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Background Context: Posterior lumbar interbody fusion (PLIF) is a popular method of arthrodesis for surgical treatment of instabilities and degenerative conditions of the spine. With the introduction of threaded titanium cage devices, surgeons began performing PLIF procedures using these cages as stand-alone devices. Complications have been reported, however, including pseudarthrosis with persistent pain. Outcomes after revision surgical treatment for these patients with failed PLIF are not known. Purpose: To prospectively evaluate clinical outcomes of revision fusion surgery in patients who previously underwent posterior lumbar interbody fusion with stand-alone metallic cages resulting in pseudarthrosis. Study Design/setting: Prospective case series. Methods: Nineteen patients referred to the senior author were evaluated and diagnosed with pseudoarthrosis having previously undergone a PLIF procedure with stand-alone metallic cages. History, physical exam, and imaging studies were performed preoperatively and postoperatively. All underwent revision posterolateral fusion with iliac crest graft and pedicle screw instrumentation. Patient demographics, SF-36, and Oswestry Disability Index (ODI) data were collected prior to surgery and two years postoperatively. Results: Patients undergoing revision fusion surgery were found to have had extensive facetectomies and pseudarthrosis intraoperatively. Outcomes data was collected on eighteen of nineteen patients (95%). Mean clinical follow up was 3.2 years (range 2.5-3.5 years). Seventeen patients (94%) achieved a solid fusion. Improvement was noted in seven of eight SF-36 sub-categories, but was significant only in two (Physical Function and Role Emotional). There was no significant difference in ODI scores. Conclusions: Pseudarthrosis should be considered in the differential diagnosis if severe symptoms persist in patients who undergo PLIF with stand-alone metallic cages. Successful revision fusion did not always correlate with improved clinical outcomes in these challenging patients undergoing further surgery. Performing PLIF using stand-alone metallic cages, especially after total resection of the facet joints, is not advocated unless supplemental instrumentation is utilized. [ABSTRACT FROM AUTHOR]

Abstract: Background data: Depression is a common co-morbidity for patients with complaints of spinal pain, yet often goes undiagnosed in clinical practice. Depressed patients who are not identified do not receive a referral or recommendation for treatments that may help ease their total illness burden. Relative to the total outcomes of spine care this may increase costs, decrease overall functional outcomes, and limit patient satisfaction. Some spine care settings track functional outcomes using a general health status survey. Although a specific and reliable survey to detect depression could be employed, an additional survey would unnecessarily increase responder and analyst burdens if the general health status survey could be used instead. Objective: To identify the Mental Component Summary (MCS) cutoff score from the Short Form 36-item Health Survey (SF-36) that best predicts a positive depression score as measured by the Center for Epidemiological Study–Depression Survey (CES-D). Study design: An analysis of the diagnostic properties of the SF-36 MCS Scale as a predictor of depressive symptoms as measured by the CES-D. Outcome measures: The SF-36 is a general health survey that contains a MCS score that represents the psychological well-being and general health perception of the respondent. This composite score is norm-based (mean=50, SD=10) with lower scores representing poorer health. The CES-D has been well-studied in patients with chronic pain complaints and was used as the gold standard for determining the MCS cutoff score. A CES-D score of 19 or greater was considered positive for depressive symptoms. Patient sample: All patients entering our facility routinely complete the SF-36. Between February 2002 and October 2002, all patients scoring 30 or less on the MCS (MCS≤30) also completed the CES-D. Patients who scored 2 standard deviations below the mean (MCS=30 or less) were considered most at risk for depression. Patients scoring above 30 on their MCS (MCS>30) were considered less likely to have depressive symptoms and were randomly chosen to complete the CES-D. There were 420 patients who completed both surveys of which there were 99 MCS≤30 patients and 321 MCS>30 patients. Methods: Receiver operating characteristic (ROC) curves were used to assess the sensitivity and specificity of the SF-36 as a screening tool for detecting depressive symptoms. Results: An MCS score of 35 has a sensitivity of 80% (76–83; 95% confidence interval), a specificity of 90% (87–93), an ROC area of 0.8517 (0.81–0.89), and correctly identified 87% of the sample. Conclusion: The SF-36 provides the benefits of a general functional health status measure and additionally appears to provide a screening tool for depressive symptoms. A cutoff score of 35 or less on the MCS scale has a high degree of sensitivity and specificity and is able to identify depressive symptoms in patients with back pain, which can help identify patients who will benefit from mental health treatments. [Copyright &y& Elsevier]

Background Context: Retrolisthesis is relatively rare but when present has been associated with increased back pain and impaired back function. Neither the prevalence of this condition in individuals with lumbar disc herniations nor its possible relation to preoperative back pain and dysfunction has been well studied.Purpose: The purposes of this study were as follows: (1) to determine the prevalence of retrolisthesis (alone or in combination with other degenerative conditions) in individuals with confirmed L5-S1 disc herniation who later underwent lumbar discectomy; (2) to determine if there is any association between retrolisthesis and degenerative changes within the same vertebral motion segment; and (3) to determine the relation between retrolisthesis (alone or in combination with other degenerative conditions) and preoperative low back pain, physical function, and quality of life.Study Design/setting: Cross-sectional study.Patient Sample: A total of 125 individuals were identified for incorporation into this study. All patients had confirmed L5-S1 disc herniation on magnetic resonance imaging (MRI) and later underwent L5-S1 discectomy. All patients were enrolled in the Spine Patient Outcomes Research Trial (SPORT) study; data were obtained from the multi-institutional database comprised of SPORT patients from across the United States.Outcome Measures: Retrolisthesis, degenerative change on MRI, and Modic changes.Methods: MRI scans of the lumbar spine were assessed at spinal level L5-S1 for all 125 patients. Retrolisthesis was defined as posterior subluxation of 8% or more. Disc degeneration was defined as any loss of disc signal on T2 imaging. Modic changes were graded 1 to 3 and collectively classified as vertebral endplate degenerative changes. The presence of facet arthropathy and ligamentum flavum hypertrophy was classified jointly as posterior degenerative changes.Results: The overall incidence of retrolisthesis at L5-S1 in our study was 23.2%. Retrolisthesis combined with posterior degenerative changes, degenerative disc disease, or vertebral endplate changes had incidences of 4.8%, 16%, and 4.8% respectively. The prevalence of retrolisthesis did not vary by sex, age, race, smoking status, or education level when compared with individuals with normal sagittal alignment. However, individuals with retrolisthesis were more likely to be receiving workers' compensation than those without retrolisthesis. Increased age was found to be associated with individuals having vertebral endplate degenerative changes (both alone and in conjunction with retrolisthesis) and degenerative disc disease. Individuals who had retrolisthesis with concomitant vertebral endplate degenerative changes were more often smokers and had no insurance. The presence of retrolisthesis was not associated with an increased incidence of having degenerative disc disease, posterior degenerative changes, or vertebral endplate changes. No statistical significance was found between the presence of retrolisthesis on the degree of patient preoperative low back pain and physical function. Patients with degenerative disc disease were found to have increased leg pain compared with those patients without degenerative disc changes.Conclusions: We found no significant relationship between retrolisthesis in patients with L5-S1 disc herniation and worse baseline pain or function. It is possible that the contribution of pain or dysfunction related to retrolisthesis was far overshadowed by the presence of symptoms caused by the concomitant disc herniation. It remains to be seen whether retrolisthesis will affect outcome after discectomy in these patients. [ABSTRACT FROM AUTHOR]

Abstract: Background context: The Short Form 36 (SF-36) health survey has been shown to be a valid instrument when used to measure the self-reported physical and mental health of patients. The impact of lumbar spinal disorders can be assessed as the difference between the SF-36 scale scores and age- and gender-specific population norms. Purpose: To establish the impact upon the self-reported health status of patients with one of four common lumbar spinal diagnoses. Study design: A cross-sectional, observational assessment of the health status of spine patients. Methods: Data from patients presenting to the participating centers of the National Spine Network with low back pain or leg pain were collected prospectively using the Health Status Questionnaire 2.0. A database search identified patients with either herniated nucleus pulposus with radicular pain (HNP), lumbar spinal stenosis without deformity (SPS), degenerative spondylolisthesis (DS), and painful disc degeneration/spondylosis (DDD). The mean SF-36 scale scores were generated for each of the diagnostic groups. The impact of these diagnoses on health status was determined as the calculated difference from the age- and gender-specific population norms for each of the eight health scale scores. These scores, usually negative in this population, represent how far below normal these patients are. The analysis was stratified according to the age of the patients (<40 years, 40–60 years, >60 years). Analysis of variance and pair-wise comparison with Bonferroni correction were used to assess the significance of differences across diagnosis and age groups. Results: Data from a total of 4,442 patients were available for this study. All four diagnostic groups had large, negative impact scores for the eight general health scales with the greatest impact upon the three scales that best measure physical health. The greatest impact on these physical health scales (physical functioning, role-physical, and bodily pain) was seen in the HNP diagnostic group. The younger age groups (<40 years and 40–60 years) had the greatest physical impairment when compared with the age- and gender-specific population norms. Analysis of variance showed a significant relationship between diagnosis and SF-36 scores, and between age groups and SF-36 scores. Conclusions: All four lumbar spine disorders have a significant negative impact on all eight of the SF-36 scales. The greatest negative impact was seen in those scales that measure physical health (role limitations due to physical symptoms [RP], physical functioning [PF], and bodily pain [BP]). The HNP diagnostic group experienced a significantly greater impact upon these three scales. This diagnostic group had the youngest patients, whose baseline physical functional status would be expected to be the most optimal. When we stratified by age in all the diagnostic groups, the greatest negative impact scores for physical health were seen in the <40 years and 40–60 years age groups. These patients were also more likely to perceive their health as poor, experience decreased energy, and have more social impairment when compared with their age/gender norms. [Copyright &y& Elsevier]

Purpose of study: Health status instruments have become important tools for understanding the impact of disease and the effectiveness of interventions. Two types of instruments are in current use. General-health surveys, such as the Short Form (SF)-36, attempt to measure the overall health status of patients, and may reflect multiple diseases or disabilities. Condition-specific surveys, such as the Oswestry, attempt to isolate the specific symptoms related to one condition and should not reflect the presence of unrelated comorbid conditions. The objectives of this study are to assess whether the SF-36 is more sensitive to the number of self-reported comorbidities than the Oswestry and to determine which comorbidities have the greatest impact on baseline health. Methods used: This is an observational study of 26,736 patients from the National Spine Network. Patients were grouped according to the number of self-reported comorbidities (0 to 5). Baseline SF-36 scores were computed for the Physical Component Summary (PCS), Bodily Pain (BP) and Physical Function (PF) scales. The Oswestry Disability Index (ODI, MODEMS version) was scored in reverse order (0 = severed disability, 100 = no disability) for consistency with the SF-36 scales. Analysis of variance was used to assess the difference in mean health status across comorbidity groups. Multiple linear regression was used to identify the most influential comorbidities. of findings: Baseline SF-36 and Oswestry scores were significantly lower for patients with a greater number of comorbidities. For patients with zero to five comorbidities, ODI scores ranged from 62.2 to 48.8, PCS scores from 33.3 to 26.0, PF scores from 50.4 to 29.1 and BP scores from 33.7 to 23.0 (p<.001 for all scales). Comorbidities most adversely impacting the ODI scores included depression, smoking, osteoporosis, osteoarthritis, blood disorders and headaches. Comorbidities most negatively impacting PCS scores include osteoarthritis, smoking, blood and lung disorders. For the BP and PF scales, the greatest negative impact came from depression, smoking, osteoporosis and osteoarthritis. Additional factors associated with low ODI and SF-36 scores included obesity, poor self-rated health, compensation and low education (factors significant at p<.01). Relationship between findings and existing knowledge: Contrary to current assumptions regarding condition-specific surveys, comorbidities are associated with lower ODI scores. The association between lower baseline ODI scores and a higher number of self-reported comorbidities may relate to worse underlying spine disease in patients with these comorbidities, but it also may reflect lack of true disease specificity for the ODI. Overall significance of findings: Clinicians and researchers should understand and consider the effect that comorbidities have on health-status measures. Further research may be necessary in order to develop a truly "condition-specific" instrument for spine patients. Disclosures: No disclosures. Conflict of interest: No conflicts. [ABSTRACT FROM AUTHOR]