Yoram Folman

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.

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.

Cyclic impacts on heel strike: A possible biomechanical factor in the etiology of degenerative disease of the human locomotor system

SummaryThe cyclic impacts induced by heel strike when walking were studied using both a high-resonance-frequency force plate and a low-mass skin-mounted accelerometer. The data were computer analyzed. The results showed that during normal human walking, the locomotor system is subjected to repetitive impact loads at heel strike, lasting about 5 ms and consisting of frequency spectra up to and above 100 Hz. The natural shock-absorbing structures in the musculoskeletal system have viscoelastic time-dependent mechanical behavior, which is relatively ineffective in withstanding sudden impulsive loads. Degenerative joint diseases may thus be seen as a late clinical result of fatigue failure of the natural shock absorbers, submitted to deleterious impacts over a period of time.

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.

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.

Late outcome of nonoperative management of thoracolumbar vertebral wedge fractures.

Objectives To study the medical and social outcome of nonoperative management of traumatic thoracolumbar vertebral wedge fractures in the absence of neurologic damage. Design Retrospective review of data, as elicited from records and from patients. Subjects and Methods We retrieved the hospital records of 85 consecutive patients who conformed to the foregoing definition and whose admission for fracture had taken place at least 3 years earlier. The current status of each patient was inquired into by a mailed questionnaire designed to determine: 1) presence and severity of back pain; 2) presence and magnitude of overall disability; and 3) current work capacity, postinjury employment history, and history of litigation concerning the injury. Using the last radiographs of the spine, measurements were taken of anterior column deformity (Willen formula) and degree of local, fracture-related kyphosis (lateral angle of Cobb). Correlations between paired variables and group comparisons with respect to means of pain indices were analyzed statistically by analysis of variance (&khgr;2) and regression analysis. Results Chronic pain predominant in the lower lumbar area was reported in 69.4% of subjects. Mean pain index was 2.94 ± 2.67 on a scale of 1 to 10. The mean overall disability score was 56.3 ± 14.2 on a scale of 1 to 100. Pain intensity was correlated with angle of local kyphosis (p = 0.04) but not with magnitude of anterior column deformity. Twenty-five percent of the subjects had changed jobs, mostly from full- to part-time employment. Forty-eight percent of patients who filed lawsuits concerning their injury versus 11% of those who did not (p = 0.04) were absent from work for ≥6 months. Conclusions Traumatic, uncomplicated thoracolumbar wedge fractures of the vertebral body, below given limits of local kyphosis and anterior column deformity, are adequately managed by a limited period of bed rest alone. Surgery, bracing, and intensive physiotherapy are not indicated.

Recovery of neurologic function after spinal cord injury in Israel.

Study Design. A retrospective cohort study was conducted. Objective. To assess neurologic recovery and the manner in which it is affected by the severity of the neurologic damage after spinal cord injury. Summary of Background Data. Studies from various countries, but not from Israel, have shown considerable potential for recovery of the damaged human spinal cord. Methods. The study sample included 250 patients with a traumatic spinal cord lesion treated between 1962 and 1992 at the major referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from the hospital charts. The degree of neurologic recovery in each patient was determined by comparing the Frankel grade of neurologic deficit at first admission for rehabilitation with the grade at discharge from that hospitalization. Results. There was median delay of 36 days between injury and admission for rehabilitation. During rehabilitation, full or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred in 27% of all the patients who were Grade A, B, or C on admission, and in 54% of those who were Grade C. The neurologic recovery was negatively associated with severity of the neurologic deficit. Conclusions. The outcome findings are similar to those reported from spinal rehabilitation units in other countries. The study is a further demonstration of the considerable potential for neurologic recovery after spinal cord injury, when posttraumatic or postsurgical management is focused on prevention of complications and maximal use of functional ability.

Harvesting bone graft from the posterior iliac crest by less traumatic, midline approach.

Complications of the donor site after the harvest of corticocancellous bone graft from the posterior iliac crest are very common. The most common are chronic donor site pain, tenderness, and sensory disturbances. This study investigates the results of the midline, lumbar fascia splitting approach for harvesting bone graft in lower lumbar spine fusion and compares them with the classic separate incision approach. A retrospective study of 107 patients compares two groups. The first group of 56 patients (35 males and 21 females with an average age of 41.8 years) had bone graft taken by splitting the two layers of the lumbar fascia down to their attachment to the iliac crest. The second group of 51 patients (29 males and 22 females with an average age of 43.7 years) had a separate incision over the iliac crest. In the first group, 82.1% had no tenderness, 8.9% mild, 7.1% moderate, and only 1.8% severe tenderness over the donor site. In the second group, 45.1% had no tenderness, 21.6% mild, 17.6% moderate, and 15.7% severe tenderness over the donor site. Five patients of the separate incision group (9.8%) had a lump in the donor site compared with none in the “same incision” group. Sensory disturbances over the donor site were found in 5.4% of the first group and in 21.6% of the second group. Harvesting bone graft from the posterior iliac crest for lower lumbar spine fusion through a midline, fascia splitting approach was found superior to the traditional, separate incision approach.

The Correlation between Spurling Test and Imaging Studies in Detecting Cervical Radiculopathy

Cervical spine symptoms are a major cause of visits to general or spinal orthopedic surgeons or even primary care physicians. Although in this era the imaging studies can precisely rule out or diagnose pathologies in the spine, all of these studies have limitations. Computerized tomography (CT) scan consists of radiation exposure to the patients and it should be done with caution. Magnetic resonance imaging (MRI) is a highly effective imaging tool, but in many countries it is still costly. The goal of our study was to determine whether a simple clinical test can help the clinician to identify the patients who need to be sent for these imaging studies.