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Background: This study aimed to investigate the effect of manual therapy on pain, kinesiophobia, pain catastrophizing, anxiety, depression, and quality of life in patients with lumbar disc herniation (LDH). Methods: The study included 32 LDH patients. Patients were divided into the Manual therapy group (MTG-age 39.81 ± 9.45 years) and the Exercise group (EG-age 38.31 ± 9.21 years) by sealed envelope randomization. Patients were evaluated pre-study, post-study, and after a 3-month period using the McGill-Melzack Pain Questionnaire (MMPQ), Hospital Anxiety and Depression Scale (HADS), Tampa Kinesiophobia Scale (TKS), Pain Catastrophizing Scale (PCS) and Nottingham Health Profile (NSP). The exercise group received a total of ten sessions of stabilization exercises and sham spinal mobilization in five weeks, two sessions per week. In addition to the stabilization exercises, mobilization applications including Anterior-Posterior Lumbar Spinal Mobilization, Lumbar Spinal Rotational Mobilization, and Joint Mobilization in Lumbar Flexion Position, were applied to the manual therapy group. Results: It was found that the HADS and TKS values decreased in the MTG group compared to the pre-treatment period ( p < 0.05), while there was no difference between these values in the EG group ( p > 0.05). There was a statistically significant difference in the MMPQ, PCS, and NHP values after treatment in both the MTG and EG groups ( p < 0.05). Conclusions: It was found that manual therapy had positive effects on psychological factors such as pain, kinesiophobia, pain catastrophizing, anxiety, depression, and quality of life in patients with LDH. Trial registration: NCT05804357 (27 March 2023) (retrospectively registered).

Rationale: With the spread of computers and mobile phones, cervical spondylosis has become a common occupational disease in clinics, which seriously affects the quality of life of patients. We used a nonsurgical spinal decompression system (SDS) combined with physical therapy electroacupuncture (EA) to treat a case of mixed cervical spondylosis caused by multi-level cervical disc herniation, and we achieved satisfactory results., Patient Concerns: A 44-year-old Caucasian Asian woman presented with neck pain and numbness on the left side of the limb. MRI showed the patient's C3-C7 segment cervical disc herniation, and the flexion arch of the cervical spine was reversed., Diagnosis: The patient was diagnosed with a mixed cervical spondylosis., Interventions: The patient received a month of physical therapy (SDS traction combined with EA)., Outcomes: Before and after treatment: VAS score of neck pain decreased from 8 to 0; Cervical spine mobility returned to normal; The grip strength of left hand increased from 7.5 kg to 19.2 kg; Cervical curvature index changed from -16.04% to -3.50%; the physiological curvature of the cervical spine was significantly restored. There was no dizziness or neck discomfort at 6 month and 1 year follow-up., Lessons Subsetions: SDS traction combined with EA is effective for the treatment of cervical disc herniation and can help restore and rebuild the biomechanical balance of the cervical spine., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Most postoperative patients with herniated lumbar disc complained of lower leg radiating pain (LRP), referred buttock pain (RBP), and low back pain (LBP). When discectomy is performed, improvement in LRP is observed due to spinal nerve irritation. However, long-term LBP due to degenerative changes in the disc may occur postoperatively. In addition, limited research has been reported on the short-term (within 1 year) improvement in LBP after discectomy. This study aimed to evaluate the effectiveness of discectomy in reducing LBP within 1 year postoperatively.Among the 183 patients who underwent discectomy performed by a single surgeon from January 2010 to December 2016, 106 who met the inclusion and exclusion criteria were enrolled. In the 106 patients who underwent lumbar discectomy, 3 types of spine-related pain were pre-operatively assessed and 3, 6, and 12 months postoperatively. Functional outcomes were evaluated, and quality of life was assessed 12 months postoperatively by using the Short-Form 36 questionnaire, which was subdivided into mental and physical components.LBP showed both statistical and clinical improvement within the first 3 months postoperatively, but the improvement was not observed until 12 months postoperatively. RBP and LRP showed both statistical and clinical improvement within the first 3 months and further consistently showed statistical improvement. LBP improved clinically only until 3 months postoperatively regardless of the type of herniation.LBP showed improvement within the first 3 months postoperatively and plateaued afterward, and RBP and radiculopathy showed consistent improvement until 12 months postoperatively. This may explain why patients from 12-month follow-up showed improvement in RBP and radiculopathy but not LBP., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

This clinical observation aims to observe and analyze the effect of Yaotongning capsule in the treatment of lumbar disc herniation, and provide valuable guidance for clinical practice. A total of 120 patients who confirmed with lumbar disc herniation in our hospital from January 2016 to December 2018 were enrolled as research objects in this study. On the other hand, another 120 patients who were treated for lumbar disc herniation in our hospital during the same period were classified in the control group. General routine treatment mode was adopted for the control group, while Yaotongning capsule was given to the study group on the basis of general routine treatment. The therapeutic effect was observed and compared between the two groups. The overall treatment efficiency, VAS score, serum cytokine levels and quality of life were compared between the two groups. The results showed the study group exhibited significant improvement compared with control group, p<0.05. The application of Yaotongning capsule can achieve markedly good results in treatment of lumbar disc herniation, which is worthy of popularization and application.

Objectives: The aim of this retrospective study was to evaluate the efficacy of transforaminal anterior epidural steroid and local anesthetic injections (TAESE) and the effects on quality of life in patients with low back pain., Methods: The study patients (n=191) were divided into 3 groups: disc herniation (DH), failed back surgery (FBS), and spinal stenosis (SS). A visual analog scale (VAS) and verbal pain scale (VPS) were used to assess patient pain. Scores were measured before treatment (VAS 0), in the first month of application (VAS 1), 3 months (VAS 3), and 6 months (VAS 6). Patient quality of life was examined using the 36-Item Short Form Health Survey (SF-36)., Results: In all 3 groups, there was a statistically significant reduction in pain compared with the VAS 0 score at 1, 3, and 6 months (p<0.001). The reduction in VAS/VPS was greatest in the DH group, followed by the FBS and SS groups, respectively. All of the parameters of the SF-36 measurement were lower in the SS patients compared with the DH patients. The quality of life score was lowest in the SS patients, though the physical health and social functioning scores were lowest in the FBS group., Conclusion: TAESE is effective and can be safely performed in patients who have low back pain due to DH, FBS, or SS. The quality of life result was less successful in SS patients, particularly in the parameter of physical role limitations.

Background: Ongoing pain after surgery is a major problem and influences recovery and the quality of life of the patient. Associations between anxiety and their impact on postoperative pain after herniated disc surgery have been reported, but the results are inconsistent. The aim of the present longitudinal study was to evaluate the predictive value of preoperative anxiety for postoperative ongoing pain and prolonged analgesic intake after herniated disc surgery., Methods: 106 patients with lumbar disc herniation were evaluated in the study. Anxiety was measured with the Generalized Anxiety Disorder 7-Item Scale (GAD-7) before surgery. Pain intensity was assessed on a numeric rating scale (NRS) at baseline, 6-weeks and 6-months after surgery. Regression analysis was performed to identify independent predictors of pain and regular utilization of analgesics up to 6 months after surgery while controlling for confounding variables., Results: 42.5% of the patients were rated as anxiety cases (sum scores GAD-7 > 5), mean scores of anxiety showed mild to moderate symptom severity, and 43% suffered from chronic pain before surgery. Six months after surgery, 55.6% of the patients indicated pain levels of 4/10 (NRS) or higher and about 40% still took pain medication on a regular basis, regardless of their preoperative classification as anxiety-case (37.7% and 41.5%). The preoperative pain level was statistically significant for ongoing postsurgical pain in all four analyses (p < 0.001). With binary logistic regression analyses, preoperative pain intensity, but neither demographic factors nor preoperative anxiety, was identified as predictor for postoperative pain and need for analgesic medication up to 6 months after lumbar disc surgery., Conclusion: We found no evidence for the presence of anxiety before disc surgery being a prognostic factor for ongoing pain and regular postoperative intake of analgesics. Only preoperative pain intensity was predictive for increased pain and continued need for analgesic medication up to 6 months after lumbar disc surgery., Trial Registration: Clinicaltrials.gov NCT01488617 . Registered 6 December 2011.

Background: This study aims to demonstrate the effectiveness of using clinical practice guideline (CPG) leaflets as a communication tool between doctors and patients. We evaluated the leaflets as a communication tool in the treatment of lumbar herniated intervertebral discs (HIVDs) in terms of patient and physician satisfaction and ease of treatment., Methods: This study is a 2-parallel-arm, assessor-blinded, randomized controlled trial at Jaseng Hospital, Seoul, South Korea. We evaluated efficacy through a comparison of satisfaction and clinical outcomes in randomly allocated groups of HIVD lumbar patients visiting Jaseng Hospital of Korean Medicine. We used leaflets on the basis of Korean medicine CPG recommendations as an intervention. The intervention group received treatment and diagnosis using the leaflet, and the control group received the typical intervention, which was provided without the leaflet., Results: The levels of patient satisfaction with and understanding of the doctors' explanation was 92% in the leaflet group and 64% in the nonleaflet group, which showed that, compared with patient satisfaction in the nonleaflet group, patient satisfaction was considerably higher by 28% in the leaflet group. In addition, the level of the reliability with treatment was 92% in the leaflet group and 64% in the control group. However, there were no significant differences in statistical analyses. The level of doctors' satisfaction with communicating with patients using the leaflet was 100% in the leaflet group. Given this satisfaction, the ease of persuasion of treatment was highest (84%) and followed the improvement in the patient's understanding of the treatment (16%) in the leaflet group. In addition, in the nonleaflet user group, almost all doctors thought that having a leaflet would be a more effective treatment., Conclusion: Although this study failed to show significant differences between the intervention and control groups, the leaflet, which included CPG information in the treatment of HIVD patients, was an effective communication tool between patients and doctors. However, further studies with larger samples should be conducted to investigate the effectiveness of the communication tool based on the CPG., Trial Registration Number: Clinical Research Information Service: KCT0001762., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: This study aims to investigate (1) motives, motivations and expectations regarding the choice for a specific rehabilitation setting after herniated disc surgery and (2) how rehabilitation-related motivations and expectations are associated with rehabilitation outcome (ability to work, health-related quality of life and satisfaction with rehabilitation) three months after disc surgery., Methods: The longitudinal cohort study refers to 452 disc surgery patients participating in a subsequent rehabilitation. Baseline interviews took part during acute hospital stay (pre-rehabilitation), follow-up interviews three months later (post-rehabilitation). Binary logistic regression and multiple linear regression analyses were applied., Results: (1) Motives, motivations and expectations: Inpatient rehabilitation (IPR) patients stated "less effort/stress" (40.9%), more "relaxation and recreation" (39.1%) and greater "intensity of care and treatment" (37.0%) regarding their setting preference, whereas outpatient rehabilitation (OPR) patients indicated "family reasons" (45.3%), the wish for "staying in familiar environment" (35.9%) as well as "job-related reasons" (11.7%) as most relevant. IPR patients showed significantly higher motivation/expectation scores regarding regeneration (p < .001), health (p < .05), coping (p < .001), retirement/job (p < .01), psychological burden (p < .05) and physical burden (p < .001) compared to OPR patients. (2) Associations with rehabilitation outcome: Besides other factors (e.g. age, gender and educational level) rehabilitation-related motivations/expectations were significantly associated with rehabilitation outcome measures. For example, patients with less motivations/expectations to achieve improvements regarding "physical burden" showed a better health-related quality of life (p < .01) three months after disc surgery. Less motivations/expectations to achieve improvements regarding "psychological burden" was linked to a better mental health status (p < .001) and a greater satisfaction with rehabilitation (OR = .806; p < .05)., Conclusion: Rehabilitation-related motivations and expectations differed substantially between IPR and OPR patients before rehabilitation and were significantly associated with rehabilitation outcome. Taking motivational and expectation-related aspects into account may help to improve allocation procedures for different rehabilitation settings and may improve rehabilitation success.

Background: Cauda equina syndrome (CES) is a rare neurologic complication of lumbar herniated disc for which emergency surgical decompression should be undertaken. Despite the common belief that the restoration of functions that are affected by CES can take several years postoperatively, follow up seldom exceeds the first year after surgery. Long term outcome of especially micturition, defecation and sexual function-which are by definition affected in CES-are unknown. The aim of this study is to evaluate 1) postoperative long term outcome of micturition, defecation and sexual function in CES patients 2) attitude of patients towards received hospital care with regard to (recovery of) these functions., Methods: CES patients were selected by screening the records of all patients operated on lumbar herniated disc in our university hospital between 1995-2010. A questionnaire was sent to the selected CES patients evaluating current complaints of micturition, defecation and sexual function and attitude towards delivered care with focus on micturition, defecation and sexual function., Results: Thirty-seven of 66 eligible CES patients were included (response rate 71%, inclusion rate 56%). Median time after surgery was 13.8 years (range 5.8-21.8 years). Dysfunction at follow up was highly prevalent: 38% micturition dysfunction, 43% defecation dysfunction and 54% sexual dysfunction. Younger age at presentation was associated with sexual dysfunction at follow up: for every year younger at presentation, odds ratio for sexual dysfunction at follow up was 1.11 (p = 0.035). Other associations with outcome were not identified. Two-third of the CES patients wished their neurosurgeon had given them more prognostic information about micturition, defecation and sexual function., Conclusion: The presented data demonstrate that dysfunction of micturition, defecation and sexual function are still highly prevalent in a large number of CES patients even years postoperatively. These alarming follow up data probably have a devastating effect on personal perceived quality of life, which should be studied in more detail. CES patients communicate a clear demand for more prognostic information. The presented figures enable clinicians to inform their CES patients more realistically about long term postoperative outcome of micturition, defecation and sexual function after surgical intervention.

Background: The development of a pain-management program tailored to the specific needs of patients with chronic low back pain (CLBP) requires the proper assessment of psychosocial factors affecting each individual. The Chronic Pain Coping Inventory-42 (CPCI-42) refers to coping strategies, which are commonly defined as the cognitive and behavioral techniques an individual may resort to in stressful or demanding situations. Evidence from a number of sources suggests that differences in pain coping strategies may significantly affect how an individual deals with chronic pain. We aimed to adapt the CPCI-42 to Polish cultural conditions (PL-CPCI-42) and then verify its psychometric properties based on a group of patients treated surgically due to herniated lumbar discs and coexisting spondylotic changes., Material and Methods: The average age of the study participants (n=90) was 43.47 years (SD 10.21). The average duration of chronic low back pain (CLBP) was 49.37 months (SD 64.71). Lumbosacral spine X-rays and magnetic resonance imaging scans were performed and all patients completed the PL-CPCI-42 and the Polish versions of the Numeric Pain Rating Scale (NPRS-PL) twice. Internal consistency of the PL-CPCI-42, floor and ceiling effects, test-retest reliability, and criterion validity were analyzed., Results: Resting, guarding, and coping self-statements were frequently used as coping strategies both in the test and in the retest, in contrast to relaxation and exercise/stretch. The NPRS-PL result was 5.70 cm in the test and 5.66 in the retest. Cronbach's alpha values were recorded for the asking for assistance, coping self-statements, and seeking social support domains (0.83, 0.80, 0.83, respectively). Test-retest reliability of the PL-CPCI-42 varied from 0.53 (relaxation domain) to 0.84 (asking for assistance and coping self-statements domains)., Conclusions: The present study provides evidence of the validity of the PL-CPCI-42 and supports its usefulness in assessing chronic pain coping strategies, which are especially important to pain adjustment and in the creation of multidisciplinary pain management programs for patients with severe CLBP.

Objective: To examine rehabilitation preferences, participation and determinants for the choice of a certain rehabilitation setting (inpatient vs. outpatient) and setting-specific rehabilitation outcomes., Methods: The longitudinal observational study referred to 534 consecutive disc surgery patients (18-55 years). Face-to-face baseline interviews took place about 3.6 days after disc surgery during acute hospital stay. 486 patients also participated in a follow-up interview via telephone three months later (dropout-rate: 9%). The following instruments were used: depression and anxiety (Hospital Anxiety and Depression Scale), pain intensity (numeric analog scale), health-related quality of life (Short Form 36 Health Survey), subjective prognosis of gainful employment (SPE-scale) as well as questions on rehabilitation attendance, return to work, and amount of sick leave days., Results: The vast majority of patients undergoing surgery for a herniated disc attended a post-hospital rehabilitation treatment program (93%). Thereby two-thirds of these patients took part in an inpatient rehabilitation program (67.9%). Physical, psychological, vocational and health-related quality of life characteristics differed widely before as well as after rehabilitation depending on the setting. Inpatient rehabilitees were significantly older, reported more pain, worse physical quality of life, more anxiety and depression and a worse subjective prognosis of gainful employment before rehabilitation. Pre-rehabilitation differences remained significant after rehabilitation. More than half of the outpatient rehabilitees (56%) compared to only one third of the inpatient rehabilitees (33%) returned to work three months after disc surgery (p<.001)., Conclusion: The results suggest a "pre-selection" of patients with better health status in outpatient rehabilitation. Gaining better knowledge about setting-specific selection processes may help optimizing rehabilitation allocation procedures and improve rehabilitation effects such as return to work.

Purpose: There is no report about psychopathological effect causing by disc herniation. The disease could impose psychopathological influence on the social life, the treatment period, and response to the treatment. This study was to evaluate retrospectively the psychopathological influence of lumbar disc herniation (LDH) among Korean 19-year-old males., Materials and Methods: We compared the Korean military multiphasic personality inventory (KMPI) profiles of 74 LDH cases with the KMPI profiles of 150 controls. The LDH groups were categorized to 2 groups according to the presence of thecal sac compression by disc materials, and evaluated the relation between the KMPI and LDH., Results: The decrease of the faking-good response scale and increase of the faking-bad response scale were observed more in the LDH group than in the normal volunteer group (p<0.05). The neurosis set such as anxiety, depression and somatization was markedly increased in the LDH group compared to the normal volunteers group (p<0.05). The scale of personality disorder was also increased more in the LDH group (p=0.002). The differences of KMPI scales were not correlated with the severe pathology of LDH., Conclusion: Young male with LDH may tend to have more abnormal results of multiphasic personality inventory test compared to the normal volunteers, suggesting that LDH may be related to the psychopathology in young males in Korea. Therefore, clinicians are recommended to evaluate and treat the psychopathological aspects in patients with LDH.

Background: Intervertebral disc disease is a widespread medical and social problem. Degeneration of intervertebral discs can lead to disc disease, commonly known as discopathy. One of the consequences of discopathy is pressure on the spinal cord or nerve roots that supply the genitals and sexual centers located in the core. In addition, the accompanying pain and limitation of mobility can lead to the occurrence of sexual dysfunction., Objectives: The goal of the study was to ascertain the influence of discopathy in the lumbosacral (L-S) segment on the occurrence of sexual dysfunction., Material and Methods: The study involved 50 hospitalized patients with discopathy in the L-S segment were asked to complete a specially prepared questionnaire (11 questions). The goal of the survey was to compare the patients' satisfaction with their sex life before and after the disease. The questions were constructed in a way that excluded other indicators that could affect their sexual activity, i.e.: bad moods, bad family relations, or a lack of sexual activity due to age or the lack of a partner., Results: Discopathy in the lumbar-sacral segment has an influence on sexual activity. A decrease in the assessment of satisfaction with one's sex life can be observed among patients with discopathy., Conclusions: The pain and neurological symptoms associated with intervertebral disc disease reduce the patients' satisfaction with their sex lives. Patients in the group surveyed noted a change in sexual performance, often resulting in passivity, discouragement, weakness or a complete lack of interest in sex. The disorders also affect the emotional state. The patients also noted a significant decrease in physical activity.

Purpose: Patient-orientated outcome questionnaires are essential to evaluate treatment success. To compare different treatments, hospitals, and surgeons, standardised questionnaires are required. The present study examined the validity and responsiveness of the Core Outcome Measurement Index for neck pain (COMI-neck), a short, multidimensional outcome instrument., Methods: Questionnaires were completed by patients with degenerative problems of the cervical spine undergoing cervical disc arthroplasty before (N = 89) and 3 months after (N = 75) surgery. The questionnaires comprised the EuroQol-Five Dimension (EQ-5D), the North American Spine Society Cervical Spine Outcome Assessment Instrument (NASS-cervical) and the COMI-neck., Results: The COMI and NASS-cervical scores displayed no notable floor or ceiling effects at any time point whereas for the EQ-5D, the highest values [corrected] were reached in around 32.5% of patients at follow-up. With one exception (symptom-specific well-being), the individual COMI items and the COMI summary score correlated to the expected extent (R = 0.4-0.8) with the scores of the chosen reference questionnaires. The area under the curve (AUC) generated by ROC analysis was significantly higher for the COMI (0.96) than for any other instrument/subscale when self reported treatment outcome was used as the external criterion, dichotomised as "good" (operation helped a lot/helped) versus "poor" (operation helped only a little/didn't help/made things worse). The COMI had a high effect size (standardised response mean; SRM) (2.34) for the good global outcome group and a low SRM for the poor outcome group (0.34). The EQ-5D and the NASS-cervical lacked this ability to differentiate between the two groups, showing less distinct SRMs for good and poor outcome groups., Conclusions: This study provides evidence that the COMI-neck is a valid and responsive questionnaire in the population of patients examined. Further investigations should examine its applicability in other patient groups with less severe neck pain or undergoing other treatment modalities.

Background and Purpose: Health-related quality of life (HRQoL) instruments have been of increasing interest for evaluation of medical treatments over the past 10-15 years. In this prospective, long-term follow-up study we investigated the influence of preoperative factors and the change in HRQoL over time after lumbar disc herniation surgery., Methods: 117 patients surgically treated for lumbar disc herniation (L4-L5 or L5-S1) were evaluated with a self-completion HRQoL instrument (EQ-5D) preoperatively, after 2 years (96 patients) and after 7 years (89 patients). Baseline data (age, sex, duration of leg pain, surgical level) and degree of leg and back pain (VAS) were obtained preoperatively. The mean age was 39 (18-66) years, 54% were men, and the surgical level was L5-S1 in 58% of the patients. The change in EQ-5D score at the 2-year follow-up was analyzed by testing for correlation and by using a multiple regression model including all baseline factors (age, sex, duration of pain, degree of leg and back pain, and baseline EQ-5D score) as potential predictors., Results: 85% of the patients reported improvement in EQ-5D two years after surgery and this result remained at the long-term follow-up. The mean difference (change) between the preoperative EQ-5D score and the 2-year and 7-year scores was 0.59 (p < 0.001) and 0.62 (p < 0.001), respectively. However, the HRQoL for this patient group did not reach the mean level of previously reported values for a normal population of the same age range at any of the follow-ups. The changes in EQ-5D score between the 2- and 7-year follow-ups were not statistically significant (mean change 0.03, p = 0.2). There was a correlation between baseline leg pain and the change in EQ-5D at the 2-year (r = 0.33, p = 0.002) and 7-year follow-up (r = 0.23, p = 0.04). However, when using regression analysis the only statistically significant predictor for change in EQ-5D was baseline EQ-5D score., Interpretation: Our findings suggest that HRQoL (as measured by EQ-5D) improved 2 years after lumbar disc herniation surgery, but there was no further improvement after 5 more years. Low quality of life and severe leg pain at baseline are important predictors of improvement in quality of life after lumbar disc herniation surgery.

There has been no agreement among different authors on guidelines to specify the situations in which arthrodesis is justified in terms of results, risks and complications. The aim of this study was to identify preoperative predictors of outcome after decompressive lumbar surgery and instrumented posterolateral fusion. A prospective observational study design was performed on 203 consecutive patients. Potential preoperative predictors of outcome included sociodemographic factors as well as variables pertaining to the preoperative clinical situation, diagnosis, expectations and surgery. Separate multiple linear regression models were used to assess the association between selected predictors and outcome variables, defined as the improvement after 1 year on the visual analog scale (VAS) for back pain, VAS for leg pain, physical component scores (PCS) of SF-36 and Oswestry disability index (ODI). Follow-up was available for 184 patients (90.6%). Patients with higher educational level and optimistic preoperative expectations had a more favourable postoperative leg pain (VAS) and ODI. Smokers had less leg pain relief. Patients with better mental component score (emotional health) had greater ODI improvement. Less preoperative walking capacity predicted more leg pain relief. Patients with disc herniation had greater relief from back pain and more PCS and ODI improvement. More severe lumbar pain was predictive of less improvement on ODI and PCS. Age, sex, body mass index, analgesic use, surgeon, self-rated health, the number of decompressed levels and the length of fusion had no association with outcome. This study concludes that a higher educational level, optimistic expectations for improvement, the diagnosis of "disc herniation", less walking capacity and good emotional health may significantly improve clinical outcome. Smoking and more severe lumbar pain are predictors of worse results.

Objective: To investigate the correlation between the coping style and mental health of patients with lumbar intervertebral disc herniation., Methods: The simplified coping style questionnaire and SCL-90 were used to conduct a survey of 106 patients with lumbar intervertebral disc herniation, and the scores were compared with the national norms., Results: The patients had a positive coping style score of 1.51-/+0.58 and negative coping style score of 1.13-/+0.58. The SCL-90 scores were significantly higher than the national norms. A significant correlation was found between the negative coping style and mental health of the patients., Conclusion: Negative coping style is an important factor influencing the mental health of patients with lumbar intervertebral disc herniation.

Background: Lumbar disc disease is a very common condition with a substantial socioeconomic impact. Studies have shown the importance of a multilevel assessment of this disease, as its course is influenced by many factors. Most follow-up studies use the degree of physical impairment to measure the outcome of a certain treatment. This remains unsatisfactory, as physical impairment itself seems to be influenced by the social, psychological and personal condition of a patient. We believe that an overall quality of life assessment is required to evaluate success of treatment. The SF-36 questionnaire seemed appropriate, as it provides consistent data of a patient's overall health status. To ensure measurement of disability due to back pain we combined the SF-36 with the NASS (North American Spine Society) questionnaire, an instrument specific for lumbar spine disorders., Method: One year after the last outpatient consultation in our neurosurgical clinic, a SF-36 questionnaire was sent to 636 patients with conservatively treated lumbar disc disease. We used the Mann Whitney Test to compare patient's data with a standard group. The demographics of the standard group were matched with the study cohort., Findings: A total of 486 patients (66.5% males and 33.5% females), mean age 49 years (range 21-82 years), returned the questionnaire. The SF-36 data was usable in 76.4% of the patients. Statistical testing reported a significant impact of the disease on all 8 items of the SF-36 questionnaire. The "Role Functioning - Physical (RF)" item was the most, the "Mental Health (MH)" item the less affected. No statistical difference was found between males and females regarding the impact on single items. The NASS scores were also affected suggesting that lumbar back disorder was the influencing factor for the low SF-36 scores., Conclusions: Besides impairment in the execution of daily physical tasks, patients with lumbar disc disease also showed a significant impact on the "Mental Health (MH)" item. Early SF-36 assessment could identify subjects with high probability of prolonged recovery and development of chronic pain syndromes. In these patients, an early rheumatologic, rehabilitative and psychiatric treatment might be the key to improve their coping abilities and should become an integral part of the treatment strategy.

Returning to work after disc surgery appears to be more heavily influenced by psychological aspects of work than by MR-identified morphological alterations. It is still not known whether psychosocial factors of importance for outcome after disc surgery are present preoperatively or develop in the postoperative phase. The aim of this study was to investigate the presence of work-related stress, life satisfaction and demanding life events, among patients undergoing first-time surgery for lumbar disc herniation in comparison with patients scheduled for arthroscopic knee surgery. Sixty-nine patients with disc herniation and 162 patients awaiting arthroscopy were included in the study, during the time period March 2003 to May 2005. Sixty-two percent of the disc patients had been on sick leave for an average of 7.8 months and 14 percent of the knee patients had been on sick leave for an average of 4.2 months. The psychosocial factors were investigated preoperatively using a questionnaire, which was a combination of the questionnaire of quality of work competence (QWC), life satisfaction (LiSat9) and life events as a modification of the social readjustment scale. There were no significant differences between the two groups in terms of work-related stress or the occurrence of demanding life events. The disc patients were significantly less satisfied with functions highly inter-related to pain and discomfort, such as present work situation, leisure-time, activities of daily living (ADL) function and sleep. Patients with disc herniation on sick leave were significantly less satisfied with their present work situation than knee patients on sick leave; this sub-group of patients with disc herniation also reported significantly higher expectations in relation to future job satisfaction than knee patients. The results indicate that psychosocial stress is not more pronounced preoperatively in this selected group of disc patients, without co-morbidity waiting for first-time disc surgery, than among knee patients awaiting arthroscopy. It was notable that the disc patients had high expectations in terms of improved job satisfaction after treatment by surgery.

Objectives: To assess the disability level and quality of life of the patients who had been reoperated and not reoperated because of lumbar disc herniation., Methods: 34 reoperated and 34 not reoperated patients with lumbar disc herniation were retrospectively included in the study. The disability levels of the patients were evaluated with the Oswestry Disability Index and the the quality of life was evaluated with SF-36. The measurements were repeated in the 2nd, 6th and 12th months after the operation., Results: The disability measurements of the reoperated and not reoperated patients were found to be significantly different in the 2nd, 6th and 12th months (p < 0.05); and it was noticed that the reoperated group had more disability levels than not reoperated patients in all the assessments. SF-36 measurement in the 2nd month showed significant differences in all parameters except pain (p < 0.05). There were important differences in all parameters of quality of life in the 6th month and significant differences were found in all parameters of quality of life except physical and emotional role limitation in the 12th month (p < 0.05) in favour of the not reoperated group., Conclusions: The increase in the number of operations affects the disability level and quality of life negatively.

Objective: For complete assessment of benefits of the surgical intervention, it is essential to provide evidence of the impact on patients in terms of health status and health-related quality of life. In the present study, the preoperative 36-item Short Form (SF-36) Health Survey scores were determined in patients before lumbar microdiscectomy due to better preoperative screening likewise in the control group--almost healthy population taken into account any habitual ailments experienced in an appropriate age., Patients and Methods: In the present study, we investigated a cohort of 100 patients with disc herniation causing low back pain and another hundred of the control subjects, matched by age and gender. The short form 36 general health questionnaire (SF-36) was applied., Results: Estimation of the SF-36 scores showed that (1) all of the domain values were considerably lower in the preoperative patient group than in the second one (P<0.01); (2) the bodily pain scores were closely correlated to the social function scores (R=0.7, P<0.01), whereas the physical function was less related to the bodily pain (R=0.6, P<0.01). The weakest correlation was observed between bodily pain and mental health and general health (R=0.4, P<0.01)., Conclusion: The present study showed that the generic instrument, SF-36 Health Survey, was optimized paraclinical method for patients predisposed to surgical treatment of the lumbar disc herniation disease likewise for normal population individuals, matched by age and sex, in the assessment of health-related quality of life.

Background: Chronic low back pain patients have a high rate of psychopathology, comprised mainly of depression, anxiety, and high levels of neuroticism. We previously found that psychopathology is associated with increased placebo analgesia in this patient group., Objective: To better understand this finding in the context of other known predictors of placebo response (such as expectations for relief), we performed a detailed analysis of expectations and other possible covariates., Design: We conducted a double-blind, placebo-controlled, randomized, crossover-designed trial of intravenous morphine vs. placebo in 60 subjects with chronic low back pain and discogenic abnormalities. Patients were stratified into three groups of psychiatric symptom severity (Low, Moderate, and High), based on composite scores on depression, anxiety for pain, and neuroticism scales. Subjects were given intravenous morphine and placebo in random order on separate visits, and completed serial pain ratings over 3 h at each session., Results: With 20 subjects per group, there were small, but significant differences between groups in baseline pain ratings. No differences were found between groups in age, gender, and radicular pain. Patients with low psychological symptomatology reported 7.7% total pain relief with placebo compared with 23.4% in the Moderate group and 23.5% in the High group (P < 0.05). Expectations were not significantly different between groups, but in the High group expectation levels predicted placebo analgesia (P < 0.001). Neuropathic pain quality was also a predictor (P < 0.05)., Conclusions: This study indicates that high and moderate levels of psychopathology are associated with heightened placebo analgesia in chronic low back pain patients. Expectations were only an influence in the high psychopathology group, and neuropathic pain affects placebo responses. These findings have implications for future research characterizing placebo responders.

Background: Pain patients are often depressed and anxious, and benefit less from psychotropic drugs than pain-free patients. We hypothesize that this partial resistance is due to the unique neurochemical contribution to mood by afferent pain projections through the spino-parabrachial-hypothalamic-amygdalar systems and their projections to other mood-mediating systems. New psychotropic drugs for pain patients might target molecules in such brain systems. We propose a method to prioritize molecular targets by studying polymorphic genes in cohorts of patients undergoing surgical procedures associated with a variable pain relief response. We seek molecules that show a significant statistical interaction between (1) the amount of surgical pain relief, and (2) the alleles of the gene, on depression and anxiety during the first postoperative year., Results: We collected DNA from 280 patients with sciatica due to a lumbar disc herniation, 162 treated surgically and 118 non-surgically, who had been followed for 10 years in the Maine Lumbar Spine Study, a large, prospective, observational study. In patients whose pain was reduced >25% by surgery, symptoms of depression and anxiety, assessed with the SF-36 Mental Health Scale, improved briskly at the first postoperative measurement. In patients with little or no surgical pain reduction, mood scores stayed about the same on average. There was large inter-individual variability at each level of residual pain. Polymorphisms in three pre-specified pain-mood candidate genes, catechol-O-methyl transferase (COMT), serotonin transporter, and brain-derived neurotrophic factor (BDNF) were not associated with late postoperative mood or with a pain-gene interaction on mood. Although the sample size did not provide enough power to persuasively search through a larger number of genes, an exploratory survey of 25 other genes provides illustrations of pain-gene interactions on postoperative mood--the mu opioid receptor for short-term effects of acute sciatica on mood, and the galanin-2 receptor for effects of unrelieved post-discectomy pain on mood one year after surgery., Conclusion: Genomic analysis of longitudinal studies of pain, depression, and anxiety in patients undergoing pain-relieving surgery may help to identify molecules through which pain alters mood. Detection of alleles with modest-sized effects will require larger cohorts.

A frequent concern among patients operated for lumbar disc herniation is the risk of "getting worse". To give an evidence-based estimate of the risk for worsening has been difficult, since previous studies have been more focused on unfavourable outcome in general, rather than on deterioration in particular. In this prospective study of 180 patients, we report the frequency of and the risk factors for getting worse after first time lumbar microdiscectomy. Follow-up time was 12 months. Primary outcome measure was the Oswestry disability index, assessing functional status and health-related quality of life. Of the patients 4% got worse. Independent risk factors of deterioration were a long duration of sick leave and a better functional status and quality of life prior to operation. We conclude that the risk of deterioration is small, but larger if the patient has been unable to work despite relatively small health problems. This study also demonstrates that changes in instrument scores should be reported, so that an accurate failure rate can be assessed.

Objective: To assess genetic and environmental influences on low back and neck pain in a classic twin design and to examine the extent to which these are explained by structural changes seen on magnetic resonance imaging (MRI) and psychological and lifestyle variables., Methods: The subjects comprised 1,064 unselected women (181 monozygotic [MZ] and 351 dizygotic [DZ] twin pairs) recruited from a national registry of twin volunteers. Outcome measures included lifetime history of low back and neck pain (using a range of increasingly stringent definitions), MRI scores of disc degeneration in the lumbar and cervical spine, psychological distress as assessed by the General Health Questionnaire (GHQ), and lifestyle variables assessed by questionnaire., Results: For all definitions of pain, there was a consistent excess concordance in MZ when compared with DZ twins, equating to a heritability for low back pain in the range of 52-68% and for neck pain in the range of 35-58%. The strongest associations were between low back pain and MRI change (odds ratio [OR] 3.6, 95% confidence interval [95% CI] 1.8-7.3]) and between neck pain and response on the GHQ (OR 3.3, 95% CI 2.1-5.0). These associations were mediated genetically., Conclusions: Genetic factors have an important influence on back and neck pain reporting in women. These factors include the genetic determinants of structural disc degeneration and an individual's inherited tendency toward psychological distress. MRI changes are the strongest predictor of low back pain.

Behavioral approaches to treating patients following lumbar disc surgery are becoming increasingly popular. The treatment method is based on the assumption that pain and pain disability are not only influenced by somatic pathology, if found, but also by psychological and social factors. A recent study highlighted the effectiveness of cognitive-behavioral interventions, as compared to no treatment, for chronic low back patients. However, to the authors' knowledge, there is no randomized controlled trial that evaluates a behavioral program for patients following lumbar disc surgery. The purpose of this study was to assess the effectiveness of a behavioral graded activity (BGA) program compared to usual care (UC) in physiotherapy following first-time lumbar disc surgery. The BGA program was a patient-tailored intervention based upon operant therapy. The essence of the BGA is to teach patients that it is safe to increase activity levels. The study was designed as a randomized controlled trial. Assessments were carried out before and after treatment by an observer blinded to treatment allocation. Patients suffering residual symptoms restricting their activities of daily living and/or work at the 6 weeks post-surgery consultation by the neurosurgeon were included. The exclusion criteria were: complications during surgery, any relevant underlying pathology, and any contraindication to physiotherapy or the BGA program. Primary outcome measures were the patient's Global Perceived Effect and the functional status. Secondary measures were: fear of movement, viewing pain as extremely threatening, pain, severity of the main complaint, range of motion, and relapses. Physiotherapists in the BGA group received proper training. Between November 1997 and December 1999, 105 patients were randomized; 53 into the UC group and 52 into the BGA group. The unadjusted analysis shows a 19.3% (95% CI: 0.1 to 38.5) statistically significant difference to the advantage of the UC group on Global Perceived Effect. This result, however, is not robust, as the adjusted analyses reveal a difference of 15.7% (95% CI: -3.9 to 35.2), which is not statistically significant. For all other outcome measures there were no statistically significant or clinically relevant differences between the two intervention groups. In general, the physiotherapists' compliance with the BGA program was satisfactory, although not all treatments, either in the BGA or the UC group, were delivered exactly as planned, resulting in less contrast between the two interventions than had been planned for. There was one re-operation in each group. The BGA program was not more effective than UC in patients following first-time lumbar disc surgery. For Global Perceived Effect there was a borderline statistically significant difference to the advantage of the UC group. On functional status and all other outcome measures there were no relevant differences between interventions. The number of re-operations was negligible, indicating that it is safe to exercise after first-time disc surgery.

Despite the continuous development of surgical techniques and implants, a substantial number of patients still undergo surgery for chronic low back pain (CLBP) without any benefit, or even become worse. With the aim of finding predictors of functional and work status outcome, 264 patients with severe CLBP of long duration, randomised to surgical or non-surgical treatment, were characterized by socio-demographic, clinical, radiological and psychological variables. The variables were estimated as predictors of outcome at the 2-year follow-up. Univariate and multiple logistic regression analyses were used in both treatment groups. We found that a personality characterized by low neuroticism and low disc height were significant predictors of functional improvement after surgical treatment. Depressive symptoms predicted functional improvement after non-surgical treatment. Work resumption was predicted by low age and short sick leave in the surgical group, and by short sick leave in the non-surgical group. We conclude that improved selection of successful surgical candidates with CLBP seems to be promoted by attention to severe disc degeneration, evaluation of personality traits and shortening of preoperative sick leave.

Objectives: To investigate the relevance of somatic, psychic and psychosocial factors on the health-related quality of life at the one year follow-up of patients with lower back pain., Methods: Prospective cohort study of 109 patients recruited consecutively. At baseline and at one year follow-up self-report instruments were administered to evaluate health-related quality of life (SF-36), psychic or psychological distress (SF-36), and coping strategies (FKV-LIS)., Results: In regards to the physical and mental dimensions of the quality of life at follow-up, psychosocial factors evaluated at baseline were far more relevant. Using a multiple regression analysis we were able to account for 38 % of the variance in the physical dimension of the quality of life and 45 % of the variance in the mental dimension. In these two dimensions the factors "psychic distress" (GSI, SCL-90-R) and "sick leave" were significant predictors, in the mental dimension additionally "doctor shopping". Beyond that, impaired health-related quality of life at baseline as well as at follow-up was related to depressive coping (FKV-LIS)., Conclusions: The study shows the high impact of psychic and psychosocial factors on health-related quality of life in patients with chronic lower back pain.

We compared the clinical outcome after spinal fusion between patients with isthmic spondylolisthesis and those with degenerative disc disease of the lumbar spine, using multiple logistic regression analysis. A questionnaire describing medication, pain, vocational status and patient satisfaction was mailed to all the patients at a median interval of 4 years after their operation. Fusion was evaluated on plain radiographs at a minimum of 12 months after surgery, and patients were classified as fused or not fused. The overall satisfaction rate was 70%. The results of the present study showed no difference in the outcome after spinal fusion between the two groups of patients. The factors that significantly increased the likelihood of an optimal result - defined as patient satisfaction, return to work, and reduced medication - were male gender, being in work prior to surgery, and being a non-smoker. Since spinal fusion is an expensive treatment with potentially serious risks, and leaves one-third of the patients with an unsatisfactory result, we believe that more studies focusing on the indications for surgery should be performed.

Objectives: In groups of lumbar surgery patients who had different expectations about postoperative pain and recovery, this study investigated disappointment three days and three months after surgery. Our hypothesis was that patients who did not expect any postoperative pain and who expected a fast rate of recovery were at risk of becoming disappointed., Methods: One day before surgery, 120 patients who underwent lumbar surgery were interviewed about their expectations regarding postoperative pain, rate of recovery, and return to work. Levels of postoperative pain and disappointment were measured three days and three months postoperatively., Results: Patients who did not expect to have any postoperative pain reported significantly less disappointment three days and three months after surgery than did patients who expected to have postoperative pain. No significant differences were found in postoperative disappointment between the groups with different expectations regarding the rate of recovery or the return to work., Conclusion: Contrary to our hypothesis, the results suggest that patients who do not expect to experience any postoperative pain will be less disappointed after surgery than patients who expect to be in pain. Implications for the theory of mental preparation and for preoperative intervention strategies aimed at diminishing the stress of surgery are discussed.

In reports of diagnostic methods in disorders of the spine focus is centred on diagnostic resolution, while psychological effects and patients' discomfort are often disregarded. To get a comprehensive picture of the appropriateness of a new technology the latter factors need to be explored and included in an assessment. In a prospective study, eight patients with signs of lumbar disc herniation underwent myelography, computed tomography and magnetic resonance imaging. A structured patient interview on attitudes to these technologies was carried out after all three examinations had been carried out. Myelography was most often reported painful and unpleasant among the three modalities. Discomfort due to magnetic resonance imaging stem from the narrow calibre of the machine and the noise. In computed tomography immobilization was the main reason for discomfort. Altogether most patients preferred computed tomography. In view of the fact that myelography must be considered as diagnostically inferior to the other two examinations, the reported discomfort from myelography indicates that computed tomography and magnetic resonance imaging should be the primary examinations for patients with lumbar disc herniation.

Numerous cases of psychogenic death have been cited throughout the world, as well by native peoples, inhabitants of concentration camps and prisoner of war camps. Psychogenic death is a generalized human extreme psychosomatic reaction. It is not specific to any culture or mentality. Psychogenic death refers to death triggered by psychic stimuli. The individual finds himself in a situation where external forces have lead to a restriction of his world and, in addition, is subjectively sensing of the inalterability of his situation. Decisive to the perception of the environment is the subjective emotional view of things which can greatly diverge reality. The physical state of these individuals is marked by total passivity. The psychic condition is characterized by regression, resignation, and apathy. The article described the psychic background and the physical process of a death by psychic phenomena. The case of a 37 year old patient with detailed anamnestic and clinical data is given. His hobby was taking photographs of natural scenery and animals. This had become vital for him, because he did not like his job. The patient suffered from a painful herniation of intervetebral disk. After the operation of the disk he still had backache. He thought that the operation had been unsuccessful. The following day the patient showed the symptoms of the psychogenic death and died within one day. The autopsy, histopathologic, and toxicologic examinations showed no indications to the cause of death.

57 patients who underwent surgery for slipped lumbar disc for the first time were examined prospectively 6 months after surgery for the purpose of deciding the correlation between the outcome of surgery and social and psychological factors. The following factors were found to be of importance: Female sex, action for damages, prolonged disease of the back; prolonged, current attack, report of long-term illness, pathological pain producing, anxiety, depression and multiple somatic complaints revealed by Minnesota Multiple Personality Inventory (MMPI), severe pain reported immediately post-operatively, employment and the presence of complete herniation at surgery. A closer study revealed 3 factors which were important independently and which explained the other factors: Admission of symptom scale (Ad) in the MMPI, the duration of the current attack and whether the patient was employed. On this basis we define a group with severe psychological and social strain (PASS), 57% of which had a poor outcome. 5% of the rest of the patients had a poor outcome. With the pre-operative assessment of whether or not the patients are under severe psychological and social strain, the outcome of surgery could be predicted correctly in 86% of the patients.