Neuropathic Pain Medication and Antidepressant Use after Disability Pension in Patients with Spinal Cord Stimulation for Persistent Spinal Pain Syndrome.

Background: Treatment of persistent spinal pain syndrome (PSPS) is challenging. Chronic pain associated with PSPS can lead to an impaired ability to work. Objective: To obtain information on whether receiving a disability pension (DP) affects pain and pain treatments in retiring working-age PSPS patients. Neuropathic pain medication and antidepressant use were considered as an indicator of neuropathic pain. Methods: The study group comprised 129 consecutive PSPS patients with spinal cord stimulation (SCS) devices implanted at Kuopio University Hospital Neurosurgery between January 1, 1996, and December 31, 2014. Purchase data of gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors from January 1995 to March 2016, as well as the data on working ability, were retrieved from national registries. Results: The data showed that 28 of 129 (21.7%) SCS permanent patients had a DP, and 27 had a sufficient follow-up time (two years before and one year after DP). Most patients (61%) used neuropathic pain medications during the follow-up, while 44% used antidepressants. Most patients (70%, n = 19) retired because of dorsopathies. The dose of gabapentinoids started to increase before the DP; after the DP, the doses started to increase again after the decrease but remained at a lower level. Conclusions: Neuropathic pain medication and antidepressant use suggest that pain continues after the DP-that is, pensioners continue to experience inconvenient chronic pain. Resources for patient care are therefore needed after the DP. However, the DP reduces the dose increase of gabapentinoids; the dose is higher immediately before retirement than at the end of the follow-up.

To what degree patient-reported symptoms of central sensitization, kinesiophobia, disability, sleep, and life quality associated with 24-h heart rate variability and actigraphy measurements?

OBJECTIVES: Chronic musculoskeletal pain is associated with decreased parasympathetic and increased sympathetic activity in the autonomic nervous system. The objective of this study was to determine the associations between objective measures of heart rate variability (a measure of autonomic nervous system function), actigraphy (a measure of activity and sleep quality), respiration rates, and subjective patient-reported outcome measures (PROMs) of central sensitization, kinesiophobia, disability, the effect of pain on sleep, and life quality. METHODS: Thirty-eight study subjects were divided into two subgroups, including low symptoms of central sensitization (n = 18) and high symptoms of central sensitization (n = 20), based on patient-reported scores on the Central Sensitization Inventory (CSI). Heart rate variability (HRV) and actigraphy measurements were carried out simultaneously in 24 h measurement during wakefulness and sleep. RESULTS: A decrease in HRV during the first 2 h of sleep was stronger in the low CSI subgroup compared to the high CSI subgroup. Otherwise, all other HRV and actigraphy parameters and subjective measures of central sensitization, disability, kinesiophobia, the effect of pain on sleep, and quality of life showed only little associations. DISCUSSION: The high CSI subgroup reported significantly more severe symptoms of disability, kinesiophobia, sleep, and quality of life compared to the low CSI subgroup. However, there were only small and nonsignificant trend in increased sympathetic nervous system activity and poorer sleep quality on the high central sensitization subgroup. Moreover, very little differences in respiratory rates were found between the groups.

Protocol of identical exercise programs with and without specific breathing techniques for the treatment of chronic non-specific low back pain: randomized feasibility trial with two-month follow-up.

BACKGROUND: Chronic low back pain (CLBP) is a leading cause of disability globally. Exercise therapies are one of the commonly prescribed treatment options for CLBP. The specific exercise therapies for CLBP most commonly target movement dysfunction, but seldom brain-based pain modulation. Exercise therapies with specific breathing techniques (SBTs) have been shown to influence and enhance brain-based structural and functional pain modulation. AIMS AND OBJECTIVES: To assess the feasibility of the SBTs protocol, eligibility criteria, randomization, and dropout rates. To quantify the changes in patient outcome measures and choose the most relevant measure for larger-scale study. To quantify self-adherence levels to home exercise and monitor and record possible pain medication and other treatment modality usage, and adverse events during exercise. DESIGN: A parallel randomised analyst-blinded feasibility trial with two-month follow-up. OUTCOME MEASURES: Feasibility related to aims and objectives. Multiple pain- and health-related patient-reported outcome measures of pain intensity, disability, central sensitization, anxiety, kinesiophobia, catastrophising, self-efficacy, sleep quality, quality of life, and health and well-being status. Exercise adherence, pain medication and other treatment modality usage, and possible adverse events related to exercises will be monitored and recorded. METHODS: Thirty participants will be randomized to movement control exercise with SBTs (15 subjects in experimental group) or movement control exercise without SBTs (15 subjects in control group) in private chiropractic practice setting with two-month follow-up. Trial registration number; NCT05268822. DISCUSSION: The clinical difference in effectiveness between practically identical exercise programs in uniform study settings with or without SBTs has not been studied before. This study aims to inform feasibility and help determine whether progression to a full-scale trial is worthwhile.

Treatment of Sciatica and Lumbar Radiculopathy with an Intervertebral Foramen Opening Protocol: Pilot Study in a Hospital Emergency and In-patient Setting.

AIMS: Perform a pilot study of a static nerve root foramen opening protocol for lumbar radiculopathy from disc hernia in an emergency hospital setting to establish if patients could execute the protocol, consistency would occur across outcomes, superior outcomes would occur in the experimental group, and if the protocol would be safe. METHODS: Patients with sciatica arrived of their own volition at the local emergency hospital department, were admitted for care and were randomized into two groups: 1) control (n = 10): forward bending, walking, and medication; and 2) experimental (n = 10) as control subjects, plus a static lumbar foramen opening protocol using flexion and contralateral lateral flexion (side-lying). Outcomes were back and leg pain (i.e. visual analog scale), disability (i.e. EuroQol5D5L and Oswestry) and straight leg raise. RESULTS: At admission, the baseline outcome variables between groups were not significantly different. All patients had moderate or large disc hernias on MRI and 75% had neurological deficits in electrophysiology. At discharge, patients in the experimental group were significantly better (p ≤ .05) than controls in all outcomes. Statistical analysis of the outcomes produced greater significance, effect sizes and minimal clinically important differences in the experimental group. Patients in the experimental group consumed less medication than control patients (21% versus 79%), including less than half the opioids (tramadol). No adverse responses occurred. CONCLUSIONS: Patients could perform the protocol and superior outcomes occurred, with no adverse effects. The data support more detailed study of therapeutic efficacy, days in hospital, costs, conversion to surgery, and medication consumption, including opioids.

Disability Pension Did Not Reduce Opioid Use Among Patients With Failed Back Surgery Syndrome Who Were Trialed and Implanted for Spinal Cord Stimulation.

BACKGROUND: Spinal cord stimulation (SCS) is an effective treatment for failed back surgery syndrome (FBSS). In patients with FBSS, opioids have often been initiated, even before SCS is trialed. OBJECTIVE: We studied the effect of retirement on opioid use in patients with chronic pain after failed back surgery. STUDY DESIGN: A retrospective study design. SETTING: The study was conducted at Kuopio University Hospital. METHODS: The study group consisted of all 230 patients with SCS trialed or implanted for FBSS at Kuopio University Hospital Neurosurgery from January 1, 1996 through December 31, 2014. All purchases of prescribed opioids and their daily defined doses, as well as data on working ability, were obtained from the Social Insurance Institution. Patients were divided into 3 groups: SCS trial only, SCS implanted permanently, and SCS implanted but later explanted. We analyzed the differences in opioid use among these groups 2 years before and 2 years after the start of their disability pension (DP). RESULTS: During the follow-up period, a total of 60 patients received a DP. One year before DP, the majority of patients used opioids (n = 43, 72%), and throughout the one-year follow-up after retirement, the number of users increased slightly (n = 46, 77%). In the permanently implanted SCS group, the number of strong opioid users decreased after retirement. Most patients used a moderate dose (0.1-10.5 morphine milligram equivalent/d). Retirement appeared to interrupt dose escalation in all groups, but doses increased further as the follow-up continued. LIMITATIONS: No structured questionnaires were used in this study. Also, many underlying factors contributing to chronic pain were missing. CONCLUSIONS: DP did not reduce the use of opioids in patients with FBSS. Opioid doses were lower and dose escalation less steep with continuous SCS therapy.

Postural sway does not differentiate individuals with chronic low back pain, single and multisite chronic musculoskeletal pain, or pain-free controls: a cross-sectional study of 229 subjects.

BACKGROUND CONTEXT: Physical activity in its various forms are the most recommended prevention and treatment strategy for chronic low back pain (CLBP). Standing postural stability is a prerequisite for many types of physical activities. Systematic reviews have investigated the evidence for an association between CLBP and postural stability but results remain inconclusive. PURPOSE: Our primary objective was to compare postural stability between pain-free controls and subjects with CLBP with or without leg pain and single and multisite chronic musculoskeletal pain subjects. The secondary objectives were to evaluate the association between postural stability with CLBP intensity and duration, demographics, physical characteristics and validated health and pain-related patient-reported outcome measures (PROMs). STUDY DESIGN/SETTING: Cross-sectional study in a private chiropractic clinic setting PATIENT SAMPLE: Subjects included 42 pain-free controls and 187 patients with chronic musculoskeletal pain divided into CLBP with or without leg pain and single and multisite pain groups. OUTCOME MEASURES: Pain intensity was measured using the numerical pain rating scale, PROMs Central Sensitization Inventory, Tampa Scale of Kinesiophobia, The Depression Scale, EuroQol-5D, Roland-Morris Disability Questionnaire, and Pain and Sleep Questionnaire Three-Item Index disability. Group differences were measured using area and velocity of sway on the force plate. METHODS: Postural stability was assessed using a force plate on four 60-second bipedal quiet stance tests: eyes open on a stable surface, eyes closed on a stable surface, eyes open on an unstable foam surface, eyes closed on an unstable foam surface. Following the clinic visit, subjects completed an online web-based data entry detailing pain history, demographic data, physical characteristics, pain intensity via the numerical pain rating scale, and PROMS. RESULTS: Postural sway parameters did not differ between pain-free controls and subjects with CLBP with or without leg pain and single and multisite chronic musculoskeletal pain subjects. Furthermore, severity and duration of CLBP pain in addition to central sensitization, kinesiophobia, depression, quality of life, disability, and effect of pain on sleep only had very weak associations with postural stability. CONCLUSIONS: Chronic musculoskeletal pain appears not to influence bipedal postural stability.

Changes in elbow flexion EMG morphology during adjustment of deep brain stimulator in advanced Parkinson's disease.

OBJECTIVE: Deep brain stimulation (DBS) is an effective treatment for motor symptoms of advanced Parkinson's disease (PD). Currently, DBS programming outcome is based on a clinical assessment. In an optimal situation, an objectively measurable feature would assist the operator to select the appropriate settings for DBS. Surface electromyographic (EMG) measurements have been used to characterise the motor symptoms of PD with good results; with proper methodology, these measurements could be used as an aid to program DBS. METHODS: Muscle activation measurements were performed for 13 patients who had advanced PD and were treated with DBS. The DBS pulse voltage, frequency, and width were changed during the measurements. The measured EMG signals were analysed with parameters that characterise the EMG signal morphology, and the results were compared to the clinical outcome of the adjustment. RESULTS: The EMG signal correlation dimension, recurrence rate, and kurtosis changed significantly when the DBS settings were changed. DBS adjustment affected the signal recurrence rate the most. Relative to the optimal settings, increased recurrence rates (median ± IQR) 1.1 ± 0.5 (-0.3 V), 1.3 ± 1.1 (+0.3 V), 1.7 ± 0.4 (-30 Hz), 1.7 ± 0.8 (+30 Hz), 2.0 ± 1.7 (+30 µs), and 1.5 ± 1.1 (DBS off) were observed. With optimal stimulation settings, the patients' Unified Parkinson's Disease Rating Scale motor part (UPDRS-III) score decreased by 35% on average compared to turning the device off. However, the changes in UPRDS-III arm tremor and rigidity scores did not differ significantly in any settings compared to the optimal stimulation settings. CONCLUSION: Adjustment of DBS treatment alters the muscle activation patterns in PD patients. The changes in the muscle activation patterns can be observed with EMG, and the parameters calculated from the signals differ between optimal and non-optimal settings of DBS. This provides a possibility for using the EMG-based measurement to aid the clinicians to adjust the DBS.

Retention of tissue texture change after cervical muscle energy and high velocity low amplitude intervention: implications for treatment intervals.

CONTEXT: When choosing to incorporate osteopathic manipulative treatment (OMT) into a patient's care, the risk-to-benefit ratio, the choice of treatment technique, as well as the frequency of treatments are always taken into consideration. This has been even more important during the COVID-19 pandemic, in which social distancing has been the best preventative measure to decrease exposure. By increasing treatment intervals, one could not only limit possible exposure/spread of viruses but also decrease the overall cost to the system as well as to the individual. This is an expansion of a previous study in which quantifiable changes in cervical hysteresis characteristics post-OMT were documented utilizing a durometer (Ultralign SA201®; Sigma Instruments; Cranberry, PA USA). This study compared two treatment modalities, muscle energy (ME) and high-velocity low-amplitude (HVLA) postcervical treatment. Subjects in this study were allowed to re-enroll, provided that they could be treated utilizing the alternate treatment modality. By allowing repeat subjects, analysis of the data for lasting effects of OMT could be observed. OBJECTIVES: To determine whether a significant change in cervical hysteresis would be observed after each treatment regardless of a short treatment interval. METHODS: A total of 34 subjects were retrospectively noted to be repeat subjects from a larger, 213-subject study. These 34 subjects were repeat participants who were treated with two different direct-treatment modalities 7-10 days apart. Each subject was randomly assigned to receive a single-segmental ME or HVLA treatment technique directed toward a cervical (C) segment (C3-C5 only). Subjects were objectively measured pretreatment in all cervical segments utilizing the Ultralign SA201®, then treated with cervical OMT to a single segment, and finally reassessed at all cervical levels with the Ultralign SA201® posttreatment to assess for change in cervical hysteresis. RESULTS: Statistically significant or suggestive changes (p-values 0.01-0.08) with good clinical effect size (0.30 or greater) were noted in all four components of the Ultralign SA201® at multiple cervical levels after the first treatment, but only one component (frequency) had a statistically significant change after the second treatment (AA cervical level, p-value 0.01) with good clinical effect size (0.45). However, when comparing the post-first-treatment values to the pre-second-treatment values, no statistically significant differences (p-value 0.10 or higher) were observed between them. CONCLUSIONS: Statistically significant changes were noted after the first treatment; however, when comparing cervical hysteresis changes after the first treatment to the cervical hysteresis values prior to the second treatment delivered 7-10 days later, there were no statistically significant or suggestive changes. This data suggest that several post-OMT changes noted after the first treatment were still in effect and may indicate that follow-up visits for direct manipulation may be deferred for a least two weeks.

Cross-Cultural Adaptation, Reliability, and Psychophysical Validation of the Pain and Sleep Questionnaire Three-Item Index in Finnish.

Reciprocal relationships between chronic musculoskeletal pain and various sleep disturbances are well established. The Pain and Sleep Questionnaire three-item index (PSQ-3) is a concise, valid, and reliable patient-reported outcome measure (PROM) that directly evaluates how sleep is affected by chronic low back pain (CLBP). Translation and cross-cultural validation of The Pain and Sleep Questionnaire three-item index Finnish version (PSQ-3-FI) were conducted according to established guidelines. The validation sample was 229 subjects, including 42 pain-free controls and 187 subjects with chronic musculoskeletal pain. Our aims were to evaluate internal consistency, test-retest reliability, measurement error, structural validity, convergent validity, and discriminative validity and, furthermore, to study the relationships between dizziness, postural control on a force plate, and objective sleep quality metrics and total PSQ-3-FI score. The PSQ-3-FI demonstrated good internal consistency, excellent test-retest reliability, and small measurement error. Confirmatory factor analysis confirmed acceptable fit indices to a one-factor model. Convergent validity indicated fair to good correlation with pain history and well-established pain-related PROMs. The PSQ-3-FI total score successfully distinguished between the groups with no pain, single-site pain, and multisite pain. A higher prevalence of dizziness, more impaired postural control, and a general trend towards poorer sleep quality were observed among subjects with higher PSQ-3-FI scores. Postural control instability was more evident in eyes-open tests. The Finnish PSQ-3 translation was successfully cross-culturally adapted and validated. The PSQ-3-FI appears to be a valid and reliable PROM for the Finnish-speaking CLBP population. More widespread implementation of PSQ-3 would lead to better understanding of the direct effects of pain on sleep.

Extending the straight leg raise test for improved clinical evaluation of sciatica: validity and diagnostic performance with reference to the magnetic resonance imaging.

BACKGROUND: The straight leg raise test (SLR) is one of the most utilized and studied physical tests in patients with low back pain (LBP) for the detection of lumbar disc herniation (LDH), showing high sensitivity and heterogeneous or low specificity. The high incidence of asymptomatic 'pathologic' findings in the magnetic resonance imaging (MRI) scans may cause verification bias to these results. We studied an extended SLR (ESLR) by adding location-specific structural differentiation movements (hip internal rotation or ankle dorsiflexion) to the traditional SLR for it to better differentiate neural symptoms from musculoskeletal. Previously, the ESLR has shown almost perfect interrater reliability between examiners and ability to detect sciatic patients. In this study, we investigated whether a 'positive' ESLR finding is associated with pathology seen on MRI. METHODS: Forty subjects comprised the study population, 20 in sciatic group and 20 in control group. The ESLR was performed 'blinded' to the subjects. After the ESLR, each subject's lumbar MRI was evaluated. The MRIs were analyzed independently by 2 senior radiologists and a spine specialist clinician. The ESLR and MRI results were cross-tabulated. To obtain the odds ratio (OR) with positive ESLR or SLR results for LDH or nerve root compression (NC), a binary logistic regression analysis with subjects' age, gender, height and weight was performed. ESLR's validity was assessed by combination of interrater agreement and percentage prevalence of both LDH and NC. RESULTS: Of sciatic (ESLR+) patients, 85 % had LDH and 75 % NC in the MRI. Not surprisingly, MRI showed a very high incidence of 'false-positive' findings with the ESLR negative group. The ESLR showed 0.85 sensitivity and 0.45 specificity for LDH and 0.75 sensitivity and 0.50 specificity for NC. A positive result in the ESLR was found to be strongly associated with for both LDH and NC: the OR was 8.0 (p = 0.028) and 5.6 (p = 0.041), respectively. CONCLUSIONS: The ESLR shows high validity in detecting neural symptoms and is strongly associated with pathology seen in the MRI when judged positive. We suggest the use of ESLR in clinical practice as a part of clinical examination, where it may prove to be a valuable tool in detecting patients with sciatic symptoms.

Extending the straight leg raise test for improved clinical evaluation of sciatica: reliability of hip internal rotation or ankle dorsiflexion.

BACKGROUND: The straight leg raise (SLR) is the most commonly applied physical tests on patients with sciatica, but the sensitivity and specificity ratings for disc hernia and neural compression leave areas for improvement. Hip internal rotation tensions the lumbosacral nerve roots and ankle dorsiflexion tensions the sciatic nerve along its course. We added these movements to the SLR (extended SLR = ESLR) as structural differentiators and tested inter-rater reliability in patients with LBP, with and without sciatica. METHODS: Forty subjects were recruited to the study by the study controller (SC), 20 in the sciatic group and in the control group. Two independent examiners (E1&E2) performed the ESLR and did not communicate to the subjects other than needed to determine the outcome of the ESLR. First, SLR was performed traditionally until first responses were evoked. At this hip flexion angle, a location-specific structural differentiation was performed to confirm whether the emerged responses were of neural origin. Cohen's Kappa score (CK) for interrater reliability was calculated for ESLR result in detection of sciatic patients. Also, the examiners' ESLR results were compared to the traditional SLR results. RESULTS: The interrater agreement between Examiner 1 and Examiner 2 for the ESLR was 0.85 (p < 0.001, 95%CI: 0.71-0.99) translating to almost perfect agreement as measured by Cohen's Kappa When the ESLR was compared to the traditional SLR, the overall agreement rate was 75% (30/40). Kappa values between the traditional SLR and the E1's or E2's ESLR results were 0.50 (p < 0.0001; 95%CI 0.27-0.73) and 0.54 (p < 0.0001; 95%CI 0.30-0.77), respectively. CONCLUSIONS: ESLR with the addition of location-specific structural differentiation is a reliable and repeatable tool in discerning neural symptoms from musculoskeletal in patients with radiating low back pain. We recommend adding these movements to the standard SLR with aim of improving diagnostic ability.

Cross-cultural adaptation and validation of the Finnish version of the central sensitization inventory and its relationship with dizziness and postural control.

BACKGROUND: Central Sensitization (CS) involves dysfunction in neurophysiological mechanisms that increase neuronal responses to both noxious and non-noxious stimuli in the central nervous system. The Central Sensitization Inventory (CSI) is considered the leading patient-reported outcome measure for assessing CS-related symptoms. The aim of this study was to translate and cross-culturally adapt the CSI into Finnish (CSI-FI) and to evaluate its psychometric properties. METHODS: Translation and cross-cultural validation of the CSI was conducted according to established guidelines. The validation sample was 229 subjects, including 42 pain free controls and 187 subjects with chronic musculoskeletal pain. The CSI-FI was evaluated for internal consistency, test-retest reliability, exploratory factor analysis with maximum likelihood extraction, relationship with subject-reported outcome measures [Tampa scale of kinesiophobia (TSK), the Depression scale (DEPS), 5-level EQ-5D version (EQ-5 L-5D), Roland-Morris Disability Questionnaire (RMDQ), and Pain and Sleep Questionnaire Three-Item Index (PSQ-3)], pain history, subjective symptoms of dizziness, and CS-related diagnoses on CSI part B. Furthermore, we studied the ability of the CSI-FI to distinguish pain free controls, subjects with chronic pain in a single body area, and subjects with multisite chronic pain. In addition, we studied the relationship of CSI-FI scores with postural control on a force plate. RESULTS: The CSI-FI demonstrated good internal consistency (0.884) and excellent test-retest reliability (0.933) with a 7 ± 1 day gap between test administrations. Exploratory factor analysis with maximum likelihood extraction yielded a one factor solution. Fair to good correlations were found between the CSI-FI and the TSK, DEPS, EQ-5 L-5D, RMDQ, and PSQ-3. Subjective symptoms of dizziness correlated better with CSI-FI scores than any of the CS-related diagnoses on CSI part B. Total CSI-FI scores successfully distinguished between pain free controls, subjects with chronic pain in a single body area, and subjects with multisite chronic pain. The multisite pain group reported significantly more dizziness symptoms than the other two groups. Force plate measurements showed no relationship between postural control and CSI-FI scores. CONCLUSION: The CSI-FI translation was successfully cross-culturally adapted and validated into Finnish. CSI-FI psychometric properties and scores were all in acceptable levels and in line with previous CSI validations. The CSI-FI appears to be a valid and reliable instrument for assessing CS-related symptomology in Finnish-speaking populations.

Preoperative Predictors of Better Long-term Functional Ability and Decreased Pain Following LSS Surgery: A Prospective Observational Study with a 10-year Follow-up Period.

STUDY DESIGN: A prospective observational 10-year follow-up study. OBJECTIVE: This study aimed to examine preoperative predictors for better surgical outcomes in patients with lumbar spinal stenosis (LSS) 10 years after surgery. SUMMARY OF BACKGROUND DATA: LSS is a leading cause of low back surgery in patients older than 65 years. Limited data are available for predictors of long-term surgical outcomes in patients with LSS. METHODS: At the baseline, 102 patients with LSS underwent decompressive surgery, and 72 of the original study sample participated in a 10-year follow-up study. Study patients filled out a questionnaire preoperatively, and follow-up data were collected at 3 months, 6 months, 1 year, 2 years, 5 years, and 10 years postoperatively. Surgical outcomes were evaluated in terms of disability with the Oswestry Disability Index (ODI) and pain with the visual analog scale (VAS). Predictors in the models were nonsmoking status, absence of previous lumbar surgery, self-rated health, regular use of painkillers for symptom alleviation, and BMI. Statistical analyses included longitudinal associations, subgroup analyses, and cross-sectional analyses. RESULTS: Using multivariate analysis, statistically significant predictors for lower ODI and VAS scores at 10 years were nonsmoking status, absence of previous lumbar surgery, better self-rated health, and regular use of painkillers for <12 months. Patients who smoked preoperatively or had previous lumbar surgery experienced more pain and disability at the 10-year follow-up. CONCLUSION: These study results can enhance informed decision-making processes for patients considering surgical treatment for LSS by showing preoperative predictors for surgical outcomes up to 10 years after surgery. Smokers and patients with previous lumbar surgery showed a decline in surgical benefits after 5 years. LEVEL OF EVIDENCE: 3.

Normalization of Spinal Cord Displacement With the Straight Leg Raise and Resolution of Sciatica in Patients With Lumbar Intervertebral Disc Herniation: A 1.5-year Follow-up Study.

STUDY DESIGN: A controlled radiologic follow-up study. OBJECTIVE: The aim of this study was to ascertain whether changes in cord excursion with straight leg raise test (SLR) at 1.5-year follow-up time accompany changes in clinical symptoms. SUMMARY OF BACKGROUND DATA: Lumbar intervertebral disc herniation (LIDH) is known to be a key cause of sciatica. Previously, we found that a significant limitation of neural displacement (66.6%) was evident with the SLR on the symptomatic side of patients with subacute single level posterolateral LIDH. METHODS: Fourteen patients with significant sciatic symptoms due to a subacute single-level posterolateral LIDH were reassessed clinically and radiologically at 1.5 years follow-up with a 1.5T MRI scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between SLRs and to data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with a decrease in low back pain (LBP) and radicular symptoms. RESULTS: Compared with previously presented baseline values, the data showed a significant increase in neural sliding in all the quantified maneuvers (P ≤ 0.01), and particularly of 2.52 mm (P ≤ 0.001) with the symptomatic SLR.Increase in neural sliding correlated significantly with decrease of both radicular symptoms (Pearson = -0.719, P ≤ 0.001) and LBP (Pearson = -0.693, P ≤ 0.001). Multivariate regression models and backward variable selection method confirmed the improvement of neural sliding effects (P ≤ 0.004) as the main variable being associated with improvement of self-reported clinical symptoms. CONCLUSION: To our knowledge, these are the first noninvasive data to objectively support the association between increase in magnitude of neural adaptive movement and resolution of both radicular and LBP symptoms in in vivo and structurally intact human subjects. LEVEL OF EVIDENCE: 2.

High Postural Sway Is an Independent Risk Factor for Osteoporotic Fractures but Not for Mortality in Elderly Women.

The aim of this prospective cohort study was to investigate the independent effect of postural sway on overall fracture and osteoporotic fracture risk after controlling for other established fracture risk factors. As a secondary outcome, mortality was also investigated. The study sample is a stratified random sample of 1568 women born between 1932 and 1941, residing in Kuopio province, eastern Finland. Fracture data were obtained through study questionnaires and verified through hospital records. Mortality data were verified through the National Registry. Using static posturography, postural sway was recorded for 1568 women at the fifth year of follow-up in 1994 through 1997. Mediolateral (ML), anteroposterior (AP), and total sway parameters were used for analysis. Mean follow-up time for any fractures, osteoporotic fractures, and mortality was 10.6, 11.4, and 17.5 years, respectively. After adjustment, subjects in the highest quartile of ML sway (HR, 2.0; 95% CI, 1.5 to 2.8) and total sway (HR, 1.6; 95% CI, 1.2 to 2.2) had a higher risk for any fracture. Osteoporotic fracture risk was also higher in the fourth quartile of ML sway (HR, 1.9; 95% CI, 1.1 to 3.0) and total sway (HR, 1.7; 95% CI, 1.0 to 2.8). The models were adjusted for fracture risk assessment tool risk factors and leg-extension strength. Further, women having both lowest bone density and highest postural sway were at 4.9 (95% CI, 2.6 to 9.5) times higher risk of overall fracture and 11.8 (95% CI, 2.7 to 51.3) times higher risk for osteoporotic fracture in comparison with subjects having highest bone density and lowest postural sway. The association between postural sway and mortality was not significant after adjustment. In conclusion, high postural sway is an independent risk factor for any fractures as well as for osteoporotic fractures. A combination of low bone density and high postural sway poses even higher fracture risk than either factor alone. Postural sway does not predict mortality independently. © 2019 American Society for Bone and Mineral Research.

Preoperative sense of coherence associated with the 10-year outcomes of lumbar spinal stenosis surgery.

A prospective 10-year follow-up study was conducted to determine the significance of the preoperative sense of coherence, with respect to the preoperative and 10-year clinical characteristics, among lumbar spinal stenosis patients ( N = 99). In addition, the predictive value of the preoperative sense of coherence regarding the 10-year surgery outcome was also evaluated. In a logistic regression analysis, a weak preoperative sense of coherence and low functional ability predicted the patients' functional ability 10 years after the surgery. Moreover, those patients with weak sense of coherence before surgery showed poorer functional ability 10 years after the surgery, but not preoperatively. A weak preoperative sense of coherence seems to associate with poorer long-term outcome after surgery; therefore, various rehabilitation strategies are discussed.

Effect of Spinal Cord Stimulation on Early Disability Pension in 198 Failed Back Surgery Syndrome Patients: Case-Control Study.

BACKGROUND: Spinal cord stimulation (SCS) has proven to be a cost-effective treatment for failed back surgery syndrome (FBSS). However, the effect on patients' working capability remains unclear. OBJECTIVE: To evaluate the impact of SCS on working capability and to identify the factors behind permanent disability in FBSS patients. METHODS: The study group consisted of 198 working-age patients with SCS trialed or implanted for FBSS in a single center between 1996 and 2014. For each patient, 3 living controls, matched by age, gender, and birthplace, were otherwise randomly selected by the Population Register Center. The data on working ability were obtained from the Social Insurance Institution. Patients were divided into 3 groups: SCS trial only, SCS implanted permanently, and SCS implanted but later explanted. RESULTS: A rehabilitation subsidy was given to 68 patients and 8 controls for a mean of 5.2 (95% confidence interval [CI] 2.4-8.2) and 0.2 (95% CI 0.05-0.6) days per month (P < .05). At the end of follow-up, 16 (37%), 13 (33%), 25 (22%), and 27 (5%) subjects were on disability pension (DP) in the SCS trial, SCS explanted, SCS permanent, and control groups. Patients in the SCS trial-only group were significantly more often on DP than were patients with permanent SCS (odds ratio 2.6; 95% CI 1.2-5.9; P = .02). CONCLUSION: Permanent SCS usage was associated with reduced sick leave and DP. Prospective study will be required to assess possible predictive value.

Strong association between vertebral endplate defect and Modic change in the general population.

Modic change (MC) is considered an independent risk factor for low back pain (LBP) but its aetiology remains unclear. In this cross-sectional, large-scale population-based study we sought to characterise associations between endplate defect (ED) and MC in a population sample of broad age range. The study population consisted of 831 twin volunteers (including 4155 discs and 8310 endplates) from TwinsUK. Lumbar T2-weighted MR images were coded for ED and MC. Total endplate (TEP) score was calculated at each intervertebral disc while receiver operating curves (ROC) were calculated to define critical endplate values predictive of MC. MC was detected in 32.1% of the subjects, with a significantly higher prevalence at lower lumbar levels (3.5% at L1/2-L3/4 vs. 15.9% at L4/5-L5/S1, p < 0.001). TEP score was strongly and independently associated with MC at each lumbar level (risk estimates from 1.49 to 2.44; all p ≤ 0.001) after adjustment for age, sex, BMI and twin pairing. ROC analysis showed a TEP score cut-off of 6 above which there was a significantly higher prevalence of MC. In conclusion, ED were strongly associated with MC at every lumbar level. These findings support the hypothesis that endplate defect is a major initiating factor for the cascade of events that may include disc degeneration (DD) and MC.