Roland Willburger

The relationship between activity and pain in patients 6 months after lumbar disc surgery: Do pain-related coping modes act as moderator variables?

Background In LBP patients, the relationship between pain and physical activity remains unclear. Whereas a negative relationship between pain and self‐reported physical activity was found, this relation disappeared in the case of overt behavioral data (e.g., accelerometer). Cognitive‐behavioral models of the development of chronic pain suggest subgroups with signs of physical underuse and overuse.

Pain-related avoidance versus endurance in primary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up.

Summary Data are presented on the concurrent and prospective validity of 4 psychosocial subgroups in subacute low back pain patients, as suggested by the avoidance‐endurance model. ABSTRACT Recent research has found individual differences in back pain patients due to behavioral avoidance vs persistence. However, there is a lack of prospective studies of nonspecific low back pain patients. The avoidance‐endurance model (AEM) suggests at least 3 pathways leading to chronic pain: fear‐avoidance response, distress‐endurance response, and eustress‐endurance response. We sought to compare these 3 maladaptive subgroups with an adaptive group using a classification tool that included the following scales: the thought suppression and behavioral endurance subscale of the Avoidance‐Endurance Questionnaire and the Beck Depression Inventory. The psychological characteristics, and pain and disability of the AEM subgroups were investigated. We report results from 177 patients with subacute nonspecific low back pain at the start of outpatient treatment and at follow‐up after 6 months. At baseline, a multivariate analysis of variance found that the fear‐avoidance patients scored higher in pain catastrophizing than the other groups. The distress‐endurance patients displayed elevated anxiety/depression and helplessness/hopelessness accompanied with the highest scores in the classification variables thought suppression and persistence behavior. The eustress‐endurance patients had the highest humor/distraction scores, pain persistence, and positive mood despite pain. All 3 maladaptive groups revealed a higher pain intensity than the adaptive patients at follow‐up after 6 months; however, disability at follow‐up was elevated only in the fear‐avoidance and distress‐endurance patients. The study provides preliminary evidence for the construct and prospective validity of AEM‐based subgroups of subacute, nonspecific back pain patients. The results suggest the need for individually targeted cognitive behavioral treatments in the maladaptive groups.

Prostaglandin release from lumbar disc and facet joint tissue.

Objectives The authors measured prostaglandin (PG) and leukotriene (LT) release from human disc and lumbar facet joint tissues. Summary of Background Data High levels of phospholipase A2 (PLA2) have been measured in the human disc. PLA2 releases fatty acids from lipid membranes. These can be converted to PG and LT, which are potent inflammatory mediators and supposed to be involved in lumbar diseases. Methods The tissues were obtained during surgery and incubated in Tyrodes solution. PG and LT release was measured radioimmunologically from the supernatant. Results Disc (4 ng/g wet weight), cartilage (21 ng/g wet weight), and bone (14 ng/g wet weight) released PGs but no LTs. Conclusion Because PG release from sequestrated disc is rather low, the inflammatory effect might be more because of immunologic reactions.

Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis – a matched-pair analysis of 100 patients

Abstract Conservative or operative treatment for rotator cuff calcifying tendinitis was investigated in 100 patients in a matched-pair analysis. They were examined clinically and ultrasonographically 35–60 months after the initial visit. The mean Patte score was 91.8 for the patients who underwent surgical treatment and 81 for the ones who received conservative therapy (p < 0.004), while the age-related Constant-score was 103.4 and 95, respectively. Ultrasonography showed 28% calcifications in the surgical group, 18% newly formed and 10% that did not resolve after surgery. In the conservatively treated group, 33% calcifications were seen, of which 67% resolved. The number of rotator cuff ruptures was significantly higher in the conservative group. In the surgical group, 2% of partial tears and in the conservative group 5% of partial and 4% of complete cuff ruptures were found. Conservative treatment for calcifying tendinitis leads to less favourable pain results in the long term than surgical treatment. Surgery shortens the painful period and may reduce the number of future rotator cuff ruptures. Finally, the subjective functional outcome is significantly better after surgery.

Local anaesthetic injection with and without corticosteroids for subacromial impingement syndrome

Abstract Fifty patients with impingement syndrome refractory to long-term conservative treatment were randomized to three treatment groups. All patients received an injection of 10 ml 0.5% bupivacaine, in group 1 without corticosteroid, in group 2 with crystalline corticosteroid and in group 3 with lipoid corticosteroid. Treatment in group 1 had to be stopped because of inefficacy. In groups 2 and 3 favorable results were achieved in 19 out of 40 patients.Résumé 50 patients avec conflit sous-aeromial, qui ne montraient pas d’amélioration après un long trâitement conservatif récevaient une injection dans la bourse subacromiale. Le premier groupe récevait une injection contenant un anaesthétique local pur, groupe 2 une mixture d’anaesthétique avec des corticostéroides cristalins et groupe 3 avec des corticostéroides lipoides. Le trâitement du groupe 1 devait être arrété cause d’inificacité. 19 de 40 patients du groupe 2 et 3 montraient une amélioration après 6 mois.

Efficacy of epidural perineural injections with autologous conditioned serum for lumbar radicular compression : An investigator-initiated, prospective, double-blind, reference-controlled study

Study Design. Prospective, double-blind, reference-controlled, investigator-initiated, single center. Objective. To evaluate the efficacy of Autologous Conditioned Serum (ACS; Orthokine) for the treatment of lumbar radicular compression in comparison to triamcinolone. Summary of Background Data. Evidence from animal studies indicates that cytokines such as interleukin-1 play a decisive role in the pathophysiology of lumbar radiculopathy. ACS is enriched in the interleukin-1 receptor antagonist and other anti-inflammatory cytokines. Methods. Thirty-two patients were treated by epidural perineural injections with ACS; 27 patients were treated with 5 mg triamcinolone and 25 patients with 10 mg triamcinolone. Treatment was applied once per week for 3 consecutive weeks and followed for 6 months. The Visual Analogue Scale (VAS) of low back pain was the primary outcome measure. The Oswestry Disability Index (ODI) was the secondary endpoint of the study. All statistical analyses were performed in an exploratory manner using SAS for Windows, version 8.2, on a personal computer. Descriptive statistics were calculated for the VAS and ODI by treatment group and time point. The data were submitted to a repeated-measurements analysis of variance with effects on treatment group, time, and treatment group-by-time interaction. Results. Patients with lumbar back pain who were treated with ACS or the 2 triamcinolone concentrations showed a clinically remarkable and statistically significant reduction in pain and disability, as measured by patient administered outcome measurements. From Week 12 to the final evaluation at Week 22, injections with ACS showed a consistent pattern of superiority over both triamcinolone groups with regard to the VAS score for pain, but statistical significance was observed only at Week 22 in direct comparison to the triamcinolone 5 group. However, there was no statistically significant difference between the 2 triamcinolone dosages during the 6 months of the study. Conclusion. ACS is an encouraging treatment option for patients with unilateral lumbar radicular compression. The decrease in pain was pronounced, clinically remarkable, and potentially superior to steroid injection.

Ten-year follow-up of silicone arthroplasty of the metacarpophalangeal joints in rheumatoid hands.

In resection arthroplasty of destroyed metacarpophalangeal joints stabilisation with a silicone spacer is regarded as the gold standard. In 28 patients with rheumatoid arthritis (34 hands) 102 arthroplasties of the metacarpophalangeal joint were assessed a median of 10 years postoperatively (range 8.7-12.5). All patients reported pronounced subjective relief of pain, and in three quarters function of the hand had improved. The median active range of movement decreased from 40 degrees (range 10 degrees-90 degrees) preoperatively to 35 degrees (range 5 degrees-85 degrees) postoperatively. Ulnar deviation was corrected from a median of 35 degrees (range 0 degrees-60 degrees) preoperatively to 10 degrees (range 0 degrees-40 degrees) postoperatively. The extension deficit was improved from a median of 35 degrees (range 10 degrees-80 degrees) before surgery to a median of 10 degrees (range 0 degrees-30 degrees) at follow up. Grip strength remained unchanged. Radiological examination showed surrounding osteolysis in 89% of the implants and 28% had broken. The well-known discrepancy between fair clinical and good subjective results with distinct radiological findings such as osteolysis was therefore confirmed. Material fatigue and sharp bony edges that result from osteolysis may be the cause of the relatively common implant fractures and ulnar deviation in this long-term follow-up.

Early results of endoscopic trochanter bursectomy

Between 1995 and 2000, we performed 45 endoscopic bursectomies in 42 patients (average age 51, range 17–61 years). All patients had at least 6 months of failed conservative treatment, and all responded positively to a sonographic-guided injection with Mepivacaine 0.5%. The bursa was removed using a synovial resector. An additional tractopexie was performed in four cases. We followed 37 patients for 12–48 months. Pre-operatively, the mean modified Japanese Orthopaedic Association (JOA) disability hip score was 40.5 points. It improved to 72.6 points after a mean of 25 months. Severe complications did not occur. The minimally invasive technique requires only stab incisions, and immobilisation and hospitalisation are minimal.RésuméEntre 1995 et 2000 nous avons exécuté 45 bursectomies endoscopiques chez 42 malades âgés en moyenne de 51 ans (17–61). Tous les malades avaient eu au moins six mois de traitement conservateur sans effet et tous ont répondu positivement à une injection de Mepivacaine 0,5% sous guidage sonographique. La bourse a été excisé en utilisant un résecteur synovial. Un tractopexie supplémentaire a été exécuté dans quatre cas. Nous avons suivi 37 malades pendant 12 à 48 mois. Le score (JOA) d’invalidité de la hanche modifié était, en préopératoire de 40,5 points en moyenne. Il a été amélioré à 72,6 points après 25 mois. Il n’y a pas eu de complication grave. La technique mini-invasive n’exige que des incisions ponctuelles avec une immobilisation et une hospitalisation sont minimales.

Physical activity and low back pain: the role of subgroups based on the avoidance-endurance model

Abstract Purpose: This study examines the relationship between low back pain, disability and fatigue and overt physical activity with respect to fear-avoidance and endurance-related subgroups. Method: 49 patients completed questionnaires (Pain, Disability, Fatigue, Depression, Pain-responses pattern) 6 months after lumbar disc surgery and underwent an 8-hour accelerometer assessment measuring overall physical activity (PAL), constant strain postures (CSP), standing time (ST) and lying time (LT). Four subgroups, representing patterns of distress-endurance (DER), eustress-endurance (EER), fear-avoidance (FAR) and adaptive responses (AR) due to the avoidance-endurance model of pain-regulation were investigated. Results: Multivariate analyses of covariance revealed significantly higher pain, disability and fatigue in FAR compared to AR patients and, as expected lower PAL and CSP in FAR than in endurance patients. Both endurance groups revealed higher pain accompanied by higher accelerometer-based physical activity (PAL, CSP) than AR and FAR patients. Most of the subgroup differences displayed moderate to high effect sizes. Conclusions: The results indicate different pathways to chronic pain and disability with physical underuse in FAR patients and overuse/overload in endurance patients suggesting the need for individually targeted cognitive-behavioral treatments in the maladaptive groups. Implications for Rehabilitation Improving the return to a normal physical activity level is an important goal for the rehabilitation of patients after lumbar disc surgery. Different pathways to chronic pain and disability with physical underuse in fear-avoidance patients and overuse in endurance patients should be considered. Different pain-related pain response pattern, based on the avoidance-endurance model, indicate the need for individual targeting of rehabilitation programs.

The correlation between magnetic resonance imaging and the operative and clinical findings after lumbar microdiscectomy

Abstract. Fifty-four consecutive patients were studied prospectively with magnetic resonance imaging before microdiscectomy, and the findings correlated with clinical symptoms before and after operation. A sequestrated fragment was found in 59% of cases, a subligamentous disc sequestration in 25% and a disc protrusion in 16%. The levels operated on were L4/5 – 36%, L5/S1 – 62.5%, and one at L3/4; 71% were laterally placed, 10% lay intraforaminal and 10% medial. The diameter of the protrusion was 4 mm to 13 mm for the craniocaudal extension, and 5 mm to 18 mm for the anteroposterior extension. No correlation could be found between a neurological deficit and the size of the prolapse. A positive correlation was present between the increasing degree of canal obstruction and the degree of disc degeneration determined by imaging for extrusions, subligamentous disc sequestrations and free sequestrations. Nerve root inflammation and enlargement was seen in 36% of the images, corresponding to an operative finding of 32%. Magnetic resonance imaging is a helpful preoperative diagnostic investigation which shows structural changes in the disc and the correct localisation and size of the disc sequestration, but there was no correlation between the imaging findings and the clinical symptoms.Résumé.Dans une étude prospective 54 patients d’un âge moyen de 41 ans ont été examinés avant une microdiscectomie au moyen d’un protocole IRM standardisé. Les résultats de l’IRM ont été mis en corrélation avec les symptomes cliniques avant et après chirurgie et les constatations operatoires. 59% des patients avaient un fragment libre, 25% un séquestre sous-ligamentaire du disque et 16% une protrusion du disque au niveau L4/5 (36%) ou L5/S1 (62%) et aussi une au niveau L3/4. 71% de celles ci étaient situées médiolatéralement, 10% latéralement ou intraforaminal et 10% seulement avaient une localisation médiale. Les diamètres de la protrusion discale variaient de 4 à 13 mm pour l’extension craniocaudale et de 5 à 18 mm pour l’extension antério-postérieure. Aucune corrélation entre un déficit neurologique et la taille du prolapse discal ont été trouvée. Une corrélation existe entre le degré d’augmentation de l’obstruction du canal et le degré de la dégénération du disque déterminéà l’aide du l’IRM pour les extrusions, les séquestres sous-ligamentaires et les séquestres libres. L’inflammation et l’agrandissement de la racine du nerf se montraient dans 36% des IRM correspondant à 32% intra-opèra- toires. Le IRM est une technique diagnostique importante préoperative pour permettre la localisation correcte, et pour une prévision de la grandeur de la séquestration disquaire. Il n’existe pas de corrélation entre le IRM et les symptomes cliniques.