Thomas R. Lehmann

Long-term follow-up of lower lumbar fusion patients.

To determine the long-term effects of lower lumbar fusion, 94 subjects were catalogued from medical records. They had a lumbar arthrodesis at the third lumbar level or below and their operations were performed before 1964. Twenty-four were not located and 8 were deceased. Sixty-two subjects (72% of available sample) completed a telephone interview; 52 subjects completed a comprehensive low back questionnaire; and 33 subjects returned for physical examination, flexion–extension lateral lumbar spine films, and a limited computerized axial tomographic (CAT) scan. In general, the subjects who returned for complete evaluation were representative of the larger sample. Forty of 62 patients were men. Ages ranged from 41 to 83 years; the median age was 66 years, 6 months. Follow-up ranged from 21 to 52 years; the median follow-up was 33 years. Forty-four percent (27/61) were currently experiencing low-back pain, 57% (35/61) had back pain in the last year. Fifty-three percent (33/62) were using medication. Fifteen percent (9/62) had undergone repeat lumbar surgery, however, only 5% (3/62) required surgery as a late sequela (more than 10 years postoperatively). Forty-two percent (14/33) had lumbar spinal stenosis, but only 15% (5/33) had dural tube measurements less than 100 mm2. Segmental instability above the fusion was present in 45% (15/33). There was a significant correlation between segmental instability and lumbar spinal stenosis (r =.57, P <.01). Neither radiographic condition correlated with symptoms, however. Patients fused for spondylolysis and spondylolisthesis were likely to report incidence of pain and reported less severe pain than patients fused for other reasons (P <.01 and <.10, respectively). There was no significant difference in the disability assessments between these surgical subgroups. Although patients after lower lumbar fusion report more pain than the general population and have more radiographic evidence of instability and stenosis than expected for the general population, they are generally doing well and are satisfied with the results of their surgery.

Thoracolumbar "burst" fractures treated conservatively: a long-term follow-up.

This report addresses the long-term results of nonoperative treatment for fractures of the thoracolumbar spine. Forty-two patients meeting specified inclusion criteria were contacted and completed questionnaires. In all cases, nonoperative treatment was the only treatment received. The average time from injury to follow-up was 20.2 years (range, 11 to 55 years). The average age at follow-up was 43 years (range, 28 to 70 years). There were 31 men and 11 women in this series. Seventy-one percent of the injuries were the result of motor vehicle accidents. The most common sites of injury were T12–L2, which accounted for 64% of the injuries. Seventy-eight percent of the patients had no neurologic deficits at the time of injury. At follow-up, the average back pain score was 3.5, with 0 being no pain at all and 10 being very severe pain. No patient demonstrated a decrease in their neurologic status at follow-up, and no patient required narcotic medication for pain control. Eighty-eight percent of patients were able to work at their usual level of activity. Follow-up radiographs revealed an average kyphosis angle of 26.4° in flexion and 16.8° in extension. The degree of kyphosis did not correlate with pain or function at follow-up. Based on this review, nonoperative treatment of thoracolumbar burst fractures remains as a viable alternative in patients without neurologic deficit and can lead to acceptable long-term results.

Efficacy of electroacupuncture and tens in the rehabilitation of chronic low back pain patients

&NA; Fifty‐four patients treated in a 3‐week inpatient rehabilitation program were randomly assigned to and accepted treatment with electroacupuncture (n = 17), TENS (low intensity transcutaneous nerve stimulation, n = 18), and TENS dead‐battery (placebo, n = 18). Outcome measures included estimates of pain (on a Visual Analogue Scale) and disability by both physician and patient, physical measures of trunk strength and spine range of motion, as well as the patients perceptions of the relative contribution of the education, exercise training, and the electrical stimulation. Analyses of variance were utilized to determine effects of treatment (electroacupuncture, TENS, placebo) across time (admission, discharge, and return) for the outcome measures. There were no significant differences between treatment groups with respect to their overall rehabilitation. All 3 treatment groups ranked the contribution of the education as being greater than the electrical stimulation. However, the electroacupuncture group consistently demonstrated greater improvement on the outcome measures than the other treatment groups. For the visual analogue scale measure of average pain, there was a statistical trend at the return visit suggesting that the acupuncture group was experiencing less pain.

Predicting long-term disability in low back injured workers presenting to a spine consultant.

Low back pain (LBP) is the most common, costly, and disabling musculoskeletal condition. Although most LBP patients recover within two months, 2-3% eventually develop disabling chronic low back pain (DCLBP). Due to the prevalence of DCLBP problems, models have been developed to predict which acute low back pain patients are predisposed to the problems associated with this condition. Many see the development of these models as a first step that must be taken before useful approaches for containing and reducing the problem can be conceptualized, implemented, and tested. A recent publication by Cats-Baril and Frymoyer considered this specific problem. While the results of their study indicate considerable success in predicting DCLBP patients, the high prediction rates they obtained may be spurious because of the characteristics of their sampled patient population in conjunction with some of the predictors they found useful in identifying DCLBP patients. The purpose of the present study was to focus on the crucial patient population (i.e., acute LBP patients who perceive their problem as work-related and who have been unable to work for more than two but less than six weeks), and evaluate the ability of various personal, medical, occupational, and psychological factors to predict predisposition to DCLBP. Fifty-five patients referred by occupational physicians were evaluated and followed successfully for at least 6 months. Patients in the study were given a physical examination that included Spratt et als assessment of pain behavior. They were then asked to fill out an extensive battery of self-report questionnaires, addressing issues associated with personal demographics, health history, work requirements, job satisfaction, injury information, and pain/function factors. At the 6-month follow-up, a structured telephone interview was used to obtain outcome information regarding patient status, including ability to return to work and general outcomes of treatment. Average patient age was 37.2 years (range, 22-57) and 67% of the patients were male. On average, patients had been unable to work for approximately 4 weeks when initially surveyed. Overall, 12.7% of the patients returned to work within 1 month of injury, 40% returned within 2 months, 54.5% within 3 months, 69% within 4 months, 74.5% within 5 months, 76.3% within 6 months, 80% within 7 months, and 83.6% after 7 months. Approximately 16% never successfully returned to work within the follow-up period of this study. DCLBP was found to be correlated only with marital status, as married patients returned to work more quickly than single patients (P < 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

Assessment of abdominal and back extensor function. A quantitative approach and results for chronic low-back patients.

A method was developed to obtain static and dynamic measures of trunk flexor and extensor strength and endurance. The method was evaluated using 32 normal subjects. Variables of trunk strength and endurance were used to compare 24 normals (12 men and 12 women) and 24 patients (16 men and eight women) with chronic low-back dysfunction. The Iowa Trunk Dynamometer is acceptably reliable and provides for assessment of isolated function of the abdominal and back muscles. For peak abdominal and back extensor strength, the range of superiority of men over women was 39–57%, and the range of superiority of normals over patients with chronic low-back dysfunction was 48–82%. Using time to percent decrement of peak strength as a criterion, the abdominals were more susceptible to fatigue than the back extensors, women demonstrated more endurance than men, and the endurance for normals was less than those patients who were able to perform dynamic reciprocal trunk movements.

Efficacy of Flexion and Extension Treatments Incorpoatin Braces for Low-back Pain Patienst With Rerodiplacement, Spondylolisthesis, or Normal Sagittal Translation

Radiographic instability seemingly enjoys the status of a well-defined clinical syndrome. The concept is widely used, and specific treatments, usually spinal fusion, are routinely performed based on the diagnosis. The minimum standards necessary to establish radiographic instability as a legitimate clinical syndrome have not been established, however. The primary purpose of this study was to determine if treatment involving bracing, exercise, and education controlling either flexion or extension postures, would result in a distinctive pattern of favorable or unfavorable results, depending on the type of radiographic instability (retrodisplacement or spondylolisthesis). Fifty-six patients meeting strict study inclusion and radiographic evaluation criteria were assigned signed to a bracing treatment (flexion, extension, placebo-control) according to a randomization scheme, designed to ensure equal representation of translation categories (retro, normal, spondy) across treatment groups, and assessed at admission and 1-month follow-up. The sample was relatively evenly divided between men (46%) and women (54%), and by age. Translation classification was related to both gender and age, with men more likely classified as retro and women more likely spondy and patients in their 20s having lower incidence of spondy and higher incidence of normal translation. Translation classification was not related to selected indices of low-back pain history. Brace treatments were not shown to reduce patient range of motion or lessen trunk strength. A significant treatment by time interaction for the modified pain interference (VAS) scale indicated improvement for patients in extension compared with patients in flexion and control-placebo treatments. In conjunction with no significant three-way interaction between treatment, translation classification, and time, it was hypothesized that radiographic instability might more appropriately be considered a corroborative sign of advanced discogenic problems. Improvement in extension treatment, regardless of the type of radiographic abnormality, suggests that the treating clinician might consider extension treatment for chronic low-back pain patients. Causes and implications for the failure of this study to provide support for considering radiographic instability as a clinical syndrome are considered and future directions for this area of research suggested.

The impact of patients with nonorganic physical findings on a controlled trial of transcutaneous electrical nerve stimulation and electroacupuncture.

Fifty-four patients treated in a three-week in-patient rehabilitation program were randomly assigned to and accepted treatment with electroacupuncture (n = 17), TENS (low-intensity transcutaneous nerve stimulation, n = 18) and TENS-dead battery (placebo, n = 18). Outcome measures included estimates of pain (on a visual analogue scale) and disability by both physician and patient as well as physical measures of spine function. Two groups were constructed based on the absence of nonorganic physical findings (Valid group, n = 30) and the presence of two or more nonorganic physical findings out of a possible four (Invalid group, n = 10). Multivariate and univariate analyses of covariance were utilized to determine effects of treatment (acupuncture, TENS, placebo) and the effects of over-reporting (presence of excessive nonorganic physical findings). Statistically significant findings demonstrated that the acupuncture group enjoyed more relief of peak pain and more relief of pain on an average day at the three-month return assessment. Additionally, the acupuncture group demonstrated greater improvement in extension trunk strength at the discharge assessment. The Invalid group were found to have a contaminating effect on the acupuncture results. Analysis also demonstrated associations between nonorganic physical findings and both personality traits (“Conversion V” profile on MMPI) and retention of an attorney. Researchers conducting clinical trials in chronic low-back pain patients should control for contamination by the presence of overreporters.

The consistency and accuracy of roentgenograms for measuring sagittal translation in the lumbar vertebral motion segment : an experimental model

An experimental model of the L4-L5 lumbar motion segment was developed that allowed precise manipulation of sagittal translation, rotation of L5 relative to L4, tilt of L4 on L5, and control of roentgenogram quality (image clarity) by placing a water bath between the tube and the vertebral body. A series of experiments were designed to systematically assess the consistency and accuracy of sagittal translation measurements from roentgenograms of varying quality, using different measurement protocols and various rater combinations on models with varying degrees of concomitant motions (rotations and tilts). Study 1 assessed the effects of roentgenogram quality, raters, and seven measurement methods on the consistency and accuracy of evaluating translations in the sagittal plane. Results indicated very high reliabilities across roentgenogram quality, raters, and measurement. As expected, high-quality roentgenograms were more accurately evaluated than lower-quality roentgenograms. However, closer inspection of the consequences of errors in measured translations indicated surprisingly high false-positive and false-negative rates, with significant differences observed between measurement methods. Study 2 assessed the effects of concomitant motions and measurement methods on the consistency and accuracy of evaluations. Within-rater consistency and accuracy indices were remarkably high and similar across measurement methods and degrees of concomitant motions. However, important differences in the false-positive and false-negative rates were again observed. Method 2, described by Morgan and King, demonstrated the overall best performance and the least interference due to concomitant motions. Study 3 assessed the effects of raters and measurement methods on the consistency of measuring translation in clinical roentgenograms, where concomitant motion factors may be present, but not explicitly considered. Results indicated substantially lower within- and between-rater consistency estimates relative to consistencies obtained from the model, although these magnitudes were similar to those reported by others evaluating clinical roentgenograms. The implications of lower consistency estimates relative to increased false- positive and false-negative rates must be more closely examined. These studies present evidence suggesting that high consistency and accuracy indices do not ensure acceptable false-positive and false-negative rates and, thus, provide empirical evidence supporting the view that using roentgenograms as a basis for diagnosing instability often can lead to errors in classification. This is less so when observed translations are relatively large (± 5 + mm) on roentgenograms that are relatively clear, with little obliquity, and when concomitant motions are minimal. However, when roentgenogram quality is lower, obliquity problems are apparent, and concomitant motions are involved, even relatively large measured translations of ±6 mm or more may occur when actual translations are substantially less. In these settings, using roentgenograms to classify patients as haying excessive translation may result in large false-positive rates.

Long-term follow-up of nonoperatively treated thoracolumbar spine fractures.

Little information is available regarding the long-term results of nonoperative treatment for fractures of the thoracolumbar spine. One thousand six hundred ninety-one fractures of the spine seen at the University of Iowa from 1935 to 1975 were reviewed; 83 fractures met strict inclusion criteria of fractures involving T10-L5. In all cases, nonoperative treatment was the only treatment received. 42 patients (51 per cent) were contacted and completed questionnaires. Twenty (48%) of these 42 patients also returned to University Hospital for a complete physical examination as well as anteropos-terior and lateral flexion-extension radiographs. The average time from injury to follow-up was 20.2 years, (range 11–55 years). The average age at follow-up was 43 years (range 28–70). There were 31 men and 11 women. Seventy-one percent of the injuries were the result of motor vehicle accidents. The most common sites of injury were T12-L2, which accounted for 64% of the injuries; 78% of the patients had no neurologic deficits at the time of injury. At follow-up, the average back pain score was 3.5, (0 = no pain at all, and 10 = very severe pain). No patient demonstrated a decrease in neurologic status at follow-up, and no patient required narcotic medication for pain control. Eighty-eight percent of the patients were able to work at their usual level of activity. Follow-up radiographs revealed an average kyphosis angle of 26.4° in flexion and 16.8° in extension. The degree of kyphosis did not correlate with pain or function parameters in the 20 examined patients. Based on this review, nonoperative treatment of thoracolumbar burst fractures remains as a viable alternative in patients without neurologic deficit and can lead to acceptable long term results.

A low-back rating scale.

Clinical research in patients with low-back pain is impeded because there is no quantitative measure of dysfunction. Such a measure would be useful as a control for the conditions severity in subjects to be admitted to clinical trials, as well as a pre- and post-treatment measure to evaluate success. The purpose of this report is to present our approach to developing a scale to measure low back dysfunction. The 105-point rating scale consists of eight parameters grouped into three major parts: (1) physical measurement of trunk strength and range of motion (40 points); (2) patients perception of pain and dysfunction assessed by an activities questionnaire and a visual analogue pain scale (40 points); (3) physicians perception of dysfunction based on report of pain and medication usage (25 points). The rating scale was tested in 29 patients undergoing lumbar surgery and 48 patients treated in a three-week rehabilitation program. In these rehabilitation patients when both the patient and the physician perceived that the treatment was a success, there was a mean increase of 12.8 points. If both perceived the treatment was unsuccessful there was a mean drop of 1.4 points. The difference between these two subgroups is statistically significant (P = .011). To improve on the rating scales discriminatory ability, principal component analysis was performed. This analysis predicts that reweighting the eight parameters of the rating scale will improve its performance. Utilizing a scale or index to determine treatment outcome in clinical trials should help to accurately discriminate between effective and ineffective treatment modalities.