p=0.69). Sleep was disturbed in 77% of patients (n=289) due to LBP, and 87% (n=327) reported difficulties due to LBP when getting up. Overall, 92% of participants (n=345) experienced difficulties sleeping or getting up in the morning due to LBP. Many patients avoided certain positions due to pain: 42% (n=157) avoided the prone position, 35% (n=131) the back, 15% (n=56) the left side, and 13% (n=49) the right side. Although the prone position was most commonly linked with pain, especially among women, our findings suggest that any sleeping position could potentially exacerbate pain in individuals with CLBP. Conclusions This study highlights the variability in how sleeping positions affect pain in patients with nonspecific CLBP. While the prone position is most frequently associated with increased pain, individual preferences and responses vary significantly, and often sidelying and supine positions provoke pain. The diversity in sleeping positions that exacerbate pain highlights the need for tailored advice in the management of patients with CLBP.
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STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To evaluate how preexisting adjacent segment degeneration status impacts revision risk for adjacent segment disease (ASD) after lumbar fusions. SUMMARY OF BACKGROUND DATA: ASD incurs late reoperations after lumbar fusion surgeries. ASD pathogenesis is multifactorial. Preexisting adjacent segment degeneration measured by Pfirrmann is suggested as one of the predisposing factors. We sought to find deeper insights into this association by using a more granular degeneration measure, the Combined imaging score (CIS). METHODS: A total of 197 consecutive lumbar fusions for degenerative pathologies were enrolled in a prospective follow-up (median 12 years). Preoperative cranial adjacent segment degeneration status was determined using Pfirrmann and CIS, which utilizes both radiographs and magnetic resonance imaging. Based on CIS, patients were trichotomized into tertiles (CIS <7, CIS 7-10, and CIS >10). The cumulative ASD revision risk was determined for each tertile. After adjusting for age, sex, body mass index, sacral fixation, and fusion length, hazard ratios (95% confidence intervals, CI) for ASD revisions were determined for each Pfirrmann and CIS score. RESULTS: Patients in the intermediate CIS tertile had a cumulative ASD revision risk of 25.4% (17.0% to 37.0%), while both milder degeneration (CIS <7) [13.2% (6.5% to 25.8%)] and end-stage degeneration (CIS >10) [13.6% (7.0% to 25.5%)] appeared to be protective against surgical ASD. Pfirrmann failed to show a significant association with ASD revision risk. Adjusted analysis of CIS suggested increased ASD revisions after CIS 7, which turned contrariwise after CIS 10. CONCLUSIONS: The effect of preexisting adjacent segment degeneration on ASD reoperation risk is not linear. The risk seems to increase with advancing degeneration but diminish with end-stage degeneration. Therefore, end-stage degenerative segments may be considered to be excluded from fusion constructs. LEVEL OF EVIDENCE: Therapeutic Level III.
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STUDY DESIGN: Cohort study. OBJECTIVE: To evaluate heterogeneity (fluctuation) in minimal important change (MIC) and patient acceptable symptom state (PASS) for patient-reported outcomes (PROMs) through 10 years after lumbar fusion. SUMMARY OF BACKGROUND DATA: PROMs have become key determinants in spine surgery outcomes studies. MIC and PASS were established to aid PROM interpretations. However, their long-term stability has not yet been reported. METHODS: A consecutive series of elective lumbar fusions were followed-up using the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) for pain. Improvement was rated by a 4-point Likert scale into "improved" or "non-improved". Satisfaction-to-treatment was rated by the patients' willingness to undergo surgery again. Receiver operating characteristics (ROC) curve analysis estimated MIC (95% confidence interval, CI) as the PROM change that best predicted improvement at distinct time-points. PASS (CI) was estimated as the lowest PROM score at which the patients were still satisfied. Heterogeneity across thresholds was evaluated using the DeLong algorithm. RESULTS: MIC for ODI represented heterogeneity across 10-years, ranging from -21 (-24 to -16) at 2-years to -8 (-7 to -4) at 5-years, P <0.001. The areas under the ROC curves (AUCs) (0.79-0.85) indicated acceptable to excellent discrimination. Heterogeneity was not significant in the MICs for the pain scores. At 1-year, MIC for back pain was -24 (-38 to -15), AUC 0.77, and for leg pain it was -26 (-44 to -8), AUC 0.78. No significant heterogeneity was observed in 10-year PASS scores. At 1-year, PASS for ODI was 22 (15 to 29), AUC 0.85. Similarly, 1-year PASS for back pain was 38 (20 to 56), AUC 0.81, and for leg pain it was 49 (26 to 72), AUC 0.81. CONCLUSIONS: MIC for ODI fluctuated over 10-years after lumbar fusions. PASS values for all PROMs seemed most stable over time. Caution is needed when generic MIC values are used in long-term studies. LEVEL OF EVIDENCE: Therapeutic Level III.