Evidence of the drug therapy for non-specific low back pain (LBP) was investigated using various meta-analyses, mainly according to the results of Cochrane Review. Non-steroidal anti-inflammatory drugs (NSAIDs) were considered effective for acute LBP, however, had no evidence for chronic LBP due to lack of valuable randomized controlled trials. Strong evidence was observed of that there was no difference of efficacy in various NSAIDs and there was moderate evidence that NSAIDs was more effective than acetaminophen. The fact that some kinds of muscle relaxants was effective than placebo, had strong evidence for acute LBP, even though the effectiveness in short term period. The results of meta-analysis showed short-term efficacy of antidepressants for acute and chronic LBP, but no difference with placebo in activity of daily life. Because of difference of drugs examined in meta-analyses and difference of drug classification such as muscle relaxants including many benzodiazepines, establishment of international drug classification for comparative data and of Japan-original meta-analyses for LBP is urgently necessary.
Exercise therapy for chronic low back pain is one of the most important conservative treatments. However, the fee-for-exercise therapy has reduced in current medical administration system for the reason of scientific grounds about the therapy effect not being established. In previous systematic reviews some problems were pointed out, which were such that definitions of chronic low back pain and outcome measures to assess the effects were not unified, and exercise for subjects and treatment for control groups were various among papers. Recently Liddle SD carried out new systematic review that were improved about these points, and it reported that exercise had a positive effect on patients with chronic low back pain and the results were largely maintained at follow-up. Now domestically high quality RCT about exercise therapy for chronic backache is ongoing, and it may be the time that we should review the evaluation for availability of exercise therapy.
This paper describes the efficacy of physical therapy for low back pain. There is insufficient basic research on the therapeutic mechanisms of thermal therapy and traction therapy, and regarding the clinical effects of these therapies, no scientific evidence has been established at present. We investigated the effects of thermal therapy and traction therapy in the prone and flexion position from the standpoint of the firmness of the spine erector muscles. In the prone position, the firmness of the muscles after traction therapy was significantly lower compared to before traction. Furthermore, in the flexion position, the firmness of the muscles after thermal therapy was also significantly lower compared to before hot pack therapy. The mechanisms of the therapeutic effects of these therapies need to be clarified to scientifically prove the efficacy of physical therapy for low back pain based on randomized controlled trials.
The invasive schwannoma in the spine is a rare clinical entity. There have been no reports of schwannoma arising from tuberculous spine. The authors report on a case in which invasive cystic schwannoma arose at old tuberculous spine and paraplesia progressed by the tumor. The tumor excision and resection of the sequestra achieved satisfying neurological improvement. Although development of cystic tumor in the tuberculous spine may be extremely rare, it should be considered in the differential diagnosis, especially when systemic symptoms of tuberculosis were absent.
We studied clinical trial of Mckenzie method for acute low back pain. 11patiens were treated by McKenzie method, and 9patients were treated by NSAIDS (control group). Average visual analogue scale for McKenzie method was 52 before trial, and gradually decreased for 3months (18 in 1week after, 14 in 1 month , 10 in 3months). There were no significant differences between 2 trials. The percentage when the pain was disappeared was 27% in 1 week , 18% n 1 month for McKenzie group, and although 33% in 1 week , 44% in 1 month for control group. McKenzie method is one of the useful treatment for acute low back pain.
Patients with chronic low back pain or leg pain were treated by Selective Serotonin Reuptake Inhibitor (SSRI). Twenty-seven subjects (4 males and 23 females) with an average age of 64 years were evaluated. The dose of paroxetine hydrochroride hydrate was either 10mg or 20mg/day. For pain assessment, the Visual Analog Scale (VAS) was used and the therapy was considered to be effective when the VAS was reduced by more than 50%. Consequently, treatment was considered to be effective in 16 patients (59%) and non-effective in 11 patients (41%). In the patients where treatment was successful, theVAS changed from average 6.3 (range 4-8) before treatment to average 1.9 (range1-4) terwards. SSRI appears to be effective when treating patients with chronic low back pain or leg pain which is suspected to be strongly influenced by psychological factors.
In some cases, the cause of low back pain and leg pain can not be supported by diagnostic imaging. This study investigates tight filum terminale (TFT) which is tethered cord syndrome with normal conus position. The diagnosis was followed by Komagata's criteria :1) low back pain, 2) non-dermatomal leg pain, 3) bladder-bowel dysfunction, 4) spinal stiffness, and 5) positieve provocation test. The operation was the transaction of the filum terminale internum at S1 level. With regard to post surgical improvement of the clinical findings after the operation, the low back pain or leg pain, muscle power and sensory disturbance, bladder-bowel dysfunction and spinal stiffness respectively improved by 96%, 68%, 79% and 80%. The change was seen in the VAS scales from 10 to 3.3 in average. TFT should be considered as differential diagnosis for low back pain, especially when no abnormality in imaging was present.
We analyzed forty-nine patients who were operated on for recurrent lumbar disc herniation. 27 patients underwent primary surgery in the other hospitals and 22 in our hospital. The period from primary surgery to revision ranged from 7 days to 11 years. 42 patients were operated on by herniotomy while another 7 were performed additional posterolateral spinal fusion with herniotomy. Average JOA scores before salvage surgery in patients with and without posterior fusion were 11.0 and 10.5 points, respectively. Postoperative JOA score improved to 24.5 and 25.0 points on an average, respectively. In patients with spinal fusion, neither obvious adjacent segment morbidity nor pseudarthrosis have been experienced. The clinical results of re-herniotomy for recurrent lumbar disc herniation were satisfactory and might be the principle method. However, especially in cases with repetitive recurrence of herniation and/or spinal instabilities including the iatrogenic posterior element insufficiencies due to exposure in the salvage surgeries, additional spinal fusion with herniotomy would be advocated.
Many surgical treatments for spinal lesions associated with rheumatoid arthritis (RA) have been reported. Although most of the reports are related to the cervical spine, involvement of the lumbar spine has also been reported in a small number of cases. A 73 year old woman with a seven years history of classical RA was admitted to our hospital suffering from acute low back pain and numbness in both legs. X-ray film revealed a burst fracture at L4. MRI revealed compression of dural sacs due to retropulsed bony fragment. A two-stage anterior and posterior spinal fixation was performed. Postoperatively, enlargement of the lumbar canal and incorporation of grafted bone, as well as the sequential collapse of the upper level vertebra were noted. The RA patients who receive glucocorticoid develop severe osteoporosis. The risk of compression fractures was found to be more strongly related to the daily dose rather than the cumulative dose of glucocorticoid. We suggest that bisphosphonates should be administered at an earlier stage for osteoporosis resulting from RA and glucocorticoid.
Early clinical outcomes of microendoscopic discectomy (MED) were evaluated by comparing it with Love's method for lumbar disc herniation at L4/5 or L5/S1. Twenty patients treated by the MED method and 20 patients by Love's method, as a control group, were included in this study. Each surgery in both groups was performed by the same surgeon. Clinical outcomes in both groups were compared on the basis of operation time, blood loss, periods to initial walking, total dose of analgesics administered, and patient-based outcome using the Visual Analogue Scale (VAS) and Roland-Morris Disability Questionnaire (RDQ). While no significant difference in operation time, blood loss and the patient-based outcome were found, periods to initial walking were significantly shorter and total doses of analgesics administered were significantly lower in the MED group. It was consequently concluded that the MED method is a useful procedure for the treatment of lumbar disc herniation.
A retrospective study of lumbar disc herniation in the elderly was performed. Fifty-nine cases (37 males, 22 females) of lumbar disc herniation in patients over 60 years old operated on from 1988 to 2001 were evaluated. Clinical manifestation, physical condition, image findings and surgical records were examined.While younger patients showed more restriction in lumbar flexion than the elderly, elderly patients showed more restriction in lumbar extension. Most elderly patients showed the positive Kemp phenomenon and difficulty in walking due to leg pain. A positive SLR-test was less common as age advanced and the raising angle increased with age. Regarding with the position of herniation in the axial view, lateral types (foraminal and extra-foraminal) were more frequent. In the elderly, ADL quality was worse than in younger people. It is assumed that such characteristics are the result from relative stenotic conditions of the spinal canal and degenerative changes in the nerve root due to the aging.
The purpose of this research was to investigate the actual situation and course of treatment of outpatients with low back pain. A self-describing questionnaire was obtained three times in total: at the first visit; after two weeks and after one year. Four hundred forty-nine subjects completed the questionnaire and 359 of them were used as subject for this research after excluding those whose descriptions were insufficient. Subjects included 160 men and 199 women, and their average age was 50.0 years. Regarding the painful region expressed on a map of the human body, 72 percent of the subjects had pain in the lumbar area, while 18% in the buttocks. About 80% of the subjects had history of low back pain, and about half of them reported possible causes for the low back pain. One hundred sixty-one subjects had history of being treated for low back pain and 60% of them had been treated at an orthopedic clinic. With regards to the final status for the low back pain obtained from outpatient records, 20% of 359 subjects reported improvement or disappearance of pain, though 11% had still some low back pain, 3% changed doctors and the situation was unclear in 237 subjects (66%). As a result of the questionnaire after 2 weeks, low back pain had disappeared in 19% and improved in 56%. At the last investigation, low back pain had disappeared in 34% of subjects, while 30% of them were still receiving treatment for their remaining low back pain.
We evaluated the relative changes in tissue oxygenation during and after exercise in human lumbar muscle using near-infrared spectroscopy. Oxygenation changes in the trunk muscle were measured non-invasively using near-infrared spectroscopy (NIRS). The subjects analyzed were 111 volunteers over 60 year-old, comprised of two groups; the low back pain (LBP) group who complained of low back pain lasting more than 3 months and the non-LBP group who had no complaints of back pain. A near-infrared spectrophotometer was applied on the back, while maximally extending and bending the lumbar spine for 15 seconds, and isometric exercise in a standing position for 10 seconds. On lumbar extension, the amount of relative change in oxygenated hemoglobin (Oxy-Hb) and the tissue oxygen saturation index (SdO2) were significantly less in the LBP group than in the non-LBP group. No significant differences in deoxygenated hemoglobin (Deoxy-Hb) were found between the two groups on both extension and flexion. Relative changes of Deoxy-Hb and SdO2 were significantly higher in the LBP group than in the non-LBP group. The increase of Oxy-Hb during lumbar extension is conceived as the most available parameter in NIRS measurements, taking into account the performance of exercise even in patients with severe low back pain.
In this study the clinical results of surgery for posterior lumbar fusion by H-shaped autologous bone graft (H-graft) associated with ceramic interspinous block (CISB) are reported. The clinical results of this procedure have been excellent during the follow-up (average: 3.9±2.8 years) in all six cases. There was a marked improvement (recovery rate: 70.4%) of clinical symptoms assessed by the pre- and postoperative Japanese Orthopaedic Association low back pain score. In radiographic evaluation, the spinal alignment was maintained successfully. H-graft with CISB is a non-instrumentation, segmental fusion and decompression surgery. We believe that those most suitable for this method are young adults suffered from spondylolysis combined with upper adjacent level disc degeneration (type III), insufficient union after anterior interbody fusion (ALIF) or segmental stenosis with instability.
The aim of the present study was to ascertain whether an oscillating board (a training device manufactured by Galileo, Elk Inc.) was useful in preventing low back pain. A survey was conducted on employees of care facilities to identify those suffering from low back pain. Subjects were 14 employees (2 men and 12 women; age range, 22 to 54 years; average age, 38 years) with low back pain but without neurological abnormality. The subjects were instructed to do stretch exercises and use the Galileo oscillating board 20 minutes, twice a week for six months. The effects of this intervention therapy were assessed by quantifying the severity of low back pain using the Visual analog scale (VAS). In addition, fluctuations in the center of gravity (balance) were assessed in terms of total tract lengths and peripheral areas prior to and six months after the intervention therapy. Furthermore, at six months after the intervention therapy, another survey was conducted to ascertain the level of satisfaction and whether or not the subjects wanted to continue with the therapy. Improvements in lumbar pain were seen 2 to 3 weeks into the intervention therapy. Fluctuations in the center of gravity improved after therapy, suggesting that training using an unstable board improved balance. The results showed that satisfaction levels were high and many subjects answered that they would like to continue with the therapy. Hence, a training program using the Galileo oscillating board appeared to be useful for preventing lumbar pain.
For 200 examples diagnosed with lumbar spinal canal stenosis (LSCS) at outpatient in Intermittent claudication (IC), PWV and ABPI were measured with a blood pressure pulse wave inspection device. Subjects consisted of 89 males and 111 females with an average age of 71.7 years old. Seven PWV cases and 6 ABPI cases could not be measured. Artery confinement could be heard in 15 cases (7.5%) and 165 cases of PWV were 1400 or above the standard value, while 9 cases (4.5%) had an ABPI of and less than 0.9. Six subjects could not be measured. Even orthopedic surgeons should always take blood vessel characteristics and mental change caused by chronic artery confinement into consideration in patients presenting with IC. When 0.91-0.99 was used as a border domain, cases increased to 38 examples (16%), but with a measurement of less than 1.0, 6 out of 32 cases could not be measured.
This study was designed to evaluate the usefulness of a lumbar clinic for patients with low back pain. The clinic focused on individuality, continuation and a team approach. A clinical evaluation of 73 cases was carried out using the visual analogue scale (VAS) for low back pain and the Japanese Orthopaedic Association Score (JOA score). VAS improved from 4.6 points before attendance at the clinic to 2.6 points after attendance and JOA scores improved from 21.5 points to 23.3 points at the final follow up period, an average 17 weeks after ceasing to attend the clinic. A lumbar clinic can be useful for patients with low back pain, while continuation of self-exercise, and individualized management is also necessary.
In an attempt to reduce low back pain with prolonged sitting, a pneumatic device was developed to provide lumbar lordotic continuous passive motion (CPM). Three different designs of a chair, i.e. without lumbar support, with lumbar support and with the CPM were compared in 10 healthy male volunteers. Each subject used the visual analogue scales (VAS) for low back pain, stiffness, fatigue, and buttock numbness after 120 min of testing. Compared with the chair without lumbar support, VAS improvements for lumbar discomfort were statistically significant in both that with lumbar support and CPM (8.0 in the chair without lumbar support, 6.2 in the chair with lumbar support, and 6.2 in the chair with CPM, p<0.05). VAS for fatigue were also statistically significantly improved in the lumbar support and CPM (7.5, 6.0 and 5.8, respectively, p<0.005). Significant improvement in buttock numbness was noted only with CPM (6.3, 5.3 and 4.5, respectively, p<0.005). CPM presumably provides a comprehensive solution for occupational disability due to sitting intolerance.
There have been patients with vague, chronic intrapelvic pain called coccygeal, sacrococcygeal, sacral pain etc.. Minute intrarectal digital examination of those patients often reaveals tender induration(s) along the pudendal nerve. All the more, accumulation of the data of the patients shows they have symptom complex of pain, incontinence, difficult evacuation of the stool and also such abdominal symptoms as pain and fullness. Laboratory and roentgenological examinations of the sensory and motility functions of the anus, rectum and colon revealed dysfunctins of the 3 organs caused by disturbanse of the pudendal nerve and pelvic splanchnic nerve plexus, both of which originated from S2, S3, S4 nerve plexus. The 4 symptoms comprising the syndrome are named “Sacral nerve neuropathy syndrome” and are often accompanied disorders of lumbar spine. Further investigation is needed.
It has been reported that sensory nerves exist in the intervertebral disc and endplate and that these transmit pain sensation. In the present study we aimed to investigate the association with discogenic pain of abnormalities of the lumbar intervertebral discs and, in particular, the adjacent lumbar endplate, on magnetic resonance imaging (MRI). Using MRI we evaluated 47 patients with low back pain who had undergone anterior discectomy with successful mitigation of pain. Discography reproduced low back pain in all patients. 1) A normal endplate was recognized in 30% of the patients (normal group); endplate abnormality was recognized in 70% of patients (Type A: 14 cases; low signal intensity) and Type B (19 cases) for high signal intensity of a T1-weighted image. 2) The extent of disc degeneration in the Type A and B groups was more severe than in the normal group. 3) Significant intervertebral instability in the normal group was seen compared with the Type A and B groups. Some patients show normal endplate and moderate disc degeneration but severe intervertebral instability with symptomatic discogenic pain. In those showing intervertebral stability, however, abnormal endplate caused discogenic low back pain.
A retrospective long-term evaluation in 31 patients with degenerative lumbar spondylolisthesis treated by posterolateral fusion combined with pedicle screw fixation was done. The mean follow-up period was 10.8 years. The fusion rate was 100%, but corrected sagittal alignment was not maintained during the follow-up period. The mean recovery rate was 54.1%. Patients were divided into four groups according to their clinical outcomes. Six patients needed further surgery for adjacent problems (mean recovery rate before second surgery: 10.6%). Seven patients had some symptoms related to adjacent levels (mean recovery rate: 24.2%). Five patients had abnormal motion of adjacent levels without any symptoms (identical rate: 64.6%). Thirteen patients had no problems (identical rate: 66%). Adjacent problem were one of the factors that caused long follow-up poor surgical results. Hypolordotic alignment of fused segment was considered to be related to the adjacent problems.
The purpose of this study is to compare surgical outcomes of the 2 groups: decompressive laminectomy and laminectomy with fusion in lumbar spinal canal stenosis. The subjects were 269 patients (209 with laminectomy alone and 60 with fusion) were followed more than 1 year. Surgical time and amount of blood loss of the laminectomy group were significantly less than the laminectomy with fusion group. No difference of the outcomes was observed between the two groups in average recovery rates at the final follow-up, and also at short (<3years after surgery), middle (≥3years, <7 years), and long term (≥7 years) follow-up. Surgical outcomes in limited to degenerative spondylolisthesis showed similar results between the two groups. Interestingly, the patients with laminectomy rather had less low back pain than those with fusion at the short and middle term follow-up. In conclusion, surgical outcome of the laminectomy group was as good as with fusion group, therefore, it is thought to be a preferable surgery for the patients with lumbar spinal canal stenosis without instability.