Reuven Gepstein

The Catz-Itzkovich SCIM: a revised version of the Spinal Cord Independence Measure

PURPOSE To examine the suitability of the revised Spinal Cord Independence Measure, the Catz-ltzkovich SCIM, for evaluation of patients with spinal cord lesions, as compared to the original SCIM and to the Functional Independence Measure (FIM). METHOD The revised SCIM was applied by paired independent teams of occupational therapists, physiotherapists and nurses and the FIM by a single nurse. The examiners assigned scores to the functional capabilities of 28 patients with spinal cord lesions. The scores by the revised SCIM were analysed for reproducibility as between the two teams of examiners (interrater reliability) and for their correlation with the FIM scores. RESULTS The frequency of identical scoring by two independent examiners (total agreement) was 80% or higher for 13/18 individual functions listed in the revised SCIM. In the self-care category it was 80-99%, as compared to 75-87% before revision. In neither bowel management nor bed mobility was there an increase over the original SCIM in the frequency of identical scores, despite rephrasing and restructuring of the scoring criteria. A high correlation was noted between the paired scores for all functions listed as well as for those comprising each of the four functional categories (r = 0.90-0.96, p <0.001). The total revised-SCIM scores were significantly correlated with those derived by the FIM (r = 0.835, p < 0.001). CONCLUSIONS The findings indicate that the newly revised SCIM (Catz-Itzkovich) is a valid and highly reproducible measure of daily function in patients with spinal cord lesions, and is superior to the original SCIM. We recommend that it supersede the original SCIM.Purpose : To examine the suitability of the revised Spinal Cord Independence Measure, the Catz-Itzkovich SCIM, for evaluation of patients with spinal cord lesions, as compared to the original SCIM and to the Functional Independence Measure (FIM). Method : The revised SCIM was applied by paired independent teams of occupational therapists, physiotherapists and nurses and the FIM by a single nurse. The examiners assigned scores to the functional capabilities of 28 patients with spinal cord lesions. The scores by the revised SCIM were analysed for reproducibility as between the two teams of examiners (interrater reliability) and for their correlation with the FIM scores. Results : The frequency of identical scoring by two independent examiners (total agreement) was 80% or higher for 13/18 individual functions listed in the revised SCIM. In the self-care category it was 80-99%, as compared to 75-87% before revision. In neither bowel management nor bed mobility was there an increase over the original SCIM in the frequency of identical scores, despite rephrasing and restructuring of the scoring criteria. A high correlation was noted between the paired scores for all functions listed as well as for those comprising each of the four functional categories ( r = 0.90-0.96, p < 0.001). The total revised-SCIM scores were significantly correlated with those derived by the FIM ( r = 0.835, p < 0.001). Conclusions : The findings indicate that the newly revised SCIM (Catz-Itzkovich) is a valid and highly reproducible measure of daily function in patients with spinal cord lesions, and is superior to the original SCIM. We recommend that it supersede the original SCIM.

Does obesity affect the results of lumbar decompressive spinal surgery in the elderly

The prevalence of obesity among the population is increasing, including in many elderly people. The purpose of this study was to evaluate whether lumbar spinal surgery in elderly patients with different body mass indices influences pain, satisfaction rate, and activities of daily living. Two hundred ninety-eight elderly patients (older than 65 years), 153 women and 145 men, who had decompressive laminectomy, discectomy, or combinations of these procedures during 1990 to 2000 were followed up. Indications for surgery included limitation in doing activities of daily living, severe pain, or both. The patients were classified into one of four categories in terms of their body mass index. The operative parameters, pain reduction, satisfaction rate, and activities of daily living using the Barthel index were assessed. The more obese patients were younger, tended to be female, and were more symptomatic. All four groups of patients had reduction in pain, improvement in activities of daily living, and were satisfied with the operation. Our data suggest that it is reasonable to operate on patients who are elderly and obese and who have lumbar symptoms, with the appropriate indications.

Outcomes of decompression surgery for lumbar spinal stenosis in elderly diabetic patients

The purpose of this study was to assess and compare the outcome of surgical decompression for spinal stenosis in diabetic and non-diabetic elderly patients. This is a retrospective chart analysis conducted in a university affiliated referral hospital. The participants were consecutive patients, age 65 and older, undergoing laminectomy for spinal stenosis during 1990–2000. We assessed patients’ clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients’ satisfaction, the need for repeated surgery, and overall mortality. A total number of 62 elderly diabetic group (DG) patients undergoing decompression surgery for spinal stenosis were compared with a sex and age-matched non-diabetic control group (CG) at baseline, and a mean of 40.3 months thereafter. We found that the DG patients had more pain (p=0.042), and suffered more frequently from neurogenic claudication (p=0.0018), motor weakness (p=0.021) and numbness of the affected limb (p=0.0069) than the CG patients. Nocturnal pain was reported in 24% of the DG patients. Pain relief was successfully achieved in both groups (p<0.001), but the patients’ satisfaction was greater in the non-diabetic patients (p=0.0067). Revision surgery was more frequently performed in the DG than the CG (non-significant difference), and the time interval for such a second intervention was shorter (p=0.04) in the DG. A higher rate of post-operative complications was observed in the DG (p<0.0001). It is concluded that surgical treatment of elderly diabetic patients suffering from spinal stenosis improves BADL and ameliorates pain, but the results remain worse than those observed in non-diabetics. The outcome of diabetic patients depends upon the presence of other comorbidities, concurrent diabetic neuropathy, duration of diabetes and insulin treatment. Successful postoperative pain reduction remained the strongest factor associated with patients’ satisfaction.

Effectiveness of the Charleston bending brace in the treatment of single-curve idiopathic scoliosis.

The purpose of this study was to determine the effectiveness of the Charleston bending brace when compared with the thoracolumbosacral orthosis (TLSO or Boston) brace in the treatment of single-curve adolescent-type idiopathic scoliosis. The Charleston and TLSO braces were applied for approximately 8 nighttime hours and 18 to 22 hours per day, respectively. Treatment success was defined as improvement of curve deterioration with <5° progression from the start of brace therapy until the conclusion of treatment, as well as the absence for the need to perform corrective surgery. The success rates were determined by Risser stage, initial angle, type of curvature, and sex of the patient. In addition, the success rate of the Charleston brace was assessed by analyzing the degree of initial correction. One hundred twenty-two patients (94 girls, 28 boys) were studied. Eighty-five patients were treated with the Charleston brace and 37 with the TLSO brace. Mean Cobb angle of curvature before bracing was 30.4°. The curvature was lumbar in 60 patients, thoracic in 56, and thoracolumbar in 6. The average follow-up time was 23 months, with a minimum follow-up of 1 year. Surgery was performed in 11.8% and 13.5% of patients in the Charleston and TLSO groups, respectively. In this patient population, no significant difference in success rate was found between the groups.

Long-term outcome of decompressive surgery for Lumbar spinal stenosis in octogenarians

The purpose of our prospective study is to evaluate the surgical outcome among patients aged 80 years and above, who underwent surgery for lumbar spinal stenosis. We assessed patients’ clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients’ satisfaction, the need for repeated surgery, and overall mortality. Thirty-nine patients more than 80 years of age were operated in our institution in the last decade. Twenty-five of them were followed-up with a mean 36.8 months after the operation. The Barthel index was used to evaluate pre and postsurgery ADL, and the visual analogue scale (VAS) was used to evaluate pain. The satisfaction rate of the patients before and after the operation and the complication rate were also evaluated. A significant reduction in VAS (P < 0.001) and a significant increase in the Barthel index (P < 0.001) were recorded. Seventy-six percent of the patients were very satisfied or somewhat satisfied with the operative results. Fifty-two percent of the patients had complications (0.9 complications per patients), however, about half of them were minor. No operative or perioperative mortality was noticed and the overall hospital stay for these elderly patients was 3.6 days on average. Surgery in very old elderly patients is safe and effective in the treatment of spinal stenosis, who did not respond well to the conservative treatment. The surgery did not increase the associated morbidity and mortality and most of the patients benefited from the surgery in terms of reduction in pain, increase in ADL and walking ability and overall increase in the satisfaction rate.

Observations on the safety and efficacy of surgical decompression for lumbar spinal stenosis in geriatric patients

Abstract. This retrospective study examines the results of surgical decompression of the lumbar spinal canal in 122 geriatric patients (age range 75–89 years) treated under general anesthesia by the same surgeon between the years 1990 and 1999. Patient demographics, perioperative complications, pain profiles before surgery and at the time of data collection (December 2000), as well as overall mortality were recorded. One hundred and twenty-two patients were studied. The average age at the time of surgery was 78.8 years (range 75–89 years). No perioperative deaths were recorded. The mean time elapsed from surgery until patient follow-up was 45.7 months (range 12–119 months). Fourteen patients had died at the time of patient follow-up (December 2000). When compared to pain experienced before surgery, at the time of the interview a significant (P<0.0001) improvement in low-back and radicular pain as well as in the ability to perform daily activities (dressing, washing, getting out of bed and walking) was described. We conclude that, for geriatric patients rated as physical status I-II (>75 years) under the American Society of Anesthesiologists (ASA) classification, surgical release of lumbar spinal stenosis is a safe and effective treatment option. However, the suitability of ASA III patients requires further investigation.

Posterior lumbar interbody fusion for degenerative disc disease using a minimally invasive B-twin expandable spinal spacer: a multicenter study.

Acquired degenerative disc disease causes gradual disc space collapse, concurrent discogenic or facet-induced pain, and possible compression radiculopathy. Surgical treatment aims to re-expand the intervertebral space and stabilize the involved segment in balanced alignment until fusion is complete. The prevailing methods make use of a twin cage device of predetermined size. Their implantation requires extensive exposure, entailing the sacrifice of posterior stabilizing structures. The procedure also results in significant traction on the dural sac and the cauda equina and is thereby a potential source of neurologic damage. The new expandable spinal spacer (ESS) was designed to mitigate all the shortcomings alluded to above. A prospective multicenter clinical study was conducted of 87 patients with chronic low back pain due to degenerative disc disease, treated by posterior lumbar interbody fusion (PLIF) using a newly designed ESS. The study protocol was approved by the ethics committees of all the participating institutions. The objective was to test the safety and efficacy of the device. Each participant was followed periodically for >1 postoperative year. The ongoing record included intraoperative difficulties and complications, if any, radiologic evidence of fusion and clinical outcome as scored by pre- and postoperative questionnaires pertaining to pain intensity and degree of disability. No dural lacerations or neurologic deficit occurred. There were no mechanical failures of the spacer. Radiologic study demonstrated fusion in all but one patient. Disc space height that averaged 7.53 ± 2.42 mm before surgery increased to 10.03 ± 2.00 mm at the time of surgery and stabilized at 9.47 ± 2.10 mm upon final follow-up. Visual Analog Scale and Oswestry Index decreased by 60% and 58%, respectively. PLIF using the ESS achieves the same ultimate outcome as do other methods currently in use but does not share the handicaps and hazards and is more user-friendly to the surgeon.

The effect of insoles on the incidence and severity of low back pain among workers whose job involves long-distance walking

The prevalence and incidence of low back pain in general society is high. Workers whose job involves walking long distances have an even higher tendency to suffer from low back pain. A positive effect of insoles in reducing low back pain was found in professional sports players. This was not examined on people whose job involves walking long distances. In this double blind prospective study we examined the effectiveness of insoles constructed in a computerized method to placebo insoles in 58 employees whose work entailed extensive walking and who suffered from low back pain. The evaluation was performed by the MILLION questionnaire, which is considered as a valid questionnaire for evaluation of low back pain. We calculated the differences of the pain intensity before and after the intervention, in the employees using the insoles manufactured by computer in comparison to the users of the placebo insoles. In each group, the analysis was performed in comparison to the baseline. A total of 81% of the employees preferred the real insoles as effective and comfortable in comparison to 19% of the users of the placebo insoles (P<0.05). The results of this study indicate a substantial improvement in the low back pain after the use of the true insoles. The average pain intensity according to the MILLION questionnaire before the use of the insoles was 5.46. However, after the use of the real insoles and the placebo insoles, the average pain intensity decreased to 3.96 and 5.11, respectively. The difference of the average pain intensity at the start of the study and after the use of the real insoles was significant: −1.49 (P=0.0001), whereas this difference after the use of the placebo insoles was not significant: −0.31 (P=0.1189). The reported severity of pain also decreased significantly: a level 5 pain and above was reported by 77% of the subjects at the start of the study. After the use of the real insoles only 37.9% of the subjects reported a similar degree of pain severity, and 50% of the subjects did so after the use of the placebo insoles (P< 0.05). We did not find a link between low back pain and other variables such as gender, age, number of offspring, work seniority, smoking, previous use of insoles and previous medication. This study demonstrates that the low back pain decreased significantly after the use of real insoles compared to placebo ones.

Reliability of the Catz-Itzkovich Spinal Cord Independence Measure assessment by interview and comparison with observation

Itzkovich M, Tamir A, Philo O, Steinberg F, Ronen J, Spasser R, Gepstein R, Ring H, Catz A: Reliability of the Catz-Itzkovich spinal cord independence measure assessment by interview and comparison with observation. Am J Phys Med Rehabil 2003;82:267–272. Objective To examine the reliability of assessment with the Catz-Itzkovich Spinal Cord Independence Measure II (SCIM II) by interview and compare the findings with assessment by observation. Design In a cohort, comparative study, 28 inpatients with spinal cord lesions were assessed by two nurses using the Catz-Itzkovich SCIM II (interview) and by a multidisciplinary team (observation). Results Total agreement between interviewers ranged from 50% to 80% (Kappa coefficients 0.40–0.60). Pearson’s coefficients of the correlation between scores obtained for the various SCIM subscales by interview or observation were 0.765–0.940 (P < 0.0001). The differences in mean scores obtained between the interview and observation methods were small and not statistically significant for most of the subscales. Conclusions The results support the reliability of the Catz-Itzkovich SCIM assessment by interview and show it to be comparable with assessment by observation. The SCIM II interview may serve as an accurate measure of daily function in patients with spinal cord injury. However, with the sample of the study being relatively small, a larger scale examination is needed to generalize the results.

Functional recovery after operative treatment of femoral neck fractures in an institutionalized elderly population

Agreement that hip fracture is best treated surgically stems from the fact that early mobilization of the patient reduces morbidity and mortality. This concept was tested in 54 elderly, institutionalized patients with femoral neck fractures who were operatively treated. The patients were reviewed within 12 months after being injured. Their average age was 81.2 years, and 94% of the patients were women. Seventy-five percent of the study population had neurological disease or heart disease and were thus limited in their motivation or ability to participate in a rehabilitation program. Only 16.7% of the patients regained their overall functional ability and only 12.9% returned to their pre-injury, ambulatory status. The therapeutic concept should be reviewed and the conservative approach be given serious consideration.