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| 2. |
- Gregebo, Birgitta, et al.
(författare)
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Private and Non-Private Disc Herniation Patients : Do they Differ?
- 2014
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Ingår i: The Open Orthopaedics Journal. - : Bentham Open. - 1874-3250. ; 8, s. 237-241
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Tidskriftsartikel (refereegranskat)abstract
- Objectives :In the 2006 yearly report from the Swedish National Register for Lumbar Spine Surgery it was claimed that international studies show obvious differences between private and non-private patients with regard to results from back surgery. Therefore our aim was to reveal such possible differences by comparing the two categories of patients at a private clinic.Material and Methods :The material comprises 1184 patients operated on for lumbar disc herniation during the period of 1987 to 2007. Basic pre-operative data were obtained from the medical records and follow-up was performed by a questionnaire around 5 years post-operatively.Results :Small but statistically significant differences between private and non-private patients were seen pre-operatively regarding the proportions of a/ men and women in the samples, b/ those with physically demanding jobs, c/ those on sick leave and d/ those with lumbar pain. Over the years the admitted private patients had a decreasing mean duration of symptoms which was not seen in the non-private patients. No apparent differences (n.s.) were seen between the two categories of patients pre-operatively regarding age, presence and level of leg pain or the proportion who smoked. Post-operative improvement in leg and lumbar pain was very similar in private and non-private patients as was satisfaction with the results and the proportion of patients returning to work.Conclusion :Despite small pre-operative differences concerning some variables and a significant difference in symptom duration between private and non-private disc herniation patients, the final clinical results were very similar.
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| 3. |
- Nystrom, Bo, et al.
(författare)
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Deep Spatial Discrimination in the Lumbar Spine
- 2016
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Ingår i: Journal of Neurology and Neuroscience. - : Scitechnol Biosoft Pvt. Ltd.. - 2171-6625. ; 7:6
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Tidskriftsartikel (refereegranskat)abstract
- Background: In patients with chronic low back pain (CLBP)who undergo fusion surgery, selecting the level to fusehas been based on radiological findings, the pain reactionat discography, disc-block and temporal external fixation,tests all found to be unreliable. An alternative would be torely on spatialdiscrimination. Our objective was thereforeto test if healthy volunteers are able to discriminatebetween lumbar vertebrae bordering one another(adjacent) and those that are one or two vertebrae apart(separated).Methods and findings: Eighteen volunteers participatedin the study. Short injection needles were introduced intothe top of the spinous processes of the L3, L4, L5 and S1vertebrae. One vertebra was tapped in the pair beingtested and immediately thereafter the other vertebra wastapped. The subject then had to decide whether the twotapped vertebrae were adjacent to one another orseparated. Outcome was measured as the number ofcorrectly specified pairs, out of the 12 alternatives,obtained for each test subject.Results: For all 18 volunteers there were altogether 87correct classifications among the adjacent pairs ofvertebrae giving a mean of 0.805, 99% CI (0.69; 0.89)bootstrap. This was regarded as the sensitivity. In thesame manner the number of 96 correctly classifiedseparate pairs gives a specificity of 0.89, 99% CI (0.70;0.95) bootstrap.Conclusion: We found our test useful in discriminatingdeep structures of the spine lying only 2-3 cm apart. Itmight therefore be useful when searching for a possiblypainful segment in patients with CLBP.
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| 4. |
- Nyström, B., et al.
(författare)
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A small group Whiplash-Associated-Disorders (WAD) patients with central neck pain and movement induced stabbing pain, the painful segment determined by mechanical provocation : Fusion surgery was superior to multimodal rehabilitation in a randomized trial
- 2016
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Ingår i: Scandinavian Journal of Pain. - : Elsevier. - 1877-8860 .- 1877-8879. ; 12, s. 33-42
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundThe majority of patients suffering from a whiplash injury will recover, but some will have symptoms (Whiplash Associated Disorders, WAD) for years despite conservative treatment. Some of these patients perceive neck pain that might come from a motion segment, possibly the disc. In comprehensive reviews no evidence has been found that fusion operations have a positive treatment effect on neck pain in WAD patients.PurposeOur aim was to evaluate the possibility of (a) selecting a subgroup of chronic WAD patients based on specified symptoms possibly indicating segmental pain, and (b) treating said segmental pain through fusion operation based on non-radiological segment localization. The hypothesis was that fusion operation in this selected subgroup of chronic WAD patients could alleviate perceived neck pain.MethodsEligible patients for the study had a traffic accident as the origin for their neck pain, and no previous neck symptoms. Neck pain should be the predominant symptom and the pain origin reported to be in the midline, being dull, aching in character and at sudden movements combined by a stabbing pain in the same area. Forty-nine patients with these specified symptoms were identified among a large number of chronic WAD patients. Those selected had pronounced symptoms for a median of around 50 months and had previously been investigated and fully treated within the ordinary healthcare system without success.No neurological abnormalities were to be found at clinical examination and no specific changes to be seen on X-ray and MRI. The patients were randomized to either cervical fusion operation or multimodal rehabilitation. By using a mechanical provocation test the level/s to be fused were identified. In all but one patient the surgery was performed anteriorly using microsurgical technique and a right-sided Smith-Pedersen approach and plate fixation. The multimodal rehabilitation at the Clinic of Medical Rehabilitation, Karolinska Hospital, Stockholm, included outpatient treatment for four days a week for six weeks and included treatment by physician, physiotherapists, occupational therapist, psychologists, social-service worker and nurses. Perceived change in neck pain was assessed using the Balanced Inventory for Spinal Disorders questionnaire at the 2-year-follow-up.ResultsMean age of the patients was 38 and 40 years (surgery and rehabilitation groups, respectively), the most common type of accident being rear-end collision. At clinical examination muscle tenderness was not an outstanding sign. In most patients the mid-cervical region appeared to be the painful area but one patient localized the pain to C1. At follow-up 67% of the patients in the surgery group and 23% in the rehabilitation group assessed improvements in the ITT analysis. Corresponding proportions in the per protocol analysis were 83% and 12%, respectively.ConclusionsThe results support the supposition that among patients with central neck pain for long periods of time following a whiplash injury there are some in whom the neck pain emanates from a motion segment, probably the disc, a situation suitable for fusion surgery.ImplicationsThorough individual symptom evaluation in patients with chronic WAD may identify patients who will benefit from cervical fusion surgery.
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| 5. |
- Nyström, Bo, et al.
(författare)
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Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
- 2017
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Ingår i: Scandinavian Journal of Pain. - : Walter de Gruyter GmbH. - 1877-8860 .- 1877-8879. ; 17, s. 22-29
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND:It has been reported that in 13-32% of patients with chronic low back pain, the pain may originate in the sacroiliac (SI) joints. When treatment of these patients with analgesics and physiotherapy has failed, a surgical solution may be discussed. Results of such surgery are often based on small series, retrospective analyses or studies using a minimal invasive technique, frequently sponsored by manufacturers.PURPOSE:To report the clinical outcome concerning pain, function and quality of life following anterior arthrodesis in patients presumed to have SI joint pain using validated questionnaires pre- and post-operatively. An additional aim was to describe the symptoms of the patients included and the preoperative investigations performed.MATERIAL AND METHODS:Over a 6 year period we treated 55 patients, all women, with a mean age of 45 years (range 28-65) and a mean pelvic pain duration of 9.1 years (range 2-30). The pain started in connection with minor trauma in seven patients, pregnancy in 20 and unspecified in 28. All patients had undergone long periods of treatment including physiotherapy, manipulation, needling, pelvic belt, massage and chiropractic without success, and 15 had been operated for various spinal diagnoses without improvement. The patients underwent thorough neurological investigation, plain X-ray and MRI of the spine and plain X-ray of the pelvis. They were investigated by seven clinical tests aimed at indicating pain from the SI joints. In addition, all patients underwent a percutaneous mechanical provocation test and extra-articular local anaesthetic blocks against the posterior part of the SI joints. Before surgery all patients answered the generic Short-Form-36 (SF-36) questionnaire, the disease specific Balanced Inventory for Spinal Disorders (BIS) questionnaire and rated their level of pelvic and leg pain (VAS, 0-100). At follow-up at a mean of 2 years 49 patients completed the same questionnaires (89%).RESULTS:At follow-up 26 patients reported a lower level of pelvic pain than before surgery, 16 the same level and six a higher level. Applying Svensson's method RPpelvic pain=0.3976, with 95% CI (0.2211, 0.5740) revealed a statistically significant systematic improvement in pelvic pain. At follow-up 28 patients reported a higher quality of life and 26 reported sleeping better than pre-operatively. In most patients the character of the pelvic pain was dull and aching, often accompanied by a stabbing component in connection with sudden movements. Referred pain down the leg/s even to the feet and toes was noted by half of the patients and 29 experienced frequency of micturition.CONCLUSIONS:It is apparent that in some patients the SI joints may cause long-term pain that can be treated by arthrodesis. We speculate that continued pain despite a healed arthrodesis may be due to persistent pain from adjacent ligaments. The next step should be a prospective randomized study comparing posterior fusion and ligament resection with non-surgical treatment.IMPLICATIONS:Anterior arthrodesis can apparently relieve pain in some patients with presumed SI joint pain. The problem is how to identify these patients within the low back pain group.
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| 6. |
- Nyström, Bo, et al.
(författare)
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Symptoms and signs possibly indicating segmental, discogenic pain : A fusion study with 18 years of follow-up
- 2017
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Ingår i: Scandinavian Journal of Pain. - : Walter de Gruyter. - 1877-8860 .- 1877-8879. ; 16, s. 213-220
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND:Only two out of the five existing randomized studies have reported better results from fusion surgery for chronic low back pain (CLBP) compared to conservative treatment. In these studies the back symptoms of the patients were described simply as "chronic low back pain". One possible reason for the modest results of surgery is the lack of a description of specified symptoms that might be related to a painful segment/disc, and patient selection may therefore be more or less a matter of chance. Previous prospective studies including facet joint injections and discography and eventually MRI have failed to identify patients with a painful segment/disc that will benefit from fusion surgery.PURPOSE:Our purpose was to analyse in detail the pre-operative symptoms and signs presented by patients who showed substantial relief from their back pain following spinal fusion surgery with the aim of possibly finding a pain pattern indicating segmental, discogenic pain.METHODS:We analysed 40 consecutive patients, mean age 41 years, with a history of disabling low back pain for a mean of 7.7 years. Before surgery the patients completed a detailed questionnaire concerning various aspects of their back pain, and findings at clinical examination were thoroughly noted. Monosegmental posterior lumbar interbody fusion without internal fixation was performed using microsurgical technique. Outcome was assessed at 1, 2 and 4 years after surgery and finally at 18 years, using self-reporting measures and assessment by an independent examiner. Assessment at 18 years applied the Balanced Inventory for Spinal Disorders Questionnaire and the Roland-Morris Disability Questionnaire.RESULTS:According to the independent observer's assessment at two years 27 of the 40 patients were much improved. Analysis of the pre-operative depiction of the back symptoms of this group revealed a rather uniform pattern, the most important being: dominating back pain originating in the midline of the spine, with a dull, aching character and stabbing pain in the same area provoked by sudden movements. Most patients in this group also had diffuse pain radiation of various extension down one or both legs and often bladder dysfunction with frequency. At clinical examination, localized interspinal tenderness was observed within the spinal area in question and the patient's back pain was provoked by pressure in that area and by tapping a neighbouring spinous process. At 18 years after surgery 19 patients assessed themselves as much improved. At that time 5 of them had pension due to age, 7 early pension, one worked full time and six patients part time. Eleven patients were re-operated due to defect bony healing.CONCLUSIONS:The results may suggest that the use of a detailed symptom analysis and clinical examination may make it possible to select a subgroup of patients within the CLBP group likely to have better outcome following fusion surgery.IMPLICATIONS:The next step would be to execute prospective studies and if our findings concerning back pain details and signs among CLPB patients can be confirmed this can provide for more accurate selection of patients suitable for fusion surgery.
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| 7. |
- Svensson, Elisabeth, et al.
(författare)
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Superior outcomes following cervical fusion vs. multimodal rehabilitation in a subgroup of randomized Whiplash-Associated-Disorders (WAD) patients indicating somatic pain origin. Comparison of outcome assessments made by four examiners from different disciplines.
- 2018
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Ingår i: Scandinavian Journal of Pain. - : Walter de Gruyter GmbH. - 1877-8860 .- 1877-8879. ; 18:2, s. 175-186
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Tidskriftsartikel (refereegranskat)abstract
- Background and aims: Whiplash-Associated Disorders (WAD) are characterized by great variability in long-term symptoms. Patients with central neck and movement-induced stabbing pain participated in a randomized study comparing cervical fusion and multimodal rehabilitation. As reported in our previous paper, more patients treated by cervical fusion than by rehabilitation experienced pain relief. Although patient reported outcome measures are a core component of outcome evaluation, independent examiner has been recommended. Because of the heterogeneity of WAD complaints the patients in our study were examined at baseline and follow-up by four experts representing neurology, orthopedics, psychology and physical medicine. The aim was to compare the professional assessments of change both regarding the possible impact of the different examiners’ perspectives on individual patient’s outcome, and also on the analysis of possible outcome differences between the treatment groups.Methods: WAD patients with long-term neck pain as the predominant symptom after a traffic accident were eligible. The neck pain origin should be in the midline and perceived as dull and aching, with sudden movement inducing midline stabbing pain. Of the 1,052 patients in contact with our team, 49 were eligible. The overall treatment effect was evaluated on a global outcome transitional scale. The criteria for the scale categories were defined by each expert’s professional perspective on change in the whiplash complaints. Statistical methods that take account of the non-metric properties of ordered categorical data were used. Observed inter-expert disagreement was evaluated by the Svensson method that identifies and measures systematic group-related disagreement separately from disagreement caused by individual variation. Possible differences in the distributions of assessments on the expert-specific outcome scales between the treatment groups were analyzed by the Kruskal-Wallis test.Results: The per-protocol evaluation showed that a majority of the 18 patients who underwent fusion surgery were assessed as somewhat or much better, ranging from 67% to 78% depending on the expert. Corresponding proportions of improvement in the 17 patients treated by multimodal rehabilitation ranged from 29% to 53%. The statistical analyses confirmed better outcomes in the patients treated by fusion surgery, with p-values ranging from 0.003 to 0.04. The experts’ assessments of intra-patient change disagreed more or less for all patients. The analyses of the paired comparisons confirmed that these disagreements could most probably be explained by the different profession-specific operational definitions of the outcome scales rather than by individual variations in data.Conclusions: The multi-dimensional complexity of WAD-related complaints was comprehensively demonstrated by the inter-disciplinary disagreements in assessing intra-patient outcomes. The superiority of positive treatment effects in patients who underwent cervical fusion compared with multimodal rehabilitation was evident to all experts.Implications: The results strengthen our previous opinion that neck pain in this subgroup of WAD patients has a somatic origin. More than one examiner is recommended for multi-dimensional outcome assessments.
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