Sibel Demir-Deviren

Studies in the Modified Scoliosis Research Society Outcomes Instrument in Adults : Validation, Reliability, and Discriminatory Capacity

Study Design. Observational study of patients with scoliosis and matched controls. Objectives. To determine the validity and reliability of the modified Scoliosis Research Society Outcomes Instrument (SRS-22) for use in the assessment of deformity in adults. To demonstrate the discriminate validity of the SRS-22 in differentiating between affected and unaffected adults. Summary of Background Data. Spinal deformity has an important impact on the general health status of adults. The magnitude of this impact has been difficult to measure and reported variably in the literature. The development of disease-specific outcomes tools permits improved sensitivity and specificity in measuring the patient’s self-assessment of health status. An instrument for measuring disease-specific health status in adults with scoliosis has not been validated. Materials and Methods. Observational study comparing the health status of adults affected by scoliosis and unaffected controls, matched for age, gender, and socioeconomic status. Pearson correlation analysis was used to determine the relationship of each domain within the SRS-22 and SF-36 with radiographic parameters including sagittal balance, coronal balance, and major curve correction. Discriminate validity of the modified SRS instrument was determined by a comparison of means between affected and unaffected cohorts. The validation of the SRS-22 was determined by criterion validity, using correlation analysis with comparable domains of the SF-36. The reliability of the SRS-22 was demonstrated using test–retest parity and Cronbach’s alpha test for internal consistency. Results. One hundred eighty adults were included in the study, 146 with scoliosis and 34 without. Adults with scoliosis scored significantly lower than unaffected controls on every domain of the SRS-22 and the SF-36. The floor and ceiling effect of the SRS-22 were less than observed in the SF-36 instrument. Pearson correlation analysis demonstrated no significant correlation between any radiographic process measure and any specific domain within the SRS-22 or the SF-36 (r < 0.25). Comparison of similar domains in the SRS-22 and the SF-36 demonstrates high correlation between the instruments. Test–retest analysis similarly demonstrates a high degree of reproducibility in each domain (r = 0.83–0.94). Cronbach’s alpha test of internal consistency within each domain demonstrates intercorrelation values greater than 0.75 within each domain of the SRS-22. Conclusions. Adult scoliosis has a significant and measurable impact on affected patients compared with controls. There is a poor correlation between radiographic parameters of outcome and patient self-assessment of health status. The SRS-22 is a reliable instrument in adults as demonstrated by a high degree of internal consistency and reproducibility. The SRS-22 is a valid instrument for use in adult deformity as demonstrated by the criterion validity assessment with the SF-36. The study supports the use of the SRS-22 in the adult spinal deformity population.

Propionibacterium acnes infected intervertebral discs cause vertebral bone marrow lesions consistent with Modic changes.

Modic type I change (MC1) are vertebral bone marrow lesions adjacent to degenerated discs that are specific for discogenic low back pain. The etiopathogenesis is unknown, but occult discitis, in particular with Propionibacteria acnes (P. acnes), has been suggested as a possible etiology. If true, antibiotic therapy should be considered for patients with MC1. However, this hypothesis is controversial. While some studies report up to 40% infection rate in herniated discs, others fail to detect infected discs and attribute reports of positive cultures to contamination during sampling procedure. Irrespective of the clinical controversy, whether it is biologically plausible for P. acnes to cause MC1 has never been investigated. Therefore, the objective of this study was to test if P. acnes can proliferate within discs and cause reactive changes in the adjacent bone marrow. P. acnes was aseptically isolated from a symptomatic human L4/5 disc with MC1 and injected into rat tail discs. We demonstrate proliferation of P. acnes and up‐regulation of IL‐1 and IL‐6 within three days of inoculation. At day‐7, disc degeneration was apparent along with fibrotic endplate erosion. TNF‐α immunoreactivity was enhanced within the effected endplates along with cellular infiltrates. The bone marrow appeared normal. At day‐14, endplates and trabecular bone close to the disc were almost completely resorbed and fibrotic tissue extended into the bone marrow. T‐cells and TNF‐α immunoreactivity were identified at the disc/marrow junction. On MRI, bone marrow showed MC1‐like changes. In conclusion, P. acnes proliferate within the disc, induce degeneration, and cause MC1‐like changes in the adjacent bone marrow.

Propionibacterium acnes biofilm is present in intervertebral discs of patients undergoing microdiscectomy.

Background In previous studies, Propionibacterium acnes was cultured from intervertebral disc tissue of ~25% of patients undergoing microdiscectomy, suggesting a possible link between chronic bacterial infection and disc degeneration. However, given the prominence of P. acnes as a skin commensal, such analyses often struggled to exclude the alternate possibility that these organisms represent perioperative microbiologic contamination. This investigation seeks to validate P. acnes prevalence in resected disc cultures, while providing microscopic evidence of P. acnes biofilm in the intervertebral discs. Methods Specimens from 368 patients undergoing microdiscectomy for disc herniation were divided into several fragments, one being homogenized, subjected to quantitative anaerobic culture, and assessed for bacterial growth, and a second fragment frozen for additional analyses. Colonies were identified by MALDI-TOF mass spectrometry and P. acnes phylotyping was conducted by multiplex PCR. For a sub-set of specimens, bacteria localization within the disc was assessed by microscopy using confocal laser scanning and FISH. Results Bacteria were cultured from 162 discs (44%), including 119 cases (32.3%) with P. acnes. In 89 cases, P. acnes was cultured exclusively; in 30 cases, it was isolated in combination with other bacteria (primarily coagulase-negative Staphylococcus spp.) Among positive specimens, the median P. acnes bacterial burden was 350 CFU/g (12 - ~20,000 CFU/g). Thirty-eight P. acnes isolates were subjected to molecular sub-typing, identifying 4 of 6 defined phylogroups: IA1, IB, IC, and II. Eight culture-positive specimens were evaluated by fluorescence microscopy and revealed P. acnes in situ. Notably, these bacteria demonstrated a biofilm distribution within the disc matrix. P. acnes bacteria were more prevalent in males than females (39% vs. 23%, p = 0.0013). Conclusions This study confirms that P. acnes is prevalent in herniated disc tissue. Moreover, it provides the first visual evidence of P. acnes biofilms within such specimens, consistent with infection rather than microbiologic contamination.

Paraspinal muscle denervation and balance impairment in lumbar spinal stenosis.

Introduction: Denervation of the paraspinal muscles may impair posture and displace the center of gravity. Therefore, we assessed balance impairment in patients with lumbar spinal stenosis (LSS) with and without paraspinal denervation. Methods: Thirty‐two women with LSS (15 symptomatic, 17 asymptomatic), aged 42–78 years, were assessed for disability, pain, and mobility, and underwent masked mini‐paraspinal mapping (mPSM). Berg Balance Scale (BBS) and device‐assisted balance (DAB) tests were used for balance assessment. Results: The symptomatic group had worse balance and higher mPSM scores than the asymptomatic group. Among DAB tests, limit of stability (LOS) had the highest correlations with BBS and mPSM in the symptomatic group. Conclusions: Paraspinal denervation correlated highly with static and dynamic balance in symptomatic patients. We recommend paraspinal mapping, balance assessment, rehabilitation, and follow‐up with the LOS test for symptomatic patients. Muscle Nerve 53: 422–430, 2016

Is IL-1β Further Evidence for the Role of Propionibacterium acnes in Degenerative Disc Disease? Lessons From the Study of the Inflammatory Skin Condition Acne Vulgaris

The pathogenesis of degenerative disc disease is a complex and multifactorial process in which genetics, mechanical trauma, altered loading and nutrition present significant etiological factors. Infection of the intervertebral disc with the anaerobic bacterium Propionibacterium acnes is now also emerging as a potentially new etiological factor. This human commensal bacterium is well known for its long association with the inflammatory skin condition acne vulgaris. A key component of inflammatory responses to P. acnes in acne appears to be interleukin (IL)-1β. Similarly, in degenerative disc disease (DDD) there is compelling evidence for the fundamental roles of IL-1β in its pathology. We therefore propose that P. acnes involvement in DDD is biologically very plausible, and that IL-1β is the key inflammatory mechanism driving the host response to P. acnes infection. Since there is a solid theoretical basis for this phenomenon, we further propose that the relationship between P. acnes infection and DDD is causal.

The effect of transforaminal epidural steroid injections in patients with spondylolisthesis

BACKGROUND Transforaminal epidural steroid injection (TFE) is a widely accepted non-surgical treatment for pain in patients with spondylolisthesis. However, the effectiveness of TFE has not been compared in patients with degenerative (DS) and isthmic spondylolisthesis (IS). OBJECTIVE To compare the effectiveness of bilateral TFEs in DS and IS. METHODS Patients who underwent bilateral TFEs for spondylolisthesis at University of California San Francisco Orthopaedic Institute from 2009 to 2014 were evaluated retrospectively. RESULTS DS patients (120 female, 51 male) were significantly older and had higher comorbidity than those with IS (18 female, 14 male). They had better pain relief after TFE than patients with IS (72.11 ± 27.46% vs 54.39 ± 34.31%; p = 0.009). The number of TFEs, the mean duration of pain relief after TFE, follow-up periods, translation and facet joint widening were similar in DS and IS groups (p > 0.05). DS group had higher successful treatment rate (66.1% vs 46.9%, p = 0.009) and longer duration of pain relief (181.29 ± 241.37 vs 140.07 ± 183.62 days, p = 0.065) compared to IS group. CONCLUSIONS Bilateral TFEs at the level of spondylolisthesis effectively decreased pain in patients. TFEs provided better pain relief for longer duration in patients with DS than for those with IS.

Negative Impact of Modic I Degenerative Disc Disease on Lumbar Paraspinal Muscles

condition walking time interaction (P 1⁄4 .02) was observed for the changes in COMP concentration. Continuous walking was associated with a significant cumulative increase in COMP concentration from baseline to 45 minutes (23% increase, P < .05), whereas, COMP concentrations dropped to baseline levels after 30 minutes of intermittent walking with rest breaks. There were no significant associations noted in TNF-a and NPY concentrations. Conclusion: This study suggests that an increase in walking exercise of greater than 30 minutes may lead to undesirable joint loading conditions, while the addition of rest breaks may attenuate the potential negative effects of longer bouts of walking exercise on cartilage health.

Poster 139 Paraspinal Muscles and Sagittal Spinopelvic Alignment in Patients with Degenerative Spondylolisthesis

Case Description: The patient, a 74-year-old right hand dominant woman, presented for evaluation of left wrist pain and dorsal hand numbness. 3 months prior, she had been treated for left shoulder pain by an acupuncturist. During the treatment, a needle was placed subcutaneously in the anatomic snuff box of her left wrist (corresponding to the acupuncture point Yang Xi/Large Intestine 5). She immediately experienced intense pain, and the needle was removed. Since that time, the patient noted intermittent paresthesias and shooting pain along the dorsal left wrist and hand. She presented to an orthopedic hand surgery clinic, where x-rays of the wrist revealed no acute abnormalities and no retained foreign bodies. The patient was prescribed hand therapy, a wrist brace, and gabapentin; all provided minimal relief. She was then referred for electrodiagnostic testing. On the day of electrodiagnostic evaluation, physical examination of the patient was remarkable for allodynia along the radial aspect of the dorsum of the left wrist. Nerve conduction studies revealed absent left radial superficial sensory nerve action potential at the thumb and reduced left superficial sensory nerve action potential at the wrist. Corresponding evoked potentials on the right side were normal. Needle EMG examination of the left upper limb and cervical paraspinals was normal. Setting: Academic Medical Center Electrodiagnostic Laboratory. Results or Clinical Course: Electrophysiologic testing demonstrated evidence of a left superficial radial sensory neuropathy. The acute onset of neuropathic symptoms in a corresponding distribution during acupuncture treatment suggests iatrogenic superficial radial nerve injury. Discussion: There have been rare case reports of iatrogenic peripheral nerve injury from acupuncture. To our knowledge, this is the first reported case of injury to the superficial radial nerve. Physiatrists performing or prescribing acupuncture for pain management should be aware of this possible complication. Particular care should be taken when employing acupuncture points in close proximity to peripheral nerves. Conclusion: Iatrogenic nerve injury is a potential complication of acupuncture treatment.

Poster 140 The Effect of Comprehensive Non-surgical Treatments in Patients with Spondylolytic Spondylolisthesis

Case Description: The patient, a 74-year-old right hand dominant woman, presented for evaluation of left wrist pain and dorsal hand numbness. 3 months prior, she had been treated for left shoulder pain by an acupuncturist. During the treatment, a needle was placed subcutaneously in the anatomic snuff box of her left wrist (corresponding to the acupuncture point Yang Xi/Large Intestine 5). She immediately experienced intense pain, and the needle was removed. Since that time, the patient noted intermittent paresthesias and shooting pain along the dorsal left wrist and hand. She presented to an orthopedic hand surgery clinic, where x-rays of the wrist revealed no acute abnormalities and no retained foreign bodies. The patient was prescribed hand therapy, a wrist brace, and gabapentin; all provided minimal relief. She was then referred for electrodiagnostic testing. On the day of electrodiagnostic evaluation, physical examination of the patient was remarkable for allodynia along the radial aspect of the dorsum of the left wrist. Nerve conduction studies revealed absent left radial superficial sensory nerve action potential at the thumb and reduced left superficial sensory nerve action potential at the wrist. Corresponding evoked potentials on the right side were normal. Needle EMG examination of the left upper limb and cervical paraspinals was normal. Setting: Academic Medical Center Electrodiagnostic Laboratory. Results or Clinical Course: Electrophysiologic testing demonstrated evidence of a left superficial radial sensory neuropathy. The acute onset of neuropathic symptoms in a corresponding distribution during acupuncture treatment suggests iatrogenic superficial radial nerve injury. Discussion: There have been rare case reports of iatrogenic peripheral nerve injury from acupuncture. To our knowledge, this is the first reported case of injury to the superficial radial nerve. Physiatrists performing or prescribing acupuncture for pain management should be aware of this possible complication. Particular care should be taken when employing acupuncture points in close proximity to peripheral nerves. Conclusion: Iatrogenic nerve injury is a potential complication of acupuncture treatment.

Poster 112: Effectiveness of Cervical Transforaminal Epidural Injections

the perceived sensation of rigidity, and an analog scale to determine the intensity of low back pain. Results: Mean lumbar flexion was 31.4°. Lumbar mobility decreased in relation to the lower level of instrumentation. Mean intensity of low back pain was 1.5 2.2. There was no relationship between the sensation of rigidity and lumbar mobility or the LIL. The LIL correlated with back pain (SRS-22 pain) (r 0.45, P .01) but not with the intensity of low back pain. The sensation of rigidity correlated with back pain (r .42, P .01) and the intensity of low back pain (r .43, P .01).There was a moderate association of the LIL and loss of mobility with quality of life (r 0.36 P .002, r 0.46 P .001).The variables independently associated with back pain were the intensity of low back pain, the radiologic magnitude of the curve, and patient age (r 0.73, P .0001). Conclusions: The LIL has an influence on lumbar mobility. The intensity of low back pain is mild in these patients and is not related to the LIL. The subjective perception of rigidity does not correspond to the loss of lumbar mobility but rather is determined by the coexistence of pain. The variables that independently determine quality of life include low back pain, the magnitude of the residual curve, and patient age.