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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Comparative Study
Effects of chronic low back pain on trunk coordination and back muscle activity during walking: changes in motor control.
Low back pain (LBP) is often accompanied by changes in gait, such as a decreased (preferred) walking velocity. Previous studies have shown that LBP diminishes the normal velocity-induced transverse counter-rotation between thorax and pelvis, and that it globally affects mean erector spinae (ES) activity. The exact nature and causation of these effects, however, are not well understood. ⋯ The gait of the LBP participants was characterized by a more rigid and less variable kinematic coordination in the transverse plane, and a less tight and more variable coordination in the frontal plane, accompanied by poorly coordinated activity of the lumbar ES. Pain intensity, fear of movement and disability were all unrelated to the observed changes in coordination, suggesting that the observed changes in trunk coordination and ES activity were a direct consequence of LBP per se. Clinically, the results imply that conservative therapy should consider gait training as well as exercises aimed at improving both intersegmental and muscle coordination.
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Comparative Study
Subsidence after anterior lumbar interbody fusion using paired stand-alone rectangular cages.
The authors conducted a study to determine at what stage after surgery the subsidence occurred, and to assess the relationships of radiographic fusion and the recurrence of symptoms with the development of subsidence. Ninety patients underwent a single-level anterior lumbar interbody fusion (ALIF) using paired stand-alone rectangular cages between November 2000 and June 2002. All patients had regular clinical or imaging follow-up for a minimum of 19 months (range 19-38 months, mean = 27 months). ⋯ There was no statistical correlation between the recurrence of symptoms (P = 0.3952) and radiographic fusion (P = 0.9518) with the log-rank test in development of subsidence. This study demonstrates that cage subsidence is an expected occurrence after ALIF using stand-alone rectangular cages. The 3- and 4-month actuarial rates for developing cage subsidence were 63.4 and 70.7%, respectively, and cage subsidence had no correlation with recurrence of symptoms and radiographic fusion in our study.
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Comparative Study
Efficacy and cost effectiveness of harmonic scalpel compared with electrocautery in posterior instrumentation of the spine.
Different methods to reduce blood loss during spinal surgery have been described already. Although the use of the harmonic scalpel (HS), an ultrasonically activated coagulator, has been described in endoscopic spinal surgery, its efficacy in posterior instrumentation of the spine remains unclear. The aim of this study was to determine if blood loss was lower using the HS than electrocauterization (EC) and to evaluate the cost effectiveness of the HS in reducing the need for transfusion in patients undergoing posterior instrumentation of the spine. ⋯ The following were significantly lower with the HS than with EC: (1) blood loss (1106+/-985 ml vs 2176+/-1764 ml, P < 0.001), (2) frequency of cell saver use (13 vs 28 patients, P = 0.001), (3) average cost of blood products (Euro 72 vs Euro 219, P < 0.001), (4) predonation of autologous fresh frozen plasma (2.58+/-2.78 vs 4.5+/-2.2 U, P = 0.002) and red blood cells (0.38+/-0.75 vs 0.88+/-1.1 U, P = 0.009). The overall costs, including the costs for the HS, remained neutral. The use of the HS in posterior spinal surgery leads to significantly lower blood loss, and less need for and cost of blood products, compared to EC in cases with major anticipated blood loss.
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Pain usually is the major complaint of patients with problems of the back, thus making pain evaluation a fundamental requisite in the outcome assessment in spinal surgery. Pain intensity, pain-related disability, pain duration and pain affect are the aspects that define pain and its effects. For each of these aspects, different assessment instruments exist and are discussed in terms of advantages and disadvantages. ⋯ Now, it has been realised that psychological and psychosocial factors may substantially influence pain perception in patients with chronic pain and thus may influence the surgical outcome. With this background, pain acceptance, pain tolerance and pain-related anxiety as factors influencing coping strategies are discussed. Finally, a recommendation for a minimum as well as for a more comprehensive pain assessment is given.
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Review
Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review.
Within the framework of evidence-based medicine high-quality randomised trials and systematic reviews are considered a necessary prerequisite for progress in orthopaedics. This paper summarises the currently available evidence on surgical and other invasive procedures for low back pain. Results of systematic reviews conducted within the framework of the Cochrane Back Review Group were used. ⋯ Surgical discectomy may be considered for selected patients with sciatica due to lumbar disc prolapses that fail to resolve with the conservative management. Cognitive intervention Combined with exercises is recommended for chronic low back pain, and fusion surgery may be considered only in carefully selected patients after active rehabilitation programmes during 2 years time have failed. Demanding surgical fusion techniques are not better than the traditional posterolateral fusion without internal fixation.