Early Lumbar Research Articles

Open-label, randomized, controlled pilot study of the effects of a glucosamine complex on Low back pain

Background: A series of studies has suggested some efficacy of glucosamine in arthrosis of the knee, but virtually no documentation exists regarding its effects on low back pain. Objectives: The primary objective of this study was to examine whether a 12-week course of a glucosamine complex (GC) could benefit patients having low back pain despite a course of noninvasive physical therapy. In addition, we sought to delineate the subgroup of responders. Methods: This open-label, randomized, controlled study was conducted at the Division of Rheumatology and Physical Medicine, Erasme University Hospital, Brussels, Belgium. Male and female outpatients aged 40 to 80 years with low back pain (duration, ≥ 12 weeks; pain score on 10-cm visual analog scale [VAS] [0 = none to 10 = worst imaginable], ≥3 cm) despite noninvasive physical therapy (massage, stretching, heat application, and analgesics for ≥4 weeks) were included. Patients were randomly assigned to receive, in addition to conventional treatment (CT) (physical therapy plus analgesics/antiinflammatories), a GC (enriched with sulfonyl methane, silicon, and a botanical extract of Ribes nigrum) or CT alone (control) for 12 weeks. Pain at rest and on movement (effort) and early morning lumbar stiffness were measured every 4 weeks using the VAS. The primary end point was improvement in VAS score for pain at rest at 12 weeks. Two validated questionnaires were used to assess improvements in quality of life (QOL) (Oswestry Disability Questionnaire [ODQ] [10 items; scale: 0 = no disability to 60 = maximal disability] and Roland-Morris Disability Questionnaire [RMDQ] [24 items; scale: 0 = no disability to 24 = severe disability]). Responders were defined as patients who positively assessed the efficacy of the GC. At each visit, patients were also asked about possible adverse events. Results: Of 36 enrolled patients, 32 completed the study (18 men, 14 women; mean [SE] age, 64 [2] years; 17 in the GC group and 15 in the control group). Four patients were lost to follow-up. At week 4, changes from baseline VAS scores for pain at rest and lumbar stiffness were significantly greater in the GC group compared with the control group ( P < 0.001 and P = 0.011, respectively). At week 4, QOL was found to be improved, as measured using the ODQ, in the GC group compared with the control group ( P = 0.028), but the between-group difference as measured using the RMDQ was not significant. The improvements from baseline on the questionnaires were sustained over the 12-week period in the GC group (all, P < 0.001). Gastrointestinal adverse effects were reported by 1 GC-treated patient and 1 patient in the control group, but neither patient withdrew from the study. Of the 17 GC-treated patients, 9 considered themselves responders, but the profile of a responder could not be delineated. Conclusions: In this study in patients with low back pain, analgesic effect and improvement in QOL were found with the use of GC. GC was well tolerated.

The Effect of Early Isolated Lumbar Extension Exercise Program for Patients with Herniated Disc Undergoing Lumbar Discectomy

To determine the effects of a postoperative early isolated lumbar extension muscle-strengthening program on pain, disability, return to work, and power of back muscle after operation for herniated lumbar disc. Seventy-five patients were randomized into an exercise group (20 men, 15 women) and a control group (18 men, 22 women) to perform a prospective controlled trial of a lumbar extension exercise program in patients who underwent lumbar microdiscectomy or percutaneous endoscopic discectomy. Six weeks after surgery, patients in the exercise group undertook a 12-week lumbar extension exercise program. The assessment included measures of lumbar extensor power by the MedX (Ocala, FL) lumbar extension machine, muscle mass of multifidus and longissimus (L4-L5 cross-sectional area) by computed tomography. All patients completed the visual analog scale and the Oswestry disability index to assess pain and disability, respectively. Return to work data were also investigated. After the exercise program, significant improvements were observed in the exercise group versus the control group for lumbar extensor power (51.67% versus 17.55%, respectively; P < 0.05), the cross-sectional area of multifidus and longissimus muscle (29.23% versus 7.2%, respectively; P < 0.05), and the visual analog scale score (2.51 versus 4.30, respectively; P < 0.05). The percentages of returning to work within 4 months after surgery were significantly greater in the exercise group than in the control group (87% versus 24%, respectively). Although this was not statistically significant (P > 0.05), the Oswestry disability index scores in the exercise group were better than that in control group (24.6 versus 30.6, respectively). These results support the positive effects of the postoperative early lumbar extension muscle-strengthening program on pain, return to work, and strength of back muscles in patients after operation of herniated lumbar disc.

The Effect of Early Isolated Lumbar Extension Exercise Program for Patients with Herniated Disc Undergoing Lumbar Discectomy

ABSTRACTOBJECTIVE:To determine the effects of a postoperative early isolated lumbar extension muscle-strengthening program on pain, disability, return to work, and power of back muscle after operation for herniated lumbar disc.METHODS:Seventy-five patients were randomized into an exercise group (20 men, 15 women) and a control group (18 men, 22 women) to perform a prospective controlled trial of a lumbar extension exercise program in patients who underwent lumbar microdiscectomy or percutaneous endoscopic discectomy. Six weeks after surgery, patients in the exercise group undertook a 12-week lumbar extension exercise program. The assessment included measures of lumbar extensor power by the MedX (Ocala, FL) lumbar extension machine, muscle mass of multifidus and longissimus (L4–L5 cross-sectional area) by computed tomography. All patients completed the visual analog scale and the Oswestry disability index to assess pain and disability, respectively. Return to work data were also investigated.RESULTS:After the exercise program, significant improvements were observed in the exercise group versus the control group for lumbar extensor power (51.67% versus 17.55%, respectively; P &amp;lt; 0.05), the cross-sectional area of multifidus and longissimus muscle (29.23% versus 7.2%, respectively; P &amp;lt; 0.05), and the visual analog scale score (2.51 versus 4.30, respectively; P &amp;lt; 0.05). The percentages of returning to work within 4 months after surgery were significantly greater in the exercise group than in the control group (87% versus 24%, respectively). Although this was not statistically significant (P &amp;gt; 0.05), the Oswestry disability index scores in the exercise group were better than that in control group (24.6 versus 30.6, respectively).CONCLUSION:These results support the positive effects of the postoperative early lumbar extension muscle-strengthening program on pain, return to work, and strength of back muscles in patients after operation of herniated lumbar disc.

Early epidural blood patch in spontaneous intracranial hypotension

Thirty patients with a typical orthostatic headache were treated by early lumbar epidural blood patch (EBP) without previously performing lumbar puncture or identifying a CSF leak and with or without typical MRI changes. A complete cure was obtained in 77% of patients after one (57%) or two (20%) EBPs. Spontaneous intracranial hypotension with typical orthostatic headache can be diagnosed without lumbar puncture and can be cured by early EBP in a majority of patients.

Posthaemorrhagic ventricular dilatation: new mechanisms and new treatment.

Post haemorrhagic ventricular dilatation is associated with a high rate of disability, multiple impairments and adverse effects of shunt surgery for hydrocephalus. Post haemorrhagic ventricular dilatation results initially from multiple small blood clots throughout the cerebrospinal fluid channels impeding circulation and re-absorption. Transforming growth factor beta is released into the cerebrospinal fluid and there is evidence that this cytokine stimulates the laying down of extracellular matrix proteins which produce permanent obstruction to the cerebrospinal fluid pathways. Prolonged raised pressure, pro-inflammatory cytokines and free radical damage from iron may contribute to periventricular white matter damage and subsequent disability. Interventions such as early lumbar punctures, diuretic drugs to reduce cerebrospinal fluid production and intraventricular fibrinolytic therapy have been tested and, not only fail to prevent shunt dependence, death or disability, but have significant adverse effects. Surgical interventions such as subcutaneous reservoir, external drain, choroid plexus coagulation and third ventriculostomy have not been subject to controlled trial. Ventriculoperitoneal shunt is not feasible in the early phase after intraventricular haemorrhage but, despite the problems with blockages and infections, remains the only option for infants with excessive head expansion over periods of weeks. We have piloted drainage, irrigation and fibrinolytic therapy as a way of removing blood early enough to stop the progressive deposition of matrix proteins, permanent hydrocephalus and shunt dependence.

Vertebrae numbers of the early hominid lumbar spine.

General doctrine holds that early hominids possessed a long lumbar spine with six segments. This is mainly based on Robinson's (1972) interpretation of a single partial Australopithecus africanus skeleton, Sts 14, from Sterkfontein, South Africa. As its sixth last presacral vertebra exhibits both thoracic and lumbar characteristics, current definitions of lumbar vertebrae and lumbar ribs are discussed in the present study. A re-analysis of its entire preserved vertebral column and comparison with Stw 431, another partial A. africanus skeleton from Sterkfontein, and the Homo erectus skeleton KNM-WT 15000 from Nariokotome, Kenya, did not provide strong evidence for the presence of six lumbar vertebrae in either of these early hominids. Thus, in Sts 14 the sixth last presacral vertebra has on one side a movable rib. In Stw 431, the corresponding vertebra shows indications for a rib facet. In KNM-WT, 15000 the same element is very fragmentary, but the neighbouring vertebrae do not support the view that it is L1. Although in all three fossils the transitional vertebra at which the articular facets change orientation seems to be at Th11, this is equal to a large percentage of modern humans. Indeed, a modal number of five lumbar vertebrae, as in modern humans, is more compatible with evolutionary principles. For example, six lumbar vertebrae would require repetitive shortening and lengthening not only of the lumbar, but also of the entire precaudal spine. Furthermore, six lumbar vertebrae are claimed to be biomechanically advantageous for early hominid bipedalism, yet an explanation is lacking as to why the lumbar region should have shortened in later humans. All this raises doubts about previous conclusions for the presence of six lumbar vertebrae in early hominids. The most parsimonious explanation is that they did not differ from modern humans in the segmentation of the vertebral column.

Mid-term clinical results of Graf stabilization for lumbar degenerative pathologies: a minimum 2-year follow-up

Background context: Spinal fusion has some adverse effects, such as nonunion and pain at the site of grafted bone, and fusion with rigid spinal instrumentation especially may have the possibility of increasing mechanical stress on the segments adjacent to the site of fusion. The theory of the Graf system is that it will decrease adjacent disc deterioration because of maintenance of regional lordosis with flexibility and restriction of the motion of unstable segments without rigid spinal fusion. Purpose: To assess the clinical and radiologic results of Graf stabilization for lumbar degenerative disorders with minimal or mild instability. Study design: This is a retrospective study examining the mid-term results of Graf stabilization. Patient sample: In total, 59 patients underwent Graf ligamentoplasty and adequate decompression from April 1993 to September 1997. The subjects were 30 men and 29 women, and the mean age at the time of surgery was 60.6 years, ranging from 23 to 82 years. The average follow-up period was 3 years and 5 months, ranging from 2 years to 5 years and 10 months. Outcome measures: We evaluated the surgical results using a scoring system, a visual analog scale, and radiological measurements. Methods: The results were assessed according to a clinical scoring system established by the Japanese Orthopaedic Association (JOA score) and ratings based on a visual analog scale. Through analysis of x-ray images, the sagittal alignment (regional lordosis) and the range of motion (ROM) of the stabilized segments were measured in all cases, and the percentage of segments slipping and posterior disc height were determined for 29 patients with degenerative spondylolisthesis. Results: Clinical scores and low back pain ratings based on a visual analog scale were significantly improved at the time of final follow-up compared with the preoperative values. Regional alignment of the operative segments was maintained in lordosis at the time of final follow-up. Preoperative ROM was significantly reduced at the time of final follow-up. There were no statistical differences in percentage of slippage or percentage of posterior disc height between the final follow-up values and the preoperative values. Conclusions: Our clinical results indicate that the Graf system is a suitable treatment option for mild and early lumbar degenerative diseases with minimum flexion instability of less than 10 degrees.

Intraventricular haemorrhage and posthaemorrhagic hydrocephalus: pathogenesis, prevention and future interventions

Intraventricular haemorrhage (IVH) is still a major complication of preterm birth with serious disability resulting. The fragile blood vessels in the germinal matrix below the ventricular lining and the instability of blood flow to this highly vascular area are the main mechanisms behind IVH. There is good evidence that corticosteroid therapy before preterm delivery reduces mortality and IVH substantially with a trend towards a reduction in disability. There is good evidence that postnatal indomethacin reduces IVH but no evidence that mortality or disability is reduced. There is evidence that stabilizing cerebral blood flow with pancuronium in infants with respiratory distress reduces IVH in the minority of infants with marked fluctuations. There is limited evidence that postnatal vitamin E and ethamsylate reduce IVH but insufficient evidence of reduced mortality or disability. Hydrocephalus following IVH results initially from multiple small blood clots throughout the CSF channels impeding circulation and re-absorption. Transforming growth factor β is released into the CSF and there is mounting evidence that this cytokine stimulates the laying down of extracellular matrix proteins such as laminin and fibronectin which produce permanent obstruction to the CSF pathways. Interventions such as early lumbar punctures, diuretic drugs to reduce CSF production and intraventricular fibrinolytic therapy have been tested and, not only fail to prevent shunt dependence, death or disability, but have significant adverse effects. Surgical interventions such as subcutaneous reservoir and external drain have not been subject to controlled trial. Ventriculoperitoneal shunt is not feasible in the early phase after IVH but, despite the problems with blockages and infections, remains the only option for infants with excessive head expansion over periods of weeks. New treatment approaches aimed at preventing hydrocephalus are needed.

Confirmation of invasive meningococcal disease by single point estimation of IgM antibody to outer membrane protein of Neisseria meningitidis

The sensitivity of laboratory confirmation of invasive meningococcal disease (IMD) by culture or PCR is affected by prior antibiotic treatment and decreasing use of early lumbar puncture. Serological diagnosis of IMD is not widely used because of reliance on paired serum samples. The application of single point estimations of IgM antibodies in the diagnosis of IMD was explored. Outer membrane proteins from a mix of commonly encountered meningococcal serotypes were partially purified and used as an antigen in an enzyme immunoassay for the detection of IgM antibody. The cut-off for the assay was derived using sera from blood bank donors and the accuracy then evaluated with sera from patients with culture-confirmed IMD, other bacterial infections and culture-proven nasopharyngeal colonisation with Neisseria meningitidis. The coefficient of variability of the assay was < 10% in negative, mid- and high-range positive sera and the specificity of the assay was at least 93%. In sera collected from 49 adult patients at various times after positive blood or CSF culture-confirmed IMD, the assay had a sensitivity of 100% in specimens collected between 5 and 18 days. At the time of isolation of meningococci from either blood or CSF, eight of 29 sera were IgM-positive, but beyond 70 days no positive results were detected. No differences were seen in the IgM responses in patients from whom different serogroups of N. meningitidis were recovered. Serological examination by single point IgM enzyme immunoassay (EIA) offers the possibility of an expanded laboratory confirmation of IMD in adults for samples taken between 5 and 18 days after onset.

Vermindering van chronische aspecifieke lage-rugpijn door het oefenen van de lumbale flexie in de vroege ochtend: een willekeurige gecontroleerde test

The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion; A randomized controlled trial [Spine 1998;23(23):2601-07]

The Ergonomic Implications of Controlling Early Morning Lumbar Flexion to Reduce Chronic, Non-Specific Low Back Pain

Previous studies have indicated an increased risk of low back pain when bending forward in the early morning, because of increased fluid in the intervertebral discs. This randomized controlled, partial crossover study tested the hypothesis that control of early morning lumbar flexion will significantly reduce chronic, non-specific low back pain. Diaries were used to record daily levels of pain intensity, disability, impairment, and medication usage. Significant reductions in pain intensity (p&lt;0.01) were recorded for the treatment group, but not for the control group. After receiving the experimental treatment, the control group responded with similar reductions (p&lt;0.05). The only subjects who did not benefit as well were those who performed heavy physical work; with a statistically significant lower reduction in mean pain intensity from those with light to moderate work (p&lt;0.05). It was concluded that controlling lumbar flexion in the early morning has the potential for reducing chronic, non-specific low back pain. The poorer results found for subjects with heavy physical work requirements emphasize the ergonomic implications of this study.

Back and hip extensor activities during trunk flexion/extension: Effects of low back pain and rehabilitation

Leinonen V, Kankaanpää M, Airaksinen O, Hänninen O. Back and hip extensor activities during trunk flexion/extension: effects of low back pain and rehabilitation. Arch Phys Med Rehabil 2000;81:32-7. Objective: To compare lumbar paraspinal, gluteus maximus, and biceps femoris muscle function during sagittal trunk flexion and extension in patients with chronic low back pain and healthy control subjects, and to assess the influence of rehabilitation in the back pain patients. Design: A cross-sectional study comparing chronic low back pain patients and healthy controls, and a prospective follow-up in back pain patients during rehabilitation. Setting: Physical medicine and rehabilitation clinic. Subjects: Nineteen women with chronic low back pain, and 19 women without pain (controls). Intervention: Five-week active outpatient rehabilitation (1 hour three times a week) guided by a physiotherapist, followed by 5-week self-motivated exercise at home. Outcome Measures: Subjects performed sagittal trunk flexion and extension while surface electromyogram was bilaterally recorded of paraspinal (L1-L2 level), gluteus maximus, and biceps femoris muscles. The muscle activity was assessed from the average electromyogram and the relative muscle activation onsets and their duration were calculated. Results: During early flexion, lumbar paraspinal and biceps femoris were activated simultaneously before gluteus maximus. At the end of flexion and during extension all investigated muscles were activated and relaxed in order. Lumbar paraspinal and biceps femoris muscles were activated in a similar order in low back pain patients and healthy controls during flexion and extension. However, the duration of gluteus maximus activity was shorter in the back pain patients than in controls during the trunk flexion (p < .05), and it ended earlier during extension. Active rehabilitation did not change the muscle activities of lumbar paraspinal and biceps femoris in the back pain patients, but in the measurements after rehabilitation the onset of gluteus maximus activity occurred later in flexion and earlier in extension. Conclusions: The activity of the gluteus maximus muscle during the flexion-extension cycle was reduced in patients with chronic low back pain. The gluteal muscles should be taken into consideration in the rehabilitation of these patients. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Early Routine Lumbar Puncture in Sick Young Infants: Prudent or Unnecessary? • 370

Early Routine Lumbar Puncture in Sick Young Infants: Prudent or Unnecessary? • 370

Miscellaneous Notes, Seventh and Eighth Series

Parkes Weber is happily still at it and should be in his 99th year by the time comments on these most recent<i>Miscellaneous Notes</i>are printed. In these books he ruminates on the influence of house officers on their junior associates, "rainbow cups," nightingales, the derivation of family names from houses, a portrait of his father, the gambling spirit, early lumbar puncture, and speculation in stock markets. There is a charming incident about James I and witchcraft. King James was a learned man, though it had been alleged before he became king that he was "the most learned fool in Christendom." Anyhow, he was quite an authority on witches and was called upon once to determine whether a young woman who was unable to move from her bed had been paralyzed by a witch casting a spell on her. He listened gravely to her story, asked a few questions, and

Value of early lumbar puncture in meningism. A. S. Gillett, practitioner, July, 1918

Value of early lumbar puncture in meningism. A. S. Gillett, practitioner, July, 1918