Improvement In Oswestry Scores Research Articles

Lumbar Spine Fusion in Obese and Morbidly Obese Patients

Single-center retrospective study. The aim of the study was to compare the surgical experience, clinical outcomes, and effect on body weight between obese and morbidly obese patients undergoing lumbar spine fusion surgery. Obese and morbidly obese patients undergoing spinal fusion surgery are a challenge to the operating surgeon. Only few reports are available on the perioperative data in this group of patients. Further, it is unknown if the degree of obesity has an effect on the surgical experience and clinical outcomes including body weight. A retrospective study of 63 patients undergoing lumbar spinal fusion was carried out. The main inclusion criteria were a body mass index (BMI) equal to or greater than 30. Information recorded included surgical set-up time, surgical time, blood loss, American Association of Anesthesiologists score, and surgical complications. At follow-up, the Oswestry Disability Index and visual analog scale for back and leg pain were recorded along with a pain diagram and radiographic evaluation. The obese group had lower American Association of Anesthesiologists scores. The surgical time was dependent on the number of levels fused and was independent of the BMI. Blood loss during surgery was marginally greater in the obese patients. Neither group showed significant change in weight and BMI. Clinical outcomes showed improvement in visual analog scale for back and leg pain with some improvement in Oswestry scores and were independent of the BMI of the patient. The incidence of postoperative complications was significant in 45% of morbidly obese and 44% of obese patients. Obese and morbidly obese patients have multiple comorbidities, and the spinal surgeon should be prepared to encounter perioperative complexities. Operative times are longer in comparison with normal weight patients with a higher incidence of postoperative complications. No weight loss occurs after spinal surgery.

Transforaminal lumbar interbody fusion using unilateral pedicle screws and a translaminar screw

Lumbar spinal fusion is advancing with minimally invasive techniques, bone graft alternatives, and new implants. This has resulted in significant reductions of operative time, duration of hospitalization, and higher success in fusion rates. However, costs have increased as many new technologies are expensive. This study was carried out to investigate the clinical outcomes and fusion rates of a low implant load construct of unilateral pedicle screws and a translaminar screw in transforaminal lumbar interbody fusion (TLIF) which reduced the cost of the posterior implants by almost 50%. Nineteen consecutive patients who underwent single level TLIF with this construct were included in the study. Sixteen patients had a TLIF allograft interbody spacer placed, while in three a polyetheretherketone (PEEK) cage was used. Follow-up ranged from 15 to 54 months with a mean of 32 months. A clinical and radiographic evaluation was carried out preoperatively and at multiple time points following surgery. An overall improvement in Oswestry scores and visual analogue scales for leg and back pain (VAS) was observed. Three patients underwent revision surgery due to recurrence of back pain. All patients showed radiographic evidence of fusion from 9 to 26 months (mean 19) following surgery. This study suggests that unilateral pedicle screws and a contralateral translaminar screw are a cheaper and viable option for single level lumbar fusion.

Success of Lumbar Microdiscectomy in Patients With Modic Changes and Low-back Pain

Prospective case controlled. To determine the outcome after microdiscectomy in patients with disc herniation, concordant sciatica, and low-back pain with Modic I and II degenerative changes compared with similar patients without Modic changes. The decision to perform a microdiscectomy versus a fusion or total disc replacement in a patient with a disc herniation and sciatica may be confounded by the presence of low-back pain, degenerative disc disease, and marrow and endplate (Modic) changes. Thirty consecutive patients underwent a microdiscectomy by a single surgeon. Group 1 consisted of 15 patients, 6 men and 9 women, with a mean age of 36.7 years (range, 21 to 48 y), with Modic I and II changes. Group 2 contained 15 patients, 9 men and 6 women, with a mean age of 34.1 years (range, 20 to 68 y), without Modic changes. The average duration of low-back pain before surgery was 25.6 months (range 4 to 120 mo) in group 1 and 17.5 months (range 5 to 120 mo) in group 2. The visual analog scale (VAS) was used to grade low-back pain and the Oswestry score was used to grade overall disability. There was no significant difference in preoperative sciatica, low-back pain, VAS or Oswestry scores for group 1 versus group 2 patients. Postoperatively, all patents had improved sciatica and resolution of any nerve tension sign. Eighty-six percent of patients in group 1 versus 93% of patients in group 2 had improvements in postoperative VAS score for low-back pain at 6 months. Average improvement within each group was 67% and 75%, respectively. VAS scores for low-back pain at 6 months improved from 6.9 to 2.3 (P=0.0005) in group 1 and 6.3 to 1.6 (P=0.0002) in group 2. Group 1 and 2 had 89% and 100% of patients show improvement in postoperative Oswestry score at 6 months with an average improvement of 58% and 84%, respectively. Oswestry scores at 6 months improved from 68.7% to 28.8% (P=0.0007) in group 1 and 61.2% to 9.9% (P=0.00003) in group 2. There was a trend toward greater improvement in Oswestry scores in patients without Modic changes (P=0.09). Both groups reported statistically significant improvement in sciatica, low-back pain, and disability after microdiscectomy. Microdiscectomy was therefore an effective treatment for disc herniation and concordant sciatica despite low-back pain and Modic I and II degenerative changes. Therapeutic II.

Evaluation of Functional and Neuromuscular Changes After Exercise Rehabilitation for Low Back Pain Using a Swiss Ball: A Pilot Study

Objective The purpose of this pilot study was to use a multidimensional model to evaluate deficits in patients with low back pain (LBP) over the course of a 12-week rehabilitation program using the Swiss ball. Methods A within-subjects, repeated-measures design based at the University exercise training clinic was used. Twenty patients with chronic nonspecific LBP (12 men, 8 women; symptom duration, 4.8 years; 38.8 ± 12.1 years old; height, 1.76 ± 0.06 m; weight, 76.15 ± 7.21 kg) participated in this study. Self-report measures were the Oswestry Disability Index, Visual Analog Scale, Medical Outcomes 12-Item Short Form Health Survey, and Self-Efficacy For Exercise Scale. Physiologic measures were electromyography measurement of feedforward muscle activation, flexion relaxation phenomenon, myoelectric fatigue, endurance capacity measured by the Sorenson test, and a modified sit-up test. Individuals performed 12 weeks of progressive exercise periodized every 4 weeks using a Swiss ball. Outcome measures were assessed at baseline, 4 weeks, 8 weeks, 12 weeks, and at a 3-month follow-up. Repeated-measures analysis for variance for time differences and regression analysis for variance in Oswestry scores were performed. Results The Oswestry score for self-reported disability significantly decreased over the intervention (F 4,14 = 19.456, P < .001). Significant improvements in pain and disability maintained to the 3 months of follow-up. There were significant changes in perceptions of physical and mental well-being, erector spinae fatigue, and flexion relaxation measures. Change in flexion relaxation explained 38% of the improvement in Oswestry scores at the 12-week measurement. Conclusions This study showed that the Swiss ball may be successfully used in a rehabilitation context for patients with LBP. This pilot study has used a novel approach to assess improvements during a rehabilitation program, which may be used in the future to explain differences between different treatment modalities.

Comparison of Smith-Petersen Versus Pedicle Subtraction Osteotomy for the Correction of Fixed Sagittal Imbalance

Clinical, radiographic, and outcomes assessment comparing two surgical techniques. Clinical data were collected prospectively. The radiographic analysis was done retrospectively. Smith-Petersen (chevron type) osteotomy (SPO) and pedicle subtraction osteotomy (PSO) have been used to correct fixed sagittal imbalance. This study compares the results of these two methods. Our hypotheses were that when comparing three or more SPOs to a single PSO, the correction of kyphotic angle at the osteotomy site would be nearly identical in each group, the correction in C7 plumb and lumbar lordosis would be identical, the SPO group would have equal tendencies to decompensation as the PSO group, blood loss would be identical in the two groups, and improvement in Oswestry scores would be identical in each group. Many papers have described the surgical technique and results of SPOs and PSOs. No effort has been made to compare the results of the respective techniques at a single institution. Thirty patients who underwent SPO were compared with 41 patients who underwent PSO (follow-up, 2-11.5 years). All patients' surgeries were performed at one institution between 1989 and 2001. Fourteen patients in the SPO group had three or more osteotomies. All of the PSOs were performed at one segment. Patients were evaluated by preoperative and ultimate postoperative standing radiographs and a prospectively collected database with outcomes questionnaires. The mean correction of the kyphotic angle at the osteotomy sites for the SPOs was 10.7 degrees per segment. For those with three or more SPOs, the average total correction was 33.0 degrees +/- 9.2 degrees, and 31.7 degrees +/- 9.0 degrees for the PSO group. However, the improvement in sagittal balance was statistically significantly less with three or more SPOs (5.5 +/- 4.5 cm)than with one PSO (11.2 +/- 7.2 cm; P < 0.01). Comparing three or more SPOs to one PSO, the SPO group decompensated the patients more substantially to the concavity (P < 0.02). The mean estimated blood loss (adding up all anterior and posterior surgeries) for the procedure was 1,398 +/- 738 mL in the SPO group (1,392 +/- 664 mL in the three or more SPO group), and 2,617 +/- 1,645 mL in the PSO group (P < 0.001; P < 0.01). The mean Oswestry score improved from 42.3 +/- 14.2 before surgery to 21.3 +/- 14.8 at the last visit in the SPO group. In the PSO group, it improved from 47.9 +/- 15.8 before surgery to 29.7 +/- 18.3 at the last visit (P = 0.35). When comparing three or more SPOs (14 patients) to one pedicle subtraction procedure (41 patients), the correction in kyphosis was nearly identical. There was a significantly greater likelihood of decompensating the patient to the concavity with three or more SPOs than with a single PSO (P < 0.02). The blood loss was substantially greater with the PSO group (P < 0.001).

772 Two-year Follow-up on Patients in a Pilot Safety and Efficacy Study of OP-1 (rhBMP-7) in Posterolateral Lumbar Fusion as a Replacement for Iliac Crest Autograft

INTRODUCTION: Posterolateral intertransverse lumbar fusion is a commonly performed procedure for stabilization of the degenerated lumbar spine. A typical clinical scenario for which such fusions are used is the stabilization of a degenerative spondylolisthesis after decompression. In a recent large series reported in literature, this type of fusion was noted to have a pseudarthrosis rate of up to 55% (Fischgrund, Spine 1997). METHODS: Thirty-six patients with the diagnosis of symptomatic spinal stenosis and single-level degenerative spondylolisthesis in the lower lumbar spine (L3–S1) were enrolled. Patients were randomized to either the OP-1 group or the control group. The OP-1 group received 3.5 mg of OP-1 per side in a bone collagen putty carrier. The control group received iliac crest autograft alone. Outcomes were measured clinically using the Oswestry score and radiographically using dynamic radiographs evaluated independently by a panel of blinded radiologists using digital calipers. Patients were deemed a clinical success if they showed an approximately 20% improvement in Oswestry score and were deemed a radiographic success if they showed bridging bone and spinal stability on flexion/extension films. RESULTS: At 24 months, 16 of 17 evaluable patients (94%) in the OP-1 group and 6 of 10 evaluable patients (60%) in the autograft group were considered clinical successes, whereas 11 of 17 patients (65%) in the OP-1 group and 4 of 10 (40%) in the autograft group were considered radiographic successes. No acute adverse events related to the use of OP-1 were noted. CONCLUSION: OP-1 seems to be a safe and effective replacement for iliac crest autograft in human posterolateral lumbar fusion. The dose, 3.5 mg per side, and the carrier, biodegradable, compression-resistant bone collagen putty, seem to provide a safe and effective means of delivering the bone morphogenetic protein OP-1 to the human lumbar spine.

The Benefits of Pilates Exercise in Orthopaedic Rehabilitation

Summary Pilates exercise has been introduced to the physical therapy community in recent years to enhance rehabilitation programs by focusing on spinal or core stabilization. This particular method can be incorporated into a patient’s treatment plan to improve strength, range of motion, coordination, balance, muscular symmetry, flexibility, and proprioception. It is a method of exercise performed on the floor, known as mat work, or on a spring-resistant apparatus. The patient, with the guidance of a physical therapist, performs efficient functional movement patterns, closed-chain and open-chain patterns, as well as multiple planes and positions provide for varied rehabilitation programming with many different orthopaedic diagnoses. Plyometric work can be incorporated with an attachment to the apparatus. There is very little research available relating to Pilates exercise for rehabilitation. A case study of a 48-year-old man with chronic low back pain reveals an 85.1% improvement on the visual analog scale for pain intensity and an 87.7% improvement in Oswestry score for functional disability after six physical therapy visits during which Pilates exercises were incorporated into patient programming.

9:34 Comparison of impacted femoral ring allografts, threaded cortical bone dowels and titanium cages in lumbar fusion

Purpose of study: To test the efficacy of recombinant human bone morphogenic protein (rhBMP-2), we compared clinical and radiographic outcomes in patients who underwent a single-level anterior lumbar interbody fusion (ALIF) and were treated with impacted femoral rings and autogenous bone graft, threaded cortical allograft dowels or titanium cages. Patients who received dowels or titanium cages were randomized to receive either BMP-soaked collagen sponges or autogenous iliac crest bone graft.Methods used: At 22 investigational sites, 387 patients with symptomatic, single-level degenerative lumbar spondylosis that was unresponsive to nonoperative treatment were enrolled in this prospective, randomized, nonblinded study. All patients had a single-level stand-alone ALIF through an open approach. Patients who received dowels or cages were randomized into two groups to receive autogenous iliac crest bone graft or rhBMP-2 on a collagen sponge carrier (InFUSE). All 62 patients who received impacted femoral rings were treated with autogenous bone graft, 46 patients received bone dowels (24 with BMP and 22 with autograft) and 279 patients received the LT-CAGE interbody fusion device (143 with BMP and 136 with autograft). Patients' average age at surgery was 42 years, average weight was 173 pounds and 34% used tobacco products. Clinical outcomes were assessed using the Oswestry Low Back Pain Disability Questionnaire. Anteroposterior, lateral, flexion-extension lateral radiographic views and computed tomography scans, used to evaluate the progression of fusion at 6, 12 and 24 months, were interpreted by two independent, blinded radiologists.of findings: at 24 months, there were no adverse events related to the use of rhBMP-2. At all follow-up visits, all groups showed statistically significant improvements in their Oswestry scores compared with their preoperative scores. Patients in the bone dowel/BMP and LT-CAGE fusion device groups showed greater improvement than the bone dowel/autograft and femoral ring groups. Of patients in the bone dowel/BMP group, 71% showed an improvement of at least 15 points in their Oswestry scores at 3 months after surgery. At all follow-up intervals, the bone dowel/BMP group and both LT-CAGE groups had greater improvements in Oswestry scores than the bone dowel/autograft and femoral ring groups. At 3, 6, 12 and 24 months, the differences in improvement were statistically significant (p=.032, p=.0389, p=.039 and p=.039, respectively). At 24 months, the mean improvement in Oswestry scores was 33.5 points in the bone dowel/BMP group and 29.3 points in the LT-CAGE groups. At 24 months, 84% of the bone dowel/BMP and LT-CAGE patients improved more than 15 points compared with 58% of the bone dowel/autograft and femoral ring groups. At 6 months after surgery, more than 90% of patients in both LT-CAGE groups and the bone dowel/BMP group had evidence of fusion compared with 65% of patients in the bone dowel/autograft group (p=.067) and 10% in the femoral ring group. At 24 months, more than 94% of patients in the two BMP groups had evidence of fusion. The LT-CAGE/autograft fusion rate decreased to 90%, the bone dowel/autograft fusion rate was 68% and the femoral ring fusion rate was 50%.Relationship between findings and existing knowledge: The use of BMP improves clinical outcomes and fusion rates of ALIF over previous standard of care spinal implants.Overall significance of findings: Overall, the groups in which BMP was used showed faster clinical improvement and higher rates of success than the autograft and impacted femoral ring allograft groups. No adverse events related to the use of BMP and the collagen sponge carrier occurred.Disclosures: Devise or Drug: LT-CAGE. Status' approved. Device or Drug: bone dowel. Status: approved. Device or Drug: rhBMP2. Status: approved.Conflict of interest: Kenneth Burkus, consultant for Medtronic Sofamor Danek.

3:51 Recombinant human bone morphogenic protein–2 for posterolateral spine fusion: a prospective/randomized clinical trial

Purpose of study: To determine if the dose and carrier for recombinant human bone morphogenetic protein–2 (rhBMP-2), which was successful in rhesus monkeys, could induce consistent radiographic spine fusions in humans.Methods used: Twenty-five patients undergoing lumbar arthrodesis were randomized (1:2:2 ratio): 1) autograft/TSRH pedicle screw instrumentation (n=5); 2) rhBMP-2/TSRH (n=11) and 3) rhBMP-2 only without internal fixation (n=9). The carrier was 60% hydroxyapatite/40% tricalcium phosphate granules (10 cm3 per side) with 20 mg rhBMP-2 per side. Patients had single-level disc degeneration, Grade I or less spondylolisthesis, mechanical low back pain with or without leg pain and failed at least 6 months of nonoperative treatment. The primary outcome was radiographic fusion measured by two independent/masked radiologists, as defined by evidence of continuous bridging trabecular bone as well as less than 3 mm translation and less than 5 degrees angular motion on flexion/extension films. Computed tomography scans were used to assess fusion mass continuity if there was uncertainly on the plain films. Secondary outcome measures included Oswestry and SF-36.of findings: All 25 patients were available for follow-up (mean, 17 months; range, 12 to 27 months). The radiographic fusion rate was 40% (2 of 5) in the autograft/TSRH group and 100% (20 of 20, p=.05) with rhBMP-2 with or without TSRH internal fixation. A statistically significant improvement in Oswestry score was seen at 6 weeks in the rhBMP-2–only group (−17.6, p=.009) and at 3 months in the rhBMP-2/TSRH group (−17.0, p=.003) but not until 6 months in the autograft/TSRH group (−17.3, p=.041). At final follow-up, Oswestry improvement was greatest in the rhBMP-2–only group (−28.7, p<.001). SF-36 Pain Index and PCS subscales showed similar changes.Relationship between findings and existing knowledge: This represents the first prospective, randomized clinical trial using a recombinant BMP for posterolateral spine fusion without autogenous bone graft. The radiographic fusion rates obtained appear to be higher than the control group in the study and most historical controls published in the literature for this diagnosis.Overall significance of findings: Recombinant human BMP-2 with the biphasic calcium phosphate granules consistently induced radiographic posterolateral lumbar spine fusion with or without internal fixation in patients with not greater than Grade I spondylolisthesis. There was a statistically greater and quicker improvement in patient-derived clinical outcome measures in the rhBMP-2 groups. These findings provide hope that bone graft harvest and its associated morbidity may not be needed and the clinical results may be at least as good or better than those with autogenous iliac crest bone.Disclosures: Device or drug: rhBMP-2. Status: investigational. Device or drug: BCP Ceramic Granules. Status: investigational. Device or drug: TSHR pedicle screws/rods. Status: approved.Conflict of interest: Scott D. Boden, grant research support; Scott D. Boden and John G. Heller, consultants Medtronic Sofamor Danek.

Video-Assisted Thoracoscopic Surgery for Thoracic Disc Disease

Prospectively collected data from regular clinical follow-up evaluations were tabulated, analyzed, reviewed using a patient self-reported questionnaire. To develop a classification system and present the long-term functional outcome of video-assisted thorascopic surgery for refractory thoracic disc disease. Recent studies have found an 11.1% to 14.5% prevalence of thoracic disc herniations. Surgical approaches have included laminectomy, pediculectomy, costotransversectomy, lateral extracavitary, transverse arthropediculectomy, transthoracic-transpleural thoracotomy, and thoracoscopy. Recent reports have documented encouraging early results with video-assisted thorascopic surgery for thoracic disc herniations. Comparisons between thoracoscopy and open thoracotomy have demonstrated improvement in postoperative pain and morbidity with the use of endoscopic techniques. This study included 100 consecutive patients (45 women and 55 men) with an average follow-up evaluation of 4 years (range, 2-6 years). The average age of the patients was 42 years (range, 22-76 years). The average duration of symptoms was 26 months (range, 6-96 months), and 18 patients had undergone prior spine surgery. Patients were graded as follows according to the presenting symptoms (Table 1): Grade 1 (pure axial; n = 28), Grade 2 (pure radicular; n = 5), Grade 3A (axial and thoracic radicular; n = 38), Grade 3B (axial with lower leg pain; n = 19), Grade 4 (myelopathic; n = 8), or Grade 5 (paralytic = 2). A total of 117 discs were excised in 100 patients. Of the 40 patients who underwent fusion, 27 had autologous rib struts and 13 had threaded fusion. The mean operative time was 173 minutes, blood loss 259 mL, average ICU stay less than 1 day, and average hospital stay 4 days. Minor complications occurred in 21 patients, all of which resolved with no untoward effect. No patient's neurologic status worsened. Four patients underwent a secondary fusion, and a pseudarthrosis developed in one patient. Clinical success was defined objectively as an improvement in Oswestry score of 20% or more at 2 years and at final follow-up assessment, as compared with the preoperative Oswestry score. Overall, objective clinical success was observed at 2 years in 73% of the patients, and at final follow-up assessment in 70% of patients. The average percentage of improvement in Oswestry scores was most marked in Grade 4 patients (myelopathy; 60%), followed by Grade 3A patients (axial and thoracic radicular pain; 37%), Grade 3B patients (axial with leg pain; 28%), and Grade 1 patients (pure axial; 24%). The Oswestry disability score (Table 2) and back pain visual analog score (Table 3) also were significantly improved (P < 0.05) at 2 years and at final follow-up assessment in these patients. In the Grade 2 patients, those pure thoracic radicular pain, Oswestry scores initially improved significantly up to 1 year (P < 0.05). At 2 years, no significant improvement could be shown, and four of the five Grade 2 patients reported increased axial pain as their main symptom at the final follow-up assessment. Significant improvement also was seen in patients with no prior spine surgery and patients with preoperative Oswestry disability scores greater than 50. Of the 68 patients who responded to the final questionnaire, 12 rated the procedure as excellent, 37 as good, 11 as fair, and 8 as poor. Also, 57 (83.8%) of these 68 patients were satisfied and indicated they would recommend the surgery. Of the 36 patients at the final follow up assessment who had severe disability, 34 (94%) were satisfied, as compared with 23 of the 32 patients (72%) who had presented with milder disability. The clinical classification system helps in differentiating different presentations of thoracic disc disease and their final outcome. Video-assisted thorascopic surgery appears to be a safe and efficacious method for the treatment of refractory symptomatic thoracic disc herniations. The current data suggest that the procedure has an acceptable long-term outcome, with an 84% overall subjective patient satisfaction rate, and with objective long-term clinical success achieved in 70% of patients.