Cost-Effectiveness of Lumbar Fusion and Nonsurgical Treatment for Chronic Low Back Pain in the Swedish Lumbar Spine Study: A Multicenter, Randomized, Controlled Trial From the Swedish Lumbar Spine Study Group

Fritzell, Peter; Hägg, Olle; Jonsson, Dick; Nordwall, Anders

doi:10.1097/01.brs.0000102681.61791.12

Cited by 210 publications

(216 citation statements)

References 32 publications

(35 reference statements)

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“…High pain scores also correlated with low scores on the pain questions of the LBPRS, reflecting the pain component of the score. An ongoing compensation case was, however, not associated with significantly higher scores, despite the fact that ongoing compensation cases have been shown to be associated with poor outcome [6,9,12,16,17] and less improvement in pain drawing scores after fusion surgery [7].…”

Section: Discussionmentioning

confidence: 99%

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Pain 5 years after instrumented and non-instrumented posterolateral lumbar spinal fusion

Andersen

Christensen

Hansen

et al. 2003

European Spine Journal

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IntroductionPosterolateral spinal fusion has become an evidence-based treatment of chronic low back pain caused by spondylolisthesis or spinal instability [12,26]. Although widely used, the beneficial effect on the clinical outcome of adding pedicle-screw fixation to the posterolateral spinal fusion has not yet been demonstrated [11,13,25,38]. All studies have shown reduction in pain and disability, but few have investigated the severity and localisation of residual pain several years after the procedure.Abstract Pain drawings have been used in spine surgery for diagnostic use and psychological evaluation of fusion candidates; they have rarely been used to evaluate pain status after spinal fusion. This study is a 5-year follow-up on a randomised clinical trial assigning patients to posterolateral spinal fusion with or without pedicle screw instrumentation. Patients were mailed a pain drawing and questionnaires including questions regarding work, social status, smoking status, the Dallas Pain Questionnaire (DPQ), and the Low Back Pain Rating Scale (LBPRS). Pain drawings were scored using a visual inspection method and a surfacebased point scoring and evaluated for the presence of donor site pain. Pain drawings from 109 patients (87% of the initially included patients), 56 men and 53 women, mean age at followup 51 years, were analysed. Fiftythree patients had undergone an instrumented fusion and 56 a non-instrumented fusion. Some presence of low back pain was marked by 79% and leg pain by 69%. Sixty-two percent of the pain drawings were classified as "organic" and 38% as "nonorganic". There was no difference between the instrumented and the uninstrumented group. DPQ and LBPRS scores were higher in the non-organic group (P=0.007). Using the point scoring, no difference between the instrumented and the uninstrumented group was seen. The results of the point scoring were found to correlate with the DPQ and LBPRS scores (P=0.001). Working patients (39%) had significantly better scores than the rest. Ten percent of the patients had donor site pain. Twenty percent of spinal fusion patients are totally pain free at 5-year follow-up. Ten percent still experience donor site pain. In general, instrumentation does not affect the amount and localisation of pain 5 years after lumbar spinal fusion surgery. The pain drawing seems to be a valuable tool when following spinal fusion patients, but its use as prognostic marker in connection with fusion surgery needs further investigation.

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Section: Discussionmentioning

confidence: 99%

“…Posterolateral spinal fusion has become an evidence-based treatment of chronic low back pain caused by spondylolisthesis or spinal instability [12,26]. Although widely used, the beneficial effect on the clinical outcome of adding pedicle-screw fixation to the posterolateral spinal fusion has not yet been demonstrated [11,13,25,38].…”

Section: Introductionmentioning

confidence: 99%

Pain 5 years after instrumented and non-instrumented posterolateral lumbar spinal fusion

Andersen

Christensen

Hansen

et al. 2003

European Spine Journal

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“…It is well known that spinal fusion surgery is an effective treatment in the management of this condition [8,9,17]. Nevertheless, recent studies indicate a rationale for conservative treatment as well, if a modern rehabilitation programme will be followed [3,11].…”

Section: Discussionmentioning

confidence: 99%

Biomechanical comparison of two different concepts for stand alone anterior lumbar interbody fusion

Schleicher

Gerlach

B³

et al. 2008

Eur Spine J

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Segmental instability in degenerative disc disease is often treated with anterior lumbar interbody fusion (ALIF). Current techniques require an additional posterior approach to achieve sufficient stability. The test device is an implant which consists of a PEEK-body and an integrated anterior titanium plate hosting four diverging locking screws. The test device avoids posterior fixation by enhancing stability via the locking screws. The test device was compared to an already established stand alone interbody implant in a human cadaveric three-dimensional stiffness test. In the biomechanical test, the L4/5 motion segment of 16 human cadaveric lumbar spines were isolated and divided into two test groups. Tests were performed in flexion, extension, right and left lateral bending, right and left axial rotation. Each specimen was tested in native state first, then a discectomy was performed and either of the test implants was applied. Finite element analysis (FE) was also performed to investigate load and stress distribution within the implant in several loading conditions. The FE models simulated two load cases. These were flexion and extension with a moment of 5 Nm. The biomechanical testing revealed a greater stiffness in lateral bending for the SynFix-LR TM compared to the established implant. Both implants showed a significantly higher stiffness in all loading directions compared to the native segment. In flexion loading, the PEEK component takes on most of the load, whereas the majority of the extension load is put on the screws and the screw-plate junction. Clinical investigation of the test device seems reasonable based on the good results reported here.

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“…Have we satisfied Koch's postulates or the updated criteria of Fredricks and Relman [20] for demonstrating a link between infection and the disease process? The use of Roland and Morris rather than the Oswestry Disability Index precludes comparisons with the major spinal surgery outcome studies [21][22][23][24]. We need stronger evidence that bacterial infection producing discitis and endplate changes is the cause of chronic low back pain in a significant number of patients.…”

Section: Responsementioning

confidence: 99%

Antibiotics a cure for back pain, a false dawn or a new era?

O’Dowd

Casey

2013

Eur Spine J

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The recent publication in this journal of papers by Albert and colleagues [1,2] from Denmark suggesting that low grade anaerobic bacterial infection may be the underlying cause of significant persistent chronic back pain in a welldefined group of patients has precipitated an unprecedented response in the medical and lay media. In the midst of claim and counterclaim, these studies represent a significant and substantial change in our understanding of the pathophysiology of back pain in some patient groups, and the importance of this should not be lost amidst the negative, unstructured and unscientific response to this study. The factsThe story starts in 2001 with the publication of a research letter in the Lancet by a group from Birmingham [3] demonstrating that 31 % of patients with sciatica tested positive to a newly developed serological test, which diagnosed deep-seated infections caused by virulent Grampositive microorganisms. In addition, intervertebral disc material excised during microdiscectomy in a different group of patients, which was cultured in a specialist anaerobic environment, had positive cultures after longterm incubation in 53 % of patients and of this group 84 % grew Propionibacterium acnes.Following the ISSLS 2006 meeting, a collaboration developed between the Birmingham group and the group from Southern Denmark. This led to publication of a pilot study in 2008 [4] where 32 chronic low back pain patients with Modic type 1 endplate changes and a previous lumbar herniated disc were treated with amoxicillin and clavulanate for 90 days. In this uncontrolled trial, there was a clinically important and statistically significant difference in outcome at 10-month follow-up following antibiotic treatment.In the meantime, the evidence was accumulating about the significant correlation between Modic endplate changes and back pain. Albert and Manniche [5] identified a strong association between Modic changes and non-specific low back pain, a stronger association with Modic type 1 than type 2, and that a lumbar disc herniation is a strong risk factor for developing Modic changes, especially type 1, during the following year and that these changes are strongly associated with low back pain.A systematic review from Southern Denmark in 2008 [6] identified the prevalence of vertebral endplate signal changes as 43 % in patients with non-specific low back pain and/or sciatica, and 6 % in a non-clinical population, demonstrating that endplate changes are associated with pain. A further systematic review in the same year from Shanghai [7] identified two possible pathophysiological mechanisms for Modic changes-one biomechanical and one biochemical. A biomechanical pathway for development of Modic changes was supported by a large population MRI scan study in 2011 [8].Against this background two key papers were then published in this journal in 2013. In one study [2] Albert and colleagues established a strong relationship between

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Cost-Effectiveness of Lumbar Fusion and Nonsurgical Treatment for Chronic Low Back Pain in the Swedish Lumbar Spine Study: A Multicenter, Randomized, Controlled Trial From the Swedish Lumbar Spine Study Group

Cited by 210 publications

References 32 publications

Pain 5 years after instrumented and non-instrumented posterolateral lumbar spinal fusion

Pain 5 years after instrumented and non-instrumented posterolateral lumbar spinal fusion

Biomechanical comparison of two different concepts for stand alone anterior lumbar interbody fusion

Antibiotics a cure for back pain, a false dawn or a new era?

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