Developing a community-based maternal obesity intervention: a qualitative study of service providers' views.

The aim of this study was to explore healthcare professionals' views on the development of multicomponent interventions for obese pregnant women. A cohort of 22 healthcare professionals was interviewed. The interview transcripts were analysed thematically. Three key themes were highlighted by the interviews: (1) the lack of existing services for obese pregnant women in south-east London; (2) the barriers and challenges that need to be overcome (e.g. ethnic and cultural) when considering the creation of a new service for obese women who are pregnant; (3) the possible components of a new intervention. The findings of this study will inform the design of a programme to combat maternal obesity.

Amitriptyline and chronic low-back pain. A randomized double-blind crossover study.

The effect of antidepressant medication on chronic low-back pain patients was studied in a randomized blind crossover study. Among those patients who completed the study, there was a 46% decrease in the use of analgesics while on amitriptyline when compared to placebo (P less than 0.005). There was also improvement in affect, but no measurable change in activity level. The MMPI profile of those patients who were unable to comply with the study protocol differed from that of patients who completed the study. The noncompliers demonstrated an elevation of the F, Pd, Pt (P less than 0.05) and Mf (P less than 0.01) scales. Although the interpretation of such a profile is left open to speculation, it may serve as an indicator of noncompliant individuals.

Bilateral laminotomy and discectomy for segmental lumbar disc disease. Decompression with stability.

A type of bilateral laminotomy with discectomy for segmental lumbar discogenic disease is presented. The procedure includes wide bilateral decompressive laminotomies and radical partial discectomies, partial V-ostectomy of the adjacent spinous processes, partial facetectomies of the inferior and superior articular processes, and foraminotomies as indicated. One hundred patients who underwent this procedure were evaluated by an independent examiner in follow-up an average of six years postoperatively. The patients were evaluated by utilizing a scale which included back and leg pain relief, restriction of physical activities, analgesic use, and return to work. Seventy patients were graded as good, 12 as fair, and 18 as poor. Preoperative factors which were highly significantly correlated with a good postoperative result included occupation other than heavy labor, present employment or less than 12 months of unemployment, unilateral subjective paresthesias, symptoms of spinal claudication, unilateral restriction of straight leg raising, a positive Cram or bowstring test, the severity of the myelographic defect, elevation of spinal fluid protein, and the severity of the disc pathology noted at surgery. Several other preoperative factors were noted to be of somewhat lesser significance and were correlated with a poor surgical outcome, including job-related injury, compensation or litigation, previous unsuccessful surgery, subjective weakness, calf atrophy, and sensory deficit.

Changes in MMPI profiles after low-back surgery.

Sixty-nine patients who had completed a Minnesota Multiphasic Personality inventory (MMPI) test preoperatively and had had low-back surgery for discogenic disease were seen in follow-up one to 11 years later. Each completed an MMPI test and pain drawing postoperatively, was examined clinically and radiographically, and was rated for surgical outcome. The preoperative MMPI hypochondriasis (Hs) and hysteria (Hy) scales were only modestly related to treatment outcome, but the postoperative scales were strongly related to outcome. Patients with good surgical outcome had lower Hs and Hy scores postoperatively than preoperatively, whereas patients with poor outcomes had higher Hs and Hy scores postoperatively. The MMPI profile of these operated low-back-pain patients was found to be changeable rather than static. The numerical value of the pain drawings was highly correlated with the elevation of the Hs or Hy scales. The MMPI should be utilized to identify patients with neurotic tendencies and prompt referral for psychologic treatment. Those patients who respond favorably to psychotherapy tend to have a better surgical outcome than those with untreated psychoneuroses or those who fail to improve with treatment.

Failed lumbar disc surgery: cause, assessment, treatment.

The challenge of failed back surgery is in the decision of when to operate and how to do it competently. Specific neuroanatomic indications as a basis for surgical treatment should reduce surgical failures. One source of failure is a "battered root" and the arachnoiditis which may follow limited or inadequate interlaminar exposure. Even with adequate interlaminar exposure, hemostasis may be difficult if preoperative positioning of the patient to diminish intra-abdominal pressure has not been performed. Bleeding can obscure the operative field and the surgeon's ability to visualize and deal with the problem at hand. A less common cause of failure is segmental instability. This may be pre-existing and related to facet tropism. It may also be a consequence of surgical removal of posterior vertebral elements, thus creating a loss of stability with or without a discernable change in vertebral alignment. The surgeon should try to: avoid becoming enmeshed in the psychodynamic problems of patients. He should use specific diagnostic tests, e.g., nerve blocks or facet injections, in an effort to localize specific sources of pain; recognize that prognosis is adversely affected by additional surgery; and avoid "exploratory" operations. Furthermore, neurolysis without spatial decompression, bony or otherwise, is eventually futile. All patients with failed back surgery have a psychodynamic component to their pain. This article will have achieved its purpose if it promotes recognition that a small percentage of patients with failed back surgery can be helped. These are individuals in whom specific diagnostic tests or clinical acumen uncover a surgically correctable lesion, be it compressive or radiculopathy or segmental instability. In such instances an adverse psychologic profile need not necessarily be a deterrent to surgical treatment.

Prone knee-flexion provocative testing for lumbar disc protrusion.

A clinical test designed to help differentiate neurologic from axial back and leg pain is described. The prone knee-flexion provocative test produces or enhances reflex suppression and/or motor weakness secondary to intervertebral disc protrusion. The pathophysiology of this test depends on compression of the spinal nerves, which may occur from a combination of biomechanical factors secondary to lumbar spinal extension. Because this maneuver is required to demonstrate evidence of neural compression, the pathologic condition of the disc is probably mild to moderate and therefore should respond to conservative therapy.

The MMPI as a predictor of outcome in low-back surgery.

Between 1965 and 1975, 103 low-back patients were rated preoperatively for general level of functioning, and each completed a Minnesota Multiphasic Personality Inventory (MMPI) test. Following surgery, patients were rated in terms of treatment effectiveness at 6 months and 1 year. The MMPI hypochondriasis and hysteria scales were moderately related to surgical success, as were the severity of initial restriction in the level of functioning and the number of operations performed during the study. However, the MMPI profiles were strikingly similar for all patients. Factors which were not predictive of surgical outcome included age, sex, duration of symptoms, number of back surgeries prior to entering this clinic, and the degree of pathologic condition discovered at operation. The failure to find a potent prediction scheme confirms that MMPI information must be used with considerable caution in treatment planning and only as an adjunct to other clinical and psychological data.

Backache- its nature, incidence and cost.

In 1974 in California, 72,645 patients were admitted to hospital for backache. In 50 percent of these patients there was a diagnosis compatible with discogenic disease. Surgical treatment was done in 27 percent of the patients admitted to hospital. Total figures were determined for hospital costs and the costs of physician-related services. Costs for surgical treatment exceeded medical costs. Extrapolated to a national scale, it appears that the national cost for patients in hospital because of backache in 1974 was $1.38 billion. This does not include outpatient care expense or loss of income.

Sources of failure in laminectomies.

Failures in laminectomy may be due to improper patient selection, of which the largest factor appears to be a lack of recognition of an underlying psychological disorder. Rarely an operative procedure is performed on the wrong side or at the wrong level. A number of elements relating to what might be termed the "wrong operation" fall under the heading of failure to recognize disease, and the largest factor here in our experience has been the inability to explore the wound because of uncontrolled bleeding. The problem also relates to a lack of understanding of the anatomy and potential disorder of the vertebral axis. This then merges with the other factor, failure to deal with disease, which may be unrecognized or, if identified, misinterpreted. Last are those elements for which there is professional responsibility, the most serious being dural or nerve root irritation predisposing to traumatic arachnoiditis.