The Outcomes of Surgical Treatment of Recurrent Lumbar Disk Herniation with Discectomy Alone and Discectomy with Posterolateral Interbody Fusion

 Background: Recurrent lumbar disk herniation (RLDH) is one of the major causes of failure of standard discectomy. The optimal treatment method for RLDH is controversial. In the current study, we aimed to compare the clinical and functional outcomes of treating RLDH with discectomy alone and discectomy associated with posterolateral interbody fusion (PLIF).Material and Methods: There were 41 patients with RLHD after primary discectomy in the current retrospective study. Patients were assigned to 2 groups based on the surgical method: discectomy alone (17 patients) and discectomy with PLIF (21 patients). At the final visit the following variables were measured and compared between groups: the back and radicular pain intensity using visual analogue scale (VAS), functional outcome using oswestry low back pain disability scale (ODI), return to previous work and complication. Patients were followed for 13.9±2.8 and 15±3 months in discectomy alone and discectomy with PLIF groups, retrospectively.Results: Complete fusion was achieved in 24 patients of PLIF group. The back pain intensity was the same; however the radicular pain intensity was significantly lower in PLIF group (1.5±0.9 V.s 2.3±1; p=0.017). Also, the mean of ODI scale was the same. 82.3% of patients in discectomy group and 87.5% of patients in PLIF group returned to previous work and the difference was not significant. One patient in discectomy group and 2 patients in PLIF group developed temporary neurological deficit which disappeared after 3 months.Conclusions: Although both discectomy alone and discectomy with PLIF were associated with favorable mid-term results in treating patients with RLDH, however, the authors recommend using discectomy with PLIF for lower radicular pain

Role of the Self-Administered, Self-Reported History Questionnaire to Identify Types of Lumbar Spinal Stenosis: A Sensitivity Analysis

Study DesignCase-control design.PurposeTo evaluate the role of the self-administered, self-reported history questionnaire (SSHQ) in identifying types of lumbar spinal stenosis (LSS).Overview of LiteratureDiagnosis of types of LSS is controversial.MethodsA total of 235 patients with LSS were asked to respond to the SSHQ. All of these patients recovered following surgical treatment. The classification of LSS patients was based on history, physical examinations, and imaging studies. It is considered to be the gold standard. Radicular and neurogenic claudication types of LSS were based on the SSHQ developed by Konno et al. Two categories of LSS were determined based on the SSHQ tool and gold standard. Finally, a sensitivity analysis was carried out to evaluate the diagnostic value of the SSHQ.ResultsThe mean age of patients was 59.4 years. According to the criteria for gold standard, patients were diagnosed with the radicular type (n=103), and neurogenic claudication type (n=132). The questionnaire had desirable sensitivity, specificity, and accuracy in categorizing the two types of LSS: 97.8%, 66.6%, and 96.8% for the radicular type, and 97.0%, 80.0%, and 95.7% for the neurogenic claudication type.ConclusionsOur findings indicate that the SSHQ is a reliable and a valid measure and it may be a clinical diagnosis support tool for identifying patients with two types of LSS

Lumbar Spinal Canal Stenosis Classification Criteria: A New Tool

Study DesignCase-control study.PurposeTo design a new tool for classifying lumbar spinal canal stenosis (CLSCS).Overview of LiteratureGrading of patients with lumbar spinal canal stenosis (LSCS) is controversial.MethodsThe Oswestry disability index (ODI) and the neurogenic claudication outcome score (NCOS) were recorded. Four parameters, which indicate the severity of LSCS disease, including Hufschmidt-grade, grading of magnetic resonance imaging, self-paced walking test, and stenosis ratio (SR) were employed. For the SR, quartile analysis was applied for classifying LSCS and the Hufschmidt-grade was modified into a 4-grade score. An initial score was assigned to each metric based on the severity of LSCS. Using the inverse-variance weighting method, the relative weights of these domains and their categories were determined. The score for all of the cases was obtained based on their weight by summing up the points of the four variables. Quartile analysis was used and a CLSCS score was proposed. Finally, intra- and interobserver reliability, and validity were assessed.ResultsA total of 357 patients were studied. The final CLSCS score for each case ranged from 4 to 16.5. Based on the quartile analysis, using the new criteria set, the CLSCS score was divided into four categories: CLSCS<7 (grade 0); 7≤CLSCS<10 (grade 1); 10≤CLSCS<13 (grade 2); and 13≤CLSCS≤16.5 (grade 3). The kappa values of for the CLSCS score indicated a perfect agreement. The CLSCS was correlated with the ODI and NCOS. All patients with grade 3 CLSCS were observed in the surgical group.ConclusionsThe CLSCS score can be helpful for classifying LSCS patients and in the decision-making process

Decision-Making Process in Patients with Thoracolumbar and Lumbar Burst Fractures with Thoracolumbar Injury Severity and Classification Score Less than Four

Study DesignCross-sectional.PurposeTo develop a strategy to determine a sound method for decision-making based on postoperative clinical outcome satisfaction.Overview of LiteratureThe ideal management of thoracolumbar and lumbar burst fractures (TLBF) without neurological compromise remains controversial.MethodsThis was a prospective study. Patients with thoracolumbar injury severity and classification score (TLICS) <4 were treated nonoperatively, with bed rest and bracing until the pain decreased sufficiently to allow mobilization. Surgery was undertaken in patients with intractable pain despite an appropriate nonoperative treatment (surgery group). The Oswestry disability index (ODI) measure was observed at baseline and at the last follow-up. Clinically success was defined at least a 30% improvement from the baseline ODI scores in both the conservative and surgery groups. All case records were assessed for gender, age, residual canal and angulations at the site of the fracture in order to determine which patients benefited from surgery or conservative treatment and which did not.ResultsIn all 113 patients with T11–L5, TLBFs were treated. The patients' mean age was 49.2 years. Patients successfully completed either nonoperative (n=99) or surgical (n=14) treatment based on ODI. Clinical examinations revealed that all of the patients had intact neurology. The mean follow-up period was 29.5 months. There was a significant difference between the two groups based on age and residual canal. The mean ODI score significantly improved for both groups (p <0.01). According to the findings, a decision matrix was proposed.ConclusionsThe findings confirm that TLICS <4, age, and residual canal can be used to guide the treatment of TLBF in conservative decision-making

Outcome Measure of Pain in Patients with Lumbar Disc Herniation: Validation Study of the Iranian version of Pain Sensitivity Questionnaire

Study DesignCross-sectional.PurposeTo translate and culturally adapt an Iranian version of the Pain Sensitivity Questionnaire (PSQ) in Iran.Overview of LiteratureInstruments measuring patient reported outcomes should satisfy certain psychometric properties.MethodsThe PSQ was translated following cross-cultural adaptation guidelines. A total of 101 patients with lumbar disc herniation (LDH), and 39 healthy cases were included in the study. All participants completed the PSQ and the Pain Catastrophizing Scale (PCS). The internal consistency, test-retest reliability, known group comparison, criterion validity and item-scale correlations were assessed.ResultsThe mean age of participants was 51.7 years. Reliability, validity and correlation of PSQ and PCS showed satisfactory results. Cronbach's alpha coefficients were 0.81 for PSQ-total, 0.82 for PSQ-minor, and 0.82 for PSQ-moderate. The intraclass correlation coefficients value was 0.84 (0.616–0.932) indicating an excellent test-retest reliability. The instrument discriminated well between sub-groups of patients who differed in a standard predictive measure of LDH surgery (the Finneson–Cooper score). Total PSQ were also significantly correlated with the total scores of the PCS, lending support to its good convergent validity. Additionally, the correlation of each item with its hypothesized domain on the PSQ indicated acceptable results, suggesting that the items had a substantial relationship with their own domains.ConclusionsThe adapted Iranian PSQ is a valid and reliable questionnaire for the assessment of pain in patients with LDH

Outcome Measures of Functionality, Social Interaction, and Pain in Patients with Cervical Spondylotic Myelopathy: A Validation Study for the Iranian Version of the Copenhagen Neck Functional Disability Scale

Study DesignCross-sectional.PurposeTo translate and validate the Iranian version of the Copenhagen Neck Functional Disability Scale (CNFDS).Overview of LiteratureInstruments measuring patient-reported outcomes should satisfy certain psychometric properties.MethodsNinety-three cases of cervical spondylotic myelopathy were entered into the study and completed the CNFDS pre and postoperatively at the 6 month follow-up. The modified Japanese Orthopedic Association Score was also completed. The internal consistency, test-retest, convergent validity, construct validity (item scale correlation), and responsiveness to change were assessed.ResultsMean age of the patients was 54.3 years (standard deviation, 8.9). The Cronbach α coefficient was satisfactory (α=0.84). Test-retest reliability as assessed by the intraclass correlation coefficient analysis was 0.95 (95% confidence interval, 0.92-0.98). The modified Japanese Orthopedic Association score correlated strongly with the CNFDS score, lending support to its good convergent validity (r=-0.80; p<0.001). Additionally, the correlation of each item with its hypothesized domain on the CNFDS was acceptable, suggesting that the items had a substantial relationship with their own domains. These results also indicate that the instrument was responsive to change (p<0.0001).ConclusionsThe findings suggest that the Iranian version of the CNFDS is a valid measure to assess functionality, social interaction, and pain among patients with cervical spondylotic myelopathy

An Outcome Measure of Functionality and Pain in Patients with Low Back Disorder: A Validation Study of the Iranian version of Low Back Outcome Score

Study DesignCross-sectional study.PurposeThis study aimed to cross-culturally translate and validate the low back outcome score (LBOS) in Iran.Overview of LiteratureLumbar disc hernia (LDH) is the most common diagnoses of low back pain and imposes a heavy burden on both individual and society. Instruments measuring patient reported outcomes should satisfy cetain psychometric properties.MethodsThe translation and cross-cultural adaptation of the original questionnaire was performed using Beaton's guideline. A total of 163 patients with LDH were asked to respond to the questionnaire at three points in time: preoperative and twice within 1-week interval after surgery assessments. The Oswestry disabilty index (ODI) was also completed. The internal consistency, test-retest, convergent validity, and responsiveness to change were assessed. Responsiveness to change also was assessed comparing patients' pre- and postoperative scores.ResultsThe mean age of the cohort was 49.8 years (standard deviation=10.1). The Cronbach's alpha coefficients for the LBOS at preoperative and postoperative assessments ranged from 0.77 to 0.79, indicating good internal consistency. Test-retest reliability as performed by intraclass correlation coefficient was found to be 0.82 (0.62–0.91). The instrument discriminated well between sub-groups of patients who differed in the Finneson-Cooper score. The ODI correlated strongly with the LBOS score, lending support to its good convergent validity (r=––0.83; p<0.001). Further analysis also indicated that the questionnaire was responsive to change (p<0.001).ConclusionsThe Iranian version of LBOS performed well and the findings suggest that it is a valid measure of back pain treatment evaluation among LDH patients

Surgical outcomes and correlation ODI and ASIA scores in patients with thoracolumbar and lumbar burst fractures

Background and Purpose: Decision-making process in Thoracolumbar and Lumbar Burst Fracture (TLBF) patients with Thoracolumbar Injury Severity and Classification Score (TLICS) &gt; 4 is remained controversial. On the other hand, the question is whether that the Oswestry Disability Index (ODI) can be use to assess to clinical outcomes in these patients. We aimed to study the correlation between the ODI and American Spinal Injury Association (ASIA) impairment scale in these patients and evaluation of surgical outcome.Methods: This was a prospective study. The TLICS were determined and TLICS &gt; 4 was included. The nerve injury was assessed according to sensory scores and motors scores of the using ASIA Scale at pre- and postoperative. It was also ODI calculated at last follow-up. In addition, correlation between ASIA and ODI was evaluated at last follow-up.Results: Fifty eight patients (20.7% female) who underwent spinal surgery for TLBF with a minimum follow up of 2 years were studied. The mean age was 30.7 ± 8.7 (24 to 65) years. Automobile accident was the predominant mode of injury. Patients were followed for 25 months on average (24 – 43 months). ASIA sensory scores and motor scores were improved significantly at last follow-up (P &lt; 0.001). No patient experienced neurological worsening during the follow-up period. The mean ODI were 29.7 (SD= 4.9) at last follow-up. Correlation test showed significant correlations among the ODI and the ASIA sensory scores (r = 0.74, P &lt; 0.02) and motor scores (r = 0.78, P &lt; 0.01) at last follow-up assessment.Conclusion: The findings confirm that for TLICS &gt; 4 surgical outcome is acceptable. It also shows that the ODI and the ASIA scores have a strong correlation in measuring disability in patients with TLBF after at least 2 year follow-up

Grading of MRI and STarT Back Screening Tool (SBST) in the diagnosis of severity of lumbar central canal stenosis: a sensitivity analysis

ABSTRACTPurpose: This study aimed to correlation between the grading stenosis and the STarT Back Screening Tool (SBST) inpatients diagnosed with lumbar central canal stenosis (LCCS). Methods: In a prospective clinical study, a total of269 patients with LCCS were asked to respond to the questionnaire at their first visits. Grading of LCCS on MRI was determined and also the severities of the disease were observed based on SBST as the gold standard. Finally grading on MRI and calcification of the SBST were determined, and sensitivity analysis carried out to evaluate severity of LCCS on grading of MRI using the SBST. Results: The mean age of patients was 58.6 (SD= 10.9) years; and 56.5% were female. According to patients’ imaging they have been diagnosed as grade 1 (n = 86), grade 2 (n =107) and grade 3 (n = 76). The sensitivity, specificity and accuracy of the estimated grading of LCCS on MRI for low, medium, and high risk groups were found to be desirable: 97.6%, 66.7%, 96.5% for low risk; 93.1%, 83.3%, 92.5% for medium risk, and 97.2%, 66.7%, 94.7% for high risk, respectively. Conclusion: Our findings indicate that grading of LCCS on MRI correlate with SBST and suggest that it is a reliable measure for screening LCCS patients

Functionality Status and Surgical Outcome of Fenestration versus Laminotomy Discectomy in Patients with Lumbar Disc Herniation

Background & Aim: To assess functionality status and surgical outcome of fenestration versus laminotomy technique based on Core Outcome Measures Index (COMI) in patients with lumbar disc hernia (LDH). Methods & Materials/Patients: A cross-sectional study was performed between January 2007 and April 2012. A total of 108 patients with a single-level disc herniation were asked to respond to the Oswestry Disabiltiy Index (ODI) and COMI at two points in time: pre- and post-operative assessments. The ODI and COMI were assessed comparing patients’ pre- and postoperative scores to determine the functionality status and surgical outcome. Results: The mean age of patients was 52.4 (SD=10.1) years who underwent fenestration (n=45) or laminotomy discectomy (n=63). The mean clinical follow-up was 27.8 (SD=3.6) months (range 24 - 37 months). Regarding COMI scores, all subgroup values showed statistical significance pre- and postoperative indicating improvements on the outcomes and functionality. The change in the ODI after surgery was strongly correlated with change in the COMI, (r=0.79; P<0.001). The ODI score also was found to be statistically different between the groups in pre-and postoperative (P<0.001) assessment. However, the functionality status rate was similar in both groups. Conclusion: The findings suggest that fenestration or laminotomy discectomy is an efficacious procedure for treatment of LDH. However, both methods are equally effective in surgical outcome