Providence nighttime brace is as effective as fulltime Boston brace for female patients with adolescent idiopathic scoliosis: A retrospective analysis of a randomized cohort.

Background: Progressive moderate scoliotic curves in patients with adolescent idiopathic scoliosis (AIS) are usually treated with a fulltime brace, e.g., the Boston brace (BB). The Providence nighttime brace (PNB), is an alternative which is designed to reach the same treatment effectiveness by nighttime wear only. Few studies compared treatment effectiveness between full and nighttime bracing with contradictory results. Methods: Immature female patients older than 10 years with progressive moderate AIS curves with an apex below T6 were randomized into PNB (n=62) or BB (n=49) treatment. Inclusion criteria were AIS, age ≥ 10 years, no previous treatment, main curve Cobb angle 20°-40° and skeletal immaturity. The increase of the main curve by > 5° of Cobb angle at the final follow-up was established as the primary outcome measure. Secondary outcome measures included (1) the Scoliosis Research Society assessment criteria of effectiveness for brace studies, (2) progression of secondary curves, (3) in-brace correction and (4) compliance to the treatment. The patients were followed until 1 year after reaching maturity. Results: A total of 105 patients (n=62 and n=43 in PNB and BB group, respectively) completed the follow-up (95%). In the PNB group, 71% patients were treated successfully compared to 65% patients in the BB group (p=.67). No significant difference of the curve progression was found between the groups (3.1°±6.3° and 2.6°±8.3° in PNB and BB group, respectively; p=.73). No significant differences were found for the thoracic or thoracolumbar/lumbar subgroups. PNB showed a superior in-brace correction for all curve types. One of four secondary curves progressed > 5°. The compliance to the treatment was significantly higher in the PNB than BB group. Conclusions: Both brace regimes are equally effective in treating moderate AIS curves with apex of the main curve below T6 in immature female patients older than 10 years.

Central lumbar spinal stenosis: natural history of non-surgical patients.

PURPOSE: The aim of the present study was to examine the natural history in patients with lumbar spinal stenosis. The incidence of surgery for this condition has increased considerably during the past decades in spite of a fairly favorable natural history in previous studies. METHODS: 146 consecutive patients with clinical signs and image findings of lumbar spinal stenosis, who were not recommended surgical treatment, were followed; the reason as to why surgery was not recommended was a moderate symptom level. The follow-up rate was 89% after 3.3 years. Group values for comorbidities and diagnostic imaging were comparable to patients selected for surgery, with the exception of a lower frequency of degenerative spondylolisthesis among the non-operative patients. The mean age of those observed was 68 (21-91), and 58% were females. RESULTS: During the observation period spontaneous improvements were found for pain and health-related quality of life, but not for walking. Using the minimum clinically important difference for VAS, leg and back pain improved in 32 and 36% of patients, respectively, were unchanged in 55 and 54%, and worsened in 13 and 10%. Findings on diagnostic imaging did not influence patient outcome, except for stenoses with cross-sectional area <0.5 cm2 where spontaneous improvement was not seen. Revision of the decision not to operate occurred in 10 cases (7%). CONCLUSIONS: The natural history of LSS with moderate symptom levels rarely shows symptom deterioration over a median of 3.3 years; in fact, a slight improvement of symptoms was seen at group levels. The treatment decision was revised for 7%, and for the rest an increase in pain was seen in 10-13%. The results support reluctance towards surgery, if the symptom levels are tolerable for the patients.

Preoperative fibrinogen plasma concentration is associated with perioperative bleeding and transfusion requirements in scoliosis surgery.

STUDY DESIGN: Prospective observational study. OBJECTIVE: To investigate the potential association between fibrinogen, bleeding, and transfusion requirements after scoliosis surgery. SUMMARY OF BACKGROUND DATA: Bleeding complications during and after orthopedic surgery are associated with increased morbidity and mortality. Early identification of patients with increased risk of excessive bleeding offers the possibility to initiate countermeasures. Fibrinogen is a key protein in the coagulation cascade, and thus a potential biomarker for bleeding risk. METHODS: A total of 82 otherwise healthy patients (mean age: 15 ± 3 years, 85% girls) undergoing surgery for adolescent idiopathic scoliosis were included in the study. Patient variables (age, gender, operation time, and thrombosis prophylaxis), preoperative laboratory variables (hemoglobin, platelet count, activated partial thromboplastin time [aPTT], prothrombin time [PT], and fibrinogen), peroperative and postoperative bleeding volume, and transfusions were registered. Correlations between laboratory variables and bleeding volume were calculated with Pearson test. Patient variables and laboratory variables were compared with Student t test between patients with bleeding volume in the upper quartile ("bleeders") and the remaining patients, and between patients with extensive transfusion (defined as >2 U of packed red cells) and no or limited transfusions (≤ 2 U). RESULTS: Mean fibrinogen concentration was 3.0 ± 0.7 g/L (range, 1.3- 4.9). Mean total perioperative bleeding volume was 1552 ± 1019 mL (range, 100-5800 mL). Total bleeding volume correlated significantly with preoperative fibrinogen concentration (r = -0.31, P = 0.005) but neither with platelet count, aPTT, nor PT (P = 0.61, 0.46, and 0.57, respectively). Bleeders had significantly lower preoperative fibrinogen plasma concentration (2.6 ± 0.6 vs. 3.1 ± 0.6 g/L, P = 0.002). Of total, 16% (13/82) of the patients were transfused with >2 U of packed red cells. Patients with extensive transfusions had significantly lower preoperative fibrinogen plasma concentration (2.5 ± 0.7 vs. 3.1 ± 0.6 g/L, P = 0.002), while preoperative platelet count, aPTT, and PT did not differ. CONCLUSION: The results indicate that preoperative fibrinogen concentration is a limiting factor for postoperative hemostasis during and after scoliosis surgery. Preoperative measurement of fibrinogen concentration provides more information about bleeding volume and transfusion requirements than standard screening tests.

Validity of a computer touch-screen questionnaire system in back patients.

STUDY DESIGN: Validation study. OBJECTIVE: A system for patient self-recording on a computer touch-screen was developed. The validity of this method compared with the use of regular paper-and-pen questionnaires was studied. SUMMARY OF BACKGROUND DATA: Systematic evaluation of health problems often involves the use of self-reporting questionnaires in order to collect data on different variables. Recording of such data for subsequent analysis requires several steps including filling out of paper forms and secretarial work. Missing values and misrecordings are frequent problems. METHODS: Seventy-nine patients with back problems visiting our outpatient clinic for surgical evaluation were invited to take part in the study by answering a mailed questionnaire concerning background data, pain, function, quality of life, and depressive symptoms approximately 3 weeks before their visit. At the day of the visit they were asked to again answer the same questions with a replicate response option format displayed on a computer touch-screen. RESULTS: The agreement concerning background history questions, measured by kappa values was generally good (0.71-1.0). For visual analogue scale recordings (0-100) of back and leg pain, the mean of the differences were 1.1 and 2.1, respectively, and the correlations (Pearson) 0.72 and 0.87. The Euro-Qol 5 Dimension Score, the General Function Score, the Zung Depression Scale and the physical dimensions of the Short Form-36 showed a high degree of agreement between paper and screen recordings with difference means close to 0 and reliabilities comparing well to published methodologic errors for paper form versions. There were, however, differences concerning the mental components of the SF-36 with somewhat higher ratings on screen recordings. Missing values were 0% for screen recordings and for paper forms, 2.3% on individual questions and 12% on composite scores. CONCLUSION: Computerized touch-screen questionnaires virtually eliminates missing values and show good validity and reliability compared to paper forms. The SF-36 tended to produce slightly higher values on touch-screen recordings in questions concerning mental health.

Surgical results in hidden lumbar spinal stenosis detected by axial loaded computed tomography and magnetic resonance imaging: an outcome study.

STUDY DESIGN: An outcome study of patients with neurogenic claudication and/or sciatica with hidden stenosis, detected only by axial loading of the lumbar spine (ACE) but not at the traditional unloaded examination (psoas relaxed position) during computed tomography (CT) myelography or magnetic resonance imaging (MRI), followed up after surgery. OBJECTIVE: To estimate the clinical effect of decompression with or without fusion in patients with hidden stenosis in the lumbar spine. SUMMARY OF BACKGROUND DATA: A number of patients with neurogenic claudicatio with or without sciatica do not have corresponding imaging abnormalities. Axial loaded CT and MRI have disclosed hidden stenosis in certain cases. The surgical effect in patients with hidden stenosis has never been described. METHODS AND MATERIALS: Axial loading of the lumbar spine during CT and MRI was performed in 250 patients with neurogenic claudication and sciatica. All fulfilled the inclusion criteria for ACE, i.e., suspected but not verified spinal stenosis in 1 to 3 levels. In 125 patients (50%), a significant narrowing of the spinal canal occurred. Out of these 125 patients, 101 had a clear stenosis besides the stenosis only detected at ACE. In 24 patients, a hidden stenosis was detected in 1 to 3 levels only at the ACE. These patients were observed for 1 to 6 years after decompression with or without fusion regarding subjective improvement of leg and back pains, walking capacity, satisfaction, and health related quality of life. RESULTS: At follow-up, 76% of the patients had leg pain less than 25/100 on a VAS scale and 62% had back pain less than 25/100. Ninety-six percent were improved or much improved regarding leg and back pains The ability to walk increased significantly after surgery. Walking capacity to more than 500 m increased from 4% to 87%. Twenty-two patients were subjectively satisfied with the surgical results. The ODI score, the SF-36 and the EQ-5D score corresponded well to the above mentioned improvements at follow-up. CONCLUSION: According to this study, the results of surgery in hidden lumbar stenosis only detected by axial compression in extension during CT or MRI, are convincing and comparable with the results of surgical treatment for stenoses diagnosed by unloaded examinations.

Comparison of Cobb angles in idiopathic scoliosis on standing radiographs and supine axially loaded MRI.

STUDY DESIGN: Prospective, patient controlled. OBJECTIVE: To compare Cobb angles in idiopathic scoliosis between standing radiographs and a nonradiographic procedure. SUMMARY OF BACKGROUND DATA: Repeated radiographic examinations at young age may increase the risk for breast cancer in adulthood. MRI images the spine satisfactorily but is cumbersome in standing. A harness supplying axial load to a lying subject simulates the standing radiograph appearance of the lumbar spine. METHODS: Thirty patients with idiopathic scoliosis greater than 20 degrees performed a routine posteroanterior and lateral standing thoracolumbar spine radiograph and an MRI in supine position without and with axial loading. RESULTS: Mean Cobb angle for the major curve was 31 degrees on standing radiographs, 23 degrees on nonloaded supine MRI, and 31 degrees on supine loaded MRI. Axially loaded, compared with nonloaded, MRI increased the Cobb angle by 8 degrees. The mean difference between standing radiograph and supine axially loaded MRI was 0 degrees, with an intermethodologic variation(s) of 3.4 degrees. Radiographic and MRI (axially loaded) Cobb angles correlated positively (r = 0.78). CONCLUSIONS: Axial loading on supine MRI produces coronal Cobb angles similar to standing radiographs. This is a way to acquire reliable Cobb angles without radiation in the monitoring of idiopathic scoliosis.

Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective multicenter randomized study from the Swedish lumbar spine study group.

STUDY DESIGN: A multicenter randomized study with a 2-year follow-up period and an independent observer was conducted. OBJECTIVE: To compare three commonly used surgical techniques to achieve lumbar fusion primarily in terms of their ability to reduce pain and decrease disability in patients with severe chronic low back pain. SUMMARY OF BACKGROUND DATA: Lumbar fusion can be used to reduce pain and decrease disability in patients with chronic low back pain, and different surgical techniques are available. The reported results after fusion surgery vary considerably, but most studies are retrospective and/or performed on heterogeneous patient groups. Spine surgeons commonly use the techniques presented in this report. However, in the absence of randomized trials it is difficult to know whether any one of them is better than the others for these patients. METHODS: From 1992 through 1998, 294 patients referred to 19 spinal centers were blindly randomized into four treatment groups: three surgical groups (n = 222) and one nonsurgical group (n = 72). The sociodemographic and clinical characteristics did not differ among the groups. Eligibility included patients 25 to 65 years of age with therapy-resistant chronic low back pain that had persisted for at least 2 years and radiologic evidence of disc degeneration (spondylosis) at L4-L5, L5-S1, or both. Only patients randomized to one of three surgical groups were analyzed in the current study: Group 1 (posterolateral fusion; n = 73), Group 2 (posterolateral fusion combined with variable screw placement, an internal fixation device; n = 74), and Group 3 (posterolateral fusion combined with variable screw placement and interbody fusion; n = 75). The "circumferential fusion" in Group 3 was performed either as an anterior lumbar interbody fusion (n = 56) or as a biomechanically similar posterior lumbar interbody fusion (n = 19). The groups were composed of 51%, 58%, and 40% men respectively, and the respective mean ages were 44, 43, and 42 years. The patients had experienced low back pain for at least 2 years (mean, approximately 8 years). They had been on sick leave for approximately 3 years. Pain was measured by a visual analog scale, and disability was assessed by the Oswestry Low Back Pain Questionnaire, the Million Visual Analogue Score, and the General Function Score. Depressive symptoms were measured by the Zung Depression Scale. The global overall rating of the result was assessed by the patient and an independent observer after 2 years. Hospitalization data including operation time, blood loss, blood transfusion, and days of hospitalization in connection with surgery were reported, along with complications and the fusion rate. Records from the Swedish Social Insurance Board providing information on sick leave and economic compensation for Swedish residents were used to evaluate the patients' work status. RESULTS: An independent observer examined 201 (91%) of 222 patients after 2 years, after 18 "group changers" and 3 dropouts had been excluded from the analyses. All surgical techniques were found to reduce pain and decrease disability substantially, but no significant differences were found among the groups. In all three groups, the patients rated the overall outcome similarly, as did the independent observer. The more demanding techniques in Groups 2 and 3 consumed significantly more resources in terms of operation time, blood transfusions, and days in hospital after surgery. The early complication rate was 6% in Group 1, 16% in Group 2, and 31% in Group 3. The fusion rate, as evaluated by plain radiograph, was 72% in Group 1, 87% in Group 2, and 91% in Group 3. CONCLUSIONS: All the fusion techniques used in the study could reduce pain and improve function in this selected group of patients with severe chronic low back pain. There was no obvious disadvantage in using the least demanding surgical technique of posterolateral fusion without internal fixation.