Associations Between Catecholaminergic and Serotonergic Genes and Persistent Breast Pain Phenotypes Following Breast Cancer Surgery

In the United States, each year more than 230,000 women are diagnosed with breast cancer.66 The majority will undergo breast conserving surgery or mastectomy as part of their treatment regimen. Unfortunately, persistent pain following these procedures is a common problem that has deleterious effects on patients’ functional status and quality of life (QOL).23,43,68 Estimates of persistent pain following breast cancer surgery range from 25% to 60%.23 This type of persistent pain is characterized by burning, throbbing, or aching in the ipsilateral chest, axilla, and/or arm, and is associated with swelling and weakness.

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“I was a little surprised”: Qualitative Insights from Patients Enrolled in a 12-Month Trial Comparing Opioids to Non-Opioid Medications for Chronic Musculoskeletal Pain

Chronic musculoskeletal pain is a major public health problem, associated with disabling physical and emotional consequences for patients and with significant costs related to medical treatment and lost worker productivity.16 Use of opioid analgesics to treat chronic pain has increased dramatically in recent years,7,25 paralleled by increases in opioid-related harms, including addiction and death.1,23,34 While harms of opioids have become apparent, evidence for long-term effectiveness of opioids for chronic pain is lacking; a recent systematic review found no randomized trials that examined effects of opioids on pain, function, or quality of life at one year or longer.

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Oxidative stress contributes to fracture/cast-induced inflammation and pain in a rat model of complex regional pain syndrome

Complex regional pain syndrome (CRPS) develops after a range of injuries including fractures and soft tissue trauma to the extremities.43 The underlying mechanism of CRPS has not been fully elucidated and there are no specific medications approved for the treatment of CRPS. Oxidative stress results from an imbalance between ROS production and antioxidant defense systems. ROS have been implicated in many degenerative neurological conditions, such as Alzheimer's disease1 and Parkinson's disease18 and oxidative stress may also contribute to pain in various diseases, including fibromyalgia,26 diabetes,35,48 and CRPS.

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Psychological factors predict an unfavorable pain trajectory after hysterectomy: a prospective cohort study on chronic postsurgical pain

Chronic postsurgical pain (CPSP) is a well-recognized potential complication with negative personal, social, and health care consequences. However, limited data exist on CPSP and on the course of pain over time after hysterectomy. Using data from a prospective cohort study on a consecutive sample assessed at 4 time points, presurgery (T1), 48 hours (T2), 4 months (T3), and 5 years postsurgery (T4), we sought to examine women's PSP trajectories using assessments of pain at T3 and T4. In addition, this study aimed to investigate presurgical and postsurgical risk factors associated with an unfavourable pain trajectory (PT). Based on pain data collected at T3 and T4, 3 distinct trajectories of PSP emerged: no CPSP (PT1; n = 88), prolonged PSP (PT2; n = 53), and CPSP (PT3; n = 29). Moreover, reported CPSP prevalence at 5 years was 17.1%. Multinomial logistic regression models controlling for age, presurgical pain, and type of hysterectomy tested for baseline and acute postsurgical predictive variables. Membership in PT2 and PT3 was predicted by presurgical anxiety (odds ratio [OR] = 1.131, P = 0.015; OR = 1.175, P = 0.009, respectively), emotional representation of the surgical disease (OR = 1.155, P = 0.034; OR = 1.213, P = 0.020, respectively), and pain catastrophizing (OR = 1.079, P = 0.043; OR = 1.143, P = 0.001, respectively). Furthermore, acute PSP intensity and frequency determined membership of women in PT3 (OR = 1.211, P = 0.033; OR = 3.000, P = 0.029, respectively), and postsurgical anxiety (OR = 1.182, P = 0.026) also played a key predictive role. This study identified factors that can be easily screened before and after surgery and are amenable to change through carefully designed timely and tailored interventions for women at risk of an unfavorable PSP trajectory posthysterectomy.

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Modic Changes and Disc Degeneration of Nonfused Segments 27 to 45 Years After Harrington Instrumentation for Adolescent Idiopathic Scoliosis: Comparison to Healthy Controls

Study Design. A case-control study. Objective. The aim of this study was to investigate the long-term prevalence of the Modic changes and disc degeneration in the nonfused segments of the surgically treated adolescent idiopathic scoliosis (AIS) patients and compare with age- and sex-matched healthy controls. Summary of Background Data. No studies have looked at the association between Modic changes and low back pain in patients who underwent AIS surgery many years ago. Methods. Study subjects consisted of 194 patients with AIS who underwent spinal fusion with Harrington instrumentation between 1968 and 1987. Twenty-six patients (AIS group) underwent lumbar magnetic resonance imaging (MRI), whole spine X-ray, and patient-reported outcomes evaluations [Scoliosis Research Society-22 Patient Questionnaire (SRS-22), Oswestry Disability Index (ODI)]. The mean duration of follow-up observation was 36.1 years. The lowest fusion vertebra was used as follows: T12: 2 patients, L1: 4, L2: 11, L3: 6, L4: 2, L5: 1. Twenty-nine healthy age- and sex-matched individuals were selected as a control (CTR) group. Results. On the basis of MRI findings, a significantly higher percentage of subjects showed Modic changes in the AIS group (AIS group: 57.7%, CTR group: 13.8%). There were no significant differences in the percentage of subjects with disc degeneration rated Pfirrmann grade 4 or higher (AIS group: 61.5%, CTR group: 65.5%). SRS-22 scores for function and self-image were significantly lower in the AIS group. ODI was significantly worse in the AIS group. Modic changes in AIS group were found in the concave side of the curve in 61.9%. The magnitude of lumbar coronal curve was found to be a significant risk factor of Modic changes. Conclusion. Modic changes were observed in 57.7% of AIS patients 27 years or more after spinal fusion with Harrington instrumentation. The magnitude of lumbar coronal curve was found to be a significant risk factor of Modic changes. Modic change occurred at a higher frequency in AIS patients than CTR individuals, with lower function and worse ODI scores. Level of Evidence: 4

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Inter- and Intra-rater Reliability of the Hart-ISSG Proximal Junctional Failure Severity Scale

Study Design. Reliability/external validation study. Objective. Investigate inter- and intrarater reliability of the Hart-International Spine Study Group (ISSG) Proximal Junctional Failure Severity Scale (PJFSS) and its correlation with operative revision in patients with proximal junctional failure (PJF). Summary of Background Data. The Hart-ISSG PJFSS is a validated classification system for PJF. Reliability of the PJFSS has not been assessed. Methods. Sixteen detailed clinical scenarios were assessed using the ISSG PJFSS classification in six categories: neurologic status, axial pain, instrumentation issue, proximal kyphotic angle, level of upper instrumented vertebrae (UIV), and severity of UIV/UIV+1 fracture. Eleven spine surgeons evaluated each case in all six categories during two different assessments, and provided recommendations regarding operative revision or observation for each case. Inter- and intrarater reliability were calculated based on intraclass correlation coefficients. Results. All intraclass correlation coefficients demonstrated “almost perfect”’ (0.817–0.988) inter-rater agreement for both assessments, except UIV/UIV+1 fracture severity during the second assessment, which demonstrated “substantial” agreement’ (0.692). Five of six categories had “almost perfect” mean intrarater reliability (0.805–0.981), while “instrumentation issue” demonstrated “substantial” mean agreement (0.757). Inter-rater reliability for recommendation of surgical intervention was “almost perfect” during both assessments (0.911 and 0.922, respectively). Mean PJFSS scores between the two assessments were significantly higher for cases recommended for operative revision (8.43 ± 0.90) versus cases recommended for observation (P < 0.0001). Conclusion. The ISSG PJFSS is a reliable and repeatable classification system for assessing patients with PJF. Higher PJFSS scales correlate with recommendation for operative revision, extending prior external validation of the PJFSS. Level of Evidence: 3

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Idiopathic Spinal Epidural Fat Accumulation Is Associated With Hyperlipidemia

Study Design. Single-center retrospective analysis of consecutively collected data. Objective. To determine the clinical characteristics of idiopathic spinal epidural lipomatosis (SEL). Summary of Background Data. SEL is associated with the overt accumulation of nonencapsulated adipose tissue in the epidural space, leading to spinal cord or nerve root compression. The etiology of this condition is currently not completely understood. Methods. Data of 166 male patients who underwent primary surgery for lumbar spinal canal stenosis (LSS) from May 2013 to February 2016 were retrospectively reviewed. Participants were divided into three groups based on the degree of epidural lipomatous lesion. Patient data of age at surgery, body mass index, prevalence of common noncommunicable diseases, blood tests, arteriosclerotic index, and preoperative clinical scores (assessed using the Japanese Orthopedic Association Back Pain Evaluation Questionnaire) were evaluated. Multivariate analysis was performed to assess the potential associated factors for idiopathic SEL. Results. Patients with LSS with severe SEL had a significantly higher body mass index and elevated serum levels of total cholesterol and triglyceride compared with those without SEL. Analysis of preoperative clinical scores revealed that patients with SEL experienced pain more frequently and showed less walking ability than did those without SEL. Multivariate analysis revealed that hyperlipidemia was significantly associated with idiopathic SEL (odds ratio = 3.74, 95% confidence interval = 1.31–10.64). Conclusion. Our data suggest that aberrant lipid metabolism is related to the pathogenesis of idiopathic SEL and that patients with LSS with idiopathic SEL have more severe pain than do those without SEL. Level of Evidence: 3

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Preoperative Opioid Use is a Predictor of Poor Return to Work in Workers’ Compensation Patients After Lumbar Diskectomy

Study Design. A retrospective cohort. Objective. The aim of this study was to determine the impact of preoperative opioid use in workers’ compensation (WC) patients undergoing lumbar diskectomy (LD). Summary of Background Data. The prevalence of back pain among opioid users approached 60%. Long-term opioid dependence in spine surgery patients is roughly 20%. Despite pervasive use, there is no evidence to support long-term opioid analgesic use for back pain. Methods. Ten thousand five hundred ninety-two patients received compensation from the Ohio Bureau of Workers’ Compensation for a lumbar disc herniation between 2005 and 2012. Patients with spine comorbidities, smoking history, or multilevel surgery were excluded. Preoperatively, 566 patients had no opioid use, 126 had short-term opioid use (STO), 315 had moderate opioid use (MTO), and 279 had long-term opioid use (LTO). The primary outcome was whether subjects returned to work (RTW). Results. Seven hundred twelve (55.4%) patients met our RTW criteria. There was a significant difference in RTW rates among the no opioid (64.1%), MTO (52.7%), and LTO (36.9%) populations. Multivariate logistic regression analysis found several covariates to be independent negative predictors of RTW status: preoperative opioid use [P < 0.01; odds ratio (OR) = 0.54], time to surgery (P < 0.01; OR = 0.98 per month), legal representation (P < 0.01; OR = 0.57), and psychiatric comorbidity (P = 0.02; OR = 0.36). Patients in the LTO group had higher medical costs (P < 0.01), rates of psychiatric comorbidity (P < 0.01), incidence of failed back surgery syndrome (FBSS) (P < 0.01), and postoperative opioid use (P < 0.01) compared with the STO and no opioid groups. Conclusion. Preoperative opioid use was determined to be a negative predictor of RTW rates after LD in WC patients. In addition, long-term preoperative opioid use was associated with higher medical costs, psychiatric illness, FBSS, and postoperative opioid use. Even a short or moderate course of preoperative opioids was associated with worse outcomes compared with no use. For WC patients undergoing LD, judicious use of preoperative opioid analgesics may improve clinical outcomes and reduce the opioid burden. Level of Evidence: 3

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Double-Sided Mechanical Shocks Provoke Larger Seated Postural Reactions Compared With Single-Sided Mechanical Shocks

Study Design. Human volunteers were exposed experimentally to single-sided mechanical shocks (SSMS) and double-sided mechanical shocks (DSMS) while seated. Objective. The aim of this study was to describe and contrast seated postural reactions due to SSMS or DSMS in healthy male adults. Summary of Background Data. Mechanical shocks to the body, caused when driving on irregular terrain, are suggested to be hazardous to the spine and may be associated with the reported musculoskeletal pain of the back and neck among professional drivers. However, very little is known about the characteristics of seated postural reactions and the biomechanical effects caused by mechanical shocks. Methods. Twenty healthy male subjects (18–43 years old) were exposed while seated to 5 SSMS and 15 DSMS in lateral directions. The second acceleration in the DSMS was in the opposite direction to the first acceleration and was fast, medium, or slow depending on the speed of direction change. Surface electromyography (EMG) was recorded in muscles of the upper neck, trapezius, erector spinae, and external oblique, while kinematics were recorded with inertial sensors placed at the neck, trunk, and pelvis. Muscle activity was normalized to maximum voluntary contractions (MVCs). Results. The EMG amplitudes were significantly higher (0.6–1%; P < 0.001) for the fast DSMS than all other shocks. Range of motion (ROM) of the neck and trunk was greater during the DSMS than the SSMS. Evoked muscle activity was less than 2% MVC in the trapezius, less than 10% MVC in the erector spinae and upper neck, while the activity exceeded 10% MVC in the external oblique muscles. Conclusion. Fast DSMS in lateral directions appear more demanding than SSMS, demonstrating augmented seated postural reactions. However, the present mechanical shocks employed did not seem to induce postural reactions with regard to ROM or muscle activity of a magnitude likely to cause musculoskeletal overload. Level of Evidence: 4

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Prevalence and Correlates of Low Pain Interference among Patients with High Pain Intensity who are Prescribed Long-Term Opioid Therapy

Chronic pain is a multifaceted experience that involves physiological, psychological, and situational components.17 The experience of pain may vary widely among individuals; differences have been observed by gender,51 ethnicity,32,42 and even certain personality characteristics.41 The pain experience may also vary greatly among individuals reporting equally high levels of pain; while one may function poorly in several areas, another may experience minimal pain-related interference. Although sophisticated diagnostic tools (e.g., imaging studies) can assess anatomic contributions to pain, these are not reliable predictors of the extent to which pain affects functioning, disability, or quality of life.

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Verbal Instruction Can Induce Extinction of Fear of Movement-Related Pain

• We used electrodermal activity to examine fear conditioning and extinction.• Movement associated with fear of pain elicits sympathetic activity and fear.• Verbal instructions can attenuate conditioned fear of movement-related pain.

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Hunger is a gatekeeper of pain in the brain

Hunger is a gatekeeper of pain in the brain

Hunger is a gatekeeper of pain in the brain, Published online: 23 April 2018; doi:10.1038/d41586-018-04759-0

A neuronal population has now been found that regulates two competing needs — hunger and pain. Urgent pain overrides hunger, but appetite-inducing neuronal activity dampens long-term pain responses to enable feeding.

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The Rodent Tibia Fracture Model: A Critical Review and Comparison with the Complex Regional Pain Syndrome Literature

• This review compared a rodent tibia fracture model (TFM) to the CRPS literature• The TFM generated nociceptive and inflammatory symptoms resembling early CRPS• Neuropeptide signaling and cytokine expression are up-regulated after fracture• Fracture activated spinal glia and induced changes in brain dendritic architecture• B cell production of IgM autoantibodies also contributed to post fracture pain

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Author Correction: Circuit dissection of the role of somatostatin in itch and pain

Author Correction: Circuit dissection of the role of somatostatin in itch and pain

Author Correction: Circuit dissection of the role of somatostatin in itch and pain, Published online: 19 April 2018; doi:10.1038/s41593-018-0149-6

Author Correction: Circuit dissection of the role of somatostatin in itch and pain

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An approach to hip pain in a young adult

What you need to knowInitial management of hip pain in young adults includes simple analgesics or non-steroidal anti-inflammatory medication (NSAIDs), activity modification, and an anteroposterior...

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Skin reaction in a patient with chronic abdominal pain

A 26 year old pregnant woman with chronic abdominal pain of unclear cause was seen at 25 weeks’ gestation with longstanding marked skin discoloration (fig 1) and fragility over her abdomen and...

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The long search for the pain gene

The long search for the pain gene

The long search for the pain gene, Published online: 18 April 2018; doi:10.1038/d41586-018-04560-z

Tor Wager lauds a book on the hunt for an elusive root of sensory suffering.

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Prescription Medication Use among Community-Based US Adults with Chronic Low Back Pain: a Cross-Sectional Population Based Study.

• Opioids were the most common prescription pain medications among US adults with cLBP.• Opioids were typically used long-term, and combined with other CNS-active agents.• Low level of education was strongly associated with opioid use in cLBP population.

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Pilot Randomized Trial of Integrated Cognitive-Behavioral Therapy and Neuromuscular Training for Juvenile Fibromyalgia: the FIT Teens Program

• Results of this pilot trial of the FIT Teens program were promising• FIT Teens was more effective than CBT-only in the reduction of disability and pain• Mood symptoms improved, and fear of movement was reduced after FIT Teens

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Randomized Controlled Trial of Nurse-Delivered Cognitive Behavioral Therapy Versus Supportive Psychotherapy Telehealth Interventions for Chronic Back Pain

• Two telephone-adapted behavioral therapies improved chronic low back pain• A nurse-delivered cognitive behavior therapy reduced pain and improved function• A nurse-delivered supportive care improved pain outcomes equivalent to CBT• Effect sizes were moderate, ranging from .33-.60 for pain severity and function.• 27-39% of the participants reported “much improved” or “very much improved”

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Nonlinear Inverted-U Shaped Relationship between Aging and Epidermal Innervation in the Rat Plantar Hind Paw: a Laser Scanning Confocal Microscopy Study

• Laser-scanning microscopy is used for quantification of rat epidermal nerves• Advanced age is associated with decreased density of epidermal nerves• Middle-aged rats have increased epidermal nerves.• An inverted-U shaped relationship between aging and epidermal nerve density• Epidermal nerve density is not correlated with paw withdrawal thresholds

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Infant Clinical Pain Assessment: Core Behavioural Cues

• NFCS and MBPS coding systems were examined using Confirmatory Factor Analysis.• A revised 3-item NFCS maintained good psychometric properties of 7-item version.• Redefinition of MBPS with cry as a sole indicator was suggested.• The revised scales increase efficiency of coding based on improved psychometrics.

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Trait- and Frequency-Dependent Dysfunctional Habituation to Trigeminal Nociceptive Stimulation in Trigeminal Autonomic Cephalalgias.

• Trigeminal autonomic cephalalgias share a deficit of habituation to trigeminal pain.• Defective habituation to pain is detectable only at faster stimulation frequencies.• In TACs common pathogenetic factors parallel with similarities in clinical features.

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An incidental finding on a knee radiograph

A 24 year old man attended the emergency department with pain in the lateral left knee after intercepting a pass playing football. Plain anteroposterior and lateral radiographs of the knee were...

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Hypnosis Enhances the Effects of Pain Education in Patients with Chronic Non-Specific Low Back Pain: a Randomized Controlled Trial

• Hypnosis can be combined with education in patients with chronic low back pain.• The addition of hypnosis improves pain intensity, disability, and catastrophizing.• The beneficial effects are enhanced, at least in the short and medium-term.• The intervention can be offered in group settings.

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Assessment of nociception and pain in participants with unresponsive or minimally conscious state after acquired brain injury: the relationship between the Coma Recovery Scale-Revised and the Nociception Coma Scale-Revised.

Metaplasticity within the Spinal Cord: Evidence brain-derived neurotrophic factor (BDNF), tumor necrosis factor (TNF), and alterations in GABA function (ionic plasticity) modulate pain and the capacity to learn

The human pain system exhibits higher-order plasticity (metaplasticity)

Self-Efficacy for Pain Communication Moderates the Relation between Ambivalence over Emotional Expression and Pain Catastrophizing among Patients with Osteoarthritis

• Ambivalence over emotional expression was related to greater pain catastrophizing• Self-efficacy for pain communication moderated this relation• Negative network orientation was not associated with pain catastrophizing

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The Effectiveness of Oral Pain Medication and Corticosteroid Injections for Carpal Tunnel Syndrome–A Systematic Review

Prospective, Randomized, Double-Blind, Placebo-Controlled Clinical Trial Assessing the Effects of Applying a Force to C5 by a Mechanically Assisted Instrument on Referred Pain to the Shoulder

Study Design. Randomized, prospective, double-blind, placebo-controlled clinical trial. Objective. To determine the effects of applying a force to C5 of the spine by a mechanically assisted instrument (MAI) in patients with referred shoulder pain. Summary of Background Data. Manipulating C5 of the spine is a chiropractic treatment for referred shoulder pain; there are no clinical trials evaluating its efficacy. Outcome measures were patient ranked questionnaires and independent examiner findings. One hundred and twenty-five patients were diagnosed with referred shoulder pain of cervical origin; 65 patients were in the treatment cohort and 60 patients in the placebo cohort. Methods. This was a prospective, randomized, double-blind, placebo-controlled trial assessing the effects of applying a force to C5 by a MAI to patients with referred shoulder pain. The treatment cohort had the MAI set at the maximum setting to transmit a force into the spine; the placebo cohort had the MAI turned off. Primary outcome measures were frequency and severity of extreme shoulder pain obtained via a patient-reported questionnaire; secondary outcome measures were patient ranked pain and functional outcomes as well as examiner assessed range of motion and strength. Assessment procedures were completed at 24 weeks posttreatment and data were analyzed with intent-to-treat protocol. Results. There was a reduction in the frequency but not severity of extreme shoulder pain in the treatment cohort, average ranking reducing from weekly to monthly (P < 0.05). Patients treated with the MAI had 10 N (P = 0.04) better internal rotation strength after 6 months posttreatment. No differences with any other outcome measures between the two cohorts at the 24-week study period. Conclusion. The major effect of applying a MAI to the level of C5 of the spine in referred shoulder pain is improved shoulder strength for internal rotation in this randomized double-blinded clinical trial. Level of Evidence: 2

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Poorer Fusion Outcomes in Diabetic Cervical Spondylotic Myelopathy Patients Undergoing Single-level Anterior Cervical Discectomy and Fusion Does Not Compromise Functional Outcomes and Quality of Life

Study Design. Retrospective matched pair cohort study using prospectively collected registry data. Objectives. The aim of this study was to determine whether patients with DM have poorer patient-reported outcomes and poorer fusion rates after undergoing a single-level anterior cervical discectomy and fusion (ACDF) for cervical myelopathy. Summary of Background Data. ACDF remains the most common procedure in the treatment of cervical spondylotic myelopathy (CSM); however, there is a paucity of literature with regards to patient-reported outcome measures (PROMs), health-related quality-of-life (HRQOL) scores, and fusion rates post-ACDF in diabetic patients with CSM. Methods. From 2002 to 2012, 29 diabetic patients were matched with 29 nondiabetic controls. Patient demographics, perioperative data, and validated spine-specific scores including the Numerical Pain Rating Scale on Neck Pain and Upper Limb Pain, American Academy of Orthopaedic Surgeons (AAOS) neck pain and disability scores, AAOS Neurogenic Symptoms Score, Neck Disability Index, Japanese Orthopaedic Association Cervical Myelopathy Score, and Short Form 36 Physical/Mental Component Summaries were recorded. Fusion rates based on Bridwell grading were assessed at 2 years. Results. After matching, there were no significant preoperative differences in patient demographics, clinical outcomes, PROMs or HRQoL measures between the DM and control group (P > 0.05). There was no difference in either length of hospital stay (P = 0.92) or length of surgery (P = 0.92) between the two groups. At 2 years postoperatively, there were no significant differences between validated spine-specific scores, PROMs, HRQoL scores, satisfaction rates, or fulfilment of expectations between the two groups. Significant poorer Bridwell fusion grades were noted in the DM group at 2 years postoperatively (P < 0.05). Subgroup analysis within the DM group demonstrated that glycated hemoglobin levels had no impact on functional outcomes, fulfilment of expectations, or patient satisfaction at 2 years (P > 0.05). Conclusion. Despite poorer fusion outcomes following single-level ACDF for symptomatic CSM, there was no significant difference in validated spine outcome scores, PROMs, HRQoL measures, or satisfaction levels when compared to nondiabetic controls at short-term follow-up. Level of Evidence: 3

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The UTE Disc Sign on MRI: A Novel Imaging Biomarker Associated With Degenerative Spine Changes, Low Back Pain, and Disability

Study Design. Cross-sectional. Objective. To assess the distribution of the ultra-short time-to-echo (UTE) disc sign (UDS) and its association with disc degeneration, other magnetic resonance imaging (MRI) phenotypes, pain, and disability profiles. Summary of Background Data. Disc degeneration has been conventionally assessed by T2-weighted (T2W) signal intensity on MRI; however, its clinical utility has been questionable. UTE MRI assesses short T2 components. The authors have identified a new imaging biomarker on UTE—the UDS. Methods. One hundred eight subjects were recruited. T2W MRI assessed disc degeneration and other phenotypes, and T1-rho MRI values represented quantitative proteoglycan disc profiles of L1-S1. UDS was detected on UTE (i.e., hyper-/hypointense disc band). A UDS score (cumulative number of UDS levels) and T2W summated lumbar degenerated scores (cumulative disc degeneration score) were assessed. Subject demographics, chronic low back pain (LBP), and disability profiles (Oswestry Disability Index: ODI) were obtained. Results. UDS was noted in 39.8% subjects, 61.4% occurred at the lower lumbar spine and 39.5% had multilevel UDS. UDS subjects had significantly greater severity and extent of disc degeneration, and Modic changes (P < 0.05). By disc levels, a higher prevalence of disc degeneration/displacement, Modic changes, and spondylolisthesis were noted in UDS discs than non-UDS discs (P < 0.05). T1-rho values were also lower in UDS discs (P = 0.022). The majority of UDS could not be detected on T2W. The UDS score significantly correlated with worse ODI scores (r = 0.311; P = 0.001), whereas T2W cumulative disc degeneration score did not (r = 0.13; P = 0.19). LBP subjects exhibited more multilevel UDS (P < 0.015) but not on T2W MRI (P = 0.53). The UDS score was significantly related to LBP (P = 0.009), whereas T2W cumulative disc degeneration score was not (P = 0.127). Conclusion. This is the first study to report “UDS” in humans. UDS is a novel imaging biomarker that is highly associated with degenerative spine changes, chronic LBP, and disability than conventional T2W MRI. Level of Evidence: 2

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Comparison of Outcomes for Anterior Cervical Discectomy and Fusion With and Without Anterior Plate Fixation: A Systematic Review and Meta-Analysis

Study Design. Systematic review and meta-analysis. Objective. To compare postoperative surgical, radiographic, and patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) with and without plate fixation. Summary of Background Data. ACDF has evolved significantly over the years, including the placement of an anterior plate construct. Although promoting bony osseo-integration at the fusion site, there are a number of plate-related complications that can arise. The non-plating approach is less invasive, however, greater rates of cage subsidence have been associated with this model. Methods. We performed an electronic literature search for human studies that directly compared ACDF with and without anterior plate fixation. Outcomes of interest comprised of postoperative dysphagia, fusion success, and cage subsidence as well as patient reported outcomes, including the Neck Disability Index (NDI) scores and Visual Analog Scale (VAS) for both neck and arm pain. Results. A total of 15 studies (12 observational and 3 randomized controlled trials) and 893 patients (57% males) were included. Overall, ACDF with plate fixation was associated with significantly higher vertebral fusion rates (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.16–3.37), lower subsidence rates (odds ratio [OR] 0.31, 95% CI 0.18–0.52), and more favorable VAS-neck pain scores at last follow-up (mean difference [MD] 0.59, 95% CI −0.78 to −0.41). Conversely, ACDF procedures without plate fixation had marginally better long-term VAS-arm pain scores (mean difference [MD] 0.2, 95% CI 0.04–0.36). No difference was found with regards to dysphagia (OR 1.21, 95% CI, 0.57–2.56) and NDI (MD 0.06, 95% C.I −0.54 to 0.42). Conclusion. Available evidence, although limited, suggests superior surgical outcomes in ACDF procedures with anterior plate fixation (increased fusion, decreased subsidence) and slightly better VAS-neck pain scores at last follow-up. Future longitudinal, multicenter randomized controlled trials should be completed to validate any associations found in this study. Level of Evidence: 3

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Patient-Reported Outcomes and Costs Associated With Revision Surgery for Degenerative Cervical Spine Diseases

Study Design. A retrospective review of a prospective database. Objective. The aim of this study was to determine cost and outcomes of revision cervical spine surgery. Summary of Background Data. Revision rates for cervical spine surgery are steadily increasing. It is important to counsel patients on expected results following a revision procedure. However, outcomes and cost of these procedures are poorly defined in the literature. Methods. Patients undergoing revision cervical spine surgery at a single institution were included between October 2010 and January 2016 in a prospective registry database. Patients were divided into three cohorts depending on their etiology for revision, including recurrent disease, pseudoarthrosis, or adjacent segment disease. Patient-reported outcomes (PROs), including Neck Disability Index (NDI), EuroQol-5D (EQ-5D), modified Japanese Orthopaedic Association (mJOA) score, numeric rating scale-neck pain (NRS-NP), and numeric rating scale-arm pain (NRS-AP), were measured at baseline and 12 months following revision surgery. Mean costs at 12 months following revision surgery were also calculated. Satisfaction was determined by the NASS patient satisfaction index. Variables were compared using Student t test. Results. A total of 115 patients underwent cervical revision surgery for recurrent disease (n = 21), pseudoarthrosis (n = 45), and adjacent segment disease (n = 49). There was significant improvement in all patient-reported outcomes at 12 months following surgery regardless of etiology (P < 0.0001). Total cost of revision surgery ranged between 21,294 ± 8614 and 23,914 ± 15,396 depending on pathology. No significant differences were seen between costs among different revision groups (P = 0.53). Satisfaction was met in 75.5% to 85.7% (P = 0.21) of patients depending on the etiology of the revision need. Complication rates were between 4% and 9%. Conclusion. This is one of the first studies to determine costs and outcome measures in the setting of cervical spine revision surgery. On the basis of our analysis, a majority of patients can expect to receive some benefit by 12 months and are satisfied with their procedure. Level of Evidence: 4

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Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a United States Primary Care Setting

Genetic and Environmental Contributions to Sleep Quality and Low Back Pain: A Population-Based Twin Study

Objective The aim of the study was to estimate the extent to which the co-occurrence of poor sleep quality and low back pain is due to the same genetic and/or environmental risk factors or due to a causal association. Methods Cross-sectional data on sleep quality (Pittsburgh Sleep Quality index) and low back pain were collected in a population-based sample of adult twins (N = 2134) registered with the Murcia Twin Registry. Bivariate analysis and structural equation modeling were used. Results The phenotypic correlation between sleep quality and low back pain was 0.23 (95% confidence interval [CI] = 0.17–0.28). The best-fitting bivariate model included additive genetic and unique environmental factors. Genetic factors accounted for 26% (95% CI = 10–40) and 34% (95% CI = 25–43) of the variability of low back pain and sleep quality, respectively. The correlation between the genetic factors underlying each trait was rG of 0.33 (95% CI = 0.03–0.66), and this overlap of genetic factors explained 42.5% of the phenotypic correlation. On the other hand, nonshared environmental factors of each variable were only fairly correlated rE of 0.19 (95% CI = 0.06–0.31), although this overlap explained 57.5% of the phenotypic correlation. In addition, twins in monozygotic pairs with poorer sleep quality presented more often with low back pain than their co-twins (ρˆ = 0.25, p < .0001). Conclusions The data are compatible with a causal effect of sleep quality on low back pain (or the reverse effect), because the correlations between the genetic and unique environmental factors for each trait were significant and there was a significant correlation between the monozygotic twins' difference scores. Apart from environmental factors that affect both characteristics, there are many individual-specific events that influence low back pain but differ from those influencing sleep quality.

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Validity of Combining History Elements and Physical Examination Tests to Diagnose Patellofemoral Pain

Agreement of Musculoskeletal Ultrasound and Clinical Assessment of Shoulder Impairment in Manual Wheelchair Users With Various Duration of Spinal Cord Injury