Yes / Lumbar radiographs remain a common imaging examination despite strategies to reduce their use. Many authors have demonstrated benefits in changing from traditional supine and recumbent lateral projections to a prone and/or erect orientation. Despite evidence of clinical and radiation dose optimisation, widespread adoption of these strategies has stalled. This article describes the single-centre implementation and evaluation of erect PA and lateral projections. This was an observational study pre- and post-implementation of an erect imaging protocol. Patient BMI, image field size, source image and source object distances and DAP were collected together with assessment of radiographic spinal alignment and disc space demonstration. Effective dose was calculated with organ specific doses. 76 (53.5%) patients were imaged in the supine AP and recumbent lateral position, 66 (46.5%) had erect PA and lateral radiographs. Despite the larger BMI of the erect cohort and similar field sizes, effective dose was lower in the PA position by an average of 20% (p

Submitted in partial compliance with the requirements for the Masters’ Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2014. / Background Spinal manipulative therapy (SMT) is a commonly used therapeutic modality. It has been shown that neuromuscular reflexes are elicited during spinal manipulation resulting in changes in the surrounding muscle tonicity and seen as changes in surface electromyography. Despite this little is known about the effect that SMT may have on muscle function. Increased maximum voluntary contraction (MVC) of the paraspinal muscles has been observed following lumbar SMT compared to a control and sham treatment; however its effect on muscle endurance has not been investigated. The aim of this study was to determine the effect of lumbar SMT compared to a placebo treatment on lumbar extensor muscle endurance in asymptomatic individuals. Method This study was a quantitative double blinded, pre-test and post-test placebo controlled experimental trial. Forty asymptomatic participants were randomly allocated to one of two treatment groups. One group received a single SMT applied to the L3 vertebrae and the other received the pre-load force of the SMT but no thrust. Subjective (a self-report of pain/discomfort while performing the Biering-Sorensen test) and objective [surface electromyography (sEMG), paraspinal muscle endurance time and lumbar spine range of motion] measurements were taken pre- and post-intervention. The latest version of SPSS version (IBM SPSS Inc.) was used to analyse the data. A p-value < 0.05 was considered statistically significant. Independent t-tests were used to compare means and two-way factor ANOVA (for repeated measures) was used to compare the change in the two time points between the two treatment groups (intervention and control). RESULTS There were no statistically significant differences between the intervention and placebo groups in terms of subjective reports of pain/discomfort and objective evidence of surface EMG readings, paraspinal muscle endurance time and lumbar spine range of motion.

Title: Physical activity of patients after surgical treatment of the lumbar spine. Aim: Main aim of my diploma thesis is to present an up to date review on the topic of postoperative physiotherapy in short-term and long-term phase after lumbar surgery and to find out how recommendations about postoperative physiotherapy are created. Methods: A systematic review on the topic. Results: The review answers the questions about physiotherapy after lumbar surgery in short-term and long-term phase and shows current trends and unique approaches in this study area. Keywords: Lumbar spine, intervertebral disc, discectomy, physiotherapy, physical activity.

The surgical treatment options in thoracolumbar spine degeneration: The importance of morphological and clinical classifications in preoperative decision making David Bludovský Abstract: Objective: The aim of our study was to investigate the relations between subjective difficulties, clinical findings and the MR imaging in patients who have been operated for symptomatic lumbar spinal stenosis (LSS), and the possibility of using these relations for surgical treatment decision. Methods: Patients operated for lumbar spinal stenosis in 2009-2010 were included in the study. Subjective difficulties were assessed using the Oswestry Disability Index (ODI), the clinical symptoms with the modified Neurological Impairment Score for Lumbar Spinal Stenosis (mNIS-LSS). We measured the spine canal area, dural sac area, and nerve root sedimentation classification on MR. By correlation analysis at significance level p <0.05, we tested the relations between these categories. 61 patients with a median age of 67 were included. Overall, we evaluated 162 spinal segments. Results: Median of ODI values were 48. Correlation coefficients for ODI, mNIS-LSS and graphical findings were less than 0.5. Correlation coefficients greater than 0.5 were between all the MR measurement methods. Conclusions: In the group of patients indicated...

Abnormalities in lumbopelvic rhythm (LPR) play a role in occurrence/recurrence of low back pain (LBP). The LPR before spinal fusion surgery and its changes following the surgery are not understood. A repeated measure study was designed to investigate timing and magnitude aspects of LPR in a group of patients (n = 5) with LBP before and after a spinal fusion surgery. Participants completed a forward bending and backward return task at their preferred pace in the sagittal plane. The ranges of thoracic and pelvic rotations and lumbar flexion (as the magnitude aspects of LPR) as well as the mean absolute relative phase (MARP) and deviation phase (DP) between thoracic and pelvic rotations (as the timing aspects) were calculated. Thoracic, pelvic, and lumbar rotations/flexion were respectively 2.19° smaller, 17.69° larger, and 19.85° smaller after the surgery. Also, MARP and DP were smaller during both bending (MARP: 0.0159; DP 0.009) and return (MARP: 0.041; DP: 0.015) phases of the motion after surgery. The alterations in LPR after surgery can be the result of changes in lumbar spine structure due to vertebral fusion and/or new neuromuscular adaptations in response to the changes of lumbar spine structure. The effects of altered LPR on load sharing between passive and active components of lower back tissues and the resultant spinal loads should be further investigated in patients with spinal fusion surgery.

Bien que les orthèses lombaires (OL) soient couramment employées depuis de nombreuses années dans le traitement conservateur des lombalgies, leurs effets mécaniques et posturaux restent, à notre connaissance, partiellement inexplorés. Des obstacles d'ordre méthodologique en sont la principale cause avec en premier lieu la difficulté d'évaluer les effets des OL à l'intérieur du tronc sans être invasif et sans nécessiter un équipement coûteux difficilement utilisable lors de la pratique médicale courante. La levée de ces verrous scientifiques a guidé l'ensemble de ce travail doctoral à travers le développement d'une méthodologie spécifique. L'effet mécanique a été étudié à partir d'une nouvelle méthode non-invasive de mesure de la pression intradiscale réalisée à partir d'une modélisation par éléments finis contrôlée par radiographie. Les premiers résultats ont démontré la possibilité de diminuer de 15 à 22% en moyenne la pression intradiscale lors du port d'une OL modifiant la statique rachidienne. Les différents travaux sur l'équilibre postural ont permis de définir une méthodologie d'analyse de la posture en station debout puis assise adaptée à l'évaluation des OL. Les premiers résultats chez des patients lombalgiques subaiguës ont mis en évidence un contrôle postural plus efficient (réduction de la raideur active du tronc) lors du port de l'OL la plus rigide. A terme, cette méthodologie facile à mettre en œuvre permettra d'adapter les caractéristiques du produit (raideur passive / forme) aux caractéristiques des patients (raideur active / courbure lombaire) dans le but d’optimiser l'efficacité clinique / Although lumbar orthoses (LO) are commonly used for many years in the conservative treatment of low back pain, postural and mechanical effects are, to our knowledge, partly unexplored. Methodological difficulties are the main cause with, in the first place, the difficulty to assess the LO effects inside the trunk with a non-invasive and not expensive method adapted for current medical practice. This Ph.D work attempts to address these difficulties through the development of a specific methodology. The mechanical effect was studied by a non-invasive estimation of the intradiscal pressure through a finite element modeling controlled by radiographs. The first results showed the possibility of a mean reduction from 15 to 22% of the intradiscal pressure while wearing an LO which is able to change the spinal posture. The different works on postural balance allowed us to define a methodology for a suitable LO assessment in standing and then sitting postures. The first results in patients with subacute low back pain showed a more efficient postural control (reduction of active stiffness of the trunk) while wearing the most stiffer LO. In the future, this easy-to-implement assessment could be helpful to more accurately target the appropriate LO for a given patient in order to improve his / her clinical status

No description available.

Objetivo: Estimar la prevalencia y factores asociados a inestabilidad lumbar y/o lumbalgia en estibadores del Mercado Mayorista de Lima. Método: Se realizó un estudio transversal analítico en 250 estibadores. Se utilizó la Escala Visual Analógica (EVA) para valorar el dolor lumbar al momento de la entrevista y, asimismo, se usó el Índice de Dolor de Espalda (IDE) para valorar la lumbalgia en 5 movimientos. Con respecto a la valoración de la inestabilidad lumbar se empleó la prueba clínica Extensión Lumbar Pasiva (ELP). Finalmente para efectos de análisis se creó la variable ambas alteraciones (IDE/ELP). Resultados: La prevalencia de lumbalgia en los últimos 3 meses en estibadores fue de 68,8% (172/250), y la inestabilidad lumbar fue de 34,4% (86/250). Se encontró asociación de Ambas Alteraciones con años de trabajo ≥ 11 años ([IC 95%= 1,08 - 3,42]; p= 0,03). Con respecto al IDE con años de uso de faja existe asociación ([IC95%= 1,01 - 1,24]; p= 0,04). En el modelo ajustado no se encontró resultados estadísticamente significativos. Conclusiones: La lumbalgia e inestabilidad de la columna tuvieron como factor de asociación el año de uso de faja. Otro factor a considerar es los años de trabajo ya que realizar la actividad mayor a 11 años podría conllevar a una lumbalgia e inestabilidad lumbar. / Objective: To estimate the prevalence and associated factors to lumbar instability and/or low back pain on the stevedores of the Mercado Mayorista de Lima. Methods: An analytical cross-sectional study was carried out in 250 stevedores. The Visual Analogue Scale (VAS) was used to estimate the low back pain at the moment of the interview. Also, the Backache Index (BAI) was used to evaluate the low back pain in 5 movements. For the evaluation of the lumbar instability, the clinic test of Passive Lumbar Extension (PLE) was used. Finally, for analysis purposes, the variable ambas alteraciones (IDE / ELP) was created. Results: The prevalence of low back pain in the last 3 months in the stevedores was 68, 8%, (172/250), and for lumbar instability was 34, 4% (86/250). An association between the variable ambas alteraciones with years of work ≥ 11 years was found ([IC 95%= 1, 08 - 3, 42]; p= 0, 03). There was also association between the Backache Index (BAI) and years of use of the lumbar belt ([IC95%= 1, 01 - 1, 24]; p= 0, 04). In the adjusted model, no significative results were found. Conclusions: The low back pain and spine instability had as an associative factor the years of use of the lumbar belt. Another factor to have in consideration is the years of work, because working more than 11 years could end in the development of low back pain and lumbar instability. / Tesis

En pathologie lombaire dégénérative, [des] procédures chirurgicales peuvent être employées pour répondre aux situations clinicoradiologiques rencontrées. Ces procédures sont efficaces mais invasives et grevées d'un taux de complications non négligeables. Les dispositifs interépineux (DIE) [diminuent] ainsi la morbidité. Cependant leur efficacité est controversée. Les effets des DIE peuvent être appréciés sur la modification cinématique de l'étage implanté et sur la modification de la taille des foramens. A travers une série d'études biomécaniques cadavériques, les auteurs tentent de vérifier s'il existe bien ces effets attendus avec 4 dispositifs différents. Concernant L4, DIAM® et In-Space® n'avaient aucun effet contrairement à Wallis qui avait un effet significatif en flexion et en extension. Concernant L5, aucun implant n'avait d'effet en flexion, alors que tous avaient un effet amortissant en extension. Il n'y avait pas d'implant supérieur aux autres. Concernant les variations de mobilité, Wallis® est l'implant qui diminue le plus les amplitudes globales de L4 et L5, de l'ordre de 50% et 42.7%, respectivement. […] Une étude cadavérique de la surface latérale du foramen intervertébrale par méthode photographique et binarisation des images a permis de montrer qu'avec le YODA, la longueur moyenne du foramen était de 15.7±2.8mm et la largeur moyenne de 9.4±1.2mm. Après implantation des DIE, ces dimensions variaient respectivement à 16.8±2.5mm et 10.1±1.3mm. La surface foraminale moyenne était de 150.4±35.8 mm2 à vide et de 165.1±28.3mm2, après implantation. Le gain moyen était de 14.7mm2 (5.3-26.9). Cependant, cet implant n'avait aucun effet sur la cinématique de l'étage implanté, même en extension, justifiant de discuter une modification de sa structure. La mesure stéréoscopique 3D des variations de surface foraminale L4-L5 et des foramens adjacents a permis de montrer que tous les implants ouvrent le foramen L4-L5 en extension. Deux catégories d'implants : 1 qui ouvrent le foramen en position neutre, en flexion et en extension ; 2 qui ferment le foramen en flexion mais l'ouvrent en extension. La mise en place des implants en L4-L5 n'avait aucune conséquence sur la taille du foramen à l'étage L3-L4. En revanche, XSTOP et DIAM entraînaient une fermeture minime du foramen L5-S1 vers l'extension. La mesure de surface nous a semblé insuffisante pour évaluer la globalité de la sténose. Nous avons développé une nouvelle mesure de la taille du foramen en appréciant son volume au scanner. Avec cette technique de mesure, le volume moyen de 60 foramens et de 20 foramens L4-L5 étaient respectivement de 1.17±0.23 et de 1.25±0.27 mm3 pour l'observateur 1 et de 1.21±0.21 et 1.29±0.23 mm3 pour l'observateur 2. Les CIC intra observateurs pour l'observateur 1 pour la mesure de l'ensemble des foramens et pour L4-L5 étaient de 0.98 et 0.99. Pour l'observateur 2, les CIC étaient de 0.90 et 0.92, respectivement. Les CIC inter observateurs pour l'observateur 1 pour la mesure de l'ensemble des foramens et pour L4-L5 étaient de 0.78 et 0.83. Pour l'observateur 2, les CIC étaient de 77 et 0.8. La moyenne des différences de mesures entre les observateurs étaient de moins de 0.2 mm3 (0.05 and 0.15). […] L'excellente reproductibilité de cette mesure simple complète les outils de mesure de la taille du foramen. La validation de cette mesure du volume a permis de vérifier s'il y avait ou pas, une variation du volume foraminal après implantation comparative des quatre dispositifs inter épineux. Les volumes des foramens L4-L5 étaient significativement augmentés après implantation de INSPACE®, XSTOP® et WALLIS®. Le volume foraminal moyen de l'étage sus jacent n'était pas modifié et seul le WALLIS® diminuait le volume en L5-S1. XSTOP® : l’implant qui ouvrait le plus les foramens. Les dispositifs interépineux ont bien des effets biomécaniques sur l'étage implanté, aussi bien en cinématique que sur les variations de la taille du foramen intervertébral. / In lumbar degenerative disease, many surgical procedures can be used to respond to different radiological clinical situations. These invasive procedures are effective, but with a significant complication rate. Interspinous devices (DIE) are positioned with more limited approaches, thereby reducing morbidity. However, their effectiveness is controversial. The effects of EIS can be evaluated on the kinematic changes of the implanted level and changing in the foramina size. Through a series of cadaveric biomechanical studies, the authors try to check if these are good effects expected with 4 devices. Concerning L4, DIAM® and In-Space® had no effect on either flexion or extension, contrary to Wallis®, which had a significant effect on flexion and extension. Concerning L5, no implant had an effect in flexion, while all presented a significant amortisation effect on extension.No significant difference was revealed between implants on flexion, in extension or on a global cycle. Concerning the mobility variations, Wallis® is the implant which decreases the global average movement of L4 and L5 the most, by 50% and 42.7%, respectively.The analysis of variations in the size of foramina is still confidential. Few authors are concerned. A cadaver study of the lateral surface of the intervertebral foramen by photographic method and binarization images has shown that with YODA, the average length of foramen was 15.7 ± 2.8mm and the average width of 9.4 ± 1.2mm. After implantation of DIE, these dimensions ranged respectively 16.8 ± 2.5mm and 10.1 ± 1.3mm. The mean foraminal area was 150.4 ± 35.8 mm2 vacuum and 165.1 ± 28.3mm2 after implantation. The average gain was 14.7mm2 (5.3-26.9). However, this implant has no effect on the kinematics of the implanted level even in extension justifying discuss a modification of the implant. Stereoscopic 3D measuring foraminal area variations on L4-L5 level and adjacent foramina has shown that all implants open the L4-L5 foramen in extension. There seems to be two types of implants: those who open the foramen in neutral, flexion and extension, and those who close the foramen bending but open to extension. There were no effects on the size of the foramen L3 -L4. However, Xstop and DIAM resulted minimal closure L5-S1 foramen to the extension. Surface measurement seemed insufficient to assess the totality of the stenosis. We developed a new measure of the foramen size enjoying its volume scanner. With this measurement technic, the mean volume of 60 foramen and 20 L4-L5 foramen were respectively 1.17 ± 0.23 and 1.25 mm 3 ± 0.27 for the observer 1 and 1.21 ± 0.21 and 1.29 ± 0.23 mm 3 for the observer 2. The intra observer CIC 1 for the observer for all measuring foramina and L4 - L5 were 0.98 and 0.99, respectively. For observer 2, ICC were 0.90 and 0.92, respectively. The inter-observer CIC for the observer 1 for measuring all foramina and L4 - L5 were 0.78 and 0.83, respectively. For observer 2, the CIC were 77 and 0.8, respectively.The average differences in measurements between observers were less than 0.2 mm3 (0.05 et 0.15). This is the first study to measure the volume of the foraminal scanner. The excellent reproducibility of this simple measure complements the tools to measure the size of the foramen. The validation of this volume measurement was used to check whether or not there was a change in the foraminal volume after comparative implementation of four interspinous devices. L4-L5 foramina volumes were significantly increased after implantation of InSpace ®, Xstop ® and WALLIS ®. The average volume of the underlying foraminal volume was not changed and only WALLIS ® decreased the volume L5 -S1. Interspinous devices have many biomechanical effects on the implanted level, as well as kinematic changes in the size (area and volume) of the intervertebral foramen. They have no impact on adjacent

La present tesi investiga l'ús de la modelització amb elements finits per a l'estudi de la biomecànica lumbar per a l'avaluació clínica. Els estudis bibliogràfics del capítol 1 mostren relacions funcionals clares entre les forces externes i les estructures i formes del teixit lumbar. Els estudis clínics demostraren que independentment del seu origen, el dolor lumbar pot veure's empitjorat per sobrecàrregues dels teixits. Les mesures experimentals són insuficients per descriure la distribució de càrrega entre els diferents teixits lumbars, és així que s'han utilitzat models d'elements finits. No obstant, la fiabilitat dels models a l'hora de predir les càrregues locals en els teixits no ha estat demostrada, essent aquest un dels objectes d'estudi.En el Capítol 2 s'elaborà un model bisegment de la columna lumbar. El model inicial es completà incloent el còrtex vertebral, una definició complerta de les juntes sinovials, les plaques terminals de cartílag i una descripció millorada de l'estructura de l'anell. Es van simular càrregues simplificades per als estudis in vitro per calcular les distribucions de tensions, deformacions i energia. El model bisegment és vàlid per interpretar les distribucions de càrrega funcionals a L3-L5 en el cas d'estructures conegudes de teixit, però el conjunt de la geometria L3-L5 necessitava ser millorat.Així al Capítol 3 es creà un model geomètric bisegment precís de L3-L5. El nou model incloïa les corregides: dimensions i formes, alçades de disc, localitzacions del nucli, formes posteriors de l'os, i distribució dels lligaments. Després de comparar a nivell biomecànic l'antiga geometria amb la nova, els resultats mostraren que els rols relatius dels teixits modelats depenen de la geometria. En general, les distribucions de càrrega predites eren més fisiològiques en el nou model. En canvi, ambdós models, reprodueixen rangs experimentals de moviment, així doncs la seva validació hauria de tenir en compte les transferències de càrrega locals.El Capítol 4 es centra en la variabilitat dels angles creuats del col·lagen de l'anell. Es crearen quatre models bisegment amb organitzacions d'anell fibrós basats en la bibliografia comparant-se sota diverses càrregues. A més es proposà un paràmetre d'estabilització de l'anell per analogia a un tub de parets gruixudes. La biomecànica del model depenia en gran mesura de l'organització de l'anell fibrós, però el paràmetre d'estabilització era soviet contradictori amb les tensions i forces predites. Així, s'assumí que la geometria de la columna i l'organització de l'anell fibrós estaven lligades. Les xarxes d'anell de col·lagen adaptades es poden determinar numèricament, però els models d'anell haurien d'estar bastats en relacions mecanobiològiques.Al Capítol 5 es presenta un model de disc artificial acoblat amb el model de L3-L5. Models bisegment amb i sense implant van ser comparats amb càrregues controlades per força o desplaçament, incloent o no l'aproximació del pes del cos. La rigidesa de la pròtesi alterava generalment les distribucions de càrrega i les rotacions controlades per desplaçament conduint a grans efectes adjacents. Incloent el pes del cos les condicions de contorn semblaven més fisòlogiques que sense. Malgrat la rigidesa del nou disc, aquest sembla més prometedor que altres dispositius comercials.En aquesta tesi s'han creat sis models nous elements finits de la columna lumbar osteoligamentosa. Les simulacions han mostrat que l'ús fiable dels models requereix d'una descripció precisa de les càrregues locals i respostes mecàniques de teixits. Les prediccions locals van estar limitades qualitativament degudes al desconeixement de les estructures de teixit tou, equacions constitutives i condicions de contorn. En canvi, els models poden ser emprats com a laboratoris in silico per superar aquestes limitacions. Basat en la informació numèrica i experimental, s'ha proposat un procediment jeràrquic per al desenvolupament qualitativament fiable de models elements finits de la columna lumbar. / This PhD thesis investigated the use of finite element modelling to study lumbar spine biomechanics for clinical assessment. Bibliographic studies reported in the first Chapter showed clear functional relations between external forces and lumbar spine tissue structures and shapes. Clinical research revealed that independently of its origin, low back pain may be worsened by altered tissue mechanical environments. Experimental measurements alone cannot truly describe the load distributions between the different lumbar spine tissues. Thus, finite element models have been used in the past. But model reliability in predicting local tissue loadings is still not manifest and has been explored in this thesis as described in the following chapters.In Chapter 2, a L3-L5 lumbar spine bi-segment model was built. An initial model was completed to include the vertebral cortex, a full definition of the facet joints, the cartilage endplates, and an improved description of the annulus fibre-reinforced structure. Simplified load-cases used for in vitro studies were simulated to calculate stress and strain energy distributions. Predictions within the L3-L5 lumbar spine bi-segment model could be interpreted in terms of functional load distributions related to known tissue structures, but the overall L3-L5 bisegment model geometry needed further update.Thus, in Chapter 3, a geometrically accurate L3-L5 lumbar spine bi-segment model was created. The new model included corrected L3 and L5 body shapes and dimensions, corrected disc heights and nucleus placements, corrected posterior bone shapes, dimensions, and orientations, and corrected ligament distributions. The new and old geometries were biomechanically compared. Results showed that the relative roles of modelled tissues greatly depend on the geometry. Predicted load distributions were generally more physiological in the new model. However, new and old models could both reproduce experimental ranges of motion, meaning that their validation should take into account local load transfers.Chapter 4 focuses on the variability of the annulus collagen criss-cross angles. Four bi-segment models with literature-based annulus fibre organizations were created and compared under diverse loads. Moreover, an annulus stabilization parameter was proposed by analogy to a thick walled pipe. Model biomechanics greatly depended on the annulus fibre organization, but annulus stabilization parameter was often contradictory with the predicted stresses and strains. Spine geometry and annulus fibrous organization were hypothesized to be linked together. Adapted annulus collagen networks may be numerically determined, but annulus modelling should be based on mechano-biological relationships.In Chapter 5, a case-study of a novel artificial disc design coupled with the L3-L5 lumbar spine model is presented. Bi-segment models with and without implant were compared under load- or displacement-controlled rotations, with or without body-weight like load. Prosthesis stiffness generally altered the load distributions and displacement-controlled rotations led to strong adjacent level effects. Including body weight-like loads seemed to give more realistic results. Although the novel disc substitute is too stiff, it is more promising than other existing commercial devices.In this thesis, six new osteoligamentous lumbar spine bi-segment finite element models were created. Simulations showed that reliable use of lumbar spine finite element models requires precise descriptions of local tissue loading and response. Local predictions were qualitatively mainly limited by a lack of knowledge about soft tissue structural organisations, constitutive equations, and boundary conditions. However, models can be used as in silico laboratories to overcome such limitations. A hierarchical procedure for the development of qualitatively reliable lumbar spine finite element models was proposed based on available numerical and experimental inputs.