News Category: Spine

Low back pain affects 60 per cent to 80 per cent of people worldwide. One of the sources of back pain can be the facet joints of the spine. They have been implicated in up to 15 per cent to 45 per cent of back pain cases. Facet joint-related symptoms could be presented with lumbar pain radiating down toward the buttock and posterior thigh.

FJRD (Facet joint radiofrequency denervation) for the treatment of facet joint related pain was first described in 1975 and has been used in as a minimally invasive procedure for pain relief. Radiofrequency denervation for the treating facet joints uses energy in the radiofrequency range to kill off specific nerves that innervate the facet joint, blocking the transmission of pain. The purpose of FJRD is for pain relief and decrease the possibility of recurrence. This study was a systematic review, meaning that it examined past studies done on radiofrequency denervation for facet joint pain. The systematic review assessed the treatment effects of FJRD for patients with facet joint related chronic LBP. Pain, quality of life, cost-effectiveness and complications were some of the outcomes examined. Studies are searched based on certain criteria and then narrowed down to the most applicable. The initial search found 329 studies and through the filtering process nine were considered to be acceptable studies to review.

Findings:
Pain reduction was demonstrated with most studies assessed in this review. Meta-analysis also suggested that there was a benefit in pain control with FJRD up to one year after the intervention.

Results for functional status improvement favored FJRD against placebo. Only one study suggested that better results were obtained for radiofrequency then for a steroid injection but the study did not use a measurement device that had been validated. There was no significant difference for quality of life through the studies examined.

There were no comparisons for cost-effectiveness of FJRD against physical therapy or steroid injection.

Conclusions:
The available evidence reviewed in this study should be read with caution. Most studies complied for this review had low to moderate methodological quality, only a few evaluated functional status, quality of life with validated scales and none controlled for other health factors. Findings indicated that FJRD is more effective then placebo in pain control and functional improvement. Comparing FJRD to steroid injections was inconclusive and it is possible that FJRD is more effective the steroid injections for pain control. Complications and adverse effects were not reported sufficiently to accurately compare. Cost-effectiveness was not examined in any studies, so no evidence is available.

There is no arguing that low back pain is an illness that burdens a large percentage of Americans. Sadly, centuries of folk cures and decades of research have fallen short predict reduce the prevalence of low back pain. Modern medicine has dramatically improved the health and livelihood in many arenas, but back pain remains an age-old, expensive, debilitating and frustrating… pain.

The average person with back pain and the American health care reform analyst are equally interested in sorting the worthwhile from the worthless treatments for reducing the duration and frequency of back pain episodes. Comparative effectiveness research hopes to shed light on what services should be recommended and reimbursed by insurance carriers. For example, the Cochrane Collaboration, another meta-analysis think tank, in 2010 looked at fifty studies on chiropractic treatments on low back pain and found muddled results across years of research.

… there is … no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in
… low back pain. … Future research is very likely to change the estimate of (the) effect and our confidence in the results.

Double doctor, J. Michael Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, found very little supportive evidence in his meta-analyses on comparative effectiveness of various manual therapies in his review of the existing literature. A comparative effectiveness meta-analysis” was performed to compare the relative effectiveness of various spinal manipulation treatments (from the ancient bonesetter to the modern back cracker), medical management (READ: drugs, injections, etc), physical therapy, and exercise for acute (less than a month) and chronic (more than three months) nonsurgical management of low back pain.

The good news is most pain originating from the muscles and joint in the human body is self-limiting, meaning slowing down, protecting your injury, and letting the body heal will often suffice. Research supports
the notion that 60 to 70 percent of acute low back pain settles in six weeks without any medical treatment. Chronic low back pain sufferers get better in a year without treatment 40 to 70 per cent of the time.
Pain whether short-term or long-term is indubitably unpleasant, so why suffer any longer than you have to if effective treatment is available.

This study looked at 56 spinal manipulation studies published between 1974 and 2010 and classified them into six different treatment categories. The categories included: 95 spinal manipulation studies, 31 exercise studies, 51 physical therapy/physiotherapy modalities (for example, ultrasound, electrical stimulation, and hot packs) studies, 40 usual medical care studies, and 40 control group studies of subjects that received no treatment.

The results found a 96 per cent relative improvement in the first 6 weeks across acute back pain studies was unrelated to treatment. Thus the “carry on with your life” control group and the various treatment groups were
nearly equal in settling their acute pain. The chronic pain comparison analyses found that 32 per cent of the various treatment studies could claim improved outcomes. The balance of the percentage of claimed improvement in the chronic pain comparison analyses can be attributed to everything else (letting the injury run its course). Looking at the printed boxplots of the six treatment categories effect sizes attributable to the passage of time alone, the three largest effect sizes were in the exercise group, then the spinal manipulation group, then the modality group.

This study also examined which spinal manipulation treatment provider did the best job for improving chronic back pain. It was determined in the comparison that getting your spine manipulated in the first six weeks has little influence on the outcome of shortening the duration of your acute pain. Five types of spinal manipulation providers (osteopaths, physical therapists, chiropractors, allopathic medical physicians, and bonesetters) were compared. Spinal manipulation by a physical therapist was found to be most effective, and most variable, in treating both acute and chronic back pain.

In the 36 years and 8,400 patients subjected to comparative spinal manipulation studies research cost from $32 to $80 million. Menke’s comparative analysis makes the bold assertion that ‘equivocal outcomes are unacceptable for this investment’, and funding more research on the topic should be stopped. It stands to reason, that inadequate analytics and methodology throughout the studies could be part of the problem. The take home message was that all of the compared treatments for acute and chronic low back pain are hard to quantify when looking at their relative effectiveness versus letting the injury run its course.

It seems to be accepted conventional wisdom that gravity has many harsh effects on the human body as we age. Dr. Videman, MD and PhD out of the University of Alberta and his team of researchers attempt to dispel the myth that spine compression causes the shortening of the human stature. Prior research has long focused on either the flattening disc as a culprit in back pain problems, or the deteriorating vertebral body, but very few studies have examined both structures and their relationship. In other words, is it the shock absorber-like cartilage disc getting squished between our spine’s vertebrae or the crumbling spinal tower theory that can explain why we seem to be shrinking in height after retirement.

Subjects in this study were selected from a 232 Finnish identical twins initially recruited in a Twin Spine Study in the late 50’s. Twin populations are particularly interesting, as they tend to tell us a lot about human similarities and differences in the context of aging and genetics. Apparently, this group of men was also highly representative of the average Finnish population and thus an applicable sample population of the typical European descendant’s spine. These selected gents were at an average age of 63 years (ranging between 50 and 79) at the time of the final follow-up, thus putting them at in their late 40’s/early 50’s on the initial measures. Videman’s team took particular interest in the low back or lumbar spine, focusing in on the MRI’s over the years. They tried to precisely measure the consistent changes in structure and form of the discs and vertebrae during five, 10, and 15-year follow-up studies.

The disc height comparisons concluded that we are indeed getting shorter gradually with a flattening of the disc at five years out by approximately three per cent. The 15-year follow-up found a continued slow compression by 8 per cent in the upper discs to 11 per cent in lower discs of the low back. Measurements of the low back’s bony vertebra at five years out could not find signs of any height changes. However, looking at the 15-year follow-up MRI’s, they found significant vertebra height growth by an average of three per cent in the upper vertebrae levels and by five per cent in the lower back vertebrae after 15 years. Thus, our discs do flatten slowly, but the spinal vertebrae keep pace in remodeling or growing taller (as well as wider) with age. Looking more closely at what exactly happens to the disc and vertebrae at their interface, this article found that the once clearly defined junction appeared to have more or less “melted” into one another. This merging of bone and cartilage results in the appearance of taller spinal vertebra and a narrowed or flattened disc. We are getting shorter, but by only .13 millimeters per year on an annual average after middle age. This not-so-incredibly shrinking average man was in line with the average decrease in our standing height by three millimeters from their baseline measured height to their re-measured height at the 15-year follow-up.

It can be confirmed that we gradually lose somewhere between 9 to 13 per cent of our lumbar disc height in a 15-year period around middle-aged, but why? Videman’s team found a lot of variations within the sample population of researched subjects. Some subjects had no measurable loss of disc height, whereas others had significant disc height flattening, due to degeneration. The exact process of degenerating discs and additional vertebral bone growth is speculated in this paper based on other spine-related research. Two proposed explanations include a cumulative micro-trauma theory at the disc-vertebra interface that creates an inflammation process and merging of the cartilage and bone. The second theory suggests a gradual tensioning of the disc pulling on the vertebra that eventually triggers a process of converting the cartilage to bone. Either way, this was a strong paper with a fairly large population size, precise MRI measurements and a 15 years of follow-up research. There was good evidence in this paper that we are losing disc height and gaining vertebral height at a nearly equal rate. Further research was suggested to explore the exact mechanism causing gain in vertebral height.

Chronic lower back pain ( lower back pain lasting for more than 12 weeks) is a serious health concern that affects 70 per cent to 85 per cent of people at some point of their life. In Australia where this study was done chronic low back pain cost $9.17 billion (yes, billion) dollars annually. The cost accounts for treatment related expenses and missed work. Obesity is also a serious health concern and it is common among people who experience low back pain. This study wanted to examine if there was a link between changes in body mass index (BMI) which is weight divided by height squared (kg/m2) {m is squared}. BMI is classified as follows: 18.5 kg/m2= underweight; 18.5 to 24.9 kg/m2= normal weight; 25 to 29.9kg/m2= overweight; 30 kg/m2 or more obese. BMI has been critizied because of its inability to discern between muscle mass and fat differences in the body.

Research on the relationship between BMI and chronic low back pain has not yielded consistent results. Studies have had inconsistent findings but these two issues present commonly enough that there relationship should be explored. Exercise is a common intervention for both health conditions and known to be helpful in controlling low back pain. Recent findings suggest that exercise may moderate the relationship between obesity and chronic low back pain. This study investivgated the relationship between BMI and exercise-related changes in pain and disability in patients with chronic lower back pain.

The study used 128 people from 18 to 55 years old that had low back pain for 12 weeks minimum. BMI was calculated for each person, a pain scale was used where particpants put a line an 100mm bar; from “no pain” to “worst pain imaginable” and a self-reported disability questionarie. In the study there were no correlations seen between initial BMI and initial pain reports or initial disability questionarie. In the group 77 per cent of the patients were classified as overweight or obese, yet there was no baseline relationship between BMI and pain or disability.

The study lasted eight weeks and each patient went through exercises after there baseline assessment. However, the type of exercises differed among patients, meaning that some used an indoor cycle, some did core stability exercises. Exercise sessions were three to five, one hour sessions with at least one being supervised.

In conclusion, the study considers that the criticism of BMI might be valid. Other measures might be more beneficial is studying the link between obesity and chronic low back pain. An example would to be measure the amount of fat tissue, as that has been linked to chronic low back pain. The study did not report on changes the exercise impact on individual markers of pain or disability. BMI changes are not related to pain or disability changes after exercise in this study.

Obesity and LBP combined make up for about 30 per cent of U.S. health care costs. More evidence is supporting an association between obesity and low back pain (LBP) but, not much is known about the relationship between the two. Obesity is listed as a impacting factor in LBP mostly described through the body mass index (BMI). Body mass index is categorized as: normal weight <25, overweight 25-30, obese 31-35, and ultraobese 36+. Physical activity is a logical suspect to connect obestiy and lower back pain, but no study has demonstrated the role of physical activity. Exercise and weight loss is know to benefit some with back pain, yet the role that physical activity plays is unclear. This study looked into the relationships between LBP, obesity and physical activity.

To collect data on the relationships between obesity, LBP and physical activity information was obtained through participant surveys, physical examinations, and for 7 days the participants wore accelerometers. (Accelerometers can measure in real-time, duration and intensity of motion). Participants wore the accelerometer while they were awake and every minute of that time was used to calculate activity level.

Once the data was collected the findings were very interesting. First, the baseline risk of LBP increased with increased BMI. Smoking was consistently a strong predictor of LBP across any BMI level. WIth overweight subjects it was found that time spent doing sustained activity in a moderate range reduced the odds of having LBP and was even protective from getting LBP. For the average overweight American increasing time doing moderate activity by 17.6 minutes a day, decreases the risk of getting LBP by 32 per cent! In obese subjects, time spent in sedentary activity states had positive relationship with increased LBP. In the morbidly obese category more time spent in moderate activity reduced odds of getting LBP. A small increase in moderate activity level for the morbidly obese by 2.1 minutes reduces back pain risk by 38 per cent!

This study shows that there is a relationship for increased BMI being a risk factor for LBP. Reduced physical activity is also a risk factor for getting LBP, lots of sedentary time and reduced moderate activity have a greater impact on increased LBP risk in overweight Americans. In the overweight population physical activity can be a dimishing factor in lower back risk and it does not take great increases in physical activity to for exercise to have a protective effects.

It is widely accepted that low back pain is one of the most common orthopedic pains we will experience in a given year. It is also a highly scrutinized and researched health condition, as it is a very costly public health problem that affects a third of all adults. Treatments for low back pain range from medication, to surgery, to therapist-delivered care. Recently, Dipesh Mistry and a team of health scientists from the UK’s Warwick Medical School, performed a systematic review of the research on the quality and effectiveness of low back pain treatments performed by therapists. Acceptable therapies for low back pain included a lot of treatments from psychological interventions to intensive rehabilitation programs, from laser acupuncture in Australia to high velocity thrust manipulation in Sweden. The targeted types of low back pain were classified as ‘nonspecific’, meaning they do not come from a likely cause such as a fracture, tumor, infection or inflammatory disease. Nonspecific back pain is generally known as the common back ache or strain.

Mistry’s team combed through the research to select only high-quality, randomized controlled trial-based articles on subjects older than 18 with a history of nonspecific low back pain. Their results largely followed the prior literature reviews consensus small, rather than the conventionally-accepted moderate positive effective gains from therapeutic treatments. They were able to use a total of 39 articles from various search engines (i.e., Medline and Cochrane Controlled Trial Register) completed between the years of 1948 to 2013. They divided the articles into two sub-classifications as either a confirmatory finding or an exploratory finding. Confirmatory are more rigorous, follow-up research that strides to confirm or test the hypothesis. Exploratory are more preliminary research that aims to generate future hypotheses or build a base for future research. Of the accepted, high-quality studies, only three studies (8 per cent) tested hypotheses and were classified as confirmatory. Eighteen studies (46 per cent) were classified as exploratory findings. The remaining 18 (46 per cent), fell short of a substantive conclusion and were given the ‘insufficient findings’ status. The researchers further tweezed each articles’ respective study methods for appropriate statistical testing for each interaction between studied variables. Fortunately, appropriate stats were employed in 27 of the 39 of the articles. The remaining articles had sub-classification reporting deficiencies or other areas deemed too weak to qualify for this paper’s systematic review.

They concluded that the sub-classified (either the confirmatory or exploratory findings) therapies for treating nonspecific low back pain have been ‘severely underpowered’ in their analysis. In other words, over the past 65 years, the 39 acceptable high-quality articles were only able to provide exploratory class research with insufficient evidence to boot. Moreover, they had poor quality data in their reported findings. Misty’s team also generalized that if we hope to better identify which form of low back pain treatment will be the most economical and effective, then we need to better classify which subgroup of persons with back pain are appropriate for each treatment. Future research was suggested here to develop new methods to effectively identify subgroups in back pain research. Furthermore, they recommended that the low back pain research community needs to collectively revise their current approach to subgrouping the back pain studies. Continued perpetuations of exploratory class research won’t help improve the care for our substantial population of persons with back aches looking for effective therapies.

Despite spending more than 86 billion dollars a year on treatment for back pain in the United States, Americans continue to struggle with this problem. It has become a national epidemic. Twenty-five years ago, prominent medical doctors called for new ways to diagnose back pain and measure outcomes of treatment. Today, very little has changed. In fact, there is evidence to suggest that Americans with spine problems are worse than ever before.

What have we learned from these last 25 years of scientific inquiry and study? In this editorial, Dr. R. G. Hazard from the Department of Orthopaedics at Dartmouth Geisel School of Medicine offers some perspective on this question.

First, it should be noted that in 1987, randomized controlled trials were started. These studies used scientifically validated measures of low back pain and subsequent disability. And second, the focus shifted from looking for a specific pathologic reason for the back pain to an understanding of the biopsychosocial factors accompanying back pain.

Stress at home and at work, feelings of being out of control of life situations, and self-perceptions were some of the biopsychosocial aspects mentioned at that time. Along with these two new approaches came awareness that treatment at that time was driven by patient complaints, distress, and behavior.

On the medical side of things, it is clear that finding a clear and accurate diagnosis to label each patient is often impossible. Imaging studies with X-rays, CT scans, and/or MRIs are often “negative” (no findings of anything “wrong” in the bones or soft tissues). Even knowing this, physicians continued to use steroid injections, narcotic medications, and surgical procedures to address the problem of back pain.

Not only that, but when clear-cut diagnoses could be made (e.g., lumbar disc herniation), patients with this diagnosis responded differently to treatment. Finding one single approach that worked for everyone just didn’t happen. Some experts even recommended providing patients with amenu of (treatment) options and letting them pick their treatment of choice. This idea was labeled a shared decision-making model. However, results so far have not been any better than with physician-prescribed treatment.

So, where are we today? There is a shift toward emphasizing ability (function) rather than disability (limitations). Instead of focusing treatment on pain relief, rehab programs aim to improve flexibility, endurance, and strength in the presence of ongoing pain. If pain is relieved, well then, so much the better. But pain relief is no longer the main treatment objective.

Recovering function (daily activities) and the ability to return to work are the main goals of today’s treatment for chronic low back pain. This approach is referred to as the Goal Achievement Model for the treatment of low back pain. Efforts to reduce disability from back pain based on patient goals is a new way of thinking about the problem of back pain.

Concepts such as setting “acceptable targets” and forming “patient-based action plans” are the new words attached to current treatment ideas about chronic low back pain. Health care providers can still use the biopsychosocial model (working with patient values, attitudes, and beliefs) while the patient gets the results he or she is after. This approach has worked quite well with other health problems (mental health and chronic diseases that lead to severe disability).

Where will we be at the end of the next 25 years? Hopefully, clinical and research efforts will solve the dilemma of chronic low back pain. Whether it is with a goal-oriented program that takes into consideration physical, emotional, psychologic, social, and spiritual or some other approach remains to be seen. Lowering costs, preventing low back pain, meeting patient expectations, and providing successful outcomes and patient satisfaction are all important but complex factors that must be taken into consideration.

Just watching golf on television is enough to see how much stress and strain is put on the low back with each swing. But give it a try sometime and you will experience firsthand why low back pain is so common among golfers — whether in the amateur or professional golfer.

In this article, physical therapist, Christopher Finn, from the Par4Success Golf Performance Center in Durham (North Carolina) presents current evidence from published studies and ideas from his own practice on injury prevention and rehabilitation among golfers.

Lumbar (low back) pain is a common symptom in most golfers who stick with the sport over a long period of time. The repetitive motion, rotation, and strain from the golf swing create pressure on the discs of the spine. The increased load and force on the spine are intense enough to damage muscles, joints, discs, and even the ribs. More than one-third (34.5 per cent) of all injuries among golfers results in low back pain.

What can be done to prevent these common low back conditions in golfers? Mr. Finn suggests the following:

Back pain with leg pain caused by disc herniation is a complex problem and not one that is easy to diagnose. Physicians rely on the patient’s history, physical examination (including specific neurologic tests), and imaging studies such as X-rays, MRIs, and CT scans. Accurately identifying the problem is one step. Determining the spinal level where the disc is pressing on the spinal nerve is a separate diagnostic step.

It would be helpful for examiners evaluating patients with back and leg pain if they knew which clinical tests are the most accurate and reliable. This is especially true if it turned out that one neurologic testing procedure could provide good overall diagnostic accuracy.

According to this study from New Zealand, current motor, sensory, and reflex testing used to diagnose disc herniation and specific level of pathology are not accurate. In fact, after pooling all the data together and analyzing the studies published so far, it looks like the accuracy value of the tests is poor at best.

After searching six of the most relevant electronic databases, they found 14 studies that matched their inclusion criteria. Their search history, search strategy, and algorithm (flow chart) for the studies was presented as an easily readable diagram. Study characteristics (e.g., author names, tests reported, type of physician examiner, herniation type and level) were presented in an easy-to-read table.

An in-depth description of the problems encountered with each study was provided. This helps explain why the neurologic testing to detect lumbar disc herniation and spinal nerve root involvement is not reliable enough to become a standardized test. Here’s a quick summary:

Today’s physicians depend on evidence from clinical studies and what are considered “best practice” approaches by experts whenever possible. When evaluating patients with degenerative lumbar spinal stenosis (DLSS or sometimes referred to as just LSS), the clinical practice guidelines of 2006 have been the “go to” document for guidance. This saves physicians from sorting through the hundreds of studies published each year in many different journals.

But now, the 2006 guidelines have been reviewed (based on published studies up to and including July 2010) and revised. In this document, members from the Degenerative Lumbar Spinal Stenosis Work Group of the North American Spine Society (NASS) provide a summary of the new guidelines. This update is now considered the most recent evidence-based clinical practice guideline (CPG) on LSS.

Sixteen questions were posed and answered in the 2006 Clinical Practice Guidelines. The questions covered topics ranging from natural history of LSS to diagnosis and treatment of this condition. All questions were reviewed and responses provided in this 2013 update. The levels of evidence were indicated for each response using grades labeled A (recommended), B (suggested), C (an option), and I (insufficient evidence to recommend for or against).

The working group also provided a consensus statement when there wasn’t enough reliable evidence to provide a guideline. This consensus statement is the opinion of the group based on all currently available evidence and expert opinion. Here is a sampling of the questions and some of the updated responses:

Patients in need of surgery for severe, chronic back pain can benefit by today’s modern surgical techniques, especially minimally invasive surgery (MIS) for spinal fusion. But this MIS technique exposes the surgeon (and operating room staff) to greater levels of radiation. The increased radiation exposure occurs because of the need for more intraoperative imaging to guide the surgeon (usually with real-time X-ray called fluoroscopy).

In this study, two groups of patients having spinal fusion were compared. All 162 patients had an anterior lumbar interbody fusion (ALIF) first and then a second procedure. The second procedure was a posterior fusion with either an open incision (group one) or a minimally invasive approach (group two). Some patients (but not all) had a decompression of the nerve tissue as part of the second procedure.

A little information about the advantages of the minimally invasive surgery (MIS) gives a greater appreciation for why this approach is being studied so closely. The traditional open incision involves cutting through the many layers of spinal muscles and other soft tissue structures to gain access to the vertebral bones.

With MIS, a tube-shaped instrument is passed down through the soft tissues between muscle groups. The soft tissue structures are pushed aside without cutting them. This technique reduces the risk instability from damage to muscles, tendons, ligaments, and bone. MIS also makes it possible for patients to get up and moving again sooner, allowing for faster recovery.

Fiber optic lighting and advanced imaging technology aid the surgeon in seeing inside the body to perform the necessary steps. After removal of the disc from an anterior (front of the body/spine), bone graft was placed inside the disc space to maintain normal disc height. Then the patients were turned over and operated on from the back. This was when the spinal fusion was done using either the open or minimally invasive approach.

Results were compared using a variety of measures including amount of blood lost during surgery (and need for blood transfusion), length of surgery and minutes of time exposed to fluoroscopy, length of hospital stay after surgery, and complications (type and severity).

As it turns out, blood loss and the corresponding transfusion rates were greater in the open group. But a second look at this difference showed that it was the patients who had an additional surgical procedure (neural decompression) who experienced these complications. And as expected, the MIS group was exposed to longer periods of radiation exposure due to the increased need for fluoroscopy during the procedure.

The unique aspect of this study was the fact that patients had an open anterior spinal fusion followed by a posterior spinal fusion (either by open or a minimally invasive approach). The authors concluded that minimally invasive posterior fusion following open anterior spinal fusion does have the advantages of less blood loss and therefore less need for a blood transfusion. MIS was also associated with a shorter hospital stay (and lower costs). Blood loss was greater in the patients who had open neural decompression.

However, rates of major complications such as blood clots, infection, or need for revision surgery due to problems with hardware were similar between the open and MIS group. The benefit or value of a minimally invasive procedure when performing a posterior spinal fusion with decompression may be compromised. And with the increased exposure to radiation required by the added decompression procedure, it may be that the open incision approach is best when decompression is needed.

SPORT stands for Spine Patient Outcomes Research Trial. It is an ongoing long-term study conducted at 13 medical centers across 11 states in the United States. These medical centers provide multidisciplinary treatment to patients with spinal disorders. Patients are followed at regular intervals and outcomes are measured in terms of pain, function, and disability.

Patients enrolled in this study had leg pain or discomfort and other neurologic symptoms for at least three months. Imaging studies showed both single-level degenerative spondylolisthesis and single or multi-level lumbar stenosis.

Degenerative spondylolisthesis occurs with aging most often affecting the L4-L5 level in people over 50 years old. Women are affected six times more often than men. Spondylolisthesis alters the alignment of the spine. In this condition, degeneration of the disc and facet (spinal) joints can lead to one of the vertebral bones to slip forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. The spinal canal narrows (a condition called stenosis) putting pressure on the spinal nerves.

This is the first study to compare the results of surgery for single-level degenerative spondylolisthesis accompanied by multilevel stenosis. The patients were divided into two groups. One group (130 patients) had a decompression procedure at more than one level (for the stenosis) and a fusion at one level (for the spondylolisthesis). The second group (77 patients) had the same multilevel decompression but only a single-level fusion.

Because SPORT is an ongoing data collecting type of study, many different pieces of information are collected about the patient, symptoms, insurance, clinical observations and test results, levels and severity of dysfunction, operative problems and results, and so on. This makes it possible to present tables of comparisons for patient demographics, comorbidities, fusion levels, and outcomes.

Although the multilevel fusion procedures took longer and the patients had more blood loss, there were no differences between the two groups in terms of blood replacement, complications during or after the surgeries, or number of reoperations required. Most other comparisons were similar between the two groups.

The only real trend was for greater improvement of physical function in the single-level fusion group compared with the patients who had multilevel fusion. But that was only seen after the third year and the benefit evened out between the two groups after the fourth year of follow-up.

Previous SPORT studies have shown that patients have more improvement with surgery compared with a conservative (nonoperative) approach for the problem of degenerative spondylolisthesis with multilevel stenosis.

This study offers the additional information that surgical results are very similar when treating patients who have single-level degenerative spondylolisthesis and multilevel lumbar stenosis using different surgical approaches. Whether performing a single-level fusion procedure or a multiple-level fusion, the outcomes (measured as bodily pain and function) are about the same (i.e., not significantly different).

Therefore, surgeons may want to limit fusion to just the spinal level where instability from the degenerative spondylolisthesis is present. In this way, patients are not exposed to longer operative times. And they are saved from higher levels of blood loss. This is an important consideration for older adults with multiple medical problems. It may be argued that fusing additional levels prevents future adjacent-segment disease but this remains under investigation.

Patients with chronic, persistent, and disabling low back pain from degenerative disc disease (DDD) will be interested in the results of this study. The authors (surgeons from four well-known Spine Centers in the U.S.) collected, reviewed, and summarized data from studies comparing surgical fusion with nonoperative (conservative) care.

They used careful selection criteria to get the best evidence possible. Studies included had to use validated patient assessment tools to measure outcomes (e.g., the Oswestry Disability Index, Short Form Health Survey). Patient satisfaction and X-ray results were also acceptable measures of clinical outcomes.

Articles considered unacceptable for review (inclusion) and therefore excluded were: 1) based on opinion, 2) only reporting on surgical technique, or 3) included patients receiving a fusion at more than two spinal levels. In addition, studies that were too small (less than 20 patients) or too short (follow-up was less than one year) were not included.

Twenty-six (26) studies with a total of over 3,000 patients met the necessary standards to be included. All patients had pain and loss of function as a result of degenerative disc disease in the lumbar spine (low back). Spinal surgery done was fusion at one or two levels.

The authors provided several summaries of data (in table form) from studies that compared results of surgery versus nonoperative care for this condition. The tables showed specific information compiled for randomized and nonrandomized controlled trials. They included length of follow-up time, patient age, baseline back pain information, change in outcome scores, fusion rates, reoperation rates, and level of patient satisfaction.

Overall patient satisfaction was 75 per cent for patients who had the fusion procedure, while patients in the nonoperative group reported a much lower rate (55.6 per cent) of satisfaction. The percentage of patients who had a successful fusion was 84 per cent. Seven per cent (7%) of the total group had a second surgery due to a failed first surgery.

Pain relief and improved function were reported for the fusion patients in the majority of cases. Type of fusion technique and age of the patient (young versus old) did not seem to affect success of the fusion procedure.

Patients evaluating results of surgery versus nonoperative care for degenerative disc disease should keep in mind that these two treatments are not really competing with one another. Patients aren’t usually given the opportunity to choose between them.

Instead, treatment is offered in a series: first conservative care with medications, physical therapy, and rest. Then, if the treatment fails, follow-up surgery (spinal fusion) is advised. Surgeons who seek the best evidence available to support their clinical decisions may rely on systematic reviews like this one to direct and guide them.

Summary: Collecting information on treatment results like in this review (especially success and failure risks and rates) is important today because of the large number of people missing work or seeking medical care for chronic low back pain. The high cost of fusion surgery also warrants knowing if surgical care is the best way to go.

As this systematic review showed, patients who do not get relief from their painful, disabling symptoms with nonsurgical treatment may find surgical fusion is a very good next step in the treatment algorithm (clinical decision pathway).

Sports athletes are not immune to low back pain. Bony defects such as spondylolysis and spondylolisthesis present from birth or as a result of stress fractures from overuse can be a common cause of lumbar instability. In the case of spondylolysis, the supporting bony column (called the pars interarticularis) fractures. If the fracture displaces (separates) and the vertebral body shifts forward, the condition is referred to as spondylolisthesis.

It is estimated that nearly half of all low back pain in athletes comes from spondylolysis/spondylolisthesis. And there isn’t one main sport or activity where these injuries occur most often. Anyone who participates in a sport that includes extension of the spine with rotation (and especially rotation with compression or load) is at risk. For example, this condition has been reported in dancers, gymnasts, figure skaters, weight lifters, and football players.

As you might imagine, most athletes would prefer a nonoperative approach to treatment — but preferably one that gets them back on their feet and returns them to full participation quickly. In an effort to identify the most helpful conservative (nonoperative) care for these patients, a group of physical therapists conducted this systematic review and reported their findings.

They conducted a computer-assisted search of articles published in English over a span of 46 years (from 1966 to 2012). After gathering all the acceptable articles and compiling all the information, the authors organized the data into five tables. Information in these tables included:

1) Description of each study (design, patient demographics, training type and duration)

2) Type of injury (acute versus chronic, severity) and type of surgery (decompression, fusion, fusion with or without instrumentation)

3) Comparison of outcomes for nonoperative treatments (bracing versus activity restriction)

4) Comparison of outcomes for nonoperative treatments (bracing and physical therapy versus placebo/control)

5) Results for exercise interventions (core training, back strengthening, postural exercises, general exercise)

Although the information was carefully organized, as it turned out, many of the studies collected (and reported on) different things. There wasn’t enough consistency across studies to make comparisons with meaning. The authors report “limited investigation” and “lack of homogeneity” as the two main reasons there was no consensus on the role of conservative care or on outcomes of nonoperative care versus surgery for this condition.

There was one other major stumbling block in studying the effects of exercise: poor patient compliance. In other words, the patients didn’t do the exercises as prescribed (or didn’t do them at all)! With the limited evidence available, the best that can be said is that surgery (over conservative care) seems to be most effective for higher grades of vertebral slippage. And exercise to strengthen the core muscles (abdominals and trunk stabilizers) decreases pain and improves function.

No evidence but clear consensus (based on expert opinion or case studies suggest) suggested that bracing works better for healing the fracture when compared with restricted activity for children and teens with spondylolysis (fracture without separation). In adults, lumbar exercises helped some people recover and return to work. But there was inconsistency in the most effective type of lumbar exercises. For example, some people responded to extension exercises better than flexion exercises and vice versa.

This very carefully constructed systematic review of the results of conservative (nonoperative care) for low back pain in athletes caused by spondylolysis or spondylolisthesis faced some challenges because of limitations in how studies are conducted. The lack of consensus or evidence-based agreement on the best way to treat these patients must be addressed in future high-quality research.