Do Former Smokers Exhibit a Distinct Profile Before and After Lumbar Spine Surgery?

Spine Jun 2017 Jazini E et al



Of 1187 eligible cases, 843 (71%) had complete data, with 477 Never, 250 Former, and 116 Current smokers. Among patients who had a fusion, baseline and 12-month post-op PROs were significantly different between cohorts, with Former smokers having intermediate scores between Current and Never smokers. In the decompression only group, 12-month ODI was worse in the Current smokers, but overall the effects were much less pronounced. There was a significant negative correlation between smoke-free days prior to surgery and baseline back pain, ODI, 12-month leg pain and ODI and improvement in ODI. However, the correlation coefficients were small.


Former smokers have distinct baseline and 12-month post-op PROs that are intermediate between those of never smokers and current smokers. Smoking cessation does not entirely mitigate the negative effects of smoking on baseline and postoperative PROs for patients undergoing lumbar fusion surgery. This effect is less pronounced in patients undergoing decompression alone.

Why Lumbar Artificial Disk Replacements (LADRs) Fail.

Clin surg 2017 Pettie et al



Every patient undergoing ADR at 1 IDE site by 2 surgeons was evaluated for clinical success. Failure was defined as <50% improvement in ODI and VAS or any additional surgery at index or adjacent spine motion segment. Three ADRs were evaluated: Maverick, 25 patients; Charité, 31 patients; and Kineflex, 35 patients. All procedures were 1-level operations performed at L4-L5 or L5-S1. Demographics and inclusion/exclusion criteria were similar and will be discussed.


Overall clinical failure occurred in 26% (24 of 91 patients) at 2-year follow-up. Clinical failure occurred in: 28% (Maverick) (7 of 25 patients), 39% (Charité) (12 of 31 patients), and 14% (Kineflex) (5 of 35 patients). Causes of failure included facet pathology, 50% of failure patients (12 of 24). Implant complications occurred in 5% of total patients and 21% of failure patients (5 of 24). Only 5 patients went from a success to failure after 3 months. Only 1 patient went from a failure to success after a facet rhizotomy 1 year after ADR.


Seventy-four percent of patients after ADR met strict clinical success after 2-year follow-up. The clinical success versus failure rate did not change from their 3-month follow-up in 85 of the 91 patients (93%). Overall clinical success may be improved most by patient selection and implant type.

Do manual therapies help low back pain? A comparative effectiveness meta-analysis.

Spine April 2014. Menke M.


Meta-analysis methodology was extended to derive comparative effectiveness information on spinal manipulation for low back pain.


Of 84% acute pain variance, 81% was from nonspecific factors and 3% from treatment. No treatment for acute pain exceeded sham’s effectiveness. Most acute results were within 95% confidence that predicted by natural history alone. For chronic pain, 66% of 98% was nonspecific, but treatments influenced 32% of outcomes. Chronic pain treatments also fit within 95% confidence bands as predicted by natural history. Though the evidential support for treating chronic back pain as compared with sham groups was weak, chronic pain seemed to respond to SMT, whereas whole systems of clinical management did not.


Meta-analyses can extract comparative effectiveness information from existing literature. The relatively small portion of outcomes attributable to treatment explains why past research results fail to converge on stable estimates. The probability of treatment superiority matched a binomial random process. Treatments serve to motivate, reassure, and calibrate patient expectations-features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain.

Intermittent cervical traction for neck pain: meta-analysis of recent RCTs.

Yang et al. Spine; July 2017.


These RCTs suggest significantly lower post-traction pain scores vs. patients getting placebo interventions. Short-term benefits are noted however significant differences on longer term follow up did not differ dramatically. It is noted further, less biased studies are necessary to draw firm conclusions of long-term benefits.

It’s important to note that ‘encouragement, ergonomic & postural advice and sensible exercise/fitness suggestions’ are all part of an evidenced-based treatment protocol.

Passive modalities and treatments are meant to stimulate healing and reduce pain-expression and the ensuing discouragement, it is vital to have non-traumatic interventions that can give good short-term relief.

Temporary, short-term relief may be all some conditions will manifest early on….that traction/decompression can improve pain quickly goes a long way to encourage and improve patient compliance so fitness and ergonomic consideration can be added in and compliance improved.


Decompression Versus Decompression and Fusion for Degenerative Lumbar Stenosis in a Workers’ Compensation Setting

Tye, Erik Y. BA*,†; Anderson, Joshua MD‡ et al Spine July 2017


Objective. The aim of this study was to compare outcomes in Workers’ compensation (WC) subjects receiving decompression alone versus decompression and fusion for the indication of degenerative spinal stenosis (DLS) without deformity or instability.

Summary of Background Data. The use of a fusion procedure during lumbar decompression for DLS alone remains controversial. We hypothesize that WC subjects receiving fusion and decompression will return to work less and incur greater medical costs than subjects receiving decompression alone.

Methods. Three hundred sixty-four Ohio WC subjects were identified  subjects who received an adjunctive fusion cost of the Ohio BWC on average, $46,115 more in costs accrued over 3 years after their index surgery compared with subjects who received a decompression alone.

Conclusion. Overall, fusion with decompression had a significantly negative impact on clinical outcomes in WC subjects with DLS. These results demonstrate the high risk of postoperative morbidity associated with fusion procedures and underscore the need to strongly reevaluate the use of fusion for DLS without instability in the WC population.


Evidence for a role of nerve injury in painful intervertebral disc degeneration: A cross-sectional proteomic analysis of human cerebrospinal fluid.

Kim TKY et al Spine 2017


Intervertebral disc degeneration (DD) is a cause of low back pain (LBP) in some individuals. However, while >30% of adults have DD, LBP only develops in a subset of individuals. To gain insight into the mechanisms underlying non-painful versus painful DD, human cerebrospinal fluid (CSF) protein expression was examined.


Cerebrospinal fluid was examined for differential protein expression in healthy controls, pain-free adults with asymptomatic intervertebral disc degeneration, and low back pain patients with painful intervertebral disc degeneration. While disc degeneration was related to inflammation regardless of pain status, painful degeneration was associated with markers linked to nerve injury.

Sedentary lifestyle as a risk factor for low back pain: A Systematic Review.

Chen SM, Liu MF, Int Arch Occup Environ Health. 2009 Jul;82(7)

OBJECTIVES: To review systematically studies examining the association between sedentary lifestyle and low back pain (LBP) using a comprehensive definition of sedentary behaviour including prolonged sitting both at work and during leisure time.

METHODS: Journal articles published between 1998 and 2006 were obtained by searching computerized bibliographical databases. Quality assessment of studies employing a cohort or case-control design was performed to assess the strength of the evidence.

RESULTS: One high-quality cohort study reported a positive association, between LBP and sitting at work only; all other studies reported no significant associations. Hence, there was limited evidence to demonstrate that sedentary behaviour is a risk factor for developing LBP.

CONCLUSIONS: The present review confirms that sedentary lifestyle by itself is not associated with LBP.

Acupuncture Effects

Review: Steve Novella MD PhD 2015

All of this evidence is in stark contrast to what most people believe about acupuncture. People actually think science supports acupuncture. That simply isn’t the case. Which isn’t really surprising, because we’re talking about a healing system that rests on a belief in auras: an alleged “energy” in and around the body that no one can or has ever actually detected.

Conclusion: Once again we see that the best acupuncture clinical trials show that it does not matter where or if you place the needles. Since these are the two interventions specific to acpuncture, we can conclude (confidently, at this point) that acupuncture does not work and that any perceived benefit from acupucture is due to placebo or nonspecific effects.
The acupuncture industry needs to be called on their continued promotion of a medical modality which has already been shown to be ineffective by clinical research. The mainstream media needs to be criticized for uncritically accepting the propaganda of the acupuncture industry.

Some ‘non-nerve compromise’ conditions may benefit in prone flexion.

We created the Neural-flex to afford multiple ‘X’-axis positional iterations. This is because after 50 years of ‘facilitated motion’ research flexion and extension motions/pivoting at the waist can make improvements to disc migration patterns better than neutral positions.
The premise of pre-positioning patients in extension (or flexion) is not new and has been borne out over several decades of ongoing clinical research.

Some patients have confounding s/s and fail to ‘easily-classify’ as directly flexion or extension. Unlike supine positioning which comes in just one ‘variety’ (flexion or hyper-flexion) prone positioning can be a multiplayer: neutral, slight-torso extension, hyper-extension, extension torso & lower-body and lower-body flexion (5-35 degrees).
Neutral is likely the most common with extension (5-25 degrees) next. Hyper-extension and dual (upper & lower) extension less common and more likely needed in patients under 40. Flexion is a transitional-position allowing traction in otherwise difficult to treat conditions i.e. nerve compromise, stenosis etc.

However some 60+ year old patients (prone tolerant) and those demonstrating extension-motion pain reduced with form-closure but otherwise modest compression findings.

The End of a Myth

J Anesthesia & analgesia. June (14) 2013 

A small excess of positive results after thousands of trials is most consistent with an inactive intervention. The small excess is predicted by poor study design and publication bias. Further, Simmons et al (2011) demonstrated that exploitation of “undisclosed flexibility in data collection and analysis” can produce statistically positive results even from a completely nonexistent effect. With acupuncture in particular there is documented profound bias among proponents (Vickers et al., 1998). Existing studies are also contaminated by variables other than acupuncture – such as the frequent inclusion of “electro-acupuncture” which is essentially transdermal electrical nerve stimulation masquerading as acupuncture.

The best controlled studies show a clear pattern – with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are what define “acupuncture” the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research. The most parsimonious conclusion is that with acupuncture there is no signal, only noise.

No doubt acupuncture will continue to exist on the High Streets where it can be tolerated as a voluntary self-imposed tax on the gullible…believing claims that are simply untrue.

It is clear from meta-analyses that results of acupuncture trials are variable and inconsistent, even for single conditions. After thousands of trials of acupuncture, and hundreds of systematic reviews (Ernst et al., 2011), arguments continue unabated. In 2011, Pain editorial summed up the present situation well:

“Is there really any need for more studies? Ernst et al. (2011) point out that the positive studies conclude that acupuncture relieves pain in some conditions but not in other very similar conditions. What would you think if a new pain pill was shown to relieve musculoskeletal pain in the arms but not in the legs? The most parsimonious explanation is that the positive studies are false positives. In his seminal article on why most published research findings are false, Ioannidis (2005) points out that when a popular but ineffective treatment is studied, false positive results are common for multiple reasons, including bias and low prior probability.”

Since it has proved impossible to find consistent evidence after more than 3000 trials, it is time to give up. It seems very unlikely that the money that it would cost to do another 3000 trials would be well-spent elsewhere.