Aims

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

Aims

The aim of this study was to compare the effect of a percutaneous radiofrequency heat lesion at the medial branch of the primary dorsal ramus with a sham procedure, for the treatment of lumbar facet joint pain.

This prospective multicentre study was undertaken to determine segmental movement, disc height and sagittal alignment after total disc replacement (TDR) in the lumbosacral spine and to assess the correlation of biomechanical properties to clinical outcomes.

A total of 173 patients with degenerative disc disease and low back pain for more than one year were randomised to receive either TDR or multidisciplinary rehabilitation (MDR). Segmental movement in the sagittal plane and disc height were measured using distortion compensated roentgen analysis (DCRA) comparing radiographs in active flexion and extension. Correlation analysis between the range of movement or disc height and patient-reported outcomes was performed in both groups. After two years, no significant change in movement in the sagittal plane was found in segments with TDR or between the two treatment groups. It remained the same or increased slightly in untreated segments in the TDR group and in this group there was a significant increase in disc height in the operated segments. There was no correlation between segmental movement or disc height and patient-reported outcomes in either group.

In this study, insertion of an intervertebral disc prosthesis TDR did not increase movement in the sagittal plane and segmental movement did not correlate with patient-reported outcomes. This suggests that in the lumbar spine the movement preserving properties of TDR are not major determinants of clinical outcomes.

Cite this article: Bone Joint J 2013;95-B:81–9.

Posterior lumbar interbody fusion (PLIF) is indicated for many patients with pain and/or instability of the lumbar spine. We performed 36 PLIF procedures using the patient’s lumbar spinous process and laminae, which were inserted as a bone graft between two vertebral bodies without using a cage. The mean lumbar lordosis and mean disc height to vertebral body ratio were restored and preserved after surgery. There were no serious complications.

These results suggest that this procedure is safe and effective.

Objectives

Normal sagittal spine-pelvis-lower extremity alignment is crucial in humans for maintaining an ergonomic upright standing posture, and pathogenesis in any segment leads to poor balance. The present study aimed to investigate how this sagittal alignment can be affected by severe knee osteoarthritis (KOA), and whether associated changes corresponded with symptoms of lower back pain (LBP) in this patient population.

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic, and long bone fractures; interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews; and pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews

Aims. The aim of this study was to report the patterns of symptoms and insufficiency fractures in patients with tumour-induced osteomalacia (TIO) to allow the early diagnosis of this rare condition. Methods. The study included 33 patients with TIO who were treated between January 2000 and June 2022. The causative tumour was detected in all patients. We investigated the symptoms and evaluated the radiological patterns of insufficiency fractures of the rib, spine, and limbs. Results. The mean age of the patients was 57 years (24 to 87), and the mean duration of pain from onset to time of presentation was 3.9 years (0.75 to 23). The primary symptoms were low back pain (ten patients), chest wall pain (eight patients), and hip pain (eight patients). There were symptoms at more sites at the time of presentation compared with that at the time of the onset of symptoms. Bone scans showed the uptake of tracer in the rib (100%), thoracic and lumbar vertebrae (83%), proximal femur (62%), distal femur (66%), and proximal tibia (72%). Plain radiographs or MRI scans identified femoral neck fractures in 14 patients, subchondral insufficiency fractures of the femoral head and knee in ten and six patients, respectively, distal femoral fractures in nine patients, and proximal tibial fractures in 12 patients. Thoracic or lumbar vertebral fractures were identified in 23 of 29 patients (79.3%) when using any imaging study, and a biconcave deformity was the most common type of fracture. Conclusion. Insufficiency fractures in patients with TIO caused spinal pain, chest wall pain, and periarticular pain in the lower limbs. Vertebral fractures tended to be biconcave deformities, and periarticular fractures of the hips and knees included subchondral insufficiency fractures and epiphyseal or metaphyseal fractures. In patients with a tumour, the presence of one or more of these symptoms and an insufficiency fracture should suggest the diagnosis of TIO. Cite this article: Bone Joint J 2023;105-B(5):568–574

Aims. To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child. Methods. A follow-up investigation was undertaken on a cohort of 28 children previously reported at a mean of 4.8 years. The present study looked at 26 patients who had an arthrodesis of the hip as a child at a mean follow-up of 20 years (15 to 29). Results. The mean Harris Hip Score (HHS) increased from 39.60 (SD 11.06) preoperatively to 81.02 (SD 8.86; p = 0.041) at final review. At latest follow-up, the HHS was found to be excellent in four patients (15%), good in 11 (42%), and fair in 11 (42%). A total of 16 patients (62%) reported mild low back pain, five (19%) had moderate pain, and five (19%) patients had no back pain. Mild ipsilateral knee pain was reported by 19 (73%), moderate pain by one (4%), and no pain by six (23%) patients. Mild contralateral hip pain was reported by ten patients (38%), and no pain by 16 (62%). The 36-Item Short Form Health Survey scores were very good in four patients (15%), good in 18 (70%), and poor in four (15%), with a mean score of 70.92 (SD 12.65). Of 13 female patients who had given birth, 12 did so with uncomplicated vaginal delivery. All patients had to modify their posture for toileting, putting on lower body clothes, foot care, and putting on shoes. Conclusion. Our results show that with hip arthrodesis, most patients have relatively good function at long-term follow-up, although some pain is experienced in adjacent joints, and modification in some activities of daily living is common. Cite this article: Bone Joint J 2022;104-B(9):1089–1094

Aims. To study the associations of lumbar developmental spinal stenosis (DSS) with low back pain (LBP), radicular leg pain, and disability. Methods. This was a cross-sectional study of 2,206 subjects along with L1-S1 axial and sagittal MRI. Clinical and radiological information regarding their demographics, workload, smoking habits, anteroposterior (AP) vertebral canal diameter, spondylolisthesis, and MRI changes were evaluated. Mann-Whitney U tests and chi-squared tests were conducted to search for differences between subjects with and without DSS. Associations of LBP and radicular pain reported within one month (30 days) and one year (365 days) of the MRI, with clinical and radiological information, were also investigated by utilizing univariate and multivariate logistic regressions. Results. Subjects with DSS had higher prevalence of radicular leg pain, more pain-related disability, and lower quality of life (all p < 0.05). Subjects with DSS had 1.5 (95% confidence interval (CI) 1.0 to 2.1; p = 0.027) and 1.8 (95% CI 1.3 to 2.6; p = 0.001) times higher odds of having radicular leg pain in the past month and the past year, respectively. However, DSS was not associated with LBP. Although, subjects with a spondylolisthesis had 1.7 (95% CI 1.1 to 2.5; p = 0.011) and 2.0 (95% CI 1.2 to 3.2; p = 0.008) times greater odds to experience LBP in the past month and the past year, respectively. Conclusion. This large-scale study identified DSS as a risk factor of acute and chronic radicular leg pain. DSS was seen in 6.9% of the study cohort and these patients had narrower spinal canals. Subjects with DSS had earlier onset of symptoms, more severe radicular leg pain, which lasted for longer and were more likely to have worse disability and poorer quality of life. In these patients there is an increased likelihood of nerve root compression due to a pre-existing narrowed canal, which is important when planning surgery as patients are likely to require multi-level decompression surgery. Cite this article: Bone Joint J 2021;103-B(1):131–140

Bertolotti’s syndrome is characterised by anomalous enlargement of the transverse process(es) of the most caudal lumbar vertebra which may articulate or fuse with the sacrum or ilium and cause isolated L4/5 disc disease. We analysed the elective MR scans of the lumbosacral spine of 769 consecutive patients with low back pain taken between July 2003 and November 2004. Of these 568 showed disc degeneration. Bertolotti’s syndrome was present in 35 patients with a mean age of 32.7 years (15 to 60). This was a younger age than that of patients with multiple disc degeneration, single-level disease and isolated disc degeneration at the L4/5 level (p ≤ 0.05). The overall incidence of Bertolotti’s syndrome in our study was 4.6% (35 of 769). It was present in 11.4% (20 patients) of the under-30 age group. Our findings suggest that Bertolotti’s syndrome must form part of a list of differential diagnoses in the investigation of low back pain in young people

We studied 27 patients with low back pain and unilateral L5 or S1 spinal nerve root pain. Significant radiological changes were restricted to the symptomatic root level, when compared with controls. Low back and leg pain were graded on a visual analogue scale. Dermatomal quantitative sensory tests revealed significant elevations of warm, cool and touch perception thresholds in the affected dermatome, compared with controls. These elevations correlated with root pain (warm v L5 root pain; r = 0.88, p < 0.0001), but not with back pain. Low back pain correlated with restriction of anteroposterior spinal flexion (p = 0.02), but not with leg pain. A subset of 16 patients underwent decompressive surgery with improvement of pain scores, sensory thresholds and spinal mobility. A further 14 patients with back pain, multilevel nerve root symptoms and radiological changes were also studied. The only correlation found was of low back pain with spinal movement (p < 0.002). We conclude that, in patients with single level disease, dermatomal sensory threshold elevation and restriction of spinal movement are independent correlates of sciatica and low back pain

To clarify the pathomechanisms of discogenic low back pain, the sympathetic afferent discharge originating from the L5-L6 disc via the L2 root were investigated neurophysiologically in 31 Lewis rats. Sympathetic afferent units were recorded from the L2 root connected to the lumbar sympathetic trunk by rami communicantes. The L5-L6 discs were mechanically probed, stimulated electrically to evoke action potentials and, finally, treated with chemicals to produce an inflammatory reaction. We could not obtain a response from any units in the L5-L6 discs using mechanical stimulation, but with electrical stimulation we identified 42 units consisting mostly of A-delta fibres. In some experiments a response to mechanical probing of the L5-L6 disc was recognised after producing an inflammatory reaction. This study suggests that mechanical stimulation of the lumbar discs may not always produce pain, whereas inflammatory changes may cause the disc to become sensitive to mechanical stimuli, resulting in nociceptive information being transmitted as discogenic low back pain to the spinal cord through the lumbar sympathetic trunk. This may partly explain the variation in human symptoms of degenerate discs

The National Institute for Health and Care Excellence has issued guidelines that state fusion for non-specific low back pain should only be performed as part of a randomised controlled trial, and that lumbar disc replacement should not be performed. Thus, spinal fusion and disc replacement will no longer be routine forms of treatment for patients with low back pain. This annotation considers the evidence upon which these guidelines are based. Cite this article: Bone Joint J 2017;99-B:1003–1005

Aims. Chronic low back pain due to degenerative disc disease is sometimes treated with fusion. We compared the outcome of three different fusion techniques in the Swedish Spine Register: noninstrumented posterolateral fusion (PLF), instrumented posterolateral fusion (IPLF), and interbody fusion (IBF). Patients and Methods. A total of 2874 patients who were operated on at one or two lumbar levels were followed for a mean of 9.2 years (3.6 to 19.1) for any additional lumbar spine surgery. Patient-reported outcome data were available preoperatively (n = 2874) and at one year (n = 2274), two years (n = 1958), and a mean of 6.9 years (n = 1518) postoperatively and consisted of global assessment and visual analogue scales of leg and back pain, Oswestry Disability Index, EuroQol five-dimensional index, 36-Item Short-Form Health Survey, and satisfaction with treatment. Statistical analyses were performed with competing-risks proportional hazards regression or analysis of covariance, adjusted for baseline variables. Results. The number of patients with additional surgery were 32/183 (17%) in the PLF group, 229/1256 (18%) in the IPLF group, and 439/1435 (31%) in the IBF group. With the PLF group as a reference, the hazard ratio for additional lumbar surgery was 1.16 (95% confidence interval (CI) 0.78 to 1.72) for the IPLF group and 2.13 (95% CI 1.45 to 3.12) for the IBF group. All patient-reported outcomes improved after surgery (p < 0.001) but were without statistically significant differences between the groups at the one-, two- and 6.9-year follow-ups (all p ≥ 0.12). Conclusion. The addition of interbody fusion to posterolateral fusion was associated with a higher risk for additional surgery and showed no advantages in patient-reported outcome. Cite this article: Bone Joint J 2019;101-B:1526–1533

We attempted to correlate the findings of MRI and discography in patients with low back pain, examining 108 lumbar intervertebral discs in 33 consecutive patients. MRI results were assessed from the intensity and shape of the signal obtained from the central part of the disc. Discography was classified according to the pattern of contrast material, the pressure accepted and the pain reproduced. All discs which were abnormal on MRI had altered patterns on discography, but 18 of the 60 discs with normal MRI had abnormal discograms. Of 39 asymptomatic discs, 33 had normal MRI signals and 24 had normal discograms. None of the 15 discs showing severe degeneration on MRI sustained high levels of intradiscal pressure, but only six of the 60 discs giving normal MRI had low pressure. With current techniques, discography is more accurate than MRI for the detection of annular pathology: a normal MRI does not exclude significant changes in the peripheral structure of the intervertebral disc which can produce low back pain

Two different classifications of discograms have been used in a prospective study of 279 injected discs in 100 patients. The five-stage classification of Adams, Dolan and Hutton (1986) showed increased degeneration in the lower lumbar discs and more degenerative changes in men than in women. Exact reproduction of the patient's pain on injection was more common in fissured or ruptured discs than in less degenerate discs, with 81% sensitivity and 64% specificity of the discogram for pain. The additional information obtained by comparing computerised tomography (CT) with discograms was minimal. Discography was found to be useful in the evaluation of chronic low back pain in patients whose ordinary CT scans, myelograms and flexion-extension radiographs were normal. In spondylolysis and spondylolisthesis, discography can disclose whether fusion needs to be extended above the lytic level, and it may show if the pain in patients who have had posterolateral fusion is discogenic. Thus, discography gives information which is useful in deciding whether to operate on patients with chronic low back pain

1. An account of experiences in seventy-five cases with a new method of treatment of low back pain and sciatica caused by intervertebral disc lesions has been presented. The method is based on the fact that chymopapain, a proteolytic enzyme, can break down displaced intervertebral disc material without deleterious effects upon adjacent tissues. 2. Chymopapain was injected into intervertebral discs by the postero-lateral or preferably the lateral approach. Two milligrams per disc constitute an effective dose. The enzyme was administered to seventy-five patients who were potential candidates for laminectomy. These patients were followed for four to thirty months and results were graded as "good" (76 per cent), "fair" (15 per cent) and "poor" (9 per cent). 3. Although untoward reactions have been encountered, none of these has been attributable to chymopapain. 4. Our investigations have convinced us that enzymatic dissolution of a lumbar intervertebral disc lesion is a safe, effective method of relieving sciatica and low back pain in selected cases

A 25-year-old male weightlifter felt increasing intractable low back pain during training but denied any acute injury. The physical examination, blood parameters, radiographs and MRI were unremarkable. He had been treated non-operatively by various means, with only temporary relief. The pressures in the lumbar paraspinal compartment were abnormally high and he was treated by surgical decompression. This gave rapid relief, he returned to training, and one year later the pain had not recurred

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded. In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket