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  • 1.
    Berg, Svante
    et al.
    Stockholm Spine Center, Löwenströmska Hospital, Upplands Väsby, Sweden.
    Tullberg, Tycho
    Stockholm Spine Center, Löwenströmska Hospital, Upplands Väsby, Sweden.
    Branth, Björn
    Stockholm Spine Center, Löwenströmska Hospital, Upplands Väsby, Sweden.
    Olerud, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Tropp, Hans
    University Hospital, Linköping, Sweden.
    Total disc replacement compared to lumbar fusion: a randomised controlled trial with 2-year follow-up2009In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 18, no 10, p. 1512-19Article in journal (Refereed)
    Abstract [en]

    The study design includes a prospective, randomised controlled study comparing total disc replacement (TDR) with posterior fusion. The main objective of this study is to compare TDR with lumbar spinal fusion, in terms of clinical outcome, in patients referred to a spine clinic for surgical evaluation. Fusion is effective for treating chronic low back pain (LBP), but has drawbacks, such as stiffness and possibly adjacent level degradation. Motion-preserving options have emerged, of which TDR is frequently used because of these drawbacks. How the results of TDR compare to fusion, however, is uncertain. One hundred and fifty-two patients with a mean age of 40 years (21-55) were included: 90 were women, and 80 underwent TDR. The patients had not responded to a conservative treatment programme and suffered from predominantly LBP, with varying degrees of leg pain. Diagnosis was based on clinical examination, radiographs, MRI, and in unclear cases, diagnostic injections. Outcome measures were global assessment (GA), VAS for back and leg pain, Oswestry Disability Index, SF36 and EQ5D at 1 and 2 years. Follow-up rate was 100%, at both 1 and 2 years. All outcome variables improved in both groups between preoperative and follow-up assessment. The primary outcome measure, GA, revealed that 30% in the TDR group and 15% in the fusion group were totally pain-free at 2 years (P = 0.031). TDR patients had reached maximum recovery in virtually all variables at 1 year, with significant differences compared to the fusion group. The fusion patients continued to improve and at 2 years had results similar to TDR patients apart from numbers of pain-free. Complications and reoperations were similar in both groups, but pedicle screw removal as additive surgery, was frequent in the fusion group. One year after surgery, TDR was superior to spinal fusion in clinical outcome, but this difference had diminished by 2 years, apart from (VAS for back pain and) numbers of pain-free. The long-term benefits have yet to be examined.

  • 2. Bertilson, Bo C.
    et al.
    Bring, Johan
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Information Science, Statistics.
    Sjöblom, Anneli
    Sundell, Karin
    Strender, Lars-Erik
    Inter-examiner reliability in the assessment of low back pain (LBP) using the Kirkaldy-Willis classification (KWC)2006In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 15, no 11, p. 1695-1703Article in journal (Refereed)
    Abstract [en]

    Reliable classification systems and clinical tests are sought for the care of patients with low back pain (LBP). The objectives of this clinical study were to evaluate inter-examiner reliability in the classification of patients with LBP, the influence of radiological findings on the classification and the reliability of some clinical tests. Two examiners independently assessed 50 outpatients with LBP. Inter-examiner reliability in classification of patients with LBP using Kirkkaldy-Willis classification (KWC) system and in 30 clinical tests was calculated as percentage agreement and kappa coefficients (kappa). Inter-examiner reliability was excellent (kappa > 0.8) for classification according to KWC. Radiological findings did not influence the reliability. Age of the patient, movement range, and pain and neurological signs seemed to guide the decision on classification. The reliability of clinical tests was good (kappa > 0.6) in 6 tests and moderate (kappa > 0.4) in 12 tests. Good inter-examiner reliability was found for the SLR test, movement range and sensibility testing with spurs in dermatome areas. We conclude that the KWC for classifying patients with LBP seems to be a reliable classification system depending on a few key observations and that moderate and good inter-examiner reliability can be achieved in several clinical tests in the assessment of LBP.

  • 3. Bodon, Gergely
    et al.
    Glasz, Tibor
    Olerud, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Anatomical changes in occipitalization: is there an increased risk during the standard posterior approach?2013In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 22, no 3 suppl., p. 512-516Article in journal (Refereed)
    Abstract [en]

    PURPOSE:

    The purpose of this study was to examine the anatomic changes in a case of occipitalization of the atlas.

    METHODS:

    Occipitalization of the atlas was found accidentally in a 64-year-old male cadaver. Anatomic dissection was carried out to examine the posterior aspect of the upper cervical region and craniocervical junction. The occipitalized atlas was then harvested and macerated to study the bony anomaly.

    RESULTS:

    In this case of occipitalization, fusion was observed at both lateral masses and at the left posterior hemiarch of the atlas. We found the following soft tissue changes: the rectus capitis posterior minor muscle was lacking on the left side and was atrophic on the right, the obliquus capitis superior muscle was present on both sides showing moderate atrophy and fatty changes. The posterior atlanto-axial membrane was thinner and asymmetric, had a free edge on the right side. Lateral to this edge the dura was lying free. We believe that these changes of the posterior atlanto-axial membrane together with the increased distance between the fused posterior arch of the atlas and the lamina of the axis could cause the observed "dura bulge" at this level. The vertebral artery was entering the skull through a canal on the left side.

    CONCLUSIONS:

    In our case, occipitalization considerably changed the anatomy of the upper cervical spine and craniocervical junction. Special care must be taken when using the posterior approach to avoid neurovascular injury in cases with occipitalization.

  • 4.
    Cornefjord, Michael
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Henriques, Thomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Alemany, Montserrat
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Oncology, Radiology and Clinical Immunology, Radiology.
    Olerud, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Posterior atlanto-axial fusion with the Olerud cervical fixation system for odontoid fractures and C1-C2 instability in reumathoid arthritis2003In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 12, no 1, p. 91-96Article in journal (Refereed)
    Abstract [en]

    In posterior C1-C2 fusion, traditional wire fixation gives poor stability. The bone quality is often insufficient to provide the competent structural bone graft that is required, and the introduction of sublaminar wires is somewhat dangerous. The stability is markedly improved by adding transarticular screws, but the drawbacks of structural bone graft and sublaminar wires remain. The C1 claw of the Olerud Cervical Fixation System improves C1-C2 fixation without relying on structural bone graft or compromising the spinal canal. The aim of this study was to evaluate radiological healing and possible complications in a consecutive series of C1-C2 fusions from our department operated with the C1 claw device. Twenty-six patients (14 women) with a mean age of 73 (range 37-93) years were included. The diagnoses were odontoid fracture in 18 patients, rheumatoid instability in 6, and odontoid non-union and os odontoideum in 1 each. The patients were followed clinically and with plain radiographs for an average of 15 (range 3-27) months. There were no neurological or vascular complications, and no secondary displacements or reoperations in the series. Twenty patients followed for 6-27 months were radiographically healed. Six patients died from unrelated causes 1-38 months postoperatively. Three of these patients had no radiographs later than the postoperative control, one had a healed odontoid fracture but resorbed bone graft at 8 months, while the remaining two patients were not healed, but showed no signs of healing disturbance at the time of death. On the basis of the findings of this study, posterior C1-C2 fusion with the Olerud Cervical Fixation System seems promising. No serious complications related to the surgical procedure were encountered. The stability of the implant obviates the use of a solid bone block as a graft and still allows a high frequency of fusion healing.

  • 5. Ekman, Per
    et al.
    Möller, Hans
    Shalabi, Adel
    Division of Radiology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital Huddinge, Karolinska Institutet, 141 86, Stockholm, Sweden .
    Yu, Yiang Xiao
    Hedlund, Rune
    A prospective randomised study on the long-term effect of lumbar fusion on adjacent disc degeneration2009In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 18, no 8, p. 1175-1186Article in journal (Refereed)
    Abstract [en]

    The existence and importance of an accelerated adjacent segment disc degeneration (ASD) after lumbar fusion have previously not been demonstrated by RCTs. The objectives of this study were, to determine whether lumbar fusion in the long term accelerates degenerative changes in the adjacent disc and whether this affects the outcome, by using a prospective randomised design. A total of 111 patients, aged 18-55, with isthmic spondylolisthesis were randomised to exercise (EX, n = 34) or posterolateral fusion (PLF, n = 77), with (n = 37) or without pedicle screw instrumentation (n = 40). The minimum 10 years FU rate was 72%, with a mean FU time of 12.6 years (range 10-17 years). Three radiographic methods of ASD quantification were used, i.e. two digital radiographic measurement methods and the semi quantitative UCLA grading scale. One digital measurement method showed a mean disc height reduction by 2% in the EX group and by 15% in the PLF group (p = 0.0016), and the other showed 0.5 mm more disc height reduction in the PLF compared to the Ex group (ns). The UCLA grading scale showed normal discs in 100% of patients in the EX group, compared to 62% in the PLF group (p = 0.026). There were no significant differences between instrumented and non-instrumented patients. In patients with laminectomy we found a significantly higher incidence of ASD compared to non laminectomised patients (22/47 vs. 2/16 respectively, p = 0.015). In the longitudinal analysis, the posterior and anterior disc heights were significantly reduced in the PLF group, whereas in the EX group only the posterior disc height was significantly reduced. Except for global outcome, which was significantly better for patients without ASD, the clinical outcome was not statistically different in patients with and without ASD. In conclusion, the long-term RCT shows that fusion accelerates degenerative changes at the adjacent level compared with natural history. The study suggests that not only fusion, but also laminectomy may be of pathogenetic importance. The clinical importance of ASD seems limited, with only the more severe forms affecting the outcome.

  • 6. Ghanei, Iman
    et al.
    Rosengren, Bjorn E.
    Hasserius, Ralph
    Nilsson, Jan-Ake
    Mellstrom, Dan
    Ohlsson, Claes
    Ljunggren, Östen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Endocrinology and mineral metabolism.
    Karlsson, Magnus K.
    The prevalence and severity of low back pain and associated symptoms in 3,009 old men2014In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 23, no 4, p. 814-820Article in journal (Refereed)
    Abstract [en]

    The aim of this study is to evaluate the prevalence and severity of low back pain (LBP) and the influence of sciatica and neurological deficits in old men. Mister osteoporosis Sweden includes 3,014 community-dwelling men aged 69-81 years. At study start 3,009 participants answered questions on LBP, low back pain and sciatica (LBP + SCI) or low back pain and sciatica with associated neurological deficits (LBP + SCI + NEU) during the preceding 12 months. Data are presented as proportions or medians with mid-quartile ranges. Differences between groups were tested by chi(2) test and Kruskall-Wallis test. 24 % had experienced LBP without SCI, 8 % LBP + SCI and 14 % LBP + SCI + NEU. 10 % of the men with LBP, 22 % of those with LBP + SCI, and 36 % of those with LBP + SCI + NEU rated the pain as severe (p < 0.001). 23 % of the men with LBP, 31 % of those with LBP + SCI and 50 % of those with LBP + SCI + NEU reported limitation in activity of daily living (ADL) (p < 0.001). Men with only LBP had to restrict their activities for 7 days (3-14), those with LBP + SCI 6 days (2-14) and those with LBP + SCI + NEU 10 days (3-30) (p < 0.05). The 1-year prevalence of LBP in community living men aged 69-81 years was close to 50 % but for individuals with LBP or LBP + SCI the morbidity was low with more than two-thirds having no limitations in ADL. In men with LBP + SCI + NEU more than one-third rated the pain as severe and close to half had limitations in ADL.

  • 7. Grooten, WJ
    et al.
    Mulder, M
    Josephson, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Occupational and Environmental Medicine.
    Alfredsson, Lars
    Wiktorin, Christina
    The influence of work-related exposures on the prognosis of neck/shoulder pain2007In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 16, no 12, p. 2083-2091Article in journal (Refereed)
    Abstract [en]

    To determine associations between work-related exposures and the prognosis of self-reported neck/shoulder pain. This prospective cohort study was based on 803 working subjects who reported neck/shoulder pain at baseline. The proportion of subjects who 5-6 years later were symptom-free was calculated. Data concerning work-related biomechanical, psychosocial, and organizational exposures were collected at baseline. The Cox regression analyses were used to calculate the relative chances (RC) of being symptom-free at the end of the study for single exposures, and also for up to three simultaneous work-related exposures. Adjustments were made for sex and age. Only 36% of the subjects were symptom-free 5-6 years later. The relative chance for being symptom-free at the end of the study was 1.32 (95% CI = 0.99-1.74) for subjects who were exposed to sitting >= 75% of the working time and 1.53 (95% CI = 1.02-2.29) for subjects who were exposed to job strain, i.e., the combination of high demands and low decision latitude. The relative chance of being symptom-free at the end of the study was 0.61 (95% CI = 0.40-0.94) for subjects with at least two out of three simultaneous biomechanical exposures at work; manual handling, working with the hands above shoulder level, and working with vibrating tools. In a heterogeneous population with moderate nonspecific neck/shoulder pain, sedentary work enhanced the chance of being symptom-free 5-6 years later, whereas simultaneous exposures to at least two of manual handling, working with hands above shoulder level and working with vibrating tools were associated with a lower chance of being symptom-free at the end of the study. This could imply that subjects with neck/shoulder pain should avoid such simultaneous exposures.

  • 8.
    Iderberg, Hanna
    et al.
    Ivbar Inst, Hantverkargatan 8, S-11221 Stockholm, Sweden;Karolinska Inst, Dept Learning Informat Management & Eth, Med Management Ctr, Stockholm, Sweden.
    Willers, Carl
    Ivbar Inst, Hantverkargatan 8, S-11221 Stockholm, Sweden;Karolinska Inst, Dept Clin Sci & Educ, Stockholm, Sweden.
    Borgstrom, Fredrik
    Ivbar Inst, Hantverkargatan 8, S-11221 Stockholm, Sweden;Karolinska Inst, Dept Learning Informat Management & Eth, Med Management Ctr, Stockholm, Sweden.
    Hedlund, Rune
    Sahlgrens Univ Hosp, Dept Orthopaed, Gothenburg, Sweden.
    Hagg, Olle
    Spine Ctr Goteborg, Gothenburg, Sweden.
    Moller, Hans
    Karolinska Inst, Dept Clin Sci Intervent & Technol CLINTEC, Stockholm, Sweden.
    Ornstein, Ewald
    Orebro Univ Hosiptal, Dept Orthopaed, Orebro, Sweden.
    Sandén, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Stalberg, Holger
    Stockholm Cty Council, Halso O Sjukvardsforvaltningen, Stockholm, Sweden.
    Torevall-Larsson, Hans
    Falu Lasarett, Falun, Sweden.
    Tullberg, Tycho
    Stockholm Spine Ctr AB, Lowenstromska Sjukhuset, Upplands Vasby, Sweden.
    Fritzell, Peter
    Futurum Acad, Jonkoping, Sweden;St Goran Hosp, Stockholm, Sweden.
    Predicting clinical outcome and length of sick leave after surgery for lumbar spinal stenosis in Sweden: a multi-register evaluation2019In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 28, no 6, p. 1423-1432Article in journal (Refereed)
    Abstract [en]

    Purpose: Lumbar spinal stenosis (LSS) can be surgically treated, with variable outcome. Studies have linked socioeconomic factors to outcome, but no nation-wide studies have been performed. This register-based study, including all patients surgically treated for LSS during 2008-2012 in Sweden, aimed to determine predictive factors for the outcome of surgery.

    Methods: Clinical and socioeconomic factors with impact on outcome in LSS surgery were identified in several high-coverage registers, e.g., the national quality registry for spine surgery (Swespine, FU-rate 70-90%). Multivariate regression analyses were conducted to assess their effect on outcome. Two patient-reported outcome measures, Global Assessment of leg pain (GA) and the Oswestry Disability Index (ODI), as well as length of sick leave after surgery were analyzed.

    Results: Clinical and socioeconomic factors significantly affected health outcome (both GA and ODI). Some predictors of a good outcome (ODI) were: being born in the EU, reporting no back pain at baseline, a high disposable income and a high educational level. Some factors predicting a worse outcome were previous surgery, having had back pain more than 2years, having comorbidities, being a smoker, being on social welfare and being unemployed.

    Conclusions: The study highlights the relevance of adding socioeconomic factors to clinical factors for analysis of patient-reported outcomes, although the causal pathway of most predictors' impact is unknown. These findings should be further investigated in the perspective of treatment selection for individual LSS patients. The study also presents a foundation of case mix algorithms for predicting outcome of surgery for LSS.

  • 9.
    Johansson, Ann-Christin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Cornefjord, Michael
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Bergkvist, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Öhrvik, John
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Linton, Steven J.
    Psychosocial stress factors among patients with lumbar disc herniation, scheduled for disc surgery in comparison with patients scheduled for arthroscopic knee surgery2007In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 16, no 7, p. 961-970Article in journal (Refereed)
    Abstract [en]

    Returning to work after disc surgery appears to be more heavily influenced by psychological aspects of work than by MR-identified morphological alterations. It is still not known whether psychosocial factors of importance for outcome after disc surgery are present preoperatively or develop in the postoperative phase. The aim of this study was to investigate the presence of work-related stress, life satisfaction and demanding life events, among patients undergoing first-time surgery for lumbar disc herniation in comparison with patients scheduled for arthroscopic knee surgery. Sixty-nine patients with disc herniation and 162 patients awaiting arthroscopy were included in the study, during the time period March 2003 to May 2005. Sixty-two percent of the disc patients had been on sick leave for an average of 7.8 months and 14 percent of the knee patients had been on sick leave for an average of 4.2 months. The psychosocial factors were investigated preoperatively using a questionnaire, which was a combination of the questionnaire of quality of work competence (QWC), life satisfaction (LiSat9) and life events as a modification of the social readjustment scale. There were no significant differences between the two groups in terms of work-related stress or the occurrence of demanding life events. The disc patients were significantly less satisfied with functions highly inter-related to pain and discomfort, such as present work situation, leisure-time, activities of daily living (ADL) function and sleep. Patients with disc herniation on sick leave were significantly less satisfied with their present work situation than knee patients on sick leave; this sub-group of patients with disc herniation also reported significantly higher expectations in relation to future job satisfaction than knee patients. The results indicate that psychosocial stress is not more pronounced preoperatively in this selected group of disc patients, without co-morbidity waiting for first-time disc surgery, than among knee patients awaiting arthroscopy. It was notable that the disc patients had high expectations in terms of improved job satisfaction after treatment by surgery.

  • 10.
    Johansson, Ann-Christin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Linton, Steven J.
    Bergkvist, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Nilsson, Olle
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Cornefjord, Michael
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Clinic-based training in comparison to home-based training after first-time lumbar disc surgery: a randomised controlled trial2009In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 18, no 3, p. 398-409Article in journal (Refereed)
    Abstract [en]

    The effectiveness of physiotherapy after first-time lumbar disc surgery is still largely unknown. Studies in this field are heterogeneous and behavioural treatment principles have only been evaluated in one earlier study. The aim of this randomised study was to compare clinic-based physiotherapy with a behavioural approach to a home-based training programme regarding back disability, activity level, behavioural aspects, pain and global health measures. A total of 59 lumbar disc patients without any previous spine surgery or comorbidity participated in the study. Clinic-based physiotherapy with a behavioural approach was compared to home-based training 3 and 12 months after surgery. Additionally, the home training group was followed up 3 months after surgery by a structured telephone interview evaluating adherence to the exercise programme. Outcome measures were: Oswestry Disability Index (ODI), physical activity level, kinesiophobia, coping, pain, quality of life and patient satisfaction. Treatment compliance was high in both groups. There were no differences between the two groups regarding back pain disability measured by ODI 3 and 12 months after surgery. However, back pain reduction and increase in quality of life were significantly higher in the home-based training group. The patients in the clinic-based training group had significantly higher activity levels 12 months after surgery and were significantly more satisfied with physiotherapy care 3 months after surgery compared to the home-based training group. Rehabilitation after first-time lumbar disc surgery can be based on home training as long as the patients receive both careful instructions from a physiotherapist and strategies for active pain coping, and have access to the physiotherapist if questions regarding training arise. This might be a convenient treatment arrangement for most patients.

  • 11.
    Johansson, Ann-Christin
    et al.
    Department of Physiotherapy, School of Health, Care and Social WelfareMälardalen UniversityVästeråsSweden.
    Öhrvik, John
    Department of MedicineKarolinska InstitutetSolnaSweden.
    Söderlund, Anne
    Department of Physiotherapy, School of Health, Care and Social WelfareMälardalen UniversityVästeråsSweden.
    Associations among pain, disability and psychosocial factors and the predictive value of expectations on returning to work in patients who undergo lumbar disc surgery2016In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 25, no 1, p. 296-303Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The aim of this study was to describe the associations among pain, disability and psychosocial factors preoperatively as well as 3 and 24 months later for patients who undergo first time discectomy and to analyse the predictive value of psychosocial factors on the outcome 24 months after surgery.

    METHODS: Fifty-nine patients, 41 % women, with a mean age of 40 years and without comorbidities were included, of whom 56 responded to the 24-month follow-up; at that point, they were divided into patients with complaints (C, n = 36) and patients without complaints (NC, n = 20). Correlations among the pain intensity, disability and psychosocial factors were analysed preoperatively, 3 and 24 months after discectomy, and regression analyses of psychosocial factors on the outcome at 24 months were performed.

    RESULTS: Psychosocial variables were weakly correlated with the pain intensity and disability preoperatively. High expectations on the return to work were predictive of both pain intensity (β = 8.0, p = 0.03) and disability (β = 9.1, p < 0.001) at 24 months. Associations between psychosocial variables and outcome variables were strengthened at the 3-month follow-up in the C group, and this association remained 24 months after surgery. Fear of movement was most strongly correlated with leg pain intensity (r (s) 0.64, p < 0.001) and the ability to decrease pain was the most correlated with disability (r (s) 0.78, p < 0.001).

    CONCLUSION: Having high expectations on the return to work after surgery was the strongest predictor for a favourable outcome. Therefore, low preoperative expectations on return to work convey an important prognostic signal.

  • 12. Karppinen, Jaro
    et al.
    Solovieva, Svetlana
    Luoma, Katariina
    Raininko, Raili
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Oncology, Radiology and Clinical Immunology, Radiology.
    Leino-Arjas, Päivi
    Riihimäki, Hilkka
    Modic changes and interleukin 1 gene locus polymorphisms in occupational cohort of middle-aged men2009In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 18, no 12, p. 1963-1970Article in journal (Refereed)
    Abstract [en]

    According to recent systematic reviews, Modic changes are associated with low-back pain. However, their pathophysiology remains largely unknown. A previous study of Northern Finnish males implicated that IL1A and MMP3 polymorphisms play a role in type II Modic changes. The purpose of the current study was to examine the association of IL1 cluster polymorphisms with Modic changes amongst middle-aged men in Southern Finland. The final study sample consisted of 108 men from three different occupations, who underwent magnetic resonance imaging (MRI) with a 0.1 T-scanner. Six single nucleotide polymorphisms (SNP) in the IL1 gene cluster (IL1A c.1-889C>T; IL1B c.3954C>T; IL1RN c.1812G>A; IL1RN c.1887G>C; IL1RN c.11100T>C; IL1RN c.1506G>A) were genotyped with the SNP-TRAP method or by allele-specific primer extension on modified microarray. In all, 45 subjects had Modic changes at one or more disc levels. The presence of the minor allele of IL1A (c.1-889C>T) was associated with these changes (any Modic change p = 0.031, type II changes p = 0.036). The carriers of the T-allele had a 2.5-fold risk of Modic change and the association was independent of the other IL1 gene cluster loci studied. In addition, a minor haplotype, with a frequency of 7.5% in the study population, including the minor alleles of IL1A c.1-889C>T, IL1RN c.1812G>A, and IL1RN c.1506G>A, was significantly associated with Modic changes. This observation is in accordance with the previous finding from a different geographical area, and thus confirms the importance of the IL1A gene in the pathophysiology of Modic changes.

  • 13. Koller, Heiko
    et al.
    Ames, Christopher
    Mehdian, Hossein
    Bartels, Ronald
    Ferch, Rüdiger
    Deriven, V
    Toyone, H
    Shaffrey, C
    Smith, Justin
    Hitzl, W
    Schröder, Johannes
    Robinson, Yohan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project.2018In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 28, no 2, p. 324-344Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION AND PURPOSE: Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study.

    METHODS: Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types A-D).

    RESULTS: Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001).

    CONCLUSIONS: Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.

  • 14. Rasmussen-Barr, E.
    et al.
    Bohman, T.
    Hallqvist, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Holm, L. W.
    Skillgate, E.
    Do physical activity level and body mass index predict recovery from persistent neck pain in men and women of working age?: A population-based cohort study2013In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 22, no 9, p. 2077-2083Article in journal (Refereed)
    Abstract [en]

    The study sought to examine the gender-specific effects of physical activity level and body mass index on recovery from persistent neck pain (PNP) among citizens of working age in Stockholm, Sweden. A population-based cohort of 1,730 subjects (18-65) with PNP answered surveys in 2002 and 2007. Prognostic factors were self-reported body mass index (BMI) and physical activity level (PAL) at baseline. Analyses were performed with odds ratios (OR) with corresponding 95 % confidence intervals (95 % CI). Women reporting higher physical activity level had higher odds of recovering from PNP than women with sedentary leisure time (OR of 1.5, 95 % CI 1.0-2.4), but no associations were found in men. No associations were found between BMI and recovery from PNP in any analyses. Physical activity seems to be associated with recovery from PNP in women and should therefore be encouraged. Future studies should continue investigating physical activity and lifestyle factors in relation to recovery from persistent neck pain, since these modifiable factors may be considered in interventions.

  • 15.
    Sandén, Bengt
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Olerud, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Johansson, Carina
    Larsson, Sune
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Improved extraction torque of hydroxyapatite-coated pedicle screws2000In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 9, no 6, p. 534-7Article in journal (Refereed)
    Abstract [en]

    Loosening of the screws is a problem in instrumentation with pedicle screws. Coating with hydroxyapatite improves the holding characteristics for metal implants, but the possible effects on the anchorage of pedicle screws have not been described. In this study, seven patients were operated on with spinal instrumentation using four stainless steel pedicle screws. Hydroxyapatite-coated screws were used in either the upper or the lower of the instrumented levels. The insertion torque was measured. In four cases the screws were removed after 10-22 months and the extraction torque was measured. The mean insertion torque was found to be significantly greater in the hydroxyapatite-coated screws (107 Ncm) than in the standard screws (76 Ncm). In three cases, the extraction torque for the hydroxyapatite-coated screws exceeded the range for the torque wrench (600 Ncm), while the conventional screws were loose (< 5 Ncm). In one case, the extraction torque was 475 and 550 Ncm for the coated screws, and 5 and 25 Ncm for the conventional screws. The difference in extraction torque was significant. Hydroxyapatite coating was shown to have improved the purchase of pedicle screws very effectively. By using fully coated screws, as in the present study, extraction was extremely difficult compared to extraction of conventional stainless steel screws, which were regularly loose. By reducing the area of the screws that is coated, it may be possible to achieve an enhanced purchase while extraction will be easier when compared to fully coated screws.

  • 16.
    Sandén, Bengt
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Olerud, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Larsson, Sune
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Hydroxyapatite coating enhances fixation of loaded pedicle screws: a mechanical in vivo study in sheep2001In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 10, no 4, p. 334-9Article in journal (Refereed)
    Abstract [en]

    Loosening of the pedicle screws with subsequent non-union or loss of correction is a frequent problem in spinal instrumentation. In a clinical pilot study, coating of pedicle screws with plasma-sprayed hydroxyapatite (HA) resulted in a significant increase of removal torque. An experimental study was performed to investigate the effects of HA coating on the pull-out resistance. Thirteen sheep were operated on with destabilising laminectomies at two levels, L2-L3 and L4-L5. Two instrumentations with four pedicle screws in each were used for stabilisation. Uncoated screws (stainless steel) or the same type of screws coated with plasma-sprayed HA were used in either the upper or the lower instrumentation in a randomised fashion. Four sheep were examined immediately after the application of the screws, three sheep at 6 weeks and four sheep at 12 weeks. Two sheep were euthanised early due to complications. The pull-out resistance was recorded in two HA-coated and two standard screws in each animal. The maximum pull-out resistance was higher for the HA-coated screws at 0 weeks (P< 0.02) and at 12 weeks (P<0.01) when compared to the uncoated screws, while there was no significant difference between the groups at 6 weeks. We believe that the higher pull-out resistance for HA-coated screws at 0 weeks was mainly caused by differences in surface roughness, while the difference at 12 weeks was due to a favourable bone reaction around the HA-coated screws. At 12 weeks, the average stiffness was significantly higher for the HA-coated screws, while there was no significant differences in stiffness between the two screw types at 0 and 6 weeks. Energy to failure was significantly higher for coated screws when compared to the uncoated screws at all three time points. HA coating improves fixation of loaded pedicle screws, with increased pull-out resistance and reduced risk of loosening.

  • 17. Schell, Elisabet
    et al.
    Theorell, Tores
    Hasson, Dan
    Arnetz, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Saraste, Helena
    Stress biomarkers' associations to pain in the neck, shoulder and back in healthy media workers: 12-month prospective follow-up.2008In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 17, no 3, p. 393-405Article in journal (Refereed)
    Abstract [en]

    Physiological and psychological mechanisms have been proposed to link stress and musculoskeletal pain (MSP), and a number of stress biomarkers in patients with chronic pain have shown to be associated with stress-related disorders as well as health and recovery. The aim was to study if similar results might be found in a working population, in stress and computer intensive occupations with mild/moderate pain in neck, shoulder and back. The questions were if there are: (1) associations between self rated neck, shoulder and back pain (VAS) on one hand and stress-related (catabolic), recovery related (anabolic) variables, cardiovascular/lifestyle factors and immune markers on the other hand. (2) associations between long term changes in pain and stress marker values (6 month period). (3) predictive values in stress biomarkers for pain (12 month period) A study group with 121 media workers, 67 males (average 45 years) and 53 females (average 43 years), at three news departments of a media company was recruited. Pain occurrence and pain level in neck, shoulder, upper and low back were self-rated at three times with a 6-month interval towards the last month. Stress biomarker sampling was performed, at the same intervals. An additional similar questionnaire with momentary ratings focusing on "at present" i.e. within the same hour as stress biomarker sampling was performed. There were no changes in medicine intake or computer working hours during the 12 month study period. The total pain level and prevalence of pain decreased between baseline and 12 months follow-up. The rate of participation was 95%. Cross-sectional analyses on differences in stress biomarkers in groups of "no pain" and "pain" showed less beneficial stress biomarker levels (P < 0.05) in the "pain" group after age and gender adjustments in: S-DHEA-S and P-endothelin, S-insulin and P-fibrinogen. Analyses of each gender separately, adjusted for age, revealed in males differences in S-insulin, saliva cortisol 3, and P-endothelin. Furthermore, tendencies were seen in BMI, P-fibrinogen, and S-testosterone. In the female "pain" group a less beneficial P-BNP level was found. Longitudinal analysis of changes in pain levels and stress biomarkers within an interval of 6 months showed beneficial changes in the following stress markers: P-NPY, S-albumin, S-growth hormone and S-HDL when pain decreased, and vice versa when pain increased. Linear regression analyses showed statistically significant predicting values at the initial test instance for pain 12 months later in lower S-DHEA-S and S-albumin and higher B-HbA1c and P-fibrinogen. In stepwise regression and after age and gender adjustments, the associations with S-DHEA-S remained statistically significant. The present study shows that individuals in working life with a high level of regenerative/anabolic activity have less pain than other subjects, and that decreased regenerative/anabolic activity is associated with increasing pain. The levels of NPY, albumin, GH and HDL increased when pain decreased and vice versa. Low DHEA-S predicted pain 12 months later. These findings might contribute to increased knowledge about strategies to prevent further progression of neck/shoulder/back pain in persons who are "not yet in chronic pain".

  • 18. Skeppholm, M
    et al.
    Olerud, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Pain from donor site after anterior cervical fusion with bone graft: a prospective randomized study with 12 months of follow-up2013In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 22, no 1, p. 142-147Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION:

    Harvesting bone graft from the iliac crest in spinal fusion surgery is a widely used technique. However, complications can occur and there are also reports of patients with persistent graft site pain after surgery. The aim of this study was to evaluate pain from the donor site (DS) over time, and register associated complications and if it affected health-related quality of life (HRQoL).

    MATERIAL AND METHODS:

    One hundred and seven patients participating in an RCT between two different methods of reconstruction after cervical decompression were included in this study. One group underwent surgery with bone graft (BG) from the iliac crest and the other with no bone graft (NBG). All patients were evaluated concerning pain at DS and HRQoL preoperatively, at 4  weeks, 3 months and 1 year. Pain was evaluated with visual analog scale (VAS) and HRQoL with EQ-5D.

    RESULTS:

    A statistically significant difference was found at all times of follow-up in the BG group compared to preoperative levels and the NBG group. The VAS levels at follow-ups at 3 months and 1 year were however of questionable clinical importance. Two patients in the BG group had superficial wound infections postoperatively and five patients still had sensory disturbance in the area of graft site at 12 months. No major complications were registered. No difference could be seen in EQ-5D at any time of follow-up between the groups.

    CONCLUSION:

    Harvesting of iliac crest bone graft is associated with significant pain. However, at 3 months postoperatively, the negative effect of clinical importance seemed to have disappeared compared to when no bone graft was harvested. The pain from bone graft harvesting does not seem to affect the quality of life at 4 weeks postoperatively and onward.

  • 19.
    Sköld, Caroline
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Tropp, Hans
    Berg, Svante
    Five-year follow-up of total disc replacement compared to fusion: a randomized controlled trial2013In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 22, no 10, p. 2288-2295Article in journal (Refereed)
    Abstract [en]

    To evaluate long-term clinical results of lumbar total disc replacement (TDR) compared with posterior lumbar fusion. This prospective randomized controlled trial comprised 152 patients; 80 were randomized to TDR and 72 to fusion. All patients had chronic low back pain (CLBP) and had not responded to nonsurgical treatment. Primary outcome measure was global assessment of back pain (GA), secondary outcome measures were back and leg pain, Oswestry Disability Index (ODI), EQ5D, and SF-36. All measures were collected from SweSpine (Swedish national register for spinal surgery) at 1, 2, and 5 years. Follow-up rate at 5 years was 99.3 %. Both groups showed clinical improvement at 5-year follow-up. For GA, 38 % (30/80) in the TDR group were totally pain free vs. 15 % (11/71) in the fusion group (p < 0.003). Back pain and improvement of back pain were better in the TDR group: VAS back pain at 5 years 23 +/- A 29 vs. 31 +/- A 27, p = 0.009, and VAS improvement of back pain at 5 years 40 +/- A 32 vs. 28 +/- A 32, p = 0.022. ODI and improvement in ODI were also better in the TDR group: ODI at 5 years 17 +/- A 19 vs. 23 + 17, p = 0.02 and ODI improvement at 5 years 25 +/- A 18 vs. 18 +/- A 19 (p = 0.02). There was no difference in complications and reoperations between the two groups. Global assessment of low back pain differed between the two surgical groups at all follow-up occasions. Significant differences between groups concerning back pain, pain improvement, and ODI were present at 1 year and disappeared at 2 years, but reappeared at the 5-year follow-up.

  • 20. Solovieva, Svetlana
    et al.
    Lohiniva, Jaana
    Leino-Arjas, Päivi
    Raininko, Raili
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Oncology, Radiology and Clinical Immunology, Radiology.
    Luoma, Katariina
    Ala-Kokko, Leena
    Riihimäki, Hilkka
    Intervertebral disc degeneration in relation to the COL9A3 and the IL-1ss gene polymorphisms2006In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 15, no 5, p. 613-9Article in journal (Refereed)
    Abstract [en]

    Disc degeneration is a complex condition in which environmental factors and multiple genes are expected to act together to determine the degenerative phenotype. Recently associations of COL9A2 (Trp2 allele) and COL9A3 (Trp3 allele) polymorphisms with lumbar disc disease characterized by sciatica have been reported. However, it is not known whether the Trp2 or Trp3 alleles contribute to disc degeneration (DD). In this study, the association between the collagen genes polymorphisms and lumbar DD was investigated. Furthermore, the influence of the IL-1beta(C(3954)-T) polymorphism on the association of collagen genes polymorphisms with DD was examined. Lumbar intervertebral discs of 135 middle-aged occupationally active men were evaluated with magnetic resonance imaging, using decreased signal intensity of the nucleus pulposus, disc bulges, and decreased disc height as signs of degeneration. Blood samples were analysed for the presence of COL9A3 and COL9A2 tryptophan alleles (Trp3 and Trp2 alleles). The COL11A2, COL2A1 and IL-1beta(C(3954)-T) polymorphisms were also analysed. Multivariate logistic regression analysis allowing for occupation and body mass index showed that the carriage of the Trp3 allele in the absence of the IL-1betaT(3954) allele increased the risk of dark nucleus pulposus (OR 7.0, 95% CI 1.3-38.8) and joint occurrence of degenerative changes (OR 8.0, 95% CI 1.4-44.7). There was no effect of the Trp3 allele on DD in the presence of the IL-1betaT(3954) allele. The carriers of the COL11A2 minor allele had an increased risk of disc bulges (OR 2.1, 95% CI 1.0-4.2) as compared with non-carriers. The results suggest that the effect of the COL9A3 gene polymorphism on DD might be modified by the IL-1beta gene polymorphism.

  • 21. Stromqvist, Bjorn
    et al.
    Fritzell, Peter
    Hagg, Olle
    Jonsson, Bo
    Sandén, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Swespine: the Swedish spine register2013In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 22, no 4, p. 953-974Article in journal (Refereed)
    Abstract [en]

    Swespine, the Swedish National Spine Register, has existed for 20 years and is in general use within the country since over 10 years regarding degenerative lumbar spine disorders. Today there are protocols for registering all disorders of the entire spinal column. Patient-based pre- and postoperative questionnaires, completed before surgery and at 1, 2, 5 and 10 years postoperatively. Among patient-based data are VAS pain, ODI, SF-36 and EQ-5D. Postoperatively evaluation of leg and back pain as compared to preoperatively ("global assessment"), overall satisfaction with outcome and working conditions are registered in addition to the same parameters as preoperatively evaluation. A yearly report is produced including an analytic part of a certain topic, in this issue disc prosthesis surgery. More than 75,000 surgically treated patients are registered to date with an increasing number yearly. The present report includes 7,285 patients; 1-, 2- and 5-year follow-up data of previously operated patients are also included for lumbar disorders as well as for disc prosthesis surgery. For the degenerative lumbar spine disorders (disc herniation, spinal stenosis, spondylolisthesis and DDD) significant improvements are seen in all aspects as exemplified by pronounced improvement regarding EQ-5D and ODI. Results seem to be stable over time. Spinal stenosis is the most common indication for spine surgery. Disc prosthesis surgery yields results on a par with fusion surgery in disc degenerative pain. The utility of spine surgery is well documented by the results. Results of spine surgery as documented on a national basis can be utilized for quality assurance and quality improvement as well as for research purposes, documenting changes over time and bench marking when introducing new surgical techniques. A basis for international comparisons is also laid.

  • 22. Strömqvist, Björn
    et al.
    Fritzell, Peter
    Department of Orthopedics, Falu Hospital.
    Hägg, Olle
    Jonsson, Bo
    The Swedish Spine Register: Development, design and utility2009In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 18, no S 3, p. 294-304Article in journal (Refereed)
    Abstract [en]

    The Swedish Spine Register enables monitoring of surgical activities focusing on changes in trends over time, techniques utilized and outcome, when implemented in general clinical practice. Basic requirements for a prosperous register are unity within the profession, mainly patient-based documentation and a well functioning support system. This presentation focuses on the development and design of the register protocol, problems encountered and solutions found underway. Various examples on how the results can be presented and utilized are given as well as validation. Register data demonstrate significant gender differences in lumbar disc herniation surgery with females having more pain, lower quality of life and more pronounced disability preoperatively while improvement after surgery is similar between genders. Quality of life after surgery for degenerative disorders is significantly improved for disc herniation, stenosis, spondylolisthesis and disc degenerative disorders. Over the last 10 years, surgical treatment for spinal stenosis has increased gradually while disc herniation surgery decreases regarding yearly number of procedures. An added function to the register enables more complex prospective clinical studies to include register data together with data suitable for the individual study. A common core set of demographic, surgical and outcome parameters would enable comparisons of clinical studies within and between nations.

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