Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation.

Radiographic instability seemingly enjoys the status of a well-defined clinical syndrome. The concept is widely used, and specific treatments, usually spinal fusion, are routinely performed based on the diagnosis. The minimum standards necessary to establish radiographic instability as a legitimate clinical syndrome have not been established, however. The primary purpose of this study was to determine if treatment involving bracing, exercise, and education controlling either flexion or extension postures, would result in a distinctive pattern of favorable or unfavorable results, depending on the type of radiographic instability (retrodisplacement or spondylolisthesis). Fifty-six patients meeting strict study inclusion and radiographic evaluation criteria were assigned signed to a bracing treatment (flexion, extension, placebo-control) according to a randomization scheme, designed to ensure equal representation of translation categories (retro, normal, spondy) across treatment groups, and assessed at admission and 1-month follow-up. The sample was relatively evenly divided between men (46%) and women (54%), and by age. Translation classification was related to both gender and age, with men more likely classified as retro and women more likely spondy and patients in their 20s having lower incidence of spondy and higher incidence of normal translation. Translation classification was not related to selected indices of low-back pain history. Brace treatments were not shown to reduce patient range of motion or lessen trunk strength. A significant treatment by time interaction for the modified pain interference (VAS) scale indicated improvement for patients in extension compared with patients in flexion and control-placebo treatments. In conjunction with no significant three-way interaction between treatment, translation classification, and time, it was hypothesized that radiographic instability might more appropriately be considered a corroborative sign of advanced discogenic problems. Improvement in extension treatment, regardless of the type of radiographic abnormality, suggests that the treating clinician might consider extension treatment for chronic low-back pain patients. Causes and implications for the failure of this study to provide support for considering radiographic instability as a clinical syndrome are considered and future directions for this area of research suggested.

Predicting long-term disability in low back injured workers presenting to a spine consultant.

Low back pain (LBP) is the most common, costly, and disabling musculoskeletal condition. Although most LBP patients recover within two months, 2-3% eventually develop disabling chronic low back pain (DCLBP). Due to the prevalence of DCLBP problems, models have been developed to predict which acute low back pain patients are predisposed to the problems associated with this condition. Many see the development of these models as a first step that must be taken before useful approaches for containing and reducing the problem can be conceptualized, implemented, and tested. A recent publication by Cats-Baril and Frymoyer considered this specific problem. While the results of their study indicate considerable success in predicting DCLBP patients, the high prediction rates they obtained may be spurious because of the characteristics of their sampled patient population in conjunction with some of the predictors they found useful in identifying DCLBP patients. The purpose of the present study was to focus on the crucial patient population (i.e., acute LBP patients who perceive their problem as work-related and who have been unable to work for more than two but less than six weeks), and evaluate the ability of various personal, medical, occupational, and psychological factors to predict predisposition to DCLBP. Fifty-five patients referred by occupational physicians were evaluated and followed successfully for at least 6 months. Patients in the study were given a physical examination that included Spratt et al's assessment of pain behavior. They were then asked to fill out an extensive battery of self-report questionnaires, addressing issues associated with personal demographics, health history, work requirements, job satisfaction, injury information, and pain/function factors. At the 6-month follow-up, a structured telephone interview was used to obtain outcome information regarding patient status, including ability to return to work and general outcomes of treatment. Average patient age was 37.2 years (range, 22-57) and 67% of the patients were male. On average, patients had been unable to work for approximately 4 weeks when initially surveyed. Overall, 12.7% of the patients returned to work within 1 month of injury, 40% returned within 2 months, 54.5% within 3 months, 69% within 4 months, 74.5% within 5 months, 76.3% within 6 months, 80% within 7 months, and 83.6% after 7 months. Approximately 16% never successfully returned to work within the follow-up period of this study. DCLBP was found to be correlated only with marital status, as married patients returned to work more quickly than single patients (P < 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

1990 Volvo Award in clinical sciences. The consistency and accuracy of roentgenograms for measuring sagittal translation in the lumbar vertebral motion segment. An experimental model.

An experimental model of the L4-L5 lumbar motion segment was developed that allowed precise manipulation of sagittal translation, rotation of L5 relative to L4, tilt of L4 on L5, and control of roentgenogram quality (image clarity) by placing a water bath between the tube and the vertebral body. A series of experiments were designed to systematically assess the consistency and accuracy of sagittal translation measurements from roentgenograms of varying quality, using different measurement protocols and various rater combinations on models with varying degrees of concomitant motions (rotations and tilts). Study 1 assessed the effects of roentgenogram quality, raters, and seven measurement methods on the consistency and accuracy of evaluating translations in the sagittal plane. Results indicated very high reliabilities across roentgenogram quality, raters, and measurement. As expected, high-quality roentgenograms were more accurately evaluated than lower-quality roentgenograms. However, closer inspection of the consequences of errors in measured translations indicated surprisingly high false-positive and false-negative rates, with significant differences observed between measurement methods. Study 2 assessed the effects of concomitant motions and measurement methods on the consistency and accuracy of evaluations. Within-rater consistency and accuracy indices were remarkably high and similar across measurement methods and degrees of concomitant motions. However, important differences in the false-positive and false-negative rates were again observed. Method 2, described by Morgan and King, demonstrated the overall best performance and the least interference due to concomitant motions. Study 3 assessed the effects of raters and measurement methods on the consistency of measuring translation in clinical roentgenograms, where concomitant motion factors may be present, but not explicitly considered. Results indicated substantially lower within- and between-rater consistency estimates relative to consistencies obtained from the model, although these magnitudes were similar to those reported by others evaluating clinical roentgenograms. The implications of lower consistency estimates relative to increased false-positive and false-negative rates must be more closely examined. These studies present evidence suggesting that high consistency and accuracy indices do not ensure acceptable false-positive and false-negative rates and, thus, provide empirical evidence supporting the view that using roentgenograms as a basis for diagnosing instability often can lead to errors in classification. This is less so when observed translations are relatively large (+/- 5+ mm) on roentgenograms that are relatively clear, with little obliquity, and when concomitant motions are minimal.(ABSTRACT TRUNCATED AT 400 WORDS)

Lumbar discography in normal subjects. A controlled, prospective study.

Major advances in the techniques of discography since 1968, in conjunction with major strides in the evaluation of pain in recent years, prompted a study in which Holt's work on the specificity of discography was replicated and extended. For the present study, seven patients who had low-back pain and ten volunteers who had been carefully screened, with a questionnaire and a physical examination, to ensure that they had no history of problems with the back, had an injection at three levels, and all sessions were videotaped. After each injection, the participant was interviewed about the pattern and intensity of the pain, and then the discs were imaged with computed tomography. Five raters, who were blind to the condition of the participant, graded each disc as normal or abnormal on the basis of findings on magnetic resonance images that had been made before the injection and computed tomography (discography) were done. There was only one disagreement between the ratings that were made on the basis of the magnetic resonance images and those that were made on the basis of the discograms. Each participant's pain-related response was evaluated independently by two raters who viewed the videotapes of the discography. Inter-rater reliability was 0.99, 0.93, and 0.88 for the evaluation of intensity of the pain, pain-related behavior, and similarity of the pain to pain that the subject had had before the injection. In the asymptomatic individuals, the discogram was interpreted as abnormal for 17 per cent (five) of the thirty discs and for five of the ten subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

A new approach to the low-back physical examination. Behavioral assessment of mechanical signs.

UNLABELLED: A rationale for a new approach to the low-back physical examination was developed. A set of 21 tests, 17 assessing organic and four assessing nonorganic signs, were organized into an examination according to specified criteria, and the reliability of the patient-reported and examiner-observed measures within the examination assessed. Primary outcome measures included patient reports of their pain location, aggravation and examiner-observed pain behaviors resulting from the maneuvers. Two pain behavior composites, conceptualized as outcome measures, were developed, one based on the 17 organic tests and one based on the four nonorganic tests. DESIGN: The reliability of the physical examination was assessed using a short-term test-retest paradigm. Three raters, two experienced orthopaedic surgeons and an RN with no previous experience in administering physical examinations were trained in the examination methods. Patients were assigned to one of three rater pairs and examined twice within a single day. During each examination both raters evaluated each patient; however, rater role as examiner or observer was reversed across examination. RESULTS: Forty-two patients were examined. Average times of 13.9 and 11.6 minutes were required to complete examinations 1 and 2, respectively. In addition, the time required to complete the examination decreased as the examiners became more familiar with the procedure, suggesting that an experienced examiner would usually be able to complete the examination in approximately 10 minutes. Within-examination reliabilities for the patient-reported measures (pain location and aggravation) were universally high, as expected, since these rating required the rater only to correctly hear and code patient responses.(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracolumbar "burst" fractures treated conservatively: a long-term follow-up.

This report addresses the long-term results of nonoperative treatment for fractures of the thoracolumbar spine. Forty-two patients meeting specified inclusion criteria were contacted and completed questionnaires. In all cases, nonoperative treatment was the only treatment received. The average time from injury to follow-up was 20.2 years (range, 11 to 55 years). The average age at follow-up was 43 years (range, 28 to 70 years). There were 31 men and 11 women in this series. Seventy-one percent of the injuries were the result of motor vehicle accidents. The most common sites of injury were T12-L2, which accounted for 64% of the injuries. Seventy-eight percent of the patients had no neurologic deficits at the time of injury. At follow-up, the average back pain score was 3.5, with 0 being no pain at all and 10 being very severe pain. No patient demonstrated a decrease in their neurologic status at follow-up, and no patient required narcotic medication for pain control. Eighty-eight percent of patients were able to work at their usual level of activity. Follow-up radiographs revealed an average kyphosis angle of 26.4 degrees in flexion and 16.8 degrees in extension. The degree of kyphosis did not correlate with pain or function at follow-up. Based on this review, nonoperative treatment of thoracolumbar burst fractures remains as a viable alternative in patients without neurologic deficit and can lead to acceptable long-term results.

Reduction of the gastrointestinal side effects of metrizamide myelography with oral dexamethasone.

A prospective, double-blind study was undertaken to assess the effectiveness of oral dexamethasone premedication in reducing a variety of side effects associated with metrizamide myelography. We also examined the relationship between side effects and needle size, total metrizamide dose, radiographic findings, and personality. Patients were randomly assigned to either a placebo group (44 patients) or a dexamethasone group (38 patients). All patients completed a 24-item symptom checklist before and 24 hr after lumbar myelography. In addition, all patients completed the Minnesota Multiphasic Personality Inventory prior to myelography. Analysis of variance demonstrated a statistically significant decrease in the frequency of gastrointestinal side effects (loss of appetite, nausea, vomiting) in the dexamethasone group. There were no significant differences between the two groups for the other 21 symptoms examined. We concluded that premedication with oral dexamethasone significantly reduces the gastrointestinal side effects associated with metrizamide myelography. This reduction was especially important in older patients.

Long-term follow-up of lower lumbar fusion patients.

To determine the long-term effects of lower lumbar fusion, 94 subjects were catalogued from medical records. They had a lumbar arthrodesis at the third lumbar level or below and their operations were performed before 1964. Twenty-four were not located and 8 were deceased. Sixty-two subjects (72% of available sample) completed a telephone interview; 52 subjects completed a comprehensive low back questionnaire; and 33 subjects returned for physical examination, flexion-extension lateral lumbar spine films, and a limited computerized axial tomographic (CAT) scan. In general, the subjects who returned for complete evaluation were representative of the larger sample. Forty of 62 patients were men. Ages ranged from 41 to 83 years; the median age was 66 years, 6 months. Follow-up ranged from 21 to 52 years; the median follow-up was 33 years. Forty-four percent (27/61) were currently experiencing low-back pain, 57% (35/61) had back pain in the last year. Fifty-three percent (33/62) were using medication. Fifteen percent (9/62) had undergone repeat lumbar surgery, however, only 5% (3/62) required surgery as a late sequela (more than 10 years postoperatively). Forty-two percent (14/33) had lumbar spinal stenosis, but only 15% (5/33) had dural tube measurements less than 100 mm2. Segmental instability above the fusion was present in 45% (15/33). There was a significant correlation between segmental instability and lumbar spinal stenosis (r = .57, P less than .01). Neither radiographic condition correlated with symptoms, however.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow-up of nonoperatively treated thoracolumbar spine fractures.

Little information is available regarding the long-term results of nonoperative treatment for fractures of the thoracolumbar spine. One thousand six hundred ninety-one fractures of the spine seen at the University of Iowa from 1935 to 1975 were reviewed; 83 fractures met strict inclusion criteria of fractures involving T10-L5. In all cases, nonoperative treatment was the only treatment received. 42 patients (51 per cent) were contacted and completed questionnaires. Twenty (48%) of these 42 patients also returned to University Hospital for a complete physical examination as well as anteroposterior and lateral flexion-extension radiographs. The average time from injury to follow-up was 20.2 years, (range 11-55 years). The average age at follow-up was 43 years (range 28-70). There were 31 men and 11 women. Seventy-one percent of the injuries were the result of motor vehicle accidents. The most common sites of injury were T12-L2, which accounted for 64% of the injuries; 78% of the patients had no neurologic deficits at the time of injury. At follow-up, the average back pain score was 3.5, (0 = no pain at all, and 10 = very severe pain). No patient demonstrated a decrease in neurologic status at follow-up, and no patient required narcotic medication for pain control. Eighty-eight percent of the patients were able to work at their usual level of activity. Follow-up radiographs revealed an average kyphosis angel of 26.4 degrees in flexion and 16.8 degrees in extension. The degree of kyphosis did not correlate with pain or function parameters in the 20 examined patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Chemonucleolysis versus open discectomy. A ten-year follow-up study.

Retrospectively 156 patients with an average follow-up period of 10.3 years were classified in two groups. Group I, 85 patients, chose chymopapain as their primary treatment. Group II, 71 patients, elected to have a laminectomy with discectomy. Overall, 98% of patients responded to follow-up investigations. Based on several well-accepted pain outcome measures there were no significant differences between the two groups at ten years. Recurrence rates, however, were greater following open discectomy at one- and ten-year follow-up examination. The question of when to return a patient to work yielded interesting results. Those patients returning to work before feeling completely recovered from symptoms had a poorer outcome at final follow-up examination.

The impact of patients with nonorganic physical findings on a controlled trial of transcutaneous electrical nerve stimulation and electroacupuncture.

Fifty-four patients treated in a three-week in-patient rehabilitation program were randomly assigned to and accepted treatment with electroacupuncture (n = 17), TENS (low-intensity transcutaneous nerve stimulation, n = 18) and TENS-dead battery (placebo, n = 18). Outcome measures included estimates of pain (on a visual analogue scale) and disability by both physician and patient as well as physical measures of spine function. Two groups were constructed based on the absence of nonorganic physical findings (Valid group, n = 30) and the presence of two or more nonorganic physical findings out of a possible four (Invalid group, n = 10). Multivariate and univariate analyses of covariance were utilized to determine effects of treatment (acupuncture, TENS, placebo) and the effects of over-reporting (presence of excessive nonorganic physical findings). Statistically significant findings demonstrated that the acupuncture group enjoyed more relief of peak pain and more relief of pain on an average day at the three-month return assessment. Additionally, the acupuncture group demonstrated greater improvement in extension trunk strength at the discharge assessment. The Invalid group were found to have a contaminating effect on the acupuncture results. Analysis also demonstrated associations between nonorganic physical findings and both personality traits ("Conversion V" profile on MMPI) and retention of an attorney. Researchers conducting clinical trials in chronic low-back pain patients should control for contamination by the presence of over-reporters.

Low-back impairment rating practices of orthopaedic surgeons.

Physicians' impairment ratings are an integral part of disability determinations. There are major difficulties in rating impairments manifested principally by pain (such as low-back pain), primarily owing to the relative absence of objective findings. Since there are no universally accepted criteria for rating low-back impairment, the authors have attempted to establish a notion of the impairment rating practices of orthopaedists through a survey. It is clear that many criteria apart from the physical examination are considered in rating low-back impairment, in spite of the fact that in most compensation or legal systems such ratings are supposed to consider only objective physical findings. Ratings are ordinarily not given until an average of 8.9 months after an injury and 9.7 months after surgery. Many orthopaedists probably give ratings in the absence of objective physical findings. Rating practices vary widely from physician to physician.

A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine.

Closed, indirect fractures and dislocations of the lower cervical spine occur in families or groups within which there is a spectrum of anatomic damage to a cervical motion segment. This study of 165 cases demonstrates the various spectra of injury, called phylogenies, and develops a classification based on the mechanism of injury. The common groups are compressive flexion, vertical compression, distractive flexion, compressive extension, distractive extension, and lateral flexion. The probability of an associated neurologic lesion relates directly to the type and severity of cervical spine injury. With use of the classification, it is possible to formulate a rational treatment plan for injuries to the cervical spine.

Repeat lumbar surgery. A review of patients with failure from previous lumbar surgery treated by spinal canal exploration and lumbar spinal fusion.

Thirty-six patients with chronic back and/or leg pain following previous lumbar surgery who underwent both spinal canal exploration and spinal fusion were subjected to retrospective review. The purpose was to determine the probability of success for this surgical approach. Twenty (56%) of the 36 patients had a satisfactory result. In 15 patients with multiple objective findings of an ongoing radiculopathy, 11 (73%) improved. Only nine (43%) of 21 patients improved if these preoperative criteria were absent. Analysis according to the type of surgery performed in the spinal canal demonstrated improvement in (a) 17 (74%) of 23 patients who had wide bony decompression, (b) eight (61%) of 12 patients who had discectomy, and (c) seven (47%) of 15 patients who had an extensive neurolysis. In 17 patients whose time interval between the previous operation and present reconstruction was greater than 18 months, 13 (76%) improved. Only seven (36%) of 19 patients with a shorter time interval improved. The presence of pseudarthrosis was a poor indication for repeat lumbar surgery. The number of previous lumbar surgeries may not necessarily preclude a satisfactory outcome. Solid fusion correlated highly with a satisfactory outcome. Best results are obtained when objective preoperative findings indicate the presence of a surgically correctable abnormality.

Pelvic displacement osteotomy in young myelodysplastic patients with dislocatable hips.

This prospective study of the role that pelvic displacement osteotomy may have in the management of dislocatable hips in patients with myelomeningocele defines the technical points to be considered and gives preliminary results for ten hips in eight children. The procedure may salvage failed posterior iliopsoas transfers or, in patients not operated on previously, it may limit cephalad displacement of the femoral head. Both control of muscle imbalance and improvement of acetabular contour appear essential to a high rate of success in these patients. Eight of ten hips in this series were stable upon short-term review. All patients were less than 7 years of age.