In osteoporotic patients acute and severe back pain usually originates from vertebral compression fractures, and chronic one most commonly from an alteration in the supporting mechanism of the spine caused by vertebral body fractures. On MR images the signal intensity of the fractured vertebral bodies generally alter low on T1WI and high on T2WI in the acute phase. This changes in signal intensity are so highly sensitive to detect an additional fresh vertebral fracture in a patient with many prevalent vertebral deformities. Nonunion of vertebral body fracture is one of the causes of chronic back pain in osteoporotics, and it is likely to occur by an inadequate management in the acute phase of a fracture. A fracture line of nonunion is more readily recognized on extension x-ray films of the spine, and MR images also clearly demonstrate nonunion as a low signal intensity area on T1WI and definitely high on T2WI. Gd-enhancement is also useful to evaluate viability of the fracture site, and to predict the fracture healing process. Accordingly, osteoporotic vertebral body fractures are successfully treated by an adequate external fixation devices including a body cast and/or a long brace with reference to MR images additionally to X-ray findings.
X ray evaluation and ADL test were performed on 101 women diagnosed with osteoporosis. Patients presenting with rounded backs manifested more vertebral fractures, ambulated with reduced gait and demonstrated abbreviated sit-up ability than patients without rounded backs, ADL was lowest in the patients with both vertebral fractures and rounded backs, In most patients with osteoporosis, rounding of the back is compensated, initially by increasing lumbar lordosis, and then by pelvic posterior inclination and flexion of the knees. Once skeletal compensation was failed, patients often resort to the use of a cane to maintain a somewhat upright standing posture.
We have developed transpedicular injection of bioactive calcium phosphate cement (CPC) into the vertebral body for repair of osteoporotic vertebral compression fracture and the pseudarthrosis without neurological involvement as a less invasive surgical treatment for back pain in patients with osteoporosis who present with fresh vertebral compression fractures associated with acute back pain, vertebral pseudarthrosis resulting from a disturbance of bone union processes, and severe kyphotic deformity. The CPC used is injectable, non-exothermic, self-setting, and bioactive with osteoconductivity, and sets by hydration to change composition into carbonated hydroxyapatite. Its compressive strength increases over time, and reaches the maximum in about 7 days after injection. The maximum value is over 80 MPa, which is strong enough to reinforce the collapsed vertebrae. Traditionally, these painful conditions have been dealt with using conservative treatment, if they are not accompanied by neurological deficits. However it is also true that satisfactory results are not always obtained by such treatment. We have studied 19 patients who presented with fresh vertebral compression fracture, and 17 patients with delayed union or pseudarthrosis with at least a 3-month follow-up. Radiological examinations indicate that all fractures have been successfully repaired except for one case of pseudarthrosis. Pre-Post operative evaluations were carried out using a 10-point pain rating scale. For fresh fracture cases, the average 10-point pain scale was 8.1 preoperatively and 0.4 immediately postoperatively, and was 0.7 at final follow-up averaging 19 months after surgery. Wedging rate, which is defined as a percentage of the anterior vertebral height to the posterior one in a lateral x-ray film, is 65% before treatment and 84% immediately after treatment. Seventy-eight percent was maintained up to the final follow-up. No loss of correction was observed after 1 month. For delayed union or pseudarthrosis, the average pain scale was 7.2 preoperatively, 1.5 postoperatively, and 1.7 at final follow-up of average 13 months after surgery. The wedging rate is 30% preoperatively, 59% postoperatively, and 49% at final follow up. Correction loss occurred within 3 months postoperatively and did not change thereafater. The transpedicular injection of CPC into the vertebral body could be a valuable addition to the physician’s strategy in the treatment of back pain due to osteoporotic vertebral fractures and associated conditions, providing early pain relief and mobility, and good correction of the collapsed deformity.
Microlumbar discectomy is less invasive and yields more stable treatment results, it is thought to be one of the most suitable treatment program to introduce the clinical pathways in the field of Orthopaedic surgery. Fifty patients presenting with lumbar disc herniation have been operated on by this method since we introduced the clinical pathways. Patients in the study were evaluated by analyzing the surgical outcome, length of hospitalization, and other variances that occurred pre- and postoperatively and their effects on the course of treatment. Longer hospital stay preoperatively and less favorable results postoperatively were the two main variances that resulted in longer hospital stays. These problems should be resolved to carry out the clinical pathways more effectively.
Love Discectomy is standard surgical method of lumbar disc herniation, removal of disc herniation after partial laminectomy. Since 1999, we have used clinical pathway, that is postoperative schedule for patients treated by Love Discectomy. This study was designed to assess the effectiveness of using clinical pathway, in determining the outcome of patients with lumbar disc herniation treated by Love Discectomy. 42 patients who received Love Discectomy were divided into two groups, and were treated and tracked postoperatively, (1) traditionally (26 patients) and (2) with clinical pathway (16 patients). Our postoperative schedule using clinical pathway considerations was, standing on 2nd day postoperatively, removal of sutures on 10th day, discharge from hospital on 14th day. We evaluated length of hospitalization after surgery, hospital charges, and clinical results of surgery. The period until standing postoperatively was shortened from 2.5 days to 2.0 days significantly. (p<0.05) Length of hospitalization after surgery was shortened from 18.8 days to 13.8 days. (p<0.005) Hospital charges decreased into 762,000 yen from 905,000 yen, significantly. (p<0.005) The difference of hospital treatment among the doctors was decreased clearly by utilizing the clinical pathway protocol. (p<0.005) Length of hospitalization and cost of treatment were significantly reduced, and the clinical results with or without clinical pathway were same. These results suggest that the clinical pathway was effective for standardizing the treatment after Love Discectomy.
A short hospitalization is one of the important aspects in the operative treatment of lumbar disc herniation (LDH) with the clinical pathway program. In this study, we examined the risk factors associated with prolonged hospital stay after surgery. From 1994 through 2000, 107 patients who suffered from LDH underwent surgery (only partial laminectomy and discectomy) in our hospital, and 87 (81.3%) of them who left the hospital for home were reviewed retrospectively. The average period of hospital stay after surgery was 22.6 days and no significant differences were identified in the gender distribution. Duration of post-operative stay statistically significantly correlated with age but not with their pre-operative Japanese Orthopedic Association (JOA) score. Patients who stayed longer after surgery tended to have back or leg pains complicated by lumbar spinal canal stenosis (LSCS) and other medical conditions. As a result of statistical analysis, we concluded that a patient more than 40 years old would be expected to stay more than 4 weeks in the hospital. We used the clinical pathway protocol for 6 patients of LDH from March 2001, and the shortening of hospitalization was achieved. Further the investigation of the relation between variances and risk factors for the treatment based on clinical pathway is needed.
Background: Many benefits have been associated with the use of clinical pathways. The idea of Clinical pathways has been used to reduce length of hospital stay, readmissions, and resource utilization and also to increase patient satisfaction. It facilitates the management of defined patient groups using interdisciplinary plans of care. The aim of this study is to evaluate the effectiveness of clinical pathways in patients with lumbar disc herniation who have undergone discectomy. Materials and Methods: We introduced a clinical path for discectomy of lumbar disc herniation from March 1999 through June 2001. One hundred and fifty eight patients who were managed on a clinical pathway for a 27-month study period were compared with a retrospective group of 64 patients who underwent the same procedure prior to the pathway’s implementation. The variables of the study are length of postoperative hospital stay, variance rates, and patient’s satisfaction. Results: Variance of discharge was recorded in eleven of these patients (6.2%). The main reasons of the variance were postoperative problems (i.e. delay of recovery, and recurrence of disc herniation). The average length of stay was reduced from 17.5 days prior to implementation of pathways to 14.8 days in clinical pathway group. Almost all patients were satisfied using clinical pathways. Conclusion: We concluded that a clinical pathway adapted for discectomy of lumbar disc herniation, provided significant improvement in outcome, satisfaction and recovery rates. Factors critical to success are multidisciplinary teamwork and communication. Clinical pathways can be used as a means of incorporating evidence-based medicine into clinical practice. Variance analysis of the pathways can be utilized as a process of quality control to improve patient outcomes.
Since September, 1998 We incorporated clinical path considerations when perfoeming lumber laminectomy. Early ambulation without brace and the cource of postoperative rehabilitation was shorter than conventional rehabilitation. Almost all patients were able to ambulate on the fourth postperative day and were discharged from our hospital on the 14 postoperative day. The average recovry rate of JOA scores did not differ between experimental and control groups. Clinical path is very useful for lumber laminectomy.
Acute locked back is characterized by the sudden onset, of severe incapacitating low back pain without radicular pain or neurological deficit in the lower extremities.We classified acute locked back as discogenic if it was relieved by an intradiscal injection of local anesthetics into the disc selected on MR imaging.Using these criteria,acute locked back was diagnosed in sixteen patients (70%) out of 23patients (mean age 36 years), and evaluated in terms of the clinical features and pathogenesis. Pain generally occurred upon casual motion of the lumbar spine during normal daily activities. Tenderness of paravertebral muscles was observed in 5 patients (31%). The painful region in 8 patients (50%) was observed at the central and bilateral portions of the low back. Severe narrowness of the disc on plain radiogram was not observed in any patients. Radiating tears on discogram, indicating intradiscal tears as far as the posterior annulus, were observed in all patients. Disc degeneration on T2-weighted image was observed in all patients and classified into grade 3 (Gibson’s classification) in 15 patients (94%). An enhanced lesion in the posterior annulus on enhanced MR images, indicating repair of the torn posterior annulus, was observed in 10 patients (63%). The pathogenesis of discogenic acute locked back is considered to be a re-rupture in the torn and repaired posterior annulus of a moderately degenerated disc.
An epidemiological study of low back and leg pain was conducted on 623 elderly persons in Sagae City, Yamagata Prefecture. There were 261 men and 362 women and the age was 65 to 93 years old. Disability in activities of daily living according to Japanese Orthopaedic Association score was investigated. Low back pain and leg pain was reported in 58.6% of respondents. 12.2% of study respondents reported difficulty in turning over while in bed; 34.2% reported difficulty in standing up; 33% reported difficulty moving from a half-sitting posture to standing upright. 1% of the s#tudy participants reported difficulty in washing their face. Sitting was difficult for 13.4% of our study group, and 48% reported difficulty in lifting heavy weights. 33.9% of the elderly experienced difficulty in walking. It is necessary to prevent disability due to low back pain and leg pain in the elderly.
Six female patients with neurological deficit due to late vertebral collapse after an osteoporotic vertebral fracture underwent posterior decompression and posterior interbody fusion without rigid instrumentation. The average age at surgery was 76 (69-86) years. T12 was collapsed in 1 patient, L1 in 1, L2 in 2, L4 in 1, and L5 in 1. The average follow-up was 25 (7-57) months after surgery. All patients had returned to their routine daily life, and symptoms were improved soon after surgery. In follow-up, no notable complication was encountered. We conclude that this procedure can provided a satisfactory outcome without instrumentation failure for elderly patients with osteoporosis.
For patients who after lumbar surgery, developed first toe pain refractory to analgesic and narcotic drugs, we administered the trigger point injection around the base of the metatarsal bone between the first toe and second toe, which happened to be markedly effective. This injection may play a role of deep fibula nerve block. We have performed deep fibula nerve block 1-3 times in 22 patients with lumbar degenerative disease, whose chief complaint was low back pain or lower extremity pain. The drug used was produced by adding a 0.5mg of dexamethasone phosphate to 1%mepivacaine hydrochloride (Final volume : 5ml). The needle used was 25G or 27G. Cramp at night in elderly patients has been hardly treated sufficiently so far. Deep fibula nerve block effectively suppressed cramps in the lower leg or the fifth toe. Therefore, we suggest that the deep fibula nerve block can be one of the effective treatment for cramps.
46 patients (23 men and 23 women) with an average age of 70.2 were diagnosed with lumbar canal stenosis and were treated by nerve root block. They presented with an average JOA score of 15.3 points. We evaluated JOA score, the findings of the myelogram and the diameter of the lateral recess. The surgery was performed in 15 cases. 31 of 46 cases were deemed unsuitable for surgical intervention. All those cases were followed up for more than 6 months. The outcome for these 31 patients was “excellent” in 12 cases, “good” in 10 cases and “poor” in 9 cases. Our study concluded that spinal nerve root block was more effective in addressing radicular symptoms without severe lateral stenosis.
This study discusses the effectiveness of lumbar flexion exercise for patients with lumbar facet syndrome (LFS), that was measured radiographically with patients standing relaxed and in lumbar maximum extension side lying saggitally. Subjects were 35 outpatients with LFS who performed lumbar flexion exercises. These patients presented with no root sign, but increased pain with backward bending. Positive therapeutic effects were obtained in 88.6% of the subjects and they combined with no and relieved low back pain (LBP). Lumbar segment motions were measured of the X-ray films in relaxed standing and lumbar maximum extension side lying. And this data was compared with the grade of LBP relief. Patients for whom this regimen was effective demonstrated increased mobility, and on the other hand, in ineffective patients showed hyperlordosis at the beginning of flexion exercises. Conclusion: Lumbar flexion exercises proved to be useful for LFS. Lumbar segment motion improved in relaxed standing and lumbar maximum extension at side lying position of the patients with relieved LBP.
Microdiscectomy was performed on 75 patients (54 males and 21 females with an average age of 35.0 years at operations) diagnosed with lumbar disc herniation. The disc herniations were located as follows: L1-2; 1, L2-3; 2, L3-4; 9, L4-5; 46, and L5-S1; 17. All patients exhibited herniation at a single level. The average follow-up period was 64.4 months. The postoperative outcomes were evaluated according to the Japanese Orthopaedic Association scoring system for lumbar disease and Hirabayashi’s improvement rate. Postoperatively, the average JOA score improved from 12.1 to 26.7 points. Hirabayashi’s improvement rate was 86.4%. A recurrence of same level disc herniation was observed in 3 patients. We conclude that microdiscectomy provided satisfactory postoperative outcome in majority cases. Average intraoperative blood loss was 36.5g. Postoperatively, only 6.7% complained of low back pain, suggesting that this procedure was less invasive. Microdiscectomy has some problems such as a postoperative treatment program and possible recurrence of herniation. However, since microdiscectomy is less invasive and obtains satisfactory postoperative outcomes, it is still considered to be an effective procedure.
The purpose of this study was to investigate trunk muscle activity on lifting with trunk rotation (6.8 kg weight, elevation from knee to shoulder, 50cm lateral shift). Twenty healthy male volunteers participated in this study. Muscle activities of the elector spinae and the oblique muscles were measured bilaterally using a surface electromyograph. Muscle activity of the subjects -with or without lumbar belt-were compared in with each subject peforming the same task. Myoelectric activities (%MVC) of the elector spinae muscles were 4.6 times larger than those of oblique muscles. No differences were observed between right and left muscle groupes. Muscle activity was significantly reduced when subjects wore the lumbar belt; elector spinae muscles by 14.6%, oblique muscles by 18.9%. Conclusion, elector spinae muscles played a greater role in lifting tasks involving trunk rotation, and the use of a lumbar belt reduced the load of both trunk muscles.
We sought to determine occupational risk factors possibly contributory to chronic low back pain (CLBP) in teachers of physically and mentally challenged children using consecutive questionnaires with a new standard for the LBP with visual analog scale (VAS) and pain drawing (PD). The investigation was designed as a prospective cross-sectional study in 2000 and 2001 based on analysis of 1,821 and 1,825 teachers respectively, who taught physically and mentally challenged children in Osaka, Japan. Survey respondents whose self-reported LBP pain score was 1.0 or higher with a pain distribution that was confirmed in the low back or buttock area comprised 30% and 31% of the samples in 2000 and 2001 respectively. In individual follow ups the rate of LBP with a positive pain score was reduced to 24% in both annual cohorts. In a univariate analysis between the two groups, comparing LBP and non-LBP groups, there were not significant risk factors associated with LBP viz. age, or BMI. Significant differences emerged with regard to reporting previous and/or present history of other illnesses in each group. We conclude that consecutive questionnaires surveying the instances of CLBP were valuable in demonstrating the rate, appearance, and the risk factors associated with chronic low back pain.
Japanese institutionalized children with mental and physical handicaps who have now become middle aged and are more difficult to manage. Low back pain is now on significant condition for the staff who take care of these patients. So we have investigated the condition of low back pain among 87 staff members (71women and 16men) in a hospital for mentally and physically handicapped patients. The mean staff age was 45 years, ranging from 23 to 63 years, and the mean length of service was 14 years. All the staff were examined using X-ray of the lumbar spine, the JOA score, and others. 71 staff complained of low back pain, especially when in a half sitting position and lifting patients. X-ray findings were not related to low back pain. However, there were increased degenerative lumbar changes in staff over fifty. Based on these findings the author suggested 4 points to prevent low back pain and emphasized to reduce the amount of lifting for staff.
Twelve patients (1 male, 11 female; mean age 75.6 years) in whom during the course of treatment for osteoporotic vertebral body fractures, a vacuum phenomenon on x-ray films was shown in the fractured vertebral body were investigated. This vertebral body vacuum phenomenon in osteoporotic vertebral body fractures was seen in the transitional area between the thoracic and lumbar spine, and appeared at a mean of 2.3 months after the onset of the vertebral body fractures. It showed a predilection for cases in which to correct kyphosis during the fracture treatment period, extension exercises were undertaken and the patient remained supine in bed. With conservative therapy, including restriction of extension of the spinal column and prohibition of the supine position while in bed, the pain disappeared or abated. In half of the patients the intravertebral vacuum disappeared, and it tended to diminish in others.
We studied the relationship between respiratory function and trunk muscle strength in patients with low back pain [Subject and Method]: At first we examined a correlation between the trunk muscle strength and respiratory function in healthy young women. Next step was that we compared the respiratory function between the patients with the low back pain and osteoarthritis of lower extremities. [Result]: No relationship between muscle strength and respiratory function was found in healthy women. The low back pain group, however, was highly significant in VC and FVC and ERV. [Conclusion]: We think that there is a little influence of rectus abdominis on the respiratory function. On the contrast, the abdominal transverse muscle could play a significant role to the abdominal transverse muscle is very important in patients with low back pain. So we suggest that ERV is to be increased by using the abdominal transverse muscle.
The clinical pathway has become popular strategies to improve the quality of medication and to obtain shorter period of hospitalization. The aim of this study was to establish the clinical pathway of lumbar microdiscectomy. Sixty-three cases of the lumbar microdiscectomy were included in this five-year retrospective study. Patient age ranged from 14 to 60 years with an average of 35.7 years. An average period of hospitalization was 27.3 days. The JOA score of before and after the operation were an average of 15.8 points and 25.4 points, respectively. The average rate of improvement was 71.1%. With regard to postoperative treatment, antibiotics were administrated intravenously an average period of 6.2 days. The cases were divided into 2 groups; patients with antibiotics for 7days or more, and those for less than 7 days. There is no difference between 2 groups in terms of the wound healing. The period of sitting and walking were divided into two groups; patients for 3 days or more, and those for less than 3 days. There is no difference between 2 groups in the average rate of improvement. Our clinical pathway is as follow; period of post operative antibiotic treatment is for 3 days, followed by a period of sitting and walking for 3 days.