Gunnar Leivseth

Sagittal plane segmental motion of the cervical spine. A new precision measurement protocol and normal motion data of healthy adults.

OBJECTIVE (1) Precise documentation of sagittal plane segmental rotational and posteroanterior translational motion of segments C0/C1-C6/C7 of the human cervical spine from lateral radiographic views. (2) Compilation of a database describing normal motion. (3) Comparison of individual motion patterns with the normal database. DESIGN Descriptive study based on computer-aided measurements from lateral radiographic views taken in flexion and extension. BACKGROUND Previous studies concentrated on segmental rotational motion of the cervical spine. Normal data for translational motion were not available. Description of cervical spine motion patterns thus remained incomplete. METHODS Based on computer-aided measurements from lateral radiographic views taken in flexion and extension, a new protocol determines rotational and translational motion for all segments (C0/C1-C6/C7) imaged on the radiographic views. Measured results are corrected for radiographic magnification and variation in stature; they are virtually uninfluenced by radiographic distortion and patient alignment errors. A database describing normal motion was compiled from 137 sets of lateral views of healthy adults taken in active flexion and extension. A specimen study as well as inter- and intra-observer studies quantify measurement errors. RESULTS The error study demonstrated the error (SD) of a rotational motion measurement to amount to slightly less than 2 degrees. The error (SD) of a translational motion measurement amounts to less than 5% of vertebral depth; for a vertebra of 15 mm depth this corresponds to 0.7 mm. A normal database for rotational and translational motion was compiled. There was a linear relation between rotational and translational motion. This finding agrees qualitatively with results from previous studies; quantitative comparisons are not possible due to divergent definitions for translational motion. The relation between rotation and translation can be employed in individual cases to predict translational motion, in dependence on the rotation actually performed. A comparison of the rotational motion with the normal database and the difference between predicted and actual translational motion allow segmental hypo-, normal or hypermobility to be quantified. CONCLUSIONS The new protocol measures segmental motion with high precision and corrects for radiographic distortion, variation in stature and alignment errors of patients. Thus, archive studies using existing radiographs are feasible. RELEVANCE Flexion-extension radiographs of the cervical spine are performed to explore potential damage to the bony or ligamentous structure resulting in abnormal, segmental motion patterns. Determining rotational motion gives only an incomplete picture. The new protocol allows for precise quantification of translational motion and classification of segments as hypo- or hypermobile by comparison with normal motion data.

Psychosocial interventions as part of breast cancer rehabilitation programs? Results from a systematic review

Objective: This systematic review aimed to determine the effectiveness of psychoeducation, cognitive behavioural therapy (CBT) and social support interventions used in the rehabilitation of breast cancer (BC) patients.

Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study

SummaryBackground. The aim of this study was to assess if transforaminal steroid injections applied to cohort of patients waiting for cervical disc surgery, reduce the pain of cervical radiculopathy and hence reduce the need for surgical intervention.Cervical radiculopathy due to cervical disc herniation or spondylosis is a common indication for cervical disc surgery. Surgery is however not always successful, and is not done without risk of complications.Transforaminal injection of steroids has gained popularity due to the rationale that inflammation of the spinal nerve roots causes radicular pain, and therefore steroids placed locally should relieve symptoms.Methods. During a 12-month period, 21 secondary referral patients with unilateral cervical radiculopathy entered the study. Cervical disc herniation or spondylosis affecting the corresponding nerve root was demonstrated by appropriate investigation (MRI or myelography).The patients then received 2 transforaminal steroid injections, at 2 weeks interval, while waiting for operative treatment.The pain intensity (VAS), Odom’s criteria and operative indications were registered at 6 weeks and 4 months.Findings. After receiving injection treatment 5 of the 21 patients decided to cancel the operation due to clinical improvement. A statistically significant reduction (0.02) in radicular pain score was simultaneously measured. This corresponds well with the reduction in operative requirements since radicular pain is the main indication for operative treatment. The responders experienced a long-lasting effect.Those responding positively however improved neck pain to the same extent as radicular pain, and patients with cervical spondylosis responded as positively as those with disc herniation.Interpetation. This prospective cohort study indicates a reduction in the need for operative treatment due to injection treatment. The clinical effect is measurable, and a statistically significant improvement of the radicular pain is registered.Routine transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.

Increased sagittal plane segmental motion in the lower cervical spine in women with chronic whiplash-associated disorders, grades I-II: a case-control study using a new measurement protocol.

Study Design. Case-control study comparing sagittal plane segmental motion in women (n = 34) with chronic whiplash-associated disorders, Grades I–II, with women (n = 35) with chronic insidious onset neck pain and with a normal database of sagittal plane rotational and translational motion. Objective. To reveal whether women with chronic whiplash-associated disorders, Grades I–II, demonstrate evidence of abnormal segmental motions in the cervical spine. Summary of Background Data. It is hypothesized that unphysiological spinal motion experienced during an automobile accident may result in a persistent disturbance of segmental motion. It is not known whether patients with chronic whiplash-associated disorders differ from patients with chronic insidious onset neck pain with respect to segmental mobility. Methods. Lateral radiographic views were taken in assisted maximal flexion and extension. A new measurement protocol determined rotational and translational motions of segments C3–C4 and C5–C6 with high precision. Segmental motion was compared with normal data as well as among groups. Results. In the whiplash-associated disorders group, the C3–C4 and C4–C5 segments showed significantly increased rotational motions. Translational motions within each segment revealed a significant deviation from normal at the C3–C4 segment in the whiplash-associated disorders and insidious onset neck pain groups and at the C5–C6 segment in the whiplash-associated disorders group. Significantly more women in the whiplash-associated disorders group (35.3%) had abnormal increased segmental motions compared to the insidious onset neck pain group (8.6%) when both the rotational and the translational parameters were analyzed. When the translational parameter was analyzed separately, no significant difference was found between groups, or 17.6% (whiplash-associated disorders group) and 8.6% (insidious onset neck pain group), respectively. Conclusion. Hypermobility in the lower cervical spine segments in 12 out of 34 patients with chronic whiplash-associated disorders in this study point to injury caused by the accident. This subgroup, identified by the new radiographic protocol, might need a specific therapeutic intervention.

Mobility of lumbar segments instrumented with a ProDisc II prosthesis: a two-year follow-up study.

Study Design. Longitudinal prospective study on a sample of 41 consecutive disc prosthesis patients, covering a postoperative time period of at least 2 years. Objectives. To document the rotational and translational range of segmental motion of patients instrumented with ProDisc II prostheses in the lumbar spine and to compare motion between instrumented and untreated adjacent segments with respect to a normative database. To discuss potential causes of the low range of rotational motion observed after instrumentation with a Prodisc II prosthesis. Summary of Background Data. Disc replacement is intended to restore physiologic motion and height of the affected levels. Published reports show, however, that the goal of restoring motion at the operated segment is missed in the majority of cases. The cause of this failure is unresolved. Methods. Rotational and translational segmental motion in the sagittal plane, disc height, and posteroanterior displacement were measured from lateral radiographic views taken standing (before surgery) and in flexion and extension (1 year and 2 years after surgery) by Distortion Compensated Roentgen Analysis (DCRA). The protocol permits to take measurements from all segments imaged on the radiographic views and compensates for variations in stature, magnification, and posture. Data from instrumented and untreated segments can be compared and related to a previously determined normative database. Results. The rotational range of motion of segments instrumented with a ProDisc II prosthesis was low, especially at L4–L5 and L5–S1. In the majority of cases, it amounted to less than 45% of the normal range. Virtually no improvement occurred between 1 and 2 years after surgery. Malalignment of the axis of rotation of the prosthesis with respect to the anatomic axis, persisting clinical symptoms, or the significant increase of intervertebral space documented after instrumentation are unlikely to cause the low range of motion. As the range of rotational motion of the untreated segments was low with respect to normal as well, it is conjectured that tissue adaptation during the preoperative symptomatic time period might have caused the postoperative motion deficit. This conjecture complies with fragmentary previous observations of a low postoperative segmental range of motion from untreated segments of fusion patients. Conclusions. Disc replacement in the lumbar spine by a ProDisc II implant fails to restore normal segmental rotational motion in the sagittal plane, specifically at levels L4–L5 and L5–S1. As segmental motion of the untreated segments was lower than normal as well, though not quite as conspicuous as that of instrumented segments, adaptation of soft tissue taken place during the preoperative symptomatic time period is conjectured to cause the observed motion deficit. Postoperative physical therapy might be considered if restoration of a normal range of rotational motion is desired.

Vertebral height, disc height, posteroanterior displacement and dens–atlas gap in the cervical spine: precision measurement protocol and normal data

OBJECTIVE (1) Precise measurement of vertebral height, disc height, posteroanterior displacement and dens-atlas gap from lateral radiographic views of the cervical spine. (2) Compilation of a normative database for these parameters, specifying dependence on gender and age. DESIGN Descriptive study, based on measurements from lateral radiographic views of the cervical spine of healthy subjects. BACKGROUND Normal data of vertebral height, disc height, posteroanterior displacement and size of the dens-atlas gap as well as their biological range of variation and potential dependence on gender and age are not available. METHODS Based on computer-aided measurements from lateral radiographic views of the cervical spine, a new protocol determines these parameters. RESULTS are compensated for radiographic magnification, variation in stature and the individually adopted posture of the cervical spine; they are virtually uninfluenced by radiographic distortion and patient alignment errors. A specimen study as well as inter- and intra-observer studies quantify measurement errors.Results. Employing the new protocol, vertebral height C3-C7 and disc height C2/C3-C6/C7 are measured with relative errors of 3.9% and 5.7% respectively. Posteroanterior displacement C1/C2 to C6/C7 is measured with an error of 2.8% of mean vertebral depth and the dens-atlas gap is measured with an error of <1.8% of the depth of C2. A normal database for the dimensions of cervical vertebrae and discs as well as of the sagittal plane alignment of the vertebrae within the cervical spine is compiled from 135 lateral views of healthy adults. CONCLUSIONS Vertebral height, disc height, posteroanterior displacement and size of the dens-atlas gap are measured with high precision. Normal data are presented for the first time. RELEVANCE The new protocol in conjunction with the normal database enables future studies detecting or monitoring morphological effects of, for example, trauma, long-term high mechanical loading, disc degeneration, rheumatoid arthritis, fusion or other surgical interventions.

Comparison of the SF6D, the EQ5D, and the oswestry disability index in patients with chronic low back pain and degenerative disc disease

BackgroundThe need for cost effectiveness analyses in randomized controlled trials that compare treatment options is increasing. The selection of the optimal utility measure is important, and a central question is whether the two most commonly used indexes - the EuroQuol 5D (EQ5D) and the Short Form 6D (SF6D) – can be used interchangeably. The aim of the present study was to compare change scores of the EQ5D and SF6D utility indexes in terms of some important measurement properties. The psychometric properties of the two utility indexes were compared to a disease-specific instrument, the Oswestry Disability Index (ODI), in the setting of a randomized controlled trial for degenerative disc disease.MethodsIn a randomized controlled multicentre trial, 172 patients who had experienced low back pain for an average of 6 years were randomized to either treatment with an intensive back rehabilitation program or surgery to insert disc prostheses. Patients filled out the ODI, EQ5D, and SF-36 at baseline and two-year follow up. The utility indexes was compared with respect to measurement error, structural validity, criterion validity, responsiveness, and interpretability according to the COSMIN taxonomy.ResultsAt follow up, 113 patients had change score values for all three instruments. The SF6D had better similarity with the disease-specific instrument (ODI) regarding sensitivity, specificity, and responsiveness. Measurement error was lower for the SF6D (0.056) compared to the EQ5D (0.155). The minimal important change score value was 0.031 for SF6D and 0.173 for EQ5D. The minimal detectable change score value at a 95% confidence level were 0.157 for SF6D and 0.429 for EQ5D, and the difference in mean change score values (SD) between them was 0.23 (0.29) and so exceeded the clinical significant change score value for both instruments. Analysis of psychometric properties indicated that the indexes are unidimensional when considered separately, but that they do not exactly measure the same underlying construct.ConclusionsThis study indicates that the difference in important measurement properties between EQ5D and SF6D is too large to consider them interchangeable. Since the similarity with the “gold standard” (the disease-specific instrument) was quite different, this could indicate that the choice of index should be determined by the diagnosis.

Assessment of Sagittal plane segmental motion in the lumbar spine : A comparison between distortion-compensated and stereophotogrammetric Roentgen analysis

Study Design. Sagittal plane translatory and rotatory motion was measured in 15 lumbar motion segments of 8 patients by distortion‐compensated and stereophotogrammetric Roentgen analysis. Objective. To compare measurement precision of the new distortion‐compensated Roentgen analysis protocol with that of the established Roentgen stereophotogrammetric technique under realistic clinical conditions. Summary of Background Data. Roentgen stereophotogrammetric analysis constitutes the most precise method available to assess segmental motion. Because of the invasive nature of the procedure, however, there is interest in alternative, noninvasive protocols suitable for studying larger patient cohorts. Methods. In 8 patients, segmental motion of 15 lumbar segments that had undergone previous spinal surgery was assessed from stereo views by using Roentgen stereophotogrammetric analysis. Sagittal plane segmental motion was assessed by distortion‐compensated Roentgen analysis. Sagittal plane translatory and rotatory motion data obtained by both methods were compared. Results. With respect to Roentgen stereophotogrammetric analysis, sagittal plane rotation was determined by distortion‐compensated Roentgen analysis with an error (standard deviation) of 1.4° and a mean difference of less than 0.05°. Sagittal plane translation was determined by distortion‐compensated Roentgen analysis, with an error of 1.25 mm and a mean difference 0.5 mm. Conclusion. Measurement precision of distortion‐compensated Roentgen analysis is slightly inferior to that of Roentgen stereophotogrammetric analysis but substantially higher than that of conventional protocols assessing lumbar segmental motion. If measurement precision is considered adequate and if a noninvasive technique is indicated, distortion‐compensated Roentgen analysis can be used to provide reliable motion data required for epidemiologic and clinical studies.

ISSLS Prize winner: Long-term follow-up suggests spinal fusion is associated with increased adjacent segment disc degeneration but without influence on clinical outcome: results of a combined follow-up from 4 randomized controlled trials.

Study Design. Cross-sectional analysis of long-term follow-up (LTFU) data from 4 randomized controlled trials of operative versus nonoperative treatment for chronic low back pain. Objective. To examine the influence of spinal fusion on adjacent segment disc space height as an indicator of disc degeneration at LTFU. Summary of Background Data. There is ongoing debate as to whether adjacent segment disc degeneration results from the increased mechanical stress of fusion. Methods. Plain standing lateral radiographs were obtained at LTFU (mean, 13 ± 4 yr postrandomization) in 229 of 464 (49%) patients randomized to surgery and 140 of 303 (46%), to nonoperative care. Disc space height and posteroanterior displacement were measured for each lumbar segment using a validated computer-assisted distortion compensated roentgen analysis technique. Values were reported in units of standard deviations above or below age and sex-adjusted normal values. Patient-rated outcomes included the Oswestry Disability Index and pain scales. Results. Radiographs were usable in 355 of 369 (96%) patients (259 fusion and 96 nonoperative treatment). Both treatment groups showed significantly lower values for disc space height of the adjacent segment than norm values. There was a significant difference between treatment groups for the disc space height of the cranial adjacent segment (in both as-treated and intention-to-treat analyses). The mean treatment effect of fusion on adjacent segment disc space height was −0.44 SDs (95% CI, −0.77 to −0.11; P = 0.01; as-treated analysis); there was no group difference for posteroanterior displacement (0.18 SDs, 95% confidence interval, −0.28 to 0.64, P = 0.45). Adjacent level disc space height and posteroanterior displacement were not correlated with Oswestry Disability Index or pain scores at LTFU (r = 0.010–0.05; P > 0.33). Conclusion. Fusion was associated with lower disc space height at the adjacent segment after an average of 13 years of FU. The reduced disc space height had no influence on patient self-rated outcomes (pain or disability). Level of Evidence: 2

Segmental motion adjacent to anterior cervical arthrodesis: a prospective study.

Study Design. Prospective, observational study. Objective. The present study describes in a prospective setting the kinematics changes occurring at segments adjacent to a one-level cervical arthrodesis. Summary of Background Data. The development of adjacent segment disease has been noticed by many clinicians. Whether symptoms develop due to fusion induced accelerated spondylosis or due to a natural development in a predisposed person is currently under debate. The motivation for introducing motion preservation procedures in the neck is primarily to protect the patients from developing symptomatic adjacent disc disease. To accept this rationale, it has to be demonstrated that a fusion creates an unfavorable biomechanical situation at adjacent levels. Methods. Forty-six patients underwent standard anterior cervical decompression and fusion using a cylindrical cage implant. Lateral radiographic views of the cervical spine in flexion and extension were obtained before surgery, and at 12 months of follow-up. Employing Distortion Compensated Roentgen Analysis, rotational and translational motion at adjacent levels was quantified prospectively. Results. Rotational and translational motion at adjacent cranial and caudal levels did not exhibit a significant change between the preoperative state and the state 12 months after the operation. Conclusion. The assumption of an iatrogenically caused increased mobility by a one-level cervical fusion could not be confirmed 12 months after surgery.