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Lumbar spinal stenosis is the leading indication for spine surgery in older adults. Surgery is recommended in clinical guidelines if non-surgical treatments have been provided with insufficient benefit. The difficulty for clinicians is that the current number of randomised controlled trials is low, which creates uncertainty about which treatments to provide. For non-surgical clinicians this paucity of data leads to a clinical dilemma of whether to continue managing the patient or refer to a spine surgeon. This Viewpoint aims to provide an update on the assessment of lumbar spinal stenosis, treatment recommendations, indications for referral to a spine surgeon, and current clinical dilemmas facing non-surgical clinicians and spinal surgeons., Competing Interests: Declaration of interests DJB holds an National Institute for Health and Care Research Senior Investigator award. FR receives payment or honoraria from Pierre Fabre, Thuasne, Institut Biochimique SA, Expanscience, Genevrier, Pfizer, MSD, Grunenthal, and Fidia Farmaceutici SpA.; has received support for attending meetings from The French Society of Physical and Rehabilitation Medicine, Osteoarthritis Research Society International, French Society of Rheumatology, AbbVie, and European Alliance of Associations for Rheumatology; participates on a data safety monitoring board and advisory board of Pierre Fabre and Thuasne; and holds leadership positions with The French Society of Physical and Rehabilitation Medicine (president elect), Osteoarthritis Research Society International (treasurer), and the Annals of Physical and Rehabilitation Medicine (associate editor). DJH provides consulting advice on scientific advisory boards for Pfizer, Lilly, Taiwan Liposome Company BioSciences, Novartis, Tissuegene, and Biobone; is the co-director of the Sydney Musculoskeletal Health Flagship; and is the editor of the osteoarthritis section for UpToDate and co-editor in chief of Osteoarthritis and Cartilage. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Background: Lumbar spinal stenosis (LSS) is a common degenerative condition that contributes to back and back-related leg pain in older adults. Most patients with symptomatic LSS initially receive non-operative care before surgical consultation. However, there is a scarcity of data regarding prognosis for patients seeking non-surgical care. The overall goal of this project is to develop and evaluate a clinically useful model to predict long-term physical function of patients initiating non-surgical care for symptomatic LSS., Methods: This is a protocol for an inception cohort study of adults 50 years and older who are initiating non-surgical care for symptomatic LSS in a secondary care setting. We plan to recruit up to 625 patients at two study sites. We exclude patients with prior lumbar spine surgeries or those who are planning on lumbar spine surgery. We also exclude patients with serious medical conditions that have back pain as a symptom or limit walking. We are using weekly, automated data pulls from the electronic health records to identify potential participants. We then contact patients by email and telephone within 21 days of a new visit to determine eligibility, obtain consent, and enroll participants. We collect data using telephone interviews, web-based surveys, and queries of electronic health records. Participants are followed for 12 months, with surveys completed at baseline, 3, 6, and 12 months. The primary outcome measure is the 8-item PROMIS Physical Function (PF) Short Form. We will identify distinct phenotypes using PROMIS PF scores at baseline and 3, 6, and 12 months using group-based trajectory modeling. We will develop and evaluate the performance of a multivariable prognostic model to predict 12-month physical function using the least absolute shrinkage and selection operator and will compare performance to other machine learning methods. Internal validation will be conducted using k-folds cross-validation., Discussion: This study will be one of the largest cohorts of individuals with symptomatic LSS initiating new episodes of non-surgical care. The successful completion of this project will produce a cross-validated prognostic model for LSS that can be used to tailor treatment approaches for patient care and clinical trials., (© 2022. The Author(s).)

Background: Modifying physician behavior to more closely align with guideline-based care can be challenging. Few effective strategies resulting in appropriate spine-related health care have been reported. The Lumbar Imaging With Reporting of Epidemiology (LIRE) intervention did not result in reductions in spine care but did in opioid prescriptions written., Objectives: To estimate organizational resource needs and costs associated with implementing a pragmatic, decision support-type intervention that inserted age- and modality-matched prevalence information for common lumbar spine imaging findings, using site-based resource use data from the LIRE trial., Research Design: Time and cost estimation associated with implementing the LIRE intervention in a health organization., Subjects: Providers and patients assessed in the LIRE trial., Measures: Expected personnel costs required to implement the LIRE intervention., Results: Annual salaries were converted to daily average per person costs, ranging from $400 to $2,200 per day (base case) for personnel (range: $300-$2,600). Estimated total average cost for implementing LIRE was $5,009 (range: $2,651-$12,020), including conducting pilot testing with providers. Costs associated with a small amount of time for a radiologist (6-12 hours) and imaging-ordering providers (1-8 hours each) account for approximately 75% of the estimated total cost., Conclusions: The process of implementing an intervention for lumbar spine imaging reports containing age- and modality-appropriate epidemiological benchmarks for common imaging findings required radiologists, imaging-ordering providers, information technology specialists, and limited testing and monitoring. The LIRE intervention seems to be a relatively low-cost, evidence-based, complementary tool that can be easily integrated into the reporting of spine imaging., (Copyright © 2021. Published by Elsevier Inc.)

Importance: Lumbar spine imaging frequently reveals findings that may seem alarming but are likely unrelated to pain. Prior work has suggested that inserting data on the prevalence of imaging findings among asymptomatic individuals into spine imaging reports may reduce unnecessary subsequent interventions., Objective: To evaluate the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions., Design, Setting, and Participants: This stepped-wedge, pragmatic randomized clinical trial included 250 401 adult participants receiving care from 98 primary care clinics at 4 large health systems in the United States. Participants had imaging of their backs between October 2013 and September 2016 without having had spine imaging in the prior year. Data analysis was conducted from November 2018 to October 2019., Interventions: Either standard lumbar spine imaging reports (control group) or reports containing age-appropriate prevalence data for common imaging findings in individuals without back pain (intervention group)., Main Outcomes and Measures: Health care utilization was measured in spine-related relative value units (RVUs) within 365 days of index imaging. The number of subsequent opioid prescriptions written by a primary care clinician was a secondary outcome, and prespecified subgroup analyses examined results by imaging modality., Results: We enrolled 250 401 participants (of whom 238 886 [95.4%] met eligibility for this analysis, with 137 373 [57.5%] women and 105 497 [44.2%] aged >60 years) from 3278 primary care clinicians. A total of 117 455 patients (49.2%) were randomized to the control group, and 121 431 patients (50.8%) were randomized to the intervention group. There was no significant difference in cumulative spine-related RVUs comparing intervention and control conditions through 365 days. The adjusted median (interquartile range) RVU for the control group was 3.56 (2.71-5.12) compared with 3.53 (2.68-5.08) for the intervention group (difference, -0.7%; 95% CI, -2.9% to 1.5%; P = .54). Rates of subsequent RVUs did not differ between groups by specific clinical findings in the report but did differ by type of index imaging (eg, computed tomography: difference, -29.3%; 95% CI, -42.1% to -13.5%; magnetic resonance imaging: difference, -3.4%; 95% CI, -8.3% to 1.8%). We observed a small but significant decrease in the likelihood of opioid prescribing from a study clinician within 1 year of the intervention (odds ratio, 0.95; 95% CI, 0.91 to 1.00; P = .04)., Conclusions and Relevance: In this study, inserting benchmark prevalence information in lumbar spine imaging reports did not decrease subsequent spine-related RVUs but did reduce subsequent opioid prescriptions. The intervention text is simple, inexpensive, and easily implemented., Trial Registration: ClinicalTrials.gov Identifier: NCT02015455.

Rationale and Objectives: To evaluate a natural language processing (NLP) system built with open-source tools for identification of lumbar spine imaging findings related to low back pain on magnetic resonance and x-ray radiology reports from four health systems., Materials and Methods: We used a limited data set (de-identified except for dates) sampled from lumbar spine imaging reports of a prospectively assembled cohort of adults. From N = 178,333 reports, we randomly selected N = 871 to form a reference-standard dataset, consisting of N = 413 x-ray reports and N = 458 MR reports. Using standardized criteria, four spine experts annotated the presence of 26 findings, where 71 reports were annotated by all four experts and 800 were each annotated by two experts. We calculated inter-rater agreement and finding prevalence from annotated data. We randomly split the annotated data into development (80%) and testing (20%) sets. We developed an NLP system from both rule-based and machine-learned models. We validated the system using accuracy metrics such as sensitivity, specificity, and area under the receiver operating characteristic curve (AUC)., Results: The multirater annotated dataset achieved inter-rater agreement of Cohen's kappa > 0.60 (substantial agreement) for 25 of 26 findings, with finding prevalence ranging from 3% to 89%. In the testing sample, rule-based and machine-learned predictions both had comparable average specificity (0.97 and 0.95, respectively). The machine-learned approach had a higher average sensitivity (0.94, compared to 0.83 for rules-based), and a higher overall AUC (0.98, compared to 0.90 for rules-based)., Conclusions: Our NLP system performed well in identifying the 26 lumbar spine findings, as benchmarked by reference-standard annotation by medical experts. Machine-learned models provided substantial gains in model sensitivity with slight loss of specificity, and overall higher AUC., (Copyright © 2018 The Association of University Radiologists. All rights reserved.)

Objectives: To identify neuromuscular attributes associated with mobility and changes in mobility over 2 years of follow-up among patients with and without symptomatic lumbar spinal stenosis (SLSS)., Design: Secondary analysis of a longitudinal cohort study., Setting: Outpatient rehabilitation center., Participants: Community-dwelling older adults ≥65 years with self-reported mobility limitations (N=430). SLSS was determined using self-reported symptoms of neurogenic claudication and imaging-detected lumbar spinal stenosis., Interventions: Not applicable., Main Outcome Measure: Basic and advanced mobility as measured by the Late-Life Function and Disability Instrument (LLFDI)., Results: Among 430 community-dwelling older adults, 54 (13%) patients met criteria for SLSS, while 246 (57%) did not. On average LLFDI basic and advanced mobility scores decreased significantly from baseline through year 2 for participants with SLSS (basic: P=.04, 95% CI 0.18, 5.21; advanced P=.03, 95% CI 0.39, 7.84). Trunk extensor muscle endurance (trunk endurance) and leg strength were associated with baseline basic mobility (R 2 =0.27, P<.001) while leg strength and knee flexion range of motion (ROM) were associated with baseline advanced mobility among participants with SLSS (R 2 =0.47, P<.001). Among participants without SLSS trunk endurance, leg strength and ankle ROM were associated with baseline basic mobility (R 2 =0.38, P<.001), while trunk endurance, leg strength, leg strength asymmetry, and knee flexion ROM were associated with advanced mobility (R 2 =0.20, P<.001). Trunk endurance and leg strength were associated with change in basic mobility (R 2 =0.29, P<.001), while trunk endurance and knee flexion ROM were associated with change in advanced mobility (R 2 =0.42, P<.001) among participants with SLSS. Among participants without SLSS trunk endurance, leg strength, knee flexion ROM, and ankle ROM were associated with change in basic mobility (R 2 =0.22, P<.001), while trunk endurance, leg strength, and knee flexion ROM were associated with change in advanced mobility (R 2 =0.36, P<.001)., Conclusions: Patients with SLSS experience greater impairment in the neuromuscular attributes: trunk endurance, leg strength, leg strength asymmetry, knee flexion and extension ROM, and ankle ROM compared to patients without SLSS. Differences exist in the neuromuscular attributes associated with mobility at baseline and decline in mobility over 2 years of follow-up for patients with and without SLSS. These findings may help guide rehabilitative care approaches for patients with SLSS., (Copyright © 2018 American Congress of Rehabilitation Medicine. All rights reserved.)

Electronic medical record (EMR) systems provide easy access to radiology reports and offer great potential to support quality improvement efforts and clinical research. Harnessing the full potential of the EMR requires scalable approaches such as natural language processing (NLP) to convert text into variables used for evaluation or analysis. Our goal was to determine the feasibility of using NLP to identify patients with Type 1 Modic endplate changes using clinical reports of magnetic resonance (MR) imaging examinations of the spine. Identifying patients with Type 1 Modic change who may be eligible for clinical trials is important as these findings may be important targets for intervention. Four annotators identified all reports that contained Type 1 Modic change, using N = 458 randomly selected lumbar spine MR reports. We then implemented a rule-based NLP algorithm in Java using regular expressions. The prevalence of Type 1 Modic change in the annotated dataset was 10%. Results were recall (sensitivity) 35/50 = 0.70 (95% confidence interval (C.I.) 0.52-0.82), specificity 404/408 = 0.99 (0.97-1.0), precision (positive predictive value) 35/39 = 0.90 (0.75-0.97), negative predictive value 404/419 = 0.96 (0.94-0.98), and F1-score 0.79 (0.43-1.0). Our evaluation shows the efficacy of rule-based NLP approach for identifying patients with Type 1 Modic change if the emphasis is on identifying only relevant cases with low concern regarding false negatives. As expected, our results show that specificity is higher than recall. This is due to the inherent difficulty of eliciting all possible keywords given the enormous variability of lumbar spine reporting, which decreases recall, while availability of good negation algorithms improves specificity.

Objective: To determine the overall long-term effectiveness of treatment with epidural corticosteroid injections for lumbar central spinal stenosis and the effect of repeat injections, including crossover injections, on outcomes through 12 months., Design: Multicenter, double-blind, randomized controlled trial comparing epidural injections of corticosteroid plus lidocaine versus lidocaine alone., Setting: Sixteen clinical sites., Participants: Participants with imaging-confirmed lumbar central spinal stenosis (N=400)., Interventions: Participants were randomized to receive either epidural injections with corticosteroid plus lidocaine or lidocaine alone with the option of blinded crossover after 6 weeks to receive the alternate treatment. Participants could receive 1 to 2 injections from 0 to 6 weeks and up to 2 injections from 6 to 12 weeks. After 12 weeks, participants received usual care., Main Outcome Measures: Primary outcomes were the Roland-Morris Disability Questionnaire (RDQ) (range, 0-24, where higher scores indicate greater disability) and leg pain intensity (range, 0 [no pain] to 10 [pain as bad as you can imagine]). Secondary outcomes included opioid use, spine surgery, and crossover rates., Results: At 12 months, both treatment groups maintained initial observed improvements, with no significant differences between groups on the RDQ (adjusted mean difference, -0.4; 95% confidence interval [CI], -1.6 to 0.9; P=.55), leg pain (adjusted mean difference, 0.1; 95% CI, -0.5 to 0.7; P=.75), opioid use (corticosteroid plus lidocaine: 41.4% vs lidocaine alone: 36.3%; P=.41), or spine surgery (corticosteroid plus lidocaine: 16.8% vs lidocaine alone: 11.8%; P=.22). Fewer participants randomized to corticosteroid plus lidocaine (30%, n=60) versus lidocaine alone (45%, n=90) crossed over after 6 weeks (P=.003). Among participants who crossed over at 6 weeks, the 6- to 12-week RDQ change did not differ between the 2 randomized treatment groups (adjusted mean difference, -1.0; 95% CI, -2.6 to 0.7; P=.24). In both groups, participants crossing over at 6 weeks had worse 12-month trajectories compared with participants who did not choose to crossover., Conclusions: For lumbar spinal stenosis symptoms, epidural injections of corticosteroid plus lidocaine offered no benefits from 6 weeks to 12 months beyond that of injections of lidocaine alone in terms of self-reported pain and function or reduction in use of opioids and spine surgery. In patients with improved pain and function 6 weeks after initial injection, these outcomes were maintained at 12 months. However, the trajectories of pain and function outcomes after 3 weeks did not differ by injectate type. Repeated injections of either type offered no additional long-term benefit if injections in the first 6 weeks did not improve pain., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To identify differences in health factors, neuromuscular attributes, and performance-based mobility among community-dwelling older adults with symptomatic lumbar spinal stenosis; and to determine which neuromuscular attributes are associated with performance-based measures of mobility., Design: Cross-sectional; secondary data analysis of a cohort study., Setting: Outpatient rehabilitation center., Participants: Community-dwelling adults aged ≥65 years with self-reported mobility limitations and symptomatic lumbar spinal stenosis (N=54)., Interventions: Not applicable., Main Outcome Measures: Short Physical Performance Battery score, habitual gait speed, and chair stand test., Results: Symptomatic lumbar spinal stenosis was classified using self-reported symptoms of neurogenic claudication and imaging. Among 430 community-dwelling older adults, 54 (13%) met criteria for symptomatic lumbar spinal stenosis. Compared with participants without symptomatic lumbar spinal stenosis, those with symptomatic lumbar spinal stenosis had more comorbidities, higher body mass index, greater pain, and less balance confidence. Participants with symptomatic lumbar spinal stenosis had greater impairment in trunk extensor muscle endurance, leg strength, leg strength asymmetry, knee flexion range of motion (ROM), knee extension ROM, and ankle ROM compared with participants without symptomatic lumbar spinal stenosis. Five neuromuscular attributes were associated with performance-based mobility among participants with symptomatic lumbar spinal stenosis: trunk extensor muscle endurance, leg strength, leg strength asymmetry, knee flexion ROM, and knee extension ROM asymmetry., Conclusions: Community-dwelling older adults with self-reported mobility limitations and symptomatic lumbar spinal stenosis exhibit poorer health characteristics, greater neuromuscular impairment, and worse mobility when compared with those without symptomatic lumbar spinal stenosis. Poorer trunk extensor muscle endurance, leg strength, leg strength asymmetry, knee flexion ROM, and knee extension ROM asymmetry were associated with performance-based mobility among participants with symptomatic lumbar spinal stenosis., (Copyright © 2017 American Congress of Rehabilitation Medicine. All rights reserved.)

Study Design: Secondary analysis of data from a concurrent randomized trial and cohort study., Objective: The aim of this study was to determine risks and predictors of recurrent pain following standard open discectomy for subacute/chronic symptomatic lumbar disc herniation (SLDH)., Summary of Background Data: Most previous studies of recurrence after discectomy do not explicitly define pain resolution and recurrence, and do not account for variable durations of time at risk for recurrence., Methods: We used survival analysis methods to examine predictors of leg pain recurrence. For individuals with initial resolution of leg pain, we defined recurrent leg pain as having leg pain, receiving lumbar epidural steroid injections, or undergoing lumbar surgery subsequent to initial leg pain resolution. We calculated cumulative risks of leg pain recurrence using Kaplan-Meier survival curves, and examined predictors of recurrence using Cox proportional hazards models. We used similar methods to examine LBP recurrence., Results: One- and three-year cumulative risks of leg pain recurrence were 20% and 45%, respectively. One- and three- year leg pain recurrence risks were substantially lower in participants with complete initial resolution of leg pain (17% and 41%, respectively) than in those without (27% and 54%, respectively). In multivariate analyses, complete leg pain resolution (adjusted hazard ratio [aHR] 0.69; 95% confidence interval [CI] 0.52-0.90), smoking (aHR 1.68 [95% CI 1.22-2.33]), and depression (aHR 1.74 [95% CI 1.18-2.56]) predicted leg pain recurrence. The 1- and 3-year risk of LBP recurrence was 29% and 65%, respectively. LBP recurrence risk at 3 years was substantially lower in participants with complete initial resolution of LBP than in those without, but not at 1 year., Conclusion: Recurrence of leg pain and LBP is common after discectomy for SLDH. Cumulative risks of both leg pain and LBP recurrence were generally lower in participants achieving complete initial resolution of pain post-discectomy., Level of Evidence: 2.

Objective: To determine whether lumbar muscle characteristics on magnetic resonance imaging (MRI) or computed tomography (CT) can inform clinicians as to the course of future low back pain (LBP), functional limitations, or physical performance, in adults with or without LBP. TYPE: Systematic review., Literature Review: We searched PubMed, Embase, and CINAHL through October 2014 for articles published in English in which authors assessed lumbar muscle characteristics on conventional MRI/CT as predictors of future LBP, functional limitations, or physical performance in adults. Studies with only postsurgical subjects were excluded. Our search identified 3554 articles, of which 6 observational cohort studies were included in the final review., Methodology: We used the Newcastle Ottawa Scale to evaluate potential bias. Data were extracted on study design, study population, sample size, participant characteristics, details of MRI/CT assessments, interventions, study outcomes, analysis methods, and study results. Because of heterogeneity between studies, we conducted a qualitative evidence synthesis., Synthesis: Among high-quality studies, there was limited evidence that, for individuals with or without LBP, greater MRI-detected multifidus cross-sectional area at L5-S1 predicted greater LBP intensity at 1-year follow-up, lesser erector spinae fat infiltration (FI) at L5-S1 predicted greater LBP intensity at 15-year follow-up, and greater erector spinae side-to-side FI asymmetry at L3-L4 predicted lower LBP frequency at 15-year follow-up; however, there was also limited evidence that all other MRI-detected paraspinal muscle characteristics examined were not predictive of LBP incidence, prevalence, frequency, or intensity at follow-up durations ranging from 1 to 15 years. There was limited evidence that greater CT-detected trunk muscle FI predicted worse physical performance in older adults at 3-year follow-up, but that trunk muscle cross-sectional area did not., Conclusion: Few lumbar muscle characteristics have limited evidence for an association with future LBP and physical performance outcomes, and the vast majority have limited evidence for having no association with such outcomes., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Study Design: Secondary analysis of data from a double-blind randomized controlled trial., Objective: To identify mediators of the effect of lumbar epidural injections of corticosteroid plus lidocaine on patient satisfaction at 6 weeks postinjection in patients with lumbar spinal stenosis. We hypothesized that short-term (≤3 wk) change in leg pain would be a significant mediator of satisfaction., Summary of Background Data: No prior studies have identified mediators of effects of epidural injections on patient satisfaction with treatment of lumbar spinal stenosis., Methods: We used mediation analysis methods to examine selected intermediate variables (adverse events and change in leg pain, back pain, disability, depression, and fatigue at 3 wk) as potential mediators of the effect of lumbar epidural injections of corticosteroid plus lidocaine on patient satisfaction with treatment. We used the overall satisfaction item from the Swiss Spinal Stenosis Questionnaire as our primary outcome to measure patient satisfaction with the injection procedure at 6 weeks., Results: Among 400 patients randomized to receive epidural injections with corticosteroid plus lidocaine or with lidocaine alone, 369 had complete data for the satisfaction outcome and potential mediators and served as the analysis sample. Contrary to our expectations, 3-week change in leg pain intensity did not have significant mediation effects on patient satisfaction. Three-week change in disability as measured by the Roland-Morris Disability Questionnaire was a significant mediator of the effects of lumbar epidural corticosteroid injections on patient satisfaction at 6 weeks, explaining 48% to 60% of the treatment effect on satisfaction. Changes in pain intensity in the leg and back together explained very little of the treatment effect on satisfaction beyond the information contributed by disability change alone. We did not find other intermediate variables to be mediators of patient satisfaction., Conclusion: These findings support the current approach of examining disability as a primary patient-reported outcome in comparative effectiveness studies of lumbar spinal stenosis., Level of Evidence: 2.

Background: Prior studies of nonoperative treatment for lumbosacral radiculopathy have identified potential predictors of treatment failure, defined by persistent pain, persistent disability, lack of recovery, or subsequent surgery. However, few predictors have been replicated, with the exception of higher leg pain intensity, as a predictor of subsequent surgery., Questions/purposes: We asked two research questions: (1) Does higher baseline leg pain intensity predict subsequent lumbar surgery? (2) Can other previously identified "candidate" predictors of nonoperative treatment failure be replicated?, Methods: Between January 2008 and March 2009, 154 participants with acute lumbosacral radicular pain were enrolled in a prospective database; 128 participants (83%) received nonoperative treatment and 26 (17%) received surgery over 2-year followup. Ninety-four nonoperative participants (73%) responded to followup questionnaires. We examined associations between previously identified "candidate" predictors and treatment failure defined as (1) subsequent surgery; (2) persistent leg pain on a visual analog scale; (3) persistent disability on the Oswestry Disability Index; or (4) participant-reported lack of recovery over 2-year followup. Confounding variables including sociodemographics, clinical factors, and imaging characteristics were evaluated using an exploratory bivariate analysis followed by a multivariate analysis., Results: With the numbers available, higher baseline leg pain intensity was not an independent predictor of subsequent surgery (adjusted odds ratio [aOR], 1.22 per point of baseline leg pain; 95% confidence interval [CI], 0.98-1.53; p = 0.08). Prior low back pain (aOR, 4.79; 95% CI, 1.01-22.7; p = 0.05) and a positive straight leg raise test (aOR, 4.38; 95% CI, 1.60-11.9; p = 0.004) predicted subsequent surgery. Workers compensation claims predicted persistent leg pain (aOR, 9.04; 95% CI, 1.01-81; p = 0.05) and disability (aOR, 5.99; 95% CI, 1.09-32.7; p = 0.04). Female sex predicted persistent disability (aOR, 3.16; 95% CI, 1.03-9.69; p = 0.05) and perceived lack of recovery (aOR, 2.44; 95% CI, 1.02-5.84; p = 0.05)., Conclusions: Higher baseline leg pain intensity was not confirmed as a predictor of subsequent surgery. However, the directionality of the association seen was consistent with prior reports, suggesting Type II error as a possible explanation; larger studies are needed to further examine this relationship. Clinicians should be aware of potential factors that may predict nonoperative treatment failure, including prior low back pain or a positive straight leg raise test as predictors of subsequent surgery, workers compensation claims as predictors of persistent leg pain and disability, and female sex as a predictor of persistent disability and lack of recovery., Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Context: There are no previous epidemiologic studies examining associations between physical activity and imaging-detected lumbar zygapophyseal joint osteoarthritis (ZJO) in a community-based sample., Purpose: To determine whether physical activity is associated with prevalent lumbar ZJO on computed tomography (CT)., Study Design/setting: A community-based cross-sectional study., Patient Sample: Four hundred twenty-four older adults from the Framingham Heart Study., Outcome Measures: Participants received standardized CT assessments of lumbar ZJO at the L2-S1 levels. Severe lumbar ZJO was defined according to the presence and/or degree of joint space narrowing, osteophytosis, articular process hypertrophy, articular erosions, subchondral cysts, and intra-articular vacuum phenomenon. This definition of lumbar ZJO was based entirely on CT imaging findings and did not include any clinical criteria such as low back pain., Methods: Physical activity was measured using the Physical Activity Index, which estimate hours per day typically spent in these activity categories: sleeping, sitting, slight activity, moderate activity, and heavy activity. Participants reported on usual frequency of walking, running, swimming, and weightlifting. We used multivariable logistic regression to examine associations between self-reported activity and severe lumbar ZJO, while adjusting for key covariates including age, sex, height, and weight., Results: In multivariable analyses, ordinal categories of heavy physical activity duration per day were significantly associated with severe lumbar ZJO (p for trend=.04), with the greatest risk observed for the category 3 or more hours per day, odds ratio 2.13 (95% confidence interval [CI] 0.97-4.67). When heavy activity was modeled as a continuous independent variable, each hour was independently associated with 1.19 times the odds of severe lumbar ZJO (95% CI 1.03-1.38, p=.02). Less vigorous types of physical activity and the type of exercise were not associated with severe lumbar ZJO. Older age, lesser height, and greater weight were independently and significantly associated with severe lumbar ZJO. In multivariable models predicting lumbar ZJO, neither model discrimination nor reclassification improved with the addition of physical activity variables, compared with a multivariable model including age, sex, height, and weight., Conclusions: Our findings demonstrate a statistically significant cross-sectional association between heavy physical activity and CT-detected severe lumbar ZJO. However, the additional discriminatory capability of heavy physical activity above and beyond that contributed by other factors was negligible., (Published by Elsevier Inc.)

Background: There are few longitudinal cohort studies examining associations between incident MRI findings and incident spine-related symptom outcomes. Prior studies do not discriminate between the two distinct outcomes of low back pain (LBP) and radicular symptoms. To address this gap in the literature, we conducted a secondary analysis of existing data from the Longitudinal Assessment of Imaging and Disability of the Back (LAIDBACK). The purpose of this study was to examine the association of incident lumbar MRI findings with two specific spine-related symptom outcomes: 1) incident chronic bothersome LBP, and 2) incident radicular symptoms such as pain, weakness, or sensation alterations in the lower extremity., Methods: The original LAIDBACK study followed 123 participants without current LBP or sciatica, administering standardized MRI assessments of the lumbar spine at baseline and at 3-year follow-up, and collecting information on participant-reported spine-related symptoms and signs every 4 months for 3 years. These analyses examined bivariable and multivariable associations between incident MRI findings and symptom outcomes (LBP and radicular symptoms) using logistic regression., Results: Three-year cumulative incidence of new MRI findings ranged between 2 and 8%, depending on the finding. Incident annular fissures were associated with incident chronic LBP, after adjustment for prior back pain and depression (adjusted odds ratio [OR] 6.6; 95% confidence interval [CI] 1.2-36.9). All participants with incident disc extrusions (OR 5.4) and nerve root impingement (OR 4.1) reported incident radicular symptoms, although associations were not statistically significant. No other incident MRI findings showed large magnitude associations with symptoms., Conclusions: Even when applying more specific definitions for spine-related symptom outcomes, few MRI findings showed large magnitude associations with symptom outcomes. Although incident annular fissures, disc extrusions, and nerve root impingement were associated with incident symptom outcomes, the 3-year incidence of these MRI findings was extremely low, and did not explain the vast majority of incident symptom cases.

Objective: Lumbar disc degeneration (LDD) is an important cause of low back pain, which is a common and costly problem. LDD is characterised by disc space narrowing and osteophyte growth at the circumference of the disc. To date, the agnostic search of the genome by genome-wide association (GWA) to identify common variants associated with LDD has not been fruitful. This study is the first GWA meta-analysis of LDD., Methods: We have developed a continuous trait based on disc space narrowing and osteophytes growth which is measurable on all forms of imaging (plain radiograph, CT scan and MRI) and performed a meta-analysis of five cohorts of Northern European extraction each having GWA data imputed to HapMap V.2., Results: This study of 4600 individuals identified four single nucleotide polymorphisms with p<5×10(-8), the threshold set for genome-wide significance. We identified a variant in the PARK2 gene (p=2.8×10(-8)) associated with LDD. Differential methylation at one CpG island of the PARK2 promoter was observed in a small subset of subjects (β=8.74×10(-4), p=0.006)., Conclusions: LDD accounts for a considerable proportion of low back pain and the pathogenesis of LDD is poorly understood. This work provides evidence of association of the PARK2 gene and suggests that methylation of the PARK2 promoter may influence degeneration of the intervertebral disc. This gene has not previously been considered a candidate in LDD and further functional work is needed on this hitherto unsuspected pathway.

Study Design: Systematic review of diagnostic studies., Objective: To update our previous systematic review on the diagnostic accuracy of tests used to diagnose lumbar spinal stenosis., Summary of Background Data: A wide range of clinical, radiological, and electrodiagnostic tests are used to diagnose lumbar spinal stenosis. An accurate diagnosis is vital, because lumbar spinal stenosis may require specific medical advice and treatment. Therefore, it is important to know the accuracy of these diagnostic tests currently available., Methods: A comprehensive literature search was conducted for original diagnostic studies on lumbar spinal stenosis, in which one or more diagnostic tests were evaluated with a reference standard, and diagnostic accuracy was reported or could be calculated. Our previous systematic review included studies up to March 2004; this review is current up to March 2011. Included studies were assessed for their methodological quality using the QUADAS tool. Study characteristics and reported diagnostic accuracy were extracted., Results: Twenty-two additional articles in addition to the 24 included in the previous review met the inclusion criteria. Combined, this resulted in 20 articles concerning imaging tests, 11 articles evaluating electrodiagnostic tests, and 15 articles evaluating clinical tests. Estimates of the diagnostic accuracy of the tests differed considerably., Conclusion: There is a need for a consensus on criteria to define and classify lumbar spinal stenosis. At present, the most promising imaging test for lumbar spinal stenosis is magnetic resonance imaging, avoiding myelography because of its invasiveness and lack of superior accuracy. Electrodiagnostic studies showed no superior accuracy for conventional electrodiagnostic testing compared with magnetic resonance imaging. These tests should be considered in the context of those presenting symptoms with the highest diagnostic value, including radiating leg pain that is exacerbated while standing up, the absence of pain when seated, the improvement of symptoms when bending forward, and a wide-based gait.

Objective: To determine the prevalence of patient-reported recovery from motor or sensory deficits over 2 years of follow-up after acute symptomatic lumbar disk herniation and to identify predictors of perceived recovery., Design: A prospective inception cohort., Setting: An outpatient spine clinic., Patients: Consecutive adults with lumbosacral radicular syndrome (onset ≤12 weeks) due to symptomatic lumbar disk herniation, confirmed by magnetic resonance imaging: 95 patients with a baseline motor deficit by physical examination and 59 patients with a baseline sensory deficit by physical examination., Methods: The patients received individualized nonsurgical treatment or, in a minority of cases, surgical treatment. All of the patients underwent a standardized baseline neurologic examination, including motor and sensory testing. Patients with a motor or sensory deficit at the baseline examination reported on whether they perceived persisting weakness or sensory deficits at 1- and 2-year follow-up. We calculated the 1- and 2-year prevalence of patient-reported persisting weakness or sensory deficits. We examined factors associated with perceived recovery from motor or sensory deficits by using bivariate analyses and multivariate logistic regression., Results: Among patients with a baseline motor deficit, the prevalence of patient-reported continuing weakness was 38% at 1 year and 25% at 2 years. Among patients with a baseline sensory deficit, the prevalence of patient-reported continuing sensory deficits was 53% at 1 year and 47% at 2 years. A positive straight leg raise test (odds ratio [OR] 0.26 [95% confidence interval (CI) 0.08-0.83]) and opioid use (OR 0.24 [95% CI 0.06-0.83]) were independently and negatively predictive of patient-reported motor recovery. Female gender was independently and negatively predictive of patient-reported sensory recovery (OR 0.20 [95% CI 0.04-0.99])., Conclusions: Patient-reported recovery from motor deficits after lumbar disk herniation occurs for 75% of patients over 2 years, but recovery from sensory deficits over this time frame occurs in only 53% of patients. A positive straight-leg raise test and female gender may predict poor recovery from motor and sensory deficits, respectively., (Copyright © 2012 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background Context: Vascular disease has been proposed as a risk factor for disc height loss (DHL)., Purpose: To examine the relationship between quantitative measures of abdominal aortic calcifications (AACs) as a marker of vascular disease, and DHL, on computed tomography (CT)., Study Design: Cross-sectional study in a community-based population., Patient Sample: Four hundred thirty-five participants from the Framingham Heart Study., Outcome Measures: Quantitative AAC scores assessed by CT were grouped as tertiles of "no" (reference), "low," and "high" calcification. Disc height loss was evaluated on CT reformations using a four-grade scale. For analytic purposes, DHL was dichotomized as moderate DHL of at least one level at L2-S1 versus less than moderate or no DHL., Methods: We examined the association of AAC and DHL using logistic regression before and after adjusting for cardiovascular risk factors and before and after adjusting for age, sex, and body mass index (BMI)., Results: In crude analyses, low AAC (odds ratio [OR], 2.05 [1.27-3.30]; p=.003) and high AAC (OR, 2.24 [1.38-3.62]; p=.001) were strongly associated with DHL, when compared with the reference group of no AAC. Diabetes, hypercholesterolemia, hypertension, and smoking were not associated with DHL and did not attenuate the observed relationship between AAC and DHL. Adjustment for age, sex, and BMI markedly attenuated the associations between DHL and low AAC (OR, 1.20 [0.69-2.09]; p=.51) and high AAC (OR, 0.74 [0.36-1.53]; p=.42)., Conclusions: Abdominal aortic calcification was associated with DHL in this community-based population. This relationship was independent of cardiovascular risk factors. However, the association of AAC with DHL was explained by the effects of age, sex, and BMI., (Published by Elsevier Inc.)

Objectives: To determine recurrence rates of lower-extremity radicular pain after nonsurgical treatment of acute symptomatic lumbar disk herniation (LDH), and to identify predictors of recurrence., Design: Prospective inception cohort., Setting: Outpatient spine clinic., Participants: Patients (N=79) reporting resolution of radicular pain after magnetic resonance imaging confirmation of LDH., Interventions: Individualized nonsurgical treatment tailored to the patient. All patients received education, but other treatments varied depending on the individual., Main Outcome Measures: Resolution of radicular pain was defined as a pain-free period of ≥1 month. Patients who reported resolution of radicular pain within 1 year after seeking care for acute LDH were asked whether pain had recurred at 1 year after seeking care and were also reassessed 1 year after the time of resolution of radicular pain and 2 years after seeking care. Patients reported on recurrence and the date of recurrence, if any. We evaluated the 1-year incidence of recurrence, using Kaplan-Meier survival plots. We examined predictors of recurrence using bivariate and multivariate Cox proportional hazards models. We examined the secondary outcome of back pain recurrence using identical methods., Results: Twenty-five percent (95% confidence interval [CI], 15-35) of individuals with resolution of radicular pain for at least 1 month reported subsequent recurrence of pain within 1 year after resolution. The only factor independently associated with radicular pain recurrence was the number of months prior to resolution of pain (hazard ratio per month=1.24; 95% CI, 1.13-1.37; P<.001). The 1-year incidence of back pain recurrence was 43% (95% CI, 30-56), and older age decreased the hazard of recurrence., Conclusions: Recurrence of radicular pain is relatively common after nonsurgical treatment of LDH and is predicted by longer time to initial resolution of pain., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the prevalence of anatomic impediments to interlaminar lumbar epidural steroid injection (LESI) in a community-based population., Design: Cross-sectional observational study., Setting: Community-based., Participants: Older adults (N=333) sampled irrespective of back pain status., Interventions: Not applicable., Main Outcome Measures: Computed tomography evaluation of 5 potential anatomic impediments to interlaminar LESI at the L2-S1 spinal levels, including (1) ligamentum flavum (LF) calcification, (2) interspinous ligament (ISL) calcification, (3) spinous process (SP) contact, (4) the absence of epidural fat in the posterior epidural space, and (5) the presence of fat density superficial to the LF in the midsagittal plane. Independent variables included age, sex, body mass index (BMI), and current smoking., Results: LF and ISL calcifications were prevalent in 3% to 7% and 2% to 3% of spinal levels, respectively, without significant differences by spinal level. SP contact was most common at the L4-5 level (22%). Absence of posterior epidural fat was very common at L5-S1 (65%), but infrequent at other levels. The presence of midline fat density superficial to LF was most common at L5-S1 (55%). The prevalence of LF calcification, ISL calcification, and SP contact increased with age, but the prevalence of absence of posterior epidural fat and the presence of a midline fat density superficial to LF did not. Sex and smoking status were not associated with the prevalence of anatomic impediments, but higher BMI was associated with a lower prevalence of absence of posterior epidural fat., Conclusions: Anatomic impediments to interlaminar LESI were common in this community-based population, particularly at the L5-S1 spinal level. Because of the high overall prevalence of anatomic impediments, and differences in prevalence by spinal level, knowledge of the distribution and frequency of these impediments may aid in aspects of decision-making for the interventional spine physician., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background Context: Walking limitations caused by neurogenic claudication (NC) are typically assessed with self-reported measures, although objective evaluation of walking using motorized treadmill test (MTT) or self-paced walking test (SPWT) has periodically appeared in the lumbar spinal stenosis (LSS) literature., Purpose: This study compared the validity and responsiveness of MTT and SPWT for assessing walking ability before and after common treatments for NC., Study Design: Prospective observational cohort study., Patient Sample: Fifty adults were recruited from an urban spine center if they had LSS and substantial walking limitations from NC and were scheduled to undergo surgery (20%) or conservative treatment (80%)., Outcome Measures: Walking times, distances, and speeds along with the characteristics of NC symptoms were recorded for MTT and SPWT. Self-reported measures included back and leg pain intensity assessed with 0 to 10 numeric pain scales, disability assessed with Oswestry Disability Index, walking ability assessed with estimated walking times and distances, and NC symptoms assessed with the subscales from the Spinal Stenosis Questionnaires., Methods: Motorized treadmill test used a level track, and SPWT was conducted in a rectangular hallway. Walking speeds were self-selected, and test end points were NC, fatigue, or completion of the 30-minute test protocol. Results from MTT and SPWT were compared with each other and self-reported measures. Internal responsiveness was assessed by comparing changes in the initial results with the posttreatment results and external responsiveness by comparing walking test results that improved with those that did not improve by self-reported criteria., Results: Mean age of the participants was 68 years, and 58% were male. Neurogenic claudication included leg pain (88%) and buttock(s) pain (12%). Five participants could not safely perform MTT. Walking speeds were faster and distances were greater with SPWT, although the results from both tests correlated with each other and self-reported measures. Of the participants, 72% reported improvement after treatment, which was confirmed by significant mean differences in self-reported measures. Motorized treadmill test results did not demonstrate internal responsiveness to change in clinical status after treatment but SPWT results did, with increased mean walking times (6 minutes) and distances (387 m). When responsiveness was assessed against external criterion, both SPWT and MTT demonstrated substantial divergence with self-reported changes in clinical status and alternative outcome measures., Conclusions: Both MTT and SPWT can quantify walking abilities in NC. As outcome tools, SPWT demonstrated better internal responsiveness than MTT, but neither test demonstrated adequate external responsiveness. Neither test should be considered as a meaningful substitution for disease-specific measures of function., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Prior studies that have concluded that disk degeneration uniformly precedes facet degeneration have been based on convenience samples of individuals with low back pain. We conducted a study to examine whether the view that spinal degeneration begins with the anterior spinal structures is supported by epidemiologic observations of degeneration in a community-based population., Methods: 361 participants from the Framingham Heart Study were included in this study. The prevalences of anterior vertebral structure degeneration (disk height loss) and posterior vertebral structure degeneration (facet joint osteoarthritis) were characterized by CT imaging. The cohort was divided into the structural subgroups of participants with 1) no degeneration, 2) isolated anterior degeneration (without posterior degeneration), 3) combined anterior and posterior degeneration, and 4) isolated posterior degeneration (without anterior structure degeneration). We determined the prevalence of each degeneration pattern by age group < 45, 45-54, 55-64, ≥65. In multivariate analyses we examined the association between disk height loss and the response variable of facet joint osteoarthritis, while adjusting for age, sex, BMI, and smoking., Results: As the prevalence of the no degeneration and isolated anterior degeneration patterns decreased with increasing age group, the prevalence of the combined anterior/posterior degeneration pattern increased. 22% of individuals demonstrated isolated posterior degeneration, without an increase in prevalence by age group. Isolated posterior degeneration was most common at the L5-S1 and L4-L5 spinal levels. In multivariate analyses, disk height loss was independently associated with facet joint osteoarthritis, as were increased age (years), female sex, and increased BMI (kg/m(2)), but not smoking., Conclusions: The observed epidemiology of lumbar spinal degeneration in the community-based population is consistent with an ordered progression beginning in the anterior structures, for the majority of individuals. However, some individuals demonstrate atypical patterns of degeneration, beginning in the posterior joints. Increased age and BMI, and female sex may be related to the occurrence of isolated posterior degeneration in these individuals.

Background Context: No prior study has investigated the frequency of patient-identified inciting events in lumbar disc herniation (LDH) or their clinical significance., Purpose: To examine the clinical frequency of patient-identified inciting events in LDH, and to identify associations between the presence of inciting events and the severity of the clinical presentation., Study Design/setting: Cross-sectional analysis of data from a cohort study with prospective recruitment, with retrospective data collection on inciting events. The setting was a hospital-based specialty spine clinic., Patient Sample: One hundred fifty-four adults with lumbosacral radicular pain and LDH confirmed by magnetic resonance imaging., Outcome Measures: Self-report measures of disability measured by the Oswestry Disability Index (ODI), the visual analog scale (VAS) for leg pain, and the VAS for back pain., Methods: Dependent variables included the presence of a patient-identified inciting event, which were categorized as spontaneous onset, nonlifting physical activity, heavy lifting (>35 lbs), light lifting (<35 lbs), nonexertional occurrence, or physical trauma. We examined the association of an inciting event, or a lifting-related event, with each outcome, first using univariate analyses, and second using multivariate modeling, accounting for important adjustment variables., Results: Sixty-two percent of LDH did not have a specific patient-identified event associated with onset of symptoms. Nonlifting activities were the most common inciting event, comprising 26% of all LDH. Heavy lifting (6.5%), light lifting (2%), nonexertional occurrences (2%), and physical trauma (1.3%) accounted for relatively small proportions of all LDH. Patient-identified inciting events were not significantly associated with a more severe clinical presentation in crude analyses. Spontaneous LDH was significantly associated with higher baseline ODI scores in multivariate analysis, although the magnitude of this effect was small. There were no significant associations (p< or =.05) between the presence of a lifting-associated event and the outcomes of ODI, VAS leg pain, or VAS back pain., Conclusions: The majority of LDH occurred without specific inciting events. A history of an inciting event was not significantly associated with a more severe clinical presentation. There was no significant association between the occurrence of a lifting-related event and the severity of the clinical presentation. This information may be useful in the counseling of patients recovering from acute LDH., (Published by Elsevier Inc.)

Study Design: Cross-sectional study., Objective: To evaluate the association between lumbar spine facet joint orientation, facet joint tropism, and spondylolysis identified by multidetector computed tomography (CT) in the community-based Framingham Heart Study., Summary of Background Data: The association between lumbar spondylolysis and facet orientation and tropism remains unclear., Methods: This study was an ancillary project to the Framingham Heart Study. Three thousand five hundred twenty-nine participants of the Framingham Heart Study aged 40 to 80 years underwent multidetector CT imaging to assess aortic calcification. One hundred ninety-one subjects were included in this ancillary study. Facet joint features and spondylolysis were evaluated on CT scans. The final analyzed sample included 104 men with mean age 51.90+/-11.25 years and 84 women with mean age 53.61+/-10.20 years. The association between spondylolysis and facet orientation and tropism was examined using univariate and multivariate analyses., Results: Spondylolysis was prevalent in 11.5% of the total population. chi2 test demonstrated a significant sex difference in prevalence of spondylolysis (P=0.0154), with almost 3 times higher prevalence among men. There was no statistically significant difference in facet orientation and continuous facet tropism between individuals with and without spondylolysis at the L5 level (P=0.49 to 0.91). After adjustment for age, sex, and body mass index, no significant association between the occurrence of spondylolysis and facet orientation and tropism was found. In the studied sample the prevalence of facet joint osteoarthritis was significantly higher in individuals with spondylolysis than in those without spondylolysis at both sides of L4-L5 spinal level (P=0.044 at the right side and P=0.003 at the left side) and at left side of L5-S1 level (P=0.038)., Conclusions: We did not find an association between facet orientation, facet tropism, and spondylolysis. One of the possible explanations for this is that the high prevalence of facet joint osteoarthritis in individuals with spondylolysis in the studied sample might have led to diminished differences in facet orientation.

Study Design: Cross-sectional study., Objective: To evaluate the association between lumbar spine facet joint orientation, facet joint tropism, and facet joint osteoarthritis (OA) and degenerative spondylolisthesis (DS) identified by multidetector computed tomography in the community-based Framingham Heart Study., Summary of Background Data: The association between lumbar facet joint OA, DS, and facet orientation and tropism remains unclear. METHODS.: This study was an ancillary project to the Framingham Heart Study. A sample of 3529 participants of the Framingham Heart Study aged 40 to 80 underwent multidetector computed tomography imaging to assess aortic calcification. One hundred eighty-eight individuals were consecutively enrolled in this ancillary study to assess radiographic features associated with low back pain. Facet joint OA was evaluated at the L3-L4, L4-L5, and L5-S1 spinal levels, using a 4-grade scale. The association between facet joint OA, DS, and facet orientation, and tropism was examined using multiple logistic regression models adjusting for age, sex, and body mass index., Results: At each spinal level the facet joints with OA were more sagittally oriented than those without OA, but the difference was statistically significant only at L4-L5 spinal level (P = 0.0007). Facet tropism did not show an association with facet joint OA at any spinal level. Facet orientation was significantly associated with DS (0.89 [0.84-0.94]), however, facet tropism showed no association with DS., Conclusions: The current study confirms a significant association between sagittal orientation and OA of the lumbar facet joints at L4-L5 and DS. Facet tropism was not associated with occurrence of facet joint OA or DS. Additional, longitudinal studies are needed to understand the causal relationship between facet joint morphology and OA.

Abstract: Identifying genetic risk factors for lumbar spine disorders may lead to knowledge regarding underlying mechanisms and the development of new treatments. We conducted a genome-wide association study involving 100,811 participants with genotypes and longitudinal electronic health record data from the Electronic Medical Records and Genomics Network and Geisinger Health. Cases and controls were defined using validated algorithms and clinical diagnostic codes. Electronic health record-defined phenotypes included low back pain requiring healthcare utilization (LBP-HC), lumbosacral radicular syndrome (LSRS), and lumbar spinal stenosis (LSS). Genome-wide association study used logistic regression with additive genetic effects adjusting for age, sex, site-specific factors, and ancestry (principal components). A fixed-effect inverse-variance weighted meta-analysis was conducted. Genetic variants of genome-wide significance (P < 5 × 10-8) were carried forward for replication in an independent sample from UK Biobank. Phenotype prevalence was 48.8% for LBP-HC, 19.8% for LSRS, and 7.9% for LSS. No variants were significantly associated with LBP-HC. One locus was associated with LSRS (lead variant rs146153280:C>G, odds ratio [OR] = 1.17 for G, P = 2.1 × 10-9), but was not replicated. Another locus on chromosome 2 spanning GFPT1, NFU1, and AAK1 was associated with LSS (lead variant rs13427243:G>A, OR = 1.10 for A, P = 4.3 × 10-8) and replicated in UK Biobank (OR = 1.11, P = 5.4 × 10-5). This was the first genome-wide association study meta-analysis of lumbar spinal disorders using electronic health record data. We identified 2 novel associations with LSRS and LSS; the latter was replicated in an independent sample. [ABSTRACT FROM AUTHOR]

Background: Information on the prevalence of common imaging findings among patients without back pain in spine imaging reports might affect pain medication prescribing for patients with back pain. Prior research on inserting this text suggested a small reduction in opioid prescribing.Objective: To evaluate the effect of epidemiologic information in spine imaging reports on non-opioid pain medication prescribing for primary care patients with back pain.Design: Post hoc analysis of the Lumbar Imaging with Reporting of Epidemiology cluster-randomized trial.Participants: A total of 170,680 patients aged ≥ 18 years from four healthcare systems who received thoracolumbar, lumbar, or lumbosacral spine imaging from 2013 to 2016 and had not received a prescription for non-opioid pain medication in the preceding 120 days.Intervention: Text of age- and modality-specific epidemiologic benchmarks indicating the prevalence of common findings in people without back pain inserted into thoracolumbar, lumbar, or lumbosacral spine imaging reports at intervention clinics.Main Measures: Primary outcomes: any non-opioid prescription within 90 days after index imaging, overall, and by sub-class (skeletal muscle relaxants, NSAIDs, gabapentinoids, tricyclic antidepressants, benzodiazepines, duloxetine).Secondary Outcomes: count of non-opioid prescriptions within 90 days, overall, and by sub-class.Key Results: The intervention was not associated with the likelihood of patients receiving at least one prescription for new non-opioid pain-related medications, overall (adjusted OR, 1.02; 95% CI, 0.97-1.08) or by sub-class. The intervention was not associated with the number of prescriptions for any non-opioid medication (adjusted incidence rate ratio [IRR], 1.02; 95% CI, 0.99-1.04). However, the intervention was associated with more new prescriptions for NSAIDs (IRR, 1.12) and tricyclic antidepressants (IRR, 1.11).Conclusions: Inserting epidemiologic text in spine imaging reports had no effect on whether new non-opioid pain-related medications were prescribed but was associated with the number of new prescriptions for certain non-opioid sub-classes.Trial Registration: ClinicalTrials.gov identifier: NCT02015455. [ABSTRACT FROM AUTHOR]

Background:: Low back pain is a common secondary disabling condition in the transfemoral amputee population. Transfemoral amputees are at risk of excessive lumbar lordosis; it has been suggested that increased lumbar lordosis may be associated with low back pain. However, the relationship between lumbar lordosis angle and low back pain has not yet been studied in this population.Objective:: To determine whether the extent of lumbar lordosis is associated with low back pain in transfemoral amputees.Study Design:: Case-control observational study.Methods:: Participants included eight transfemoral amputees without low back pain and nine transfemoral amputees with low back pain. Etiology of amputation was primarily trauma. All participants underwent lateral view radiographs of the lumbar spine, from which lumbar lordosis angle and sacral inclination angle were measured.Results:: Lumbar lordosis angle mean ± standard deviation was 46.1° ± 12.4° in participants with low back pain and 51.0° ± 12.6° in those without. Sacral inclination angle mean ± standard deviation was 38.3° ± 8.7° in participants with low back pain and 39.1° ± 7.5° in those without. There was no significant difference in lumbar lordosis angle or sacral inclination angle between participants with and without low back pain.Conclusion:: This study suggests that increased lumbar lordosis angle and sacral inclination angle are not significantly associated with low back pain in transfemoral amputees of a primarily traumatic etiology.Clinical Relevance: Low back pain (LBP) is a common, disabling condition in transfemoral amputees. In the clinical setting, increased lumbar lordosis is implicated in LBP. This study does not support an association between increased lumbar lordosis and LBP; further study is needed to understand the increased prevalence of LBP in this population. [ABSTRACT FROM AUTHOR]

Background and Purpose: Mobility problems are common among older adults. Symptomatic lumbar spinal stenosis (SLSS) is a major contributor to mobility limitations among older primary care patients. In comparison with older primary care patients with mobility problems but without SLSS, it is unclear how mobility problems differ in older primary care patients with SLSS. The purpose of this study was to compare health characteristics, neuromuscular attributes, and mobility status in a sample of older primary care patients with and without SLSS who were at risk for mobility decline. We hypothesized that patients with SLSS will manifest poorer health and greater severity of neuromuscular impairments and mobility limitations. Methods: This is a secondary analysis of the Boston Rehabilitative Study of the Elderly (Boston RISE). Fifty community-dwelling primary care patients aged 65 years or older at risk for mobility decline met inclusion criteria. SLSS was determined on the basis of computerized tomography (CT) scan and self-reported symptoms characteristic of neurogenic claudication. Outcome measures included health characteristics, neuromuscular attributes (trunk endurance, limb strength, limb speed, limb strength asymmetry, ankle range of motion [ROM], knee ROM, kyphosis, sensory loss), and mobility (Late-Life Function and Disability Instrument: basic and advanced lower extremity function subscales, 400-meter walk test, habitual gait speed, and Short Physical Performance Battery score). Health characteristics were collected at a baseline assessment. Neuromuscular attributes and mobility status were measured at the annual visit closest to conducting the CT scan. Results and Discussion: Five participants met criteria for having SLSS. Differences are reported in medians and interquartile ranges. Participants with SLSS reported more global pain, a greater number of comorbid conditions [SLSS: 7.0 (2.0) vs no-SLSS: 4.0 (2.0), P < .001], and experienced greater limitation in knee ROM [SLSS: 115.0° (8.0°) vs no-SLSS: 126.0° (10.0°), P = .04] and advanced lower extremity function than those without SLSS. A limitation of this study was its small sample size and therefore inability to detect potential differences across additional measures of neuromuscular attributes and mobility. Despite the limitation, the differences in mobility for participants with SLSS may support physical therapists in designing interventions for older adults with SLSS. Participants with SLSS manifested greater mobility limitations that exceeded meaningful thresholds across all performance-based and self-reported measures. In addition, our study identified that differences in mobility extended beyond not just walking capacity but also across a variety of tasks that make up mobility for those with and without SLSS. Conclusion: Among older primary care patients who are at risk for mobility decline, patients with SLSS had greater pain, higher levels of comorbidity, greater limitation in knee ROM, and greater limitations in mobility that surpassed meaningful thresholds. These findings can be useful when prioritizing interventions that target mobility for patients with SLSS. [ABSTRACT FROM AUTHOR]

Objective: To determine risks and predictors of recurrent leg and low back pain (LBP) after unstructured, usual nonoperative care for subacute/chronic symptomatic lumbar disk herniation (LDH).Design: Secondary analysis of data from a concurrent randomized trial and observational cohort study.Setting: Thirteen outpatient spine practices.Participants: A total of 199 participants with resolution of leg pain and 142 participants with resolution of LBP from among 478 participants receiving usual nonoperative care for symptomatic LDH.Assessment Of Risk Factors: Potential predictors of recurrence included time to initial symptom resolution, sociodemographics, clinical characteristics, work-related factors, imaging-detected herniation characteristics, and baseline pain bothersomeness.Main Outcome Measurements: Leg pain and LBP bothersomeness were assessed by the use of a 0-6 numerical scale at up to 4 years of follow-up. For individuals with initial resolution of leg pain, we defined recurrent leg pain as having leg pain, receiving lumbar epidural steroid injections, or undergoing lumbar surgery subsequent to initial leg pain resolution. We calculated cumulative risks of recurrence by using Kaplan-Meier survival plots and examined predictors of recurrence using Cox proportional hazards models. We used similar definitions for LBP recurrence.Results: One- and 3-year cumulative recurrence risks were 23% and 51% for leg pain, and 28% and 70% for LBP, respectively. Early leg pain resolution did not predict future leg pain recurrence. Complete leg pain resolution (adjusted hazard ratio [aHR] 0.47, 95% confidence interval [CI] 0.31-0.72) and posterolateral herniation location (aHR 0.61; 95% CI 0.39-0.97) predicted a lower risk of leg pain recurrence, and joint problems (aHR 1.89; 95% CI 1.16-3.05) and smoking (aHR 1.81; 95% CI 1.07-3.05) predicted a greater risk of leg pain recurrence. For participants with complete initial resolution of pain, recurrence risks at 1 and 3 years were 16% and 41% for leg pain and 24% and 59% for LBP, respectively.Conclusions: Recurrence of pain is common after unstructured, usual nonsurgical care for LDH. These risk estimates depend on the specific definitions applied, and the predictors identified require replication in future studies. [ABSTRACT FROM AUTHOR]

Objective: To determine whether lumbar muscle characteristics on magnetic resonance imaging (MRI) or computed tomography (CT) can inform clinicians as to the course of future low back pain (LBP), functional limitations, or physical performance, in adults with or without LBP. TYPE: Systematic review.Literature Review: We searched PubMed, Embase, and CINAHL through October 2014 for articles published in English in which authors assessed lumbar muscle characteristics on conventional MRI/CT as predictors of future LBP, functional limitations, or physical performance in adults. Studies with only postsurgical subjects were excluded. Our search identified 3554 articles, of which 6 observational cohort studies were included in the final review.Methodology: We used the Newcastle Ottawa Scale to evaluate potential bias. Data were extracted on study design, study population, sample size, participant characteristics, details of MRI/CT assessments, interventions, study outcomes, analysis methods, and study results. Because of heterogeneity between studies, we conducted a qualitative evidence synthesis.Synthesis: Among high-quality studies, there was limited evidence that, for individuals with or without LBP, greater MRI-detected multifidus cross-sectional area at L5-S1 predicted greater LBP intensity at 1-year follow-up, lesser erector spinae fat infiltration (FI) at L5-S1 predicted greater LBP intensity at 15-year follow-up, and greater erector spinae side-to-side FI asymmetry at L3-L4 predicted lower LBP frequency at 15-year follow-up; however, there was also limited evidence that all other MRI-detected paraspinal muscle characteristics examined were not predictive of LBP incidence, prevalence, frequency, or intensity at follow-up durations ranging from 1 to 15 years. There was limited evidence that greater CT-detected trunk muscle FI predicted worse physical performance in older adults at 3-year follow-up, but that trunk muscle cross-sectional area did not.Conclusion: Few lumbar muscle characteristics have limited evidence for an association with future LBP and physical performance outcomes, and the vast majority have limited evidence for having no association with such outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Background context: The prevalence of lumbar spinal stenosis (LSS) in the general population and association with low back pain (LBP) remain unclear. Purpose: To evaluate the prevalence of congenital and acquired LSS observed on computed tomography in a community-based sample; and to evaluate the association between LSS and LBP. Study design/setting: Cross-sectional observational study. This study was an ancillary project to the Framingham Heart Study. Patient sample: A total of 3,529 participants underwent multidetector computed tomography; 191 were enrolled in this study. Outcome measures: Self-report measures: LBP in the preceding 12 months was evaluated using a self-report questionnaire. Physiologic measures: LSS (congenital and acquired) was characterized using two cut-points: 12mm for relative LSS and 10mm for absolute LSS. Methods: Using multiple logistic regression, we examined the association between LSS and LBP, adjusting for sex, age, and body mass index. Results: In the congenital group, relative LSS was found in 4.7% and absolute LSS in 2.6% of patients. Acquired LSS was found in 22.5% and in 7.3%, respectively. Acquired LSS showed increasing prevalence with age less than 40 years, the prevalence of relative and absolute LSS was 20.0% and 4.0%, respectively, and in those 60 to 69 years the prevalence was 47.2% and 19.4%, respectively. The presence of absolute LSS was associated with LBP with an odds ratio of 3.16 (95% confidence interval [CI]: 1.05–9.53). Conclusions: The prevalence of congenital and acquired LSS in a community-based sample was characterized. The prevalence of acquired stenosis increased with age. LSS is associated with a threefold higher risk of experiencing LBP. [Copyright &y& Elsevier]