The Oswestry Disability Index has been one of the most common disease specific measures for patients with back symptoms in the world, and has been cross-culturally translated into Japanese without loosing psychometric properties of the original versions. This instrument correlates well with mental sub-scales of the SF-36 as well as physical ones, and it is suited to situations in which patients have persistent severe disability, though it functions satisfactorily in groups with mild to moderate disability. New instruments have been developed with higher reliability and validity compared to older ones in Japan. The availability and its history of the Oswestry Disability Index in a wide range of languages have great advantages in direct comparison with past numerous studies through the same instrument.
Roland-Morris Disability Questionnaire(RDQ)is a scale that allows the patients themselves to assess the degree of disability experienced during daily activities as a result of low back pain. There are 24 items that ask about the degree of disability experienced during daily activities such as standing, walking, sitting, getting dressed, and working. Each item in the RDQ can be answered with either"Yes" or "No", and the number of "Yes" results the RDQ score. The RDQ Japanese version was reported to have sufficient psychometric properties. Strength of this scale is their feasibility and interpretability (i.e. RDQ has Japanese norm score) . Limitation of this scale is insufficient accuracy due to few items. It is important to select the scale on the intended use in consideration of the above properties.
JOABPEQ was made for developing a new scientific outcome measure to revise the JOA scoring systems for low back pain. The Japanese Society for Spine Surgery and Related Research (JSSR) held the first working group meeting on June 2000, and finished and released it as new one of JOA scores on May 2007. The basic ideas were to be; 1) disease-specific, 2) patient based, 3) from the viewpoints of dysfunctions, disabilities, handicaps in the social life multi-dimensionally, and with evidence-based methods. The user's guide gives some instructions; 1) JOABPEQ consists of five factors; Low back pain, Lumbar function, Walking ability, Social life function and Mental health, and the range of the score for each domain is from 0 to 100, with higher scores indicating better condition. 2) Five severity scores should be used independently. Adding all or some of the five scores makes no sense, so do not try to total the scores.3) As the five severity scores are not confirmed to follow normal distribution, noarametric statistical tests should be used.
There was no gold standard diagnostic criteria for LSS. Clinicians cannot rely solely upon diagnostic imaging tests to make the diagnosis of LSS. Therefore, we developed diagnostic support tools for LSS with high sensitivity and specificity. We have the diagnostic support tool for doctors and the simple questionnaire for patients. It is possible to diagnose patients with LSS using these tools; and we expect that its use for patients to diagnose themselves will contribute to making a better diagnosis for patients undergoing primary care treatment.
The aim of the present study was to clarify the actual state of low back pain and disability in quality of life(QOL)with among carers. A survey was conducted on 894 carers(319 men and 575 women; age range, 19 to 60 years; average age, 46.1 years). Disability in QOL according to the Japanese version of the Roland-Morris Disability Questionnaire(RDQ)was investigated. RDQ score 0 was reported in 67%. RDQ score 1-4 was reported in 24.6%. RDQ score 5-22 was reported in 8.4%. Since the results of the survey showed that few subjects have poor QOL related to low back pain.
Examining the effect of muscle stretching and self-training (hospital-prescribed method) for chronic lower-back pain. The maximum treatment period in the survey was 3 months since the previous outpatient consultation. The test group was divided into three: a control group, Exercise 1 group (carrying out SLR with trunk muscle contract relaxation), and Exercise 2 group (carrying out SLR with trunk muscle strengthening and lower back stretching). For each group, the pain, change of physical function and health-related QOL were examined at 3 months and 6 months after the start of the research period. The results showed that in the Exercise 2 group, pain and physical function was improved at 3 months; in the Exercise 1 group, almost the same effect was shown as in the Exercise 2 group at 6 months. The item which was most closely related to pain alleviation was trunk flexibility and trunk extension strength. In conclusion, for outpatients suffering chronic lower-back pain, follow-up treatment which gives precedence to trunk muscle strengthening and flexibility improvement through self-training would be an effective means of alleviating pain and improving physical function and patient satisfaction.
We can evaluate a degree of low back pain objectively by measuring paraspinal muscle activity using a surface electromyogram. For example paraspinal muscle activity during walking in patients with lumbar degenerative kyphosis was detected to resume a normal rhythmic pattern by means of a cane. In patients with acute low back pain, a lumbar corset was presumed to make paraspinal muscle activity decrease during motion. Together with a similar report in patients with chronic low back pain, this decrease effect for muscle activity may be attributed to a clinical effectiveness of a lumbar corset. On the other hand, long-term wearing of orthosis might cause disuse atrophy of paraspinal muscle. A lumbar corset usage is so far recommended for patients with acute low back pain in a short term.
Low back pain is common disease, and is one of the most crucial problems in the world. Fifty thousands million dollars per year were paid for the low back problem in the United States. Many authors have reported etiology, pathology, diagnosis, and treatment of pain originated from lumbar intervertebral disc, however the mechanism and treatment for discogenic pain remains to be unclear. In our department, we performed anterior lumbar interbody fusion for discogenic low back pain. We clarified patho-mechanism of discogenic pain from this procedure. In this manuscript, we stated mechanism, estimation, treatment, and surgical results of the discogenic low back pain.
The purpose of study is to consider the indication and limitation of posterolateral fusion using pedicle screw systems (PLF) for degenerative lumber spondylolisthesis. Clinical and radiographic outcomes for 49 patients who underwent one-level PLF were analyzed. The mean follow-up period was 7.2years. JOA score was maintained at the time of the last investigation. The corrected alignment was not maintained during the follow-up period. The kyphotic bony union caused by correction loss was recognized quite frequently in PLF, but it was converged to less than 5 degrees by pedicle screw systems. The one-level kyphosis at less than 5 degrees did not influence postoperative clinical outcomes. A clinical result of PLF was good in degenerative lumber spondylolisthesis to usually experience. PLIF is superior at the point of alignment correction, but the operative indication may be limited to some high instability cases when adjacent problems and the difficulty of the re-operation are considered.
Approach related back muscle injuries have been focused on recent years as a drawback of posterior spinal fusion. Several minimal access fusion techniques were developed to prevent back muscle injuries. The authors have developed mini-open TLIF technique in which combined midline and Wiltse approach was employed for lumbar interbody fusion. In this article, surgical techniques, learning curve, and effectiveness of mini-open TLIF against approach related back muscle injuries were demonstrated.
An instrument and an implant are developed for minimally invasive spine surgery (MISS), and, as for the operation manual skill, it is devised having many kinds. As for the approach, intermuscle approach and hemi partial laminectomy and bothside decompression became popular. We performed MIS-PLIF in 319 cases for LSCS from 2003. The use system is SEXTANT 143 cases, PathFinder 113 cases, XIAprecision 11 cases, MANTIS 6 cases, others 45 cases. The operation method does a small open wound by tube retractor and decompress spinal canal and one intervertebra cage and fixation by both sides percutaneous pedicle screws and rods. An average amount of bleeding is 119g for 107 minutes for one level. I place the operation manual skill of MISS as a new spine surgery skill not extension of the conventional surgery. A system for MISS develops, and it is used for a multi level case in future. Therefore it is important that we know the structure and the character for uses well and apply it to one's operation.
In order to solve the loss of segmental mobility and adjacent segment degeneration after spinal fusion, various motion preservation technologies were clinically applied. They were mainly divided into the total artificial disc replacement (TDR), artificial nucleus, dynamic stabilization, facet joint replacement, and the intervertebral disc regeneration. Regarding TDR, the clinical trials of anterior lumbar TDRs have been performed in USA, and there have been several discussions about the surgical indications, clinical outcome, and complications. These 1st generation TDRs provided the acceptable short-term results, however, the surgical complications regarding anterior lumbar approach, device dislodgement, and the limited surgical indication were pointed out. Our biomimetic three-dimensional fabric disc (3DF disc forth model) includes the two designs of anterior cervical and posterior lumbar replacements that will solve the above-mentioned surgical issues. After obtaining the acceptance for starting the clinical trial from the ministry of health and welfare, our artificial disc will be evaluated by international multicenter clinical trials.
Intervertebral disc disease are one of the most frequent reason to see a doctor. In order to establish a simple and effective method to evaluate the quality of disc cells taken from surgery, we performed a colony assay and found that several different colonized cells can be seen. With the use of the colony assay, we were able to detect the biological potential of intervertebral disc cells for clinical application.
Low back pain and associated spinal disorders are formidable problem. Although disc degeneration is believed to be one of the major causes of low back pain, patho-mechanisms are still unknown. Biological approaches to regenerating these pathological discs started by using proteins so called growth factors. To overcome relative short duration of growth factors effects, transfer the genes encoding these growth factors to the disc cells was developed. Furthermore, cell therapy is recently reported using, for example, "stem cells". Within gene therapy fields, developments were attempted to use non-viral vectors and the RNA interference technique to continuously down regulate the harmful genes for normal physiology of the discs, so that we can expect more prophylactic effect such as delay the process of disc degeneration or regenerating disc in a long periods.
Lumbar support is one of the most common treatments for low back pain patients in Japan and around the world. However, there is no established consensus in terms of indication and mechanism of the effect. We conducted a questionnaire survey among orthopedic surgeons concerning the use of lumbar supports and reviewed related studies. In addition, we examined ROM, extra-abdominal pressure, physiological cost index(PCI)with a lumbar corset and two types of lumbar supports to investigate their effectiveness. The results were as follows; 1)80% of orthopedic surgeons responded that lumbar supports were effective for pain management and it was clear that they considered that ROM and external-abdominal pressure could relieve pain. 2)We obtained limited evidence that lumbar supports are an effective treatment and also useful for prevention. It was also shown that the definition of lumbar support has not yet been established. 3) It was shown that lumbar support causes more than 30% ROM limitation and more than 4.0kPa external-abdominal pressure increase. With a lumbar corset the PCI result of walking was not very good.
Radicular pain can occur in either subarticular entrapment in the lateral recess or central stenosis. Because many central stenosis patients were associated with subarticular entrapment, the incidence of subarticular entrapment as a cause of radicular pain has not yet been elucidated. Magnetic resonance myelography (MRM) can differentiate subarticular entrapment from central stenosis by visualization of the nerve root in the distal portion of compression. In the present study, morphologies of the root sleeve in patients with painful radiculopathy due to spinal canal stenosis were determined on MR myelograms. Of 65 affected nerve roots in 48 consecutive patients (M/F = 25/23, mean age = 68.2 years), 35 nerve roots showed purely antero-posterior compression (subarticular entrapment) and 30 nerve roots showed medial deviation. The site of compression was classified as above (8) or at the exit of the root sleeve from the dural tube (57).
Recently we demonstrated that the dual CPM device works effectively in the prevention of low back pain during prolonged sitting. This device has two synchronized bladders, one providing lumbar support and one located in the front portion of the seat providing reciprocal motion. In the present study, whole body movements and pressure distribution changes at the human-seat interface were analyzed in 13 normal male volunteers. The benefits of the dual CPM over lumbar support CPM may be explained by equivalent, but unstrained anterior pelvic rotation in simultaneously synchronized motion modality and significantly larger motion in the lumbo-pelvic spine in reversely synchronized motion modality.
McKenzie method (MDT) is a system for assessment and treatment for musculoskeletal disorders developed by Robin McKenzie, PT in New Zealand. MDT was applied to a patient who was diagnosed as having lumbar disc hernia and presented severe gait disturbance due to sciatica. Although the patient presented many features of irreducible derangement in the initial evaluation, deliberate loading strategy following the principle of MDT resulted in remarkable improvement of gait and sciatica within 3 weeks, which was deemed to be a faster recovery than expected.
To facilitate the clinical diagnosis of lumbar spinal stenosis, we developed a self-report instrument based on five of the ten items in the existing clinical diagnosis support tool. The unmodified tool was administered to 280 patients consisting of 142 with lumbar disc herniation and 138 with lumbar spinal stenosis, confirmed at surgery. The resulting sensitivity was 92.0% and the specificity was 63.4%. Then the new instrument, as well as the previously available tool were used to evaluate 201 outpatients with unknown diagnosis. In these 201 outpatients, the resulting sensitivity was 95.7% (compared to 97.4% for the tool), and the specificity was 31.8% (compared to 53.6% for the tool). The 201 outpatients consisted of 116 with lumbar spinal stenosis and 85 with no stenosis. The new instrument may be useful for initial screening because it is simple and easy. Further refinements are planned to improve its usefulness.
The objective of this study was to assess the validity of the SLR test for lumbar disk hernia(LDH)and osteoarthritis of the hip(OAH). The subjects included 23 male and 118 female patients(43-89years)with OAH and 63 male and 39 female patients(16-76years)with LDH. The clinical findings of the SLR test were investigated in the two groups. The incidence of limited of SLR angle(<70°)was 79% in LDH , 26% in OAH and the pain rate was 83% in LDH, 25% in OAH. All of the above of the SLR test were significantly more frequent in LDH than OAH(p<0.01). The SLR test was demonstrated to be very sensitive for the detection of LDH. However, based on the fact that the sensitivity of the SLR test was about 30% in OAH, the SLR test did not always differentiate OAH from LDH.
In general, therapeutic exercise for lumbar herniated nucleus pulposus (LHNP) is lumbar extension exercise, and that for lumbar facet syndrome (LFS) is lumbar flexion exercise. However, it is sometimes very difficult to choose which of these therapeutic exercises is appropriate, since both symptoms may be very similar on occasion. Therefore, we devised an estimation method for diagnosing LFS. This study investigated the usefulness of the knee lifting test (KL-t). Seventy-three patients treated by therapeutic exercises were analyzed. As symptoms after this test, reduced LBP was a positive reaction, while no reduction of LBP was a negative reaction. Forty-six patients were positive, 40 of whom were diagnosed as having LFS. Lumbar vertebrae lordosis was significantly decreased in the positive patients after the test. KL-t is a useful test to select the therapeutic exercises for LHNP or LFS.
One hundred seven patients with low back pain without neurological deficit were evaluated using JOA Back Pain Evaluation Questionnaire (JOABPEQ). Every JOABPEQ score of the patients was significantly lower than that of the control. Every JOABPEQ score had a moderate positive correlation with the other, and each had a moderate negative correlation with VAS related to low back pain. Different outcomes of JOABPEQ score were obtained when the pain site was different. With or without pain at every level of the multifidus muscles, there were significant differences in the pain-related score of JOABPEQ. Patients with or without pain of the upper portion of the spine erector muscles showed significant differences in all JOABPEQ scores.
Spondylolysis is known as a cause of the waist pain by the sport,but articular process fractures are seen rarely. Although eight of the cases in our series presented bone fragments at inferior articular process ,there was no symptom in two cases. Six of the cases presented bone fragments at superior articular process.
Current trends in delayed diagnosis of tuberculous (TB) spine and associated factors were retrospectively analyzed. A total of 17 subjects who were admitted to our hospital between 2005 and 2009 were included in this study. Diagnosis of TB was made by PCR in 8 patients (57%). Culture for acid-fast bacteria was negative in 3 patients 8 (37%).There were 7 patients in the delayed diagnosis group, defined as patients whose diagnosis of TB spine required more than 5 months. In this group, there was no past history of TB. Mantoux test was never attempted. Of these 7 patients, 5 had been surgically treated because of misdiagnosed etiologies. Although osteoporotic compression fracture was a common misdiagnosis (n=4), three patients showed abscess formation and/or disc lesion on retrospective review of the pre-surgical diagnostic imaging studies.
Percutaneous Endoscopic Lumbar Discectomy is a one night stay surgery with a 7 mm incision under local anesthesia. We discuss 3 methods and each indication for 197 herniations from April 2007 to March 2008. The average age was 48.8 years old, 136 men, 61 women. They were 112 transforaminal approaches from L2/3 to L5/S1, 64 interlaminar approaches for L5/S1 with high iliac crest and 21 extraforaminal approaches for lateral herniations. The migration over more than 1cm, instability, lateral recess less than 3mm and osseous proliferation were excluded. JOA score was 11.1 preoperatively, 20.5 (1 month later), 22.2(3M), and 22.0(6M). VAS of buttock and legs pain were 7.2 preoperatively, 2.1(1M), 1.6(3M), 1.5(6M later). 16 revision operations(8%) were for 1 level mistook case, 1 unclear view due to bleeding, 1 decreased blood pressure, 2 impossible insertions, 4 remnants, 4 recurrences and 3 adhesions of post-operation.
This study investigated in detail the disabilities of 122 patients with residual symptoms after herniotomy for lumbar disc herniation. Ten cases showed exacerbation of symptoms two weeks after discharge. Thirty cases showing good results at surgery were also selected as the control group. Disabilities were evaluated using ODI and ODI sub-score. In general, ODI sub-scores of the exacerbation group, especially that for "sitting", were significantly higher than those of a control group. In addition, patients showing higher scores for "sitting" and "lifting" had increased lumbar pain and could not return to work early. This study indicated that suitable exercise and daily habits can prevent exacerbation of symptoms after discharge.