Search

Objective: Sacroiliac (SI) joint bone marrow edema (BME) is considered to be pivotal in the detection of early spondyloarthritis. However, the link between BME and development of spondyloarthritis‐related bone remodeling remains unclear. This study was undertaken to investigate the evolution of BME and structural lesions in the SI joints over time. Methods: Baseline and 4‐year follow‐up magnetic resonance imaging scans were conducted in 604 patients ages 18–40 years who were referred with low back pain to an outpatient spine clinic. Eight SI joint regions were scored for BME and categorized as absent, limited (<25% of subcortical bone region), intermediate (25–50%), or extensive (>50%). Structural lesions including erosions and fat lesions were scored as absent or present. Results: SI joint BME was seen at either time point (baseline or at 4 years) in 41% of participants but was persistent at both time points in only 16% of participants. Structural SI joint lesions developed according to the extent of BME at baseline: limited, intermediate, and extensive BME (as compared to absent BME) were independently associated with erosion at follow‐up with odds ratios (ORs) of 3, 5, and 46, respectively, and with fat lesions (ORs 3, 7, and 33, respectively). In regions with limited and intermediate BME at baseline, 60% and 50% had resolved by follow‐up, respectively, while only 2% and 7% had evolved into extensive BME by follow‐up. Conclusion: While extensive SI joint BME was a strong independent predictor of development of structural lesions, limited and intermediate BME were mostly transient and only rarely evolved into extensive BME or structural lesions. These findings enhance our understanding of the natural development of SI joint lesions and indicate different progression patterns for limited/intermediate versus extensive BME, possibly due to different etiologies. [ABSTRACT FROM AUTHOR]

Hypothesis: To assess whether a chronic bacterial infection is present in a subset of patients with pseudarthrosis after instrumented spinal fusion.Methods: This was a prospective diagnostic study including adult patients with previous instrumented spinal fusion. Patients underwent revision surgery for either pseudarthrosis or other causes (e.g. implant removal, curve progression or junctional kyphosis) (control group). Five separate biopsies were randomly collected, intraoperatively, from the pseudarthrosis site and cultivated under both aerobic (5 days) and anaerobic (14 days) conditions. If cultivation was positive in at least 2/5 tissue samples, the biopsy was sectioned and stained using peptide nucleic acid fluorescence in situ hybridization (PNA-FISH). Confocal laser scanning microscopy was used to examine the sections and visualize bacterial aggregates.Results: The study included 32 pseudarthrosis and 32 control patients. Cultivation yielded bacteria in at least 1/5 biopsies in 52% of patients with no difference between the groups (p = 1.0). Bacteria of the same species was found in at least 2/5 samples in seven pseudarthrosis patients and four controls (p = 0.509). Propionibacterium acnes was found in 8 of these 11 samples. Microscopy demonstrated tissue-embedded bacterial aggregates in two of these patients but with no inflammatory cells indicating an active infection. The presence of bacteria was not associated with the number of previous spinal procedures or the pre-revision fusion length (p ≥ 0.503).Conclusions: Pseudarthrosis after instrumented spinal surgery was not significantly associated with the presence of bacteria at the pseudarthrosis site. Positive cultivation results are common after spinal instrumentation, but our results indicate that they rarely represent an organized infection. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Background and aims Patients with chronic neck pain can present with disability, low quality of life, psychological factors and clinical symptoms. It is unclear whether patients with a traumatic onset differ from those with a non-traumatic onset, by having more complex and severe symptoms. The purpose of this study was to investigate the clinical presentation of chronic neck pain patients with and without traumatic onset by examining cervical mobility, sensorimotor function, cervical muscle performance and pressure pain threshold in addition to the following self-reported characteristics: quality of life, neck pain and function, kinesiophobia, depression, and pain bothersomeness. Methods This cross-sectional study included 200 participants with chronic neck pain: 120 with traumatic onset and 80 with non-traumatic onset. Participants were recruited from physiotherapy clinics in primary and secondary health care. For participants to be included, they were required to be at least 18 years of age, have had neck pain for at least 6 months, and experienced neck-related activity limitation as determined by a score of at least 10 on the Neck Disability Index. We conducted the following clinical tests of cervical range of motion, gaze stability, eye movement, cranio-cervical flexion, cervical extensors, and pressure pain threshold. The participants completed the following questionnaires: physical and mental component summary of the Short Form Health Survey, EuroQol-5D, Neck Disability Index, Patient-Specific Functional Scale, Pain Bothersomeness, Beck Depression Inventory-II, and TAMPA scale of kinesiophobia. The level of significance for all analyses was defined as p < 0.01. Differences between groups for the continuous data were determined using either a Student's t -test or Mann Whitney U test. Results In both groups, the majority of the participants were female (approximately 75%). Age, educational level, working situation and sleeping patterns were similar in both groups. The traumatic group had symptoms for a shorter duration (88 vs. 138 months p = 0.001). Participants in the traumatic group showed worse results on all measures compared with those in the non-traumatic group, significantly on neck muscle function (cervical extension mobility p = 0.005, cranio-cervical flexion test p = 0.007, cervical extensor test p = 0.006) and cervical pressure pain threshold bilateral ( p = 0.002/0.004), as well on self-reported function (Neck Disability Index p = 0.001 and Patient-Specific Functional Scale p = 0.007), mental quality of life (mental component summary of the Short Form Health Survey p = 0.004 and EuroQol-5D p = 0.001) and depression (Beck Depression Inventory-II p = 0.001). Conclusions This study showed significant differences between chronic neck pain patients when differentiated into groups based on their onset of pain. However, no specific clinical test or self-reported characteristic could differentiate between the groups at an individual patient level. Implications Pressure pain threshold tests, cervical muscle performance tests and patient-reported characteristics about self-perceived function and psychological factors may assist in profiling chronic neck pain patients. The need for more intensive management of those with a traumatic onset compared with those with a non-traumatic onset should be examined further. [ABSTRACT FROM AUTHOR]

Objective: To estimate the prevalence of degenerative and spondyloarthritis (SpA)-related magnetic resonance imaging (MRI) findings in the spine and sacroiliac joints (SIJs) and analyse their association with gender and age in persistent low back pain (LBP) patients.Methods: Degenerative and SpA-related MRI findings in the whole spine and SIJs were evaluated in Spine Centre patients aged 18-40 years with LBP.Results: Among the 1,037 patients, the prevalence of disc degeneration, disc contour changes and vertebral endplate signal (Modic) changes were 87 % (±SEM 1.1), 82 % (±1.2) and 48 % (±1.6). All degenerative spinal findings were most frequent in men and patients aged 30-40 years. Spinal SpA-related MRI findings were rare. In the SIJs, 28 % (±1.4) had at least one MRI finding, with bone marrow oedema being the most common (21 % (±1.3)). SIJ erosions were most prevalent in patients aged 18-29 years and bone marrow oedema in patients aged 30-40 years. SIJ sclerosis and fatty marrow deposition were most common in women. SIJ bone marrow oedema, sclerosis and erosions were most frequent in women indicating pregnancy-related LBP.Conclusion: The high prevalence of SIJ MRI findings associated with age, gender, and pregnancy-related LBP need further investigation of their clinical importance in LBP patients.Key Points: • The location of vertebral endplate signal changes supports a mechanical aetiology. • Several sacroiliac joint findings were associated with female gender and pregnancy-related back pain. • Sacroiliac joint bone marrow oedema was frequent and age-associated, indicating a possible degenerative aetiology. • More knowledge of the clinical importance of sacroiliac joint MRI findings is needed. [ABSTRACT FROM AUTHOR]

Low back pain (LBP) is common and social isolation is both a risk factor for poor recovery from LBP and a consequence of LBP. The Friendship Scale is a brief measure of social isolation that has been validated for use in the general population and in people with LBP. The aim of this study was to translate, culturally adapt and validate the Friendship Scale into Danish. Translation of the English version of the Friendship Scale was performed independently by professional translators and overseen by an expert team. The Danish version was initially tested for face validity in a sample of 44 LBP patients. Subsequently, validity was examined through factor analysis, internal consistency, sensitivity by known groups and Rasch analysis in a sample of 382 Danish adult patients with LBP attending a secondary care spine centre and a general population sample of 293 people. Construct validity was examined by the relationship between Friendship Scale classification scores and study group membership and pain level. A linguistically accurate translation was achieved and no hesitation or ambiguity was observed in people completing this version. The psychometric properties of the Danish version were very similar to those found in the original version. This Danish translation of the Friendship Scale appeared to be easily understood by Danish people and has similar performance characteristics to the original version. These data indicate it has validity for use in Danish people seeking care for spinal pain and also for use in the general population. [ABSTRACT FROM AUTHOR]

Purpose: The STarT Back Tool (SBT) was recently translated into Danish and its concurrent validity described. This study tested the predictive validity of the Danish SBT. Methods: Danish primary care patients ( n = 344) were compared to a UK cohort. SBT subgroup validity for predicting high activity limitation at 3 months' follow-up was assessed using descriptive proportions, relative risks, AUC and odds ratios. Results: The SBT had a statistically similar predictive ability in Danish primary care as in UK primary care. Unadjusted relative risks for poor clinical outcome on activity limitation in the Danish cohort were 2.4 (1.7-3.4) for the medium-risk subgroup and 2.8 (1.8-3.8) for the high-risk subgroup versus 3.1 (2.5-3.9) and 4.5 (3.6-5.6) for the UK cohort. Adjusting for confounders appeared to explain the lower predictive ability of the Danish high-risk group. Conclusions: The Danish SBT distinguished between low- and medium-risk subgroups with a similar predictive ability of the UK SBT. That distinction is useful information for informing patients about their expected prognosis and may help guiding clinicians' choice of treatment. However, cross-cultural differences in the SBT psychosocial subscale may reduce the predictive ability of the high-risk subgroup in Danish primary care. [ABSTRACT FROM AUTHOR]

Purpose: Modic type 1 changes/bone edema in the vertebrae are present in 6 % of the general population and 35-40 % of the low back pain population. It is strongly associated with low back pain. The aim was to test the efficacy of antibiotic treatment in patients with chronic low back pain (>6 months) and Modic type 1 changes (bone edema). Methods: The study was a double-blind RCT with 162 patients whose only known illness was chronic LBP of greater than 6 months duration occurring after a previous disc herniation and who also had bone edema demonstrated as Modic type 1 changes in the vertebrae adjacent to the previous herniation. Patients were randomized to either 100 days of antibiotic treatment (Bioclavid) or placebo and were blindly evaluated at baseline, end of treatment and at 1-year follow-up. Outcome measures: Primary outcome, disease-specific disability, lumbar pain. Secondary outcome leg pain, number of hours with pain last 4 weeks, global perceived health, EQ-5D thermometer, days with sick leave, bothersomeness, constant pain, magnetic resonance image (MRI). Results: 144 of the 162 original patients were evaluated at 1-year follow-up. The two groups were similar at baseline. The antibiotic group improved highly statistically significantly on all outcome measures and improvement continued from 100 days follow-up until 1-year follow-up. At baseline, 100 days follow-up, 1-year follow-up the disease-specific disability-RMDQ changed: antibiotic 15, 11, 5.7; placebo 15, 14, 14. Leg pain: antibiotics 5.3, 3.0, 1.4; placebo 4.0, 4.3, 4.3. Lumbar pain: antibiotics 6.7, 5.0, 3.7; placebo 6.3, 6.3, 6.3. For the outcome measures, where a clinically important effect size was defined, improvements exceeded the thresholds, and a trend towards a dose-response relationship with double dose antibiotics being more efficacious. Conclusions: The antibiotic protocol in this study was significantly more effective for this group of patients (CLBP associated with Modic I) than placebo in all the primary and secondary outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the prevalence of infected herniated nucleus material in lumbar disc herniations and to determine if patients with an anaerobic infected disc are more likely to develop Modic change (MC) (bone oedema) in the adjacent vertebrae after the disc herniation. MCs (bone oedema) in vertebrae are observed in 6 % of the general population and in 35-40 % of people with low back pain. These changes are strongly associated with low back pain. There are probably a mechanical cause and an infective cause that causes MC. Several studies on nuclear tissue from herniated discs have demonstrated the presence of low virulent anaerobic microorganisms, predominantly Propionibacterium acnes, in 7-53 % of patients. At the time of a herniation these low virulent anaerobic bacteria may enter the disc and give rise to an insidious infection. Local inflammation in the adjacent bone may be a secondary effect due to cytokine and propionic acid production. Methods: Patients undergoing primary surgery at a single spinal level for lumbar disc herniation with an MRI-confirmed lumbar disc herniation, where the annular fibres were penetrated by visible nuclear tissue, had the nucleus material removed. Stringent antiseptic sterile protocols were followed. Results: Sixty-one patients were included, mean age 46.4 years (SD 9.7), 27 % female. All patients were immunocompetent. No patient had received a previous epidural steroid injection or undergone previous back surgery. In total, microbiological cultures were positive in 28 (46 %) patients. Anaerobic cultures were positive in 26 (43 %) patients, and of these 4 (7 %) had dual microbial infections, containing both one aerobic and one anaerobic culture. No tissue specimens had more than two types of bacteria identified. Two (3 %) cultures only had aerobic bacteria isolated. In the discs with a nucleus with anaerobic bacteria, 80 % developed new MC in the vertebrae adjacent to the previous disc herniation. In contrast, none of those with aerobic bacteria and only 44 % of patients with negative cultures developed new MC. The association between an anaerobic culture and new MCs is highly statistically significant ( P = 0.0038), with an odds ratio of 5.60 (95 % CI 1.51-21.95). Conclusion: These findings support the theory that the occurrence of MCs Type 1 in the vertebrae adjacent to a previously herniated disc may be due to oedema surrounding an infected disc. The discs infected with anaerobic bacteria were more likely ( P < 0.0038) to develop MCs in the adjacent vertebrae than those in which no bacteria were found or those in which aerobic bacteria were found. [ABSTRACT FROM AUTHOR]

Purpose: Modic changes (MCs) have been suggested to be a diagnostic subgroup of low back pain (LBP). However, the clinical implications of MCs remain unclear. For this reason, the aims of this study were to investigate how MCs developed over a 14-month period and if changes in the size and/or the pathological type of MCs were associated with changes in clinical symptoms in a cohort of patients with persistent LBP and MCs. Methods: Information on LBP intensity and detailed information from MRI on the presence, type and size of MCs was collected at baseline and follow-up. Changes in type (Type I, II, III and mixed types) and size of MCs were quantified at both time points according to a standardised evaluation protocol. The associations between change in type, change in size and change in LBP intensity were calculated using odds ratios (ORs). Results: Approximately 40 % of the MCs followed the expected developmental path from Type I (here Type I or I/II) to Type II (here Type II or II/III) or Type I to Type I/II. In general, the bigger the size of the MC at baseline, the more likely it was that it remained unchanged in size after 14 months. Patients who had MC Type I at both baseline and 14-month follow-up were less likely to experience an improvement in their LBP intensity as compared to patients who did not have Type I changes at both time points (OR 7.2, CI 1.3-37). There was no association between change in size of MCs Type I and change in LBP intensity. Conclusions: The presence of MCs Type I at both baseline and follow-up is associated with a poor outcome in patients with persistent LBP and MCs. [ABSTRACT FROM AUTHOR]

Objective: The STarT Back Screening Tool (STarT) is a nine-item patient self-report questionnaire that classifies low back pain patients into low, medium or high risk of poor prognosis. When assessed by GPs, these subgroups can be used to triage patients into different evidence-based treatment pathways. The objective of this study was to translate the English version of STarT into Danish (STarT-dk) and test its discriminative validity.Methods: Translation was performed using methods recommended by best practice translation guidelines. Psychometric validation of the discriminative ability was performed using the Area Under the Curve statistic. The Area Under the Curve was calculated for seven of the nine items where reference standards were available and compared with the original English version.Results: The linguistic translation required minor semantic and layout alterations. The response options were changed from "agree/disagree" to "yes/no" for four items. No patients reported item ambiguity using the final version. The Area Under the Curve ranged from 0.735 to 0.855 (CI95% 0.678-0.897) in a Danish cohort (n = 311) and 0.840 to 0.925 (CI95% 0.772-0.948) in the original English cohort (n = 500). On four items, the Area Under the Curve was statistically similar between the two cohorts but lower on three psychosocial sub-score items.Conclusions: The translation was linguistically accurate and the discriminative validity broadly similar, with some differences probably due to differences in severity between the cohorts and the Danish reference standard questionnaires not having been validated. Despite those differences, we believe the results show that the STarT-dk has sufficient patient acceptability and discriminative validity to be used in Denmark. [ABSTRACT FROM AUTHOR]

Vertebral endplate signal changes (VESC), also known as Modic changes, have been reported to be associated with low back pain (LBP). However, little is known about predisposing factors for the development of new VESC. The aim of this study was to investigate the predictive value of lifestyle factors and disc-related magnetic resonance imaging (MRI) findings in relation to the development of new VESC. This prospective observational study included 344 people from the Danish general population who had an MRI and completed LBP questionnaires at the age of 40 and again at 44 years. Potential predictors of new VESC were female gender, disc-related MRI findings (disc degeneration, disc bulges, disc herniation, and other endplate changes) and lifestyle factors [high physical work or leisure activity, high body mass index (BMI), and heavy smoking]. Bivariate and multivariate logistic regressions were used to identify predictors of new VESC. New VESC at the age of 44 appeared in 67 of the 344. The majority (84%) of these new signal changes were type 1 VESC and almost half (45%) were only in the endplate and did not extend into the vertebral body. In the multivariate analysis, lumbar disc levels with disc degeneration, bulges or herniations at 40 were the only predictors of new VESC at age 44. Therefore, the development of new VESC at the age of 44 appears to be based on the status and dynamics of the disc, rather than being the result of gender or lifestyle factors such as smoking and physical load. [ABSTRACT FROM AUTHOR]

Abstract: Understanding a change score is indispensable for interpretation of results from clinical studies. One way of determining the relevance of change scores is through the use of transition questions that assesses patients’ retrospective perception of treatment effect. Unfortunately, results from studies using transition questions are difficult to compare since wording of questions and definitions of important improvements vary between studies. The objectives of this study were to determine the consequence of using different transition questions on pain and disability measures and make proposals for a standardised use of such questions. Two hundred and thirty-three patients with low back pain and/or leg pain were recruited. Participants were followed over an 8-week period and randomised to two groups receiving a 7- (TQ1) and 15-point (TQ2) transition question, respectively, in addition to a numeric rating scale evaluating the importance of the perceived change. Four external criteria were generated using both stringent and less stringent standards to dichotomise patients. Discrimination was determined using area under the receiver operating characteristic curve (ROCauc) and responsiveness using standardised response mean (SRM). Results demonstrated small variations in ROCauc across the external criteria for all outcome measures. 7% more patients were classified as improved in the group receiving the 15-point TQ compared to the 7-point TQ (stringent standard). SRMs were higher for the retrospective TQs in primary sector patients compared to the serial measures with no difference between TQ1 and TQ2. On the basis of our findings we have outlined a proposal for a standardised use of transition questions. [Copyright &y& Elsevier]