| 51. |
- Elmose, Signe Forbech, et al.
(författare)
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Magnetic Resonance Imaging Proxies for Segmental Instability in Degenerative Lumbar Spondylolisthesis Patients
- 2022
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Ingår i: Spine. - : Wolters Kluwer. - 0362-2436 .- 1528-1159. ; 47:21, s. 1473-1482
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Tidskriftsartikel (refereegranskat)abstract
- Study design: Retrospective cohort study.Objective: The aim was to investigate whether findings on magnetic resonance imaging (MRI) can be proxies (MRIPs) for segmental instability in patients with degenerative lumbar spinal stenosis (LSS) and/or degenerative spondylolisthesis (LDS) L4/L5.Background: LDS has a heterogeneous nature. Some patients have a dynamic component of segmental instability associated with LDS. Studies have shown that MRI can show signs of instability.Methods: Patients with LSS or LDS at L4/L5 undergoing decompressive surgery +/- fusion from 2010 to 2017, with preoperative standing lateral spine radiographs and supine lumbar MRI and enrolled in Danish national spine surgical database, DaneSpine. Instability defined as slip of >3 mm on radiographs. Patients divided into two groups based upon presence of instability. Outcome measures: radiograph: sagittal slip (mm). MRIPs for instability: sagittal slip >3 mm, facet joint angle (degrees), facet joint effusion (mm), disk height index (%), and presence of vacuum phenomena. Optimal thresholds for MRIPs was determined by receiver operating characteristic (ROC) curves and area under the curve (AUC). Logistic regression to investigate association between instability and MRIPs.Results: Two hundred thirty-two patients: 47 stable group and 185 unstable group. The two groups were comparable with regard to baseline patient-reported outcome measures. Thresholds for MRIPs: bilateral facet joint angle >= 46 degrees; bilateral facet effusion >= 1.5 mm and disk height index >= 13%. Logistic regression showed statistically significant association with MRIPs except vacuum phenomena, ROC curve AUC of 0.951. By absence of slip on MRI logistic regression showed statistically significant association between instability on radiograph and the remaining MRIPs, ROC curve AUC 0.757.Conclusion: Presence of MRIPs for instability showed statistically significant association with instability and excellent ability to predict instability on standing radiograph in LSS and LDS patients. Even in the absence of slip on MRI the MRIPs had a good ability to discriminate presence of instability.
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| 52. |
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| 53. |
- Elmqvist, Erik, et al.
(författare)
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No Benefit with Preservation of Midline Structures in Decompression for Lumbar Spinal Stenosis Results From the National Swedish Spine Registry 2-Year Post-Op
- 2022
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Ingår i: Spine. - : Ovid Technologies (Wolters Kluwer Health). - 0362-2436 .- 1528-1159. ; 47:7, s. 531-538
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Tidskriftsartikel (refereegranskat)abstract
- Study Design. Observational cohort study. Objective. The aim of this study was to investigate whether preservation of the midline structures is associated with a better clinical outcome compared to classic central decompression for lumbar spinal stenosis (LSS). Summary of Background Data. The classic surgical procedure for LSS is a central, facet joint sparing decompressive laminectomy (LE). Alternative approaches have been developed to preserve the midline structures. The effect of the alternative techniques compared to LE remains unclear. Methods. All patients >50 years of age who underwent decompression surgery for LSS without concomitant fusion in the National Swedish Spine Registry (Swespine) from December 31, 2015 until October 6, 2017 were included in this study based on surgeon-reported data and patient questionnaires before and 2 years postoperatively. Propensity score matching was used to compare decompression with preservation of midline structures with patients who underwent LE. The primary outcome was the Oswestry Disability Index (ODI) and secondary outcomes were the Numeric Rating Scale (NRS) for leg and back pain, EuroQol-5 Dimensions (EQ-5D), Global Assessment (GA), patient satisfaction and rate of subsequent surgery. Results. Some 3339 patients completed a 2-year follow-up. Of these, 2974 (89%) had decompression with LE and 365 underwent midline preserving surgery. Baseline scores were comparable between the groups. Mean ODI improvement at follow-up was 16.6 (SD = 20.0) in the LE group and 16.9 (SD = 20.2) in the midline preserving surgery group. In the propensity score-matched analysis the difference in improved ODI was 0.53 (95% confidence interval, CI -1.71 to 2.76; P = 0.64). The proportion of patients who showed a decreased ODI score of at least our defined minimal clinically important difference (=8) was 68.3% after LE and 67.0% after preserving the midline structures (P = 0.73). No significant differences were found in the improvement of NRS for leg and back pain, EQ-5D, GA or patient satisfaction. The rate of subsequent surgery was 5.5% after LE and 4.9% after midline preserving surgery without a significant difference in the propensity score-matched analysis (hazard ratio, HR 0.87; 95% CI 0.49-1.54; P = 0.64). Conclusion. In this study on decompression techniques for LSS, there was no benefit in preserving the midline structures compared to LE 2 years after decompression. The conclusion is that the surgeon is free to choose the surgical method that is thought most suitable for the patient and the condition with which the patient presents.
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| 54. |
- Engquist, Markus, et al.
(författare)
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Factors Affecting the Outcome of Surgical Versus Nonsurgical Treatment of Cervical Radiculopathy
- 2015
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Ingår i: Spine. - : LIPPINCOTT WILLIAMS & WILKINS. - 0362-2436 .- 1528-1159. ; 40:20, s. 1553-1563
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Tidskriftsartikel (refereegranskat)abstract
- Study Design. Prospective randomized controlled trial. Objective. To analyze factors that may influence the outcome of anterior cervical decompression and fusion (ACDF) followed by physiotherapy versus physiotherapy alone for treatment of patients with cervical radiculopathy. Summary of Background Data. An understanding of patient-related factors affecting the outcome of ACDF is important for preoperative patient selection. No previous prospective, randomized study of treatment effect modifiers relating to outcome of ACDF compared with physiotherapy has been carried out. Methods. 60 patients with cervical radiculopathy were randomized to ACDF followed by physiotherapy or physiotherapy alone. Data for possible modifiers of treatment outcome at 1 year, such as sex, age, duration of pain, pain intensity, disability (Neck Disability Index, NDI), patient expectations of treatment, anxiety due to neck/arm pain, distress (Distress and Risk Assessment Method), self-efficacy (Self-Efficacy Scale) health status (EQ-5D), and magnetic resonance imaging findings were collected. A multivariate analysis was performed to find treatment effect modifiers affecting the outcome regarding arm/neck pain intensity and NDI. Results. Factors that significantly altered the treatment effect between treatment groups in favor of surgery were: duration of neck pain less than 12 months (P = 0.007), duration of arm pain less than 12 months (P = 0.01) and female sex (P = 0.007) (outcome: arm pain), low EQ-5D index (outcome: neck pain, P = 0.02), high levels of anxiety due to neck/arm pain (outcome: neck pain, P = 0.02 and NDI, P = 0.02), low Self-Efficacy Scale score (P = 0.05), and high Distress and Risk Assessment Method score (P = 0.04) (outcome: NDI). No factors were found to be associated with better outcome with physiotherapy alone. Conclusion. In this prospective, randomized study of patients with cervical radiculopathy, short duration of pain, female sex, low health quality, high levels of anxiety due to neck/arm pain, low self-efficacy, and a high level of distress before treatment were associated with better outcome from surgery. No factors were found to be associated with better outcome from physiotherapy alone.
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| 55. |
- Engquist, M., et al.
(författare)
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Surgery versus nonsurgical treatment of cervical radiculopathy : A prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up
- 2013
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Ingår i: Spine. - : Lippincott Williams & Wilkins. - 0362-2436 .- 1528-1159. ; 38:20, s. 1715-1722
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Tidskriftsartikel (refereegranskat)abstract
- STUDY DESIGN.: Prospective randomized controlled trial. OBJECTIVE.: To study the outcome of anterior cervical decompression and fusion combined with a structured physiotherapy program compared with the same physiotherapy program alone for patients with cervical radiculopathy. SUMMARY OF BACKGROUND DATA.: Knowledge concerning the effects of interventions for patients with cervical radiculopathy is scarce due to a lack of randomized studies. METHODS.: Sixty-three patients were randomized to surgery with postoperative physiotherapy (n = 31) or physiotherapy alone (n = 32). The surgical group was treated with anterior cervical decompression and fusion. The physiotherapy program included general/specific exercises and pain-coping strategies. The outcome measures were disability (Neck Disability Index), neck and arm pain intensity (visual analogue scale), and the patient's global assessment. Patients were followed for 24 months. RESULTS.: The result from the repeated-measures analysis of variance showed no significant between-group difference for Neck Disability Index (P = 0.23). For neck pain intensity, the repeated-measures analysis of variance showed a significant between-group difference during the study period in favor of the surgical group (P = 0.039). For arm pain intensity, no significant between-group differences were found according to the repeated-measures analysis of variance (P = 0.580). Eighty-seven percent of the patients in the surgical group rated their symptoms as "better/much better" at the 12-month follow-up compared with 62% in the nonsurgical group (P < 0.05). At 24 months, the corresponding figures were 81% and 69% (P = 0.28). The difference was significant only at the 12-month follow-up in favor of the surgical group. Significant reduction in Neck Disability Index, neck pain, and arm pain compared with baseline was seen in both groups (P < 0.001). CONCLUSION.: In this prospective, randomized study of patients with cervical radiculopathy, it was shown that surgery with physiotherapy resulted in a more rapid improvement during the first postoperative year, with significantly greater improvement in neck pain and the patient's global assessment than physiotherapy alone, but the differences between the groups decreased after 2 years. Structured physiotherapy should be tried before surgery is chosen. Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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| 56. |
- Enthoven, Paul, 1955-, et al.
(författare)
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Clinical course in patients seeking primary care for back or neck pain : a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis
- 2004
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Ingår i: Spine. - : Ovid Technologies (Wolters Kluwer Health). - 0362-2436 .- 1528-1159. ; 29:21, s. 2458-2465
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Tidskriftsartikel (refereegranskat)abstract
- Study Design. Prospective follow-up.Objective. To describe the 5-year clinical course in a cohort of patients treated for back or neck pain in primary care and compare results with the 1-year outcome both for the whole group and for subgroups.Summary of Background Data. A randomized study showed a decrease in perceived pain and disability after treatment by chiropractic or physiotherapy, but many reported recurrence or continual pain at the 1-year follow-up. Knowledge of the clinical course over longer follow-up periods is limited.Methods. A 5-year follow-up questionnaire was sent to 314 individuals. Main outcome measures were pain intensity, Oswestry score, and general health. Recurrence, health care consumption, and other measures were described.Results. Fifty-two percent of respondents reported pain (visual analog scale, >10 mm) and back-related disability (Oswestry, >10%) at the 5-year follow-up. This was similar to 1-year results, and 84% of these were the same individuals. Sixty-three percent reported recurrence or continual pain, and 32% reported health care consumption at the 5-year follow-up.Conclusions. In a cohort of individuals of working age seeking primary care for nonspecific back or neck pain, it can be expected that about half of the population will report pain and disability at the 5-year follow-up. A significant proportion will report recurrence or continual pain and health care consumption. Pain and disability were associated with recurrence or continual pain and health care consumption. Further analysis is needed to identify additional predictors for 5-year outcome, taking into account 1-year follow-up results. Since many patients will have recurrence or continual pain, health policies and clinical decision models for long-term outcome must allow for these aspects.
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| 57. |
- Finskas, Oscar, et al.
(författare)
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New, clinically more relevant model for nerve root injury in the rat
- 2013
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Ingår i: Spine. - 0362-2436 .- 1528-1159. ; 38:20, s. 1744-8
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Tidskriftsartikel (refereegranskat)abstract
- STUDY DESIGN: Exposure to nucleus pulposus and displacement of intraspinal nervous structures with assessment of spontaneous behavioral changes in rats. OBJECTIVE: To develop a controlled, experimental model for nerve root injury. SUMMARY OF BACKGROUND DATA: There are a number of experimental models presented for studies on radiculopathies. One frequently used model is based on exposure to nucleus pulposus and displacement of the dorsal root ganglion (DRG). However, it is clinically more common that the nerve roots are displaced/compressed than the DRG. In this study, we developed a model for displacement of the nerve root by modifying the DRG model. METHODS: After removing the left L3-L4 facet joint, the underlying disc was punctured, and the L4 nerve root was displaced laterally by an injection needle (n = 10). In sham experiments, the same procedure was performed without disc puncture and displacement (n = 10). In 10 rats, the left L4-L5 facet joint was removed. The underlying disc was punctured and the L4 DRG was displaced medially by an injection needle. Assessment of spontaneous behavioral changes was performed on days 1, 3, 7, 14, and 21, postsurgery. RESULTS: There was a clear increase in duration of the behavior "unloading of the paw" after displacement of the DRG that was most pronounced on day 1 and then gradually declined. There was a similar pattern for this behavior induced by nerve root displacement, although the duration was higher than that for the DRG displacement. No apparent trends in behavioral changes were observed for the other behaviors studied. CONCLUSION: Displacement of the nerve root induced more changes in the pain behavior than displacement of the DRG, but only for the behavior unloading of the paw. Because nerve root injury is more common than DRG injury, this model may be more clinically relevant than the DRG model. LEVEL OF EVIDENCE: N/A.
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| 58. |
- Fritzell, Peter, 1948, et al.
(författare)
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2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.
- 2001
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Ingår i: Spine. - 0362-2436. ; 26:23
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Tidskriftsartikel (refereegranskat)abstract
- A randomized controlled multicenter study with a 2-year follow-up by an independent observer.To determine whether fusion of the lower lumbar spine could reduce pain and diminish disability more effectively when compared with nonsurgical treatment in patients with severe chronic low back pain (CLBP).The reported results after fusion surgery on patients with CLBP vary considerably, and the evidence of treatment efficacy is weak in the absence of randomized controlled studies.A total of 294 patients referred to 19 spinal centers from 1992 through 1998 were randomized blindly into four treatment groups. Patients aged 25-65 years with CLBP for at least 2 years and with radiologic evidence of disc degeneration at L4-L5, L5-S1, or both were eligible to participate in the study. The surgical group (n=222) included three different fusion techniques, not analyzed separately in this study. Patients in the nonsurgical group (n=72) were treated with different kinds of physical therapy. The surgical group comprised 49.5% men, and the mean age was 43 years. The corresponding figures for the nonsurgical group were 48.6% and 44 years. The patients had suffered from low back pain for a mean of 7.8 and 8.5 years and been on sick leave due to back pain for a mean of 3.2 and 2.9 years, respectively. The Visual Analogue Scale (VAS) was used to measure pain. The Oswestry Low Back Pain Questionnaire, the Million Score and the General Function Score (GFS) were used to measure disability. The Zung Depression Scale was used to measure depressive symptoms. The overall result was assessed by the patient and by an independent observer. Records from the Swedish Social Insurance were used to evaluate work disability. Patients who changed groups were included in the analyses of significance according to the intention-to-treat principle.At the 2-year follow-up 289 of 294 (98%) patients, including 25 who had changed groups, were examined. Back pain was reduced in the surgical group by 33% (64 to 43), compared with 7% (63 to 58) in the nonsurgical group (P=0.0002). Pain improved most during the first 6 months and then gradually deteriorated. Disability according to Oswestry was reduced by 25% (47 to 36) compared with 6% (48 to 46) among nonsurgical patients (P=0.015), according to Million by 28% (64 to 46) compared with 8% (66 to 60) (P=0.004), and accordingtoGFS by 31% (49 to 34) compared with 4% (48 to 46) (P=0.005). The depressive symptoms, according to Zung, were reduced by 20% (39 to 31) in the surgical group compared with 7% (39 to 36) in the nonsurgical group (P=0.123). In the surgical group 63% (122/195) rated themselves as "much better" or "better" compared with 29% (18/62) in the nonsurgical group (P<0.0001). The "net back to work rate" was significantly in favor of surgical treatment, or 36% vs. 13% (P=0.002). The early complication rate in the surgical group was 17%.Lumbar fusion in a well-informed and selected group of patients with severe CLBP can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatment.
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| 59. |
- Fritzell, Peter, et al.
(författare)
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Cost-Effectiveness of Balloon Kyphoplasty Versus Standard Medical Treatment in Patients With Osteoporotic Vertebral Compression Fracture
- 2011
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Ingår i: Spine. - 0362-2436. ; 36:26, s. 2243-2251
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Tidskriftsartikel (refereegranskat)abstract
- Study Design. A multicenter, randomized, controlled, cost-effectiveness analysis. Objective. To assess the cost-effectiveness of balloon kyphoplasty (BKP) compared with standard medical treatment (control) in patients with acute/subacute (<3 months) vertebral compression fracture (VCF) due to osteoporosis. Summary of Background Data. Patients with a VCF due to osteoporosis are common and will increase in number in an aging population, putting a substantial strain on health care. Selected patients may benefit from stabilizing the fracture with cement through BKP, a minimally invasive procedure. BKP has been reported to give good short-time clinical results, and economic modeling has suggested that the procedure could be cost-effective after 2 years compared with standard treatment. Methods. Hospitalized patients with back pain due to VCF were randomized to BKP or to control using a computer-generated random list. All costs associated with VCF and cost-effectiveness were reported primarily from the perspective of society. We used EQ-5D to assess quality of life (QoL). The accumulated quality-adjusted life years (QALYs) gained and costs/QALY gained were assessed using intention to treat. Results. Between February 2003 and December 2005, a total of 63 out of 67 Swedish patients were analyzed: BKP (n = 32) and control (n = 31). Societal cost per patient for BKP was SEK 160,017 (SD = 151,083) = (sic)16,668 (SD = 15,735), and for control SEK 84,816 (SD = - 40,954) = (sic) 8835 (SD = 4266), a significant difference of 75,198 (95% confidence intervals [CI] = 16,037-120,104) = (sic)7833 (95% CI = 1671-12,511). The accumulated difference in QALYs was 0.085 (95% CI = -0.132 to 0.306) in favor of BKP. Cost/QALY gained using BKP was SEK 884,682 = (sic)92,154 and US (sic)134,043. Conclusion. In this randomized controlled trial, it was not possible to demonstrate that BKP was cost-effective compared with standard medical treatment in patients treated for an acute/subacute vertebral fracture due to osteoporosis. However, sensitivity analysis indicated a certain degree of uncertainty, which needs to be considered.
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| 60. |
- Fritzell, Peter, et al.
(författare)
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Cost-effectiveness of lumbar fusion and nonsurgical treatment for chronic low back pain in the Swedish lumbar spine study : A multicenter, randomized, controlled trial from the Swedish Lumbar Spine Study Group
- 2004
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Ingår i: Spine. - : Lippincott Williams & Wilkins. - 0362-2436 .- 1528-1159. ; 29:4, s. 421-434
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Tidskriftsartikel (refereegranskat)abstract
- Study Design. A cost-effectiveness study was performed from the societal and health care perspectives. Objective. To evaluate the costs-effectiveness of lumbar fusion for chronic low back pain (CLBP) during a 2-year follow-up. Summary of Background Data. A full economic evaluation comparing costs related to treatment effects in patients with CLBP is lacking. Patients and Methods. A total of 284 of 294 patients with CLBP for at least 2 years were randomized to either lumbar fusion or a nonsurgical control group. Costs for the health care sector ( direct costs), and costs associated with production losses ( indirect costs) were calculated. Societal total costs were identified as the sum of direct and indirect costs. Treatment effects were measured using patient global assessment of improvement, back pain ( VAS), functional disability (Owestry), and return to work. Results. The societal total cost per patient ( standard deviations) in the surgical group was significantly higher than in the nonsurgical group: Swedish kroner (SEK) 704,000 ( 254,000) vs. SEK 636,000 ( 208,000). The cost per patient for the health care sector was significantly higher for the surgical group, SEK 123,000 ( 60,100) vs. 65,200 ( 38,400) for the control group. All treatment effects were significantly better after surgery. The incremental cost-effectiveness ratio ( ICER), illustrating the extra cost per extra effect unit gained by using fusion instead of nonsurgical treatment, were for improvement: SEK 2,600 ( 600 - 5,900), for back pain: SEK 5,200 ( 1,100 - 11,500), for Oswestry: SEK 11,300 ( 1,200 - 48,000), and for return to work: SEK 4,100 ( 100 21,400). Conclusion. For both the society and the health care sectors, the 2-year costs for lumbar fusion was significantly higher compared with nonsurgical treatment but all treatment effects were significantly in favor of surgery. The probability of lumbar fusion being cost-effective increased with the value put on extra effect units gained by using surgery.
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