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Background Context: The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016., Purpose: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition., Study Design: This is a guideline summary review., Methods: This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors., Results: Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature., Conclusions: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx., (Copyright © 2020. Published by Elsevier Inc.)

Study Design: An experimental study of fatiguing isometric trunk extension was conducted to investigate the spinal loading estimated from an electromyogram-assisted biomechanical model., Objective: To evaluate the sensitivity of the model outputs to two crucial assumptions: electromyogram-force relationship and method of gain estimation., Summary of Background Data: In the proposed electromyogram-assisted models of the trunk, the nature of the electromyogram-force relationship and the wide variation in reported muscle gains can result in a wide variation in estimates of spinal loading. Given the absence of any gold standard for validation of muscle forces, the delineation of confidence intervals for the estimated loads has become critical., Methods: Ten subjects performed a fatiguing isometric trunk extension while the net muscular torque output and trunk muscular activity were measured. An electromyogram-assisted model was used to estimate the torque output and spinal loading. Linear and nonlinear erector spinae electromyogram-force relationships and three methods for gain estimation were investigated: constant gain determined from an initial maximum extension exertion, constant gain based on the fatiguing exertion, and a time-varying gain from the fatigue test., Results: The predicted torque was not sensitive to the electromyogram-force relationship; the nonlinear model produced 10% lower estimates of peak spinal compression force and 14% higher estimates of peak anterior shear force. The gain determined from an initial calibration exertion underestimated the external torque and underpredicted the peak compression force by 20%, compared with gains calculated in the fatigue test., Conclusion: The nature of the electromyogram-force relationship and of the method for estimating the gain significantly affect the outcomes of an electromyogram-assisted model of spinal loading.

The evaluation of the effect of lifting belts on multijoint coordinated lifting performance has been limited. Thirteen subjects participated in two experiments: (a) fatiguing repetitive sagittal lifting and (b) asymmetric lifting. Both experiments were performed with and without the use of a common flexible lifting belt to determine the effect of belt use on the trunk and lower extremity motion and load sharing. During both tests, the use of the belt was observed to restrict the sagittal trunk range of motion and velocity, while the hip motion and velocity increased. Although one of the risk factors for acquisition of low back pain may be reduced while wearing the belt, the results also demonstrate a need for greater study of the consequences on the risk of injury to the other joints. More laboratory experiments and prospective epidemiological studies are needed before a conclusive recommendation could be made in favor of using the belt as a valid preventive measure.

A novel testing protocol was used to investigate changes in neuromuscular performance, muscle recruitment, and spinal loading as subjects became fatigued while performing an isometric endurance test of varying torque requirements. There was decreased accuracy in maintenance of a reference torque but no change in response time as subjects became fatigued. The study of trunk-muscle recruitment indicated significant increases in internal oblique and latissimus dorsi muscle activity. This change in recruitment led to changes in spinal loading despite a relatively constant torque output. The use of an electromyogram (EMG)-assisted model demonstrated that when subjects are expected to become fatigued during test performance, the assumption of a constant maximal stress capacity of the muscle may not be robust.

Because of the inability of strength tests to accurately discriminate between low back pain patients and healthy subjects, a multifactorial evaluation of low back pain patients is warranted. It is postulated that measurements of endurance, kinematics, postural stability, and coordination, in addition to strength, are necessary to fully document the patients' functional capabilities. This research study was conducted in order to understand the effects of fatigue on the above factors. Twelve healthy male subjects performed a repetitive lifting test in which a submaximal load was lifted at a maximal rate. Knee, hip, and trunk motion was measured using videography and electrogoniometry, postural stability was measured using a forceplate, and coordination parameters were determined using phase-plane analysis. Fatigue was documented by a 31% reduction in lifting power. At the end of the endurance test, there was less knee and hip range of motion and greater spine peak flexion, while the coordination measures demonstrated that there was greater hip and lumbar spine extension earlier in the lifting phase. The postural stability declined as the test endured. Utilization of these measures may guide physical therapists in their rehabilitation of low back pain patients.

Spinal subdural hematoma is a rare condition with numerous etiologies. It is even more rare in the postoperative period and must be differentiated from the more common causes of postoperative pain and radiculopathy. We report a 36-year-old man presenting 6 weeks after surgery with incapacitating pain who was found to have a subdural but extraarachnoid fluid collection. We describe clinical presentation, radiological findings, etiology, and treatment. We conclude that, although rare, the spinal subdural hematoma should be considered in patients with postoperative pain. Prompt recognition and surgical evacuation are important for optimal recovery.

A-2 pulleys were replaced in the hand of the nonhuman primate; on the long/little fingers the pulleys were reconstructed with a woven nylon fabric (Nitex), and on the ring/index fingers the pulleys were reconstructed with fascia lata. The opposite unoperated hand served as a control. At 2, 3, and 6 months postoperative, the animals were killed to compare the function of the reconstructed pulleys with the control pulleys of the opposite digit. Using a tensile testing machine, two parameters, work of flexion and tendon excursion, showed that both pulley reconstructions permitted minimal tendon bow-stringing and had excellent gliding function. Both materials increased in strength over time to become stronger than the control pulley. Histologic examination showed no foreign body reaction to the Nitex; excellent fibrous ingrowth into the woven nylon was seen, which matured in time. The surface of the Nitex pulley facing the tendon developed and maintained a synovial-like gliding surface. The Nitex pulley compared favorably with the fascial pulley biomechanically and histologically; both reconstructed pulleys functioned well compared with normal pulleys.