53. A new evaluation method for lumbar spinal instability: passive lumbar extension test

Proceedings of the NASS 19th Annual Meeting / The Spine Journal 4 (2004) 3S–119S for radiographic evaluation of the cervical spine in patients who are symptomatic after traumatic injury (Neurosurgery, March 2002 Supplement). However, it has been suggested that the AP view can be dropped from the initial screening of cervical spinal injury because of low sensitivity (Holliman et al, 1991). Others have claimed that lateral radiograph alone will miss cervical spine injuries detected on a three way series (Cohn et al, 1991 and Shaffer and Doris, 1981) and therefore the AP view necessary. PURPOSE: The purpose of this study is to evaluate the usefulness of the AP view as part of the initial radiographic evaluation of the cervical spine trauma patient. The elimination of the AP radiograph in the acute trauma screening could save time in the initial assessment of the patient, would reduce radiation and could lead to significant cost savings. STUDY DESIGN/SETTING: This was a retrospective study. PATIENT SAMPLE: Trauma patients with cervical spine fracture, dislocation, or cord injury treated at University of California, Davis Medical Center (UCDMC), a level 1 trauma center, from January 2003 through September 2003 were reviewed. OUTCOME MEASURES: Whether the diagnosis was changed after reviewing the AP view was the outcome measure. METHODS: Original radiographs from the initial trauma screening were obtained from these cases and sequentially presented to two board certified neuroradiologists at UCDMC. Three way views in which there were no abnormalities were added randomly to serve as controls. The radiologists first reviewed the lateral cervical spine and odontoid views and made a diagnosis based on these two films together. Swimmer’s and Fuch’s views were reviewed if needed. Finally the AP view was viewed and any change in diagnosis was noted. RESULTS: 49 cervical spine injuries and 9 control cases were reviewed. In 3/49 cases, a fracture was seen on the AP view that was not detected on the other views. False positives were present on the AP radiograph in 6/ 49 cases, determined after review of the cervical spine CT of the patient. All nine of the control cases were read as negative after lateral and odontoid views and one of the nine cases had a false positive reading of the AP view. CONCLUSIONS: In 6% of cases, fracture was detected on AP view only. Thus, caution should be exercised in considering removal of this view from radiographic series used in the initial evaluation of cervical spine trauma patients. However the cost paid is that of a 12% false positive rate. DISCLOSURES: No disclosures. CONFLICT OF INTEREST: No Conflicts. doi: 10.1016/j.spinee.2004.05.053 3:54 53. A new evaluation method for lumbar spinal instability: passive lumbar extension test Yuichi Kasai, Koichiro Morishita, Atsumasa Uchida; Mie University, Tsu, Mie prefecture, Japan BACKGROUND CONTEXT: There is no clear definition about clinical symptoms associated with lumbar spinal instability and few researchers have discussed lumbar spinal instability based on physical findings. No researcher has assessed sensitivity or specificity of the physical findings. PURPOSE: The authors contrived Passive Lumbar Extension Test (PLE Test) for assessing lumbar spinal instability by passively extending the lumbar spine and inducing pain. We discuss the usefulness. STUDY DESIGN/SETTING: A prospective clinical and radiographic study conducted by an independent observer was performed on 67 patients with lumbar degenerative diseases. PATIENT SAMPLE: The study was conducted in 67 patients who underwent surgery for the diagnosis of lumbar spinal canal stenosis, lumbar spondylolisthesis and lumbar spinal degenerative scoliosis at the age of between 39 and 76 years old (mean: 63.9 years old) at the author’s hospital during the period from 1998 to 2000 (male: 34, female: 33). They were followed for 2 years and 9 months in the average (2 year to 3 years and 4 months). OUTCOME MEASURES: The authors made a diagnosis of lumbar spinal instability according to the following assessment criteria: In the

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functional lateral radiographs of the lumbar spine in the standing position, if range of motion for intervertebral space is 15 ⬚or over or slipping degree of vertebral body is 3mm or over, the patient should be diagnosed as having instability. According to the criteria, 28 of 67 patients were diagnosed as having instability and 39 were diagnosed as not having instability. METHODS: Regarding the PLE Test, the authors instructed patients lie on the bed in the prone position and lifted both legs concurrently to the height of about 30cm from the bed while maintaining the knees extended and gently pulling the legs and thus those who developed severe lumbar and gluteal pain were diagnosed as positive in PLE Test. The location and condition of pain complained by the patient, pain of hip joint or related pain of femoral nerve were cautiously differentiated. We investigate the sensitivity and specificity of the PLE Test. RESULTS: Of the 28 patients diagnosed as having instability based on the X-ray findings, 26 patients were tested positive in PLE Test. Of the 39 patients diagnosed as not having instability based on the X-ray findings, 33 patients were tested negative in PLE Test. The data suggest the sensitivity and specificity of the PLE Test is 92.3% and 84.6%, respectively. CONCLUSIONS: The Passive Lumbar Extension Test, a new diagnostic tool is considered to be a convenient method that enables orthopaedists to assess lumbar spinal instability easily. DISCLOSURES: No disclosures. CONFLICT OF INTEREST: No Conflicts. doi: 10.1016/j.spinee.2004.05.054 3:58 54. Importance of deformity apex in adult lumbar scoliosis: a multicenter radiographic and health status analysis Frank Schwab1, Jean-Pierre Farcy2, Sigurd Berven3, Steven Glassman4, Keith Bridwell5, William Horton6; 1Maimonides Medical Center, Brooklyn, NY, USA; 2New York University, New York, NY, USA; 3 University of California, San Francisco, San Francisco, CA, USA; 4 University of Louisville, Louisville, KY, USA; 5Washington University in St. Louis, Saint Louis, MO, USA; 6Emory University, Atlanta, GA, USA BACKGROUND CONTEXT: Classification systems and prognostic parameters based on radiographic parameters have been outlined for adolescent idiopathic scoliosis. Such information is lacking for adult scoliotic deformities although recent studies have reported radiographic criteria with significant correlation to clinical symptoms. PURPOSE: To analyze correlation between lumbar scoliosis apex/end level and intervertebral subluxation with outcomes measures. This may lay the groundwork to a clinically useful classification. STUDY DESIGN/SETTING: Multi-center database review. PATIENT SAMPLE: All consecutively enrolled Spinal Deformity Study Group (SDSG) adult patients with scoliosis of the lumbar spine and apex L1, L2 or L3 (of degenerative or idiopathic origin). Apical levels below L3 were excluded, as these were likely to represent fractional curves or focal rotatory subluxation. OUTCOME MEASURES: Oswestry Disability Index, Scoliosis Research Society (SRS-29) instrument. METHODS: The study included 209 patients. For all subjects radiographic analysis (from full-length standing films) included: apical level and lower end level of the lumbar deformity, sagittal plane lumbar lordosis (L1– S1), spondylolisthesis (in mm.), frontal plane intervertebral olisthesis (in mm.). Subjects were divided into groups by apical level of the lumbar scoliosis and further subdivided by degree of lumbar lordosis, frontal and sagittal plane intervertebral subluxations. Statistical comparison (ttest) amongst subgroups in terms of ODI and SRS function/pain scores was made. RESULTS: For the 209 patients, distribution by apical level was as follows: L1⫽26, L2⫽113, L3⫽70. Significant differences between apex L1 and apex L3 subjects were found (L1: ODI mean 18, L3 ODI mean 28 p⫽0.015, L1 SRS pain 79, L3 SRS pain 64, p⫽0.006). Lumbar lordosis was significantly correlated with SRS function score (100 patients without lordosis