Comparing the Effect of Exercises With Different Gluteal-to-Tensor Fasciae Latae Activation Index in Patients With Chronic Low Back Pain.

CONTEXT: Hip muscle imbalance, especially between gluteal muscles and tensor fasciae latae (TFL), is one of the risk factors for developing low back pain which should be considered in rehabilitation programs. This study compared the effect of exercises with gluteal-to-TFL muscle activation index above and below 50 on pain intensity, disability, and lower limbs' range of motion (ROM) in patients with nonspecific chronic low back pain. DESIGN: A semiexperimental intervention study with a pretest and posttest. METHODS: A total of 45 patients with nonspecific chronic low back pain were randomly divided into 2 experimental groups of gluteal-to-TFL muscle activation index above 50 (n = 15), below 50 (n = 15), and a control group (n = 15). Pain intensity (visual analog scale), disability (Roland-Morris Disability Questionnaire), and lower limbs' ROM including hip extension, hip abduction, hip external rotation, and knee extension (goniometer) were assessed at pretest and after 8 weeks of intervention. RESULTS: Within-group comparison showed significant improvement of pain, disability, and ROMs in both experimental groups. No significant changes were observed in the control group. In between-group analysis, significant differences were observed in group of gluteal-to-TFL muscle activation index above 50 for only pain (P = .03) and disability (P = .01). For ROMs, although clinical improvement of lower limbs' ROMs was higher in group of gluteal-to-TFL muscle activation index above 50, no statistically significant differences were found between 2 experimental groups. Both experimental groups were superior to the control group for all outcomes. CONCLUSIONS: Findings indicate the statistically and clinically superior effectiveness of exercises with a gluteal-to-TFL muscle activation index above 50 in the reduction of pain and disability. Based on the clinical significance of exercises with a gluteal-to-TFL muscle activation index above 50 for improving ROMs, utilizing specific exercises that more activated gluteal muscle compared to TFL is recommended for patient with restricted lower limbs' ROMs.

The Responsiveness of Three Persian Outcome Measures Following Physiotherapy Intervention in Patients with Chronic Non-Specific Neck Pain.

Objectives: A prospective cohort study to evaluate and compare the responsiveness of the Persian version of the neck disability index (NDI), neck pain & disability scale (NPDS), neck outcome score (NOOS), and to determine the minimal clinically important difference (MCID) and minimal detectable change (MDC). To date, no studies have made a direct comparison between the responsiveness of the Persian version of NPDS, NDI, and NOOS questionnaires. Methods: At the end of the study, 55 patients with chronic non-specific neck pain completed the NPDS, NDI, and NOOS questionnaires at the beginning and end of three weeks of physiotherapy treatment. Additionally, patients completed the global rating of change scale to differentiate between improved and unimproved patients. Comparison of responsiveness was performed using anchor-based methods (receiver operating characteristic (ROC) curve and correlation analysis). MCID and MDC were assessed to investigate relevant changes for each questionnaire. Results: ROC curves analysis showed areas under the curves of 0.70, 0.64, and 0.43 to 0.63 for the NPDS, NDI, and NOOS subscales, respectively. The correlation coefficients between the global rating of the change scale and the change scores of the NPDS and NDI were 0.38 (P<0.01) and 0.30 (P<0.05), respectively. There were no significant correlations between NOOS subscales and global rating of change score (r=0.001- 0.21, P>0.05). The MCID for the NPDS, NDI, and NOOS subscales were 28.09 (score 0-100), 7.5 (score 0-50), and 13.75 to 28.64 (score 0-100), respectively. The MDCs were found to be in the following order: 47.1 points for NPDS, 36.1 for NDI, and 23.5 to 39.7 for NOOS subscales. Conclusion: The Persian NPDS seems more responsive than the NDI and NOOS questionnaires. The level of clinically meaningful change in NDI, NPDS, and NOOS questionnaires is in the range of measurement error.

Impending cauda equina syndrome due to Kummell disease; A case report and literature review.

INTRODUCTION: Kummell disease (KD) is a rare cause of vertebral fracture due to osteonecrosis. The natural history of the disease is characterized by a previous minor trauma, a subclinical window period, and then a symptomatic period presenting with disabling pain, kyphosis, or neurologic deficit. IMPORTANCE: As an important but rare cause of non-discogenic cauda equina syndrome. CASE PRESENTATION: Here, we report on a wheelchair-bound 28-years-old bodybuilder man with KD who presented with progressive paresthesia and weakness of both legs (impending cauda equina syndrome) due to L5 involvement. He had a past medical history of arbitrary use of licensed and unlicensed drugs in the fitness field. The patient underwent posterior decompression, spinopelvic stabilization, and fusion. Postoperative rehabilitation was satisfactory and after six months, the leg muscle strength returned to normal and the patient's back pain disappeared. CONCLUSION: KD should be considered as a rare differential diagnosis when dealing with any patient with a vertebral fracture associated with a history of minor trauma and an asymptomatic window period.

A Survey on the Short-term Outcome of Microlumbar Discectomy with General versus Spinal Anesthesia.

BACKGROUND: Surgery on the lower thoracic and lumbosacral spine is possible with both general and spinal anesthesia, but most spine surgeons are reluctant to perform the surgery with spinal anesthesia. We aimed to conduct a survey on the short-term outcome of microlumbar discectomy in the patients who had been treated under general or spinal anesthesia. METHODS: In this prospective study, we performed a survey on 72 patients who underwent microlumbar discectomy under general anesthesia (group A) or spinal anesthesia (group B). Demographic characteristics, American Society of Anesthesiologists physical status, duration of operation, blood loss, and complications were all documented. Preoperative and early postoperative (at the time of discharge) disability and pain were assessed by using Japanese Orthopedic Association (JOA) scoring system and a visual analog scale questionnaire. RESULTS: The two groups were homogenous preoperatively. The mean intraoperative blood loss was less and the mean operating time was shorter in group A than in group B, but there was no statistically significant difference between groups. The rate of postoperative improvement in JOA score and improvement in pain were similar between groups. Anesthetic complications were unremarkable. CONCLUSIONS: Simple lumbar disc operations in the otherwise healthy patients can be safely performed under either spinal or general anesthesia. Both anesthetic methods led to comparable outcomes with minimal complications.

Effect of interbody fusion cage on clinical and radiological outcome of surgery in L4-L5 lumbar degenerative spondylolisthesis.

BACKGROUND: Lumbar degenerative spondylolisthesis (LDS) is a degenerative slippage of a lumbar vertebra relative to the adjacent vertebra below that can be clinically symptomatic. We aim to compare radiological and clinical outcome of surgery in L4-L5 LDS with or without applying the interbody fusion cage. METHODS: We studied 60 patients (mean age, 51.3±13.2 years; follow-up, 53.3±14.6 months) with L4-L5 LDS who had been treated by decompression, pedicle screw and rod instrumentation associated with posterolateral fusion (PLF) without and with transforaminal lumbar interbody fusion (TLIF) in equally divided groups A and B, respectively. Intraoperative parameters were recorded and outcome assessment carried out by visual analog scale (VAS), Oswestry Disability Index questionnaire (ODI), subjective satisfaction, radiologic union, and loss of reduction. We judged the differences by t-test and cross-tab. RESULTS: Using an interbody fusion cage was associated with a significant increase in intraoperative blood loss, operative time, and instrument cost. Improvement in VAS and ODI were significant but comparable. Satisfaction rate was higher in group A (P=0.52). Fusion rate and loss of correction were more favorable in group B but these differences were not significant. CONCLUSIONS: In the surgical treatment of the patients with L4-L5 LDS, interbody fusion cage probably does not significantly improve the radiologic and clinical outcomes and may also be associated with more complication and morbidity.

A Survey on Low Back Pain Risk Factors in Steel Industry Workers in 2015.

STUDY DESIGN: This was a cross-sectional study. PURPOSE: The aim of this study was to determine the prevalence of low back pain (LBP) and its association with individual factors and current job status among steel industry workers in Mashhad, Iran. OVERVIEW OF LITERATURE: Several studies have been conducted on LBP and its related risk factors, some of which emphasized oc-cupational factors as the main etiology of LBP. Meanwhile, individual risk factors have been emphasized in other studies. Despite several published articles, there are still many unresolved, basic issues about developing LBP. METHODS: For this study, 358 male workers were selected by a random sampling method and divided into two groups: production workers (n=201) and administrative personnel (n=157). Data were collected using modified Nordic questionnaire and physical examination. Statistical analysis was performed to identify the correlation between individual factors and current job status with LBP. RESULTS: Despite the young age of participants and their short employment duration, the overall prevalence of LBP was high (32.4%) in this industry. The prevalence of non-specific LBP in production workers and administrative personnel was 26.8% and 21.0%, respectively. Disk herniation was observed in 10.4% of production workers and 6.3% of administrative personnel. Age, employment duration, body mass index and smoking status were similar in the two groups. There was no significant relationship between LBP and current job status; however, a significant relationship was found between prevalence of LBP with age, duration of employment, and leisure time physical activity (p<0.05). CONCLUSIONS: We have not found any relationship between LBP and current occupational status suggesting that the effects of general health-related factors such as weight, age, leisure time physical activity, and duration of employment are more important than occupational factors in developing LBP.

Comparison of Clinical and Radiologic Outcome of Adolescent Idiopathic Scoliosis Treated with Hybrid Hook-Screw Instrumentation versus Universal Clamp System.

Background. In surgical treatment of adolescent idiopathic scoliosis (AIS), hybrid universal clamp system has been used by some authors. We aimed to compare the clinical and radiologic outcome of hybrid universal clamp with hybrid thoracic hook lumbar screw. Methods. A prospective study was performed on 56 consecutive patients with AIS, who had alternatively undergone a posterior spinal fusion and instrumentation with hybrid thoracic hook lumbar screw system (28 patients: group A) and hybrid universal clamp system (28 patients: group B) between June 2006 and January 2014 at Imam Reza University Hospital and had been followed up for more than two years. The comparison was according to radiographic changes, operative time, intraoperative blood loss, complications, and Scoliosis Research Society (SRS-22) outcome scores. Results. The preoperative mean curve Cobb angle was 58° ± 7° (42°-74°) in group A and 60° ± 9° (46°-75°) in group B. The mean final coronal curve correction was 60.4% and 75.5% in groups A and B, respectively (P = 0.001). Postoperative SRS outcome scores were also comparable. Conclusion. Universal clamp instrumentation had a significantly better curve correction and lower complication rate compared with hybrid thoracic hook lumbar screw. Both instrumentation methods had similar operative time, intraoperative blood loss, and postoperative SRS outcome scores.

Ten Important Tips in Treating a Patient with Lumbar Disc Herniation.

Lumbar disc herniation is a common spinal disorder that usually responds favorably to conservative treatment. In a small percentage of the patients, surgical decompression is necessary. Even though lumbar discectomy constitutes the most common and easiest spine surgery globally, adverse or even catastrophic events can occur. Appropriate patient selection and effective neural decompression constitute the most important points for better surgical outcomes and avoidance of unpleasant complications. Other important tips include timely performance of magnetic resonance imaging, correct interpretation of scan data, preoperative detection of underlying instability, exclusion of non-discogenic sciatica, determination of the main cause of clinical pathology, avoidance of the wrong side or level, and being sure that the more detailed procedure does not necessarily mean the more effective procedure.

Failure Rate of Spine Surgeons in Preoperative Clinical Screening of Severe Psychological Disorders.

BACKGROUND: The surgeon's attention to the patient's underlying psychological state is essential to attaining desired outcomes. We aimed to investigate the prevalence and severity of psychological disorders in patients undergoing elective spine surgery. METHODS: In this case-control study, associated psychological disorders were assessed using the Hospital Anxiety and Depression Scale (HADS) questionnaire at a single academic spine surgery center from August 2013 to June 2015. The case group consisted of 68 adult patients (mean age, 38.2 ± 9.6 years; male:female = 41:27) undergoing elective spine surgery and the control group included 69 healthy visitors of the orthopedic patients (mean age, 37.1 ± 6.9 years; male:female = 40:29) who voluntarily participated in the study. The 2 groups were compared for statistical analysis and a p-value < 5% was considered significance. RESULTS: There was no statistically significant intergroup difference with regard to gender and age. The incidences of abnormal anxiety and depression were the same in the case group (14 patients, 20.6%). The values were 3 (4.3%) and 5 (7.2%), respectively, in the control group, showing statistically significant difference. Any association between the severity of depression and age or sex could not be identified. CONCLUSIONS: In spite of spine surgeons' attempts to screen severe psychological disorders preoperatively, up to 21% of which cannot be diagnosed prior to elective spine surgery. Therefore, we believe the use of a questionnaire would be helpful in assessing patients' underlying psychological state before elective spine surgery.

Huge Intracanal Lumbar Disc Herniation: a Review of Four Cases.

Lumbar disc herniation (LDH) is the most common cause of sciatica and only in about 10% of the affected patients, surgical intervention is necessary. The side of the patient (the side of most prominent clinical complaints) is usually consistent with the side of imaging (the side with most prominent disc herniation on imaging scans). In this case series, we presented our experience in four cases with huge intracanal LDH that a mismatch between the patient's side and the imaging's side was present. In these cases, for deciding to do the operation, the physicians need to rely more on clinical findings, but for deciding the side of discectomy, imaging characteristic (imaging side) may be a more important criterion.

Prognostic Value of Impaired Preoperative Ankle Reflex in Surgical Outcome of Lumbar Disc Herniation.

BACKGROUND: Several prognostic factors exist influencing the outcome of surgical discectomy in the patients with lumbar disc herniation (LDH). The aim of this study is to evaluate the relationship between severity of preoperative impaired ankle reflex and outcomes of lumbar discectomy in the patients with L5-S1 LDH. METHODS: We retrospectively evaluated 181 patients (108 male and 73 female) who underwent simple discectomy in our orthopedic department from April 2009 to April 2013 and followed them up for more than one year. The mean age of the patients was 35.3±8.9 years old. Severity of reflex impairment was graded from 0 to 4+ and radicular pain and disability were assessed by visual analogue scale (VAS) and Oswestry disability index (ODI) questionnaires, respectively. Subjective satisfaction was also evaluated at the last follow-up visit. Chi-square and Kruskal-Wallis tests were used to compare qualitative variables. RESULTS: Reflex impairment existed in 44.8% preoperatively that improved to 10% at the last follow-up visit. Statistical analyses could not find a significant relationship between the severity of impaired ankle reflex and sex or age (P=0.538 and P=0.709, respectively). There was a remarkable relationship between severity of reflex impairment and preoperative radicular pain or disability (P=0.012 and P=0.002, respectively). Kruskal-Wallis test showed that a more severity in ankle reflex impairment was associated with not only less improvement in postoperative pain and disability but also less satisfaction rate (P<0.001 in all three). CONCLUSIONS: In the patients with L5-S1 LDH, more severe ankle reflex impairment is associated with less improvement in postoperative pain, disability, and subjective satisfaction.

Surgical Outcome of Reduction and Instrumented Fusion in Lumbar Degenerative Spondylolisthesis.

BACKGROUND: Lumbar degenerative spondylolisthesis (LDS) is a degenerative slippage of the lumbar vertebrae. We aimed to evaluate the surgical outcome of degenerative spondylolisthesis with neural decompression, pedicular screw fixation, reduction, and posterolateral fusion. METHODS: This before-after study was carried out on 45 patients (37 female and 8 male) with LDS operated from August 2008 to January 2011. The patients' pain and disability were assessed by visual analogue scale (VAS) and Oswestry disability index (ODI) questionnaire. In surgery, we applied distraction force to facilitate slip reduction. All the intra- and postoperative complications were recorded. The paired t-test and Pearson correlation coefficient were used for statistical analysis. RESULTS: The mean age of patients and mean follow-up period were 58.3±3.5 years and 31.2±4.8 months, respectively. The mean slip correction rate was 52.2% with a mean correction loss of 4.8%. Preoperative VAS and ODI improved from 8.8 and 71.6 to postoperative 2.1 and 28.7, respectively. Clinical improvement was more prominent in more reduced patients, but Pearson coefficient could not find a significant correlation. CONCLUSION: Although spinal decompression with fusion and posterior instrumentation in surgical treatment of the patients with LDS result in satisfactory outcome, vertebral reduction cannot significantly enhance the clinical improvement.

Intrapelvic Lumbosacral Fracture Dislocation in a Neurologically Intact Patient: A Case Report.

INTRODUCTION: Lumbosacral fracture dislocation is a rare entity mainly occurred in high-energy trauma accidents. In this unstable injury, anatomical separation of the spinal column from pelvis is usually associated with severe neurological deficits. CASE PRESENTATION: We described a 16-year-old girl with extremely severe axial trauma to the lumbosacral spine who presented with fracture dislocation of the lumbosacral spine and its intrusion to the pelvic space. Despite violent lumbosacral joint dissociation on imaging studies, the patient was neurologically intact. She was treated with spinopelvic fusion and instrumentation. CONCLUSIONS: Although spinopelvic fracture dislocation injuries are severe high-energy entities, in cases with traumatic spondylolytic spondylolisthesis due to widening of the vertebral canal, neurologic deficit may not be seen at all.

Primary Epidural Varicosis as a Rare Cause of Sciatica: A Case Report.

Non-discogenic sciatica can be caused by any lesion along the course of the lumbosacral nerve roots and sciatic nerve. We aim to present a rare case of refractory sciatica in an otherwise healthy 25-year-old man. He complained of left leg pain without significant back pain. Extensor hallucis longus muscle was weak on the left side with limited straight leg rising. On magnetic resonance imaging, a space-occupying lesion resembling a sequestrated disc was noted that after surgical decompression, epidural varicosis was demonstrated.

Translation and cultural adaptation of the Manchester-Oxford Foot Questionnaire (MOXFQ) into Persian language.

PURPOSE: In this study, we aimed to translate and test the validity and reliablity of the Persian version of the Manchester-Oxford Foot Questionnaire in foot and ankle patients. METHODS: We translated the Manchester-Oxford Foot Questionnaire to Persian language according to the accepted guidelines, then assessed the psychometric properties including the validity and reliability on 308 patients with long-standing foot and ankle problems. To test the reliability, we calculated the intra-class correlation coefficient (ICC) for test-retest reliability and measured Cronbach's alpha to test the internal consistency. To test the construct validity of the Manchester-Oxford Foot Questionnaire we also administered the Short-Form 36 to patients. RESULTS: Construct validity was supported by significant correlation with SF36 subscales except for pain subscale of the persian MOXFQ with mental health of the SF36 (r=0.207). Intraclass correlation coefficient was 0.79 for the total MOXFQ and ranged from 0.83 to 0.89 for the three subscales. Cronbach's alpha for pain, walking/standing, and social interaction was 0.86, 0.88, and 0.89, respectively, and was 0.79 for the total MOXFQ showing good internal consistency in each domain. CONCLUSION: The Persian Manchester-Oxford Foot Questionnaire health scoring system is a valid and reliable patient-reported instrument for foot and ankle problems.

Pedicle Subtraction Osteotomy in a 5-Year-Old Child with Congenital Kyphosis.

Vertebral anomalies may also distort the normal regional or global spinal alignment and necessitate some therapeutic interventions. Hemiepiphysiodesis is a traditional procedure usually described for these young patients but in more severe cases some type of osteotomy seems to be necessary. In this technical note, we describe a 5-year-old boy with failed previous hemiepiphysiodesis surgery, who was successfully treated with one level pedicle subtraction osteotomy. This procedure not only corrects the kyphotic deformity at the time of the procedure (not relying on future spinal growth), but also avoids more hazardous anterior approach.

Clinical instability of the knee and functional differences following tibial plateau fractures versus distal femoral fractures.

BACKGROUND: Fractures of the knee account for about 6% of all trauma admissions. While its management is mostly focused on fracture treatment, it is not the only factor that defines the final outcome. OBJECTIVES: This study aimed to study objective and subjective outcomes after proximal tibial versus distal femoral fractures in terms of knee instability and health-related quality of life. PATIENTS AND METHODS: This retrospective, cross-sectional, cohort study was carried out on 80 patients with either isolated proximal tibial (n = 42) or distal femoral (n = 38) fractures, who underwent open reduction and internal fixation. All the fractures were classified based on the Schatzker and AO classification for tibial plateau and distal femoral fractures, respectively. The patients were followed and examined by an orthopedic knee surgeon for clinical assessment of knee instability. In their last follow-up visit, these patients completed a Lysholm knee score and the short-form (SF) 36 health survey. RESULTS: Among the 42 tibial plateau fractures, 25% were classified as Schatzker type 2. Of the 38 distal femoral fractures, we did not find any type B1 or B3 fractures. The overall prevalence of anterior and posterior instability was 42% and 20%, respectively. Medial Collateral Ligament (MCL) and Lateral Collateral Ligament (LCL) injuries were detected clinically in 50% and 28%, respectively. The incidence rates of ligament injuries in tibial plateau fractures were as follows: Anterior Collateral Ligament (ACL) 26%, Posterior Collateral Ligament (PCL) 7%, MCL 24%, and LCL 14%. Medial collateral ligament injury was the most common in the Schatzker type 2 (50% of the injuries). Distal femoral fractures were associated with ACL injury in 16%, PCL in 13%, MCL in 26% and LCL in 14%. However, final knee range of motion (ROM) and function (Lysholm score) were not associated with fracture location. No statistically significant difference was observed between the two groups, except for the valgus stress test at 30°knee flexion, which was more positive in tibial fractures. All eight domains of SF-36 score in the distal femoral and proximal tibial fractures were significantly different from the normal values; however, there were no statistically significant differences between femoral and tibial fracture scores. CONCLUSIONS: Although ROM is acceptable in knee joint fractures, instability is common. However, it seems that knee function and quality of life are not associated with the location of the fracture.

Radiologic and clinical outcomes of surgery in high grade spondylolisthesis treated with temporary distraction rod.

BACKGROUND: Surgical techniques used in the treatment of patients with high grade lumbar spondylolisthesis (> 50% slippage) are usually associated with a great deal of controversies. We aim to evaluate the surgical outcomes of high grade spondylolisthesis treated with an intraoperative temporary distraction rod. METHODS: We retrospectively studied 21 patients (14 females and 7 males), aged 50.4 ± 9.2 years, who had high grade lumbar spondylolisthesis that was treated with intraoperative temporary distraction rods, neural decompression, pedicular screw fixation, and posterolateral fusion involving one more intact upper vertebra. The mean follow-up period was 39.2 months. Radiologic and clinical outcomes were measured by slip angle, slip percentage, correction rate, Oswestry Disability Index (ODI), visual analogue scale (VAS), patient's satisfaction rate in the pre- and postoperative period. Data were analyzed by SPSS ver. 11.5. RESULTS: Analysis of the preoperative visits and final follow-up visits indicated that surgery could improve ODI, lumbar VAS, and leg VAS from 60.5% to 8.2%, from 6.7 to 2.2, and from 6.9 to 1.3, respectively. Slip angle and slip percentage were also changed from -8° to -15° and from 59.2% to 21.4%, respectively. Mean correction rate at the final follow-up visit was 64.1%. Loss of correction was insignificant and a neurologic complication occurred in one patient due to misplacement of one screw. Excellent and good levels of satisfaction were observed in 90.5% of the patients. CONCLUSIONS: In the surgical treatment of refractory high grade spondylolisthesis, the use of a temporary distraction rod to reduce the slipped vertebra in combination with neural decompression, posterolateral fusion, and longer instrumentation is associated with satisfactory clinical and radiologic outcomes.