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Study Design. This was a multicenter, factorial, randomized, controlled trial on the postoperative management of spinal surgery patients, with randomization stratified by surgeon and operative procedure.Objective. This study sought to determine whether the functional outcome of two common spinal operations could be improved by a program of postoperative rehabilitation that combines professional support and advice with graded active exercise commencing 6 weeks after surgery and/or an educational booklet based on evidence-based messages and advice received at discharge from hospital, each compared with usual care.Summary of Background Data. Surgical interventions on the spine are increasing, and while surgery for spinal stenosis and disc prolapse have been shown to be superior to conservative management, functional outcome, and patient satisfaction are not optimal.Methods. The study compared the effectiveness of a rehabilitation program and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with "usual care" using a 2 x 2 factorial design, randomizing patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analog scale measures of back and leg pain.Results. Three hundred thirty-eight patients were recruited into the study and measurements were obtained preoperatively and then repeated at 6 weeks, 3, 6, 9 and 12 months postoperatively. Twelve months postoperatively the observed effect of rehabilitation on ODI was -2.7 (95% CI: -6.8 to 1.5) and the effect of booklet was 2.7 (95% CI: -1.5 to 6.9).Conclusion. This study found that neither intervention had a significant impact on long-term outcome.

STUDY DESIGN Prospective cohort study. OBJECTIVE To study the effect of surgical retraction on paraspinal muscle function and investigate the effect of intermittent muscle retraction. SUMMARY OF BACKGROUND DATA Paraspinal muscle retraction leads to increased intramuscular pressure with a reduction in local blood flow resulting in ischemic damage. This may lead to muscle dysfunction and increased back pain after surgery. METHODS Two groups of 20 patients underwent one-level decompressive lumbar surgery. Group A underwent continuous muscle retraction, group B underwent intermittent muscle retraction. All patients completed pain questionnaires and underwent spinal strength assessment, paraspinal needle electromyography (EMG) before and after surgery, and had intraoperative muscle biopsy analysis using the technique of birefringence. RESULTS Pain questionnaires revealed a reduction in back pain in all patients following surgery; patients with shorter retraction times had less pain (P < 0.05). Paraspinal muscle histochemistry revealed patients with shorter muscle retraction times and patients who underwent intermittent muscle retraction has less damage (P < 0.05). Isometric strength testing revealed patients in the intermittent retraction group had a less profound reduction in strength after surgery (P < 0.05). Needle EMG data and pain questionnaires showed no differences between the continuous and intermittent groups, although EMG data did show that muscle shows evidence of reinnervation after surgery. CONCLUSION Although histologically there was a reduction in muscle damage in patients that underwent intermittent retraction, there was no benefit on clinical outcome. Paraspinal muscle shows evidence of reinnervation after surgery.

STUDY DESIGN This was a prospective pilot study examining pre-, intra- and postoperative measures. OBJECTIVES The aim of the study was to investigate the effect of muscle retractors on the posterior spinal muscles during posterior spinal surgery. SUMMARY OF BACKGROUND DATA Previous studies have identified changes in the structure and function of the back extensor mechanism as a result of low back pain. However, the effect of surgery on the functioning of these muscles, particularly surgical retraction, has received less attention. METHODS Twenty patients undergoing posterior spinal surgery were recruited into this study, and recordings of intramuscular pressure during surgery were performed using a pressure-monitoring system before insertion of retractors, 5, 30, and 60 minutes into surgery, and on removal of retractors. Before and following use of the retractors, muscle biopsies were taken from the multifidus muscle for analysis using birefringence techniques. RESULTS A significant increase in intramuscular pressure (P < 0.001) was observed during surgery. On removal of retractors, this pressure returned to or near to the original value. Analysis of muscle biopsies using calcium activated adenosine triphosphatase birefringence revealed a reduction in muscle function following prolonged use of self-retaining retractors. CONCLUSIONS A substantial rise in pressure in the erector spinae muscle during posterior spinal surgery was observed, and this appeared to be associated with marked changes in the function of the muscles. This could be an important factor in the generation of operative scar tissue and postoperative dysfunction of the spinal muscles.

Study Design. Open interventional MRI techniques were used to investigate the intervertebral mobility of the lumbar spine in subjects with isthmic and degenerative spondylolisthesis. The findings were compared with those in a published database of subjects with no history of low back pain. Objective. To investigate patterns of intervertebral mobility in subjects with spondylolisthesis to determine the level of spinal instability in this population. Summary of Background Data. Subjects with spondylolisthesis have been considered to present with a special form of spinal instability. Consequently, this condition is frequently managed by spinal fusion. However, confusion exists regarding whether there is excessive motion at the level of the defect. Methods. For this study, 29 subjects presenting to spinal clinics with spondylolisthesis (15 isthmic and 14 degenerative) were recruited and compared with an existing database of control subjects. The motion characteristics of these subjects in flexed and extended positions were investigated using interventional open MRI of known precision. In all the subjects, the level of resting pain, the grade of slip, and the level of the defect were noted. Results. No mobility differences, in terms of both angular and translational motion, were found between the subjects with spondylolisthesis and those with no history of low back pain, suggesting that subjects with spondylolisthesis do not present with either instability or hypermobility. Conclusion. A spondylolytic defect does not lead to detectable instability or hypermobility in the lumbar spine.

Study Design\ud A systematic review of randomised controlled trials (RCTs) \ud Objective\ud To determine the effects of active rehabilitation on functional outcome following lumbar spinal stenosis surgery when compared with 'usual postoperative care'.\ud Summary of background data\ud Surgery rates for lumbar spinal stenosis have risen, yet outcomes remain suboptimal. Post-operative rehabilitation has been suggested as a tool to improve post-operative function but, to date, there is limited evidence to support its use.\ud Methods\ud CENTRAL (The Cochrane Library), the Cochrane Back Review Group Trials Register, MEDLINE, EMBASE, CINAHL and PEDro electronic databases were searched. Randomised controlled trials (RCTs) comparing the effectiveness of active rehabilitation with usual care in adults with lumbar spinal stenosis who had undergone primary spinal decompression surgery were included. Two authors independently selected studies, assessed the risk of bias, and extracted the data in line with the recommendations of the Cochrane Back Review Group. Study results were pooled in a meta-analysis when appropriate using functional status as the primary outcome, with secondary outcomes including measures of leg pain, low back pain, and global improvement/general health. The GRADE approach was used to assess the quality of the evidence.\ud Results\ud Our searches yielded 1,726 articles, of which three studies (N = 373 participants) were suitable for inclusion in meta-analysis. All included studies were deemed to have low risk of bias; no study had unacceptably high dropout rates. There was moderate evidence suggesting that active rehabilitation was more effective than usual care in improving both short- and long-term functional status following surgery. Similar findings were noted for secondary outcomes, including short-term improvement in low back pain and long-term improvement in both low back pain and leg pain. \ud Conclusions\ud We obtained moderate-quality evidence indicating that postoperative active rehabilitation after decompression surgery for lumbar spinal stenosis is more effective than usual care. Further work is required particularly with respect to the cost effectiveness of such interventions.

STUDY DESIGN This was a prospective pilot study to investigate the global motion characteristics of the spondylolysis and spondylolisthesis populations. OBJECTIVES The aim of this study is to determine the influence of a spondylolisthesis or a spondylolysis on global spinal motion and to establish whether this is dependent on the cause of the slip or the degree/grade of the slip. SUMMARY OF BACKGROUND DATA The condition of spondylolisthesis has been extensively discussed in the literature with respect to its etiology and management. However, the mechanics and movement of the spine in relation to pathology and the effect of this condition on function have received scant attention. METHODS The motion of the lumbar spine was investigated in 31 patients (19 men, 12 women, mean age 47.7 +/- 17.8 years) who were diagnosed as having either a lumbar spondylolysis or a spondylolisthesis. These patients were compared with a preexisting database of 203 normal subjects (100 men, 103 women, mean age 39.8 +/- 13.4 years). Patients were graded according to the type of spondylolisthesis or spondylolysis they had, and the extent of slip was rated using Meyerding's classification (1932) and measured directly using methods of Boxall et al (1979) and Wiltse et al (1983). RESULTS Direct measurements of the extent of slip using Boxall et al (1979) and Wiltse et al (1983) methods were found to have no significant correlation with the resultant range of motion (ROM) or the speed of movement. This study suggests that motion parameters are influenced by the grade of slip in patients with spondylolisthesis, and the type of spondylolisthesis i.e., whether isthmic or degenerative. In the A-P flexion-extension plane, the results indicate that subjects with a defect only, i.e., a spondylolysis, and thus no slip present with a spinal hypermobility (P < 0.01). Subjects with an isthmic slip tend to be either slightly hypermobile or within the anticipated range of motion, whereas those subjects with a degenerative slip tend to be hypomobile (P < 0.05). Movements into lateral flexion were restricted in both the isthmic and degenerative spondylolisthesis patients, whereas rotation was only influenced by the level at which the defect occurred. In terms of degree of displacement, in higher grades of displacement, there was a trend towards hypermobility. CONCLUSIONS The findings of this study suggest that the grade and type of spondylolisthesis do influence global motion parameters. This information may be useful in the clinical assessment of this patient group.

The present study investigated the dynamic motion characteristics of the lumbar spine in the normal population using a potentiometric analysis system.To assess the ability of a triaxial potentiometric analysis system to measure dynamic motion in the lumbar spine, and to use this system to form a database of dynamic motion characteristics from which normal parameters of motion and the factors affecting this motion could be defined.Spinal motion has been studied using a variety of different methods, the majority of which have been limited either in terms of reliability, accuracy, or invasiveness and many have been only of a static nature. There has been no previous study into the normal dynamic motion characteristics of the lumbar spine.The accuracy of the system was determined by a series of tests against a calibrated engineering mill, and the reliability of the system was assessed on 10 subjects with repeated measurements over a 3-day period. Values of range of motion and angular velocity were obtained from 203 normal subjects during flexion and extension, lateral flexion, and rotation.The results of the calibration testing revealed excellent accuracy, and it was shown that the system was repeatable. Initial analysis of the results indicated that sex differences did exist with men having 58.4 degrees of flexion and women having 53.4 degrees. Age appeared to have an influence on motion, and a gradual reduction was seen with each decade (P0.001), with the 20-29-year age range having 59.5 degrees mean flexion, the 30-39-year group having 58.1 degrees, the 40-49-year group having 53.7 degrees, the 50-60-year group having 57.5 degrees, and the 60-70-year group having 45.9 degrees. Multiple regression techniques revealed that only a few factors are important with respect to motion and that these varied according to the characteristic being defined.Range of motion tended to be affected by age and sex, whereas velocity was only affected by distance moved, with occupation and body mass index having little or no influence on the motion. The factors identified could only account for a small proportion of the variation seen, suggesting that it is difficult to predict the motion characteristics with any degree of sensitivity.

Study Design. This study invited patients to evaluate the content and style of a rehabilitation program used as an intervention in a multicenter, factorial, randomized controlled trial of the postoperative management of spinal surgery patients. Objective. To determine the acceptability and content of the rehabilitation program. Summary of Background Data. The use of rehabilitation after spinal surgery is sporadic, and the evidence for its benefit is mixed. A randomized controlled trial was conducted to determine whether functional outcome of spinal surgery could be improved by a postoperative rehabilitation program and/or an educational booklet provided at hospital discharge, each compared with usual care. Methods. Patients randomized to postoperative rehabilitation began the course 6 weeks after surgery. At the end of the course of 12 classes, patients completed an evaluation of content, style, and length using forced choice and open questions. Patients not attending the final class completed the evaluation at their 3-month review. Results. Compliance with rehabilitation was poor, with 41% of subjects failing to attend any classes and 16% attending less than half. Compliance with the evaluation was 100% for the 105 patients attending 1 or more classes. The length, content, and approach to the classes were rated positively, and patients gave the class a median rating of 9 of 10, range 5 to 10, with 91% rating the classes as 7 or above. Conclusion. Compliance with a postoperative rehabilitation program was disappointing, but the program was assessed positively and of benefit by those who attended. Issues were raised in relation to timing and location of classes.

Study Design. Cost-effectiveness analysis alongside a factorial randomized controlled trial.Objective. To assess the cost-effectiveness of a rehabilitation program and/or an education booklet each compared with usual care for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery.Summary of Background Data. There is little knowledge about the cost-effectiveness of postoperative management of patients after spinal surgery.Methods. A total of 338 patients were recruited into the study between June 2005 and March 2009. Patients were randomized to rehabilitation only, booklet only, rehabilitation plus booklet, or usual care only. Interactions between booklet and rehabilitation were nonsignificant; hence, we compare booklet versus no booklet and rehabilitation versus no rehabilitation. We adopt an English National Health Service and personal social services perspective. Data on outcomes and costs are based on patient level data from the trial. A 1-year time horizon was used. Outcomes were measured in terms of quality-adjusted life years. Health-related quality of life was reported by patients using the EuroQol-5D (EQ-5D). A comprehensive range of health service contacts were included in the cost analysis.Results. There were no significant differences in costs or outcomes associated with either intervention. Mean incremental costs and mean quality-adjusted life years gained per patient of booklet versus no booklet were -87 pound (95% CI: -1221 pound to 1047) pound and -0.023 (95% CI: -0.068 to 0.023), respectively. Figures for rehabilitation versus no rehabilitation were 160 pound (95% CI: -984 pound to 1304) pound and 0.002 (95% CI: -0.044 to 0.048), respectively. Neither intervention was cost-effective when compared with the threshold range commonly used to judge whether or not an intervention is cost-effective in the English National Health Service.Conclusion. Cost-effectiveness evidence does not support use of booklet over no booklet or rehabilitation over no rehabilitation for the postoperative management of patients after spinal surgery.

This was a multicenter, factorial, randomized, controlled trial on the postoperative management of spinal surgery patients, with randomization stratified by surgeon and operative procedure.This study sought to determine whether the functional outcome of two common spinal operations could be improved by a program of postoperative rehabilitation that combines professional support and advice with graded active exercise commencing 6 weeks after surgery and/or an educational booklet based on evidence-based messages and advice received at discharge from hospital, each compared with usual care.Surgical interventions on the spine are increasing, and while surgery for spinal stenosis and disc prolapse have been shown to be superior to conservative management, functional outcome, and patient satisfaction are not optimal.The study compared the effectiveness of a rehabilitation program and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with "usual care" using a 2 × 2 factorial design, randomizing patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analog scale measures of back and leg pain.Three hundred thirty-eight patients were recruited into the study and measurements were obtained preoperatively and then repeated at 6 weeks, 3, 6, 9 and 12 months postoperatively. Twelve months postoperatively the observed effect of rehabilitation on ODI was -2.7 (95% CI: -6.8 to 1.5) and the effect of booklet was 2.7 (95% CI: -1.5 to 6.9).This study found that neither intervention had a significant impact on long-term outcome.

Study Design. This was a prospective study investigating patient expectations of and satisfaction with the outcome of decompression surgery. Objectives. To investigate patient expectations of surgery and short- and long-term satisfaction with the outcome of decompression surgery in terms of pain, function, disability, and general health. Summary of Background Data. Information is scarce regarding patient-rated expectations of surgery and measures of satisfaction with surgery in terms of specific outcome measures such as pain. Methods. Eighty-four patients undergoing spinal stenosis surgery were recruited into this study. Before surgery, patients were also asked to rate their expectations in terms of improvement in pain, general health, function, and other such characteristics. in addition, at each postoperative review stage, patients were asked to rate their satisfaction with their improvement in these key outcome measures. Results. The results demonstrated that patients had very high expectations of recovery, particularly in terms of pain and function, and that patients were confident of achieving this recovery (76.8%). Levels of satisfaction, however, varied considerably: 41% of patients were 50% satisfied with the outcome, and 30% were dissatisfied. Most patients felt that they had made the right decision to have surgery, although the surgery had achieved only 43.4% ± 37.8 of the outcome they had expected. Conclusions. Examination of patients' expectations of and satisfaction with surgery revealed that patients frequently had unrealistic expectations of their surgery and as a consequence tended to have lower levels of satisfaction.

Study Design. This was a prospective study investigating the outcome of decompression surgery using validated measures of outcome. Objectives. To investigate the outcome of lumbar decompressive surgery in the initial postoperative year period in terms of function, disability, general health, and psychological well-being. Summary of Background Data. The majority of studies investigating the outcome of lumbar decompression surgery have been retrospective and have not used validated measures of outcome. This limits their interpretation and usefulness. Methods. Eighty-four patients undergoing lumbar spinal stenosis surgery were recruited into this study. Patients were assessed by use of validated measures of outcome including the Oswestry Disability index and the Short Form SF-36 General Health Questionnaire before surgery and 6 weeks, 6 months, and 1 year after surgery. Results. A significant reduction in pain (P < 0.001) was observed at the 6-week postoperative stage; this did not change at the subsequent assessment stages. Only some of the SF-36 categories were sensitive to change. The subcategories that were sensitive to change were physical function (P < 0. 05), bodily pain (P < 0.001), and social function (P < 0.05). Improvements were observed in these categories at the 6-week and 6-month reviews. A gradual reduction in the Oswestry Disability Index was observed with time, with changes principally being observed between the 8-week and 6-month review and the 6-week and 1-year review stages (P < 0.05). Minimal changes were observed in the psychological assessments with time. The outcome of surgery could not be predicted reliably from psychological, functional, or pain measures. Conclusions. The visual analogue pain scales, the Oswestry Disability Index, and certain categories of the SF-36 Questionnaire, namely bodily pain and physical and social function, appeared to be the most sensitive outcome measures, with significant improvements occurring at the 6-week and 6-month reviews.

STUDY DESIGN Motor-evoked responses to transcranial magnetic stimulation of the motor cortex were recorded from erector spinae and deltoid muscles while the arm was abducted voluntarily in 10 normal subjects. OBJECTIVE To understand the neuronal substrate for the activation of the contralateral erector spinae muscle when the opposite arm is abducted. BACKGROUND DATA When a standing individual abducts an arm, the center of gravity is altered; to avoid falling, trunk muscles become activated on the contralateral side. METHODS Surface EMG activity was recorded from the right deltoid and left and right erector spinae muscles. Subjects maintained abduction of their right arm to 90 degrees at five different levels of isometric force in standing and lying postures. Transcranial magnetic stimulation was delivered to the motor cortex, producing motor-evoked responses in the three muscles during arm abduction and while relaxed. RESULTS EMG activity in the left erector spinae increased with the force of right arm abduction in both postures. EMG levels in right erector spinae showed no consistent change with right arm abduction force. As arm abduction force was increased, motor-evoked responses were facilitated in deltoid and the left erector spinae but not the right erector spinae in both postures. The pattern of motor-evoked potential facilitation with arm abduction force tended to plateau between 50% and 70% maximum voluntary contraction in the deltoid, whereas it continued to climb more linearly in the left erector spinae. CONCLUSIONS Facilitation of erector spinae with arm abduction remains evident in the lying posture when spinal postural stabilization mechanisms are presumably reduced. Similar facilitation profiles have been seen previously with changing voluntary activation of erector spinae in a trunk extension task, supporting the notion that during arm abduction the drive to the contralateral erector spinae has a corticospinal origin.