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Abstract: Background context: Ten percent of patients with low back pain (LBP) are not able to resume work within 3 months of sick leave, accounting for 90% of all medical and indemnity costs. Purpose: To quantify the relative contribution of sociodemographic, clinical, occupational, and psychological risk factors in determining the non–return to work after 3 months of compensated LBP and to develop a screening tool to identify patients who require further guidance and rehabilitation. Study design/setting: A 6-month prospective cohort study of disabled workers applying for compensation benefit because of LBP during a 6-month period in the Belgian compulsory health insurance system. Patient sample: Three hundred and forty-six patients. Outcome measures: Patients unable to resume work within 3 months of sick leave were classified as bad outcomes. Methods: Consecutively, injured workers applying for income replacement benefits between October 2003 and March 2004 because of LBP were followed 6 months after the start of the sick leave period. All subjects underwent a standardized physical examination and completed a battery of 12 self-report questionnaires. Results: Forty-seven percent of the population had not resumed work 3 months after the start of the sick leave period. The risk factors for sickness absence more than 3 months were Oswestry disability index (odds ratio for each point increase: 1.04; 95% confidence interval: 1.02–1.06), fear of avoidance severity score (odds ratio for each point increase: 1.05; confidence interval: 1.02–1.09), blue collar worker (odds ratio: 2.18; confidence interval: 1.21–3.92), LBP for less than 12 weeks before sick leave (odds ratio: 0.32; confidence interval: 0.17–0.64), and pain behavior (odds ratio for each point increase: 1.72; confidence interval: 1.25–2.39). A multivariate screening test based on five questions identified 80% of the patients unable to resume work after 3 months of sick leave (specificity: 56.6; cut off: 0.4). Conclusions: A questionnaire comprising a limited set of items allows a practical screening of LBP patients unlikely to resume work. [Copyright &y& Elsevier]

Abstract: Background context: Ten percent of patients with low back pain (LBP) are not able to resume work within 3 months of sick leave, accounting for 90% of all medical and indemnity costs. Purpose: To quantify the relative contribution of sociodemographic, clinical, occupational, and psychological risk factors in determining the non–return to work after 3 months of compensated LBP and to develop a screening tool to identify patients who require further guidance and rehabilitation. Study design/setting: A 6-month prospective cohort study of disabled workers applying for compensation benefit because of LBP during a 6-month period in the Belgian compulsory health insurance system. Patient sample: Three hundred and forty-six patients. Outcome measures: Patients unable to resume work within 3 months of sick leave were classified as bad outcomes. Methods: Consecutively, injured workers applying for income replacement benefits between October 2003 and March 2004 because of LBP were followed 6 months after the start of the sick leave period. All subjects underwent a standardized physical examination and completed a battery of 12 self-report questionnaires. Results: Forty-seven percent of the population had not resumed work 3 months after the start of the sick leave period. The risk factors for sickness absence more than 3 months were Oswestry disability index (odds ratio for each point increase: 1.04; 95% confidence interval: 1.02–1.06), fear of avoidance severity score (odds ratio for each point increase: 1.05; confidence interval: 1.02–1.09), blue collar worker (odds ratio: 2.18; confidence interval: 1.21–3.92), LBP for less than 12 weeks before sick leave (odds ratio: 0.32; confidence interval: 0.17–0.64), and pain behavior (odds ratio for each point increase: 1.72; confidence interval: 1.25–2.39). A multivariate screening test based on five questions identified 80% of the patients unable to resume work after 3 months of sick leave (specificity: 56.6; cut off: 0.4). Conclusions: A questionnaire comprising a limited set of items allows a practical screening of LBP patients unlikely to resume work. [Copyright &y& Elsevier]

Interspinous devices have been introduced to provide a minimally invasive surgical alternative for patients with lumbar spinal stenosis or foraminal stenosis. Little is known however, of the effect of interspinous devices on intersegmental range of motion (ROM). The aim of this in vivo study was to investigate the effect of a novel minimally invasive interspinous implant, InSwing, on sagittal plane ROM of the lumbar spine using an ovine model. Ten adolescent Merino lambs underwent a destabilization procedure at the L1-L2 level simulating a stenotic degenerative spondylolisthesis (as described in our earlier work; Spine 15:571-576, 1990). All animals were placed in a side-lying posture and lateral radiographs were taken in full flexion and extension of the trunk in a standardized manner. Radiographs were repeated following the insertion of an 8-mm InSwing interspinous device at L1-L2, and again with the implant secured by means of a tension band tightened to 1 N/m around the L1 and L2 spinous processes. ROM was assessed in each of the three conditions and compared using Cobb's method. A paired t-test compared ROM for each of the experimental conditions (P < 0.05). After instrumentation with the InSwing interspinous implant, the mean total sagittal ROM (from full extension to full flexion) was reduced by 16% from 6.3 degrees to 5.3 +/- 2.7 degrees. The addition of the tension band resulted in a 43% reduction in total sagittal ROM to 3.6 +/- 1.9 degrees which approached significance. When looking at flexion only, the addition of the interspinous implant without the tension band did not significantly reduce lumbar flexion, however, a statistically significant 15% reduction in lumbar flexion was observed with the addition of the tension band (P = 0.01). To our knowledge, this is the first in vivo study radiographically showing the advantage of using an interspinous device to stabilize the spine in flexion. These results are important findings particularly for patients with clinical symptoms related to instable degenerative spondylolisthesis. [ABSTRACT FROM AUTHOR]

Editorial. Explains the review of articles featured in 2004 issues of the "European Spine Journal" by Robert Mulholland and Michel Benoist. Selection of articles for discussion by controversy, novelty and deficiency; Aim of crystallizing new ideas and write better papers.

The article reports that the structure of postgraduate courses has very much changed over the last 10-15 years. Medical education has gained in importance, with thousands of web sites and even several journals devoted to it. Moreover, leading general medical journals have demonstrated an increasing interest in this topic. Since 2002, the Spine Society of Europe has organised a programme of instructional courses aimed at covering the entire catalogue of spinal pathologies. It was decided from the start that the quality of the courses would be evaluated.

The article states that scientific research is going through a difficult period. Due to the economic recession, many public funding resources have been scaled down. In this situation, research contracts with the support of the industry are welcome. However, it must be borne in mind that the relationship between the researcher and players in the biomedical field is a delicate one. While it is often based on a win-win cooperation between the researcher and the funding company, it is questionable whether it is always a winning situation for scientific truth. It also states that from an ethical point of view it is certainly unacceptable that any research should be kept undisclosed just because of commercial interests.

Objective: This study assessed utilization and cost of allogeneic blood transfusion (ABT) associated with spinal surgery in the United States (US) and Belgium.Methods: A retrospective cohort of 292,864 spinal surgery inpatients in US hospitals was pooled with a cohort of 27,952 inpatients who had similar procedures in Belgian hospitals. Utilization and cost data were derived from hospital accounting systems. Costs were converted to US dollars. Descriptive and multivariate statistics were used to describe the factors associated with the use and cost of ABT. Missing data, confounding, and variable measurement error were addressed using standard approaches for observational studies.Results: US hospitalizations cost $12,044 (SD = 15,920) over 3.6 days compared to $4010 (SD = 3586) over 10.3 days in Belgium. Low molecular weight heparin was used by 78% of Belgian patients and 4% of US patients. Red blood cell utilization occurred in approximately 7% of patients from both countries; however US patients received 6 units compared to 3 units by Belgian patients. US patients spent 3.5 (p < 0.0001) less days in hospital, 1.0 (p < 0.0001) more days in an intensive care unit, used 64% more allogeneic blood (OR = 1.64, 95% CI 1.53-1.75), and incurred $13,647 (p < 0.0001) more per hospitalization than Belgian patients.Conclusions: US patients used more blood products, had shorter hospital stays, and incurred greater costs than Belgian patients. Specialists as attending physicians were associated with lower utilization of ABT; this may be an administrative change that hospitals can implement to reduce utilization and costs. [ABSTRACT FROM AUTHOR]

This study was designed to develop predictive models for surgical outcome based on information available prior to lumbar stenosis surgery. Forty patients underwent decompressive laminarthrectomy. Preop and 1-year postop evaluation included Waddell’s nonorganic signs, CT scan, Waddell disability index, Oswestry low back pain disability questionnaire, low back outcome score (LBOS), visual analog scale (VAS) for pain intensity, and trunk strength testing. Statistical comparisons of data used adjusted error rates within families of predictors. Mathematical models were developed to predict outcome success using stepwise logistic regression and decision-tree methodologies (chi-squared automatic interaction detection, or CHAID). Successful outcome was defined as improvement in at least three of four criteria: VAS, LBOS, and reductions in claudication and leg pain. Exact logistic regression analysis resulted in a three-predictor model. This model was more accurate in predicting unsuccessful outcome (negative predictive value 75.0%) than in successful outcome (positive predictive value 69.6%). A CHAID model correctly classified 90.1% of successful outcomes (positive predictive value 85.7%, negative predictive value 100%). The use of conservative surgical decompression for lumbar stenosis can be recommended, as it demonstrated a success rate similar to that of more invasive techniques. Given its physiologic and biomechanical advantages, it can be recommended as the surgical method of choice in this indication. Underlying subclinical vascular factors may be involved in the complaints of spinal stenosis patients. Those factors should be investigated more thoroughly, as they may account for some of the failures of surgical relief. The CHAID decision tree appears to be a novel and useful tool for predicting the results of spinal stenosis surgery [ABSTRACT FROM AUTHOR]

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. Forty patients had a lumbar laminectomy procedure, which preserved the integrity of the neural arches, facet joints and most muscle attachments. Pre-operative clinical evaluation of the patients included: Waddell's non-organic signs (NOS) performed by an independent surgeon observer; three self-report questionnaires – the Waddell Disability Index (WDI), the Oswestry Low Back Pain Disability Questionnaire (ODI), and the Low Back Outcome Score (LBOS); and a general questionnaire that included a visual analog pain intensity scale (VAS). Post-operative clinical evaluations and questionnaires were obtained in 36 subjects (mean age 59.8 years) after a 1.7-year follow-up (range 1–2.6 years). Pre-operative versus post-operative statistical comparisons of the data were performed using adjusted error rates within families of predictors. Successful surgical outcome was defined as an improvement in at least three of the following four criteria: self-reported pain on a VAS, self-reported functional status measured by LBOS, reduction of pain during walking and reduction of leg pain. At follow-up, there was a statistically significant improvement in VAS pain intensity, ODI, WDI, and LBOS. Patients classified as having mixed stenosis had a higher incidence of continuous pain symptoms in comparison with acquired stenosis, but there was no differential improvement with treatment depending upon stenosis classification and/or number of operative levels. 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. [ABSTRACT FROM AUTHOR]

The author reflects on the several techniques which are use in pediatric spinal surgery. Topics discussed include the origination of medical term pediatric orthopedics, the vertebral surgery for spine deformities as major branch of pediatric surgery, and the three-dimensional analysis which uses low-dose imaging system including EOS imaging which ca provide accurate analysis of scoliosis deformities.

Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. A standardized approach for the detection, evaluation, and management of anaemia in this setting has been identified as an unmet medical need. A multidisciplinary panel of physicians was convened by the Network for Advancement of Transfusion Alternatives (NATA) with the aim of developing practice guidelines for the detection, evaluation, and management of preoperative anaemia in elective orthopaedic surgery. A systematic literature review and critical evaluation of the evidence was performed, and recommendations were formulated according to the method proposed by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. We recommend that elective orthopaedic surgical patients have a haemoglobin (Hb) level determination 28 days before the scheduled surgical procedure if possible (Grade 1C). We suggest that the patient's target Hb before elective surgery be within the normal range, according to the World Health Organization criteria (Grade 2C). We recommend further laboratory testing to evaluate anaemia for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C). We recommend that nutritional deficiencies be treated (Grade 1C). We suggest that erythropoiesis-stimulating agents be used for anaemic patients in whom nutritional deficiencies have been ruled out, corrected, or both (Grade 2A). Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value. Implementation of anaemia management in the elective orthopaedic surgery setting will improve patient outcomes. [ABSTRACT FROM AUTHOR]

The author comments on issues of medical ethics related to the relationship between spine surgeons involved in clinical studies of spinal implants and the spinal implant industry. The author discusses several cases involving spine surgeons who stood to make financial gains from manufacturers for positive implant research results. He asserts that such behavior tarnishes the profession. He calls for transparency and honesty in addressing this fundamental conflict of interest.