Assessment of factors affecting quality of life in patients with chronic pain due to knee osteoarthritis and spondylosis: spine versus knee?

OBJECTIVE: There is no study comparing knee and spine osteoarthritis. The purpose of the study is to examine the effects of pain and disability on quality of life (QoL) and the factors affecting QoL in patients with knee osteoarthritis and spondylosis. METHODS: This cross-sectional study included 114 patients with spondylosis and 126 patients with knee osteoarthritis. Demographic data were recorded. The visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Roland Morris Questionnaire (RMQ), and the Short Form Health Questionnaire (SF-36) were filled out. RESULTS: Statistically, patients with spondylosis and knee osteoarthritis did not differ significantly in terms of gender, age, body mass index, number of concomitant conditions, marital status, years of schooling, pain scores, or SF-36 characteristics. SF-36 physical function, vitality, and mental health assessments were lower in women than men, while VAS scores were higher. There was no correlation between marital status, educational level, and QoL subscales. WOMAC and RMQ scores were negatively correlated with the SF-36 subscales. RMS scores were not related to mental health. CONCLUSIONS: Spondylosis and knee osteoarthritis affect all subscales of QoL in the same way. The management of patients with spondylosis and knee osteoarthritis should focus on pain and functionality to improve QoL.

Time Course of Physical and Mental Well-being Improvements After Cervical Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To elucidate the postoperative time course of improvements in physical and mental well-being in patients with cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Spinal surgeons should understand the postoperative course in detail. However, data are still needed regarding the time course of improvements in well-being, a fundamental aspect of human life, after cervical surgery for CSM. METHODS: One hundred consecutive patients who underwent laminoplasty for CSM, with complete clinical data preoperatively and 3 months and 2 years postoperatively, were enrolled. The Short Form-36 physical component summary (PCS) and mental component summary (MCS) scores were used as parameters of physical and mental well-being, respectively, and 4.0 was defined as the minimal clinically important difference (MCID) for both parameters. RESULTS: On average, PCS and MCS scores were significantly improved after surgery (P < 0.001, P=0.004, respectively). Moreover, 64 and 48 patients achieved meaningful improvement (>MCID) in PCS and MCS scores at 3 months postoperatively, with maintained improvement (to 2 yr) in 46/64 (71.9%) and 34/48 patients (70.8%), respectively (PCS vs. MCS: P = 0.912). Additionally, 15 of 36 patients (41.7%) and 8 of 52 patients (15.4%) achieved late improvement (meaningful improvement at 2 yr but not at 3 months) in PCS and MCS scores, respectively (PCS vs. MCS: P = 0.007). In multivariate regression analysis, improvement in cJOA score was significantly associated with PCS improvement, but not MCS improvement, at both 3 months and 2 years (P = 0.001, P > 0.001, respectively). CONCLUSION: The overall outcome of physical well-being improvement is decided within 3 months postoperatively, in proportion to the recovery in myelopathy, with a relatively high chance of meaningful improvement over the next 21 months. The outcome of improvement in mental well-being is decided within 3 months postoperatively, independently from the recovery in myelopathy, with a low chance of meaningful improvement over the next 21 months.Level of Evidence: 3.

Analysis of Cervical Sagittal Balance in Treating Cervical Spondylotic Myelopathy: 1-Level Anterior Cervical Corpectomy and Fusion Versus 2-Level Anterior Cervical Discectomy and Fusion.

BACKGROUND Anterior cervical corpectomy and fusion (ACCF), together with anterior cervical discectomy and fusion (ACDF) are both effective clinical treatments for cervical spondylotic myelopathy (CSM). Cervical sagittal balance is critical to preserving normal alignment, and is also associated with clinical outcomes. MATERIAL AND METHODS We retrospectively reviewed patients who had suffered from CSM and had undergone 1-level ACCF or 2-level ACDF surgery between December 2016 and November 2017. Forty-eight patients were identified: 25 in the ACDF group and 23 in the ACCF group. All patients received follow-up for more than 12 months. The demographic data, radiographic parameters, and clinical efficacy were compared between and within groups, both pre- and postoperatively. RESULTS Both groups acquired good clinical efficacy; both Japanese Orthopedic Association (JOA) scores and Neck Disability Index (NDI) scores improved significantly. At the final follow-up visit, patients in the ACCF and ACDF groups did not differ significantly in C2-C7 Sagittal Vertebral Axis (cSVA), T1 Pelvic Angle (TPA), Neck Tilt (NT), Thoracic Inlet Angle (TIA), JOA, or NDI scores. However, the ACDF group had a significantly larger Cobb angle and T1 Slope (T1S) than the ACCF group. The postoperative Cobb angle increased significantly only in the ACDF group, while postoperative T1S significantly increased in both ACCF and ACDF groups. CONCLUSIONS Anterior cervical surgery may change the sagittal balance in terms of T1S or Cobb angle. No significant difference was found between ACCF and ACDF in clinical outcomes or representative global sagittal parameters. ACDF achieved more lordosis improvement than ACCF, with higher T1S. Surgeons need to pay extra attention to cervical sagittal balance, rather than focusing solely on decompression.

Improvement in Patient Mental Well-being After Surgery for Cervical Spondylotic Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to investigate changes in mental well-being after surgery for cervical spondylotic myelopathy (CSM) and identify factors associated with improvement. SUMMARY OF BACKGROUND DATA: Posterior cervical surgery with laminoplasty significantly improves myelopathy and physical function in patients with CSM. However, its impact on mental well-being is unclear. METHODS: Patients who underwent laminoplasty for CSM and had >2 years of follow-up were reviewed (n = 111). The mental component summary (MCS) score was used as a measure of mental well-being. The trend in MCS score change was evaluated using the Jonckheere-Terpstra trend test. Preoperative clinical scores were compared between patients with improvements greater and less than the minimal clinically important difference (MCID). Significant variables were included in a multinomial logistic regression analysis and further validated in a receiver-operating characteristic (ROC) curve analysis. Additionally, the results were confirmed in a long-term observation cohort of patients followed up for >5 years (n = 46). RESULTS: The improvement in the average MCS score (5.6) was greater than the MCID (4.0). The trend of improvement was sustained for 2 years (P = 0.002), but not for 5 years (P = 0.130). In terms of individual cases, 56 patients (50.5%) achieved MCS score improvement greater than the MCID. These patients showed significantly lower preoperative MCS scores than those without meaningful improvement (P < 0.001). The preoperative "social functioning (SF)" score was independently associated with MCS score improvement (P = 0.001). ROC curve analysis validated the ability of preoperative SF to predict MCS score improvement at 2 and 5 years postoperatively (area under the curve: 0.744, 0.893, respectively). CONCLUSION: Half of the patients achieved meaningful improvement in mental well-being. A lower preoperative SF score was independently associated with improvement. These results may help identify patients who could experience an improvement in mental well-being after surgery and develop novel approaches to achieve further improvement. LEVEL OF EVIDENCE: 3.

Patients' beliefs about diagnosis and treatment of cervical spondylosis with radiculopathy.

BACKGROUND: The clinical results of surgical spine care may be influenced by the patients' understanding and knowledge of his or her condition, treatment options and decision-making process. The aim of this survey study was to evaluate certain beliefs and opinions of patients with a degenerative condition in the cervical spine with a history of cervical radiculopathy such as importance of magnetic resonance imaging, risk factors, treatment alternatives and effectiveness. METHODS: An anonymous questionnaire survey was performed on two different patient populations with a degenerative condition in the cervical spine with a history of cervical radiculopathy referred to the outpatients' clinics of two neurosurgical departments in Germany and Norway. The survey consisted of seven questions: four questions about the respondents' gender and age, history of previous spine surgery and/or conservative treatment for cervical disorder and three questions regarding the importance of imaging in the decision-making process, patients' willingness to undergo cervical surgery based on imaging findings even with few or no symptoms and the effectiveness of surgical or conservative treatment. RESULTS: Two hundred eleven patients answered the questionnaire. Sixty-seven percent of all patients with a degenerative cervical condition believe that results from MRI studies are more important than clinical findings. Forty-seven percent were willing to undergo surgery based on MRI showing abnormalities even without or having few symptoms. Fifty percent believe that surgery is more effective in the treatment of axial neck pain. CONCLUSION: Misbeliefs and misconceptions exist concerning certain aspects of the diagnosis and management in patients with degenerative conditions in the cervical spine with a history of cervical radiculopathy in a large proportion of patients referred to neurosurgical outpatient clinics.

Comparing Quality of Life in Cervical Spondylotic Myelopathy with Other Chronic Debilitating Diseases Using the Short Form Survey 36-Health Survey.

BACKGROUND: Although cervical spondylotic myelopathy (CSM) can be devastating, its relative impact on general health remains unclear. Patient responses to the Short Form Survey 36-Health Survey (SF-36) Physical Component Summary (PCS)/Mental Component Summary (MCS) were compared between CSM and other diseases to evaluate their respective impacts on quality of life. The objective of this study was to compare SF-36 PCS/MCS scores in CSM with population and disease-specific norms. METHODS: Retrospective analysis of a prospective, multicenter AOSpine North American CSM Study database. Inclusion criteria were symptomatic disease, age older than 18 years, cord compression on magnetic resonance imaging or computed tomography myelography, and baseline SF-36 values. SF-36 PCS/MCS scores in CSM were compared with national normative values and disease-specific norms using Student t test. Analysis of variance was used to assess differences across age groups and offsets from age-matched controls. Threshold for significance was P < 0.05. RESULTS: There were 285 patients who met the inclusion criteria. The mean age was 56.6 ± 12.0 years, with male predominance (60%). SF-36 scores revealed significant baseline disability (PCS: 34.5 ± 9.8; MCS: 41.5 ± 14.4). Although there were no differences across age groups, when compared with age-matched normative data, younger patients had a larger PCS offset than older patients. CSM caused worse physical disability than most diseases except heart failure. Only back pain/sciatica induced worse mental disability. CONCLUSIONS: CSM affects quality of life to an extent greater than diabetes or cancer. Although mean impact of CSM does not vary with age, younger patients suffer from greater differences in baseline function. This study highlights the impact of myelopathy on patient function, particularly among younger age groups, and suggests that CSM merits a similar caliber of healthy policy attention as more well-studied diseases.

Psychometric properties of the 30-m walking test in patients with degenerative cervical myelopathy: results from two prospective multicenter cohort studies.

BACKGROUND CONTEXT: The timed 30-m walking test (30MWT) is used in clinical practice and in research to objectively quantify gait impairment. The psychometric properties of 30MWT have not yet been rigorously evaluated. PURPOSE: This study aimed to determine test-retest reliability, divergent and convergent validity, and responsiveness to change of the 30MWT in patients with degenerative cervical myelopathy (DCM). STUDY DESIGN/SETTING: A retrospective observational study was carried out. PATIENT SAMPLE: The sample consisted of patients with symptomatic DCM enrolled in the AOSpine North America or AOSpine International cervical spondylotic myelopathy studies at 26 sites. OUTCOME MEASURES: Modified Japanese Orthopaedic Association scale (mJOA), Nurick scale, 30MWT, Neck Disability Index (NDI), and Short-Form-36 (SF-36v2) physical component score (PCS) and mental component score (MCS) were the outcome measures. METHODS: Data from two prospective multicenter cohort myelopathy studies were merged. Each patient was evaluated at baseline and 6 months postoperatively. RESULTS: Of 757 total patients, 682 (90.09%) attempted to perform the 30MWT at baseline. Of these 682 patients, 602 (88.12%) performed the 30MWT at baseline. One patient was excluded, leaving601 in the analysis. At baseline, 81 of 682 (11.88%) patients were unable to perform the test, and their mJOA, NDI, and SF-36v2 PCS scores were lower compared with those who performed the test at baseline. In patients who performed the 30MWT at baseline, there was very high correlation among the three baseline 30MWT measurements (r=0.9569-0.9919). The 30MWT demonstrated good convergent and divergent validity. It was moderately correlated with the Nurick (r=0.4932), mJOA (r=-0.4424), and SF-36v2 PCS (r=-0.3537) (convergent validity) and poorly correlated with the NDI (r=0.2107) and SF-36v2 MCS (r=-0.1984) (divergent validity). Overall, the 30MWT was not responsive to change (standardized response mean [SRM]=0.30). However, for patients who had a baseline time above the median value of 29 seconds, the SRM was 0.45. CONCLUSIONS: The 30MWT shows high test-retest reliability and good divergent and convergent validity. It is responsive to change only in patients with more severe myelopathy. The 30MWT is a simple, quick, and affordable test, and should be used as an ancillary test to evaluate gait parameters in patients with DCM.

Psychometric analysis and critical appraisal of the original, revised, and modified versions of the Japanese Orthopaedic Association score in the assessment of patients with cervical spondylotic myelopathy.

OBJECTIVE Cervical spondylotic myelopathy (CSM) is the most common cause of nontraumatic spinal cord impairment and disability in the world. Given that the Japanese Orthopaedic Association (JOA) score is the most frequently used outcome measure in clinical research and practice for treating patients with CSM, this review was undertaken to comprehensively and critically evaluate the psychometric properties of the JOA score. METHODS The authors identified studies (published in the period of January 1975 to November 2015) on the psychometric properties of the original, revised, and modified versions of the JOA score in Medline, PsycINFO, Excerpta Medica dataBASE (EMBASE), American College of Physicians Journal Club, and Cochrane Database of Systematic Reviews. Additional publications were captured in a secondary search of the bibliographies in both original research articles and literature reviews identified in the original search. The JOA scores were evaluated for item generation and reduction, internal consistency, reliability, validity, and responsiveness. This review included all those versions of the JOA score whose psychometric properties had been reported in at least 2 published studies. RESULTS The primary search strategy identified 59 studies, of which 9 fulfilled the inclusion and exclusion criteria. An additional 18 publications were captured in the secondary search and included in the analysis. The key findings from the 27 studies analyzed indicated the following: 1) the original JOA score (1975) was the source for the revised JOA score (1994) and 3 modified versions (1991, 1993, and 1999 JOA scores) reported or used in at least 2 published studies; 2) the revised and modified versions of the JOA score are markedly different from each other; 3) only the revised JOA score (1994) was validated with the original JOA score; and 4) the 1975 JOA score is the most appropriate instrument for assessing patients in Asian populations (especially from Japan) because of its psychometric attributes, and the 1991 JOA score is the most appropriate version for use in Western populations. CONCLUSIONS The authors' results indicate that the original (1975), revised (1994), and modified (1991, 1993, and 1999) versions of the JOA score are substantially different from each other in terms of their content and have been incompletely examined for their psychometric properties and cultural sensitivity. Whereas the 1975 JOA score is the most appropriate version for assessing individuals from Asian populations (particularly those eating with chopsticks), the 1991 JOA score is most suitable for evaluating patients in Western populations. Nonetheless, further investigation of the psychometric properties of the 1975 and 1991 JOA scores is recommended because of a paucity of studies reporting on the responsiveness of these 2 scoring instruments.

Correlation of quality of life and functional outcome measures for cervical spondylotic myelopathy.

OBJECT: Studies comparing surgical treatments for cervical spondylotic myelopathy (CSM) are heterogeneous, using a variety of different quality of life (QOL) outcomes and myelopathy-specific measures. This study sought to evaluate the relationship of these measures to each other, and to better understand their use in evaluating patients with CSM. METHODS: A retrospective study was performed in all patients with CSM who underwent either ventral or dorsal cervical spine surgery at a single tertiary-care institution between January 2008 and July 2013. Severity of myelopathy was assessed pre- and postoperatively using both the Nurick scale and the modified Japanese Orthopaedic Association (mJOA) classification of disability. Prospectively collected QOL outcomes data included Pain Disability Questionnaire (PDQ), Patient Health Questionnaire-9 (PHQ-9), and EQ-5D. Spearman rank correlations were calculated to assess the construct convergent validity for each pair of health status measures (HSMs). To assess each HSM's ability to discriminate favorable EQ-5D index, we performed receiver operating characteristic (ROC) curve analysis and assessed the area under the curve (AUC). RESULTS: A total of 119 patients were included. The PDQ total score had the highest correlation with EQ-5D index (Spearman's rho = -0.82). Neither of the myelopathy scales (mJOA or Nurick) had strong correlations between themselves (0.41) or with the other QOL measures (absolute value range 0.13-0.49). In contrast, the QOL measures correlated relatively well with each other (absolute value range 0.68-0.97). For predicting favorable EQ-5D outcomes, PDQ total score had an AUC of 0.909. The AUCs were significantly greater for the QOL measures in comparison with the myelopathy measures (AUCs were 0.677 and 0.607 for mJOA and Nurick scale scores, respectively). CONCLUSIONS: The authors found that all included measures of QOL and CSM-specific (mJOA or Nurick scale) measures were valid and responsive. The PDQ was the most predictive of positive QOL after surgery (as measured by the EQ-5D index) for patients with CSM. The substantially lower correlation between myelopathy and QOL outcomes, compared with the various QOL measures themselves, suggests that these questionnaires are measuring different aspects of the patient experience. Solely assessing the myelopathy or disease-specific signs and symptoms is likely insufficient to fully understand and appreciate clinical outcome in its totality. These questionnaire types should be used together to best evaluate patients pre- and postoperatively.

Assessment of the minimum clinically important difference in neurological function and quality of life after surgery in cervical spondylotic myelopathy patients: a prospective cohort study.

PURPOSE: The purpose of this study was to evaluate the application of the minimum clinically important difference (MCID) concept to postoperative clinical results by using a prospective cohort study in Chinese patients with cervical spondylotic myelopathy (CSM). METHODS: The sample consisted of 113 patients who underwent surgical treatment for CSM in our hospital between February 2008 and November 2012. The preoperative and 1-year postoperative modified Japanese Orthopaedic Association (mJOA) scores, mJOA score recovery rate, physical component summary (PCS) and mental component summary (MCS) of the Short Form 36 were collected. The MCID of each outcome measurement was calculated by four approaches including average change, minimum detectable change, change difference and receiver operating characteristic curve. The responsiveness of each measurement was then analyzed. RESULTS: The patients presented a statistically significant improvement (p < 0.01) postoperatively in mJOA, PCS, and MCS. The MCID calculated by four approaches varied from 4.09 to 9.62 for the PCS, 3.11 to 7.41 for the MCS, 1.25 to 3.07 for mJOA score, and 31.37 to 44.02% for mJOA recovery rate. In addition, the improvement of the mJOA score owned the highest responsiveness of the four outcome measurements. CONCLUSIONS: The threshold value of the MCID was determined by the choice of the assessment approach. In addition, the recovery rate of the mJOA score appeared to be the most valid and responsive measure of effectiveness of surgery in CSM patients.

Assessment of health-related quality of life using the SF-36 in Chinese cervical spondylotic myelopathy patients after surgery and its consistency with neurological function assessment: a cohort study.

BACKGROUND: We aimed to calculate the responsiveness and statistically prove the reliability of the Medical Outcomes Study Short Form Health Survey (SF-36) in a prospective cohort study. We investigated the profile of mid-term health-related quality of life (QOL) outcome assessments after surgery for cervical spondylotic myelopathy (CSM) and determined the consistency of the SF-36 assessments of neurological function. METHODS: A total of 142 consecutive patients with CSM who underwent surgery were enrolled in the study. QOL and neurological assessments were evaluated before and at 3 months, 1 year, and more than 2 years postoperatively. We subsequently analyzed the reliability and responsiveness of the SF-36 and the QOL profile for its consistency regarding the neurological function assessment. RESULTS: (1) Cronbach's α ranged from 0.73 (for role-emotional) to 0.85 (for physical function). The effect size ranged from 0.57 to 0.93 for SF-36's eight scales. Minimum clinically important differences (MCIDs) in the physical scores (PCS) and mental scores (MCS) were 5.52 and 3.43, respectively. (2) The scores for all SF-36 scale sections indicated that patients with CSM were significantly impaired compared with healthy adults. SF-36 PCS and MCS peaked at 17.7 and 18.9 months after surgery, respectively. (3) At 3 months after surgery, improvements in the modified Japanese Orthopaedic Association (mJOA) scores significantly correlated only with patients' physical function and bodily pain scores. At 1 year after surgery, improvements in the mJOA scores significantly correlated with physical function, general health, social function, and role-emotional. At the final follow-up, improvements in the mJOA scores significantly correlated with physical function, vitality, and role-emotional. CONCLUSIONS: SF-36 is reliable and has moderate responsiveness for evaluating patients with CSM, with MCID at 5.52 for the PCS and at 3.43 for the MCS. The preoperative QOL of the CSM patients was severely impaired compared with that of the normal population. Postoperatively, each SF-36 domain improved to a variable degree. During the early stage of recovery the mJOA score improvements correlated with SF-36's physical component domains, whereas during the later stages the improvements were associated with the mental component domains.

The impact of preoperative depression on quality of life outcomes after posterior cervical fusion.

BACKGROUND CONTEXT: Posterior cervical fusion (PCF) has been shown to be an effective treatment for cervical spondylosis, but is associated with a 9% complication rate and high costs. To limit such complications and costs, it is imperative that proper selection of surgical candidates occur for those most likely to do well with the surgery. Affective disorders, such as depression, are associated with worsened outcomes after lumbar surgery; however, this effect has not been evaluated in patients undergoing cervical spine surgery. PURPOSE: To assess the predictive value of preoperative depression and the health state on 1-year quality of life (QOL) outcomes after PCF. STUDY DESIGN: A retrospective cohort analysis. PATIENT SAMPLE: Eighty-eight patients who underwent PCF for cervical spondylosis were reviewed. OUTCOME MEASURES: Preoperative and 1-year postoperative health outcomes were assessed based on the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire-9 (PHQ-9), and the EuroQol five-dimensions (EQ-5D) questionnaire. METHODS: Univariable and multivariable regression analyses were performed to assess for preoperative predictors of 1-year change in health status. RESULTS: Compared with preoperative health states, the PCF cohort showed statistically significant improved PDQ (87.8 vs. 73.6), PHQ-9 (7.7 vs. 6.6), and EQ-5D (0.50 vs. 0.60) scores at 1 year postoperatively. Only 10/88 (11%) patients achieved or surpassed the minimum clinically important difference for the PHQ-9 (5). Multiple linear and logistic regression analyses showed that increasing PHQ-9 and EQ-5D preoperative scores were associated with reduced 1-year postoperative improvement in health status (EQ-5D index). CONCLUSIONS: Of patients who undergo PCF, those with a greater degree of preoperative depression have lower improvements in postoperative QOL compared with those with less depression. Additionally, patients with better preoperative health states also attain lower 1-year QOL improvements.

Psychometric properties of the Polish language version of the chronic pain coping inventory-42 for patients treated surgically due to herniated lumbar discs and spondylotic changes.

BACKGROUND: The development of a pain-management program tailored to the specific needs of patients with chronic low back pain (CLBP) requires the proper assessment of psychosocial factors affecting each individual. The Chronic Pain Coping Inventory-42 (CPCI-42) refers to coping strategies, which are commonly defined as the cognitive and behavioral techniques an individual may resort to in stressful or demanding situations. Evidence from a number of sources suggests that differences in pain coping strategies may significantly affect how an individual deals with chronic pain. We aimed to adapt the CPCI-42 to Polish cultural conditions (PL-CPCI-42) and then verify its psychometric properties based on a group of patients treated surgically due to herniated lumbar discs and coexisting spondylotic changes. MATERIAL AND METHODS: The average age of the study participants (n=90) was 43.47 years (SD 10.21). The average duration of chronic low back pain (CLBP) was 49.37 months (SD 64.71). Lumbosacral spine X-rays and magnetic resonance imaging scans were performed and all patients completed the PL-CPCI-42 and the Polish versions of the Numeric Pain Rating Scale (NPRS-PL) twice. Internal consistency of the PL-CPCI-42, floor and ceiling effects, test-retest reliability, and criterion validity were analyzed. RESULTS: Resting, guarding, and coping self-statements were frequently used as coping strategies both in the test and in the retest, in contrast to relaxation and exercise/stretch. The NPRS-PL result was 5.70 cm in the test and 5.66 in the retest. Cronbach's alpha values were recorded for the asking for assistance, coping self-statements, and seeking social support domains (0.83, 0.80, 0.83, respectively). Test-retest reliability of the PL-CPCI-42 varied from 0.53 (relaxation domain) to 0.84 (asking for assistance and coping self-statements domains). CONCLUSIONS: The present study provides evidence of the validity of the PL-CPCI-42 and supports its usefulness in assessing chronic pain coping strategies, which are especially important to pain adjustment and in the creation of multidisciplinary pain management programs for patients with severe CLBP.

Effectiveness of acupuncture intervention for neck pain caused by cervical spondylosis: study protocol for a randomized controlled trial.

BACKGROUND: Neck pain caused by cervical spondylosis has become a common health problem worldwide among >40-year-old adults. Acupuncture intervention is one of the most popular treatment measures for this disorder. However, evidence for its efficacy in relieving neck pain and recovering neck physiological function has not been established in randomized, placebo-controlled trials. The primary aim of this trial is to assess the efficacy and safety of active acupuncture compared with sham acupuncture intervention for neck pain caused by cervical spondylosis. METHODS/DESIGN: We will conduct a randomized, double-blind, parallel-group, placebo-controlled trial comparing active acupuncture with placebo (sham acupuncture). A total of 456 patients with neck pain caused by cervical spondylosis who meet the eligibility criteria from outpatient clinics of the Second People's Hospital of Fujian Province and the Affiliated Rehabilitation Hospital, Fujian University of Traditional Chinese Medicine will be recruited and randomized into an active acupuncture or sham acupuncture group. The participants will undergo treatment sessions with either active or sham acupuncture intervention five times a week for 2 weeks. Evaluation by blinded assessors at baseline and at intervention for 1 and 2 weeks will include demographic characteristics, validated questionnaires (Northwick Park Neck Pain Questionnaire (NPQ) scale, Short-Form 36 (SF-36) scale, and McGill pain scale), examination of neck physiological function, and adverse events. All included patients will be followed up and investigated for relapse of neck pain at 4, 8, and 12 weeks after intervention. DISCUSSION: This paper describes the rationale and design of a randomized double-blind, placebo-controlled trial that aims to determine the efficacy and safety of acupuncture intervention for neck pain caused by cervical spondylosis. The primary outcomes are changes in the NPQ score and neck physiological function. Secondary outcome measures include quality of life, adverse events, and relapse of neck pain. If successful, this project will provide evidence of the efficacy and safety of acupuncture for neck pain caused by cervical spondylosis. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR-TRC-12002206. Registration date: 11 May 2012.

A questionnaire-based study on patients' experiences with rechargeable implanted programmable generators for spinal cord stimulation to treat chronic lumbar spondylosis pain.

OBJECTIVE: The latest generation of rechargeable implantable programmable generators (IPGs) for spinal cord stimulation may greatly extend IPG lifespan compared with previous nonrechargeable devices. This study explores patients' experiences with these devices. MATERIALS AND METHODS: Twenty-five patients attending the Department of Neurostimulation, Royal London Hospital, who were implanted with a rechargeable IPG (SC-1110; Boston Scientific, Minneapolis, MN, USA) to provide pain relief from post-surgical lumbosacral spondylosis were surveyed using a questionnaire. RESULTS: Patients reported a mean (SD) benefit from stimulation of 43.7% (32.6%). On a 1 (worst) to 5 (best) scale, the median score was 5 for ease of recharging. Eight patients who had previously had nonrechargeable IPGs felt the rechargeable system was better (p= 0.0143). A particular issue with nonrechargeable batteries was that, while patients considered 5 years an acceptable interval for battery replacements and the procedure itself not too inconvenient, they felt an acceptable wait for replacement after failure to be only 1 week, much shorter than actual waiting times. CONCLUSIONS: Patients found the rechargeable IPG easy to recharge and those who had had previous experience with nonrechargeable devices preferred using the rechargeable device. Its benefits in terms of pain relief fell within the range expected from previous studies using nonrechargeable batteries. The main disadvantage of nonrechargeable devices as reported by the patients in this study was concern over the length of time they would have to wait without pain relief between battery replacements.

Psychological attachment in patients with spondylosis of cervical and lumbar spine.

Persons with spondylosis of the cervical spine have a low sense of security, difficulties in relationships with their mothers, difficulties in contact with their own body and in coping with dysphoric affect. The question arises: Are those problems the result of the current medical condition, or one of its causes? In order to find the answer one should look closer at the period of an individual's life when a sense of security and a pattern of emotional relationships are formed, and a sense of own body and defence attitudes are developed. The earliest period of life in which these processes occur is the initial relationship between the child and mother; the period of attachment and object relation. If the attachment style in the group studied does not deviate significantly from the control group, it ought to be assumed that the present problems are situational. The problems would then a result of a chronic difficult (stressful) situation which is spondylosis of cervical or lumbar spine. In an attempt to answer the above question, preliminary studies in a 90-person group were conducted. The group included 30 patients with spondylosis of the cervical spine, 30 patients with spondylosis of the lumbar spine, and 30 control persons without spondylosis.

Depression Subscale of the Hospital Anxiety and Depression Scale applied preoperatively in spinal surgery.

OBJECTIVE: To evaluate the accuracy of the Depression Subscale of Hospital Anxiety and Depression Scale (HADS-D) in spine surgery, comparing it to Beck Depression Inventory (BDI). METHODS: In a cross-sectional study, the HADS-D and the BDI were applied to patients undergoing spine surgery for lumbar (n=139) or cervical spondylosis (n=17). Spearman correlation tests for HADS-D and BDI were applied. The internal consistency of HADS-D was estimated by Cronbach's alpha coefficient. RESULTS: According to the BDI, the prevalence of depression was of 28.8% (n=45). The Spearman r coefficient between HADS-D and BDI was 0.714 (p<0.001). Cronbach's alpha for HADS-D was 0.795. The area of the ROC curve was 0.845. Using a cutoff for HADS-D >10, there was a sensitivity of 71.1%, specificity of 95.4%, and positive likelihood-ratio of 15.78. CONCLUSIONS: HADS-D showed a strong correlation with BDI and good reliability. HADS-D is a good alternative for screening depression and assessing its severity.

Depression Subscale of the Hospital Anxiety and Depression Scale applied preoperatively in spinal surgery / Subescala de Depressão da Escala Hospitalar de Depressão e Ansiedade no pré-operatório de coluna vertebral

OBJECTIVE: To evaluate the accuracy of the Depression Subscale of Hospital Anxiety and Depression Scale (HADS-D) in spine surgery, comparing it to Beck Depression Inventory (BDI). METHODS: In a cross-sectional study, the HADS-D and the BDI were applied to patients undergoing spine surgery for lumbar (n=139) or cervical spondylosis (n=17). Spearman correlation tests for HADS-D and BDI were applied. The internal consistency of HADS-D was estimated by Cronbach's alpha coefficient. RESULTS: According to the BDI, the prevalence of depression was of 28.8% (n=45). The Spearman r coefficient between HADS-D and BDI was 0.714 (p<0.001). Cronbach's alpha for HADS-D was 0.795. The area of the ROC curve was 0.845. Using a cutoff for HADS-D >10, there was a sensitivity of 71.1%, specificity of 95.4%, and positive likelihood-ratio of 15.78. CONCLUSIONS: HADS-D showed a strong correlation with BDI and good reliability. HADS-D is a good alternative for screening depression and assessing its severity.

OBJETIVO: Avaliar a acurácia da Subescala de Depressão da Escala Hospitalar de Depressão e Ansiedade (HADS-D) em cirurgia da coluna, comparando-a com o Inventário de Depressão de Beck (BDI). MÉTODOS: Estudo transversal, no qual a HADS-D e o BDI foram aplicados em pacientes submetidos à cirurgia da coluna vertebral por espondilose lombar (n=139) ou cervical (n=17). Teste de correlação de Spearman foi aplicado entre HADS-D e BDI. A consistência interna da HADS-D foi estimada pelo coeficiente alfa de Cronbach. RESULTADOS: De acordo com o BDI, a prevalência de depressão foi de 28,8% (n=45). O coeficiente r de Spearman entre HADS-D e BDI foi de 0,714 (p <0,001). Alpha de Cronbach para o HADS-D foi de 0,795. A área da curva ROC foi de 0,845. Usando um corte para HADS-D >10, houve sensibilidade de 71,1%, especificidade de 95,4% e razão de verossimilhança positiva de 15,78. CONCLUSÕES: HADS-D apresentou forte correlação com o BDI e boa confiabilidade. A HADS-D é uma boa alternativa para a triagem de depressão e verificação da gravidade dos sintomas.

Comparison between anterior and posterior decompression for cervical spondylotic myelopathy: subjective evaluation and cost analysis.

OBJECTIVE: To compare anterior and posterior approaches for treating cervical spondylotic myelopathy (CSM) involving more than two levels, especially in regard to quality of life and cost effectiveness. METHODS: The authors studied 116 CSM patients who underwent decompressive surgery by either an anterior or a posterior approach with instrumentation. In the anterior group, 1-3 levels subtotal vertebrectomy was followed by bone graft and Orion anterior cervical locking plate fixation. In the posterior group, multilevel laminectomy with posterior screw-rod fixation was performed. Follow-up, which included radiographic assessment, clinical examination and documentation of length of any hospitalization and cost and incidence of complications, was performed 1 day before discharge, 6 months after leaving hospital, and at final follow-up. RESULTS: Both groups had improved clinical outcomes. The anterior group showed greater satisfaction but lower visual analog scale scores than the posterior group, whereas SF-36 emotional role and mental health scores were higher in the anterior group. There was no marked difference between the two groups in length of hospitalization and most of the costs of treating CSM, however treatment and examination fees were significantly higher in the posterior group. CONCLUSIONS: Both anterior and posterior decompressions (with instrumentation) are effective procedures for improving the neurological outcomes of patients with CSM. However, although the two approaches have similar health care costs, anterior cervical corpectomy (with instrumentation) seems to be subjectively assessed by patients as better.

Validity and responsiveness of the Core Outcome Measures Index (COMI) for the neck.

PURPOSE: Patient-orientated outcome questionnaires are essential to evaluate treatment success. To compare different treatments, hospitals, and surgeons, standardised questionnaires are required. The present study examined the validity and responsiveness of the Core Outcome Measurement Index for neck pain (COMI-neck), a short, multidimensional outcome instrument. METHODS: Questionnaires were completed by patients with degenerative problems of the cervical spine undergoing cervical disc arthroplasty before (N = 89) and 3 months after (N = 75) surgery. The questionnaires comprised the EuroQol-Five Dimension (EQ-5D), the North American Spine Society Cervical Spine Outcome Assessment Instrument (NASS-cervical) and the COMI-neck. RESULTS: The COMI and NASS-cervical scores displayed no notable floor or ceiling effects at any time point whereas for the EQ-5D, the highest values [corrected] were reached in around 32.5% of patients at follow-up. With one exception (symptom-specific well-being), the individual COMI items and the COMI summary score correlated to the expected extent (R = 0.4-0.8) with the scores of the chosen reference questionnaires. The area under the curve (AUC) generated by ROC analysis was significantly higher for the COMI (0.96) than for any other instrument/subscale when self reported treatment outcome was used as the external criterion, dichotomised as "good" (operation helped a lot/helped) versus "poor" (operation helped only a little/didn't help/made things worse). The COMI had a high effect size (standardised response mean; SRM) (2.34) for the good global outcome group and a low SRM for the poor outcome group (0.34). The EQ-5D and the NASS-cervical lacked this ability to differentiate between the two groups, showing less distinct SRMs for good and poor outcome groups. CONCLUSIONS: This study provides evidence that the COMI-neck is a valid and responsive questionnaire in the population of patients examined. Further investigations should examine its applicability in other patient groups with less severe neck pain or undergoing other treatment modalities.