As doenças que provocam a estenose da coluna lombar têm contribuído para a piora da qualidade de vida, ocasionando dor e limitações funcionais em uma parcela considerável da população ativa. O tratamento cirúrgico da estenose geralmente é indicado quando ocorre déficit neurológico progressivo, resistente ao tratamento conservador e se a doença apresenta impacto na qualidade de vida do paciente. A carência de pesquisas nacionais já publicadas sobre o tema, principalmente aquelas com enfoque na avaliação subjetiva desses indivíduos nos motivou a realização deste estudo observacional e analítico, de delineamento transversal. O objetivo foi avaliar as expectativas e a associação da qualidade de vida relacionada à saúde (QVRS) com a presença de sintomas de ansiedade e depressão em pacientes que aguardavam o tratamento cirúrgico da Estenose do Canal Lombar. A amostra foi composta por pacientes com indicação cirúrgica de estenose lombar, atendidos entre agosto de 2011 e novembro de 2012, em um hospital geral público de ensino. Os dados foram coletados por entrevistas individuais e consulta aos prontuários dos participantes. As variáveis de interesse foram mensuradas por instrumentos específicos e previamente validados. A QVRS foi avaliada pelo Índice de Incapacidade de Oswestry e pelo SF-36. Os sintomas de ansiedade e depressão foram avaliados segundo as subescalas do Hospital Anxiety and Depression Scale (HADs). As expectativas frente ao tratamento cirúrgico da estenose foram investigadas por questões previamente usadas em estudos internacionais. Os dados foram analisados descritivamente, e o teste t de Student foi utilizado para amostras independentes e realizado para comparar as médias das variáveis de interesse, segundo a presença de sintomas de ansiedade ou depressão. O nível de significância adotado foi de 0,05. Participaram da investigação 38 pacientes, sendo 32 (84,2%) com diagnóstico de estenose lombar, três (7,9%) com espondiloartrose, dois (5,3%) com estenose lombar/listese e um (2,6%) apresentava diagnóstico de discopatia. O tempo médio de evolução da doença foi de 38,3 meses. A média de idade foi 60,4 anos, e 63,2% eram mulheres. Na avaliação da QVRS, pelo SF-36, os domínios mais comprometidos foram aqueles relacionados às atividades físicas como Aspectos físicos (M=4,61; D.P.=11,4) e Capacidade funcional (M=25,8; D.P.=11,4) e os mais bem avaliados foram Estado geral de saúde (M=73; D.P.=12,5) e Saúde mental (M=63,8; D.P.=17,2). A média do ODI obtida entre os participantes foi de 50,9%. A classificação dos participantes mostrou que 55,3% apresentavam incapacidade grave, 23,7%, incapacidade moderada e 21,1%, invalidez. Sintomas de ansiedade e de depressão estavam presentes, respectivamente, em 31,6% e 10,5%. Comparando os valores médios dos domínios do SF-36, segundo a presença ou não desses sintomas, em sete dos oito domínios, o grupo com sintomas apresentou médias menores do que o grupo sem sintomas, indicando pior QVRS. Entretanto, as diferenças entre os grupos foram estatisticamente significantes apenas para o domínio Estado geral de saúde, considerando a presença de ansiedade, e para o domínio Saúde mental quando os grupos foram comparados segundo a presença de sintomas de depressão. Na avaliação das expectativas, 47,4% dos participantes esperavam ficar \"Muito melhor\" com relação à dor nas pernas, capacidade de caminhar e independência das atividades diárias. Embora com limitações, o presente estudo, contribuiu para a prática clínica, uma vez que pode ampliar o conhecimento sobre os pacientes com estenose lombar. Diante da nossa prática clínica, consideramos que as expectativas referidas pelos pacientes frente ao tratamento cirúrgico nem sempre podem ser satisfeitas. Assim, os enfermeiros, entre outros profissionais que cuidam destes pacientes, precisam se responsabilizar por uma orientação mais clara e objetiva, voltada às reais possibilidades advindas da cirurgia para a melhora da qualidade de vida. A presença de sintomas de ansiedade e depressão também deve ser considerada como relevantes no pré-operatório destes indivíduos. / The diseases that cause stenosis of the lumbar spine have contributed to the worsen the quality of life and cause pain and functional limitations in a considerable portion of the working population. Surgical treatment of stenosis is usually indicated in case of progressive neurological deficit, resistance to conservative treatment and when the disease has an impact on quality of life of the patient. The lack of national researches already published on the subject, especially those focusing on the subjective evaluation of those individuals, motivated us to conduct this observational and analytical study, cross-sectional design. The objective was to evaluate the association of expectations and the Health-Related Quality of Life (HRQoL) with symptoms of anxiety and depression in patients awaiting surgical treatment of lumbar stenosis. The sample was consisted of patients with surgical indication for lumbar stenosis, treated between August 2011 and November 2012, in a hospital of public teaching. Data were collected through individual interviews and hospital records of participants. The variables of interest were measured by specific instruments, previously validated. HRQoL was assessed by the Oswestry Disability Index and the SF-36. Symptoms of anxiety and depression were assessed by the subscales of the Hospital Anxiety and Depression Scale (HADS). Expectations for the surgical treatment of stenosis were investigated by questions previously used in international studies. Data were analyzed descriptively and the Student t test for independent samples was performed to compare the means of the variables of interest, according to the presence of symptoms of anxiety or depression. The significance level was 0.05. 38 patients participated in the study, 32 (84.2%) with a diagnosis of lumbar stenosis, three (7.9%) espondiloarthrosis, two (5.3%) lumbar stenosis / listese and one (2.6%) had been diagnosed of discopathy. The duration of disease was on average 38, 3 months. The mean age was 60.4 years and 63.2% were women. In the assessment of HRQOL by SF-36, the amost affected areas were those related to physical activities like physical aspects (M = 4.61, SD = 11.4) and functional capacity (M = 25.8, SD = 11, 4) and areas with better evaluation were General health (M = 73, SD = 12.5) and Mental health (M = 63.8, SD = 17.2). The average of ODI obtained among participants was 50.9%. The classification of the participants showed that 55.3% had severe disability, 23.7% moderate disability and 21.1% invalidity. Symptoms of anxiety and depression were present, respectively, in 31.6% and 10.5%. Comparing the mean values of the SF-36 in the presence or absence of these symptoms, in seven of the eight domains, the group with symptoms showed lower average than the group without symptoms indicating worse HRQOL. However, the differences between the groups were statistically significant only for the domain general health, considering the presence of anxiety, and for the domain mental health when the groups were compared according to the symptoms of depression. In evaluating the expectations, 47.4% of respondents were expected to be \"much better\" about leg pain, walking ability and independence of activities daily. Even with limitations, this study has contributed to the clinical practice, since it can increase knowledge about patients with lumbar stenosis, we believe that the expectations reported by patients about surgical treatment can not be always satisfied. Thus, nurses, and other professionals who care for these patients need to take responsibility for clearer and objective guidance, oriented for the real possibilities arising from the surgery to improve the quality of life. The presence of symptoms of anxiety and depression should also be considered as relevant preoperatively these individuals.

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...

Dor lombar é uma queixa comum especialmente entre os idosos. O termo estenose espinal é baseado no fato de que um espaço mínimo do canal vertebral é necessário para o funcionamento normal das estruturas nervosas e quando esse espaço torna-se estreito, resulta em sintomas como dor, dormência e fraqueza dos membros inferiores e claudicação neurogênica, que pioram com o esforço e melhoram com o repouso. Objetivos: Avaliar as alterações cinemáticas da marcha antes e após esforço físico em teste de esteira e correlacionar com a percepção de dor e com o grau de estenose do canal vertebral lombar obtido através do exame de ressonância nuclear magnética. Método: 14 pacientes com diagnóstico de estenose do canal vertebral lombar, com média de idade de 74,5 (9,8) anos e a área transversal média do canal vertebral foi de 43,86 (28,76) mm2. Para análise cinemática foram utilizados o sistema Vicon® MX 40 e o software Nexus® de reconstrução tridimensional das imagens. O exame constou de três fases: 1) Captura de seis ciclos de marcha após um período de descanso; 2) Caminhada em esteira durante um período máximo de 20 minutos; 3) Nova captura de outros 6 ciclos da marcha imediatamente após o esforço. A partir destes dados, as variáveis espaço temporais e angulares foram extraídas e analisadas individualmente e, em seguida, comparadas com a percepção da dor de cada paciente obtido pela escala visual analógica no inicio e ao final do exame e com a área transversal do canal vertebral medida em exames de ressonância nuclear magnética. Resultados: A maior parte das correlações se mostraram fracas e os resultados mais expressivos se referiram ao GDI onde notamos diminuição das medianas para ambos os membros com correlação negativa moderada com a percepção da dor pós-esforço, tanto para o membro esquerdo (r= -0,64, p=0,014) quanto para o direito (r= -0,53, p= 0,05), o que significa que existe uma diminuição significante da função geral dos membros inferiores conforme o sintoma da dor aumenta ( p= 0,002). Este fato pode ter reflexo na diminuição da cadência e da velocidade além dos tempos de apoio simples (significante para o membro esquerdo, p= 0,019) e balanço (significante para o membro direito, p= 0,013) como parte de uma estratégia de proteção contra a dor e o desequilíbrio. Conclusão: Há alteração da velocidade, cadência e dos tempos de apoio simples e duplo apoio para compensar a dor e a diminuição da função dos membros inferiores medida pelo GDI se correlaciona com o aumento da dor. Porém, as variáveis cinemáticas da marcha e a dor não tiveram correlação com tamanho da área transversal do canal vertebral / Back pain is a common complaint especially among older patients.The spinal stenosis term is based on the fact that a minimum space of the spinal canal is necessary for normal functioning of the nervous structures, and when this space becomes narrow, results in nerve compression symptoms such as pain, lower limbs numbness and weakness and neurogenic claudication, which increase with stress and decreases with rest. Objective: Evaluate kinematics changes of gait before and after physical effort in treadmill test, and correlate with the perception of pain and the lumbar stenosis degree obtained by nuclear magnetic resonance. Method: 14 subjects were evaluated with diagnostic of lumbar stenosis with a mean age of 74,5 (9,8) years and average size of the spinal canal was 43.86 (28.76) mm2. Were used for kinematic analysis Vicon ® MX 40 system and Nexus ® software for images three-dimensional reconstruction. The exam consisted of three phases: 1) Capture of six gait cycles after a rest period; 2) Walk on treadmill for a maximum of 20 minutes; 3) New capture of other 6 gait cycles immediately after the effort. From these data, temporal-spatial and angular variables were extracted and analyzed individually and compared to the pain perception obtained by visual analog scale at the beginning and the end of the exam and the cross-sectional area of the dural sac obtained from the nuclear magnetic resonance. Results: Most of the correlations were weak and the most significant results are reported to GDI when we observed decrease in medians for both lower limbs to moderate negative correlation when compared to pain perception after effort for both left (r = - 0.64, p= 0.014) and right limb (r= -0.53, p= 0.05), which means that there is a significant reduction in the global function of the lower limbs according the symptom of pain increases (p = 0.002). This fact may be reflected in decreased cadence and gait speed and also the times of single support (significant for the left limb, p= 0.019) and balance (significant for the right limb, p= 0.013) as a protection strategy against pain and imbalance. Conclusion: There is changing the speed, cadence and time of single and double support for compensation of pain and decreased function of the lower limbs measured by GDI correlates with increased pain. However, the kinematic variables of gait and pain did not correlate with the size of cross-sectional area of the spinal canal

Background:Lower back pain is one of the most common health-related complaints in the adult population. Thirty percent of Americans 65 years and older reported symptoms of lower back pain in 2004. With an aging population, the proportion of people over the age of 65 is expected to reach 20% by the year 2030. Because of this increase in older adults, lumbar spinal stenosis (LSS) associated with arthritic changes will also likely increase. In older adults, lower back pain is most often caused by degenerative lumbar spinal stenosis. Stenosis is the narrowing ofthe spinal canal, causing pressure on the nerve roots and is frequently treated surgically. Lumbar spinal stenosis is one of the most common reasons for back surgery in patients 65 years and older 2. However, risks associated with surgery increase with age 3-5 and older patients may choose non-surgical treatment for their lower back pain, including injection treatment. Injection treatment, usually consisting of anti-inflammatory medications and analgesics, has improved since the mid-1990's when fluoroscopic guidance was developed. Information about injection treatment for lower back pain is limited, especially in the older population. An extensive review of published literature regarding injection treatment revealed a paucity of information about older adults diagnosed with lumbar spinal stenosis. In this study, three aims were designed to gain more information about the effectiveness of injection treatment in older patients with lumbar spinal stenosis. In the first (retrospective) study, information about receipt of second injections and time between injections was collected to examine injection usage. In the second and third (prospective) studies, information about pain relief and functional return following injection treatment was collected to examine the effectiveness of injection treatment in patients age 60 and older diagnosed with lumbar spinal stenosis. To our knowledge, such results have not been repolted for this population in the literature. Objective:Injection treatment is a commonly used non-surgical procedure to alleviate lower back pain in older adults. However, older patients do not have enough information about how long pain relief will last after treatment or the amount of pain relief and functional return they will experience. These studies focused on three topics: 1) usage of injection treatment; 2) effectiveness of injection treatment on pain relief; 3) effectiveness of injection treatment on functional return. In addition, the variations of the effectiveness were examined by selected patient attributes. Methods:In a retrospective study, medical records of patients aged 60 years or older from a high volume dedicated spine center at the University of Massachusetts Memorial Hospital were retrospectively reviewed. This study included those diagnosed with degenerative LSS, who had not received an injection for lower back pain within six months, and whom were treated between June I, 2006 and May 31, 2007. In two prospective studies, patients scheduled for lumbar injection treatment between January 1 and June 30, 2008 were selected from the University of Massachusetts Memorial Hospital Spine Center. Selection criteria included patients age 60 and over, diagnosed with degenerative lumbar spinal stenosis and no previous lumbar injection within 6 months or lumbar surgery within 2 years. The Pain sub-score of the SF-36 questionnaire was used to measure pain at baseline and at one and three months post injection. The Physical Component Score (PCS) of the SF-36 questionnaire and the Oswestry Disability Index (ODI) were used to measure function at baseline and at one and three months post injection. Variations in longitudinal changes in scores by patient characteristics were analyzed in both unadjusted (univariate) analyses using one-way analysis of variance (ANOVA), and adjusted (multiple regression) analyses using linear mixed effects models. Results: In the retrospective cohort, the mean age of the cohort was 68, 64% were female, 59% were married, with a mean Body Mass index of 32 kg/m2. Of 92 eligible patients, 57% returned for a second injection within six months of the first. The mean number of months between injections was 4.8 for all patients, ranging from 1 to 22 months. When patient characteristics were examined, the only variable that showed a statistically significant difference was age. Patients aged 70 years and older were found to be 67% less likely to return for a second injection when compared to patients age 60-69 (OR=0.33 (0.12 - 0.94)p In the prospective cohort, information was collected on 62 patients. Mean Pain scores improved significantly from baseline to one month (14.1 points), and from baseline to three months (8.3 points). Post injection changes in Pain scores varied by Body Mass Index (BMI) and baseline emotional health. Based on a linear mixed effects model analysis, higher baseline emotional health, as measured by the SF-36 Mental Component Score (MCS>50), was associated with greater reduction in pain over three months when compared to lower emotional health (MCS Conclusion: Patients over age 70 do not return for repeat injection as frequently as patients age 60-69. In addition, each year a patient ages over age 60, they are 10% less likely to return for a repeat injection. Lower back pain in older adults with LSS is clinically significantly alleviated after injection treatment. In addition, injection treatment for LSS is associated with return of lost function needed for daily living activities in older adults. Pain relief and functional return varies by patient personal and clinical characteristics. Higher emotional health was associated with more pain relief and more functional return experienced over three months following injection treatment. Additional information is needed about why older patients do not return for second injections at the same rate as younger patients and how emotional health affects response to injection treatment in older adults.

Background: The use of manual therapy for the management of lumbar spinal stenosis (LSS) has not been adequately systematically reviewed in an attempt to determine its effectiveness on patients with LSS. The lack of evidence in support ofcommonly used conservative interventions continues to result in a lack of clarity regarding what interventions should be used to manage patients with LSS. Objective: To use a randomized comparative trial to compare the functional clinical outcomes achieved by patients with LSS receiving two different physical therapy interventions. Methods: In this randomized controlled trial, a total of40 participants diagnosed with LSS were randomized into two groups. Both groups received 6 weeks of treatment. Participants assigned to group 1 (EX Group) received impairment-based exercises. Participants assigned to group 2 (EXMT Group) received impairment-based exercises as well as manual physical therapy techniques. The evaluation parameters included (1) McGill Pain Questionnaire, (2) the original version of the Oswestry Low Back Pain Disability Questionnaire (ODQ), (3) double inclinometer measurement for measuring thoracolumbar flexion and extension, (4) self-pace walking test, (5) hip abductor and extensor strength, and (6) hip external rotation and extension range of motion. All participants were evaluated before starting treatment, once at the end of 6 weeks of treatment, and again at 6 weeks following the completion of treatment. Results: In terms of overall treatmentefficacy, there were notable improvements observed over time regardless of treatment group. Results indicated significant improvement in perceived disability using ODQ in the EXMT treatment group in comparison to the EX group at follow-up. For the EXMT group, there were notable improvements in comparison to the EX group in multiple objective functional improvement measures. Conclusion: Results of this study suggest that a multimodal approach using manual therapy and therapeutic exercises is an effective treatment option for providing clinically significant short-term reduction in back pain and disability, as well as improvements in back mobility in patients with LSS. Physical therapists should strongly consider the impairment-based approachof manual therapy and specific exercises program for lumbar spine and hips as a treatment option for patients with lumbarspinal stenosis.

Introdução: O acesso lombar transpsoas extremo lateral (LLIF) é uma abordagem retroperitoneal para artrodese intersomática que constitui num implante (cage) o qual se sustenta nas duas margens laterais do anel epifisário, maximizando o apoio na placa terminal. Há também a descompressão indireta das estruturas nervosas através da discectomia e restauro da altura discal pelo cage. Objetivo: Avaliar a eficácia clínica e radiológica da descompressão indireta após o LLIF para estenose do canal lombar. Métodos: Estudo prospectivo clínico e radiológico em único centro, com 20 pacientes portadores de estenose do canal lombar, sem resposta ao tratamento clínico, submetidos à cirurgia de artrodese por via lateral transpsoas minimamente invasiva. Foram coletados dados clínicos e radiológicos no período pré-operatório, em 6 semanas, em três meses, seis e doze meses após a cirurgia. Dados radiológicos medidos em RNM incluíram área e altura dos forâmens, área do canal, diâmetro do canal e altura anterior e posterior do disco intervertebral. Questionários clínicos incluíram EVA e ODI. A incidência de complicações e re-operações foram descritas. Resultados: A idade média do grupo foi de 57,8 anos. Foram tratados ao todo 25 níveis. As cirurgias decorreram sem complicações intra-operatórias. Um caso (5%) recebeu re-operação. A área do canal aumentou de 109 mm para 149mm (p < 0,001) e de 9,3mm para 12,2mm (p < 0,001) em diâmetro anteroposterior. Os valores de área dos forâmens também demonstraram o efeito da descompressão indireta em ambos lados (p < 0,001). A altura do forâmen mostrou ganhos significativos, de 2,8mm de média (p < 0,001). A altura discal foi aumentada em média 25% (p < 0,001). Os resultados de questionários EVA e ODI respondidos pelos pacientes confirmaram o efeito clínico da descompressão indireta demonstrada radiologicamente. Conclusão: Observamos que a descompressão indireta pelo método de LLIF apresenta resultados que comprovam a melhora tanto radiológica quanto clínica com baixa taxa de complicações e re-operações / Background: Lateral transpsoas lateral access (LLIF) is a retroperitoneal approach for intersomatic arthrodesis that constitutes an implant, which is supported on the two lateral margins of the epiphyseal ring, maximizing the support in the terminal plate. There is also indirect decompression of nerve structures through discectomy and restoration of disc height by cage. Aim: Evaluate the clinical and radiological improvement of the indirect decompression after LLIF for lumbar canal stenosis. Methods: Prospective clinical and radiological study in a single center, with 20 patients with lumbar canal stenosis, without response to clinical treatment, submitted to minimally invasive transpsoas lateral lumbar interbody fusion (LLIF) surgery. Clinical and radiological data were collected in the preoperative period, at 6 weeks, at three, six and twelve months after surgery. Radiological data measured on MRI included area and height of foramen, canal area, canal diameter and anterior and posterior height of the intervertebral disc. Clinical questionnaires included VAS and ODI. Complications and re-operations were described. Results: The mean age of the group was 57.8 years. A total of 25 levels were treated. Surgeries were performed without intraoperative complications. One case (5%) received reoperation. The canal area increased from 109 mm to 149 mm (p < 0.001) and from 9.3 mm to 12.2 mm (p < 0.001) in the anteroposterior diameter. The values of the foramen area also demonstrated the effect of indirect decompression on both sides (p < 0.001). The height of the foramen showed significant gains, of 2.8 mm of mean (p < 0.001). Disc height was increased by an average of 25% (p < 0.001). The results of VAS and ODI questionnaires answered by the patients confirmed the clinical effect radiologically demonstrated of indirect decompression. Conclusion: We observed that indirect decompression by the LLIF method is feasible radiologically and clinically with a low rate of complications and reoperations

No description available.

During recent decades, lumbar spinal stenosis (LSS) has become the most common indication for spine surgery, a change that coincides with a higher worldwide prevalence of overweight and obesity. Thus, surgical treatment of LSS in the overweight and obese population is common and increasing in scope. The overall aim of this thesis was to investigate whether body mass index (BMI) is related to the development of LSS, and whether BMI is linked to outcome after surgery for LSS. We further evaluated whether there are specific experiences of LSS from a patient perspective. Data were obtained for all patients registered in the Swedish Spine Register who had undergone surgery for LSS between January 1, 2006 and June 30, 2008. After adjusting for differences in baseline characteristics, patients with obesity showed both poorer results after surgery and a higher rate of dissatisfaction than patients with normal weight (odds ratio 1.73; 95% confidence interval, CI, 1.36-2.19). Furthermore, patients with obesity in the cohort reported modest weight loss at follow-up (2.0 kg; 95% CI, 1.5-2.4), and only 8% reported a clinical important weight loss 2 years after surgery. Our analysis of 389,132 construction workers, showed that overweight (incidence rate ratio, IRR 1.68; 95% CI, 1.54-1.83) and obesity (IRR 2.18; 95% CI, 1.87-2.53) were associated with an increased future risk in developing LSS when compared with patients with normal weight. To gain insight into the patients' perspective of LSS, we performed interviews with 18 patients who were on a waiting list for LSS surgery. The transcripts, analyzed with content analysis, revealed that living with LSS is a physical, mental and social challenge in which resources to cope with the condition are of major importance. In summary, obesity is associated with poorer results after surgery, and patients with obesity report modest weight loss during follow-up. In addition, obesity is associated with an increased risk to develop LSS. Our findings revealed that being a patient with LSS, naturally involves considerable suffering and pain, but it also implies being a person with his or her own resources who is able to cope with these adverse conditions.