News Category: General Spine

Finding a quick and easy way to measure effectiveness of treatment is important in today’s evidence-based medical practice. Doctors, nurses, and therapists must be able to show that treatment works, and that it’s the best treatment for the problem.

Unfortunately, there isn’t a one-size-fits-all tool to measure health outcomes. Health care professionals treat patients of all ages, backgrounds, and medical conditions. And overburdening patients with too much paperwork can be a problem.

In this study, physical therapists tested a self-report survey tool with two groups of patients. One group had cervical (neck) spinal disorders. The second group had lumbosacral (low back) spinal disorders. They used the 12-Item Short-Form Health Survey (SF-12). This is a shortened version of the 36-Item Short-Form Health Survey (SF-36).

The 12-Item survey is a one-page questionnaire that assesses physical and mental health. They gave the SF-36 test and the SF-12 test to patients before and after spinal surgery. Only the pre-op test scores were analyzed for this study.

The researchers expected to find similar responses (and test scores) using these two tools between the two groups of patients. They also looked for any other factors that might influence health and explain any differences in results between the two groups.

They did, indeed, find a close correlation in the results between the two tests. This was true for everything except general health status. These results may be because the shorter test version did not ask as many detailed questions about age, smoking, and health history.

In general, the SF-12 was found to be a valid and reliable tool to use with patients who have spinal disorders. It’s fast and efficient. The clinician can still ask other questions about general health (age, other problems, tobacco use).

Aquatic exercise is widely used in the treatment of many orthopedic and neurologic conditions. It is a popular therapy modality around the world. But is it any more effective than land exercise? Does it relieve pain better than no treatment at all? These are the questions researchers set out to answer with this study.

The authors searched 14 different research databases looking for information that might help. The search included literature published over a period of 26 years. Only studies with adults who had neurologic or musculoskeletal diseases were included.

There were five studies of acceptable quality for review. Some compared aquatic exercise with no treatment (or with a control group waiting for aquatic therapy). Others compared aquatic exercise with land exercise. Pain relief was the main measure of outcome for this review.

The aquatic exercise programs included muscle strengthening, range of motion exercises, aerobic exercise, and functional activities. The programs were held in a variety of locations. Some pools were in clinics, hospitals, or public areas. Sessions lasted at least 30 minutes over a period of six weeks or longer.

The results showed a small posttreatment effect of aquatic therapy. Participants in the aquatic program had more pain relief than sujects who had no treatment at all. Results were the same for aquatic therapy compared to land exercise.

There wasn’t enough evidence to clearly show that aquatic exercise is an effective way to relieve pain. This study did not review the effect of aquatic exercise on joint motion, muscle strength, fitness, or endurance. Aquatic exercise is used to improve all of these areas.

More study is needed to find out what are the effects of aquatic exercise and who can benefit the most from this type of program.

Treatment for spinal fractures may be operative (surgery) or nonoperative (conservative care). Research comparing these two treatment methods is very limited. It’s difficult to compare the results between these two interventions. For one thing, surgeons use different methods to classify the injury.

And patient populations vary considerably. More serious injuries are often treated surgically creating a bias in favor of one treatment over another. The question has been raised as to whether or not surgery is really needed just because the injury is more severe. Some experts have suggested that the long-term results wouldn’t be any different between operative and nonoperative care.

In this study, differences in results between operative and nonoperative patients with traumatic thoracic or lumbar spine fractures are reported. Measures of outcome included quality of life, residual pain, and neurologic recovery. Work status was also reviewed.

Patients were treated at one of two surgery centers. One center only performs surgery in unusual cases. All other patients are treated conservatively without surgery. The second center has adopted a more aggressive approach. Surgery is done on anyone with unstable or neurologically involved fractures.

Conservative care consisted of bed rest and/or a plaster cast until fracture healing occurred. Alternately, the surgical group had a stabilization and fusion operation of the fractured segment. After the operation, everyone wore a protective brace called a thoracic-lumbar-sacral orthosis (TLSO).

All things considered, patients in the two groups were very similar. The main difference was the larger number of men in both groups but especially in the operative group. Results were assessed using two well-known surveys of health status. The complication rate was high (20 per cent) but equal between the two groups. Types of problems varied from infection to bowel paralysis.

Pain and disability were also equal between the two groups. Health-related quality of life was also comparable from one group to the other. Patients in both groups who had neurologic involvement had the worst results.

Women in both groups tended to have lower scores in terms of physical and mental function. The reason for this was not clear. Osteoporosis and a stiffer spine in women may account for some of the differences between the sexes.

And finally, patients in the operative group had a shorter rehab period and faster earlier return to work date. Even with the higher costs related to surgery, operative care was still more cost-effective than nonoperative care. This factor alone might tip the scales in favor of operative therapy for traumatic spinal fractures.

In this study, researchers analyze patient cases from a regional spinal cord injury center who suffered injuries from a fall out of a hunting tree stand. The intent of the study was to show how often this happens, what causes these types of injuries, and how to prevent them.

The records of all patients were reviewed over a 10-year period of time. They were able to identify 22 cases of spinal cord injuries from such a fall. All 22 patients were men who fell from an average height of 18 feet. Impact velocity from the fall was estimated at 30 miles per hour. Most of the falls occurred in the evening.

Some of the men were constructing the tree stand. Others were getting into or out of the stand when the accident happened. No one was using a safety harness. The harness is made up of straps attaching the hunter to the stand. The use of such a safety device does reduce the risk of a fall.

The primary injury was paralysis from vertebral bone fracture and/or dislocation with damage to the spinal cord. Many of the hunters suffered injuries in addition to paralysis. These included rib fractures, punctured lungs, hemorrhage, and nerve compression.

It’s likely that many more minor injuries from hunting tree stand falls are never reported. Such falls actually represent a major cause of hunting-related accidents. The authors suggest from the results of this study that most of these accidents could be prevented.

Fatigue, low-light conditions, and alcohol-use are modifiable risk factors. Poorly constructed homemade tree stands and failure to use a safety harness add to the risk of serious falls.

Hunting alone without a safety partner or safety plan can lead to hypothermia after injury. The result is a delay in the diagnosis and treatment of potentially serious life-threatening injuries.

Hunters need to be educated as to the dangers of drinking while hunting and especially when using an elevated tree stand. Annual inspections of tree stands and maintaining communication with others while hunting are important injury prevention measures. Improved treatment for spinal cord injuries is available these days, but prevention is an even better method for avoiding serious hunting-related spinal cord injuries.

Vertebral compression fractures (VCFs) can be treated with vertebroplasty or kyphoplasty. Comparing the results of these two procedures will help surgeons decide which procedure to use for each patient. In this study, 168 published articles on these treatment techniques were analyzed. The authors present a summary of the findings.

Vertebroplasty and kyphoplasty are fairly similar procedures. In vertebroplasty, cement is injected into the collapsed vertebral body. The cement fills all the cracks and openings in the fracture. Once the cement hardens, it provides a stable segment that won’t collapse further.

In kyphoplasty, a balloon is inserted first into a collapsed vertebra. The balloon is inflated to create a cavity and then deflated and removed. Then bone cement is injected into the space created by the balloon. The fracture is stabilized and the height of the vertebral column in maintained. Both procedures are used to control pain and prevent spine deformity associated with VCFs.

The importance of this study is that it is a meta-analysis of the current literature. That means data from many smaller but acceptable studies was pooled together and analyzed. The results give us a reliable way to see how effective these two treatments are and how the outcomes compare. Type and rate of complications were also included.

Of the 1,036 studies available, 168 met all the pre-set standards to be included in the meta-analysis. The majority of the articles reported on vertebroplasty. Kyphoplasty was used and/or studied less often.

Pain relief and complications were the two areas compared. Patients in both groups got good pain reduction. Vertebroplasty was more effective in decreasing patients’ pain levels. But the difference between the two treatment methods wasn’t statistically significant. That suggests patients benefit equally, no matter which method is used.

Problems with cement leakage and new compression fractures were more likely to occur with vertebroplasty. But there was a greater risk of heart attack with the kyphoplasty procedure.

The authors conclude that vertebroplasty and kyphoplasty achieve similar results. There’s a greater risk of complications with vertebroplasty. In general, more studies are needed comparing these two procedures with each other and with other medical (nonoperative) care. Longer follow-up periods are needed to see just what are the long-term effects of each treatment.

While many patients report the advantage or disadvantage of certain mattresses, studies have been inconclusive. The authors of the study compared three different types of mattresses in persons with chronic low back pain. They investigated their effect on back pain, leg pain, activities of daily living, and hours of sleep.

The three mattresses used were a waterbed, built with layers of fibers to stabilize water movement, a body conforming mattress that is made of a temperature-sensitive pressure relieving material, and a futon with a foam core surrounded by layers of cotton making the mattress firm.

One hundred twenty subjects were placed into one of the three mattress groups matched by age, sex, duration and severity of low back pain-related days off and daily physical workload. They were given a one month trial using the specific mattress. Quite a large number of subjects dropped out during the trial, most due to more pain. Of interest, the drop out rate was three times greater in the futon mattress group than the body contour mattress group, and six times greater than the waterbed group.

The results of the study demonstrate that of those who remained in the study, the subjects using the waterbed and body conforming mattresses became slightly better. There was no statistical difference between these two types of mattresses. While there were some subjects who felt better with the futon mattress, it generally influenced back problems negatively.

Although back pain and spinal disease have been around for generations, it has only been in the past 70 years that spinal care has seen major developments in spinal care. This article reviews the history of spinal disease and care, as well as the diagnosis and the implications of treatment.

Because the cause of back pain was poorly understood, as recently as before the mid-1800s, only the symptoms of spinal disease were treated. In the mid-1840s, there developed an understanding of the pathophysiology of the body and the back, leading to the beginning of understanding the causes of spinal disease.

At this point, doctors began putting together the similarities in patient complaints and grouping the similar complaints into disease entities. When this happened, researchers could focus on one particular disease and its diagnosis and management.

As their knowledge grew, the development of chemical and mechanical treatments progressed. Many of the problems that were treated in the previous two centuries are now rarely seen, such as polio, systemic tuberculosis, and others.

The “biomechanical model,” which arose from the earlier years affected all aspects of medical care, including spinal care. Doctors and researchers moved from focusing on symptoms and deformities to more in-depth issues. By 1841, in an autopsy, a physician found evidence of disc protrusions and this was followed by similar discoveries by others in the following years. Although surgery may have occurred as early as 1896, the first noted surgical intervention occurred in 1909, when a disc herniation was removed from a patient experiencing paralysis.

In 1929, two cases of discectomies were reported and spinal surgery continued to grow and develop. The literature included articles on intervertebral disc herniation as a disease entity that could be diagnosed. This diagnosis progressed over the decades from clinically to myelographically, to computed tomography, and now through magnetic resonance imaging.

Throughout the mid-19th century, diagnosis were not yet done; rather, physicians described their findings, but the use of the biomedical model led to diagnosis, which is now the driving force behind treating. Physicians have a diagnosis and then they treat.

Treatment, originally through trial and error, became based on experience over the years, but has now become based on randomized trials and care guidelines. As well, patients are having more say in their care as they become more informed and educated in health and medical matters.

The rise of specialty medicine also came to be and specialties such as spinal surgery resulted from that first discovery of disease categories.

There are both positive and negative implications with the biomedical model and its disease categories, methods of diagnosis and therapies. On the positive side, this has allowed the medical field to eliminate or drastically reduce many of the ills of the past. The negative side, however, has a few issues.

People with diseases are unique. Their diseases and diagnosis may be common among others, but the individuals are unique. There are many outside factors that should be taken into account when a diagnosis is made, although this was not immediately apparent in the earlier days of medicine. It was only in the mid-1960s that this individuality began to be addressed, and only in the 1970s when it was addressed in more depth. Psychiatric disease was adapted to somatic disease in 1977 and spinal disease in the 1980s.

By encompassing this approach, the proponents believe that the more complicated spinal diseases are not good representatives of the biomechanical model, but that patients with spinal disease are unique, with their biologic, psychological, and social factors. This leads to the Biopsychosocial Model, which has gained widespread acceptance in the spinal care community.

Another negative implication is that of the creation or emergence of new categories. Newer syndromes or problems are still being treated as the older problems and this may not be appropriate. Another concern is the inappropriate use of disease categories to use or restrict care. In this day and age of high healthcare costs, some people are concerned that those people making payment decisions may be making their decisions based on old models.

The introduction of other players into healthcare, such as the government or insurance, is another negative implication. The concern is with these people making the decisions, as well. Finally, the last negative implication is the iatrogenesis, or inducing of patient complaints as the result of diagnosing disease.

The author of this article concludes that the act of placing a diagnosis on spinal disease is what sets the wheels into motion in terms of medicine and social (finances, for example). Knowing that diagnosis does have such a power, the author suggests that physicians be aware of what can be caused by the pronouncement of a diagnosis and be prepared for the outcome.

There’s some thought that middle-aged working people are at greatest risk for back pain. But, in fact, according to this study of centenarians (age 100 or more), neck and back pain are just as common at age 20, 40, 60, up to 100-plus.

A survey of Danish 100-year-olds conducted by face-to-face interviews assessed the prevalence of back and neck pain. Such a study was possible since all Danish citizens are required to register with the Danish Civil Registration System.

Anyone born in 1905 was contacted in 2005 by telephone. Participation was voluntary. About half the people old enough in the registry to participate agreed to the interview. Data was collected about general health (physical and mental), function, and quality of life.

The results showed that neck and back pain are a fact of life at any age. Age doesn’t really seem to be a factor at all — unless specific types of back or neck pain only occur at certain ages. More study is needed to sort out that idea. The survey did show that anyone with back pain had poorer self-rated health, including physical function and depression.

It’s likely that the oldest of the old who didn’t respond to this survey may have worse health compared to those who did get involved with this study. That means the results of this study are probably underestimated.

Given the results of this survey, the authors suggest that preventing pain may not be a realistic goal. It may make more sense to focus on avoiding irrational pain behavior and keeping symptoms from becoming chronic. Given the high prevalence of this condition in the general population of all ages, the cost of neck and back pain to society may be less with this type of approach. This would be true for young and old alike.

If you have a vertebroplasty procedure for a vertebral compression fracture (VCFs) and it doesn’t relieve the pain, should you have it done a second time? That’s the question the authors of this study asked.

Vertebroplasty is a minimally invasive medical procedure. A tiny incision is made in the skin over the fractured vertebra. This is called a percutaneous vertebroplasty. Bone cement is injected through the incision into the affected vertebra. The goal is to stabilize the bone and reduce pain caused by the fracture.

Repeat vertebroplasty was done in 15 patients who had continued painful osteoporotic VCFs. The second percutaneous vertebroplasty was done as early as four days after the first one. Some repeat injections were done up to 32 days later.

Complete pain relief was achieved in 73 per cent of the patients receiving their second percutaneous vertebroplasty. The rest of the patients had at least partial pain relief. The authors reported that failure to fill the fractured vertebra with cement was the reason for the first failed procedure. Sometimes the cement reached the target area but there just wasn’t enough to stabilize the vertebra.

Percutaneous vertebroplasty is quickly becoming the treatment of choice for painful osteoporotic VCFs. Successful management of the pain has been reported in many studies. Restoring vertebral height, strength, and stiffness results in pain relief. Proper technique is important to get good results the first time.

A second percutaneous vertebroplasty is an acceptable follow-up treatment if pain persists after the first one. This is true even if the persistent symptoms aren’t caused by another (new) fracture.

The authors advise using a single injection of cement, making sure the needle reaches close to the midline of the vertebrae. Fluoroscopic guidance should be used to ensure accurate needle placement.

Fluoroscopy is a form of X-ray imaging that allows the surgeon to see real-time images inside the body. Enough cement must be used to fill the bone without overfilling, causing cement leakage. The patient can expect pain relief within 24 hours after the second vertebroplasty.

Patients with chronic neck or back pain from a motor-vehicle accident (MVA) seeking medical care often fill out paperwork asking for their health history. They may be asked about previous episodes of pain, history of depression, and psychologic problems. A drug and alcohol history is also included.

The information taken from the health history can be very valuable in guiding the treatment plan. For example, depression, drug abuse, alcoholism, and psychologic distress have all been linked with a poor prognosis for new episodes of musculoskeletal pain.

The risk of a future MVA with possible serious injury is also increased in patients with a history of drug or alcohol abuse. Usually, patient answers are assumed to be accurate and true.

But in this study, more than two-thirds of the patients denied a previous history of psychologic distress. They also denied alcohol or other drug abuse and previous neck or back pain. Looking back at their medical records, this information was incorrect. And 80 per cent of the patients who were involved with legal proceedings did not reveal a past history of musculoskeletal pain or other serious health problems.

It appears that patients who think the accident was someone else’s fault were more likely to deny a positive social history for the use of alcohol and other drugs or mental health problems. The rates of these problems reported were much lower in patients after a MVA than when compared to others. The standard for comparison was people of similar ages and gender who had not had an accident.

The results of this study question the validity of neck and back pain patients’ self-reported history after a car accident. Under-reporting pain and other problems is common in patients who have filed a compensation claim or retained a lawyer.

Treatment decisions based on self-reported responses must be made carefully. Failure to identify serious psychologic and substance abuse problems can have a major effect on public health such as cost and policies.

Health care professionals can use the period after a serious MVA to find out about alcohol and other drug problems. Patients may be more open to an intervention program. Patients can be educated about the risk of another MVA with more serious injuries.

Like lower back injuries and back pain, upper extremity disorders can cause significant economic and quality-of-life costs. Traditionally, the estimated prevalence rates of upper extremity disorders range from two percent to 53 percent. The 12-month range is almost equally as broad, ranging from two percent to 41 percent.

The need for a consistent use of terminologies and classifications is vital in order for the medical community to accurately assess the impact of complaints of arm, neck, and/or shoulder (CANS). This was done and a definition was issued: “musculoskeletal complaints of arm, neck and shoulder not caused by acute trauma or by any systematic disease.”

The authors of this article evaluated data in order to determine the prevalence of specific and nonspecific CANS, the patients’ contact with healthcare professionals, the relationship between the health and sickness absence characteristics and patient use of healthcare, and the overlap of pain locations visualized within CANS.

Using the results of a study done in the Netherlands, involving responses from 3664 people, researchers assessed the baseline data regarding symptoms in the neck, shoulder, elbow and wrist/hand. Patients who had symptoms caused by acute trauma or a systemic disease were excluded from the assessment.

the researchers found that, according to the CANS definition, 48 percent of the Dutch population who were over 25 years old reported upper extremity disorders (UEDs) within the previous year, and 36.8 percent reported CANS. Almost 37 percent of those with UEDs had them at the time of the survey. Of these patients, 27.2 percent met the criteria for chronic pain. for patients who reported CANS, 26.4 percent reported current CANS and 19 percent met the criteria for chronic pain.

Examining the demographics of the people with UEDs and CANs, the researchers noted that CANs were more prevalent in women and most common among those between the ages of 45 and 64 years. With chronic CANS, 58 percent said they had sought medical help; more women than men sought help. There was also a difference between working and nonworking populations – those who worked were more likely to seek medical help.

For the study, all subjects completed the Short Form 36, SF-36, which is questionnaire that assesses general health. The scores range from zero to 100; the higher the score, the better the health. People with chronic CANS scored higher on the SF-36 than did those with UEDs. subjects with UEDs were more likely to see a doctor if they were affected by a systemic disease or had sustained a trauma, which caused the UED. Among all subjects who used healthcare services more, there were more complaints of continuous and recurrent pain, more limitations on daily life, and more sickness absence because of CANS.

The authors point out some weaknesses in the study, which include the relatively low response rate of the original questionnaire. Out of 8000 questionnaires sent out, only 46.9 percent were returned. As well, much of the information was based on subject self-reporting and patient recall. However, despite the study drawbacks, the authors do state that their study showed that slightly fewer than 60 percent of subjects with CANS sought medical treatment and those are the ones who complained of more pain and disability. The prevalence of CANS was higher in the working population and among women. The area affected, the neck and shoulders were most commonly reported as being troublesome.

Damage to the spinal cord or spinal nerves is always a risk with spine surgery. To avoid neurologic damage, surgeons use intraoperative monitoring (IOM). With IOM, the surgical team uses equipment to test the function of the spinal cord and nerves during spine surgery. To do this, they monitor the contraction of target muscles. The role of IOM is to give the surgeon a warning before permanent nerve injury occurs.

There are many different ways to monitor motor function of the muscles during surgery. One commonly used method is EMG-based motor-evoked potentials (MEPs). MEPs monitor the contraction of muscles using electrical stimulation.

During surgery, while the patient is asleep, needle electrodes are placed in the muscle groups. Needles are placed in muscles that correspond to the area where the surgeon will be working. A machine can monitor electrical activity from the muscle.

In this study, MEPS from 903 patients are reviewed. Repeated transcranial electrical stimulation of the brain (TES) was the specific MEP method used. This is the favored choice of MEPs for many neurosurgeons. The goal was to find the most accurate way to interpret the MEPs.

In some surgical centers, the Presence-or-Absence method of reading MEPs is used. If the muscle contracts when stimulated, then everything is okay. The surgeon considers it a warning if the target muscle(s) don’t contract. Measures are then taken to prevent neurologic injury.

Another way to interpret responses is the Threshold-level approach. This method tracks the intensity (in volts) of TES needed to cause a minimal muscle contraction. If the amount of voltage needed to cause a muscle contraction (the threshold) starts to go up, the surgeon is warned of the change.

The results of this study showed that using the Threshold-level alarm is an earlier warning system than the Presence-or-Absence approach. Postoperative weakness was avoided in patients for whom the Threshold method was used. Compared with the Presence-or-Absence approach, the surgeon was warned minutes-to-hours ahead by the Threshold method.

The authors conclude that the Presence-or-Absence method to interpret MEPs should not be used. The Presence-or-Absence method is an accurate and reliable method of triggering a warning. But the warning is delayed and may come too late to protect the patient’s motor function.

Spine surgery can result in permanent damage to the spinal cord or spinal nerves. To avoid this, intraoperative monitoring (IOM) is used. Special devices are used to alert the surgeon to any problems. There are several ways to do this including somatosensory evoked potential (SSEP), motor evoked potential (MEP), and electromyography (EMG).

None of these methods is 100 per cent accurate. As a result, many surgery centers use multimodal monitoring in all spinal operations. This means they use more than one monitoring device at the same time. Using these together improves the precision and accuracy of early warnings. The surgeon can then avoid causing further harm to the neural tissue.

In this study, neurosurgeons look back over 1,055 cervical spine patients treated at a university-based neurosurgical unit between the years 2001 and 2005. The data collected from each monitoring method was compared later to the kinds of postoperative results patients had.

Any new deficits were noted compared to the baseline. Then they compared the methods used to see which one worked best. They also calculated the rate of incidence for new sensory or motor deficits. Patients were followed for up 10 19 months to see if the problems resolved.

Two cases studies were presented to show how the monitoring helped the surgeon. The authors presented how the procedure was adapted due to the problems that occurred. For example, one patient had a tumor inside the spinal cord. As soon as a decline in the SSEP was noted, the surgeon stopped trying to cut the tumor out. The operation continued in a start-and-stop fashion. The surgeon used the SSEP to show how much the tumor and spinal cord could be moved around.

The second patient was suspected of having spinal cord injury during the surgery. The surgeon stopped the operation right away. Drugs were given to raise the blood pressure and reduce swelling in the spinal cord area. The surgery was finished after the patient was stabilized.

The results showed that patients with the worst results had a major problem before the operation. Pressure on the spinal cord was significant. For these patients, they couldn’t even get a baseline measurement of neurologic function using IOM.

A number of cord injuries did not show up with SSEPs alone. For this reason, the authors advise against using this method alone in high-risk cases. Using SSEP with EMG was not as good as monitoring with MEP. Combining MEP and SSEP gave the best results and should be used to improve spinal cord monitoring. This is especially true for high-risk patients.

In this article, a group of rheumatic diseases affecting the tendons and joints are reviewed. This group of chronic inflammatory diseases are called spondyloarthropathies (SpA). SpA include ankylosing spondylitis (AS),psoriatic arthritis (PsA), and reactive arthritis (ReA).

Since arthritis can occur in up to 30 per cent of patients with inflammatory bowel disease (IBD), this group is included in the spondyloarthropathies as well. This is referred to as enteric arthritis. Signs and symptoms and lab values for each of the SpAs are described.

X-rays and other imaging studies are helpful in making the diagnosis. Total body MRI scans only take 30 minutes and can show all areas affected. The authors present specific radiographic findings for AS. Certain features and deformities typical of each particular spondyloarthropathy help make the diagosis. For example, a destructive pencil-in-cup deformity may be seen with PsA. The end of the affected bone becomes pointed while the opposite joint surface becomes shaped like a cup.

Management of the SpAs begins with patient education. Individuals affected by the SpAs must take their home program seriously for the best results. Making choices to stop smoking and exercise daily are strongly encouraged. Physical therapy to address issues of posture, self-care, breathing, and strength training is advised. Patients who understand the need to follow their doctor and therapist’s suggestions may have the best outcomes.

Drug treatment begins with a nonsteroidal anti-inflammatory (NSAID). Osteoarthritis is a common problem for patients with SpA and must be treated as well. For patients whose disease does not respond to therapy, tumor necrosis factor-alpha inhibitors (TNF-a inhibitors) may be used. These biologic agents include infliximab, adalimumab, and etanercept.

When and how to use these TNF-a inhibitors can be difficult to decide. The authors provide a detailed table of diagnosis, dosing, and expected results for drug treatment. If one TNF-a inhibitor doesn’t work, another can be tried.

These drugs must be used on a long-term basis, but they are expensive. They also have some serious side effects. The most common problems are allergic reactions and an increased number of infections. Patients with a past history of tuberculosis (TB) may be at risk for reactivation of the TB.

Each patient will require a unique management program. Treatment depends on the underlying disease and current symptoms. Surgery is an option for some patients. Referral to a specialist is needed from time to time for patients with skin (psoriasis), eye (uveitis),or other problems.

Studies show that rates of infection after spinal surgery can range from zero to 15 per cent. The wide variation is linked to the type of operation, site, and approach. Whether or not metal implants are used is another important factor.

Spinal surgery can be done by neurosurgeons or orthopedic surgeons. The choice of surgeon is linked to the type of procedure. The authors of this study published the results of a previous study looking at risk factors for patients who had a spinal operation done by neurosurgeons.

In this new report, the rate of infection and risk factors are reviewed for spinal surgeries performed by orthopedic surgeons. The medical records of 2,316 patients who had spinal operations by orthopedic surgeons were reviewed.

There were 46 cases of surgical site infection. This means there was a two per cent rate of infection involving the spinal incision. The infections were classified as deep, organ space, or superficial.

Areas affected by deep infections included fascia and/or muscle. Organ space infections involved any space opened during the operation other than the incision. Superficial infections involved just the skin or subcutaneous tissue. Subcutaneous refers to the area just below the skin.

These 46 records were compared to 227 uninfected patients (control cases). Data collected included details about the operation and signs and symptoms of infection. They also reviewed the charts for possible risk factors.

Patients with diabetes or elevated blood sugar levels (more than 125 mg/dL but not yet diagnosed as diabetic) had the highest rates of infection. Obesity and incontinence of the bowel or bladder (before or after the operation) were additional risk factors for spinal infection.

Patients with vertebral fractures were at greater risk than those with herniated discs. Malnutrition was not a major risk factor. Timing of preventive antibiotics was also a risk factor for infection at the surgical site.

The authors suggest several strategies for reducing infection. First, monitor and balance patients’ blood glucose levels before and after surgery. Second, give prophylactic (preventative) antibiotics within 60 minutes of the incision. Antibiotics given more than an hour before the incision or after the procedure are considered suboptimal. Third, give a higher dose of antibiotic to obese patients.

Finally, having two or more surgical residents involved in the operation appears to be a risk factor for infection. This may be linked with the duration of the operation and/or the complexity of the procedure. More study is needed to examine this factor more closely.

Defining prevalence of low back pain is difficult, in part due to the variablility of back pain research. The differences in definitions and other methodology make regional and international comparisons nearly impossible.

The authors attempted to standardize the definitions of low back pain for epidemiological prevalence studies relying on input from an international panel of experts in back pain. 28 experts from 12 different countries participated in the process. The authors had hoped to develop at least two definitions of low back pain. A minimal definition to be used for large population-based general surveys, and an optimal definition for use in focused studies.

The authors reviewed 51 articles reporting population-based prevalence studies.They extracted 77 elements that could be included in a definition of low back pain prevalence. These elements were listed in a questionnaire and then ranked by the participants in round one.

Elements which were determined to reach a certain level of consensus were included in the elements for the questionnaire in round two. Also included in the round two questionnaire were new items suggested by the participants in round one.

Round three included items that reached a certain level of consensus from round two. Participants were asked to choose only one item in each element, for each of the two definitions.

A workshop orgainzed at the International Forum VIII for Primary Care Research on Low Back Pain in Amsterdam on June 8, 2006 was held to present the results of rounds one to three and discuss with the 24 participants.

Results of the workshop were included with those of rounds one throuh three in an online summary document. Participants were asked to vote for or against one minmal definition, and one optimal definition.

The final minimal definition of low back pain included two questions. The final optimal definition asked six questions and also included the numerical rating scale to measure severity.

The authors suggest that the results of this work should be considered as a step toward better standardization of definitions of low back pain for use in epidemiological studies. Their use is hoped to improve the synergy and usefulness for comparison between back pain studies internationally. Most likely researchers will want to also include their own preferred items. The hope is that they will use them in addition to the standard definitions developed and agreed upon.

Most episodes of back pain resolve within six weeks although many have symptoms which persist and debilitate them for years. The definition of acute pain used was pain lasting less than six weeks. Chronic pain was defined as pain persisting for three months or longer. Psychological factors are known to play a role in chronic pain. Other studies have shown that acute pain intensity, depressive symptoms, exposure to severe stressors and traumas, and negative pain beliefs can cause perpetuation of pain.

The authors studied the cognitive, affective and trauma factors in 84 acute back pain patients to see if any of the measures were predictive of progression to chronic pain and disability. The subjects were followed for three months. Subjects were excluded from the study if they had any history of spine surgery, previous neck or back pain within the six months prior to their current pain episode, history of any psychotic or delusional disorder, or if they had any serious co-occuring pain-related medical conditions. The mean duration of pain at the time of the initial visit was 3.6 weeks.

A battery of questionnaires was completed at enrollment and three months later. Pain intensity, pain disability, cumulative trauma exposure, depression, and pain schemas were assessed.

The authors found that greater exposure to past traumatic life events and depressed mood were most predictive of chronic pain. Depressed mood and negative pain beliefs were most predictive of chronic disability. Early detection of depressive symptoms and significant trauma exposure may identify those patients with acute neck or back pain who may be at greater risk for progressing to chronic pain and disability.

Physical therapists (PTs) use a test of spinal mobility called the PA maneuver. PArefers to posterior-anterior. This is the direction of the force applied by the PT at each spinal segment during testing.

The force is generated by the examiner’s hand down through the segment with the patient lying face down on a table. The movement is classified as hypomobile (decreased), normal, or hypermobile (increased).

In this study, PTs at the University of Southern California (USC) test the validity and reliability of the PA maneuver. Can joint mobility be tested accurately with a manual maneuver of this type? Can the examiner test every patient with the same amount of force? Can more than one PT get the same result using this test?

Young adults (aged 18 to 45) with low back pain of three months or less were included. Each patient was tested by two different therapists with and without dynamic MRI. Dynamic MRI makes it possible to measure the actual motion of the spinal segment as the examiner performs the test.

Computer analysis of the results showed that the PA maneuver is reliable in finding the least mobile spinal segment. This test was not a good way to find the most mobile segment.

Further testing is needed to identify when the PA maneuver should be used. It’s possible that the testing process helps loosen up a stiff segment, thus altering the results. The age of the patient may make a difference. There may be more stiffness perceived in older adults. And stiffness may be misjudged as a loss of segmental motion.

The authors conclude that accurately and reliably assessing joint mobility with manual techniques is difficult at best. In the future, dynamic testing and advanced technology with force sensors may help show us when back pain is caused by spinal instability, stiffness, or some other factor.

Spinal fusion is usually done with metal plates, screws, and rods. Implant failure can occur but the cause is not always known. In this study, scientists look for corrosion currents around the implants. They suspect these electric currents result in bone loss and loosening of the implant.

Past studies have shown that corrosion and wear of metal implants does release metal ions into the area. The cells of the body react to these degradation products. The immune system forms complexes to destroy this debris. The result is inflammation and scarring.

When two metals are in the same area, they can generate electric currents. The electric current has a biologic effect on the bone. Bone-building cells called osteoblasts are destroyed when exposed to this electromagnetic field (EMF).

Without enough bone build-up around the implant, the device can come loose. Bone loss is a common cause of implant and fusion failure. The authors examined implants that had been removed early due to wear and corrosion.

Tests performed on the implants showed scratches and corrosion on the surface of the devices. There was a continuous electrochemical current around the metal. Constant EMF stimulation resulted in a lower number of osteoblasts.

Implant loosening from this sequence of events is called periprosthetic aseptic osteolysis. Periprosthetic means around the prosthesis or implant. Aseptic tells us that there was no infection. Osteolysis is the loss of bone.

This is the first study to show that metal implants can generate electric and electromagnetic energy. The effect on bone leads to bone loss and implant failure. The next step is to find out how this kind of EMF affects osteoblasts and stop it from altering bone growth.

Congenital scoliosis and/or kyphosis, curvature of the spine from birth, develops during the first eight weeks of prenatal development. At this time, other problems can develop with the spine, including tethering of the cord (spinal cord is attached to the spinal column), diastematomyelia (spinal cord is divided in half), lipoma (a non-cancerous tumor), and various others.

Many spinal abnormalities are detected by magnetic resonance images (MRIs), which are better than standard x-rays or even myelography (x-ray of the spinal cord using a contrast dye). The MRI detects from 20 percent to 58 percent of the abnormalities. The most common ones found are the tethered cord and diastematomyelia. Finding these deformities is important in order to provide correction before damage, or further damage, results. The authors of this study evaluated the effectiveness and safety of performing simultaneous surgery – correction of the scoliosis or kyphosis at the same time as the other deformities.

Twenty-one patients were included in the study. Sixteen patients had congenital scoliosis and the remaining five had congenital kyphosis. After the MRIs, seven patients were found to have a tethered cord, three had failure of segmentation, one had retethering of the cord, and 13 had diastematomyelia plus tethered cord. Four patients had neurological problems and they were in the kyphosis group.

Five patients were found to have problems with their kidneys although this was not found before the screening for the study as they had no symptoms. Cardiovascular (heart) abnormalities were found in six patients.

The simultaneous surgery took between seven to 12 hours with blood loss ranging from 1500 milliliters to 3000 milliliters. All patients stayed in intensive care for at least one day and the hospital stay ranged from five days to 12 days.

Researchers followed the patients for an average of 6.8 years. They found that no patient had any deterioration in their neurological function among the four who showed signs before the surgery. One patient needed a follow-up surgery because of a leak of spinal fluid. No infections or other surgery-related issues were found in the group.

The authors conclude that no research could be found in the English literature about similar surgical approaches. They say that, according to their study findings, performing such simultaneous surgeries was safe and effective, and eliminated the risks of having to undergo two procedures.