European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
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Randomized Controlled Trial Multicenter Study Comparative Study Clinical Trial
Complications in lumbar fusion surgery for chronic low back pain: comparison of three surgical techniques used in a prospective randomized study. A report from the Swedish Lumbar Spine Study Group.
The reported complication rates after various surgical techniques used to create a lumbar fusion vary within wide ranges. In a previous paper, the Swedish Lumbar Spine Study Group have reported on the clinical outcome of lumbar spine fusion for chronic low back pain in a comparably homogeneous patient population where there were no significant differences between baseline sociodemographic, clinical and paraclinical characteristics. In this report we compared the complication rates of the surgical procedures used in that study and analyzed the association between complications and baseline variables, and between outcome results and complications. ⋯ Even though we did not find a significant association between clinical outcome and complications after 2 years, the increased morbidity inflicted on an individual patient was not negligible. In this light, and as no fusion technique produced superior clinical outcome irrespective of whether complications were included or excluded in the analyses, the patient and the treating physician should carefully discuss the possible advantages and drawbacks of the different surgical options before making a decision. In order to make valid comparisons of both complication and reintervention rates after lumbar fusion, there is a need for a consensus in the spinal society regarding the definition of these entities.
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Review
Low back pain: what is the long-term course? A review of studies of general patient populations.
It is often claimed that up to 90% of low back pain (LBP) episodes resolve spontaneously within 1 month. However, the literature in this area is confusing due to considerable variations regarding the exact definitions of LBP as well as recovery. Therefore, the claim--attractive as it might be to some--may not reflect reality. ⋯ The risk of LBP was consistently about twice as high for those with a history of LBP. The results of the review show that, despite the methodological variations and the lack of comparable definitions, the overall picture is that LBP does not resolve itself when ignored. Future research should include subgroup analyses and strive for a consensus regarding the precise definitions of LBP.
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Less invasive decompressive surgery has emerged as a logical surgical treatment alternative to wide decompression of spinal stenosis. The clinical outcomes of such conservative surgical treatment, however, are not well known. The aim of the study was to evaluate short-term psychometric and functional outcomes after conservative decompressive surgery for lumbar canal stenosis. ⋯ Overall, 58% (21/36) of patients met the successful surgical outcome criteria, including 14 subjects who met all four success criteria. Based upon a stringent definition of successful surgical outcome, the results of a conservative laminectomy were as good as those of more aggressive decompressive procedures presented in the literature. Our findings indicate that, even in a highly organic disorder such as spinal stenosis, illness behavior plays an important role in predicting surgical outcome.
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Patients with cervical facet lesions and facet joint injury sometimes experience diffuse neck pain, headache, and arm and shoulder pain. However, the pathophysiology of the intensity and expansion of facet joint pain has not yet been investigated. Retrograde transport of fluoro-gold (F-G) and immunohistochemistry of calcitonin gene-related peptide (CGRP) was used in 20 rats (control group, n=10; injured group, n=10). ⋯ The numbers of CGRP-ir F-G labelled DRG neurons as a percentage of all F-G labelled DRG neurons at C3, C4, C5, C6, C7, C8, T1, T2, and T3 respectively were 30, 22, 43, 47, 21, 19, 25, 36 and 30% in the control group, and 13, 15, 23, 17, 15, 8, 16, 28 and 35% in the injured group, with the injured group showing a significantly lower percentage of CGRP-ir F-G labelled neurons than the control group at C5 and C6 (P<0.05). However, the mean cross-sectional area of F-G labelled CGRP-ir cells from C3 to C8 DRGs increased from 625+/-22 micro m(2) to 878+/-33 micro m(2) in the injured group (P<0.001). Associated with the injured facet joints, the phenotypic switch to large neurons may complicate the mechanism of injured facet pain.
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Posterior lumbar interbody fusion (PLIF) using threaded cages has gained wide popularity for lumbosacral spinal disease. Our biomechanical tests showed that PLIF using a single diagonal cage with unilateral facetectomy does add a little to spinal stability and provides equal or even higher postoperative stability than PLIF using two posterior cages with bilateral facetectomy. Studies also demonstrated that cages placed using a posterior approach did not cause the same increase in spinal stiffness seen with pedicle screw instrumentation, and we concluded that cages should not be used posteriorly without other forms of fixation. ⋯ No implant fractures or deformities occurred in any of the patients. PLIF using diagonal insertion of a single threaded cage with supplemental transpedicular screw/rod instrumentation enables sufficient decompression and solid interbody fusion to be achieved with minimal invasion of the posterior spinal elements. It is a clinically safer, easier, and more economical means of accomplishing PLIF.