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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.)

The motivation for this study is to provide design guidance for a new halo system that minimizes pin loosening. If halo pin loosening can be substantially decreased with a new halo system, then the current standard of care of overtightening halo pins will not be necessary. Accordingly, there is a need to determine the halo pin force that should be applied to ensure adequate fixation. A biomechanical test was performed using cadaver head constructs, a custom halo fixture, and a tensile testing machine in an attempt to determine the relationship between the force required to dislodge a halo ring and the initial halo pin force. Three cadaver head constructs were tested at initial pin forces of 120, 240, and 360 N. For each test, the halo was pulled from a cadaver head with a displacement rate of 2.5 mm/min until the halo ring disengaged from the head. The vertical force that caused disengagement of the halo from the head was determined from the resulting load-displacement curves. A linear regression of the data predicts disengagement forces of 80, 320, and 570 N, respectively, for initial pin forces of 120, 240, and 360 N. The 95% prediction interval of disengagement forces for initial pin forces of 120, 240, and 360 N were +/-130, 120, and 130 N, respectively. A previously published study reported the maximum vertical load on a halo orthosis during patient usage to be 186 N. The lower 95% prediction interval from this study indicates that an average initial pin force of 230 N is necessary to prevent halo pin disengagement from a 186-N vertical load.

Complications arising from antibiotic use are of interest to neurosurgeons because many neurosurgical patients are treated for infection. In this report, the authors describe three patients with spine disorders who developed coagulopathies after treatment with levofloxacin, an antibiotic commonly used by neurosurgical services. Three patients with spine disorders developed urinary tract infections (UTIs) for which they received a 3-day course of oral levofloxacin. Subsequently, they demonstrated prolonged prothrombin times and increased international normalized ratios. One of those patients later developed acquired von Willebrand syndrome during surgery. Coagulopathies were successfully corrected preoperatively with parenteral vitamin K. The patient with acquired von Willebrand syndrome required multiple transfusions. There seems to be an association between levofloxacin and coagulation abnormalities in neurosurgical patients treated for UTIs. Neurosurgical services prescribing this common antibiotic should be aware of this problem.

We studied 108 adult cases of elective lumbar surgery using dermatomal somatosensory-evoked potential (DSEP) monitoring to evaluate its usefulness due to concern over potential neurologic injury during pedicle screw insertion. Both surgeons used all of the necessary precautions required during surgery so that DSEP monitoring was not the "primary," but rather a backup system for operative security. Quality tracings were obtained in 71% of cases; anesthetic difficulties being the major cause of poor monitoring. There were no neurological complications related to pedicle screw insertion. We found that DSEP monitoring was an excellent method to verify intraoperative neurological status, but required a high degree of cooperation between the anesthesiologists, monitoring technician, and surgeons. In today's cost-containment environment, its usefulness is subjected to the expertise of the spine surgeon and the hospital setting.

The treatment of thoracolumbar spinal fractures has evolved significantly in the last 50 years. Clear classification systems now allow physicians to predict which fracture patterns will require surgery and which may be adequately treated non-operatively. These indications, as well as a brief overview of thoracolumbar spinal fracture care, are presented.

Ninety-six patients (63 females and 33 males) who underwent total joint arthroplasty or spinal reconstructive surgery were randomized to receive either a Solcotrans Plus or a Stryker-CBC ConstaVAC closed-wound drainage system. A binomial test showed that the Stryker-CBC ConstaVAC system was significantly preferred over the Solcotrans Plus system for ease of use, as reported by nurses. However, Solcotrans Plus was more cost-effective because a larger volume of blood shed by a patient could be reinfused while maintaining the standards of the American Association of Blood Banks. The difference in the occurrence of side effects between the two systems was not statistically significant.

Interpeduncular segmental fixation of the lumbar and lumbosacral spine with Luque screws and plates is becoming increasingly popular. In this retrospective study, 52 consecutive patients treated with this technique were followed for 16 to 44 months (average, 21). Indications for surgical arthrodesis included lumbar instability from degenerative disease (16 cases), spondylolisthesis (25 cases), pseudarthrosis (eight cases), fracture (two cases), and tumor (one case). Fusion with instrumentation spanned one level in nine patients, two in 38 patients, three in four patients, and four in one patient. Patients wore a rigid lumbar orthosis for an average of six months (range, two to 16). Ten complications occurred in nine patients: two superficial wound infections, four neurologic complications, three loosened screws, and one broken screw. An overall fusion rate of 96% was achieved; pseudarthrosis is suspected in one case and failed arthrodesis secondary to trauma in a second patient. At four months postoperatively, solid unions had resulted in most of the cases, as seen roentgenographically. All patients reported decreased back pain; however, one patient is addicted to narcotics. Twenty-five of the 29 patients employed were able to return to work at an average of six months postoperatively.

In brief: Sixty-nine race car drivers were surveyed in a study of the Indianapolis 500 from 1981 to 1984 and the 1984 Championship Auto Racing Teams (CART) series. The purpose was to evaluate the frequency of accidents and the nature of the resulting injuries that occur in Indianapolis-type race cars. Findings revealed that lower extremity injuries occurred most frequently. Accident frequency was one per 1,414 miles of racing in the CART series and one per 3,000 miles at the Indianapolis Motor Speedway. The number of accidents per injury was 9.5 in the CART series and 3.2 at Indianapolis, compared with 8.2 on US highways. This study suggests that current technology, which has shifted the spectrum of injuries from life-threatening to limb-threatening on the race track, could be applied to everyday highway safety as well.

Pain relief, function, and range of motion in surface replacement hip arthroplasty is comparable to the Charnley-type conventional arthroplasty. Patients with primary and secondary degenerative hip disease are the most suitable candidates for surface replacement. Previous operations, especially mold arthroplasty, increases incidence of failure. Osteopenia, obesity, or congenital deficiency of the acetabulum also increases the incidence of failure. Intraoperative preservation of abductor continuity and rigorous postoperative abductor strengthening are necessary to insure the success of the procedure. A minimum of 18 months is necessary to adequately evaluate the procedure. Acetabular loosening is avoidable. Hemispherical reaming of the femoral head did not contribute to femoral component loosening. Traumatic femoral neck fracture is a concern, but atraumatic femoral neck fracture can be avoided through improved operative technique, and by a program of rehabilitation of hip musculature. The procedure is indicated in the relatively young, well-motivated, non-obese patient with degenerative joint disease who has normal hip musculature.

Lateral subluxation of one vertebral body upon another (rotatory olisthesis) has been associated with increased incidence of back pain in scoliosis. This study was undertaken to identify the presence of and characterize rotatory olisthesis and its association with the following parameters: age, sex, curve type, curve magnitude, level of occurrence, region within curves, primary vs. secondary curves, severity of slip, and association with pain. Charts of 636 patients were reviewed for the presence or absence of pain. Curve measurements and the occurrence of rotatory olisthesis were noted. Rotatory olisthesis was statistically unrelated to the occurrence of pain associated with idiopathic scoliosis. It was significantly associated with increasing age and curve magnitude. Lumbar curves with rotatory olisthesis were more likely to be associated with radicular pain.

A 36-year-old white male schoolteacher presented with a painless, semifluctuant mass on the volar aspect of his forearm and symptoms of ring finger tenosynovitis and median nerve compression. At operation there was a widespread infestation of the flexor tendon compartment, the carpal tunnel, and the tendon sheaths of the ringer finger with Onchocerca volvulus, a filarial nematode, not previously reported in the these tissues.

Controlled mobilization is necessary in certain situations during the management of patients undergoing reconstructive spinal surgery. Chart review of 39 patients (20 maintained on the Roto-rest bed, 19 maintained on the Foster frame) was undertaken. Both beds protected spinal stability and no delays occurred in any staged surgical procedure. Patients maintained on the Roto-rest bed did have a significantly higher incidence of skin problems (p less than .05), but had no pulmonary emboli. Pulmonary emboli occurred in two of the 19 patients maintained on the Foster frame. Successful use of the Roto-rest bed was dependent upon skilled nursing personnel who were knowledgeable in the mechanical aspects of the bed and could provide a sense of security for the patient. No evidence was found that the Roto-rest bed affected the patients' use of postoperative analgesics. Both beds provided adequate controlled mobilization. Consideration of the patients' total medical profile would determine the choice of bed.