Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial

Objective To determine whether, from a health provider and patient perspective, surgical stabilisation of the spine is cost effective when compared with an intensive programme of rehabilitation in patients with chronic low back pain.Design Economic evaluation alongside a pragmatic randomised controlled trial.Setting Secondary care.Participants 349 patients randomised to surgery (n = 176) or to an intensive rehabilitation programme (n = 173) from 15 centres across the United Kingdom between June 1996 and February 2002.Main outcome measures Costs related to back pain and incurred by the NHS and patients up to 24 months after randomisation. Return to paid employment and total hours worked. Patient utility as estimated by using the EuroQol EQ-5D questionnaire at several time points and used to calculate quality adjusted life years (QALYs). Cost effectiveness was expressed as an incremental cost per QALY.Results At two years, 38 patients randomised to rehabilitation had received rehabilitation and surgery whereas just seven surgery patients had received both treatments. The mean total cost per patient was estimated to be £7830 (SD £5202) in the surgery group and £4526 (SD £4155) in the intensive rehabilitation arm, a significant difference of £3304 (95% confidence interval £2317 to £4291). Mean QALYs over the trial period were 1.004 (SD 0.405) in the surgery group and 0.936 (SD 0.431) in the intensive rehabilitation group, giving a non-significant difference of 0.068 (–0.020 to 0.156). The incremental cost effectiveness ratio was estimated to be £48 588 per QALY gained (–£279 883 to £372 406).Conclusion Two year follow-up data show that surgical stabilisation of the spine may not be a cost effective use of scarce healthcare resources. However, sensitivity analyses show that this could change—for example, if the proportion of rehabilitation patients requiring subsequent surgery continues to increase.     

Effectiveness of Surgery for Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis

Background

The management of spinal stenosis by surgery has increased rapidly in the past two decades, however, there is still controversy regarding the efficacy of surgery for this condition. Our aim was to investigate the efficacy and comparative effectiveness of surgery in the management of patients with lumbar spinal stenosis.

Methods

Electronic searches were performed on MEDLINE, EMBASE, AMED, CINAHL, Web of Science, LILACS and Cochrane Library from inception to November 2014. Hand searches were conducted on included articles and relevant reviews. We included randomised controlled trials evaluating surgery compared to no treatment, placebo/sham, or to another surgical technique in patients with lumbar spinal stenosis. Primary outcome measures were pain, disability, recovery and quality of life. The PEDro scale was used for risk of bias assessment. Data were pooled with a random-effects model, and the GRADE approach was used to summarise conclusions.

Results

Nineteen published reports (17 trials) were included. No trials were identified comparing surgery to no treatment or placebo/sham. Pooling revealed that decompression plus fusion is not superior to decompression alone for pain (mean difference –3.7, 95% confidence interval –15.6 to 8.1), disability (mean difference 9.8, 95% confidence interval –9.4 to 28.9), or walking ability (risk ratio 0.9, 95% confidence interval 0.4 to 1.9). Interspinous process spacer devices are slightly more effective than decompression plus fusion for disability (mean difference 5.7, 95% confidence interval 1.3 to 10.0), but they resulted in significantly higher reoperation rates when compared to decompression alone (28% v 7%, P < 0.001). There are no differences in the effectiveness between other surgical techniques for our main outcomes.

Conclusions

The relative efficacy of various surgical options for treatment of spinal stenosis remains uncertain. Decompression plus fusion is not more effective than decompression alone. Interspinous process spacer devices result in higher reoperation rates than bony decompression.     

Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain.

OBJECTIVE--To evaluate a progressive fitness programme for patients with chronic low back pain. DESIGN--Single blind randomised controlled trial. Assessments were carried out before and after treatment by an observer blinded to the study and included a battery of validated measures. All patients were followed up by postal questionnaire six months after treatment. SETTING--Physiotherapy department of orthopaedic hospital. SUBJECTS--81 patients with chronic low back pain referred from orthopaedic consultants for physiotherapy. The patients were randomly allocated to a fitness programme or control group. INTERVENTION--Both groups were taught specific exercises to carry out at home and referred to a back-school for education in back care. Patients allocated to the fitness class attended eight exercise classes over four weeks in addition to the home programme and backschool. RESULTS--Significant differences between the groups were shown in the changes before and after treatment in scores on the Oswestry low back pain disability index (P < 0.005), pain reports (sensory P < 0.05 and affective P < 0.005), self efficacy reports (P < 0.05), and walking distance (P < 0.005). No significant differences between the groups were found by the general health questionnaire or questionnaire on pain locus of control. A benefit of about 6 percentage points on the disability index was maintained by patients in the fitness group at six months. CONCLUSION--There is a role for supervised fitness programmes in the management of moderately disabled patients with chronic low back pain. Further clinical trials, however, need to be established in other centres to confirm these findings.     

Preoperative MRI Findings Predict Two-Year Postoperative Clinical Outcome in Lumbar Spinal Stenosis

Purpose

To study the predictive value of preoperative magnetic resonance imaging (MRI) findings for the two-year postoperative clinical outcome in lumbar spinal stenosis (LSS).

Methods

84 patients (mean age 63±11 years, male 43%) with symptoms severe enough to indicate LSS surgery were included in this prospective observational single-center study. Preoperative MRI of the lumbar spine was performed with a 1.5-T unit. The imaging protocol conformed to the requirements of the American College of Radiology for the performance of MRI of the adult spine. Visual and quantitative assessment of MRI was performed by one experienced neuroradiologist. At the two-year postoperative follow-up, functional ability was assessed with the Oswestry Disability Index (ODI 0–100%) and treadmill test (0–1000 m), pain symptoms with the overall Visual Analogue Scale (VAS 0–100 mm), and specific low back pain (LBP) and specific leg pain (LP) separately with a numeric rating scale from 0–10 (NRS-11). Satisfaction with the surgical outcome was also assessed.

Results

Preoperative severe central stenosis predicted postoperatively lower LP, LBP, and VAS when compared in patients with moderate central stenosis (p<0.05). Moreover, severe stenosis predicted higher postoperative satisfaction (p = 0.029). Preoperative scoliosis predicted an impaired outcome in the ODI (p = 0.031) and lowered the walking distance in the treadmill test (p = 0.001). The preoperative finding of only one stenotic level in visual assessment predicted less postoperative LBP when compared with patients having 2 or more stenotic levels (p = 0.026). No significant differences were detected between quantitative measurements and the patient outcome.

Conclusions

Routine preoperative lumbar spine MRI can predict the patient outcome in a two-year follow up in patients with LSS surgery. Severe central stenosis and one-level central stenosis are predictors of good outcome. Preoperative finding of scoliosis may indicate worse functional ability.     

Psychometric Properties of the Japanese Version of the STarT Back Tool in Patients with Low Back Pain

Background and Objective

The STarT Back Tool uses prognostic indicators to classify patients with low back pain into three risk groups to guide early secondary prevention in primary care. The present study aimed to evaluate the psychometric properties of the Japanese version of the tool (STarT-J).

Methods

An online survey was conducted among Japanese patients with low back pain aged 20–64 years. Reliability was assessed by examining the internal consistency of the overall and psychosocial subscales using Cronbach’s alpha coefficients. Spearman’s correlation coefficients were used to evaluate the concurrent validity between the STarT-J total score/psychosocial subscore and standard reference questionnaires. Discriminant validity was evaluated by calculating the area under the curves (AUCs) for the total and psychosocial subscale scores against standard reference cases. Known-groups validity was assessed by examining the relationship between low back pain-related disability and STarT-J scores.

Results

The analysis included data for 2000 Japanese patients with low back pain; the mean (standard deviation [SD]) age was 47.7 (9.3) years, and 54.1% were male. The mean (SD) STarT-J score was 2.2 (2.1). The Cronbach’s alpha coefficient was 0.75 for the overall scale and 0.66 for the psychosocial subscale. Spearman’s correlation coefficients ranged from 0.30 to 0.59, demonstrating moderate to strong concurrent validity. The AUCs for the total score ranged from 0.65 to 0.83, mostly demonstrating acceptable discriminative ability. For known-groups validity, participants with more somatic symptoms had higher total scores. Those in higher STarT-J risk groups had experienced more low back pain-related absences.

Conclusions

The overall STarT-J scale was internally consistent and had acceptable concurrent, discriminant, and known-groups validity. The STarT-J can be used with Japanese patients with low back pain.     

Surgical Data and Early Postoperative Outcomes after Minimally Invasive Lumbar Interbody Fusion: Results of a Prospective,Multicenter, Observational Data-Monitored Study

Minimally invasive lumbar interbody fusion (MILIF) offers potential for reduced operative morbidity and earlier recovery compared with open procedures for patients with degenerative lumbar disorders (DLD). Firm conclusions about advantages of MILIF over open procedures cannot be made because of limited number of large studies of MILIF in a real-world setting. Clinical effectiveness of MILIF in a large, unselected real-world patient population was assessed in this Prospective, monitored, international, multicenter, observational study. Objective: To observe and document short-term recovery after minimally invasive interbody fusion for DLD. Materials and Methods: In a predefined 4-week analysis from this study, experienced surgeons (≥30 MILIF surgeries pre-study) treated patients with DLD by one- or two-level MILIF. The primary study objective was to document patients’ short-term post-interventional recovery (primary objective) including back/leg pain (visual analog scale [VAS]), disability (Oswestry Disability Index [ODI]), health status (EQ-5D) and Patient satisfaction. Results: At 4 weeks, 249 of 252 patients were remaining in the study; the majority received one-level MILIF (83%) and TLIF was the preferred approach (94.8%). For one-level (and two-level) procedures, surgery duration was 128 (182) min, fluoroscopy time 115 (154) sec, and blood-loss 164 (233) mL. Time to first ambulation was 1.3 days and time to study-defined surgery recovery was 3.2 days. Patients reported significantly (P < 0.0001) reduced back pain (VAS: 2.9 vs 6.2), leg pain (VAS: 2.5 vs 5.9), and disability (ODI: 34.5% vs 45.5%), and a significantly (P < 0.0001) improved health status (EQ-5D index: 0.61 vs 0.34; EQ VAS: 65.4 vs 52.9) 4 weeks postoperatively. One adverse event was classified as related to the minimally invasive surgical approach. No deep site infections or deaths were reported. Conclusions: For experienced surgeons, MILIF for DLD demonstrated early benefits (short time to first ambulation, early recovery, high patient satisfaction and improved patient-reported outcomes) and low major perioperative morbidity at 4 weeks postoperatively.     

Reliability and validity of simplified Chinese version of Roland-Morris questionnaire in evaluating rural and urban patients with low back pain

Objective

The causes of low back pain in China and Western countries are extremely different. We attempted to analyze the risk factors of low back pain in urban and rural patients under the dual economy with the simplified Chinese version of Roland-Morris disability questionnaire (SC-RMDQ) to demonstrate that SC-RMDQ could evaluate patients with low back pain arising from different causes.

Methods

Roland-Morris disability questionnaire was translated into SCRMDQ according to international guidelines for questionnaire adaptation. In this study, causes of low back pain of 187 outpatients and inpatients (99 urban patients and 88 rural patients) were analyzed. All patients underwent simplified Chinese version of Roland-Morris disability questionnaire (SC-RMDQ), simplified Chinese Oswestry disability index (SCODI) and visual analogue scale (VAS). Reliability was tested using reproducibility (intraclass coefficient of correlation – ICC) and internal consistency (Cronbach''s alpha). Validity was tested using Pearson correlation analysis.

Results

The leading causes for low back pain were sedentariness (38.4%) and vibration (18.1%) in urban patients and waist bending (48.9%) and spraining (25%) in rural patients. Although causes of low back pain in the two groups of population were completely different, SCRMDQ had high internal consistency (Cronbach''s α value of 0.874 in urban patients and 0.883 in rural patients) and good reproducibility (ICC value of .952 in urban patients and 0.949 in rural patients, P<0.01). SCRMDQ also showed significant correlation with Simplified Chinese version of Oswestry disability index (SCODI) and visual analogue scale (VAS) in rural areas (SCRMDQ-SCODI r = 0.841; SCRMDQ -VAS: r = 0.685, P<0.01) and in urban areas (SCRMDQ-SCODI: r = 0.818, P<0.01; SCRMDQ –VAS: r = 0.666, P<0.01).

Conclusions

Although causes of low back pain are completely different in rural and urban patients, SCRMDQ has a good reliability and validity, which is a reliable clinical method to evaluate disability of rural and urban patients.     

Accelerated Postero-Lateral Spinal Fusion by Collagen Scaffolds Modified with Engineered Collagen-Binding Human Bone Morphogenetic Protein-2 in Rats

Bone morphogenetic protein-2 (BMP-2) is a potent osteoinductive cytokine that plays a critical role in bone regeneration and repair. However, its distribution and side effects are major barriers to its success as therapeutic treatment. The improvement of therapy using collagen delivery matrices has been reported. To investigate a delivery system on postero-lateral spinal fusion, both engineered human BMP-2 with a collagen binding domain (CBD-BMP-2) and collagen scaffolds were developed and their combination was implanted into Sprague-Dawley (SD) rats to study Lumbar 4–5 (L4–L5) posterolateral spine fusion. We divided SD rats into three groups, the sham group (G1, n = 20), the collagen scaffold-treated group (G2, n = 20) and the BMP-2-loaded collagen scaffolds group (G3, n = 20). 16 weeks after surgery, the spines of the rats were evaluated by X-radiographs, high-resolution micro-computed tomography (micro-CT), manual palpation and hematoxylin and eosin (H&E) staining. The results showed that spine L4–L5 fusions occurred in G2(40%) and G3(100%) group, while results from the sham group were inconsistent. Moreover, G3 had better results than G2, including higher fusion efficiency (X score, G2 = 2.4±0.163, G3 = 3.0±0, p<0.05), higher bone mineral density (BMD, G2: 0.3337±0.0025g/cm3, G3: 0.4353±0.0234g/cm3. p<0.05) and more bone trabecular formation. The results demonstrated that with site-specific collagen binding domain, a dose of BMP-2 as low as 0.02mg CBD-BMP-2/cm³ collagen scaffold could enhance the posterolateral intertransverse process fusion in rats. It suggested that combination delivery could be an alternative in spine fusion with dramatically decreased side effects caused by high dose of BMP-2.     

The impact of wool in the patients with chronic non-specific low back pain

The aim was to assess the effect of wool underwear use in patients with chronic non specific low back pain. The study employed two-group, experimental design. A total of 48 patients with chronic non specific low back pain were selected for the study. They were distributed into two groups: a control group and a treatment group. The 24 patients in each group were randomly selected and the compositions of the two groups. The patients in the treatment group wore woolen underwear during the experimental period of 2 month. All patients were assessed at the beginning the trial (pre-test) and the end of 8th (post-test) week. Data were collected using the visual analogue pain scale, Oswestry Disability Index and Schober test measurements. Patients in the treatment group reported significant improvements in their conditions including a reduction in pain levels and Oswestry Disability Index, and Schober test measurements increased (p<0.001). Patients with chronic non-specific low back pain who wore wool underwear experienced significant improvements in pain intensity, disability, and lower back flexibility.     

Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial

Objectives To evaluate the effects of early lumbar disc surgery compared with prolonged conservative care for patients with sciatica over two years of follow-up.Design Randomised controlled trial.Setting Nine Dutch hospitals.Participants 283 patients with 6-12 weeks of sciatica.Interventions Early surgery or an intended six months of continued conservative treatment, with delayed surgery if needed.Main outcome measures Scores from Roland disability questionnaire for sciatica, visual analogue scale for leg pain, and Likert self rating scale of global perceived recovery.Results Of the 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy. Of the 142 patients assigned to conservative treatment, 62 (44%) eventually required surgery, seven doing so in the second year of follow-up. There was no significant overall difference between treatment arms in disability scores during the first two years (P=0.25). Improvement in leg pain was faster for patients randomised to early surgery, with a significant difference between “areas under the curves” over two years (P=0.05). This short term benefit of early surgery was no longer significant by six months and continued to narrow between six months and 24 months. Patient satisfaction decreased slightly between one and two years for both groups. At two years 20% of all patients reported an unsatisfactory outcome.Conclusions Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.Trial Registry ISRCT No 26872154.     

Changes in the endurance shuttle walk test in COPD patients with chronic respiratory failure after pulmonary rehabilitation: the minimal important difference obtained with anchor- and distribution-based method

Background

Although the endurance shuttle walk test (ESWT) has proven to be responsive to change in exercise capacity after pulmonary rehabilitation (PR) for COPD, the minimally important difference (MID) has not yet been established. We aimed to establish the MID of the ESWT in patients with severe COPD and chronic hypercapnic respiratory failure following PR.

Methods

Data were derived from a randomized controlled trial, investigating the value of noninvasive positive pressure ventilation added to PR. Fifty-five patients with stable COPD, GOLD stage IV, with chronic respiratory failure were included (mean (SD) FEV₁ 31.1 (12.0) % pred, age 62 (9) y). MID estimates of the ESWT in seconds, percentage and meters change were calculated with anchor based and distribution based methods. Six minute walking distance (6MWD), peak work rate on bicycle ergometry (Wpeak) and Chronic Respiratory Questionnaire (CRQ) were used as anchors and Cohen’s effect size was used as distribution based method.

Results

The estimated MID of the ESWT with the different anchors ranged from 186–199 s, 76–82% and 154–164 m. Using the distribution based method the MID was 144 s, 61% and 137 m.

Conclusions

Estimates of the MID for the ESWT after PR showed only small differences using different anchors in patients with COPD and chronic respiratory failure. Therefore we recommend using a range of 186–199 s, 76–82% or 154–164 m as MID of the ESWT in COPD patients with chronic respiratory failure. Further research in larger populations should elucidate whether this cut-off value is also valid in other COPD populations and with other interventions.

Trial registration

ClinicalTrials.Gov (ID {"type":"clinical-trial","attrs":{"text":"NCT00135538","term_id":"NCT00135538"}}NCT00135538).

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-015-0182-x) contains supplementary material, which is available to authorized users.     

骨水泥强化椎弓根螺钉联合椎间融合复位治疗老年重度腰椎滑脱的临床研究

摘要 目的：观察椎间融合复位联合骨水泥强化椎弓根螺钉治疗老年重度腰椎滑脱的临床效果。方法：回顾性分析我院于2016年3月~2019年3月期间收治的老年重度腰椎滑脱患者92例,根据治疗方案的不同可将患者分为A组（n=44）和B组（n=48）,A组给予椎弓根螺钉联合椎间融合复位治疗,B组给予骨水泥强化椎弓根螺钉联合椎间融合复位治疗,对比两组视觉疼痛模拟评分（VAS）、Oswestry功能障碍指数（ODI）及日本骨科协会（JOA）腰腿痛评分、临床指标、滑脱距离、滑脱率、椎间隙高度、椎间融合率、椎间孔高度、并发症及螺钉松动情况。结果：术后12个月,两组VAS、ODI、JOA评分均下降,且B组低于A组（P<0.05）。两组术中出血量对比组间无统计学差异（P>0.05）,B组手术时间长于A组,住院时间短于A组,椎间融合率高于A组（P<0.05）。术后12个月,两组滑脱距离、滑脱率均下降,且B组小于A组（P<0.05）。术后12个月,两组椎间隙高度、椎间孔高度均升高,且B组高于A组（P<0.05）。两组并发症发生率组间对比无差异（P>0.05）。结论：老年重度腰椎滑脱患者椎间融合复位联合骨水泥强化椎弓根螺钉治疗,虽一定程度上延长了手术时间,但可促进临床症状,改善椎间高度及腰椎滑脱程度,缩短住院时间,且不增加并发症发生率。     

Health Impacts of Active Transportation in Europe

Policies that stimulate active transportation (walking and bicycling) have been related to heath benefits. This study aims to assess the potential health risks and benefits of promoting active transportation for commuting populations (age groups 16–64) in six European cities. We conducted a health impact assessment using two scenarios: increased cycling and increased walking. The primary outcome measure was all-cause mortality related to changes in physical activity level, exposure to fine particulate matter air pollution with a diameter <2.5 μm, as well as traffic fatalities in the cities of Barcelona, Basel, Copenhagen, Paris, Prague, and Warsaw. All scenarios produced health benefits in the six cities. An increase in bicycle trips to 35% of all trips (as in Copenhagen) produced the highest benefits among the different scenarios analysed in Warsaw 113 (76–163) annual deaths avoided, Prague 61 (29–104), Barcelona 37 (24–56), Paris 37 (18–64) and Basel 5 (3–9). An increase in walking trips to 50% of all trips (as in Paris) resulted in 19 (3–42) deaths avoided annually in Warsaw, 11(3–21) in Prague, 6 (4–9) in Basel, 3 (2–6) in Copenhagen and 3 (2–4) in Barcelona. The scenarios would also reduce carbon dioxide emissions in the six cities by 1,139 to 26,423 (metric tonnes per year). Policies to promote active transportation may produce health benefits, but these depend of the existing characteristics of the cities. Increased collaboration between health practitioners, transport specialists and urban planners will help to introduce the health perspective in transport policies and promote active transportation.     

The NHV Rehabilitation Services Program Improves Long-Term Physical Functioning in Survivors of the 2008 Sichuan Earthquake: A Longitudinal Quasi Experiment

Background

Long-term disability following natural disasters significantly burdens survivors and the impacted society. Nevertheless, medical rehabilitation programming has been historically neglected in disaster relief planning. ‘NHV’ is a rehabilitation services program comprised of non–governmental organizations (NGOs) (N), local health departments (H), and professional rehabilitation volunteers (V) which aims to improve long-term physical functioning in survivors of the 2008 Sichuan earthquake. We aimed to evaluate the effectiveness of the NHV program.

Methods/Findings

510 of 591 enrolled earthquake survivors participated in this longitudinal quasi-experimental study (86.3%). The early intervention group (NHV–E) consisted of 298 survivors who received institutional-based rehabilitation (IBR) followed by community-based rehabilitation (CBR); the late intervention group (NHV–L) was comprised of 101 survivors who began rehabilitation one year later. The control group of 111 earthquake survivors did not receive IBR/CBR. Physical functioning was assessed using the Barthel Index (BI). Data were analyzed with a mixed-effects Tobit regression model. Physical functioning was significantly increased in the NHV–E and NHV–L groups at follow-up but not in the control group after adjustment for gender, age, type of injury, and time to measurement. We found significant effects of both NHV (11.14, 95% CI 9.0–13.3) and sponaneaous recovery (5.03; 95% CI 1.73–8.34). The effect of NHV-E (11.3, 95% CI 9.0–13.7) was marginally greater than that of NHV-L (10.7, 95% CI 7.9–13.6). It could, however, not be determined whether specific IBR or CBR program components were effective since individual component exposures were not evaluated.

Conclusion

Our analysis shows that the NHV improved the long-term physical functioning of Sichuan earthquake survivors with disabling injuries. The comprehensive rehabilitation program benefitted the individual and society, rehabilitation services in China, and international rehabilitation disaster relief planning. Similar IBR/CBR programs should therefore be considered for future large-scale rehabilitation disaster relief efforts.     

The Clinical Outcomes of Surgical Treatment of Noncontiguous Spinal Tuberculosis: A Retrospective Study in 23 Cases

Study design

A retrospective clinical study.

Objective

To evaluate the clinical efficacy of the surgical treatment of noncontiguous spinal tuberculosis (NSTB), and to discuss its therapeutic strategies.

Methods

We performed a retrospective review of clinical and radiographic data that were prospectively collected on 550 consecutive spinal tubercular patients including 27 patients who were diagnosed and treated as NSTB in our institution from June 2005 to June 2011. Apart from 4 patients being treated conservatively, the remainder received surgery by posterior transforaminal debridement, interbody fusion with instrumentation, posterior instrumentation and anterior debridement with fusion in a single or two-stage operation. The clinical outcomes were evaluated before and after treatment in terms of hematologic and radiographic examinations, bone fusion and neurologic status. The Oswestry Disability Index score was determined before treatment and at the last follow-up visit.

Results

23 patients (15 M/8F), averaged 44.6±14.2 years old (range, 19 to 70 yd), who received surgical treatment, were followed up after surgery for a mean of 52.5±19.5 months (range, 24 to 72 months). The kyphotic angle was changed significantly between pre- and postoperation (P<0.05). The mean amount of correction was 12.6±7.2 degrees, with a small loss of correction at last follow-up. All patients achieved solid bone fusion. No patients with neurological deficit deteriorated postoperatively. Neither mortalities nor any major complications were found. There was a significant difference of Oswestry Disability Index scores between preoperation and the final follow-up.

Conclusion

The outcomes of follow-up showed that posterior and posterior-anterior surgical treatment methods were both viable surgical options for NSTB. Posterior transforaminal debridement, interbody fusion and posterior instrumentation, as a less invasive technique, was feasible and effective to treat specific tubercular foci.     

MSCs复合双相磷酸钙陶瓷促进腰椎骨折患者脊柱融合

目的:探索自体骨髓间充质干细胞(Mesenchymal stem cells,MSCs)复合双相磷酸钙陶瓷(Biphasic calcium phosphate ceramics,BCP)在腰椎骨折患者脊柱融合中的应用。方法:收集我院住院腰椎骨折患者50例,随机分为两组:MSCs复合BCP组和自体髂骨组。MSCs复合BCP组中,体外分离培养患者自体MSCs,复合BCP材料后共聚焦显微镜观察细胞和材料复合生长状况;然后回植于胸腰椎体骨折处,采用后路腰椎椎体间融合术(PLIF),钛合金椎弓根钉棒系统作脊柱内固定。自体髂骨组中,用患者自体髂骨代替BCP骨移植物。术前、术后1、3、6、12个月行X线和CT检查,同时采用Lenke字母分级评价脊柱融合情况,LBOS评分评价临床疗效,Cobb角评价患者伤椎复位效果。结果:两组患者术后6个月Lenke字母分级法表明两组患者均为A、B级,无C、D级;LBOS评分表明MSCs复合BCP组的优良率为68%(17/25),自体髂骨组优良率为76%(19/25);Cobb角结果表明两组伤椎复位效果良好。所有数据两组差异无明显统计学意义(P0.05)。结论:MSCs复合BCP材料是一种优良的促进脊柱融合方法,可替代自体髂骨移植。     

Obesity Is Independently Associated with Spinal Anesthesia Outcomes: A Prospective Observational Study

The influence of body-mass index (BMI) on spinal anesthesia is still controversial, with discrepant results reported in previous studies. To compare spinal anesthesia in obese and non-obese subjects, the anesthesia profiles in patients who underwent spinal anesthesia using intrathecal hyperbaric bupivacaine were compared. A total of 209 patients undergoing elective total knee replacement arthroplasty (TKRA) surgery under spinal anesthesia were divided into an NO (non-obese) group (BMI < 30 kg/m², n = 141) and an O (obese) group (BMI ≥ 30 kg/m², n = 68). Anesthesia was deemed successful if a bilateral T12 sensory block occurred within 15 minutes of intrathecal drug administration, and if the level of sensory block was higher than T12 when the surgery ended. Logistic regression analysis with multiple variables known to influence spinal anesthesia was performed to identify which parameters independently determined the spinal anesthesia outcome. Similar doses of bupivacaine were administered to the NO and O groups. The incidence of anesthesia failure was significantly lower in the O group [n = 43 (30.5%) in the NO group vs. n = 10 (18.9%) in the O group, p = 0.014]. The independent predictors for successful anesthesia in all patients were dose of hyperbaric bupivacaine [odds ratio (OR) 2.12, 95% CI: 1.64–2.73] and obese status (BMI ≥ 30 kg/m², OR 2.86, 95% CI: 1.25–6.52). Time to first report of postoperative pain and time to first self-void were significantly longer in the O group. These results suggest that the duration of block with hyperbaric bupivacaine is prolonged in obese patients and obesity is independently associated with spinal anesthesia outcomes, as is bupivacaine dosage. A further study enrolling patients with morbid obesity and using a fixed bupivacaine dosage is required to confirm the effect of obesity on spinal anesthesia.     

Effects of Aging on Arm Swing during Gait: The Role of Gait Speed and Dual Tasking

Healthy walking is characterized by pronounced arm swing and axial rotation. Aging effects on gait speed, stride length and stride time variability have been previously reported, however, less is known about aging effects on arm swing and axial rotation and their relationship to age-associated gait changes during usual walking and during more challenging conditions like dual tasking. Sixty healthy adults between the ages of 30–77 were included in this study designed to address this gap. Lightweight body fixed sensors were placed on each wrist and lower back. Participants walked under 3 walking conditions each of 1 minute: 1) comfortable speed, 2) walking while serially subtracting 3’s (Dual Task), 3) walking at fast speed. Aging effects on arm swing amplitude, range, symmetry, jerk and axial rotation amplitude and jerk were compared between decades of age (30–40; 41–50; 51–60; 61–77 years). As expected, older adults walked slower (p = 0.03) and with increased stride variability (p = 0.02). Arm swing amplitude decreased with age under all conditions (p = 0.04). In the oldest group, arm swing decreased during dual task and increased during the fast walking condition (p<0.0001). Similarly, arm swing asymmetry increased during the dual task in the older groups (p<0.004), but not in the younger groups (p = 0.67). Significant differences between groups and within conditions were observed in arm swing jerk (p<0.02), axial rotation amplitude (p<0.02) and axial jerk (p<0.001). Gait speed, arm swing amplitude of the dominant arm, arm swing asymmetry and axial rotation jerk were all independent predictors of age in a multivariate model. These findings suggest that the effects of gait speed and dual tasking on arm swing and axial rotation during walking are altered among healthy older adults. Follow-up work is needed to examine if these effects contribute to reduced stability in aging.     

皮质骨轨迹螺钉与椎弓根螺钉行经椎间孔入路椎间融合术的疗效比较

目的:探讨皮质骨轨迹螺钉(cortical bone trajectory,CBT)与椎弓根螺钉(pedicle screw,PS)行经椎间孔入路椎间融合术(transforaminal lumbar interbody fusion,TLIF)治疗腰椎退行性疾病的临床疗效。方法:选取2016年5月至2018年5月采用TLIF治疗的腰椎退行性疾病患者资料50例作为研究对象,其中行CBT螺钉固定组25例,行PS螺钉内固定组25例。分别记录患者一般资料、围手术期参数及并发症发生情况。腰痛VAS评分、腿痛VAS评分及ODI功能指数评分评估临床效果。Bridwell分级标准评价两组融合情况。结果:平均随访时间16.72±3.6个月。两组患者在性别、年龄、疾病诊断、手术节段方面组间差异无统计学意义(P0.05)。皮质骨轨迹螺钉组平均手术时间及术中出血量为171.88±25.75 min、225.20±51.57 m L,椎弓根螺钉组为221.24±33.53 min、297.60±66.40 m L,两组比较差异有统计学意义(P0.05)。两组患者术后1月及末次随访腰痛VAS评分、腿痛VAS评分及ODI功能指数评分均较术前有明显改善,两组间差异无统计学意义。末次随访两组患者均取得骨性融合。结论:对于腰椎退行性疾病患者,采用CBT螺钉和PS螺钉内固定方式行TLIF均能到达良好的临床疗效及融合率,采用皮质骨轨迹螺钉行TLIF患者手术时间短,术中出血量更少。     

A Meta Analysis of Lumbar Spinal Fusion Surgery Using Bone Morphogenetic Proteins and Autologous Iliac Crest Bone Graft

BackgroundBone morphogenetic protein (BMPs) as a substitute for iliac crest bone graft (ICBG) has been increasingly widely used in lumbar fusion. The purpose of this study is to systematically compare the effectiveness and safety of fusion with BMPs for the treatment of lumbar disease.MethodsCochrane review methods were used to analyze all relevant randomized controlled trials (RCTs) published up to nov 2013.Results19 RCTs (1,852 patients) met the inclusion criteria. BMPs group significantly increased fusion rate (RR: 1.13; 95% CI 1.05–1.23, P = 0.001), while there was no statistical difference in overall success of clinical outcomes (RR: 1.04; 95% CI 0.95–1.13, P = 0.38) and complications (RR: 0.96; 95% CI 0.85–1.09, p = 0.54). A significant reduction of the reoperation rate was found in BMPs group (RR: 0.57; 95% CI 0.42–0.77, p = 0.0002). Significant difference was found in the operating time (MD−0.32; 95% CI−0.55, −0.08; P = 0.009), but no significant difference was found in the blood loss, the hospital stay, patient satisfaction, and work status.ConclusionCompared with ICBG, BMPs in lumbar fusion can increase the fusion rate, while reduce the reoperation rate and operating time. However, it doesn’t increase the complication rate, the amount of blood loss and hospital stay. No significant difference was found in the overall success of clinical outcome of the two groups.