Jeremy Fairbank

The Roland-Morris disability questionnaire and the oswestry disability questionnaire

Condition-specific health status measures are commonly used as outcome measures in clinical trials and to assess patient progress in routine clinical practice. The expert panel that met to discuss this special issue of Spine recommended that, when possible, a condition-specific measure for back pain should be chosen from two widely used measures, the Roland–Morris Disability Questionnaire (RDQ) or the Oswestry Disability Index (ODI). These two measures have been used in a wide variety of situations over many years, and each is available in a number of languages. In this article, the authors describe these two instruments and provide evidence of their validity and reliability and some comparative results obtained with the use of the two questionnaires. The instruments themselves are included in the appendixes. When used in the forms reproduced in the appendixes, no permission is required from the authors or from Spine. Other back pain–specific health status measures are described by Kopec elsewhere in this edition of Spine.

Nutrition of the intervertebral disc.

Study Design. A review of the literature on disc nutrition. Objectives. To summarize the information on disc nutrition in relation to disc degeneration. Summary of the Background Data. The disc is avascular, and the disc cells depend on diffusion from blood vessels at the disc’s margins to supply the nutrients essential for cellular activity and viability and to remove metabolic wastes such as lactic acid. The nutrient supply can fail due to changes in blood supply, sclerosis of the subchondral bone or endplate calcification, all of which can block transport from blood supply to the disc or due to changes in cellular demand. Methods. A review of the studies on disc blood supply, solute transport, studies of solute transport in animal and human disc in vitro, and of theoretical modeling studies that have examined factors affecting disc nutrition. Results. Small nutrients such as oxygen and glucose are supplied to the disc’s cells virtually entirely by diffusion; convective transport, arising from load-induced fluid movement in and out of the disc, has virtually no direct influence on transport of these nutrients. Consequently, there are steep concentration gradients of oxygen, glucose, and lactic acid across the disc; oxygen and glucose concentrations are lowest in the center of the nucleus where lactic acid concentrations are greatest. The actual levels of concentration depend on the balance between diffusive transport and cellular demand and can fall to critical levels if the endplate calcifies or nutritional demand increases. Conclusions. Loss of nutrient supply can lead to cell death, loss of matrix production, and increase in matrix degradation and hence to disc degeneration.

Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial

Abstract Objectives To assess the clinical effectiveness of surgical stabilisation (spinal fusion) compared with intensive rehabilitation for patients with chronic low back pain. Design Multicentre randomised controlled trial. Setting 15 secondary care orthopaedic and rehabilitation centres across the United Kingdom. Participants 349 participants aged 18-55 with chronic low back pain of at least one years duration who were considered candidates for spinal fusion. Intervention Lumbar spine fusion or an intensive rehabilitation programme based on principles of cognitive behaviour therapy. Main outcome measure The primary outcomes were the Oswestry disability index and the shuttle walking test measured at baseline and two years after randomisation. The SF-36 instrument was used as a secondary outcome measure. Results 176 participants were assigned to surgery and 173 to rehabilitation. 284 (81%) provided follow-up data at 24 months. The mean Oswestry disability index changed favourably from 46.5 (SD 14.6) to 34.0 (SD 21.1) in the surgery group and from 44.8 (SD14.8) to 36.1 (SD 20.6) in the rehabilitation group. The estimated mean difference between the groups was –4.1 (95% confidence interval –8.1 to –0.1, P = 0.045) in favour of surgery. No significant differences between the treatment groups were observed in the shuttle walking test or any of the other outcome measures. Conclusions Both groups reported reductions in disability during two years of follow-up, possibly unrelated to the interventions. The statistical difference between treatment groups in one of the two primary outcome measures was marginal and only just reached the predefined minimal clinical difference, and the potential risk and additional cost of surgery also need to be considered. No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.

Influence of anthropometric factors and joint laxity in the incidence of adolescent back pain.

Out of 446 pupils aged 13–17 years, 115 were found to have a history of back pain. These pupils tended to have decreased lower limb joint mobility and increased trunk length compared with pupils without back pain. In 77 pupils whose site of back pain was identified, 38 had pain associated with the lumbar spine. These pupils had an increased trunk length while those with thoracolumbar or thoracic pain did not. Back pain was more common in those who avoided sports.

Mechanical factors in the incidence of knee pain in adolescents and young adults

Mechanical abnormalities of the patellofemoral joint are among the many causes that have been suggested for adolescent knee pain. This study seeks to identify these factors. Measurements of joint mobility and lower limb morphology were made on 446 pupils at a comprehensive school, 136 of whom had suffered knee pain in the previous year. The pupils with symptoms enjoyed sporting activities significantly more than their symptom-free contemporaries. Joint mobility, the Q-angle, genu valgum and anteversion of the femoral neck were not significantly different between those pupils with and those without anterior knee pain. Data on lower limb morphology of normal adolescents are presented. Examination of 52 hospital outpatients aged 13 to 36 years with anterior knee pain produced results comparable with those for the pupils. It is concluded that chronic overloading, rather than faulty mechanics, is the dominant factor in the genesis of anterior knee pain in adolescent patients.

The Reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the Assessment of Patients With Lumbar Spinal Stenosis

Study Design. The Shuttle Walking Test (SWT), the Swiss Spinal Stenosis (SSS) Questionnaire, the Oxford Claudication Score (OCS), and the Oswestry Disability Index (ODI) were administered to patients with lumbar spinal stenosis and neurogenic claudication. Objective. To determine reliability of the SWT, the SSS (Q1–12), the OCS, and the ODI in lumbar spinal stenosis assessment. Summary of Background Data. Reliability data for exercise tests in lumbar spinal stenosis are lacking. Methods. To determine reliability, 32 clinic patients with lumbar spinal stenosis were assessed twice, with 1 week between assessments. Retrospective data from 17 patients assessed before surgery and 18 months after surgery for lumbar spinal stenosis were used to investigate the use of reliability in a clinical setting. Results. Test–retest reliability in terms of the intraclass correlation coefficient (ICC) was 0.92 for the SWT, 0.92 for the SSS, 0.83 for the OCS and 0.89 for the ODI. The mean percentage scores were 51 for the SSS, 45 for the OCS, and 40 for the ODI. To achieve 95% certainty of change between assessments for a single patient, the SSS would need to change by 15, the OCS by 20, and the ODI by 16. The mean SWT was 150 m, with a change of 76 m required for 95% confidence. Cronbach’s alpha was 0.91 for the SSS, 0.90 for the OCS, and 0.89 for the ODI. The change in ODI correlated most strongly with patient satisfaction after surgery (&rgr; = 0.80;P < 0.001). Conclusions. Fluctuations in a patient’s symptoms result in wide individual confidence intervals. Performance on the SSS, OCS, and ODI questionnaires are broadly similar, the most precise being the condition-specific SSS. The SWT gives a snapshot of physical function, which is acceptable for group analysis. Use of the SWT for individual assessment after surgery is feasible.

A fitness programme for patients with chronic low back pain: 2-year follow-up of a randomised controlled trial.

&NA; The aim of this study was to assess the long‐term effect of a supervised fitness programme on patients with chronic low back pain. The design of the study was a single blind randomised controlled trial with follow‐up, by postal questionnaire, 2 years after intervention. The Oswestry Low Back Pain Disability Index was used as the outcome measure to assess daily activity affected by back pain. Eighty‐one patients with chronic low back pain, who were referred to the physiotherapy department of a National Health Service orthopaedic hospital, were randomised to either a supervised fitness programme or a control group. Patients in the intervention group and control group were taught specific exercises to be continued at home and referred to a backschool for back care education. In addition, the intervention group attended eight sessions of a supervised fitness programme. Sixty‐two patients (76%) with a mean age of 37 years, returned the Oswestry Low Back Pain Disability Index questionnaire. Of these, 29 were in the intervention group and 31 in the control group. Patients in the intervention group demonstrated a mean reduction of 7.7% in the Oswestry Low Back Pain Disability Index score (95% confidence interval of mean paired difference 3.9, 11.6 P<0.001), compared with only 2.4% in the control group (95% confidence interval of mean paired difference −2.0, 6.9 P>0.05). Between group comparisons demonstrated a statistically significant difference in disability scores between the treatment and control group (mean difference 5.8, 95% confidence interval 0.3, 11.4 P<0.04). This study supports the current trend towards a more active treatment approach to low back pain. We have demonstrated clinical effectiveness of a fitness programme 2 years after treatment but this needs to be replicated in a larger study which should include a cost effectiveness analysis, further analysis of objective functional status and a placebo intervention group.

Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial.

Abstract Objective To determine whether, from a health provider and patient perspective, surgical stabilisation of the spine is cost effective when compared with an intensive programme of rehabilitation in patients with chronic low back pain. Design Economic evaluation alongside a pragmatic randomised controlled trial. Setting Secondary care. Participants 349 patients randomised to surgery (n = 176) or to an intensive rehabilitation programme (n = 173) from 15 centres across the United Kingdom between June 1996 and February 2002. Main outcome measures Costs related to back pain and incurred by the NHS and patients up to 24 months after randomisation. Return to paid employment and total hours worked. Patient utility as estimated by using the EuroQol EQ-5D questionnaire at several time points and used to calculate quality adjusted life years (QALYs). Cost effectiveness was expressed as an incremental cost per QALY. Results At two years, 38 patients randomised to rehabilitation had received rehabilitation and surgery whereas just seven surgery patients had received both treatments. The mean total cost per patient was estimated to be £7830 (SD £5202) in the surgery group and £4526 (SD £4155) in the intensive rehabilitation arm, a significant difference of £3304 (95% confidence interval £2317 to £4291). Mean QALYs over the trial period were 1.004 (SD 0.405) in the surgery group and 0.936 (SD 0.431) in the intensive rehabilitation group, giving a non-significant difference of 0.068 (–0.020 to 0.156). The incremental cost effectiveness ratio was estimated to be £48 588 per QALY gained (–£279 883 to £372 406). Conclusion Two year follow-up data show that surgical stabilisation of the spine may not be a cost effective use of scarce healthcare resources. However, sensitivity analyses show that this could change—for example, if the proportion of rehabilitation patients requiring subsequent surgery continues to increase.

Apophyseal injection of local anesthetic as a diagnostic aid in primary low-back pain syndromes.

Twenty-five out of 41 adult patients suffering from their first attack of acute low-back pain were subjected to local anesthetic injection into the maximally tender lumbar apophyseal joints under controlled conditions. Two clinical syndromes can be identified according to whether the patients responded to the facet injection or not. Various clinical differences were statistically significant and included a wider than normal spinal canal in the responding group. The clinical significance of these two distinct groups is discussed in detail.

The diagnosis and management of infection following instrumented spinal fusion.

A 10-year retrospective audit. (1) The incidence of infection; (2) causative organisms; (3) whether eradication of infection is achievable with spinal implant retention; (4) patient outcome. The reported incidence of infection following posterior spinal instrumentation is between 2.6 and 3.8%. Management of infection is controversial, with some advocating serial wound debridement while others report that infection cannot be eradicated with retention of implants. There are no published data demonstrating that propionibacteria are associated with early postoperative infection. The management of infected cases at our institution includes eventual removal of their implants. Our population was identified by studying the case notes of all patients who had undergone removal of spinal implants and cross-referencing this population with positive microbiology or histology reports. The incidence of infection was 3.7%. Propionibacteria were isolated in 45% of cases. The diagnosis of infection was unexpected in 25% of patients, following removal of implants for prominence of implants or back pain. Sixty per cent of patients with acute postoperative deep wound infection had continuing active infection on subsequent removal of implants, despite long-term antibiotics and wound debridement. Fourty-six per cent of patients had a stable, pain-free spine at the end of their treatment. This is the largest reported series of infections following posterior spinal instrumented fusions of which we are aware. Propionibacteria are a common cause of infection and successful eradication of infection cannot be reliably achieved with antibiotics and wound debridement alone.