Chronic low back pain (CLBP) is often accompanied by an abnormal motor performance. However, it has not been clarified yet whether these deviations also occur during motor tasks not involving the back and whether the performance is influenced by pain and pain-related cognitions. Therefore, the aim of the present study is to get insight in the contribution of both pain experience and pain-related cognitions to general motor task performance in CLBP.13 CLBP patients and 15 healthy subjects performed a hand-function task in three conditions: sitting, lying prone (lying) and lying prone without trunk support (provoking). The last condition was assumed to provoke pain-related cognitions, which was considered successful when a patients' pain expectancy on a numeric rating scale was at least 1 point higher than actual pain experienced. Subjects' performance was expressed in reaction time and movement time. Repeated measures analysis of variance was performed to detect main effect for group and condition. Special interest was given to group*condition interaction, since significant interaction would indicate that patients and healthy subjects performed differently throughout the three conditions.Patients were slower throughout all conditions compared to healthy subjects. With respect to the provoking condition, patients showed deteriorated performance compared to lying while healthy subjects' performance remained equal between these two conditions. Further analysis of patients' data showed that provocation was successful in 54% of the patients. Especially this group showed deteriorated performance in the provoking condition.It can be concluded that CLBP patients in general have worse motor task performance compared to healthy subjects and that provoking pain-related cognitions further worsened performance. Chronic low back pain (CLBP) is often accompanied by deviations in motor performance -3. FrequHowever, to date the majority of research on motor performance in CLBP has been focusing only on motor tasks directly involving the lower back . As these lower back motor tasks are often considered both painful and threatening by patients, it is hard to distinguish whether deviations in performance should be attributed to pain experience or to pain-related cognitions. Although insight in the effect of these parameters separately would provide valuable information regarding the CLBP problem, only a few studies tried to enable analysis of pain effect apart from cognition effect. Lamoth and coworkers studied the influence of both parameters on gait in healthy subjects . Their rIn sum, there is lack of knowledge concerning the relation between pain, pain-related cognitions and deviations in CLBP patients' motor performance. As it is conceivable that managing pain demands a different treatment approach than managing pain-related cognitions, this knowledge might be useful to increase CLBP therapy effectiveness.Therefore, the aim of the present study is to gain insight in motor performance of CLBP as well as the contribution of both pain experience and pain-related cognitions to motor task performance. For this, both CLBP patients and healthy subjects were asked to perform a hand-function task in a neutral sitting position and two conditions (lying and provoking) that were assumed to increasingly provoke pain-related cognitions.It was hypothesized that patients would perform worse compared to healthy subjects in all conditions. Furthermore, it was expected that performance would worsen from neutral to lying condition in both groups and that performance in the provoking condition would be further deteriorated in CLBP patients, but not in healthy subjects.Fifteen CLBP patients and fifteen age-matched subjects without low back complaints participated in this study. Patients were referred from the Roessingh Rehabilitation Centre and local physiotherapists. Healthy subjects were recruited amongst family and friends of Roessingh Research and Development personnel and by poster advertising in local (sports) clubs.To be included patients had to be at least 18 years of age, have chronic low back pain without identifiable pathological causes, continuously or recurrently present for at least 12 weeks, and be free of other pain problems. As the objective of the study was to gain insight in the contribution of both pain experience and pain-related cognitions to motor task performance in CLBP patients, patients that were not experiencing pain at the time of testing were excluded from participation. Healthy subjects were included if they were least 18 years of age and had not had (back) pain complaints during at least 6 months previous to study participation. Both patients and healthy subjects were excluded from the study in case of upper-extremity disorders, psychopathology or insufficient mastering of the Dutch language. In addition, experimental layout required subjects' heights to be between 150 cm and 200 cm. Consequently, subjects that did not meet this criterion were also excluded from the study.All included subjects gave their written informed consent prior to participation in this study. The study protocol was approved by the local Medical Ethics Committee.All participants were asked to fill out a question form regarding socio-demographic characteristics . In addition, CLBP patients completed a series of self-report questionnaires to assess pain intensity, fear of movement and pain catastrophizing.Pain intensity was measured by a visual analogue scale (VAS). Patients were asked to score their minimal and maximal pain in the last week and present pain on 100 mm lines anchored on the left with "no pain at all" and on the right with "worst pain imaginable".Fear of movement was assessed by the Dutch version of the TAMPA scale of kinesiophobia (TSK-DV ), a 17-iTo assess level of pain catastrophizing the Dutch version of the Pain Catastrophizing Scale (PCS-DV ) was useSubjects had to perform a motor task based on the hand-function task described by Jebsen et al. . The tasTo rule out learning, the actual test phase was preceded by a practice phase. It was assumed that subjects had mastered the test sufficiently if they were equally fast (time difference less than 500 ms) in three subsequent trials.After this practice phase the actual test phase began. The motor task was performed subsequently in the three different conditions illustrated in Figure expected being at least 1 point higher than NRSexperienced.Especially, the provoking condition required active, volitional exertion of the back muscles and was, therefore, expected to provoke pain-related cognitions in the CLBP patients but not in the healthy subjects. To further increase the provoking effect of this condition, subjects were told that the posture was very demanding on their low back muscles. Provocation of pain cognitions was assumed to be successful if expected pain was higher than the pain patients actually experienced due to task performance. This assumption was based on the findings of a previous study by Crombez et al. . To deteThe auditory signal that subjects had to react to was generated by a random beep generator at a time interval ranging from 1 to 10 seconds after pressing the button. The interval was randomized to prevent subjects from anticipating the sound signal. Both onset of the auditory signal and release of the button were registered by means of an alteration to the output signal.Light sensors were used to monitor cylinder placement. Sensor output signal altered in case of cylinder placement. All sensors generated a slightly different output signal to be able to distinguish separate cylinder placements. All signals were measured at an auxiliary channel of a TMSi REFA data acquisition device at a sampling frequency of 2048 Hz, using Portilab 2 software . Raw data were stored for off-line data analysis.To facilitate data analysis, the raw output signal was converted into time measures using a custom-written Labview routine . After this final data processing stage, reaction time (RT) and movement time (MT) were determined. RT was defined as the time between onset of the auditory signal and release of the button. Minimal RT to an auditory stimulus  has proven to be between 140-160 ms in adults . Therefo2 tests for categorical variables.In order to ensure that no socio-demographic differences existed between groups characteristics of CLBP patients and healthy subjects were analyzed by independent t-tests for numerical variables and by χA repeated measures analysis of variance was performed for analysis of both RT and MT. To evaluate group and condition effects post-hoc Sidak tests were performed. Special interest was given to group*condition interaction, since significant interaction would indicate that patients and healthy subjects performed differently throughout the three conditions.Furthermore, relations between pain measures, baseline cognition measures (i.e. fear of movement and catastrophizing) and task performance were examined by using Pearson's correlation. Special attention was given to the relation between NRS scores and cognition measures as a significant relation would indicate mediating effect on performance.Fifteen CLBP patients were originally included in the study. Yet two of them were excluded after questionnaire assessment, because their VAS scores appeared to be less than 10 mm, indicating no pain experience at the time of testing. The socio-demographic characteristics of the remaining 13 CLBP patients and those of the 15 healthy subjects are depicted in Table experienced = 0) or expected pain (NRSexpected = 0) in any of the three conditions. Contrarily, manipulation of pain-related cognition (i.e. overestimation of pain) by the provoking posture seemed successful in the patient group.With respect to the manipulation of pain-related cognitions, results showed that healthy subjects did not report either experienced pain . Contrarily, the other six patients predicted their pain correctly and, thus, seemed to be unsusceptible for the provoking condition. For this reason, it was decided to divide the patient population in two groups ("susceptible" vs. "unsusceptible") and perform separate analysis on these groups - additional to the analysis of group (patients vs. controls) and conditions effect - to explore whether differences in outcome measures could be attributed to susceptibility for provocation.Furthermore, the hypothesis that the provoking condition would result in an increase in patients' expected pain compared to the experienced pain (i.e. provoke pain-related cognitions) was tested. Indeed, there was a trend of expected pain being higher than experienced pain, but this difference failed to reach significance (p = 0.175). Yet an explorative analysis on the individual patient scores showed that individual subjects reacted differently to the provocation. In seven out of 13 patients provocation appeared to be successful as they predicted higher expected pain than actual pain experience : 61.7 (6.4)) than the unsusceptible ones (mean (SD): 50.3 (9.5)). Therefore, in the statistical analysis of performance differences at subgroup level age was included as a covariate (ANCOVA). Interestingly, there appeared to be a trend that baseline pain (VAS) was lower in the susceptible patients than in the unsusceptible patients.Figure Furthermore, condition appeared to have a significant effect on RT (p = 0.003). Both CLBP patients and healthy subjects showed increasing RTs across the three successive conditions. Post hoc Sidak testing showed that the condition effect was based on a significant difference between sitting compared to both lying and provoking condition (resp. p = 0.017 and p = 0.018), but not between lying and provoking condition (p = 0.559).The increase in RT across conditions was not different between patients and healthy subjects as can be concluded from the lack of significant interaction between the three task conditions and experimental group (p = 0.804).Results of the CLBP patients were additionally analyzed on differences between the two subgroups but this analysis revealed no differences with respect to RT between the two subgroups.Correlation analysis showed only poor correlation of RT with NRS scores (r = - 0.032 to - 0.140), fear of movement  and catastrophizing  in all three task conditions. None of the correlations was significant at a P < 0.05 level. In addition, there were no significant correlations between NRS scores and TSK  or PCS .The results of the repeated measures analysis of variance on MT are presented in Figure Also the condition in which the task was performed affected MT (p < 0.001). Post hoc analysis (Sidak) of differences in MT between the three conditions revealed that the task was performed faster in sitting compared to both lying and provoking (both p < 0.001) conditions, but that there was no significant difference between lying and provoking conditions (p = 0.239). However, a significant interaction between group and condition (p = 0.032) confirmed that the change in MT across the successive conditions differed between healthy subjects and patients. Post hoc analysis showed that this mainly applied to the changes in MT from lying to provoking condition. In healthy subjects MT hardly increased from lying to provoking condition , while patients' MT did increase across the two conditions although the difference just failed to reach significance . However, the significant interaction between subgroup and condition (p = 0.042) makes clear that susceptible patients performed differently throughout the three conditions than unsusceptible patients did Figure . PatientAs both subgroups showed similar accumulation of both baseline pain (p = 0.943) and experienced pain (p = 0.601) across conditions Figure , the worexpected and MT in sitting condition ; all other correlations were rather low (r = 0.055 to 0.384) and non-significant (p > 0.15).Just as RT, MT did not significantly correlate with baseline fear of movement  nor catastrophizing  in any of the three task conditions. With respect to NRS scores there was only a significant moderate correlation between NRSThe goal of this study was to identify deviations in  motor performance of CLBP patients and determine in what way both pain experience and pain-related cognitions contributed to these deviations. For this, reaction time (RT) and movement time (MT) on a hand-function task were compared between the CLBP patients and healthy subjects in three increasingly provoking conditions. Results show that patients score higher on RT as well as MT compared to healthy subject, which implies that pain experience indeed can deteriorate motor performance in CLBP. Provoking pain-related cognitions affected only MT task performance at group level. Additional explorative analysis on individual data of the patient population identified two groups of patients based on susceptibility to provocation. The group of patients that was identified as being susceptible to provocation (n = 7) most clearly deviated from healthy MT performance throughout conditions. Correlation analysis showed that neither cognitions measured by means of baseline questionnaires (i.e. fear of movement and catastrophizing) nor pain (NRS scores) appeared to be related to either RT or MT.As hypothesized, RT of CLBP patients differed significantly from that of healthy subjects in all three conditions. This is in agreement with studies that found delayed muscle reaction times in CLBP patients as a responds to sudden (trunk) loading ,17. HoweApart from the significant group effect, results indicate that the condition in which the task was performed also influenced RT. RTs in lying and provoking conditions were higher than those in sitting condition. However, compared to healthy controls, patients showed no bigger increase from lying to provoking despite the apparent success of provoking pain-related cognitions by posture - as shown by the increased pain expectancy in the provoking condition. Based on this finding it can be concluded that the RT in CLBP patients was not influenced by cognitions.This finding contradicts previous studies that demonstrated a deteriorating role for pain-related cognitions and RT performance -22. DiffAs expected, CLBP patients showed slower movement times than healthy subjects in all conditions. This is in agreement with several other studies showing CLBP patients to be slower than healthy subjects on various low back motor tasks ,17,23-26Apart from the significant differences between groups, results showed that the condition in which the task was performed affected MT. In line with the hypothesis, the MT appeared to deteriorate in lying and provoking condition compared to sitting condition. Apparently, the lying posture posed a challenge to task performance, since both patients and healthy subjects showed higher MT in lying condition compared to sitting condition. Subsequent performance in provoking condition did not further change MT in healthy subjects, while in patients MT seemed to increase. A significant interaction between group and condition proved that indeed patients performed differently throughout the conditions compared to healthy subjects. Presumably, this interaction is based on the trend for lower movement speed in the provoking condition in patients, which can be assumed to be attributable to the successful manipulation of pain-related cognitions (i.e. pain expectancy at least 1 NRS point higher than pain experience). The results of the patient subgroups analysis confirm this notion. Patients susceptible to provocation showed increased MT in provoking compared to lying condition, while patients unsusceptible to provocation showed no change in MT across these two conditions. In addition, the level of actual pain experience seemed to be lower in the susceptible group, indicating that pain (intensity) cannot explain the MT increase in provoking condition. This was further supported by the lack of correlation between NRS scores and MT. Neither can general cognition measures explain the increase as no correlations between baseline questionnaires (i.e. TSK and PCS) and MT were found and groups didn't differ with respect to these characteristics either. Thus, deteriorations in MT are assumedly determined by the amount of pain that patients anticipate rather than either the pain they actually experience or their general characteristics with respect to pain-related cognitions.The trend that pain expectancy influences motor performance has previously been described by studies in which a deteriorating role of pain anticipation (i.e. increased expected pain) on motor performance was found. Al-Obaidi et al. (2000) showed that anticipation of pain was a strong predictor for variance in lumbar maximal isometric torque . Also PfStill, the finding that posture can provoke falsely increased pain expectancy and, consequently, seems to worsen general motor task performance (i.e. MT) is considered to be of importance for CLBP therapy. For, it implies that adequate motor performance that is taught in a relatively safe clinical environment might worsen when patients are confronted with more challenging situations in daily life.Some remarks should be taken into account with respect to interpreting the results of the present study. First of all, the present study comprised a rather small study population and should, therefore, be regarded as a pilot study. In particular, the explorative results of the patient subgroups are based on small sample sizes. Additionally, the present study included only patients that were experiencing pain at the time of testing and, thus, one should be careful with extrapolating the results to the entire CLBP population. Future studies with larger patient populations are needed to confirm the preliminary findings of differences due to pain expectancy. Nevertheless, the fact that significant differences are found strongly strengthened the hypothesis that pain-related cognitions indeed influence motor performance of (symptomatic) CLBP patients.Another possible limitation with respect to analysis is the lack of randomization of the three experimental conditions. Given that all conditions were more or less demanding on the back, the fixed order of condition might have caused fatigue to play a role in the last (i.e. provoking) condition, possibly more in CLBP patients than in healthy subjects. It was tried to avoid this by offering subjects rest periods between successive conditions, yet as fatigue was not measured during the experiments it was impossible to determine whether or not rest was sufficient. Still, to the authors opinion the possible influence of fatigue counts for little compared to the main reason to choose for task performance in the present fixed order : to rule out that the effect of the provoking condition (i.e. increased pain-cognitions) sustained and would obscure performance measures in the other conditions.Finally, a remark can be made on the choice of motor task. The hand-function task is minimally representative for daily life activities. It was performed in a laboratory situation and the task in itself did not represent a common motor activity. Therefore, one should be careful with translating the findings of the present study into a daily life situation. Nevertheless, the present study provides evidence for the role of pain and particularly pain-related cognitions with respect to motor performance and, therewith, offers a first indication of possible mechanisms behind the abnormal motor performance in CLBP patients. Future studies should further look into causalities with respect to chronic pain and performance, since identifying the main determinants of deviated motor performance in low back pain provides valuable information for motor therapy improvement. Furthermore, confirming these results in a design with activities of daily living should be an aim in future studies, because effect of pain and pain-related cognitions for relevant motor activities is probably of value for therapy improvement.The present study shows that CLBP patients have worse motor task performance compared to healthy subjects. This might be partly attributable to an altered motor strategy due to pain experience. Yet the worsening of performance in case of successful additional provocation of pain-related cognitions  indicates that pain-related cognitions might be as important as mere pain experience.The authors declare that they have no competing interests.DK: Design, conducting the experiment, analysis of the data, writing and editing of the manuscript. MV: Initiating the study, design, monitoring progress and editing of the manuscript. HH: Design, monitoring progress and editing of the manuscript. All authors read and approved the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/12/211/prepub


To determine the efficacy of antidepressants for treating idiopathic orofacial pain fulfilling the International Classification of Headache Disorders 2nd edition (ICHD-II) criteria of persistent idiopathic facial pain  or burning mouth syndrome .Participants comprised 195 outpatients who attended our orofacial pain liaison clinic between January 1, 2009 and December 31, 2011 and were diagnosed with IFP or BMS. IFP was diagnosed in 124 patients , with a mean age of 54.8 ±14.4 years and a mean duration of illness of 50.7 ± 62.8 months. BMS was diagnosed in 71 patients , n=43), with a mean age of 67.2 ± 10.8 years and a mean duration of illness of 23.1 ± 27.3 months. Patients with mental disorders, including major depressive disorders, who were currently taking antipsychotic agents were excluded. All participants were treated with antidepressants, with first-line therapy comprising amitriptyline or another tricyclic antidepressant (TCA). If a TCA alone proved insufficient for pain control, one of the following agents was added to the TCA for combination therapy, in this order: risperidone; sodium valproate; or lithium. These other antidepressants were also used if the patient could not use TCAs due to underlying disease. Outcomes were assessed as: -effective, pain disappeared or no pain was experienced for 90% of each week; -moderately effective, pain improved, but did not disappear; -no effect, no change; and dropped out, including referral due to difficulty making visits because of the distance.For IFP, treatment was effective for 91 patients (73.4%), moderately effective, 3.2%, no effect, 0%, dropped out, 23.4%. For BMS, treatment was effective for 56 patients (78.9%), moderately effective, 4.2%, no effect, 1.4%, dropped out, 15.5%.Use of antidepressants can be helpful in the treatment of idiopathic orofacial pain such as IFP or BMS.


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 , 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  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. This report was written in autumn 2012, as we celebrated the 20th anniversary of the inception of the spine register. Historically, the register was introduced in 1992 at the state-of-the-art meeting, “The Degenerative Lumbar Spine” in Lund during an evaluation symposium led by Gunnar Andersson. At that time, the register involved a short form completed by doctors, and was presented in Acta Orthopaedica Scandinavica 1993 (Strömqvist and Jönsson 1993). Prospective data registration was not common then and was enthusiastically welcomed by the majority of spine surgeons in Sweden. However, only 4–6 departments actually began recording data in the early years during the mid-1990s. Consequently, Peter Fritzell, Olle Hägg, Bo Jönsson and Björn Strömqvist, who were all interested in establishing a register, formed a group to analyze the problems and suggest improvements. In the late 1990s, responsibility for the spine register was transferred to the Swedish Society of Spinal Surgeons (4 s), the current owner of what is now known as the Swedish Spine Register/Swespine. A largely patient-based online registration form was designed to address preoperative and postoperative variables. In addition, the coordinators/secretaries Carina Blom and Lena Oreby developed and provided on-line support services over time; and it is fair to say that without this organization and without their efforts, the register would not be what it is today.These modifications, together with the conclusion that the register database should be stored on an “independent server”, that simplifications are crucial, and that physicians should be involved in the actual registering work as little as possible but instead be responsible for the analyses, reports and register-based improvement projects, changed the scene. In the late 1990s, the number of participating departments increased, and is currently varying between 35 and 39 of 42–45 departments providing spinal surgery services in Sweden (90 % coverage).This Annual 2012 Register Report contains, in addition to a default presentation of updated FU-results from all spinal procedures covering degenerative disorders, an analysis specifically focused on total disc replacement (TDR).http://www.4s.nu/pdf/Report_2007_englishversion.pdf)Spinal stenosis Disc herniation (http://www.4s.nu/pdf/Report_2011_Swespine_Englishversion.pdf)Isthmic spondylolisthesis (http://www.4s.nu/pdf/Englishversion%20_report2009.pdf).Segmental pain/DDD .The surgical data are the only data completed by the surgeon at the time of discharge from hospital, and include diagnosis, procedure, implant (if any), hospitalization time, antibiotic prophylaxis and occurrence of complications.At follow-up, the same data (PROM) as registered at baseline are completed and also patient-based evaluation of leg and back pain as compared to preoperatively  of outcome, meaning that the patient reports the change with respect to the indication for surgery (for example change in leg pain in LDH-patients). Overall satisfaction with outcome  also was graded by the patients.The group “spondylolisthesis” refers to patients with isthmic spondylolisthesis.In this report, a total of 7,208 patients who had had lumbar spine surgery for different diagnoses, at a total of 43 departments, were entered in the register in 2011. The corresponding figure for 2010 was 6,992 patients from 38 departments.The distribution of diagnoses for patients operated in 2011 was as follows: disc herniation 28 %, central spinal stenosis 45 %, lateral spinal stenosis 7 %, spondylolisthesis 4 %, segmental pain/DDD (disc degenerative disorder) 8 % and other 8 %, see Fig. Diagnosis-related patient demographics and surgical data are presented below.In 2011, 2,118 patients operated for lumbar disc herniation were registered in Swespine. There were 55 % men and 45 % women. The proportion of smokers was 17 %. The mean age was 45 (15–91) years, Fig. For 88 % of patients, this discectomy was their first lumbar spine surgery, while 12 % had been previously operated.Preoperative duration of back pain was as follows: 6 % reported no back pain, 11 % had a history of less than 3 months of back pain, 48 % 3–12 months, 15 % 1–2 years and 20 % more than 2 years. Preoperative duration of leg pain/sciatica was as follows: 1 % reported no leg pain, 16 % had leg pain for less than 3 months, 55 % for 3–12 months, 16 % for 1–2 years and 16 % had pain for more than 2 years. Mean back pain on the visual analog scale (VAS) was 48 with a spread from 0 to 100, while mean leg pain/sciatica on the VAS was 67 with the same spread from 0 to 100. Distribution regarding both back and leg pain can be seen in Figs. Regular analgesic use was reported by 64 % of patients, intermittent use by 26 %, while 10 % reported that they did not take any form of analgesics.Walking distance was estimated at less than 100 m by 31 % of patients, 100–500 m by 23 % of patients, 500 m–1 km for 15 % of patients and more than 1 km by 31 % of patients.Conventional discectomy was carried out in 45 % of cases and microscopic discectomy in 41 %. The remaining procedures consisted of various combinations mainly involving decompressive surgery for patients with disc herniation with spinal stenosis. Mean length of stay in days, i.e., time from surgery through discharge, was 2.73 (0–22).A total of 3,367 patients were registered for operations for central spinal stenosis in 2011. The patients included 44 % men and 56 % women. Mean age was 68 (23–95) years. Figure The proportion of smokers was 10 %. For 79 % of patients, this operation was their first surgery, while 21 % had been previously operated one to three times.Preoperative duration of back pain was as follows: 5 % reported no back pain, 2 % had a history of less than 3 months of back pain, 16 % 3–12 months, 23 % 1–2 years and 55 % more than 2 years. Regarding leg pain, 4 % of patients reported no leg pain, 2 % of patients with central spinal stenosis reported leg problems for less than 3 months, 24 % for 3–12 months, 29 % for 1–2 years and 41 % reported problems for more than 2 years.Mean back pain on the VAS in the group was 58 (0–100) and mean leg pain/sciatica (VAS) 63 (0–100). Figures Of patients with central spinal stenosis, 55 % reported regular use of analgesics, 29 % reported intermittent use and 15 % reported that they did not take any analgesic medication.Walking distance was estimated at less than 100 m by 40 % of patients, 100–500 m by 31 % of patients, 500 m–1 km for 15 % of patients and more than 1 km by 14 % of patients.72 % of the patients had decompressive surgery as the sole procedure, in 52 % conventional surgery and in 21 % of cases microscopic surgery. Decompression combined with posterior instrumented fusion was carried out in 20 % of the patients, decompression + posterior non-instrumented fusion in 3 %, decompression + TLIF in 1 % and other procedures in 4 %. Mean length of stay in days was 4.31 (0–29).During the year, 532 patients were operated for lateral spinal stenosis. The patients included 52 % men and 49 % women. The group included 16 % smokers. Mean age was 61 18–88) years; Fig. –88 yearsThe majority of patients with lateral spinal stenosis, 75 %, had had no previous spine surgery while 25 % had been operated on one or more times before the current procedure.Preoperative duration of back pain was as follows: 6 % reported no back pain, 2 % had a history of less than 3 months of back pain, 19 % 3–12 months, 18 % 1–2 years and 54 % more than 2 years. Regarding leg pain, 1 % of patients with lateral spinal stenosis reported no leg pain, 2 % of patients reported leg problems for less than 3 months, 27 % for 3–12 months, 29 % for 1–2 years and 41 % reported problems for more than 2 years. Mean back pain on the VAS in the group was 56 0–100) and mean leg pain (VAS) 67 (0–100). Figures 0 and meaRegular analgesic use was reported by 60 % of patients, intermittent use by 29 %, and 12 % reported that they did not take any analgesics. The majority of patients reported limited walking ability, 28 % reported that they were able to walk less than 100 m, 32 % were able to walk 100–500 m, 20 % 500 m–1 km and 20 % had a walking distance of more than 1 km.Decompression surgery was the type of procedure in the majority of cases, 72 %, including 49 % conventional, 23 % microscopic decompression, 18 % had decompression + posterior instrumented fusion and 3 % decompression + TLIF. Mean length of stay  was 3.5 (0–23) days.A total of 323 patients, including 47 % men and 53 % women, were reported for 2011. This group included 12 % smokers. Mean age was 50 (14–82) years and Fig. For 89 % of patients, the current procedure was the first time they had surgery on the lumbar spine, while the remainder had one or two previous procedures.Preoperative duration of back pain was as follows: 2 % reported no back pain, 1 % had a history of less than 3 months of back pain, 11 % 3–12 months, 19 % 1–2 years and 66 % more than 2 years. Regarding leg pain, 6 % of patients with spondylolisthesis reported no leg pain, 1 % reported leg problems for less than 3 months, 18 % 3–12 months, 29 % 1–2 years and 47 % reported problems for more than 2 years.Preoperative lumbar pain on the VAS was 62 (0–100) and preoperative leg pain was 55 (0–99). Figures Regular analgesic use was reported by 48 % of patients, intermittent use by 37 %, while 14 % did not use analgesics.Walking distance was estimated to less than 100 m by 22 % of patients, 100–500 m by 24 % of patients, 500 m–1 km by 20 % of patients and more than 1 km by 34 % of patients.Patients with spondylolisthesis had a variety of different procedures. They are presented in descending order of frequency: decompression + instrumented fusion 53 %, posterior instrumented fusion 15 %, PLIF with or without foreign implant 14 %, decompression + TLIF 4 %, decompression + non-instrumented fusion 3 %, decompression + PLIF 1 %, posterior non-instrumented fusion 1 % and decompressive interventions in the remaining cases. Mean length of stay in days was 5.54 (1–27).A total of 620 patients were registered for surgical intervention for DDD in 2011, including 43 % men and 57 % women. The proportion of smokers was 11 %. Mean age was 47 (16–80) years; Fig. In this group of patients, 68 % had lumbar spine surgery for the first time, while 32 % had been operated one or more times previously.Preoperative duration of back pain in patients with DDD was as follows: 0.4 % reported no back pain, 0.2 % had a history of less than 3 months of back pain, 9 % 3–12 months, 16 % 1–2 years and 75 % more than 2 years. Regarding leg pain, 18 % of patients with DDD reported no leg pain, 2 % reported leg problems for less than 3 months, 16 % 3–12 months, 18 % 1–2 years and 47 % reported problems for more than 2 years.Estimation on the VAS scale for back pain showed a mean of 65 (0–100) and leg pain, 43 (0–100). Figures Regular analgesic use was reported by 61 % of patients, intermittent use by 31 %, while 8 % never took analgesics.Walking distance was estimated at less than 100 m by 15 % of patients, 100–500 m by 21 % of patients, 500 m–1 km by 19 % of patients and more than 1 km by 45 % of patients.A heterogenous surgical treatment spectrum was also seen for this diagnosis as follows: posterior instrumented fusion 29 %, PLIF 18 %, disc replacement 18 %, decompression + posterior instrumented fusion 14 %, TLIF 5 %, decompression + TLIF 5 %, decompression + PLIF 4 %, ALIF with instrument 2 %, posterior non-instrumented fusion 1 %, decompression + posterior non-instrumented fusion 1 % and a smaller quantity in other interventions. Mean length of stay was 5.08 (1–18) days.n = 159) are not presented in the following results.A total of 7,051 patients were operated in 2010 and 5,124 (73 %) completed 1-year follow-up. The distribution is as follows: disc herniation 1,365, central spinal stenosis 2,412, lateral spinal stenosis 399, spondylolisthesis 259 and DDD 530. Patients with “other operations”  years.Mean preoperative VAS for back pain was 46, compared with 26 at follow-up. The corresponding figures for leg pain were 67 preoperatively, and 22 at follow-up. Figures Perceived improvement relating to back pain: completely pain-free 20 %, significantly improved 45 %, somewhat improved 17 %, unchanged 6 %, deteriorated 5 % and 7 % did not report preoperative back pain.Perceived improvement relating to leg pain : completely pain-free 35 %, significantly improved 37 %, somewhat improved 15 %, unchanged 6 %, deteriorated 5 % and 2 % did not report preoperative leg pain.Overall patient satisfaction with surgical outcome: 78 % were satisfied, 15 % uncertain and 7 % dissatisfied.Use of analgesics 1 year postoperatively: regular 17 %, intermittent 31 % and none 52 %.Ability to walk 1 year postoperatively: <100 m 5 %, 100–500 m 8 %, 500 m–1 km 11 %, >1 km 76 %, a substantial improvement compared with preoperatively.Figure The results from the EQ-5D analysis are presented both as an EQ-5D index value, i.e. the answers of the five questions included in the questionnaire presented as an index value where 1 represents perfect quality of life and 0 represents “equal to death”, and also on the VAS scale, EQ-VAS, ranging from 0 to 100 where a high value is better. The results for lumbar disc herniation are as follows: the mean EQ-5D index value preoperatively was 0.26, and 1 year postoperatively it was 0.71. The mean EQ-VAS preoperatively was 46, and 1 year postoperatively it was 72.This group includes 2,412 patients, 45 % men and 55 % women, with a mean age of 68 (18–95) years.Mean preoperative VAS for back pain was 56, compared with 35 1 year postoperatively. The corresponding figures for leg pain were 63 and 34, respectively. Figures One year postoperatively, 16 % of patients felt they were completely pain-free, 36 % significantly improved, 18 % somewhat improved, 13 % unchanged, 9 % deteriorated with regard to back pain and 8 % reported no preoperative back pain. The corresponding figures for leg pain were 24 % completely pain-free, 29 % significantly improved, 18 % somewhat improved, 12 % unchanged and 11 % deteriorated and 7 % reported no preoperative leg pain.Overall patient satisfaction with outcome of the procedure was as follows: 64 % were satisfied, 22 % uncertain and 13 % dissatisfied with the surgical outcome.Analgesic use 1 year postoperatively: regular 31 %, intermittent 33 % and none 36 %.Ability to walk 1 year postoperatively: <100 m 20 %, 100–500 m 21 %, 500 m–1 km 17 % and >1 km 42 %, which was a substantial improvement compared with preoperatively.In addition, 1 year postoperatively, patients in the central spinal stenosis category demonstrated improvement of SF-36 score in all dimensions except “General health”. The improvement was less pronounced than in the disc herniation group, but was probably similar when adjusted for age, see Fig. The mean EQ-5D index value preoperatively: 0.35, and 1 year postoperatively 0.63. Mean EQ-VAS preoperatively (max 100): 48, 1 year postoperatively 64.This patient group included 335 patients, 50 % men and 50 % women, with a mean age of 61 (26–88) years.Mean preoperative VAS for back pain was 53, compared with 33 1 year postoperatively. The corresponding figures for leg pain were 65 and 34, respectively. Figures One year postoperatively, 14 % of patients were completely pain-free, 33 % significantly improved, 22 % somewhat improved, 13 % unchanged, 11 % deteriorated with regard to back pain and 8 % reported no preoperative back pain. The corresponding figures for leg pain were 24 % completely pain-free, 30 % significantly improved, 21 % somewhat improved, 13 % unchanged, 9 % deteriorated and 3 % reported no preoperative leg pain.Patient satisfaction with surgical outcome: 62 % satisfied, 25 % uncertain and 14 % dissatisfied.Medication use 1 year postoperatively: 30 % regularly, 33 % intermittently and 38 % took no medication.Ability to walk 1 year postoperatively: <100 m 15 %, 100–500 m 19 %, 500 m–1 km 17 % and >1 km 49 %.The patient group operated for lateral spinal stenosis also showed improvement in SF-36 scores, though somewhat less pronounced, see Fig. The mean EQ-5D index value preoperatively was 0.35, and 1 year postoperatively 0.62. The mean EQ-VAS preoperatively was 47, and 1 year postoperatively 65.In all, 247 patients, 45 % men and 55 % women, operated during the period for spondylolisthesis completed 1-year follow-up. Mean age was 50 (11–83) years.Mean preoperative VAS for back pain was 60, compared with 29 1 year postoperatively. The corresponding figures for leg pain were 52 and 23, respectively. Figures At the 1-year follow-up, 15 % of patients felt they were completely pain-free, 47 % significantly improved, 18 % somewhat improved, 9 % unchanged, 7 % deteriorated with regard to back pain and 4 % did not report back pain preoperatively. The corresponding figures for leg pain were 27 % completely pain-free, 39 % significantly improved, 13 % somewhat improved, 7 % unchanged, 6 % deteriorated and 9 % reported no preoperative leg pain.Overall patient satisfaction with outcome of the operation: 73 % satisfied, 16 % uncertain and 11 % dissatisfied.Regular intake of analgesics 1 year postoperatively was reported by 23 %, intermittent use by 32 % and no intake of analgesics at all by 45 %.Ability to walk 1 year postoperatively: <100 m 7 %, 100–500 m 11 %, 500 m–1 km 13 % and >1 km 70 %, a substantial improvement compared with preoperatively.Spondylolisthesis patients showed good improvement in their SF-36 scores 1 year postoperatively compared with preoperatively, see Fig. The mean value for EQ-5D preoperatively was 0.37, and 1 year postoperatively 0.69. The mean EQ-VAS preoperatively was 48, and 1 year postoperatively 68.In all, 1-year follow-up was completed by 518 patients, 48 % men and 52 % women, operated during the period. Mean age was 45 (18–80) years.Mean preoperative VAS for back pain was 62, compared with 30 1 year postoperatively. The corresponding figures for leg pain were 42 and 23, respectively. Figures One year postoperatively, patients operated for DDD perceived back pain as follows: completely pain-free 20 %, significantly improved 47 %, somewhat improved 17 %, unchanged 7 %, deteriorated 8 % and 1 % reported no back pain before surgery. The corresponding figures for leg pain: completely pain-free 26 %, significantly improved 28 %, somewhat improved 15 %, unchanged 7 %, deteriorated 9 % and 14 % reported no preoperative leg pain.Regarding patient satisfaction with outcome of the operation: 74 % were satisfied, 14 % uncertain and 12 % dissatisfied.Among these patients, 26 % took analgesics regularly 1 year postoperatively, 30 % did so intermittently and 44 % reported that they did not use any analgesics.Ability to walk 1 year postoperatively: <100 m 6 %, 100–500 m 9 %, 500 m–1 km 13 % and >1 km 73 %, a substantial improvement compared with preoperatively.Figure The mean EQ-5D index value preoperatively was 0.33, and 1 year postoperatively 0.65. The mean EQ-VAS preoperatively was 44, and 1 year postoperatively 68.Below is a comparison of pre- and postoperative “disability” as measured by the Oswestry index. All diagnoses show a significant reduction in measured functional limitation; most pronounced is disc herniation, see Fig. A total of 3,912 patients operated on in 2009 have completed preoperative, 1- and 2-year follow-up postoperative protocols. The most common diagnoses are disc herniation, 1,035 and central spinal stenosis, 1,907 patients. In all, 249 patients had been operated for lateral spinal stenosis, 1,202 for spondylolisthesis and 391 for DDD. The remaining 102 had other diagnoses. Below is a comparison of several parameters assessed at 1- and 2-year follow-up. Only patients who responded on all three occasions are included.Table A total of 1,840 patients completed 1, 2 and 5-year follow-up after having undergone lumbar spine surgery in 2006. The most common diagnoses are disc herniation, 581 and central spinal stenosis, 706 patients. In all, 140 patients had been operated for lateral spinal stenosis, 130 for spondylolisthesis and 230 for segmental pain (DDD). The remaining 53 had other diagnoses Table . Below iPain on the VAS, diagnosis-related, is remarkably stable over time Table . Tables In 2011, 698 patients were included in the register after surgery for degenerative cervical spine disease, including 53 % men and 47 % women. In all, 20 % of the patients were smokers and 10 % had previously undergone cervical spine surgery.Preoperative duration of pain was as follows: <3 months 2 %, 3–12 months 24 %, 1–2 years 20 % and more than 2 years 45 %, while 9 % denied any neck pain. Patients experienced radiation of pain to the arm(s) as follows: 4 % of patients for <3 months, 32 % for 3–12 months, 24 % for 1–2 years and 33 % for more than 2 years, while 7 % denied any arm pain.Regular consumption of analgesics was confirmed by 53 % of patients, intermittent by 30 % and none by the remaining 17 %.Estimated walking distance was reported by 13 % of patients to be <100 m, 12 % 100–500 m, 16 % 500 m–1 km and 59 % >1 km. In all, 75 % reported subjective deterioration of fine motor function in their hands.Co-morbidity was reported in the form of heart disease 2 %, neurological disease 3 %, cancer 0 %, other disease affecting ability to walk 9 %, or other disease causing pain 13 %, while 72 % denied any co-morbidity.Mean neck pain on the VAS was 55 with a spread from 0 to 100. The corresponding figures for arm pain were 53 with a spread from 0 to 100.Mean preoperative EQ-5D index value was 0.38 for patients, while the results of the Neck Disability Index (NDI) were as follows: mean 62.6. Distribution on the European myelopathy score was 15.11.In all, 44 % of the patients were operated for cervical disc herniation, 26 % for cervical spinal stenosis, 23 % for cervical foraminal stenosis, 1.48 % for segmental neck pain, 1.9 % for rheumatoid arthritis and 0.1 % for ankylosing spondylitis; 3.2 % were operated for some other diagnosis.With respect to the clinical presentation, 12 % of patients had no neurological findings, 59 % radicular involvement, 23 % medullary involvement and the remaining 6 % combined radicular and medullary involvement.Horizontal instability between C1 and C2 was seen in 2 % of cases, vertical between C0 and C2 in <1 % of cases and subaxial instability between C2 and Th1 in 2.7 % of cases. Combined instability was assessed to be present in 0.6 % of cases.Disk removal without fusion <1 %Disc removal with fusion without plate 2 %Disc removal with fusion with plate 9 %Disc removal with fusion cage without plate 20 %Disc removal with fusion cage with plate 35 %Corpectomy 7 %Disc replacement 5 %Laminectomy without fixation 4 %Laminectomy with fixation 6 %Laminoplasty <1 %Foraminotomy 6 %Combination laminectomy/foraminotomy 2 %Posterior fixation without decompression 2 %Other procedure without implant <1 %, andOther procedure with implant 2 %.Surgical interventions were performed as follows:Anterior implant was used in 80 % of cases and posterior in 10 % of cases.About 76 % of the 620 patients operated in 2010 also had 1-year follow-up. Average preoperative NDI was 63 and postoperative 47. Radiculopathy/arm pain improved from an average of 48 on the VAS preoperatively to an average of 26 postoperatively.Corresponding subjective scoring of change in arm pain 1 year postoperatively: greatly improved 53 %, somewhat improved 18 %, unchanged 23 and 7 % perceived worsening.Patient assessment of change in walking distance 1 year postoperatively: >100 m 9 %, 100–500 m 12 %, 0.5–1 km 14 % and >1 km 64 %.Quality of life as measured by EQ-5D improved from mean 0.39 preoperatively to 0.64 postoperatively at 1 year.This diagnostic category has been recently added to Swespine and totally 2,299 fractures have been recorded. However, only limited and mainly preoperative data are available to date.In 2011, 423 operations were registered for spinal column fractures. The majority of patients subjected to surgery for vertebral fractures belonged to the age group 60–69 years, and 65 % were male. In all, 22 % of patients operated had some degree of neurological damage, and 92 % of the procedures registered were carried out at university hospitals. According to AO classification, 31 % of the fractures were type A, 46 % type B and 23 % type C Table .Table 30The single largest group of fractures in the register involved Th11–L2 fractures. Of the fractures registered, 86 % were operated with posterior fusion with or without decompression and 4 % with vertebroplasty. Even here, the most common age group was 60–69 years, but these fractures also have a clear peak at age 20–29 years as they include both high-energy injuries in younger and middle-aged patients and osteoporotic fractures in older patients.Neurological involvement in the form radiculopathy was seen in 20 % of cases and in the form myelopathy in 21 % of cases with the following distribution according to the Frankel Scale: A 28 %, B 9 %, C 19 %, D 24 % and E 20 % Table .Table 31Two years after surgery, 72 % of the patients were satisfied with the outcome of the procedure, 21 % uncertain and 6 % dissatisfied. However, many of the patients probably had no or very moderate back pain before the fracture and have difficulty assessing what the status would have been without surgery. Of those who worked before the fracture, 38 % returned to work full-time and 15 % had returned to work part-time. In all, 29 % of patients took analgesics regularly and 33 % occasionally. The mean EQ-5D index value was 0.66 2 years after the procedure.This diagnostic category has also been recently added to Swespine and contains totally 794 operations for spinal metastasis. To date, only limited and mainly preoperative data are available.In all, 211 patients were registered for spinal metastasis surgery in 2011. 8 % of the patients were smokers. Indications for surgery are as follows: neurological involvement 53 %, back/leg pain 14.5 %, progressive deformity 1.4 %, neurological involvement + back/leg pain 18.8 %, neurological involvement + progressive deformity 2.2 %, back + progressive deformity 3.6 %, neurological involvement + back + progressive deformity 6.5 %. For the remaining 34.6 %, the indication for surgery was not reported.The primary tumor was known in 72 % of cases and unknown in 28 %. Among known primary tumors, the following were most common: prostate 41 %, breast 9.8 %, kidney 3.9 %, thyroid 1 %, lung 10.8 %, blood-forming organs 12.7 %, GI tract 2.9 % and other 17.6 % Table .Table 32In 41.8 % of cases, a pathologic fracture was diagnosed. Neurological involvement was distributed as follows on the Frankel Scale: A 6 %, B 6.7 %, C 32.8 %, D 31.3 % and E 23.1 %. Preoperative analgesic consumption was as follows: 81.9 % morphine analgesics, 13.4 % non-morphine analgesics and 4.7 % no analgesic consumption.Surgical procedures included posterior and anterior decompression as well as possible fusion. In all, 90 % had posterior decompression at the following levels: cervical, thoracic and lumbar levels, while 10 % had anterior decompression at the following levels: cervical, thoracic and lumbar. Fusion was carried out in 39 % of cases.Resection of the tumor was carried out in 84 % of cases; in 5 % of cases as wide excision, 19 % marginal excision, and 76 % intralesional excision.While quite common in European continental countries and subsequently in the US, only a few total disc replacements (TDR) were carried out in Sweden in the 1990s, but they are not included in the register. TDR has been performed more routinely and systematically in Sweden since 2003. Little scientific documentation is available. Two randomized FDA studies in the US have been published. However, their results have been strongly disputed and it is doubtful whether these results can be applied to Swedish conditions.TDR in Sweden has been evaluated in a randomized study published in a thesis in 2010 with 2-year follow-up .A total of 879 disc replacements in the lumbar spine have been registered in our database through the end of September 2012. Figure The diagnoses entered in the register are as follows: segmental pain 834, paramedian disc herniation 17, central disc herniation 11, postoperative instability 8, central spinal stenosis 3, isthmic spondylolisthesis 2, other diagnosis 2, and no information about diagnosis in two cases.The majority of operations (773) were carried out at one center and the remainder at five different centers.This analysis compares the 879 disc replacements with 3,066 fusions carried out during the same time period. Follow-up data for at least 1 year were available for 670 disc replacements and 2,517 fusions. Table The Full-time sick leave after surgery is consistently higher for TDR, probably due to the previously mentioned dissertation project carried out during the period. Table Global assessment, which means that the patient answers the question “How is your back pain today compared with before surgery?” and we have calculated the proportion of patients who state they are “pain-free or significantly improved”.Full-time sick leave after surgery.Patient satisfaction with the surgical outcome by asking the question “What is your opinion of the surgical outcome?” with response options “Satisfied, uncertain, dissatisfied”.Change in quality of life as measured by EQ-5D.Changes in back pain as measured by VAS.The results are presented in five different ways:Tables Figure Table The term “new index surgery” refers to a new operation carried out to address a new diagnosis in a different segment from prior surgery. Reoperation refers to a repeat procedure in the previously operated segment. In the fusion group, 457 of 3,066 (15 %) patients underwent a new fusion procedure in an adjacent segment. A new disc replacement procedure was carried out in 79 of 879 cases (9 %).Tables In Tables The documentation and follow-up rate are good for the results reported at 1- and 2-year follow-up, while the statistical base is smaller for the 5-year follow-up, which is why the interpretation of 5-year results is much more uncertain. However, the results at 1 and 2 years for patients who undergo disc replacement are significantly better in many respects than for patients who undergo fusion surgery. The finding that there was no difference in change (improvement) of quality of life may be explained by the fact that disc replacement patients begin at a higher level and therefore end at a higher level of quality of life. Also in regard to capacity to work, disc replacement patients fare better than fusion patients.The multivariate analysis also shows that the surgical procedure seems to be less important than several individual-dependent factors. Nevertheless, the surgical method should not be construed as irrelevant. However, it does express the differences in case mix between the two surgical groups. Patients who are candidates for disc replacement are a subgroup among those diagnosed with segmental pain with other prognostic factors than patients who are candidates for fusion. There is a selection process before surgery which most likely influences the outcome in favor of TDR.The results support the conclusion that TDR works as well as fusion in patients with lumbar pain due to degenerative disc disease. However, it must be underscored that patient selection appears to be more important than surgical method, and that TDR candidates have a better initial status than fusion patients as a group. This assessment also applies only to 1-year follow-up. Data from subsequent follow-ups are still insufficient. Problems with reoperations in the aftermath of surgical procedures for DDD, regardless of method, can still be seen and have not yet been resolved. It should also be noted that most TDR surgeries were performed at one clinic by the same surgeon, which is why the generalizability of these results must be questioned.TDR may be a viable alternative to fusion in a small group of patients with chronic low back pain who meet strict selection criteria; however, the time perspective is definitely a matter of concern, and the final comparison also cannot be based solely on registry data, but also requires prospective randomized studies.The number of patients entered in the surgery register for degenerative lumbar disorders has steadily increased in recent years, as illustrated in Fig. The increase is mainly due to more complete registration within Swespine over time but, also, due to a slight increase in surgical lumbar spine interventions. The annual number of operations for degenerative lumbar disorders  is approximately 8,000 which means that reporting today covers 90 % of the operations.The follow-up rate has been consistent over the last years and amounts to 79 % at 1 year and 67 % at 2 years. Figure The last decade has witnessed an enormous increase in research concerning spinal disorders and the outcome of spinal surgery. Also, a very high number of new implants and new techniques have been introduced on the market, some of which have gained a place in the surgical armamentarium and some of which have disappeared again.For the introduction of new methods and techniques, basic studies such as biomechanical testing, biochemical investigations, etc. are required. They should be followed by pilot studies and, after that, randomized-controlled trials comparing the new technique to the existing golden standard for the treatment modality in question.The final proof of the value of the new technique is documenting its effect when implemented in general practice, i.e. when it is utilized by spine surgeons in general. Here, broad registrations like local and national registers are important for giving us knowledge in this aspect. Other benefits from large registries are the possibilities to achieve quality assurance and observing trends and changes over time. Also, the documentation of the effect of a surgical procedure in the long-term is possible to evaluate. Due to this fact, an increasing interest has focused on large registries; and Swespine is among those being on the scene for the longest time and also being most disseminated.Another issue that registers can provide is international comparisons. Swespine has been recently adopted in Denmark (Danespine), Iceland (Icespine) and the Netherlands. Several other countries are interested in negotiating a collaboration of the same type. Other registers can be exemplified by Spine Tango, administered by the Spine Society of Europe, which already has several centers in Europe delivering data. Other registers, as the Norwegian spine register and the Singapore register, are examples of comprehensive and successful registers.http://www.issls.org/home.aspx.For this purpose, an international meeting on Spine registries is planned in conjunction with the upcoming meeting of the International Society for the Study of the Lumbar Spine (ISSLS) in Scottsdale, Arizona May 2013. If for example a common platform of baseline data (core data set) could be agreed upon, international comparisons would be strongly facilitated. The authors of this report, the Swespine Steering Group welcome all interest and contributions to this work, and we welcome all interested parties to Scottsdale on May 12;


A nummular headache is a headache that is characterized by pain localized to a small, circumscribed area of the head, typically measuring 2 to 6 cm in diameter in the absence of any lesion of the underlying structures.Neurotropin is a non-protein extract isolated from the inflamed skin of rabbits inoculated with the vaccinia virus that is used to treat neuropathic pain. In this study, we reviewed three cases retrospectively to assess the possible efficacy of neurotropin in patients with nummular headaches.Three nummular headache patients participated in this study. For each patient, the diagnosis of nummular headache was made based on the ICHD - II nummular headache diagnostic criteria. We prescribed neurotropin at a dose of 16 NU/day to the patients during the clinical course of this study.Case 1: A 39-year-old male developed bifocal pain one week previously in a circumscribed area of the left temporal region measuring 4 cm in diameter. Treatment with NSAIDs was determined to be invalid. Treatment with neurotropin relieved the patient's pain, and the headache resolved after four days. Case 2: A 57-year-old female developed bifocal pain one week previously in a circumscribed area including both temporal regions measuring 3 cm in diameter. Treatment with neurotropin relieved the patient's pain slightly; however, the headache remained. Case 3: A 71-year-old male developed pain more than one year previously in a circumscribed area of the left parietal region measuring 3 cm in diameter. Treatment with NSAIDs was determined to be invalid. Treatment with neurotropin relieved the patient's pain, and the headache resolved after three months. In two of the three cases of patients with nummular headaches, treatment with neurotropin was found to be very effective for pain reduction.The present results suggest that prescribing neurotropin may be a possible choice for treating patients with nummular headaches.


McKenzie and Back School treatment programs. These programs have good biological plausibility, are widely available and have a modest cost. Although these treatments are already available for patients, the evidence that supports their use is largely based on low quality methodological studies. Therefore, a high-quality randomised controlled trial is required to compare, for the first time, the effectiveness of these treatments in patients with chronic low back pain.Chronic low back pain is a highly prevalent condition, which is associated with high direct and indirect costs to the society. Although this condition is highly prevalent, it is still extremely difficult to treat. Two potentially useful treatments for patients with chronic low back pain are called the McKenzie or Back School principles. Clinical outcomes  will be obtained at follow-up appointments at 1, 3 and 6 months after randomisation. The data will be collected by an assessor who will be blinded to the group allocation.One hundred and forty-eight patients will be randomly allocated to a four-week treatment program based upon the McKenzie and Back School approaches in patients with chronic low back pain. The results of this trial may help in the decision-making process of allied health providers for the treatment of chronic low back pain and reduce the health-related costs of this condition.This will be the first study aimed to compare the ACTRN12610000435088 Low back pain is an important health problem with significant consequences from a socio-economic point of view and is associated with high costs, work absenteeism and disability. Prevalence estimates of low back pain vary considerably depending on the population being studied as well as with regards to the definition of a low back pain episode. The only systematic review on this topic estimated that the point prevalence of low back pain ranges from 12 to 33%, the one-year prevalence of low back pain ranges from 22 to 65%, and the lifetime prevalence of low back pain ranges from 11 to 84%[Given the high prevalence of this condition, low back pain is considered to be an important public health problem in many countries, including the United States , AustralEstimates of the prognosis of chronic low back pain are based on a limited number of studies. The largest prospective inception cohort that investigated the prognosis of chronic low back pain was conducted in Australia . This stEuropean Guidelines for the Management of Chronic Low Back Pain[European Guidelines, which suggest "that the effectiveness of specific exercise programs needs to be evaluated, specially programs that are commonly utilised but which have been inadequately researched (p. S196)"[A range of therapeutic possibilities are available for patients with chronic low back pain. These treatments include educational programs , cognitiBack Pain, where tBack Pain. Howeverp. S196)".Back School (a group-based treatment approach) and the McKenzie  methods are promising therapeutic options [The  options ,18 that Back School method was developed in 1969 in Sweden by Mariane Zachrisson Forssel, with the goal of preventing and avoiding recurrent episodes of low back pain. The program is composed of 4 sessions lasting approximately 45 minutes, being each session organised by theoretical components, which include: anatomy and spinal biomechanics; epidemiology; physiopathology of the most frequent back disorders; posture; ergonomics; common treatment modalities and a practical component [The hy back").McKenzie[McKenzie method consists of three steps: evaluation, treatment, and prevention. The evaluation step is conducted using repeated movements and sustained positions where the symptoms in the lower back and lower limbs are classified into three subgroups: 1) derangement syndrome, 2) dysfunction syndrome, and 3) posture syndrome [McKenzie method is based upon the direction  that can lead to the following possible responses: pain reduction, "centralisation of symptoms" , and the complete recovery of pain. The prevention step consists of educating and encouraging the patient to exercise regularly and self-care [In 1981, Robin McKenzie proposed a classification system and individualised treatment regimen for low back pain called "diagnostic and mechanical therapy" or, simply, the elf-care .McKenzie and Back School techniques in patients with chronic low back pain. Our goal is to conduct a robust, randomised controlled trial from both a methodological point of view as well as in terms of generalizability.Although both methods have been previously investigated, there have been criticisms regarding the methodological quality of these popular treatment programs for patients with chronic low back pain ,20. ExamAustralian and New Zealand Clinical Trials Registry (registration number ACTRN12610000435088).The study commenced recruitment in May 2011 at the outpatient Physiotherapy Clinic of the Universidade Cidade de São Paulo (UNICID), in São Paulo/Brazil. The study design, procedures and informed consent were approved by the Ethics Committee in Research of UNICID (research protocol number 1349394) and was prospectively registered  in the AAmerican College of Sports Medicine. Patients with serious spinal pathology , nerve root compromise, cardio respiratory illnesses, and pregnancy will be also excluded.We will recruit patients presenting with low back pain for at least three months and aged between 18 and 80 years. Participants with any contraindication to physical exercise  will be Potential participants in the study will be welcomed by the study assessor who will determine which patients will or will not participate in the study, in accordance with the previously described eligibility criteria. The patients will receive information about the study and the criteria for study eligibility. If the patient is considered eligible, the assessor will collect the baseline data prior to randomisation. The assessor will be blinded with regards to the allocation of patients into the treatment groups. The primary outcomes of our study are pain intensity and disability at 4-weeks after randomisation. The secondary outcomes are range of motion of trunk flexion at 4-weeks, pain intensity and disability in evaluations at 3 and 6 months after randomisation, and quality of life in the evaluations at 4 weeks, 3 months and 6 months after randomisation. The study assessor will be unaware of the treatment that the patients received. Given the nature of the study, it will not be possible for the therapist or the patients to be blinded, which is expected in studies that compare the effectiveness of complex interventions such as exercise therapy.(Back School or McKenzie) through a computer-generated randomisation schedule that was performed by one of the investigators who is not involved in the recruitment or treatment of the patients. The allocation of subjects will be concealed by using consecutive numbered, sealed and opaque envelopes [Immediately after the baseline evaluation, patients will be sent to the physiotherapist responsible for the interventions. Before initiating the treatment, the patients will be randomly allocated into the two treatment arms nvelopes . Before pain intensity will be measured by the Pain Numerical Rating Scale (NRS); 2) disability associated with back pain will be measured by the Roland Morris Disability Questionnaire; 3) a © Fleximeterwill be used for measuring the range of movement (ROM) of the trunk flexion, and 4) the WHOQOL-Bref [quality of life. A detailed description of each of these instruments is described as it follows.To evaluate the participants, four instruments will be used: 1) QOL-Bref  will be Pain Numerical Rating Scale (NRS) measures the levels of pain intensity perceived by the patient using an 11-point scale that ranges from 0 to 10, where 0 is classified as "no pain" and 10 is classified as "worst possible pain"[The ble pain",26. The Roland Morris Disability Questionnaire is an instrument that is widely used in research and clinical practice for the measurement of disability associated with low back pain and has been translated, cross-culturally adapted and clinimetrically tested for the Brazilian population [The pulation -27. It i©Fleximeter) is a measurement tool used for measuring flexibility and range of motion through an angular scale based on the mechanism of gravitational action. As it is an instrument that does not have articular vertices, but rather has a velcro that is placed at the articulation of interest which allows a number of diverse joint movements to be isolated, guaranteeing a measurement precision. The range of back flexion movement will be measured with the patient in orthostatic position with their knees extended and arms crossed across the thorax. The fleximeter will be positioned laterally in the thoracic region at breast height with the subject facing the assessor. The patient will be asked to bend his/her trunk to the maximum range possible. For logistical reasons , we will measure ROM only at the baseline and at the 4 weeks follow-up.The Fleximeter .The QOL-Bref  quality Back School method requires four treatment sessions [McKenzie method group in order to standardise the total treatment time for both groups. Table As the sessions , the samMcKenzie group will receive four individual sessions, once per week, lasting an average of 45 minutes to an hour each. Treatment will be provided in accordance with the direction of the preference of movement, or rather, flexion, extension or lateral shift of the spine [Participants in the he spine . The proBack School group will receive four treatment sessions, once per week, lasting an average of 45 minutes to one hour each. As the participants will commence the treatments immediately after randomisation; the first session of the Back School method will be conducted individually. The remaining sessions will be conducted as group sessions. The program will be divided based on theoretical and practical information (Tables The participants in the n Tables  and 3.Pain Numerical Rating Scale[The sample size calculation for this study was performed to detect a between-group difference of 1 point in the outcome pain intensity as measured by the Portuguese version of the ing Scale (with aning Scale (with anSPSS 19 and SigmaPlot 10 will be used for this analysis.All of the statistical procedures will be conducted on a intention-to-treat basis . In our McKenzie and Back School methods in patients with chronic low back pain. The results of this study will be published once the study is concluded.In this study, we present the rationale and design for a randomised controlled trial comparing the effects of the The authors declare that they have no competing interests.ANG, FLBG, RAC, FNC and LOPC were responsible for designing the study. TMS and LCMC will act as the study coordinators. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/12/179/prepub


Post endodontic pain is often linked to the inflammatory process as well as additional central mechanisms. The purpose of the present double-blind randomized clinical trial study was to compare the prophylactic effects of a derivative of Zingiber Officinale, Zintoma, and Ibuprofen on post endodontic pain of molars with irreversible pulpitis.The post endodontic pain of 72 enrolled patients suffering from irreversible pulpitis was assessed after prophylactic use of 400 mg Ibuprofen, 2 gr Zintoma and placebo. Using the Heft-Parker Visual Analogue Scale, the patients recorded their perceived pain before taking the medicament (baseline), immediately after and also at 4, 8, 12, 24, 48, and 72 h post one-visit endodontic treatment. The statistical analysis was done using Kruskal-Wallis, Mann-Whitney, and Freedman tests (P<0.05).At all times, there was significant difference between the Ibuprofen and Zintoma (P<0.05) and also between the Ibuprofen and placebo (P<0.05). However, there was no significant difference between Zintoma and the placebo in any of time intervals (P>0.05). No side effects were observed.The obtained results of the trial revealed that prophylactic use of 2 gr Zintoma is not an effective pain relieving agent. Pain control during and after endodontic treatment is one of the most important issues in endodontics , 2. It hZingiber officinale , commonly known as ginger is an anti-inflammatory agent for musculoskeletal diseases. Recently, there has been a lot of research performed on using the active ingredients of ginger and understanding it pharmacological effects in patients [Z.officinale is a complex mixture of pharmacological compounds containing several hundred known constituents, including gingerols, beta-carotene, capsaicin, caffeic acid, curcumin, and salicylate [Z.officinale and it’s constituents-particularly shogaols-have agonize vallinoid (capsaicin) receptors TRPV1, which are involved in the central and peripheral processing of noxious stimuli [NSAIDs are generally considered to be the most effective treatment for inflammation and hence inflammatory pain. However, the many adverse effects, most important of which are gastrointestinal and cardiovascular, may outweigh the benefits . That ispatients . Z.officlicylate -20. It hlicylate . In addi stimuli .Zintoma. Direct and indirect capabilities of Z. Officinale for pain management are well documented [Zintoma (a derivative of Ginger) and Ibuprofen on post endodontic pain related to one-step treatment of molar teeth with irreversible pulpitis. There are a lot of studies conducted on the prophylactic effects of the prescribed chemical drugs on post endodontic pain , 13, 22,cumented , 21; theThis study has been independently reviewed and approved by the ethics committee of Babol University of Medical Sciences , and has been submitted on the website of Iranian Registry of Clinical Trial (ID No: IRCT138903174116N1). The initial sample size has been determined based on the power of 0.9 and the type I error of 0.05, with 30 subjects in each group . The inclusion criteria included: healthy persons (ASA I or II), age 18 to 65, active pain in one of the mandibular molars, prolonged pain to cold test, spontaneous pain reported , normal priapical view on radiographs, the patients ability in reading, comprehending and filling out the VAS form. The samples with the following criteria were excluded from the study: pain in more than one tooth, the existence of contributory medical history, allergy to lidocaine, NSAIDs or ginger, pregnancy or lactation, use of any sedatives or analgesics within the past 24 h, non-restorable tooth, tooth that was over instrumented or overfilled during treatment and where the patient was unable to comprehend the protocol of the study or sign the informed consent. The clinical diagnosis of irreversible pulpitis was done through the intense or prolonged reaction to cold stimuli for at least 10 sec, and the existence of reaction to the electric pulp tester .Zintoma, and placebo, using the “simple randomized allocation” method. It means each subject entering our study was allotted to one group by sequence.After explaining the nature, purpose of the study and any probable risk and side effects of drug/treatment to the 90 participants, the written informed consent was obtained. Before taking the drugs, the patients were asked to record their pain intensity based on VAS as baseline, which was taught to the participants. Afterwards, the patients were randomly aligned into 3 groups of Ibuprofen, The three drugs had been prepared by a pharmacologist in the same color and size capsules made of hard gelatin, and put in similar specially encoded pockets. The pharmacologist was in charge of encoding the capsules, in a way that neither the operator  nor the patient was informed of the drug. According to the group dedicated, each of the subjects was given a pack of the drugs along with Acetaminophen 325 mg . The design of using drug for each group was as follows:Ibuprofen Group: 1.5 h before the treatment, 2 placebo capsules and 0.5 h before the treatment, 2 capsules, one of which including placebo and the other having 400 mg Ibuprofen . Placebo capsules were given in this group to mirror the number of capsules given in the Zintoma group.Zintoma Group: 1.5 and 0.5 h before the treatment, each time two 500-mg capsules of Zintoma  given. Active ingredient in each 500-mg capsule is 2.5 mg, .Placebo Group: 1.5 and 0.5 h before the treatment, each time 2 placebo capsules (Lactose powder) were given to the participants.In case of the rescue drug (acetaminophen), the patients were asked to record the time and amount taken. All the patients were treated by one practitioner who was a final year postgraduate student of endodontics from September 2010 until April 2011. Half an hour after taking the second dosage of the drug, one cartridge of anesthetic solution including 2% lidocaine with epinephrine 1:200000  was injected for inferior alveolar nerve block (IANB). Root canal therapy started 15 min after anesthesia injection, if lip numbness had been obtained as the first sign of IANB success; otherwise the same injection was repeated. If the patient had recorded any pain or sensitivity to cold after IANB and before the start of endodontic therapy or any time during the treatment, complementary anesthesia techniques  were used. After preparing the access cavity, isolation with rubber dam and canal negotiation, working length determination was performed with apex locator  and was verified through PA radiography taken with bisected technique (1 mm shorter than radiographic apex). The primary canal cleaning and shaping was done by #10 and #15 K-Files  and #20, 25 and 30 K-Flex files  in pressurless crown-down technique. Canal irrigation was performed with 2.5 % NaOCl. The coronal areas of the canal were enlarged with #2 and #3 Gates Glidden and then #15 to #35 Mtwo rotary files, canals were prepared sufficiently. After completion of cleaning and shaping, the canals were dried with paper point  and filled with nonstandard gutta-percha  and sealer AH26 with cold lateral condensation technique.The access cavity was sealed with the temporary restoration  and patient was referred for the permanent filling of the tooth.The VAS form was filled out by the patients immediately after temporization and then in 4, 8, 12, 24, 48, and 72 h, subsequently. Moreover, they were asked to fill out another form to record the time and amount of rescue (acetaminophen), if they had used it. The patients who had to take analgesic other than acetaminophen, because of intense pain or any other, were omitted from the study and replaced with other ones.The data were analyzed through software SPSS 16 and Kruskal-Wallis, Mann-Whitney, and Freedman tests. The level of significance was 0.05. It also should be mentioned that there was no conflict of interest in this study.Out of 90 patients entering this study, only 72 patients (80%) returned the questionnaires regarding post endodontic pain, meaning that the rest 18 subjects were lost to follow. The data related to number, age, gender, type of tooth, and initial pain score of each group has been shown in the P>0.05). Furthermore, there was no significant correlation between gender and tooth type with perceived post endodontic pain. There was no significant difference observed in terms of age, gender, the number of the first, second, and third molars in any of the groups and initial pain score (P>0.05).In the comparison between the post endodontic pain scores, at all times of the study, there was no significant difference between the three groups (P<0.05). In the two by two comparison between the groups at all times, the significant statistical difference was seen between the Ibuprofen and the Zintoma groups (P<0.05) and Ibuprofen and the Placebo groups (P<0.05). The pain score difference in each group was significant in different times (P<0.0001)  .P<0.05). There was no significant statistical difference observed as a result of taking acetaminophen by the patients in the three groups (P>0.05). Statistical analysis related to the rescue drug (Acetaminophen) showed no significance (P>0.05).The perceived pain by the patients in each of the three groups had been significantly reduced after the endodontic treatment  on the level of cytokines in periapical exudates and the post-treatment pain, showed that NAC can be a substitute for Ibuprofen in the management of post endodontic pain [et al, done to evaluate effectiveness of tenoxicam and Ibuprofen for pain prevention following endodontic therapy in comparison to placebo, prophylactic administration of a single dose of 20 mg tenoxicam or 200 mg Ibuprofen before root canal therapy provides an effective pain reduction at 6 h. Superiority of Ibuprofen to placebo was also confirmed in present research. Because of the advantages of tenoxicam, the authors suggested it may be useful as a prophylactic analgesic when post-endodontic pain is anticipated [Zintoma did not show effectiveness for pain relief in our trial may be due to its short -term usage. In another study done by Rogers et al, to compare the effect of intracanal use of ketorolac tromethamine and dexamethasone with oral Ibuprofen on post endodontic pain, no significant differences were demonstrated between Ibuprofen and either dexamethasone or ketorolac tromethamine which prophylactically had been used intra canal. Although Ibuprofen pain ratings were less than the placebo at all-time points [Although in this research, like the Seymour’s trial there was just a single dosage of Ibuprofen (400 mg) analyzed, the acceptable effect of the drug, was also determined. In the study by Attar research . In a stEtodolac . Of courtic pain , whereastic pain . In the icipated , wherease points , that isal, the prophylactic effect of prednisone was compared to placebo in terms of the endodontic pain, in which prednisone was more effective [et al. assessed the effect of supraperiosteal injection of dexamethasone on postoperative pain. According to their results, dexamethasone was considerably effective on controlling the severity of pain during the first 24 h; in contrast, there was no difference between dexamethasone and placebo groups 48 h after the first appointment. They concluded that a single dose of dexamethasone infiltrated around the apex of a tooth with irreversible pulpitis could be effective in reduction or prevention of postoperative endodontic pain during the first 24 h [In the research done by Jalalzadeh et ffective . Mehrvarrst 24 h . Up togeZ.Officinale were related to either clinical chronic or experimentally induced acute pains, none of which had been conducted to assess the analgesic effect of Z.Officinale in dental practice, [Z.Officinale on acute pain resulted from pulpitis.In our electronic search, all of the previous well-documented researches found regarding the analgesic effect of ractice, -46. ThatZintoma is an analgesic that is highly applied in medical science and has the least side effects. In most of the previous studies carried out on Zintoma such as the studies by Haghighi et al., Altman et al. and Bliddal et al., chronic use of the drug had significant difference with Ibuprofen in reducing the pain caused by osteoarthritis [rthritis -43.Zintoma, it could not present its anti-inflammatory and hence painkilling effect, and that can be why the findings indicated that the effect of Zintoma on post endodontic pain had no significant difference with the placebo. Another reason to mention for the little effect of Zintoma is related to the formation and continuation of all the inflammatory pains, such as the pain caused by tooth pulpitis, there have been a set of inflammatory mediators such as prostaglandins, serotonin, and histamine, with their synergic effect on each other [Zintoma, that reduce the production of new mediators which are specially of prostaglandin type, not only doesn’t prevent the action of previously-existent mediators of any type, but also are less effective on the activity of other types of inflammatory mediators, and as a result, might have no significant effect on the reduction of inflammatory pain. Hence, the patients who have the inflammatory pain, before the embark of the treatment, may use less prophylactic effect of this anti-inflammatory drugs, in short period, in comparison with those who don’t have the pain beforehand. This could be one of the reasons for the difference observed between the results of the various studies. In the present study, the hand and rotary instruments were applied using crown-down technique. Since among of the effective factors on the post endodontic pain is the extruded debris behind the apex. It has been shown that this technique would lead to the lesser extrusion of the debris behind the apex [In this study, which aimed at analyzing the short-term effect of ch other , 48. Howthe apex .Zintoma.It should be mentioned that use of placebo in this study had no conflict with ethical issues; since all the patients were informed of the procedure. Furthermore, it has been scientifically proved that the placebo along with the full pulpectomy of the teeth could cause pain reduction to 71% . In the Z.officinale to treat pain remains insufficient. However, the available data provide tentative support for the anti-inflammatory role of Z. officinale constituents, which may reduce the subjective experience of pain in some inflammatory conditions. Further trials, particularly in dentistry field, therefore, seem to be warranted.Due to a paucity of well-conducted trials, evidence of the efficacy of Zintoma (1 gr, 1.5 h and 1 gr, 0.5 h prior to commence of endodontic treatment is not effective for post-treatment pain relief in molar teeth with irreversible pulpitis. It is recommended that further studies be done as for this drug, so that an appropriate dosage of Zintoma could be determined for endodontic treatments.Regarding the results of this double-blind randomized clinical trial study, it can be concluded that the drug regimen of