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A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy
68
Journal of Manipulative and PhysiologicalTherapeutics Volume 23 • Number 1 • January 2000
Journal Abstracts
upper limb injuries being 6.4:1. The commonest single injury was an isolated medial collateral ligament knee sprain (23.7% of all consultations). Head injuries comprised 8.5% and ulnar collateral ligament thumb sprains 5.1%. Assessment of injury by the Injury Severity Score (ISS) showed that skiing injuries were significantly more likely to be nontrivial (ISS > 2) than work-related injuries [X2(1, N = 56) = 55.6, p < 0.001 ] or injuries of all causes [X2(1, N = 56) = 65.0, p < 0.001]. They were significantly mote likely to need radiological investigation than all injuries [X2(1, N = 59) = 22.0, p < 0.001]. The most severe (ISS 13), survivable injury seen during the study period resulted from a skiing accident. This excess of non-trivial injury raises important management issues, particularly as the majority (81%) were recreational. © Elsevier Science Ltd. All rights reserved.
Daly KA, Brown JE,Lindgren BR, Meland MH, Le CT, Giebink GS. Epidemiology of otitis media onset by six months of age. Pediatrics 1999;103:1158-66.
ABSTRACT: Objective: Although early otitis media (OM) onset predicts later recurrent and chronic OM, little research has been directed at illuminating the role of prenatal exposures in early OM. This prospective study examined prenatal, innate, and early environmental exposures associated with acute otitis media (AOM) onset and recurrent OM (ROM) by age 6 months. Design and Methods: Prospective study of 596 infants from a health maintenance organization followed from birth to 6 months. Mothers completed monthly forms on prenatal exposures (diet, medications, and illnesses) and infant risk factors (eg, smoke exposure and child care) during pregnancy and until infants were 6 months old. Urine samples were collected when infants were 2 months of age and analyzed for cotinine and creatinine. Physicians and nurse practitioners examined infants at each clinic visit and completed standard ear examination forms. Results: Thirty-nine percent had an episode of AOM and 20% had ROM by age 6 months. Using Cox's regression models to control for confounding, respiratory tract infection (relative risk [RR] 7.5), day care (RR 1.7), >1 sibling (RR 1.4), maternal, paternal, and sibling OM history (RR 1.6, 1.5, and 1.7, respectively) were significantly related to early OM onset. ROM was related to respiratory tract infection (RR 9.5), day care (RR 1.9), conjunctivitis (RR 2.0), maternal OM history (RR 1.9), and birth in the fall (RR 2.6). Among prenatal exposures, only high prenatal dietary vitamin C intake was significantly inversely related to early AOM with univariate but not multivariate analysis. Conclusion: Prenatal factors were not linked to early AOM onset with multivariate analysis, but environmental and innate factors play an important role in early AOM onset. Strategies to reduce exposure to environmental variables could reduce rates of early AOM, which could potentially result in declining rates of ROM and chronic OME. Reproduced by permission of Pediatrics.
Guerriero RC, Rajwani M, Gray E, Platnick H, Da Re R, Dodsworth P. A retrospective study of the effectiveness of physical rehabilitation of low back pain patients in a multidisciplinary setting. J Canadian ChiroprAssoc 1999;43(2):89-103.
ABSTRACT: Objective: To evaluate the effectiveness of physical rehabilitation of low back pain patients in a multidisciplinary setting. Design: A retrospective study profiled and analysed objective data from patients seen through a rehabilitation program in a private multidisciplinary facility. Patients: 147 patients with low back pain were analysed. Population: The sample consisted mainly of patients with motor vehicle accident-related or work-related injuries to the lower back. They ranged from acute to chronic in nature. Main outcome measures: The primary measures were the Oswestry Pain Disability Index (ODI) and the Pain Visual Analogue Scale. Secondary measures included SLR, sit and reach test, grip strength, leg lift strength and ranges of motion. Results: The outcome measures used in the study showed statistical significance (p < 0.05). Positive clinical trends were shown in pain VAS, ODI, leg lift and sig and reach tests. Ninety percent of patients were cleared to return to work upon discharge from the program. Conclusions: Further studies of active physical rehabilitation should employ a prospective randomized controlled trial design. The study should also follow up patients to confirm that they have continued to work following discharge from the program. As indicated by the statistical analysis provided by this study, a minimum sample size of 53 subjects per intervention group would be required.
Hermantin FU, PetersT, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg (AM) 1999;81-A:958-65.
ABSTRACT: Background: The usefulness of video-assisted arthroscopic microdiscectomy for the treatment of a herniated lumbar disc has been studied previously. In the current prospective, randomized study, the results of this procedure were compared with those of conventional open laminotomy and discectomy. Methods: Sixty patients who had objective evidence of a single intracanalicular herniation of a lumbar disc caudad to the first lumbar vertebra were randomized into two groups consisting of thirty patients each; Group 1 was managed with open laminotomy and discectomy, and Group 2 was managed with video-assisted arthroscopic microdiscectomy. None of the patients had had a previous operation on the low back, and all had failed to respond to nonoperative measures. Analysis of the outcomes of both procedures was based on the patient's selfevaluation before and after the operation, the preoperative and postoperative clinical findings, and the patient's ability to return to a functional status. The patients were followed for nineteen to forty-two months postoperatively. Results: On the basis of the patient's preoperative and postoperative self-evaluation, the findings on physical examination, and the patient's ability to return to work or to normal activity, twenty-eight patients (93 percent) in Group 1 and twenty-nine patients (97 percent) in Group 2 were considered to have had a satisfactory outcome. The mean duration of postoperative disability before the patients were able to return to work was considerably longer in Group 1 than in Group 2 (forty-nine com-
Journal of Manipulative and Physiological Therapeutics Volume 23 • Number I • January 2000
69
Journal Abstracts pared with twenty-seven days). The patients in Group 1 used narcotics for a longer duration postoperatively. No neurovasculat" complications or infections were encountered in either group. Conclusions: Although the rate of satisfactory outcomes was approximately the same in both groups, the patients who had had an arthroscopic microdiscectomy had a shorter duration of postoperative disability and used narcotics for a shorter period. These findings suggest that arthroscopic microdiscectomy may be useful for the operative treatment of specific symptoms, including radiculopathy, tfiat are caused by lumbar disc herniation, provided that patients are properly selected-that is, they must have a herniated disc at a single level as confirmed on imaging studies, have failed to respond to nonoperarive management, have no evidence of spinal stenosis, and have a herniation not exceeding one-half of the anteroposterior diameter of the spinal canal. Moreover. the surgeon must be familiar with this technique and must have received training in its use.
Jia M, Shu-xia Z.
Cervical spondylosis. International J Clinical Acupuncture 1999; 10(2): 145-50.
ABSTRACT: A disease common among the middle-aged and the elderly, cervical spondylosis is characterized by dizziness, headache, and pain and numbness of the neck, shoulder and upper back. Recent years have seen increased incidence among younger persons. Acupuncture has proved effective and convenient for patients. This paper is a report on recent advances in this area.
Lip GYH, RathoreVS, Katira R,Watson RDS,Singh SP. Do IndoAsians have smaller coronary arteries? Postgrad Med J 1999;75:463-6.
ABSTRACT: Summary: There is a widespread belief that coronary arteries are smaller in Indo-Asians. The aim of the present study was to compare the size of atheroma-free proximal and distal epicardial coronary arteries of Indo-Asians and Caucasians. We analysed normal coronary angiograms fi'om 77 Caucasians and 39 Indo-Asians. The two groups were comparable for dominance of the coronary arteries. Indo-Asian patients had generally smaller coronary arteries, with a statistically significant difference in the mean diameters of the left main coronary artery, proximal, mid and left anterior descending, and proximal and distal right coronary artery segments. There was a non-significant trend towards smaller coronary artery segment diameters for the distal left anterior descending, proximal and distal circumflex, and obtuse marginal artery segments. However, after correction for body surface area, none of these differences in size were statistically significant. Thus, the smaller coronary arteries in Indo-Asian patients were explained by body size alone and were not due to ethnic origin perse. This finding nevertheless has important therapeutic implications, since smaller coronary arteries may give rise to technical difficulties during bypass graft and intervention procedures such as percutaneous transluminal coronary angioplasty, scents and atherectomy. On smaller arteries, atheroma may also give an impression of more severe disease than on larger diameter arteries.
Marriott A, Newman NM, Gracovetsky SA, Richards MP, A s s e l i n S. Improving the evaluation of benign low back pain. Spine 1999;24( 10):952-60.
Levangie PKt
Association of low back pain with self-reported risk factors among patients seeking physical therapy services. Phys Ther 1999;79:757-66.
ABSTRACT: Background and Purpose: This study investigated the magnitude of association between low back pain (LBP) and selfreported factors thought to increase the risk of LBE Subjects and Methods: Questionnaires were completed by 150 patients who were receiving physical therapy for LBP and by 138 patients who were being treated for other reasons. The solicited information was used to estimate odds ratios and 95% confidence intervals for the LBP-risk factor association. Results: Low back pain was positively associated with smoking status, pregnancy, industrial vibration exposure, and time spent in a car (odds ratios >_ 2.21). Daily lifting; body mass index, activity level, and time sitting or standing showed at most a weak positive association with LBP. Comparisons with estimated associations from other studies were made. Conclusion and Discussion: Data from this study support a statistically significant association between LBP and some factors found in other research to increase the risk of LBE Study findings may have implications for targeting at-risk groups for back care education or intervention programs. Reprinted from Levangie PK. Association of low back pain with self-reported risk factors among patients seeking physicial therapy services. Phys Ther 1999;79:757-66. With permission of the American Physical Therapy Association.
ABSTRACT: Study Design: A prospective, blind study was conducted to investigate the factors underlying the decisions of expert clinicians in diagnosis of acute, benign low back pain, compared with results obtained with an automated physical examination by machine. From the results, a strategy to significantly improve clinical diagnosis in cases of discordance was determined. Objectives: To identify factors in the clinical assessment of low back pain that indicate when independent diagnostic testing would be useful. Summary of Background Data: The clinical evaluation of low back pain is often dominated by subjective reports of pain. Published medical literature has underscored several inherent weaknesses of the clinical examination, and concerns have been raised about its effectiveness for assessing patients with low back pain. Thus, it has been proposed that objective measures to complement the clinician's examination would be beneficial in the formulation of dependable diagnoses. Methods: Randomly designated subjects, who in describing their conditions were objective or role playing, were assessed by clinicians and a machine for diagnosis of low back pain assessment versus normal backs. Each subject's pain assessment was compared with a gold standard that was established by experts in low back pain. Components of the clinical examination were analyzed to assess which were the most informative in making a reliable diagnosis. The information content of" the machine assessment was also analyzed and a strategy to
Journal of Manipulative and PhysiologicalTherapeutics Volume 23 • Number 1 • January 2000
Journal Abstracts
upper limb injuries being 6.4:1. The commonest single injury was an isolated medial collateral ligament knee sprain (23.7% of all consultations). Head injuries comprised 8.5% and ulnar collateral ligament thumb sprains 5.1%. Assessment of injury by the Injury Severity Score (ISS) showed that skiing injuries were significantly more likely to be nontrivial (ISS > 2) than work-related injuries [X2(1, N = 56) = 55.6, p < 0.001 ] or injuries of all causes [X2(1, N = 56) = 65.0, p < 0.001]. They were significantly mote likely to need radiological investigation than all injuries [X2(1, N = 59) = 22.0, p < 0.001]. The most severe (ISS 13), survivable injury seen during the study period resulted from a skiing accident. This excess of non-trivial injury raises important management issues, particularly as the majority (81%) were recreational. © Elsevier Science Ltd. All rights reserved.
Daly KA, Brown JE,Lindgren BR, Meland MH, Le CT, Giebink GS. Epidemiology of otitis media onset by six months of age. Pediatrics 1999;103:1158-66.
ABSTRACT: Objective: Although early otitis media (OM) onset predicts later recurrent and chronic OM, little research has been directed at illuminating the role of prenatal exposures in early OM. This prospective study examined prenatal, innate, and early environmental exposures associated with acute otitis media (AOM) onset and recurrent OM (ROM) by age 6 months. Design and Methods: Prospective study of 596 infants from a health maintenance organization followed from birth to 6 months. Mothers completed monthly forms on prenatal exposures (diet, medications, and illnesses) and infant risk factors (eg, smoke exposure and child care) during pregnancy and until infants were 6 months old. Urine samples were collected when infants were 2 months of age and analyzed for cotinine and creatinine. Physicians and nurse practitioners examined infants at each clinic visit and completed standard ear examination forms. Results: Thirty-nine percent had an episode of AOM and 20% had ROM by age 6 months. Using Cox's regression models to control for confounding, respiratory tract infection (relative risk [RR] 7.5), day care (RR 1.7), >1 sibling (RR 1.4), maternal, paternal, and sibling OM history (RR 1.6, 1.5, and 1.7, respectively) were significantly related to early OM onset. ROM was related to respiratory tract infection (RR 9.5), day care (RR 1.9), conjunctivitis (RR 2.0), maternal OM history (RR 1.9), and birth in the fall (RR 2.6). Among prenatal exposures, only high prenatal dietary vitamin C intake was significantly inversely related to early AOM with univariate but not multivariate analysis. Conclusion: Prenatal factors were not linked to early AOM onset with multivariate analysis, but environmental and innate factors play an important role in early AOM onset. Strategies to reduce exposure to environmental variables could reduce rates of early AOM, which could potentially result in declining rates of ROM and chronic OME. Reproduced by permission of Pediatrics.
Guerriero RC, Rajwani M, Gray E, Platnick H, Da Re R, Dodsworth P. A retrospective study of the effectiveness of physical rehabilitation of low back pain patients in a multidisciplinary setting. J Canadian ChiroprAssoc 1999;43(2):89-103.
ABSTRACT: Objective: To evaluate the effectiveness of physical rehabilitation of low back pain patients in a multidisciplinary setting. Design: A retrospective study profiled and analysed objective data from patients seen through a rehabilitation program in a private multidisciplinary facility. Patients: 147 patients with low back pain were analysed. Population: The sample consisted mainly of patients with motor vehicle accident-related or work-related injuries to the lower back. They ranged from acute to chronic in nature. Main outcome measures: The primary measures were the Oswestry Pain Disability Index (ODI) and the Pain Visual Analogue Scale. Secondary measures included SLR, sit and reach test, grip strength, leg lift strength and ranges of motion. Results: The outcome measures used in the study showed statistical significance (p < 0.05). Positive clinical trends were shown in pain VAS, ODI, leg lift and sig and reach tests. Ninety percent of patients were cleared to return to work upon discharge from the program. Conclusions: Further studies of active physical rehabilitation should employ a prospective randomized controlled trial design. The study should also follow up patients to confirm that they have continued to work following discharge from the program. As indicated by the statistical analysis provided by this study, a minimum sample size of 53 subjects per intervention group would be required.
Hermantin FU, PetersT, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg (AM) 1999;81-A:958-65.
ABSTRACT: Background: The usefulness of video-assisted arthroscopic microdiscectomy for the treatment of a herniated lumbar disc has been studied previously. In the current prospective, randomized study, the results of this procedure were compared with those of conventional open laminotomy and discectomy. Methods: Sixty patients who had objective evidence of a single intracanalicular herniation of a lumbar disc caudad to the first lumbar vertebra were randomized into two groups consisting of thirty patients each; Group 1 was managed with open laminotomy and discectomy, and Group 2 was managed with video-assisted arthroscopic microdiscectomy. None of the patients had had a previous operation on the low back, and all had failed to respond to nonoperative measures. Analysis of the outcomes of both procedures was based on the patient's selfevaluation before and after the operation, the preoperative and postoperative clinical findings, and the patient's ability to return to a functional status. The patients were followed for nineteen to forty-two months postoperatively. Results: On the basis of the patient's preoperative and postoperative self-evaluation, the findings on physical examination, and the patient's ability to return to work or to normal activity, twenty-eight patients (93 percent) in Group 1 and twenty-nine patients (97 percent) in Group 2 were considered to have had a satisfactory outcome. The mean duration of postoperative disability before the patients were able to return to work was considerably longer in Group 1 than in Group 2 (forty-nine com-
Journal of Manipulative and Physiological Therapeutics Volume 23 • Number I • January 2000
69
Journal Abstracts pared with twenty-seven days). The patients in Group 1 used narcotics for a longer duration postoperatively. No neurovasculat" complications or infections were encountered in either group. Conclusions: Although the rate of satisfactory outcomes was approximately the same in both groups, the patients who had had an arthroscopic microdiscectomy had a shorter duration of postoperative disability and used narcotics for a shorter period. These findings suggest that arthroscopic microdiscectomy may be useful for the operative treatment of specific symptoms, including radiculopathy, tfiat are caused by lumbar disc herniation, provided that patients are properly selected-that is, they must have a herniated disc at a single level as confirmed on imaging studies, have failed to respond to nonoperarive management, have no evidence of spinal stenosis, and have a herniation not exceeding one-half of the anteroposterior diameter of the spinal canal. Moreover. the surgeon must be familiar with this technique and must have received training in its use.
Jia M, Shu-xia Z.
Cervical spondylosis. International J Clinical Acupuncture 1999; 10(2): 145-50.
ABSTRACT: A disease common among the middle-aged and the elderly, cervical spondylosis is characterized by dizziness, headache, and pain and numbness of the neck, shoulder and upper back. Recent years have seen increased incidence among younger persons. Acupuncture has proved effective and convenient for patients. This paper is a report on recent advances in this area.
Lip GYH, RathoreVS, Katira R,Watson RDS,Singh SP. Do IndoAsians have smaller coronary arteries? Postgrad Med J 1999;75:463-6.
ABSTRACT: Summary: There is a widespread belief that coronary arteries are smaller in Indo-Asians. The aim of the present study was to compare the size of atheroma-free proximal and distal epicardial coronary arteries of Indo-Asians and Caucasians. We analysed normal coronary angiograms fi'om 77 Caucasians and 39 Indo-Asians. The two groups were comparable for dominance of the coronary arteries. Indo-Asian patients had generally smaller coronary arteries, with a statistically significant difference in the mean diameters of the left main coronary artery, proximal, mid and left anterior descending, and proximal and distal right coronary artery segments. There was a non-significant trend towards smaller coronary artery segment diameters for the distal left anterior descending, proximal and distal circumflex, and obtuse marginal artery segments. However, after correction for body surface area, none of these differences in size were statistically significant. Thus, the smaller coronary arteries in Indo-Asian patients were explained by body size alone and were not due to ethnic origin perse. This finding nevertheless has important therapeutic implications, since smaller coronary arteries may give rise to technical difficulties during bypass graft and intervention procedures such as percutaneous transluminal coronary angioplasty, scents and atherectomy. On smaller arteries, atheroma may also give an impression of more severe disease than on larger diameter arteries.
Marriott A, Newman NM, Gracovetsky SA, Richards MP, A s s e l i n S. Improving the evaluation of benign low back pain. Spine 1999;24( 10):952-60.
Levangie PKt
Association of low back pain with self-reported risk factors among patients seeking physical therapy services. Phys Ther 1999;79:757-66.
ABSTRACT: Background and Purpose: This study investigated the magnitude of association between low back pain (LBP) and selfreported factors thought to increase the risk of LBE Subjects and Methods: Questionnaires were completed by 150 patients who were receiving physical therapy for LBP and by 138 patients who were being treated for other reasons. The solicited information was used to estimate odds ratios and 95% confidence intervals for the LBP-risk factor association. Results: Low back pain was positively associated with smoking status, pregnancy, industrial vibration exposure, and time spent in a car (odds ratios >_ 2.21). Daily lifting; body mass index, activity level, and time sitting or standing showed at most a weak positive association with LBP. Comparisons with estimated associations from other studies were made. Conclusion and Discussion: Data from this study support a statistically significant association between LBP and some factors found in other research to increase the risk of LBE Study findings may have implications for targeting at-risk groups for back care education or intervention programs. Reprinted from Levangie PK. Association of low back pain with self-reported risk factors among patients seeking physicial therapy services. Phys Ther 1999;79:757-66. With permission of the American Physical Therapy Association.
ABSTRACT: Study Design: A prospective, blind study was conducted to investigate the factors underlying the decisions of expert clinicians in diagnosis of acute, benign low back pain, compared with results obtained with an automated physical examination by machine. From the results, a strategy to significantly improve clinical diagnosis in cases of discordance was determined. Objectives: To identify factors in the clinical assessment of low back pain that indicate when independent diagnostic testing would be useful. Summary of Background Data: The clinical evaluation of low back pain is often dominated by subjective reports of pain. Published medical literature has underscored several inherent weaknesses of the clinical examination, and concerns have been raised about its effectiveness for assessing patients with low back pain. Thus, it has been proposed that objective measures to complement the clinician's examination would be beneficial in the formulation of dependable diagnoses. Methods: Randomly designated subjects, who in describing their conditions were objective or role playing, were assessed by clinicians and a machine for diagnosis of low back pain assessment versus normal backs. Each subject's pain assessment was compared with a gold standard that was established by experts in low back pain. Components of the clinical examination were analyzed to assess which were the most informative in making a reliable diagnosis. The information content of" the machine assessment was also analyzed and a strategy to