A comparison of patient-reported outcome measures after spinal surgery.

Minimal clinically important differences (MCID) in the scores of patient-reported outcome measures allow clinicians to assess the outcome of intervention from the perspective of the patient. There has been significant variation in their absolute values in previous publications and a lack of consistency in their calculation. The purpose of this study was first, to establish whether these values, following spinal surgery, vary depending on the surgical intervention and their method of calculation and secondly, to assess whether there is any correlation between the two external anchors most frequently used to calculate the MCID. We carried out a retrospective analysis of prospectively gathered data of adult patients who underwent elective spinal surgery between 1994 and 2009. A total of 244 patients were included. There were 125 men and 119 women with a mean age of 54 years (16 to 84); the mean follow-up was 62 months (6 to 199) The MCID was calculated using three previously published methods. Our results show that the value of the MCID varies considerably with the operation and its method of calculation. There was good correlation between the two external anchors. The global outcome tool correlated significantly better. We conclude that consensus needs to be reached on the best method of calculating the MCID. This then needs to be defined for each spinal procedure. Using a blanket value for the MCID for all spinal procedures should be avoided.

Stellar feedback as the origin of an extended molecular outflow in a starburst galaxy.

Recent observations have revealed that starburst galaxies can drive molecular gas outflows through stellar radiation pressure. Molecular gas is the phase of the interstellar medium from which stars form, so these outflows curtail stellar mass growth in galaxies. Previously known outflows, however, involve small fractions of the total molecular gas content and have typical scales of less than a kiloparsec. In at least some cases, input from active galactic nuclei is dynamically important, so pure stellar feedback (the momentum return into the interstellar medium) has been considered incapable of rapidly terminating star formation on galactic scales. Molecular gas has been detected outside the galactic plane of the archetypal starburst galaxy M82 (refs 4 and 5), but so far there has been no evidence that starbursts can propel substantial quantities of cold molecular gas to the same galactocentric radius (about 10 kiloparsecs) as the warmer gas that has been traced by metal ion absorbers in the circumgalactic medium. Here we report observations of molecular gas in a compact (effective radius 100 parsecs) massive starburst galaxy at redshift 0.7, which is known to drive a fast outflow of ionized gas. We find that 35 per cent of the total molecular gas extends approximately 10 kiloparsecs, and one-third of this extended gas has a velocity of up to 1,000 kilometres per second. The kinetic energy associated with this high-velocity component is consistent with the momentum flux available from stellar radiation pressure. This demonstrates that nuclear bursts of star formation are capable of ejecting large amounts of cold gas from the central regions of galaxies, thereby strongly affecting their evolution by truncating star formation and redistributing matter.

A comparative study of the outcomes of primary and revision lumbar discectomy surgery.

The outcome of surgery for recurrent lumbar disc herniation is debatable. Some studies show results that are comparable with those of primary discectomy, whereas others report worse outcomes. The purpose of this study was to compare the outcome of revision lumbar discectomy with that of primary discectomy in the same cohort of patients who had both the primary and the recurrent herniation at the same level and side.A retrospective analysis of prospectively gathered data was undertaken in 30 patients who had undergone both primary and revision surgery for late recurrent lumbar disc herniation. The outcome measures used were visual analogue scales for lower limb (VAL) and back (VAB) pain and the Oswestry Disability Index (ODI).There was a significant improvement in the mean VAL and ODI scores (both p < 0.001) after primary discectomy. Revision surgery also resulted in improvements in the mean VAL (p < 0.001), VAB (p = 0.030) and ODI scores (p < 0.001). The changes were similar in the two groups (all p > 0.05).Revision discectomy can give results that are as good as those seen after primary surgery.

CT scanning reduces the risk of missing a fracture of the thoracolumbar spine.

The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of 'missed injury'. We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk. Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury.

Type II odontoid fractures in the elderly: an evidence-based narrative review of management.

Considerable controversy exists regarding the optimal management of elderly patients with type II odontoid fractures. There is uncertainty regarding the consequences of non-union. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. The objective of the study was to evaluate the published literature and determine the current evidence for the management of type II odontoid fractures in elderly. A search of the English language literature from January 1970 to date was performed using Medline and the following keywords: odontoid, fractures, cervical spine and elderly. The search was supplemented by cross-referencing between articles. Case reports and review articles were excluded although some were referred to in the discussion. Studies in patients aged 65 years with a minimum follow-up of 12 months were selected. One-hundred twenty-six articles were reviewed. No class I study was identified. There were two class II studies and the remaining were class III. Significant variability was found in the literature regarding mortality and morbidity rates in patients treated with and without halo vest immobilisation. In recent years several authors have claimed satisfactory results with anterior odontoid screw fixation while others have argued that this may lead to increased complications in this age group. Lately, the posterior cervical (Goel-Harms) construct has also gained popularity amongst surgeons. There is insufficient evidence to establish a standard or guideline for odontoid fracture management in elderly. While most authors agree that cervical immobilisation yields satisfactory results for type I and III fractures in the elderly, the optimal management for type II fractures remain unsolved. A prospective randomised controlled trial is recommended.

The prediction of outcome in somatised patients undergoing elective lumbar surgery.

We compared a group of 46 somatised patients with a control group of 41 non-somatised patients who had undergone elective surgery to the lumbar spine in an attempt to identify pre-operative factors which could predict the outcome. In a prospective single-centre study, the Distress and Risk Assessment method consisting of a modified somatic perception questionnaire and modified Zung depression index was used pre-operatively to identify somatised patients. The type and number of consultations were correlated with functional indicators of outcome, such as the Oswestry disability index and a visual analogue score for pain in the leg after follow-up for six and 12 months. Similar improvements in the Oswestry disability index were found in the somatised and non-somatised groups. Somatised patients who had a good outcome on the Oswestry disability index had an increased number of orthopaedic consultations (50 of 83 patients (60%) vs 29 of 73 patients (39.7%); p = 0.16) and waited less time for their surgery (5.5 months) (sd 5.26) vs 10.1 months (sd 6.29); p = 0.026). No other identifiable factors were found. A shorter wait for surgery appeared to predict a good outcome. Early review by a spinal surgeon and a reduced waiting time to surgery appear to be of particular benefit to somatised patients.

Patient information and education with modern media: the Spine Society of Europe Patient Line.

The role of the patient as an active partner in health care, and not just a passive object of diagnostic testing and medical treatment, is widely accepted. Providing information to patients is considered a crucial issue and the central focus in patient educational activities. It is necessary to educate patients on the nature of the outcomes and the benefits and risks of the procedures to involve them in the decision-making process and enable them to achieve fully informed consent. Information materials must contain scientifically reliable information and be presented in a form that is acceptable and useful to patients. Given the mismatch between public beliefs and current evidence, strategies for changing the public perceptions are required. Traditional patient education programmes have to face the potential barriers of storage, access problems and the need to keep content materials up to date. A computer-based resource provides many advantages, including "just-in-time" availability and a private learning environment. The use of the Internet for patient information needs will continue to expand as Internet access becomes readily available. However, the problem is no longer in finding information, but in assessing the credibility and validity of it. Health Web sites should provide health information that is secure and trustworthy. The large majority of the Web sites providing information related to spinal disorders are of limited and poor quality. Patient Line (PL), a patient information section in the Web site of Eurospine, was born in 2005 to offer patients and the general population the accumulated expertise represented by the members of the society and provide up-to-date information related to spinal disorders. In areas where evidence is scarce, Patient Line provides a real-time opinion of the EuroSpine membership. The published data reflect the pragmatic and the common sense range of treatments offered by the Eurospine membership. The first chapters have been dedicated to sciatica, scoliosis, cervical pain syndromes, low back pain and motion preservation surgery. Since 2008, the information has been available in English, German, French and Spanish. The goal is for Patient Line to become THE European patient information Web site on spinal disorders, providing reliable and updated best practice and evidence-based information where the evidence exists.

A comparison of functional assessment instruments and work status in chronic back pain.

AIM: The aim of this cross sectional study was to analyse whether low back pain (LBP) functional assessment instruments correlate well with work status measures. METHODS: This study was a cross sectional study that enrolled 375 patients with chronic LBP attending back pain outpatient clinics of a University Hospital and a specialist rehabilitation centre over a period of one year. The outcome scores measured were Oswestry Disability Index, Roland Morris Disability Questionnaire and Orebro Musculoskeletal Pain Questionnaire. The effect of back pain on their work status was also recorded and correlated to the above instrument values. RESULTS: There was a only a modest correlation between work status and the three measured outcome scores, with the Spearman rank correlation being 0.47 for OMPQ, 0.43 for ODI and 0.39 for RMQ. CONCLUSION: The studied standard LBP outcome measures and work status are not interchangeable. The impact on work status should not be assumed based on the severity of these outcome measures and should be recorded as a separate outcome measure in chronic low back pain.

The outcome of a functional restoration programme for chronic low back pain.

BACKGROUND: Multidisciplinary rehabilitation programmes have been successfully advocated for chronic low back pain. AIM: The aim of the study was to establish the functional and vocational outcome of a 3-week functional restoration programme. LEVEL OF EVIDENCE: IV, Uncontrolled clinical series. METHODS: One hundred and eighteen chronic low back pain patients underwent a 100-h programme consisting of back exercises, hydrotherapy, gymnasium work education and cognitive behavioural therapy. OUTCOME MEASURES: Oswestry Disability Index (ODI), Roland Morris (RM), 'patient global assessment tool' and work status scores were completed pre-programme and at least 1 year post programme. RESULTS: The ODI score improved by 15.6% (95% CI 11.8-19.4) and RM score by 4.6 points (95% CI 3.6-5.6). The proportion of patients who were seriously affected in the workplace had dropped from 59 to 22%. More than 85% of patients were satisfied with the outcome. CONCLUSION: Functional restoration programme improves the functional activity and vocational status of patients with chronic low back pain.

The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression.

Post-operative management after lumbar surgery is inconsistent leading to uncertainty amongst surgeons and patients about post-operative restrictions, reactivation, and return to work. This study aimed to review the evidence on post-operative management, with a view to developing evidence-based messages for a patient booklet on post-operative management after lumbar discectomy or un-instrumented decompression. A systematic literature search produced a best-evidence synthesis of information and advice on post-operative restrictions, activation, rehabilitation, and expectations about outcomes. Evidence statements were extracted and developed into patient-centred messages for an educational booklet. The draft text was evaluated by peer and patient review. The literature review found little evidence for post-operative activity restrictions, and a strong case for an early active approach to post-operative management. The booklet was built around key messages derived from the literature review and aimed to reduce uncertainty, promote positive beliefs, encourage early reactivation, and provide practical advice on self-management. Feedback from the evaluations were favourable from both review groups, suggesting that this evidence-based approach to management is acceptable and it has clinical potential.

Predictive value of the duration of sciatica for lumbar discectomy. A prospective cohort study.

The optimum timing of lumbar discectomy for sciatica is imprecise. We have investigated a number of prognostic factors in relation to the outcome of radiculopathy after lumbar discectomy. We recruited 113 consecutive patients of whom 103 (91%) were followed up at one year. We found a significant association between the duration of radiculopathy and the changes in the Oswestry Disability Index score (p = 0.005) and the low back outcome score (p = 0.03). Improvement in pain was independent of all variables. Patients with an uncontained herniated disc had a shorter duration of symptoms and a better functional outcome than those with a contained herniation. Our study suggests that patients with sciatica for more than 12 months have a less favourable outcome. We detected no variation in the results for patients operated on in whom the duration of sciatica was less than 12 months.

The effect of age on the change in deformity after anterior débridement surgery for tuberculosis of the spine.

STUDY DESIGN: This article evaluates how an immature spine responds to anterior débridement surgery (without bone grafting) for spinal tuberculosis during growth and development. Sixty-three patients were studied, 29 of whom were children aged 10 years or less at the time of surgery, whereas the remaining 34 subjects were adults. These patients were the subject of the Medical Research Council Working Party's prospective study, started in Hong Kong in the mid-1960s. OBJECTIVES: To evaluate how an immature spine responds to débridement surgery for tuberculosis, during growth and development, to determine whether there are differences in the longitudinal pattern of deformity between children and adults, and to determine the influence of disproportionate spinal growth on the progression of deformity in children. SUMMARY OF BACKGROUND DATA: All patients were followed prospectively for a mean period of 19.6 years after débridement surgery. The mean age at surgery for children (n = 29) was 4.3 years and for adults (n = 34) 35.3 years. METHODS: The kyphos and deformity angles were measured from lateral spinal radiographs obtained at preoperative evaluation and postoperatively at 6 months, 1 year, 5 years, and at final follow-up evaluation using an electronic digitizer. RESULTS: The results showed that the longitudinal pattern of changes in the mean kyphos and deformity angles in young children presented a picture slightly different from that in adults. The mean angles were increased at the 6-month and at 1-year evaluations after débridement surgery in both groups. Afterward, in children there was some spontaneous correction in these mean angles, whereas in adults these angles showed variation according to the site of lesion during the follow-up years. Statistical analysis according to the site of spinal lesion showed that in thoracic tuberculosis, there was an increase in kyphos and deformity angles at the 6-months postoperative evaluation (more in children than in adults). There were no significant changes in these angles from the 1-year to the final follow-up evaluations. In thoracolumbar tuberculosis, there were significant increases in kyphos and deformity angles at the 6-month postoperative evaluation, and thereafter adults did not show any significant change until final follow-up examination, whereas children showed a tendency toward spontaneous correction, although this finding was not statistically significant. In lumbar tuberculosis, there was an equal tendency toward spontaneous correction in children and adults from 1 postoperative year onward. CONCLUSIONS: The authors could find no evidence of disproportionate posterior spinal growth, which has been suspected in the past to be a factor involved in contributing to progression of kyphotic deformity after anterior débridement surgery for spinal tuberculosis.

Surgical management of spinal tuberculosis in adults. Hong Kong operation compared with debridement surgery for short and long term outcome of deformity.

Of 112 patients who were subjects of the Medical Research Council's prospective study, 105 (94%) were involved in a longitudinal study follow-up for a mean of 15.3 years postoperatively. Seventy-one patients had radical resection of the tuberculous lesion and bone grafting, and the remaining 34 were treated with debridement surgery at a mean age of 36.7 and 35.3 years, respectively. All these patients were aged 18 years or older at the time of surgery. The kyphosis and deformity angles were measured on lateral spinal radiographs using an electronic digitizer. The results can be summarized as follows: (1) Neurologic recovery in both radical and debridement surgical groups were equally good and no patient had pain two years after surgery. There was no incidence of reactivation or recurrence of tuberculosis in either surgical group. (2) At the six-month postoperative evaluation, patients who had radical surgery showed marginal correction in deformity, whereas those who were treated with debridement showed deterioration in both kyphosis and deformity angles. There was a statistically significant difference between the two surgical groups for the mean changes in kyphosis and deformity angles at the six-month postoperative evaluation compared with their preoperative evaluation. (3) The mean difference for kyphosis and deformity angles at final follow-up evaluation from the patients' six-month postoperative measurements were not statistically significantly different between the two surgical groups. (4) Forty percent of patients showed an improvement in deformity angle by 5 degrees or more after radical surgery at the six-months postoperative evaluation, whereas 53% of patients showed deterioration after debridement surgery. (5) All patients with tuberculosis of the lumbar spine treated with radical surgery had normal lordosis in the lumbar spine at final follow-up evaluation, compared with only 63% of patients after debridement surgery. Correction achieved after surgery at the six-month evaluation was practically maintained up to final follow-up evaluation. Radical resection and bone grafting provided better correction of deformity than did debridement surgery.