Jakob M. Burgstaller

Influence of catastrophizing on treatment outcome in patients with nonspecific low back pain: a systematic review.

Study Design. Systematic review. Objective. The aim of this study was to assess the effect of catastrophizing on treatment efficacy and outcome in patients treated for low back pain. Summary of Background Data. Psychological factors including catastrophizing thoughts are thought to increase the risk for chronic low back pain. The influence of catastrophizing is debated. Methods. In September 2012, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, EMBASE, OTseeker, PeDRO, PsycINFO, MEDLINE, Scopus, and Web of Science. For 50 of 706 references, full text was assessed. Results based on 11 studies were included in this analysis. Results. In the 11 studies, a total of 2269 patients were included. Seven studies were of good and 4 of moderate methodological quality. Heterogeneity in study settings, treatments, outcomes, and patient populations impeded meta-analysis. Catastrophizing at baseline was predictive for disability at follow-up in 4 studies and for pain in 2 studies. Three studies found no predictive effect of catastrophizing. A mediating effect was found in all studies (n = 5) assessing the impact of a decrease in catastrophizing during treatment. A greater decrease was associated with better outcome. Most studies that investigated the moderating effects on treatment efficacy found no effect (n = 5). However, most studies did not look for a direct interaction between the treatment and catastrophizing thoughts. No study investigated the influence of catastrophizing on work-related outcomes including return to work. Conclusion. Catastrophizing predicted degree of pain and disability and mediated treatment efficacy in most studies. The presence of catastrophizing should be considered in patients with persisting back pain. Limited evidence was found for the moderating effects on treatment efficacy. Future research should aim to clarify the role of catastrophizing as a moderator of outcome and investigate its importance for work-related outcomes. Level of Evidence: 1

Clinical outcome in lumbar decompression surgery for spinal canal stenosis in the aged population: a prospective Swiss multicenter cohort study.

Study Design. This is a prospective, multicenter cohort study including 8 medical centers in the metropolitan area of the Canton Zurich, Switzerland. Objectives. To examine whether outcome and quality of life might improve after decompression surgery for degenerative lumbar spinal stenosis (DLSS) even in patients older than 80 years and to compare data with a younger patient population from our own patient collective. Summary and Background Data. Lumbar decompression surgery without fusion has been shown to improve quality of life in lumbar spinal canal stenosis. In the population older than 80 years, treatment recommendations for DLSS show conflicting results. Methods. Eight centers in the metropolitan area of Zurich, Switzerland agreed on the classification of DLSS, surgical principles, and follow-up protocols. Patients were followed from baseline, at 6 months, and 12 months. Baseline characteristics were analyzed with 5 different questionnaires “Spinal Stenosis Measure, Feeling Thermometer, Numeric Rating Scale, 5D-3L, and Roland and Morris Disability Questionnaire.” In addition, our study population was compared with a younger control group. Furthermore, we calculated the minimal clinically important differences. Results. Thirty-seven patients with an average age of 82.5 ± 2.5 years reached the 12-month follow-up. Spinal Stenosis Measure scores, the Feeling Thermometer, the Numeric Rating Scale, and the Roland and Morris Disability Questionnaire showed significant improvements at the 6-month and 12-month follow-ups (P < 0.001). One EQ-5D-3Lsubgroup “anxiety/depression” showed no significant improvement (P = 0.109) at 12-month follow-up. The minimal clinically important difference for the “Symptom Severity scale” in the Spinal Stenosis Measure was achieved with improvement of 70% in the older patient population. Conclusion. Patients 80 years or older can expect a clinically meaningful improvement after lumbar decompression for symptomatic DLSS. Our patient population showed significant positive development in quality of life in the short- and long-term follow-ups. Level of Evidence: 3

Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis.

Background Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment. Objectives To summarize treatment efficacy for patients presenting with NCCP. Methods Systematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs) evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group). Results Thirty eligible RCT’s were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10). Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients) was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%)]. The pooled OR in GERD negative patients (4 RCTs, 156 patients) was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%). In musculoskeletal NCCP (2 RCTs, 229 patients) manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI −0.3 to 1.3, heterogeneity I2 = 46.2%)]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions. Limitations Only a small number of studies were available. Conclusions Timely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available for most prevalent diseases manifesting with chest pain. In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered.

The Impact of Obesity on the Outcome of Decompression Surgery in Degenerative Lumbar Spinal Canal Stenosis: Analysis of the Lumbar Spinal Outcome Study (LSOS): A Swiss Prospective Multicenter Cohort Study.

Study Design. Prospective, multicenter cohort study including 8 medical centers of the Cantons Zurich, Lucerne, and Thurgau, Switzerland. Objective. The aim of the study was to assess whether obese patients benefit after decompression surgery for degenerative lumbar spinal stenosis (DLSS). Summary and Background Data. Lumbar decompression surgery has been shown to improve quality of life in patients with DLSS. In the existing literature, the efficacy of lumbar decompression in the obese population remains controversial. Methods. Baseline patient characteristics and outcomes were analyzed at 6 and 12 months follow-up with the Spinal Stenosis Measure (SSM), the Numeric Rating Scale (NRS), Feeling Thermometer (FT), the EQ-5D-EL, and the Roland and Morris Disability Questionnaire (RMDQ). Body mass index (BMI) was classified into 3 categories according to the WHO. Minimal clinically important differences (MCIDs) in SSM for different BMI categories were considered as main outcome. Results. Of the 656 patients in the Lumbar Spinal Outcome Study database as of end of October 2014, 166 patients met the inclusion criteria. Fifty (30.1%) had a BMI less than 25 (underweight and normal weight group), 72 (43.4%) had a BMI between 25 and less than 30 (preobesity group), and 44 (26.5%) patients had a BMI at least 30 (obese group). We found for the main outcome that in obese patients 36% reached MCID at 6 months, and 48% at 12 months. The estimated odds ratios for MCID in the obese group were 0.78 (0.34–1.82) at 6 months and 0.99 (0.44–2.23) at 12 months in a logistic regression model adjusting for levels of laminectomy. In the additional outcomes, SSM, NRS, FT, and RMDQ showed statistically significant mean improvements in the 6 and 12 months follow-up. Conclusion. Obese patients can expect clinical improvement after lumbar decompression for DLSS, but the percentage of patients with a meaningful improvement is lower than in the group of patients with underweight, normal weight, and preobese weight at 6 and 12 months.

Is There an Association Between Pain and Magnetic Resonance Imaging Parameters in Patients With Lumbar Spinal Stenosis

Study Design. A prospective multicenter cohort study. Objective. The aim of this study was to identify an association between pain and magnetic resonance imaging (MRI) parameters in patients with lumbar spinal stenosis (LSS). Summary of Background Data. At present, the relationship between abnormal MRI findings and pain in patients with LSS is still unclear. Methods. First, we conducted a systematic literature search. We identified relationships of relevant MRI parameters and pain in patients with LSS. Second, we addressed the study question with a thorough descriptive and graphical analysis to establish a relationship between MRI parameters and pain using data of the LSS outcome study (LSOS). Results. In the systematic review including four papers about the associations between radiological findings in the MRI and pain, the authors of two articles reported no association and two of them did. Of the latters, only one study found a moderate correlation between leg pain measured by Visual Analog Scale (VAS) and the degree of stenosis assessed by spine surgeons. In the data of the LSOS study, we could not identify a relevant association between any of the MRI parameters and buttock, leg, and back pain, quantified by the Spinal Stenosis Measure (SSM) and the Numeric Rating Scale (NRS). Even by restricting the analysis to the level of the lumbar spine with the most prominent radiological “stenosis,” no relevant association could be shown. Conclusion. Despite a thorough analysis of the data, we were not able to prove any correlation between radiological findings (MRI) and the severity of pain. There is a need for innovative “methods/techniques” to learn more about the causal relationship between radiological findings and the patients’ pain-related complaints. Level of Evidence: 2

Arguments for the choice of surgical treatments in patients with lumbar spinal stenosis – a systematic appraisal of randomized controlled trials

BackgroundLumbar spinal stenosis is the most common reason for spinal surgery in elderly patients. However, the surgical management of spinal stenosis is controversial. The aim of this review was to list aspects a surgeon considers when choosing a specific type of treatment.MethodsAppraisal of arguments reported in randomized controlled trials (RCTs) included in systematic reviews published or indexed in the Cochrane library studying surgical treatments in patients with spinal stenosis.ResultsEight out of nine RCTs listed arguments for the choice of their treatments under investigation. The argument for decompression alone was the high success rate, the argument against was a potential increase in vertebral instability. The argument for decompression and fusion without instrumentation was that it is a well-established technique with a high fusion success rate, the argument against it was that the indication for fusion in spinal stenosis has remained unclear. The argument for decompression and fusion with instrumentation was an increased fusion rate compared to decompression and fusion without instrumentation, the argument against this was that the invasive procedure is associated with more complications.ConclusionsThe main argument identified in this appraisal for and against decompression alone in patient with lumbar spinal stenosis was whether or not instability should be treated with (instrumented) fusion procedures. However, there is disagreement on how instability should be defined. In a first step it is important that researchers and clinicians agree on definitions for important key concepts such as instability and reoperations.

Decompression Surgery Alone Versus Decompression Plus Fusion in Symptomatic Lumbar Spinal Stenosis: A Swiss Prospective Multicenter Cohort Study With 3 Years of Follow-up

Study Design. Retrospective analysis of a prospective, multicenter cohort study. Objective. To estimate the added effect of surgical fusion as compared to decompression surgery alone in symptomatic lumbar spinal stenosis patients with spondylolisthesis. Summary of Background Data. The optimal surgical management of lumbar spinal stenosis patients with spondylolisthesis remains controversial. Methods. Patients of the Lumbar Stenosis Outcome Study with confirmed DLSS and spondylolisthesis were enrolled in this study. The outcomes of this study were Spinal Stenosis Measure (SSM) symptoms (score range 1–5, best-worst) and function (1–4) over time, measured at baseline, 6, 12, 24, and 36 months follow-up. In order to quantify the effect of fusion surgery as compared to decompression alone and number of decompressed levels, we used mixed effects models and accounted for the repeated observations in main outcomes (SSM symptoms and SSM function) over time. In addition to individual patients’ random effects, we also fitted random slopes for follow-up time points and compared these two approaches with Akaikes Information Criterion and the chi-square test. Confounders were adjusted with fixed effects for age, sex, body mass index, diabetes, Cumulative Illness Rating Scale musculoskeletal disorders, and duration of symptoms. Results. One hundred thirty-one patients undergoing decompression surgery alone (n = 85) or decompression with fusion surgery (n = 46) were included in this study. In the multiple mixed effects model the adjusted effect of fusion compared with decompression alone surgery on SSM symptoms was 0.06 (95% confidence interval: −0.16–0.27) and −0.07 (95% confidence interval: −0.25–0.10) on SSM function, respectively. Conclusion. Among the patients with degenerative lumbar spinal stenosis and spondylolisthesis our study confirms that in the two groups, decompression alone and decompression with fusion, patients distinctively benefited from surgical treatment. When adjusted for confounders, fusion surgery was not associated with a more favorable outcome in both SSM scores as compared to decompression alone surgery. Level of Evidence: 3

Changes over time in prescription practices of pain medications in Switzerland between 2006 and 2013: an analysis of insurance claims

BackgroundIn Europe, scant information is available about prescription practices for pain medications. The aim of this research was to assess changes in prescription rates of non-opioid, weak opioid, and strong opioid medications between 2006 and 2013 in the Swiss population.MethodsUsing insurance claims data covering one-sixth of the Swiss population, we analyzed the numbers of reimbursed pain medications, the number of reimbursements per persons, and the cumulative dose in milligrams. For opioids, the morphine equivalent dose and treatment days were calculated. Data were extrapolated to the dose per day per 100’000 population stratified by age, gender, and canton.ResultsIn total, 4’746’942 paracetamol, 2’156’620 NSAIDs or Coxibs, 931’129 metamizole, 1’322’272 weak opioid, and 807’835 strong opioid claims were analyzed. Between 2006 and 2013, the increase in claims per 100’000 persons was 32% for paracetamol, 242% for metamizole, 107% for NSAIDS, 86% for Coxibs, 13% for weak opioids, and 121% for strong opioids. For strong opioids the total MED in mg /100’000 increased by 117%, the treatment days /100’000 by 101%. For strong opioids, fentanyl was most frequently used (increase between 2006 and 2013 by 91% for MED/100’000 persons and 94% treatment days / 100’000) followed by buprenorphine and oxycodone. The highest proportional increase in MED / 100’000 was observed for methadone (+1414%) and oxycodone (+313%). Marked geographical variation was detected in the use of metamizole, paracetamole, and strong opioids in different cantons.ConclusionThe analysis of insurance claims data provides evidence that the prescription rates for pain medications increased in Switzerland within the last ten years, in particular for metamizole and strong opioids. Furthermore, the prescription rates for metamizole, paracetamol, and strong opioids varied substantially between different cantons in Switzerland.

Efficacy of compression stockings in preventing post-thrombotic syndrome in patients with deep venous thrombosis: a systematic review and metaanalysis

BACKGROUND Here, we update an earlier systematic review on the preventive efficacy of active compression stockings in patients with diagnosed proximal deep venous thrombosis (DVT) by including the results of recently published trials. The aims are to synthesize the results of the original studies, and to identify details to explain heterogeneous results. METHODS We searched the Cochrane Library, PubMed, Scopus, and Medline for original studies that compared the preventive efficacy of active compression stockings with placebo or no compression stockings in patients with diagnosed proximal DVT. Only randomized controlled trials (RCTs) were included. RESULTS Five eligible RCTs with a total of 1393 patients (sample sizes ranged from 47 to 803 patients) were included. In three RCTs, patients started to wear compression stockings, placebo stockings or no stockings within the first three weeks after the diagnosis of DVT. The results of two RCTs indicate a statistically significant reduction in post-thrombotic syndrome (PTS) of 50% or more after two or more years. The result of one RCT shows no preventive effect of compression stockings at all. Due to the heterogeneity of the study results, we refrained from pooling the results of the RCTs. In a further RCT, randomization to groups with and without compression stockings took place six months after the diagnosis of DVT, and in another RCT, only patients with the absence of PTS one year after the diagnosis of DVT were analyzed. One RCT revealed a significant reduction in symptoms, whereas another RCT failed to show any benefit of using compression stockings. CONCLUSIONS At this time, it does not seem to be justifiable to entirely abandon the recommendations regarding compression stockings to prevent PTS in patients with DVT. There is evidence favoring compression stockings, but there is also evidence showing no benefit of compression stockings.

The Influence of Pre- and Postoperative Fear Avoidance Beliefs on Postoperative Pain and Disability in Patients with Lumbar Spinal Stenosis: Analysis of the Lumbar Spinal Outcome Study (LSOS) Data.

Study Design. Prospective multicenter cohort study. Objective. To evaluate the effect of pre- and postoperatively assessed fear avoidance beliefs (FAB) on pain and disability in patients with degenerative lumbar spinal stenosis (LSS) after decompression surgery. Summary of Background Data. To the present, the influence of pre- and postoperative FAB on the prognosis after surgery for LLS is still unclear. Methods. Patients of the Swiss Lumbar Stenosis Outcome Study (LSOS) with confirmed LSS undergoing first-time decompression without fusion were enrolled in this study. The main outcome of this study was minimal clinically important difference (MCID) in spinal stenosis measure symptoms (pain) and function (disability) after 12 months. To analyze the influence of pre- and postoperatively assessed FAB on pain and disability we built simple and multiple logistic regression models. Results. In this analysis of 234 patients undergoing decompression surgery for symptomatic degenerative LSS we found baseline FAB measured by the FAB physical activity subscale (FABQ-P) not to be associated with pain (OR 0.95; 95% CI: 0.55–1.67) and disability (OR 1.11; 95% CI: 0.64–1.92) at 12 months’ follow-up. In the final multiple logistic regression models patients with high FABQ-P at 6 months (OR 0.46; 95% CI: 0.24–0.91) and high persistent FABQ-P at baseline and 6 months (OR 0.34, 95% CI: 0.16–0.73) were less likely to report a MCID for spinal stenosis measure symptoms at 12 months. Our analysis found a similar trend for disability; however, the results were not statistically significant. Conclusion. In elderly patients undergoing decompression surgery for symptomatic degenerative LSS preoperative fear avoidance beliefs were not a prognostic indicator for the outcome. Patients with FAB at 6 months and persistent FAB were less likely to experience clinically relevant improvement in pain at 12 months. Studies should address the importance of persistent postoperative FAB. Level of Evidence: 3