Long-term outcome of decompressive surgery for lumbar spinal stenosis in octogenarians.

The purpose of our prospective study is to evaluate the surgical outcome among patients aged 80 years and above, who underwent surgery for lumbar spinal stenosis. We assessed patients' clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients' satisfaction, the need for repeated surgery, and overall mortality. Thirty-nine patients more than 80 years of age were operated in our institution in the last decade. Twenty-five of them were followed-up with a mean 36.8 months after the operation. The Barthel index was used to evaluate pre and postsurgery ADL, and the visual analogue scale (VAS) was used to evaluate pain. The satisfaction rate of the patients before and after the operation and the complication rate were also evaluated. A significant reduction in VAS (P < 0.001) and a significant increase in the Barthel index (P < 0.001) were recorded. Seventy-six percent of the patients were very satisfied or somewhat satisfied with the operative results. Fifty-two percent of the patients had complications (0.9 complications per patients), however, about half of them were minor. No operative or perioperative mortality was noticed and the overall hospital stay for these elderly patients was 3.6 days on average. Surgery in very old elderly patients is safe and effective in the treatment of spinal stenosis, who did not respond well to the conservative treatment. The surgery did not increase the associated morbidity and mortality and most of the patients benefited from the surgery in terms of reduction in pain, increase in ADL and walking ability and overall increase in the satisfaction rate.

Reproducibility of pressure pain threshold and visual analog scale findings in chronic whiplash patients.

BACKGROUND: Assessment of pain in patients with whiplash-associated disorders has been previously reported using a variety of instruments. However, the reproducibility of the findings derived from such measurements has not been explored with respect to this particular patients group. OBJECTIVES: To evaluate the intratester and intertester reproducibility of pressure pain threshold (PPT) findings and the intratester reproducibility of visual analog scale (VAS) findings relating to the cervical region of chronic whiplash patients for the determination of smallest real difference values. METHODS: Twenty-one chronic whiplash patients: 13 women and 8 men participated in this study. The intratester paradigm was based on 2 testing sessions over a period of 5 to 11 days (7.95+/-1.90) and incorporated recording of VAS scores and also PPT scores relating to 3 pairs of right and left homologous cervical sites. The intertester study was conducted within the first testing session and referred to the PPT measurement only. In this session, patients were also asked to fill in the Neck Disability Index questionnaire. RESULTS: The interclass correlation coefficient-derived reproducibility of the PPT scores was good to excellent within and between testers ranging 0.85 to 0.91 and 0.88 to 0.97, respectively. There was, however, a significant difference between the testers. The VAS scores demonstrated lower reproducibility (interclass correlation coefficient=0.67). On the basis of the standard error of measurement, the smallest real difference of PPT ranged 40.2 to 58.9 kPa whereas the corresponding figure for the VAS was 3.76 cm. CONCLUSIONS: On the basis of the current patient sample, this study demonstrates that although PPT findings may generally be applied for monitoring change in chronic whiplash patients, the use of VAS scores should be limited to patients whose initial score is above 4. It is also suggested that if the PPT is to serve as an outcome measure, its measurement should be performed by the same tester.

Cervical motion in patients with chronic disorders of the cervical spine: a reproducibility study.

STUDY DESIGN: Test-retest of cervical motion in patients with chronic disorders of the cervical spine. OBJECTIVES: To determine the reproducibility of cervical motion and examine the feasibility of its representation by a single parameter. SUMMARY OF BACKGROUND DATA: Reproducibility of cervical motion findings has been largely limited to normal subjects, leaving a conspicuous void regarding the measurement error in clinical groups. METHODS: There were 2 groups of 25 chronic patients with whiplash and degenerative changes of the cervical spine tested twice (4-7 days). Head movement was measured along the 6 directions, as well as during rotation out of flexion and extension (cervical degenerative changes only). RESULTS: Compared to normal subjects, both groups had a 25% to 35% reduction in cervical motion. High intraclass correlation coefficients (ICCs) (range 0.8-0.92) were derived for all directions. The ICCs for rotation out of flexion and extension were low. The relative standard error of measurement ranged from 15% to 28% for all directions, whereas the corresponding scores of the total cervical motion excursion were 10.6 (cervical degenerative changes) and 13.6% (whiplash). CONCLUSIONS: Judged by the ICCs cervical motion, findings were reproducible. However, in view of the measurement error as well as the homogenous reductions, total cervical range of motion should be considered a suitable parameter for interpretation of cervical motion limitations in these patients.

Cervical radiofrequency neurotomy in patients with chronic whiplash: a study of multiple outcome measures.

OBJECT: Cervical radiofrequency neurotomy (CRFN) is used in the treatment of patients with chronic pain and disability due to whiplash injury. Confirmation of its efficiency has, however, been based solely on pain and psychological distress factors. The aim of the present study was to extend the assessment of CRFN efficacy by adding other outcome measures to shed light on neuromotor-functional-psychological interactions by undertaking comparison of pre- and 1-year postintervention data. METHODS: Forty patients with chronic whiplash injury-associated disorders were evaluated prior to and at two separate sessions after CRFN. The evaluation included Neck Disability Index, cervical range of motion, isometric cervical muscle strength, cervical pressure pain threshold, Symptom Check List-90-Revised, and subjective Self-Report of Improvement (SRI). The authors found that the CRFN had a significantly positive effect on all measured parameters. A case-by-case analysis revealed improvement in 70% of the patients at the final follow-up examination. Using stringent cutoff values, between 30 and 60% of the patients experienced measurable improvement. Evaluation of SRI results indicated that more than 80% of the patients were satisfied with the procedure. CONCLUSIONS: Approximately 1 year after intervention, CRFN was associated with an acceptable rate of success, as reflected by objective and subjective outcome measures.

Performance of cervical motion in chronic whiplash patients and healthy subjects: the case of atypical patients.

STUDY DESIGN: A comparative study of cervical motion performance in chronic whiplash (CW) patients and healthy subjects. OBJECTIVES: To examine the efficiency of total cervical range of motion (TCROM), which consists of the combined score of all six primary movements and their mean coefficient of variation (MCV), in differentiating CW patients from healthy subjects as well as typical from atypical patients. Additionally to explore in the patients possible relationships between their cervical motion profile and functional and personality traits. SUMMARY OF BACKGROUND DATA: Previous studies revealed that cervical motion was an efficient discriminator between healthy and CW patients. However, none of these studies provided either guidelines regarding cutoff scores or insight as to what should be considered typical compared with atypical patient with respect to cervical motion performance. METHODS: Cervical motion was measured in 75 healthy subjects and 101 CW patients in each of the six primary movements. In addition, patients filled the functional neck disability index (NDI) and personality symptom check list (SCL-R-90) questionnaire. RESULTS: Total CROM was significantly lower and the MCV was significantly higher in patients compared with healthy subjects. Age and gender affected TCROM significantly in both groups while MCV remained unaffected, respectively. Atypical patients were identified by having a TCROM < 58 degrees and or MCV > 22%, both scores corresponding to 2 SDs below and above group means, respectively. These benchmarks resulted in classifying as atypical 6% of the CW group who also scored drastically higher in the NDI and SCL-R-90 questioners. CONCLUSIONS: Using MCV and TCROM adds new insight regarding what should be considered as atypical cervical motion profile in CW patients. Several aspects of this complex clinical entity are discussed.

[Pulsed radiofrequency treatment of severe radicular pain].

UNLABELLED: Radiofrequency (RF) lesions have been used for over 25 years in the treatment of intractable pain of spinal origin. The conventional idea is that the heat generated in the tissue surrounding the electrode tip leads to destruction of nerve fibers. In case of mechanical back pain, an electrode positioned adjacent to the medial branch of the dorsal root may reduce the input of noxious nerve stimuli and alleviate pain. For treatment of patients with severe radicular pain the authors often apply pulsed radiofrequency current. This technique enables the application of a relatively high voltage near the dorsal root ganglion, avoiding the deleterious thermal effect of the current. It was found to exert a beneficial effect in cases of intractable radicular pain. This study reports the result of pulsed RF in 28 patients suffering from severe radicular pain treated by pulsed radiofrequency current with follow-up at periods of 3, 6 and 12 months after treatment. There were 20 cases of low back pain and 8 with neck pain, with an average age of 56.7 years. The first follow-up after 3 months revealed the following results: excellent results in 2 cases (7.1%), good results in 12 cases (42/9%), fair in 9 (32/1%) and 5 (17/9%) reported that their condition have not changed. Results after 6 and 12 months were excellent in 2 (both groups), good in 7 and 6 respectively, 11 fair (both groups) and unresponsiveness to treatment was noticed in 8 patients after 6 and 9 after 12 months. Significant reduction was found in the Visual Analog Scale for pain from an average of 8.8 to 4.2 after 3 months, 4.8 after 6 months and 4.9 after 1 year. CONCLUSION: Pulsed RF treatment is a safe and simple procedure to control radicular pain in the cervical and lumbar regions. Following the current study the authors stress the need for further prospective, double-blind studies for better investigation of this technique.

Simulated pain and cervical motion in patients with chronic disorders of the cervical spine.

The primary objective of the present study was to determine how simulated severe cervical pain affects cervical motion in patients suffering from two distinct chronic cervical disorders: whiplash (n=25) and degenerative changes (n=25). The second objective was to derive an index that would allow the differentiation of maximal from submaximal performances of cervical range of motion. Patients first performed maximal movement of the head (maximal effort) in each of the six primary directions and then repeated the test as if they were suffering from a much more intense level of pain (submaximal effort). All measurements were repeated within four to seven days. In both groups, there was significant compression of cervical motion during the submaximal effort. This compression was also highly stable on a test-retest basis. In both groups, a significantly higher average coefficient of variation was associated with the imagined pain and it was significantly different between the two clinical groups. In the whiplash group, a logistic regression model allowed the derivation of coefficient of variation-based cutoff scores that might, at selected levels of probability and an individual level, identify chronic whiplash patients who intentionally magnify their motion restriction using pain as a cue. However, the relatively small and very stable compression of cervical motion under pain simulation supports the view that the likelihood that chronic whiplash patients are magnifying their restriction of cervical range of motion using pain as a cue is very low.