An Outcome Measure of Functionality and Pain in Patients with Low Back Disorder: A Validation Study of the Iranian version of Low Back Outcome Score

Parisa Azimi,Hossein Nayeb Aghaei,Shirzad Azhari,Sohrab Shazadi,Hamid Khayat Kashany,Hassan Reza Mohammadi,Ali Montazeri 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.4

Study Design: Cross-sectional study. Purpose: This study aimed to cross-culturally translate and validate the low back outcome score (LBOS) in Iran. Overview of Literature: Lumbar disc hernia (LDH) is the most common diagnoses of low back pain and imposes a heavy burden on both individual and society. Instruments measuring patient reported outcomes should satisfy cetain psychometric properties. Methods: The translation and cross-cultural adaptation of the original questionnaire was performed using Beaton’s guideline. A total of 163 patients with LDH were asked to respond to the questionnaire at three points in time: preoperative and twice within 1-week interval after surgery assessments. The Oswestry disabilty index (ODI) was also completed. The internal consistency, test-retest, convergent validity, and responsiveness to change were assessed. Responsiveness to change also was assessed comparing patients’ pre- and postoperative scores. Results: The mean age of the cohort was 49.8 years (standard deviation=10.1). The Cronbach’s alpha coefficients for the LBOS at preoperative and postoperative assessments ranged from 0.77 to 0.79, indicating good internal consistency. Test-retest reliability as performed by intraclass correlation coefficient was found to be 0.82 (0.62–0.91). The instrument discriminated well between subgroups of patients who differed in the Finneson-Cooper score. The ODI correlated strongly with the LBOS score, lending support to its good convergent validity (r =–0.83; p <0.001). Further analysis also indicated that the questionnaire was responsive to change (p <0.001). Conclusions: The Iranian version of LBOS performed well and the findings suggest that it is a valid measure of back pain treatment evaluation among LDH patients.

Lumbar Spinal Canal Stenosis Classification Criteria: A New Tool

Parisa Azimi,Hassan Reza Mohammadi,Edward C. Benzel,Sohrab Shahzadi,Shirzad Azhari 대한척추외과학회 2015 Asian Spine Journal Vol.9 No.3

Study Design: Case-control study. Purpose: To design a new tool for classifying lumbar spinal canal stenosis (CLSCS). Overview of Literature: Grading of patients with lumbar spinal canal stenosis (LSCS) is controversial. Methods: The Oswestry disability index (ODI) and the neurogenic claudication outcome score (NCOS) were recorded. Four parameters, which indicate the severity of LSCS disease, including Hufschmidt-grade, grading of magnetic resonance imaging, self-paced walking test, and stenosis ratio (SR) were employed. For the SR, quartile analysis was applied for classifying LSCS and the Hufschmidt- grade was modified into a 4-grade score. An initial score was assigned to each metric based on the severity of LSCS. Using the inverse-variance weighting method, the relative weights of these domains and their categories were determined. The score for all of the cases was obtained based on their weight by summing up the points of the four variables. Quartile analysis was used and a CLSCS score was proposed. Finally, intra- and interobserver reliability, and validity were assessed. Results: A total of 357 patients were studied. The final CLSCS score for each case ranged from 4 to 16.5. Based on the quartile analysis, using the new criteria set, the CLSCS score was divided into four categories: CLSCS<7 (grade 0); 7≤CLSCS<10 (grade 1); 10≤CLSCS<13 (grade 2); and 13≤CLSCS≤16.5 (grade 3). The kappa values of for the CLSCS score indicated a perfect agreement. The CLSCS was correlated with the ODI and NCOS. All patients with grade 3 CLSCS were observed in the surgical group. Conclusions: The CLSCS score can be helpful for classifying LSCS patients and in the decision-making process.

Outcome Measure of Pain in Patients with Lumbar Disc Herniation: Validation Study of the Iranian version of Pain Sensitivity Questionnaire

Parisa Azimi,Shirzad Azhari,Sohrab Shahzadi,Hossain Nayeb Aghaei,Hassan Reza Mohammadi,Ali Montazeri 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.3

Study Design: Cross-sectional. Purpose: To translate and culturally adapt an Iranian version of the Pain Sensitivity Questionnaire (PSQ) in Iran. Overview of Literature: Instruments measuring patient reported outcomes should satisfy certain psychometric properties. Methods: The PSQ was translated following cross-cultural adaptation guidelines. A total of 101 patients with lumbar disc herniation (LDH), and 39 healthy cases were included in the study. All participants completed the PSQ and the Pain Catastrophizing Scale (PCS). The internal consistency, test-retest reliability, known group comparison, criterion validity and item-scale correlations were assessed. Results: The mean age of participants was 51.7 years. Reliability, validity and correlation of PSQ and PCS showed satisfactory results. Cronbach’s alpha coefficients were 0.81 for PSQ-total, 0.82 for PSQ-minor, and 0.82 for PSQ-moderate. The intraclass correlation coefficients value was 0.84 (0.616–0.932) indicating an excellent test-retest reliability. The instrument discriminated well between sub-groups of patients who differed in a standard predictive measure of LDH surgery (the Finneson–Cooper score). Total PSQ were also significantly correlated with the total scores of the PCS, lending support to its good convergent validity. Additionally, the correlation of each item with its hypothesized domain on the PSQ indicated acceptable results, suggesting that the items had a substantial relationship with their own domains. Conclusions: The adapted Iranian PSQ is a valid and reliable questionnaire for the assessment of pain in patients with LDH.

Validation of the Iranian Version of the ECOS-16 Questionnaire in Patients with Osteoporotic Vertebral Fractures

Parisa Azimi,Taravat Yazdanian,Ali Montazeri 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.4

Study Design: Prospective clinical study. Purpose: To translate and validate the Quality of Life Questionnaire of the European Foundation for Osteoporosis (ECOS-16) in patients with osteoporotic vertebral fractures in Iran. Overview of Literature: It is important to assess the psychometric properties of instruments measuring patient-reported outcomes. Methods: The translation was performed using the backward-forward translation method. The final version was generated by consensus among the translators. Every woman who had a T-score of <−2.5 completed ECOS-16. Patients were divided into two study groups according to the World Health Organization’s criteria: those with at least one vertebral fracture (surgery group) and those with no fractures (control group). They were asked to respond to the questionnaire at three points in time: preoperative and twice within 1-week interval after surgery assessments (6-month follow-up). The 36-item short-form health survey (SF-36) also was completed. The psychometric properties of the questionnaire were assessed using internal consistency, test-retest reliability, convergent validity, discriminant validity, and responsiveness. Results: Of 137 recruited women, 39 underwent surgery and 98 did not. Analysis of the ECOS-16 scales showed an appropriate reliability with Cronbach’s alpha of >0.70 for all scales. Test-retest reliability as indicated by intraclass correlation coefficient was found to be 0.85 (0.68–0.91). Additionally, the correlation of each item with its hypothesized domain of the ECOS-16 showed acceptable results, suggesting that the items had a substantial relationship with their own domains. Further analysis also indicated that the questionnaire was responsive to change (effect size, 0.85; standardized response mean, 0.93) (p <0.001). Significant correlations existed between scores of similar subscales of ECOS-16 and SF-36 (p <0.001). Conclusions: ECOS-16 is an acceptable, reliable, valid, and responsive measure to assess the quality of life in patients with osteoporotic vertebral fractures.

Preliminary Results of Relationship between Preoperative Walking Ability and Magnetic Resonance Imaging Morphology in Patients with Lumbar Canal Stenosis: Comparison between Trefoil and Triangle Types of Spinal Stenosis

Parisa Azimi,Taravat Yazdanian,Edward C. Benzel 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.4

Study Design: Cross-sectional. Purpose: To examine the relationship between magnetic resonance imaging (MRI) morphology stenosis grades and preoperative walking ability in patients with lumbar canal stenosis (LCS). Overview of Literature: No previous study has analyzed the correlation between MRI morphology stenosis grades and walking ability in patients with LCS. Methods: This prospective study included 98 consecutive patients with LCS who were candidates for surgery. Using features identified in T2-weighted axial magnetic, stenosis type was determined at the maximal stenosis level, and only trefoil and triangle stenosis grade types were considered because of sufficient sample size. Intraobserver and interobserver reliability were assessed by calculating weighted kappa coefficients. Symptom severity was evaluated via the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ). Walking ability was assessed using the Self-Paced Walking Test (SPWT) and JOABPEQ subscales. Demographic characteristics, SPWT scores, and JOABPEQ scores were compared between patients with trefoil and triangle stenosis types. Results: The mean patient age was 58.1 (standard deviation, 8.4) years. The kappa values of the MRI morphology stenosis grade types showed a perfect agreement between the stenosis grade types. The trefoil group (n=53) and triangle group (n=45) showed similar preoperative JOABPEQ subscale scores (e.g., low back pain, lumbar function, and mental health) and were not significantly different in age, BMI, duration of symptoms, or lumbar stenosis levels (all p >0.05); however, trefoil stenosis grade type was associated with a decreased walking ability according to the SPWT and JOABPEQ subscale scores. Conclusions: These findings suggest preoperative walking ability is more profoundly affected in patients with trefoil type stenosis than in those with triangle type stenosis.

Cut-off Value for Body Mass Index in Predicting Surgical Success in Patients with Lumbar Spinal Canal Stenosis

Parisa Azimi,Taravat Yazdanian,Sohrab Shahzadi,Edward C. Benzel,Shirzad Azhari,Hossein Nayeb Aghaei,Ali Montazeri 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.6

Study Design: Case-control. Purpose: To determine optimal cut-off value for body mass index (BMI) in predicting surgical success in patients with lumbar spinal canal stenosis (LSCS). Overview of Literature: BMI is an essential variable in the assessment of patients with LSCS. Methods: We conducted a prospective study with obese and non-obese LSCS surgical patients and analyzed data on age, sex, duration of symptoms, walking distance, morphologic grade of stenosis, BMI, postoperative complications, and functional disability. Obesity was defined as BMI of ≥30 kg/m2. Patients completed the Oswestry Disability Index (ODI) questionnaire before surgery and 2 years after surgery. Surgical success was defined as ≥30% improvement from the baseline ODI score. Receiver operating characteristic (ROC) analysis was used to estimate the optimal cut-off values of BMI to predict surgical success. In addition, correlation was assessed between BMI and stenosis grade based on morphology as defined by Schizas and colleague in total, 189 patients were eligible to enter the study. Results: Mean age of patients was 61.5±9.6 years. Mean follow-up was 36±12 months. Most patients (88.4%) were classified with grades C (severe stenosis) and D (extreme stenosis). Post-surgical success was 85.7% at the 2-year follow-up. A weak correlation was observed between morphologic grade of stenosis and BMI. Rates of postoperative complications were similar between patients who were obese and those who were non-obese. Both cohorts had similar degree of improvement in the ODI at the 2-year followup. However, patients who were non-obese presented significantly higher surgical success than those who were obese. In ROC curve analysis, a cut-off value of ≤29.1 kg/m2 for BMI in patients with LSCS was suggestive of surgical success, with 81.1% sensitivity and 82.2% specificity (area under the curve, 0.857; 95% confidence interval, 0.788–0.927). Conclusion: This study showed that the BMI can be considered a parameter for predicting surgical success in patients with LSCS and can be useful in clinical practice.

A Review on the Use of Artificial Intelligence in Spinal Diseases

Azimi Parisa,Yazdanian Taravat,Benzel Edward C.,Aghaei Hossein Nayeb,Azhari Shirzad,Sadeghi Sohrab,Montazeri Ali 대한척추외과학회 2020 Asian Spine Journal Vol.14 No.4

Artificial neural networks (ANNs) have been used in a wide variety of real-world applications and it emerges as a promising field across various branches of medicine. This review aims to identify the role of ANNs in spinal diseases. Literature were searched from electronic databases of Scopus and Medline from 1993 to 2020 with English publications reported on the application of ANNs in spinal diseases. The search strategy was set as the combinations of the following keywords: “artificial neural networks,” “spine,” “back pain,” “prognosis,” “grading,” “classification,” “prediction,” “segmentation,” “biomechanics,” “deep learning,” and “imaging.” The main findings of the included studies were summarized, with an emphasis on the recent advances in spinal diseases and its application in the diagnostic and prognostic procedures. According to the search strategy, a set of 3,653 articles were retrieved from Medline and Scopus databases. After careful evaluation of the abstracts, the full texts of 89 eligible papers were further examined, of which 79 articles satisfied the inclusion criteria of this review. Our review indicates several applications of ANNs in the management of spinal diseases including (1) diagnosis and assessment of spinal disease progression in the patients with low back pain, perioperative complications, and readmission rate following spine surgery; (2) enhancement of the clinically relevant information extracted from radiographic images to predict Pfirrmann grades, Modic changes, and spinal stenosis grades on magnetic resonance images automatically; (3) prediction of outcomes in lumbar spinal stenosis, lumbar disc herniation and patient-reported outcomes in lumbar fusion surgery, and preoperative planning and intraoperative assistance; and (4) its application in the biomechanical assessment of spinal diseases. The evidence suggests that ANNs can be successfully used for optimizing the diagnosis, prognosis and outcome prediction in spinal diseases. Therefore, incorporation of ANNs into spine clinical practice may improve clinical decision making.

An Iranian Version of the Fukushima Lumbar Spinal Stenosis Scale (FLS-25): A Validation Study

Parisa Azimi,Ali Montazeri 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.2

Study Design: Cross-sectional study. Purpose: To translate and validate the Fukushima lumbar spinal stenosis (LSS) scale 25 (FLS-25) for use in Iran. Overview of Literature: Tools measuring patient-reported outcomes should satisfy certain psychometric properties. Methods: FLS-25 is a self-administered scale for evaluating symptoms of LSS. A forward-backward procedure was applied to translate the questionnaire from English into Persian. A sample of patients with LSS completed the questionnaire at two points in time: once before surgery and once 6 months after the surgery. The Neurogenic Claudication Outcome Score (NCOS) was also used for assessment. The psychometric properties of FLS-25 were evaluated for internal consistency, test-retest and interobserver reliabilities, responsiveness to change, known-group comparison, and convergent validity. Results: In all, 131 patients were included in the study. The mean age of the patients was 61.4 (standard deviation, 11.1) years. The Cronbach’s alpha coefficient for FLS-25 was 0.89. Test-retest reliability as carried out by the intraclass correlation coefficient was 0.94 (95% confidence interval, 0.95). Interobserver agreement as measured by the kappa statistics also was found to be acceptable (kappa value, 0.88), and validity was found to be satisfactory. The instrument was able to discriminate between the subgroups of patients who differed in symptom severity. The correlation between FLS-25 and NCOS scores was excellent, indicating good convergent validity (r =0.82, p <0.001). The results also indicated that the instrument was responsive to change (p <0.001). Conclusions: The Iranian version of FLS-25 performed well, and the findings suggest that it is a valid measure of symptom severity in LSS patients.

Surgical Outcomes and Correlation of the Copenhagen Neck Functional Disability Scale and Modified Japanese Orthopedic Association Assessment Scales in Patients with Cervical Spondylotic Myelopathy

Shirzad Azhari,Parisa Azimi,Sohrab Shazadi,Hamid Khayat Kashany,Hossein Nayeb Aghaei,Hassan Reza Mohammadi 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.3

Study Design: Cross-sectional. Purpose: Clinical outcome study comparing the Copenhagen Neck Functional Disability Scale (CNFDS) and modified Japanese orthopedic association (mJOA) assessment scales in patients with cervical spondylotic myelopathy (CSM). Overview of Literature: Comparison of instruments that measure patient-reported outcomes is needed. Methods: A cross-sectional analysis was conducted. Ninety five patients with CSM were entered into the study and completed the CNFDS and the mJOA preoperatively and postoperatively. Correlation between the CNFDS and the mJOA was evaluated preoperatively and at the end of follow-up. Responsiveness to change of CNFDS and mJOA was also assessed. Clinical outcomes were also measured with the recovery rate of mJOA score at end of follow-up. Results: The mean age of patients was 58.2 (standard deviation, SD=8.7) years. Mean follow-up was 2.1 years (range, 1 to 4 years). The mJOA correlated strongly with the CNFDS score preoperatively and postoperatively (r =–0.81 and –0.82, respectively; p <0.001). The CNFDS and the mJOA were able to detect changes after the surgery (p <0.001). The mean mJOA recovery rate was 51.8% (SD=13.1%). Conclusions: Surgery for the treatment of patients with CSM is an efficacious procedure. CNFDS and mJOA scores have a strong correlation in measuring disability among CSM patients.

Decision-Making Process in Patients with Thoracolumbar and Lumbar Burst Fractures with Thoracolumbar Injury Severity and Classification Score Less than Four

Shirzad Azhari,Parisa Azimi,Sohrab Shahzadi,Hassan Reza Mohammadi,Hamid Reza Khayat Kashani 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.1

Study Design: Cross-sectional. Purpose: To develop a strategy to determine a sound method for decision-making based on postoperative clinical outcome satisfaction. Overview of Literature: The ideal management of thoracolumbar and lumbar burst fractures (TLBF) without neurological compromise remains controversial. Methods: This was a prospective study. Patients with thoracolumbar injury severity and classification score (TLICS) <4 were treated nonoperatively, with bed rest and bracing until the pain decreased sufficiently to allow mobilization. Surgery was undertaken in patients with intractable pain despite an appropriate nonoperative treatment (surgery group). The Oswestry disability index (ODI) measure was observed at baseline and at the last follow-up. Clinically success was defined at least a 30% improvement from the baseline ODI scores in both the conservative and surgery groups. All case records were assessed for gender, age, residual canal and angulations at the site of the fracture in order to determine which patients benefited from surgery or conservative treatment and which did not. Results: In all 113 patients with T11–L5, TLBFs were treated. The patients’ mean age was 49.2 years. Patients successfully completed either nonoperative (n=99) or surgical (n=14) treatment based on ODI. Clinical examinations revealed that all of the patients had intact neurology. The mean follow-up period was 29.5 months. There was a significant difference between the two groups based on age and residual canal. The mean ODI score significantly improved for both groups (p <0.01). According to the findings, a decision matrix was proposed. Conclusions: The findings confirm that TLICS <4, age, and residual canal can be used to guide the treatment of TLBF in conservative decision-making.