A comparison of radiographic degeneration features of older Chinese women and older Italian Caucasian women with a focus on thoracic spine.

BACKGROUND: Compared with Caucasians, East Asians have a lower incident of back pain, lower prevalence and severity of osteoporotic vertebral fracture and lumbar spine degeneration. AIM: This study compares radiographic spine degeneration features of older Chinese women (as an example of East Asians) and older Italian women (as an example of Caucasians) with a focus on the thoracic spine. METHODS: From two population-based epidemiological studies conducted in Hong Kong, China and Rome, Italy, 297 pairs (mean age: 73.6 years) age-matched older community women's lateral spine radiographs were sampled. Existence (or absence) of seven degeneration features were assessed including: (1) hyper-kyphosis, (2) disc space narrowing (T3/T4 ~ T11/T12), (3) osteoarthritic (OA) wedging (T4 ~ T12), (4) generalised osteophyte formation (T4 ~ T12); (5) acquired short vertebrae (T4 ~ T12), (6) Schmorl node (T4 - L5), (7) disc calcification (T4-L5). RESULTS: Italian women were more likely to have hyper-kyphosis (53.4% vs 25.6%), disc space narrowing (34.4% vs. 17.2%), OA wedging (6.4% vs. 0.67%), Schmorl node (19.5% vs. 4.4%, all P < 0.001). However, there was no statistically significant difference in osteophyte formation (7.7% vs. 9.4%, P > 0.1) and acquired short vertebrae (8.0% vs. 10.4%, P > 0.1). Disc calcification was uncommon among both Chinese and Italians. DISCUSSION AND CONCLUSION: For the first time, this study documented a lower prevalence of a number of thoracic spine degeneration features among Chinese. This study further affirms the concept of a generally healthier spine in older Chinese relative to older Caucasians. The observed differences may reflect a foundational background influence of genetic predisposition that represents an important line of future research.

Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease. METHODS: We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups. RESULTS: We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I2 = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I2 = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I2 = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I2 = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates. CONCLUSIONS: Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

Construct Validity and Reliability of the Japanese Version of the Lumbar Stiffness Disability Index.

STUDY DESIGN: Outcome study to determine the construct validity and reliability of the Japanese version of the Lumbar Stiffness Disability Index. OBJECTIVE: The aim of this study was to evaluate the psychometric measurement properties of the Japanese version of the Lumbar Stiffness Disability Index (J-LSDI) following lumbar spinal surgery in order to assess its construct validity and reliability. SUMMARY OF BACKGROUND DATA: The LSDI was designed and validated as a tool to assess functional impacts of lumbar spine stiffness and diminished spinal flexibility. A Japanese version has been developed, but its construct validity and reliability have not been evaluated. METHODS: A Pearson correlation coefficient was calculated using flexion and extension range of motion, Oswestry Disability Index (ODI) and Tampa Scale for Kinesiophobia (TSK) as external standards to evaluate construct validity. An intraclass correlation coefficient (ICC) and a Bland-Altman analysis were used to evaluate test-retest reliability. RESULTS: A total of 244 patients following lumbar spinal surgery participated in the study. Fifty one of the 244 patients participated in the reliability study. The ICC of the J-LSDI for test-retest reliability was 0.89 (95% confidence interval, 0.79-0.93). There was no systematic error found in the results of the Bland-Altman analysis. One hundred ninety-three of the 244 patients participated in the validity study. There were significant correlations between the J-LSDI and trunk flexion range of motion (r = -0.66), extension (r = -0.51), ODI (r = 0.62), and TSK (r = 0.38). CONCLUSION: The construct validity and reliability of the Japanese version of the LSDI were confirmed. The J-LSDI can be used to evaluate lumbar stiffness and associated disability in Japanese patients following lumbar spinal surgery.Level of Evidence: 2.

Lower Satisfaction After Adult Spinal Deformity Surgery in Japan Than in the United States Despite Similar SRS-22 Pain and Function Scores: A Propensity-Score Matched Analysis.

STUDY DESIGN: A multicenter retrospective case series. OBJECTIVE: The purpose of this study was to compare the clinical outcomes of a surgical treatment for adult spinal deformity (ASD) in the United States (US) with those in Japan (JP) in a matched cohort. SUMMARY OF BACKGROUND DATA: Surgical outcomes of thoracic-lumbar-sacral (TLS) spinal fusions in adult spinal deformity ASD patients who live in Asian countries are poorly understood. METHODS: A total of 300 surgically treated ASDs of age more than 50 years with the lowest instrumented vertebra at the pelvis and a minimum follow-up of 2 years (2y) were consecutively included. Patients were propensity-score matched for age, sex, levels fused, and 2y postop sagittal spinal alignment. Demographic, surgical, and radiographic parameters were compared between the US and JP groups. RESULTS: A total of 186 patients were matched by propensity score and were almost identical within these parameters: age (US vs. JP: 66 ±â€Š8 vs. 65 ±â€Š7 yr), sex (females: 90% vs. 89%), levels fused (10 ±â€Š3 vs. 10 ±â€Š2), 2y C7 sagittal vertical axis (C7SVA) (5 ±â€Š5 vs. 5 ±â€Š4 cm), 2y Pelvic incidence minus lumbar lordosis (9 ±â€Š15° vs. 9 ±â€Š15°), and 2y pelvic tilt (PT) (25 ±â€Š10° vs. 24 ±â€Š10°). Oswestry Disability Index (ODI) scores and Scoliosis Research Society patient questionnaire ((SRS-22) function and pain scores were similar at 2y between the US and JP groups (ODI: 27 ±â€Š19% vs. 28 ±â€Š14%, P = 0.72; SRS-22 function: 3.6 ±â€Š0.9 vs. 3.6 ±â€Š0.7, P = 0.54; SRS-22 pain: 3.6 ±â€Š1.0 vs. 3.8 ±â€Š0.8, P = 0.11). However, significantly lower satisfaction was observed in JP than in the US (SRS-22 satisfaction: 4.3 ±â€Š0.9 vs. 4.0 ±â€Š0.8, P < 0.01). CONCLUSION: Surgical treatment for ASD was similarly effective in patients in the US and in JP. However, satisfaction scores were lower in JP compared with the US. Differences in lifestyle and cultural expectations may impact patient satisfaction following ASD surgery. LEVEL OF EVIDENCE: 3.

A Chinese CARASIL Patient Caused by Novel Compound Heterozygous Mutations in HTRA1.

Our objective is to reported a Chinese CARASIL patient caused by novel compound heterozygous mutations in HTRA1. Detailed clinical and neuroimaging examination were conducted in proband and her available family members. Sanger sequencing of NOTCH3 and HTRA1 was used to investigate causative mutations. The patient was born in an outbred family. She experienced recurrent transient ischemic attacks, hair loss, and low back pain. Brain magnetic resonance imaging showed multiple lacunar infarctions, diffuse leukoencephalopathy, and multiple microbleeds of white matter. A compound heterozygous mutation, c.958G > A (p.D320N) and c.1021G > A (p.G341J), were identified in the proband. This report highlights that screening of HTRA1 should be considered in young SVD patient despite from outbred families.

Is C1 lateral mass screw placement safe for the Chinese, Indians, and Malays? An analysis of 180 computed tomography scans.

INTRODUCTION: C1 lateral mass (C1LM) screw is a common procedure in spine surgery. However, related studies are lacking in Asia. We aim to determine the safety of C1LM screw for the Chinese, Indians, and Malays. METHODS: Three-dimensional computed tomographies of 180 subjects (60 from each ethnic) were analyzed. The length and angulations of C1LM screw and the location of internal carotid artery (ICA) in relation to C1LM were assessed and classified according to the classification by Murakami et al. The incidence of ponticulus posticus (PP) was determined and the differences among the population of these three ethnics were recorded. RESULTS: The average base length was 8.5 ± 1.4 mm. The lengths within the lateral mass were between 14.7 ± 1.6 mm and 21.7 ± 2.3 mm. The prevalence of PP was 8.3%. 55.3% (199) of ICA were located in zone 0, 38.3% (138) in zone 1-1, 6.4% (23) in zone 1-2, and none in zone 1-3 and zone 2. The average angulation from the entry point to the ICA was 8.5° ± 6.4° laterally. The mean distance of ICA from C1 anterior cortex was 3.7 ± 1.7 mm (range: 0.6∼11.3). There was no difference in distribution of ICA in zone 1 among the three population (Chinese-47%, Indians-61%, and Malays-53%; p > 0.05). CONCLUSIONS: No ICA is located medial to the entry point of C1LM screw. If bicortical purchase of C1LM screw is needed, screw protrusion of less than 3 mm or medially angulated is safe for ICA. The incidence of PP is 8.3% with higher prevalence among the Indian population.

A novel mutation of the high-temperature requirement A serine peptidase 1 (HTRA1) gene in a Chinese family with cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL).

OBJECTIVE: Mutations in the high-temperature requirement A serine peptidase 1 (HTRA1) gene were studied in a Chinese family with cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL). METHODS: Exons 1-9 of the HTRA1 gene were amplified and bidirectionally sequenced in a Chinese family with CARASIL. Mutation effects were analysed by three-dimensional modelling of the serine protease HTRA1 protein. RESULTS: The proband was found to be homozygous for a novel missense mutation (c.854 C > T) identified in exon 4 of the HTRA1 gene; the parents of the proband were heterozygous for the same missense mutation. This c.854 C > T mutation resulted in a change from proline to leucine (p.P285L) in serine protease HTRA1, and was absent in 260 control chromosomes. Three-dimensional models showed that the change from proline to leucine (p.P285L) could attenuate the hydrogen bond between S284 and S287 residues, which might affect function of serine protease HTRA1. CONCLUSION: Discovery of a novel missense mutation (c.854C>T) associated with CARASIL expands the known CARASIL-related mutations in HTRA1.

The effect of race on outcomes of surgical or nonsurgical treatment of patients in the Spine Patient Outcomes Research Trial (SPORT).

STUDY DESIGN: Retrospective review of the data collected prospectively through the Spine Patient Outcomes Research Trial (SPORT). OBJECTIVE: To determine the effect that race or ethnicity had on outcomes after spine surgery in the 3 arms of SPORT. SUMMARY OF BACKGROUND DATA: There is a dearth of research regarding the effect of race or ethnicity on outcome after treatment of spinal disorders. METHODS: All participants from the 3 arms of the SPORT were evaluated in an as-treated analysis, with patients categorized as white, black, or other. Baseline and operative characteristics of the groups were compared using the χ test and analysis of variance. Differences in the changes between baseline and 1-, 2-, 3-, and 4-year time points in the operative and nonoperative treatments were evaluated with a mixed effects longitudinal regression model, and differences between racial groups were compared with a multiple degrees of freedom Wald test. RESULTS: A total of 2427 patients (85% white, 8% black, and 7% other) were included. Surgery was performed on 67% of white patients, 54% of blacks, and 68% of others. Whites and others were significantly more likely to undergo surgery than blacks (67% and 68% vs. 54%, P = 0.003). Complications and the risk of additional surgeries were not significantly different between racial groups. Regardless of race, all patients improved more with surgical management than with nonoperative treatment for all outcome measures at all time points. The average 4-year area-under-the-curve results revealed surgical and nonoperative treatment resulted in statistically significant improvement in whites relative to blacks for SF-36 bodily pain (P < 0.001), physical function (P < 0.001), and Oswestry Disability Index (P < 0.001). No significant differences were noted in treatment effect for primary outcome measures or self-rated progress across racial groups. CONCLUSION: These results illustrate important differences between racial groups in terms of response to spine care. Although there were quantitative differences between groups, these findings are not necessarily indications of health care disparities.

Vertebral coccidioidomycosis: presentation and multidisciplinary management.

BACKGROUND: Vertebral involvement is a severe complication of infection caused by Coccidioides species. METHODS: We conducted a retrospective review of patients diagnosed with vertebral coccidioidomycosis at an academic medical center between 1996 and 2009. RESULTS: We identified 39 cases of vertebral coccidioidomycosis. Thirty-four patients (79%) were male, and 23 patients (61%) were black. Black patients were overrepresented in comparison with all other patients by a 50-fold odds ratio (95% confidence interval, 26-95). Only 8 patients (20%) were immunocompromised, including 7 who had received systemic steroids. The number of infected vertebrae ranged from 1 to 24; 8 patients (21%) had epidural involvement. All patients received a triazole as part of medical therapy, and 20 patients also received amphotericin B, typically early in the course. Twenty-six patients (67%) required surgery, 18 of whom also required hardware placement. The most common indication for surgery was pain, but 7 patients had neurologic compromise. No patients developed recurrent or refractory infection at the site of surgical debridement, but 6 patients experienced disease relapse after stopping antifungal therapy. CONCLUSION: Vertebral infection caused by Coccidioides species requires a multispecialty approach that always includes medical therapy and frequently requires surgical intervention for debridement or stabilization. A favorable outcome can usually be achieved, but discontinuation of medical therapy is associated with a high risk of relapse, which can occur years later.

Outcomes after spine surgery among racial/ethnic minorities: a meta-analysis of the literature.

BACKGROUND CONTEXT: Prior research has identified disparities in access to care, resource utilization, and outcomes in members of racial and ethnic minorities. However, the role that race/ethnicity may play in influencing outcomes after spine surgery has not been previously studied. PURPOSE: To characterize the effect of race and ethnicity on outcome after spine surgery. STUDY DESIGN: Systematic literature review and meta-analysis. PATIENT SAMPLE: Of 11 investigations selected in the initial analysis, four reported results in a fashion that enabled their inclusion in the meta-analysis. These four studies included a total of 128,635 patients. OUTCOME MEASURES: "Favorable" or "unfavorable" postsurgical outcomes were determined based on parameters described in each included investigation. METHODS: A systematic literature review was performed to identify all studies documenting outcomes, complications, or mortality after spine surgical procedures. Eligible studies had to include raw data that enabled separate analysis of white and nonwhite patients. Outcome was categorized as "favorable" or "unfavorable" based on scales included in each investigation. The Q-statistic was used to determine heterogeneity, and a meta-analysis was performed to assess the relative risk for unfavorable outcome among nonwhite patients after spine surgery. RESULTS: Eleven studies met initial selection criteria but only four were eligible for inclusion in the meta-analysis. The meta-analysis included 128,635 patients among whom 12,194 (9.5%) had unfavorable outcomes. Among white patients, 9.4% sustained an unfavorable outcome as compared with 10.4% of nonwhites. CONCLUSIONS: In light of the small number of studies able to be included in the meta-analysis, no firm conclusions can be drawn regarding the effect of race/ethnicity on outcome after spinal surgery. There is a pressing need for more robust research regarding spine surgical outcomes among different racial and ethnic minority groups.

An anatomical study in a Chinese population of the position of the rib head for placing anterior vertebral body screws.

The instrumentation of anterior vertebral body screws has become an important approach for the treatment of unstable fractures or curvature of the spine, but little attention has been paid to the starting point of placing the screws and the variability of the rib head position. We analysed the variability of rib head position in a Chinese population in terms of the spinal canal and vertebral body using computed tomography (CT). Images from transverse CT scans of the T4-T12 vertebral bodies of 30 normal individuals were 3-D reconstructed and analysed for measurement of parameters which included: 1) distance between the left (or right) anterior border of the rib head and the posterior (or anterior) margin of the vertebral body [L(R)ARHP(A)VB]; 2) left (or right) transverse dimension [L(R)TD]; 3) left (or right) posterior (or anterior) safe angle [L(R)P(A)SA]; and 4) distance between the inferior border of the left (or right) rib head and the superior (or inferior) end-plate in the sagittal plane [I L(R)RHS(I)EP]. The ARHPVB, PSA, and IRHIEP gradually decrease, but ARHAVB, TD, ASA, and IRHSEP gradually increase, from T4 to T12, indicating that the position of the rib head changes from a more anterior position to a more posterior position and from a more superior position to a more inferior position, as the number of the vertebra increases. Our study has provided a comprehensive reference guide for accurate and safe instrumentation of vertebral body screws in treating related spine diseases.

Lumbar spine flexion and extension extremes of motion in women of different age and racial groups: the WIN Study.

STUDY DESIGN: Observational. OBJECTIVE: To provide normative values of lumbar flexion and extension for women of different age and racial groups. SUMMARY OF BACKGROUND DATA: Spinal range of motion (ROM) is one of the AMA Guides criteria used to estimate level of impairment and subsequent compensation entitlement. Studies show that spinal ROM varies with age, gender, and possibly race/ethnicity, but adequate normative values for different age and racial/ethnic groups do not exist. METHODS: A cohort of free-living women was recruited for the Women's Injury Study at The Cooper Institute in Dallas. Originally, 917 women between the ages of 20 and 83 (M = 52 +/- 13) underwent an orthopedic examination including lumbar spine flexion and extension measurement using an electronic inclinometer. Measurements were taken in the fully extended and flexed positions, respectively. This removes the influence of initial resting posture and is termed "extreme of motion" (EOM) as opposed to ROM. Age and racial groups were compared using a 2-way multivariate analysis of variance (MANOVA) followed with post hoc tests. RESULTS: Means (+/-SD) were calculated for racial (white, N = 619, African-American, N = 147) and age groups (young, 20-39 years, n = 126; middle, 40-59 years, n = 412; older, > or = 60 years, n = 228). Lumbar extension for African-American women (60.1 degrees) was significantly greater (P < 0.05) than for white women (52.6 degrees), but flexion was not different (15.2 degrees and 17.0 degrees), respectively. Extension EOM for the young group (61.6 degrees) was greater (P < 0.05) than the middle (56.6 degrees) and older (50.8 degrees) groups. Extension difference between the middle and older groups was significant. Flexion EOM for the young group (20.1 degrees) was greater (P < 0.05) than the middle (15.2 degrees) and older (12.8 degrees) groups. The difference in flexion between the middle and older groups was not significant. CONCLUSION: Normative values of lumbar extension are different for white and African-American women. Values for lumbar flexion and extension are different between age groups. Different criteria should be used to estimate impairment level in women of different racial and age groups.

Safety of thoracic pedicle screw application using the funnel technique in Asians: a cadaveric evaluation.

The objective of this cadaveric study is to determine the safety and outcome of thoracic pedicle screw placement in Asians using the funnel technique. Pedicle screws have superior biomechanical as well as clinical data when compared to other methods of instrumentation. However, misplacement in the thoracic spine can result in major neurological implications. There is great variability of the thoracic pedicle morphometry between the Western and the Asian population. The feasibility of thoracic pedicle screw insertion in Asians has not been fully elucidated yet. A pre-insertion radiograph was performed and surgeons were blinded to the morphometry of the thoracic pedicles. 240 pedicle screws were inserted in ten Asian cadavers from T1 to T12 using the funnel technique. 5.0 mm screws were used from T1 to T6 while 6.0 mm screws were used from T7 to T12. Perforations were detected by direct visualization via a wide laminectomy. The narrowest pedicles are found between T3 and T6. T5 pedicle width is smallest measuring 4.1 +/- 1.3 mm. There were 24 (10.0%) Grade 1 perforations and only 1 (0.4%) Grade 2 perforation. Grade 2 or worse perforation is considered significant perforation which would threaten the neural structures. There were twice as many lateral and inferior perforations compared to medial perforations. 48.0% of the perforations occurred at T1, T2 and T3 pedicles. Pedicle fracture occurred in 10.4% of pedicles. Intra-operatively, the absence of funnel was found in 24.5% of pedicles. In conclusion, thoracic pedicle screws using 5.0 mm at T1-T6 and 6.0 mm at T7-T12 can be inserted safely in Asian cadavers using the funnel technique despite having smaller thoracic pedicle morphometry.

Insurance status, geography, race, and ethnicity as predictors of anterior cervical spine surgery rates and in-hospital mortality: an examination of United States trends from 1992 to 2005.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVE: To determine the role of race, insurance status, and geographic location on US anterior cervical spine surgery rates and in-hospital mortality between 1992 and 2005. SUMMARY OF BACKGROUND DATA: Previous investigation indicates that anterior cervical spine surgery has been increasingly used in the management of degenerative cervical spine disease throughout the 1990s. Significant predictors of health outcomes, including race, ethnicity, geography, and insurance coverage have yet to be investigated in detail for these procedures. METHODS: Cases of anterior cervical spine surgery were identified from the Nationwide Inpatient Sample. The US population counts were taken from the Current Population Survey. Multivariate regression models were employed to describe national rates of anterior cervical spine surgery and model the odds of death among admissions for anterior cervical spine surgery. All models incorporated adjustment for hospital sample clustering, age, and comorbidity status. RESULTS: Based on an analysis of a total 100,286,482 hospital discharge records, an estimated 965,600 anterior cervical spine procedures were performed between 1992 and 2005 in the United States. During this period, rates of surgery increased by 289%. Though adjusted rates of surgery were lowest among minority populations, disparities decreased with time. The mean age of patients, as well as the average preoperative comorbidity status, increased with time. The odds of mortality did not significantly increase between 1992 and 2005. Odds of in-hospital death were greatest in among black patients (P < 0.001) and lowest in Southern states (P < 0.001) and patients with private insurance (P < 0.001). CONCLUSION: With the recent rise of anterior cervical spine procedures in the United States, substantial variation in the delivery of surgical care exists along a number of demographic factors. A detailed investigation of variation in surgical decision-making algorithms among spine specialists, as well as a determination of differences among patient populations in attitudes toward surgery, may help elucidate the trends observed in this study.

Racial variation in treatment preferences and willingness to randomize in the Spine Patient Outcomes Research Trial (SPORT).

STUDY DESIGN: Analysis of baseline data for patients enrolled in Spine Patient Outcomes Research Trial (SPORT), a project conducting three randomized and three observational cohort studies of surgical and nonoperative treatments for intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS). OBJECTIVE: To explore racial variation in treatment preferences and willingness to be randomized. SUMMARY OF BACKGROUND DATA: Increasing minority participation in research has been a priority at the NIH. Prior studies have documented lower rates of participation in research and preferences for invasive treatment among African-Americans. METHODS: Patients enrolled in SPORT (March 2000 to February 2005) that reported data on their race (n = 2,323) were classified as White (87%), Black (8%), or Other (5%). Treatment preferences (nonoperative, unsure, surgical), and willingness to be randomized were compared among these groups while controlling for baseline differences using multivariate logistic regression. RESULTS.: There were numerous significant differences in baseline characteristics among the racial groups. Following adjustment for these differences, Blacks remained less likely to prefer surgical treatment among both IDH (White, 55%; Black, 37%; Other, 55%, P = 0.023) and SpS/DS (White, 46%; Black, 30%; Other, 43%; P = 0.017) patients. Higher randomization rates among Black IDH patients (46% vs. 30%) were no longer significant following adjustment (odds ratio [OR] = 1.45, P = 0.235). Treatment preference remained a strong independent predictor of randomization in multivariate analyses for both IDH (unsure OR = 3.88, P < 0.001 and surgical OR = 0.23, P < 0.001) and SpS/DS (unsure OR = 6.93, P < 0.001 and surgical OR = 0.45, P < 0.001) patients. CONCLUSIONS: Similar to prior studies, Black participants were less likely than Whites or Others to prefer surgical treatment; however, they were no less likely to agree to be randomized. Treatment preferences were strongly related to both race and willingness to be randomized.

Are gender, marital status or parenthood risk factors for outcome of treatment for chronic disabling spinal disorders?

Recent clinical research has suggested that single working mothers may differ in their response to health treatment and outcomes, relative to their married female or male counterparts. The present study explored, on an a priori basis, the existence and extent of differences in chronic pain rehabilitation outcomes of pain report, return-to-work and future health utilization for single working mothers, relative to other patients. A cohort of 1,679 consecutive chronically disabled work related spinal disorder (CDWRSD) patients were placed into one of eight groups as a function of gender, marital status (single/married), and parenthood (with/without children). All patients completed an assessment battery measuring psychosocial variables at pre- and post-treatment, and a structured clinical interview evaluating socioeconomic outcomes at 1 year following completion of a 5-7 week functional restoration program. Results revealed that single females with children differed from all other groups in racial representation, with 57.1% of these individuals being African American, widely disparate from the prevailing local ethnicity. Single females and males with children were represented by a higher incidence of cervical injuries (25.0% and 26.7%, respectively) than all other groups (5.4-16.6%, p < .001). Contrary to expectation, the 8 groups did not differ significantly in program completion rate, work return, work retention, health utilization, recurrent injury or case settlement rates at one-year follow-up. The single females with children group did display greater levels of depression pre-treatment compared to the other groups. However, at post-treatment, these differences no longer existed. This investigation is one of the first to examine if the combination of gender and parenthood distinguishes significantly among CDWRSD patients. Overall, contrary to expectation, the single mothers did not show any significant differences in CDWRSD outcome at one-year post-rehab follow-up, and the single mothers and fathers showed no differences in depression or pain severity post-treatment. Thus, in spite of the societal belief to the contrary, it seems that single parent patients can show similar chronic pain rehabilitation outcomes, relative to other CDWRSD patients, after a prescribed course of tertiary functional restoration rehabilitation.

Validation of the Korean version of the oswestry disability index.

STUDY DESIGN: Validation of a translated, culturally adapted questionnaire. OBJECTIVES: To translate and culturally adapt a Korean version of the Oswestry Disability Index (ODI) and to validate its use in Korean patients. SUMMARY OF BACKGROUND DATA: The ODI is one of the most widely used and validated instruments for measuring disability in spinal disorders. However, no validated Korean version of the index was available at the time our study was initiated. METHODS: The study was carried out in three phases: the first was translation into Korean and cultural adaptation of the questionnaire; the second was a pilot study to assess the comprehensibility of the prefinal version and modification; the third was a reliability and validity study of the final version. The Korean version was tested on 206 patients with lumbar spinal disorders who had undergone operations at the authors' institute. Test-retest reliability, internal consistency, concurrent validity, and construct validity were investigated. Follow-up questionnaires were obtained from 39 patients at the 3-month postoperative follow-up meeting. Differences in the ODI, visual analog scale (VAS), and World Health Organization (WHO) quality of life assessment (WHOQOL-BREF) between preoperative and follow-up questionnaires were evaluated. The correlation of the postoperative ODI with the pain rating on a visual analog scale and WHOQOL-BREF was also analyzed. RESULTS: Test-retest reliability was assessed with 88 patients in a time interval of 48 hours. The intraclass correlation coefficient of test-retest reliability was 0.9167. Reliability estimated by the internal consistency reached a Cronbach's alpha of 0.84. The correlation of the preoperative ODI with the pain rating on a visual analog scale (100 mm) was r = 0.425 (P = 0.0001). The correlation between three of the WHOQOL-BREF domains (physical health, psychological health, and environment) and the ODI was statistically significant. The correlation coefficient between the ODI and physical health domain of the WHOQOL-BREF was r = -0.48 (P < 0.05). The correlations with psychological health and environment domains were low with r = -0.192 and -0.160, respectively, even though statistically significant (P < 0.05). The correlation of the postoperative ODI with the pain rating on a visual analog scale (100 mm) was r = 0.626 (P = 0.0001). The correlation between all four domains of the WHOQOL-BREF and the postoperative ODI was statistically significant. CONCLUSIONS: The results of this study indicate that the Korean version of the ODI is a reliable and valid instrument for the measurement of disability in Korean patients with lower back problems. The authors recommend this Korean version of the ODI for use in future clinical studies in Korea.

Differences in the work-up and treatment of conditions associated with low back pain by patient gender and ethnic background.

STUDY DESIGN: Retrospective review comparing physician workup of degenerative lumbosacral pathologies between different genders and ethnic groups. OBJECTIVES: To investigate whether patient ethnicity and gender influence the workup and treatment of degenerative spinal pathologies. SUMMARY OF BACKGROUND DATA: Data from numerous studies suggest that patient gender and ethnicity play a role in medical decision-making, with white males receiving more frequent interventions than women and minorities. METHODS: Patients enrolled for an "initial visit" in the National Spine Network database with lumbosacral level degenerative diagnosis were reviewed. Variables included patient gender, ethnicity, age, duration of symptoms, patient-graded severity of symptoms, radicular symptom pattern, and work status. RESULTS: We identified 5690 patients with degenerative lumbosacral pathologies. Although females were more likely than males to have imaging tests ordered, male (18.5%) patients were significantly more likely to have surgery recommended than female (16.3%) patients (P < 0.031). Nonwhite females were 52% less likely to have surgery offered at initial visit, as compared to white males (P < 0.005). More imaging tests were ordered or reviewed among whites (76.6%) than among any other ethnic group (P = 0.162). White (18.3%) and Asian (22.5%) patients were significantly more likely to have surgery recommended or prescribed than black (11.1%) and Hispanic (14.5) patients (P < 0.0001). CONCLUSIONS: This study suggests that ethnicity and gender affect the workup and surgical management of degenerative spinal disorders. However, it should be noted that there are a number of confounding factors not identified in the database, including managed care and insurance status and cultural differences, which may affect both test ordering and treatment recommendations. Further study of bias in clinical decision-making is indicated to assure equal delivery of quality care.

Spinal bone mineral density by quantitative computed tomography in Thais compared with Westerners.

The present study was to determine age- and gender-based spinal bone mineral density (BMD) by quantitative computed tomography (QCT) in Thais and to compare it with that of Westerners. Four hundred and twenty five healthy Thais, age 20 to 76 years (322 females, mean age 43.4 years; 103 males, mean age 42.8 years) were recruited for BMD assessment by QCT. Spinal BMD peaks in the 20-29 year age group in both genders with a mean value of 171.9 mg/cu cm in females and 171.0 mg/cu cm in males. It subsequently decreases in older age groups. Males' BMD has a higher rate of decline than females' until age 40-49. It then stabilizes from 50-59 while females' BMD shows the highest rate decline at this period After the mid-50's, both genders have bone loss from aging. Compared to Westerners, peak bone mass is reached in the same age group in both genders. Peak bone mass of Thai females is significantly higher than Western females, but that of Thai males is not significantly higher than Western males. BMD of Thai males in the 50-59 and over-60 age groups is higher than that of Westerners. The findings suggest that the cut-off points for osteopenia and osteoporosis, in Thai females are at spinal BMD lower than 143.6 mg/cu cm and 101.15 mg/cu cm, respectively. While the values lie at 143.2 mg/cu cm and 101.5 mg/cu cm among Thai males for osteopenia and osteoporosis, respectively.

Spondyloarthropathies in eastern Asia.

The association between HLA-B27 and the spondyloarthropathies (SpAs) is so strong that it is supposed that the HLA-B27 molecule plays a pathogenetic role. In whites and Indonesians, the frequency of HLA-B27 is about 10%; in Chinese it is about 8%; and in Japanese it is only about 1%. The prevalence of SpA in the Chinese is at least 0.2%, but in native Indonesians, Philippinos, and Malaysians, SpA is rarely seen. Twenty-three subtypes (B*2701-B*2723) have been distinguished. These subtypes are not equally distributed over the world. In most countries the distribution of the subtypes among HLA-B27 SpA patients is the same as that among the normal HLA-B27-positive population. In China, the subtype B*2704 is frequent and the prevalence of SpA is high. Native Indonesians, however, mostly have subtype B*2706, and SpA is rarely seen in this population. It was shown that B*2706, probably like B*2709 in Sardinia, is not associated with SpA. The difference between the SpA-associated and non-SpA-associated subtypes is limited to only two amino acid residues (114 and 116) at the bottom of the peptide-binding groove of HLA-B27. This small difference between health and disease rewards studies for different peptide-binding capacities and may help us characterize the peptides that are involved in the pathogenesis of SpA. The differences in disease associations in these countries also have clinical implications. In Southeast Asia, HLA-B27 typing without subtyping has less clinical usefulness than in parts of the world where B*2706 is rarely seen. When native Indonesians, Malaysians, or Philippinos are suspected of having ankylosing spondylitis or a related SpA, it is worth asking if they had white or Chinese ancestors. If native HLA-B27-positive Indonesians (with subtypes other than B*2706) develop SpA, the clinical features are not different from those in other parts of the world. In the Chinese population on the mainland and in Taiwan, juvenile SpA is frequently seen. The onset is often a peripheral arthritis or enthesitis.