Christoph Roeder

Identification of prognostic factors for chronicity in patients with low back pain: a review of screening instruments

Low back pain (LBP) is currently the most prevalent and costly musculoskeletal problem in modern societies. Screening instruments for the identification of prognostic factors in LBP may help to identify patients with an unfavourable outcome. In this systematic review screening instruments published between 1970 and 2007 were identified by a literature search. Nine different instruments were analysed and their different items grouped into ten structures. Finally, the predictive effectiveness of these structures was examined for the dependent variables including “work status“, “functional limitation”, and “pain“. The strongest predictors for “work status” were psychosocial and occupational structures, whereas for “functional limitation” and “pain” psychological structures were dominating. Psychological and occupational factors show a high reliability for the prognosis of patients with LBP. Screening instruments for the identification of prognostic factors in patients with LBP should include these factors as a minimum core set.RésuméLa lombalgie (LBP) est un problème important notamment sur le poste des dépenses dans nos sociétés modernes. Sur le plan évolutif, il est primordial de pouvoir dépister des facteurs pronostics négatifs de ces patients. entre 1970 et 2007, un certain nombre d’éléments permettant cette analyse ont été identifiés dans la littérature. Ces instruments d’analyse nous semblent importants de façon à déterminer la limitation fonctionnelle, les possibilités de travail et la douleur. l’élément de prévision le plus important pour la poursuite d’un emploi est psychosocial, de ce fait l’élément important pour apprécier le pronostic de limitation fonctionnelle ou de douleur est plutôt psychologique. les facteurs psychologiques et sociaux permettent de faire le pronostic des lombalgies, il s’agit d’un tronc commun des éléments de dépistage, devant inclure tous ces facteurs.

Condition-specific outcome measures for low back pain. Part I: validation.

A literature review of the nine most widely used, condition-specific, self-administered assessment questionnaires for low back pain has been undertaken. General and historic aspects, reliability, responsiveness and minimum clinically important difference, external validity, floor and ceiling effects and available languages were analysed for the nine most-used outcome tools. When considering which condition-specific measure to employ, the present overview on assessment tools should provide the necessary information to define the technical aspects of the nine questionnaires. These criteria, however, are only part of the consideration. In part II the construction of these scales in relationship to the measurement domains will be evaluated.

The international spine registry SPINE TANGO: status quo and first results

With an official life time of over 5 years, Spine Tango can meanwhile be considered the first international spine registry. In this paper we present an overview of frequency statistics of Spine Tango for demonstrating the genesis of questionnaire development and the constantly increasing activity in the registry. Results from two exemplar studies serve for showing concepts of data analysis applied to a spine registry. Between 2002 and 2006, about 6,000 datasets were submitted by 25 centres. Descriptive analyses were performed for demographic, surgical and follow-up data of three generations of the Spine Tango surgery and follow-up forms. The two exemplar studies used multiple linear regression models to identify potential predictor variables for the occurrence of dura lesions in posterior spinal fusion, and to evaluate which covariates influenced the length of hospital stay. Over the study period there was a rise in median patient age from 52.3 to 58.6 years in the Spine Tango data pool and an increasing percentage of degenerative diseases as main pathology from 59.9 to 71.4%. Posterior decompression was the most frequent surgical measure. About one-third of all patients had documented follow-ups. The complication rate remained below 10%. The exemplar studies identified ‘‘centre of intervention’’ and ‘‘number of segments of fusion’’ as predictors of the occurrence of dura lesions in posterior spinal fusion surgery. Length of hospital stay among patients with posterior fusion was significantly influenced by ‘‘centre of intervention’’, ‘‘surgeon credentials’’, ‘‘number of segments of fusion’’, ‘‘age group’’ and ‘‘sex’’. Data analysis from Spine Tango is possible but complicated by the incompatibility of questionnaire generations 1 and 2 with the more recent generation 3. Although descriptive and also analytic studies at evidence level 2++ can be performed, findings cannot yet be generalised to any specific country or patient population. Current limitations of Spine Tango include the low number and short duration of follow-ups and the lack of sufficiently detailed patient data on subgroup levels. Although the number of participants is steadily growing, no country is yet represented with a sufficient number of hospitals. Nevertheless, the benefits of the project for the whole spine community become increasingly visible.

A pain assessment scale for population-based studies: Development and validation of the Pain Module of the Standard Evaluation Questionnaire

&NA; The objectives of this study were to develop and validate a tool for assessing pain in population‐based observational studies and to develop three subscales for back/neck, upper extremity and lower extremity pain. Based on a literature review, items were extracted from validated questionnaires and reviewed by an expert panel. The initial questionnaire consisted of a pain manikin and 34 items relating to (i) intensity of pain in different body regions (7 items), (ii) pain during activities of daily living (18 items) and (iii) various pain modalities (9 items). Psychometric validation of the initial questionnaire was performed in a random sample of the German‐speaking Swiss population. Analyses included tests for reliability, correlation analysis, principal components factor analysis, tests for internal consistency and validity. Overall, 16,634 of 23,763 eligible individuals participated (70%). Test–retest reliability coefficients ranged from 0.32 to 0.97, but only three coefficients were below 0.60. Subscales were constructed combining four items for each of the subscales. Item‐total coefficients ranged from 0.76 to 0.86 and Cronbach’s α were 0.75 or higher for all subscales. Correlation coefficients between subscales and three validated instruments (WOMAC, SPADI and Oswestry) ranged from 0.62 to 0.79. The final Pain Standard Evaluation Questionnaire (SEQ Pain) included 28 items and the pain manikin and accounted for the multidimensionality of pain by assessing pain location and intensity, pain during activity, triggers and time of onset of pain and frequency of pain medication. It was found to be reliable and valid for the assessment of pain in population‐based observational studies.

Effect of a flow chart on use of blood transfusions in primary total hip and knee replacement: prospective before and after study

Problem A suspected high proportion of unnecessary blood transfusions occur in patients undergoing total joint replacement. Design Prospective before and after study evaluating the impact of a one page flow chart aimed at reducing the use of blood transfusions. Setting Orthopaedic tertiary care centre in Winterthur, Switzerland. 208 patients underwent primary total joint replacement of hips or knees during the control period (October 1998 to September 1999) and 217 during the intervention period (October 1999 to September 2000). Key measures for improvement Proportion of patients receiving allogeneic blood transfusions. Strategies for change A simple one page flow chart, which summarised graphically the perioperative decision pathways for anaemic patients, was placed in all charts of patients undergoing total joint replacement and handed out to medical staff from 4 October 1999 onwards. The implementation of the flow chart focused on its endorsement by chief physicians and the development of a sense of “ownership” among physicians and nurses. Effects of change The proportion of patients receiving allogeneic blood decreased from 35.0% to 19.8% (absolute difference -15.2%, 95% confidence interval -23.3 to -7.0%). The percentage of patients donating and receiving autologous blood also decreased. This led to overall savings of about £23 000 (

Condition-specific outcome measures for low back pain: Part II: Scale construction

42 470; €34 441) (£103.50 per patient undergoing total joint replacement). Differences became more pronounced after adjustment for confounding factors. Lessons learnt Allogeneic blood transfusions in primary hip and knee replacement surgery may be reduced cost effectively by implementing a one page flow chart. Five key elements may have contributed: simplicity; wide distribution; no requirement for major changes; endorsement by local opinion leaders; and development of a sense of ownership. These elements may be used in other contexts to achieve sustained change of clinical practice.

Virtopsy - the concept of a centralized database in forensic medicine for analysis and comparison of radiological and autopsy data.

A literature review of the most widely used, condition-specific, self-administered assessment questionnaires for low back pain has been undertaken. In part I, technical issues such as validity, reliability, availability and comparability were analyzed for the nine most widely used outcome tools. This second part focuses on the content and wording of questions and answers in each of the nine questionnaires, and an analysis of the different score results is performed. The issue of score bias is discussed and suggestions are given in order to increase the construct validity in the practical use of the individual questionnaires.

An intraoperatively moulded PMMA prostheses like spacer for two-stage revision of infected total knee arthroplasty

Recent developments in clinical radiology have resulted in additional developments in the field of forensic radiology. After implementation of cross-sectional radiology and optical surface documentation in forensic medicine, difficulties in the validation and analysis of the acquired data was experienced. To address this problem and for the comparison of autopsy and radiological data a centralized database with internet technology for forensic cases was created. The main goals of the database are (1) creation of a digital and standardized documentation tool for forensic-radiological and pathological findings; (2) establishing a basis for validation of forensic cross-sectional radiology as a non-invasive examination method in forensic medicine that means comparing and evaluating the radiological and autopsy data and analyzing the accuracy of such data; and (3) providing a conduit for continuing research and education in forensic medicine. Considering the infrequent availability of CT or MRI for forensic institutions and the heterogeneous nature of case material in forensic medicine an evaluation of benefits and limitations of cross-sectional imaging concerning certain forensic features by a single institution may be of limited value. A centralized database permitting international forensic and cross disciplinary collaborations may provide important support for forensic-radiological casework and research.

LiLa classification for paediatric long bone fractures. Intraobserver and interobserver reliability

We report a series of 16 consecutive total knee arthroplasty (TKA) revision procedures for deep infection, treated with a newly developed intraoperatively moulded PMMA cement-prostheses-like spacer (CPLS). The standard treatment consisted of a two-stage protocol with initial explantation of the infected components combined with radical debridement, followed by implantation of a temporary cement spacer and final reimplantation of a new TKA. A sterilizeable Teflon tapered aluminium mould was developed for production of a custom made CPLS during the intervention. Stable implantation of the CPLS was achieved with a second cementation, allowing for correct alignment and ligament balancing. The spacer remained 3.5 months on average until reimplantation of a TKA occurred. At time of reimplantation, patients had an average KSS score of 84.44 points with an average flexion capacity of 102°. There was no recurrent infection during the study period of minimum 2 years. With this new technique, a low friction articulation with good stability, high comfort and a better range of motion compared to handcrafted spacers was achieved. The use of this spacer is a time sparing, cheap and convenient option in 2-stage TKA revision.

Neurological outcome, working capacity and prognostic factors of patients with SCIWORA

BACKGROUND There are two child-specific fracture classification systems for long bone fractures: the AO classification of pediatric long-bone fractures (PCCF) and the LiLa classification of pediatric fractures of long bones (LiLa classification). Both are still not widely established in comparison to the adult AO classification for long bone fractures. METHODS During a period of 12 months all long bone fractures in children were documented and classified according to the LiLa classification by experts and non-experts. Intraobserver and interobserver reliability were calculated according to Cohen (kappa). RESULTS A total of 408 fractures were classified. The intraobserver reliability for location in the skeletal and bone segment showed an almost perfect agreement (K = 0.91-0.95) and also the morphology (joint/shaft fracture) (K = 0.87-0.93). Due to different judgment of the fracture displacement in the second classification round, the intraobserver reliability of the whole classification revealed moderate agreement (K = 0.53-0.58). Interobserver reliability showed moderate agreement (K = 0.55) often due to the low quality of the X-rays. Further differences occurred due to difficulties in assigning the precise transition from metaphysis to diaphysis. CONCLUSIONS The LiLa classification is suitable and in most cases user-friendly for classifying long bone fractures in children. Reliability is higher than in established fracture specific classifications and comparable to the AO classification of pediatric long bone fractures. Some mistakes were due to a low quality of the X-rays and some due to difficulties to classify the fractures themselves. Improvements include a more precise definition of the metaphysis and the kind of displacement. Overall the LiLa classification should still be considered as an alternative for classifying pediatric long bone fractures.