Clinical classification criteria for neurogenic claudication caused by lumbar spinal stenosis. The N-CLASS criteria

Background Context Since imaging findings of lumbar spinal stenosis (LSS) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are needed. Purpose To develop clinical classification criteria that identify patients with neurogenic claudication (NC) caused by LSS. Study Design Two stage process. Phase 1: Delphi process; Phase 2: cross-sectional study. Patient Sample Outpatients recruited from spine clinics in 5 countries. Outcome Measure Items from history and physical examination. Methods Phase 1: A list of potential predictors of NC caused by LSS was based on the available literature and evaluated through a Delphi process involving seventeen spine specialists (surgeons and non-surgeons) from 8 countries. Phase 2: Nineteen different clinical spine specialists from 5 countries identified patients they classified as having: 1) NC caused by LSS 2) Radicular pain caused by lumbar disc herniation (LDH), or 3) non-specific low back pain (NSLBP) with radiating leg pain. Patients completed survey items and specialists documented examination signs. Coefficients from General Estimating Equation models were used to select predictors, generate a clinical classification score and obtain a receiver operating characteristic (ROC) curve. Conduction of the Delphi process, data management and statistical analysis were partially supported by an unrestricted grant of less than 15000 US dollars from Merck Sharp and Dohme. No fees were allocated to participating spine specialists. Results Phase 1 generated a final list of 46 items related to LSS. In phase 2, 209 patients with leg pain caused by LSS (n=63), LDH (n=89) or NSLBP (n=57) were included. Criteria which independently predicted NC (p<0.05) were: age over 60; positive 30 second extension test; negative straight leg test; pain in both legs; leg pain relieved by sitting, and leg pain decreased by leaning forward or flexing the spine. A classification score using a weighted set of these criteria was developed. The proposed N-CLASS score ranged from 0 to 19, had an area under the curve of 0.92, and the cutoff (>10/19) to obtain a specificity of >90.0% resulted in a sensitivity of 82.0%. Conclusion Clinical criteria independently associated with neurogenic claudication due to LSS were identified. Use of these symptom and physical variables as a classification score for clinical research could improve homogeneity among enrolled patients

Risk factors of anterior cruciate ligament tears: Neuromuscular status

Peer reviewe

Alternative and complementary therapies in osteoarthritis and cartilage repair

Osteoarthritis (OA) is the most common joint condition and, with a burgeoning ageing population, is due to increase in prevalence. Beyond conventional medical and surgical interventions, there are an increasing number of ‘alternative’ therapies. These alternative therapies may have a limited evidence base and, for this reason, are often only afforded brief reference (or completely excluded) from current OA guidelines. Thus, the aim of this review was to synthesize the current evidence regarding autologous chondrocyte implantation (ACI), mesenchymal stem cell (MSC) therapy, platelet-rich plasma (PRP), vitamin D and other alternative therapies. The majority of studies were in knee OA or chondral defects. Matrix-assisted ACI has demonstrated exceedingly limited, symptomatic improvements in the treatment of cartilage defects of the knee and is not supported for the treatment of knee OA. There is some evidence to suggest symptomatic improvement with MSC injection in knee OA, with the suggestion of minimal structural improvement demonstrated on MRI and there are positive signals that PRP may also lead to symptomatic improvement, though variation in preparation makes inter-study comparison difficult. There is variability in findings with vitamin D supplementation in OA, and the only recommendation which can be made, at this time, is for replacement when vitamin D is deplete. Other alternative therapies reviewed have some evidence (though from small, poor-quality studies) to support improvement in symptoms and again there is often a wide variation in dosage and regimens. For all these therapeutic modalities, although controlled studies have been undertaken to evaluate effectiveness in OA, these have often been of small size, limited statistical power, uncertain blindness and using various methodologies. These deficiencies must leave the question as to whether they have been validated as effective therapies in OA (or chondral defects). The conclusions of this review are that all alternative interventions definitely require clinical trials with robust methodology, to assess their efficacy and safety in the treatment of OA beyond contextual and placebo effects

Letter to the editor entitled “fairness and scientific correctness is needed in the debate on transgender athletes”

editorial reviewe