Lumbar segmental rigidity: can its identification with facet injections and stretching exercises be useful?

OBJECTIVES: To describe a method for observing lumbar segmental rigidity and to show how motion measurements and pain/disability questionnaires can be used to evaluate outcomes of combined facet injections and stretching exercises. DESIGN: Preliminary 2-part study: (1) presentation of a technique for, identifying lumbar segmental rigidity based on physical observation of the spine's lateral bending; and (2) repeated measures of motion and pain/disability self-report in a chronic lumbar spinal disorder cohort, performed before and after treatment with combined facet injections and stretching exercises. SETTING: An outpatient tertiary rehabilitation facility providing interdisciplinary functional restoration for chronic disabling work-related spinal disorders. PATIENTS: Chronically disabled patients with lumbar spinal disorder (n = 39; mean age, 41yr; 82% male) with segmental rigidity at 1 or more levels on physical examination. Subjects averaged 20 months of disability, and 51% had preinjection spine surgery (average, 1.7 procedures involving up to 3 spinal segments). Thirty-nine percent of the cohort had a fusion at levels 1 or 2. INTERVENTIONS: Bilateral facet injections were administered under fluoroscopy to all patients, and 2 or 3 levels were performed in 93% of cases (range, levels 1-4). Patients were instructed in an unsupervised stretching program and were reassessed 2 to 4 weeks later. After an intensive supervised resistance exercise training program as part of interdisciplinary functional restoration, a third set of motion, pain, and disability measures were collected. MAIN OUTCOME MEASURES: Changes in true lumbar sagittal and coronal motion (T12-S1), measured with inclinometers, and pain/disability self-report were compared statistically. RESULTS: Patients' mobility improved significantly (p < .01-.0001) across all 4 motions. A large majority (71%-97%) of individuals improved on motion. According to self-reports made over the postinjection period, most patients improved their disability (83%) and pain intensity (63%) ratings. CONCLUSIONS: A simple physical examination technique for assessing lumbar spine segmental rigidity was used in this preliminary study to select patients and levels for combined facet injection and stretching exercise, with resultant improvements in mobility and self-reported pain/disability that may extend beyond the pharmacologic duration of the corticosteroid. The efficacy of either the facet injection or stretching components alone in achieving objective mobility improvements cannot be determined from the present study, but warrants future investigation.

Socioeconomic outcomes of combined spine surgery and functional restoration in workers' compensation spinal disorders with matched controls.

STUDY DESIGN: A longitudinal cohort study (n = 448) comparing functionally restored discectomy (n = 123) and fusion (n = 101) workers' compensation patients to matched, unoperated control patients (n = 123 and n = 101, respectively). OBJECTIVES: To determine successful treatment outcomes uniquely important in a workers' compensation environment when spine surgery is combined with comprehensive tertiary rehabilitation, to optimize anatomic and social sequelae. SUMMARY OF BACKGROUND DATA: Multiple recent studies confirm suboptimal socioeconomic outcomes for spinal surgery for degenerative conditions in a workers' compensation venue. In other musculoskeletal regions, there is a clear relationship between the quality of postsurgical rehabilitation and the impact on disability, recurrent injury, and future health care use. It is hypothesized that poor surgical outcomes in compensation injuries may result from outmoded postoperative methods, rather than failures of patient selection or surgical technique. No previous combination of surgery plus rehabilitation has been carefully evaluated with disabled workers undergoing spine surgery. Functional restoration is an individualized medically directed, interdisciplinary program using quantitatively directed exercise progression, psychotherapeutic interventions, and monitoring of specific socioeconomic outcomes for chronically disabled workers. METHODS: This study prospectively evaluated a cohort of consecutive functional restoration program graduates (n = 1202). Two surgical groups, discectomy (n = 123) and fusion (n = 101) were matched to two groups of unoperated control patients, control/discectomy and control/fusion, selected from the same cohort of patients with chronic spinal disorders based on age, gender, race, length of disability, and workers' compensation jurisdiction. A structured clinical interview was administered 12 months after program completion, with a contact rate of 95% to 98%. RESULTS: Socioeconomic outcomes for work return, health care use, and recurrent lost-time injury were assessed. All groups demonstrated a return-to-work incidence of more than 85%, but work retention at 1 year was higher for the fusion group than for the discectomy or control/fusion groups. Health care use was significantly higher for the discectomy group than the control/discectomy or fusion groups for reoperation (8% vs. 4%/ 2%), as well as other factors. All groups showed comparable recurrent lost-time injury rates (2-3.3%), and made comparable improvements in prospectively collected physical and psychological measures. CONCLUSIONS: Discectomy patients had work, health care utilization, and recurrent injury outcomes comparable with those for unoperated control patients. Fusion patients had better outcomes of work retention, reoperation, and health care use compared with the unoperated control patients and even with discectomy patients, in spite of more cases of previous surgery and greater duration of disability. The discectomy and fusion cohorts of operated chronic spinal disorder compensation patients with subsequent functional restoration had the best documented outcomes found in the literature for this population. In spite of the common presumption that spine surgery patients fare poorly in a workers' compensation environment, these results demonstrate that such patients can show remarkably successful objective outcomes if accompanied by effective rehabilitation, documenting efficacy and clinical utility. A new clinical approach is required to evaluate prospectively the combination of surgery and rehabilitation in chronic pain/disability workers' compensation patients, in which the surgical role is to correct an anatomic lesion, but the socioeconomic outcomes either occur spontaneously or are effected through some form of rehabilitation.