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NONOPERATIVE VERSUS OPERATIVE INTERVENTION IN LOW BACK DISORDERS.
Semin Neurol. 1989 Sep;9(3):176-85. Sugar O. Department of Surgery, School of Medicine, University of California, San Diego 92103.

Examination of the patient is necessary to rule out those numerous causes of lumbosacral backache that need not involve the neurosurgeon. A variety of nonoperative treatments (rest, injection of tender pressure points, extradural injections, traction in which the pelvis is fixed and the chest and upper spine can be pulled from the pelvis, and manipulations of the spine) can be used with proper precautions. Injections of enzymes to dissolve the disc have had declining use among neurosurgeons because of actual or feared complications. Operations range from percutaneous disc excision or laminotomy with decompression of nerve roots, to disc excision with interbody fusion. Selection of proper operative treatment to be undertaken when an adequate period of conservative (nonoperative) therapy has been fruitless is controversial. Probably the simplest way of excising a disc with small incisions and minimal disruption of normal anatomic relationships is preferred.

VERTEBRAL AXIAL DECOMPRESSION THERAPY FOR PAIN ASSOCIATED WITH HERNIATED OR DEGENERATED DISCS OR FACET SYNDROME: AN OUTCOME STUDY.
Neurol Res. 1998 Apr;20(3):186-90. Gose EE, Naguszewski WK, Naguszewski RK. Department of Bioengineering, University of Illinois at Chicago, USA.

The outcomes of vertebral axial decompression (VAX-D) therapy for patients with low back pain from various causes are reported. Data was collected from twenty-two medical centers for patients who received VAX-D therapy for low back pain, which was sometimes accompanied by referred leg pain. Only patients who received at least ten sessions and had a diagnosis of herniated disc, degenerative disc, or facet syndrome, which were confirmed by diagnostic imaging, were included in this study; a total of 778 cases. The average time between the initial onset of symptoms and the beginning of this therapy was 40 months, and it was four months or more in 83% of the cases. The data contained the patients' quantitative assessments of their own pain, mobility, and ability to carry out the usual 'activities of daily living'. The treatment was successful in 71% of the 778 cases, when success was defined as a reduction in pain to 0 or 1, on a 0 to 5 scale. Improvements in mobility and activities of daily living correlated strongly with pain reduction. The causes of back pain and their relationship to this therapy are also discussed.

EFFECTS OF VERTEBRAL AXIAL DECOMPRESSION ON INTRADISCAL PRESSURE.
J Neurosurg. 1995 Jun;82(6):1095. Ramos G, Martin W. Department of Neurosurgery, Rio Grande Regional Hospital, McAllen, Texas.

The object of this study was to examine the effect of vertebral axial decompression on pressure in the nucleus pulposus of lumbar discs. Intradiscal pressure measurement was performed by connecting a cannula inserted into the patient's L4-5 disc space to a pressure transducer. The patient was placed in a prone position on a VAX-D therapeutic table and the tensionometer on the table was attached via a pelvic harness. Changes in intradiscal pressure were recorded at resting state and while controlled tension was applied by the equipment to the pelvic harness. Intradiscal pressure demonstrated an inverse relationship to the tension applied. Tension in the upper range was observed to decompress the nucleus pulposus significantly, to below -100 mm Hg.

COMPUTED TOMOGRAPHIC EVALUATION OF LUMBAR SPINAL STRUCTURES DURING TRACTION.
Physiother Theory Pract. 2005 Jan-Mar;21(1):3-11. Sari H, Akarirmak U, Karacan I, Akman H. Department of Physical Medicine and Rehabilitation, Medical Faculty of Cerrahpasa, Istanbul University, Istanbul, Turkey. PMID: 16385939 [PubMed - indexed for MEDLINE]

In the previous studies, it is reported that traction diminishes the compressive load on intervertebral discs, reduces herniation, stretches lumbar spinal muscle and ligaments, decreases muscle spasm, and widens intervertebral foramina. The aim of this study was to evaluate the effects of horizontal motorized static traction on spinal anatomic structures (herniated area, spinal canal area, intervertebral disc heights, neural foraminal diameter, and m.psoas diameter) by quantitative measures in patients with lumbar disc herniation (LDH). At the same time the effect of traction in different localizations (median and posterolateral herniation) and at different levels (L4-L5 and L5-S1) was assessed. Thirty two patients with acute LDH participated in the study. A special traction system was used to apply horizontally-motorized static lumbar traction. Before and during traction a CT- scan was made to observe the changes in the area of spinal canal and herniated disc material, in the width of neural foramina, intervertebral disc heights, and in the thickness of psoas muscle. During traction, the area of protruded disc area, and the thickness of psoas muscle decreased 24.5% (p = 0.0001), and 5.7% (p = 0.0001), respectively. The area of the spinal canal and the width of the neural foramen increased 21.6% (p = 0.0001) and 26.7% (p = 0.0001), respectively. The anterior intervertebral disc height remained unchanged with traction however the posterior intervertebral disc height was significantly expanded. This study is the first to evaluated in detail and quantitatively the effect of motorized horizontal lumbar spinal traction on spinal structures and herniated area. According to detailed measures it was concluded that during traction of individuals with acute LDH there was a reduction of the size of the herniation, increased space within the spinal canal, widening of the neural foramina, and decreased thickness of the psoas muscle.

EFFECT OF CONTINUOUS LUMBAR TRACTION ON THE SIZE OF HERNIATED DISC MATERIAL IN LUMBAR DISC HERNIATION.
Rheumatol Int. 2006 May;26(7):622-6. Epub 2005 Oct 25. Ozturk B, Gunduz OH, Ozoran K, Bostanoglu S. Department of Physical Medicine and Rehabilitation, Institution of Origin, Ankara Numune Education and Research Hospital, Ankara, Turkey.

We investigated the effects of continuous lumbar traction in patients with lumbar disc herniation on clinical findings, and size of the herniated disc measured by computed tomography (CT). In this prospective, randomized, controlled study, 46 patients with lumbar disc herniation were included, and randomized into two groups as the traction group (24 patients), and the control group (22 patients). The traction group was given a physical therapy program and continuous lumbar traction. The control group was given the same physical therapy program without traction, for the same duration of time. Data for the clinical symptoms and signs were collected before and after the treatment together with calculation of a herniation index, from the CT images that showed the size of the herniated disc material. In the traction group, most of the clinical findings significantly improved with treatment. Size of the herniated disc material in CT decreased significantly only in the traction group. In the traction group the herniation index decreased from 276.6+/-129.6 to 212.5+/-84.3 with treatment (p<0.01). In the control group, pretreatment value was 293.4+/-112.1, and it decreased to 285.4+/-115.4 after the treatment (p>0.05). Patients with greater herniations tended to respond better to traction. In conclusion, lumbar traction is both effective in improving symptoms and clinical findings in patients with lumbar disc herniation and also in decreasing the size of the herniated disc material as measured by CT.

THE EFFICACY OF LUMBAR TRACTION IN THE MANAGEMENT OF PATIENTS WITH LOW BACK PAIN.
Rheumatol Int. 2003 Mar;23(2):82-6. Epub 2002 Sep 26. Borman P, Keskin D, Bodur H. Clinic of Physical Medicine and Rehabilitation, Numune Training and Research Hospital, Ankara, Turkey. pinarb@ato.org.tr

The literature on the efficacy of traction in the treatment of low back pain (LBP) is conflicting. The aim of this study was to examine its efficacy in this disorder. Forty-two patients with at least 6 weeks of nonspecific LBP were selected. Demographic data were obtained. All patients completed the Oswestry disability index (ODI) to assess disability and the 10-cm visual analog scale (VAS) for evaluation of pain. Subjects were randomly assigned into group 1, receiving only standard physical therapy, or group 2, receiving standard physical therapy with conventional lumbar traction. Standard physical therapy consisted of local heat, ultrasound for the lumbar region, and an active exercise program, given for ten sessions in all. The subjects received instruction on correct posture and recommended therapeutic exercises. They were reevaluated at the end of treatment and at 3-month follow-up. The mean outcome measures were global improvement and satisfaction with the therapy, as well as disability by ODI and pain by VAS. There were no group differences in terms of demographic and baseline clinical characteristics. There was a significant reduction in pain intensity and disability at the end of treatment in both groups. There was complete or mild improvement in 47.6% of group 1 and 40% of group 2. The satisfaction rate with both treatments was more than 70% immediately after the therapies. During the 3-month period, the outcome measures except disability remained statistically stable, with no difference amongst groups. Disability was significantly reduced at follow-up in both groups. Of the patients, 51% continued with the recommended exercises and had significantly lower disability scores than those who did not continue with the exercises. Pain and global improvement were also better in this group, but the difference was not statistically significant. In conclusion, no specific effect of traction on standard physical therapy was observed in our study group. We suggest focusing on back education and exercise therapy in the management of patients suffering from this chronic condition.

[BIOMECHANICAL EXPERIMENTS FOR MEASURING TRACTION LENGTHENING OF THE LUMBAR SPINE DURING WEIGHT BATH THERAPY]
Orv Hetil. 2002 Mar 31;143(13):673-84. Kurutzne KM, Bene E, Lovas A, Molnar P, Monori E. Tartoszerkezetek Mechanikaja Tanszek, Budapesti Muszaki es Gazdasagtudomanyi Egyetem, Budapest. kurutzm@eik.bme.hu

INTRODUCTION: Weight-bath as an effective traction therapy has successfully been applied in Hungary for nearly a half century, however, it has still been constrained exclusively to empirical bases until the numerical biomechanical analysis of Bene and Kurutz appeared in 1993. Due to their calculations, for cervical suspension in traction bath, the value and distribution of tensile force along the spine became known, however, the most important information, namely, the deformation of spine segments to be stretched by the therapy is so far unknown. AIMS: In this paper the results of a wide-ranging in vivo biomechanical experimental analysis are presented, aimed partly to obtain the traction deformation effects of weight-bath therapy, partly to obtain the biomechanical traction model of human lumbar segments. The analysis aimed to clear the effect of decompression, extra weights, sex, aging, body height and weight. PATIENTS/METHODS: The experiments have been executed during the prescribed 20 minutes long weight-bath treatment of patients having indication for cervical suspension. Patients with other forms of suspension, like armpit bars, have been excluded from the analysis. Two groups of patients have been distinguished: 67 patients without and 88 patients with extra weight loads of 20-20 N (2-2 kgf) applied on the ankles. Extension values of lumbar segments LIII-IV, LIV-V and LV-SI have been measured. Tensile deformations have been specified as the change of the distance between two spinous process of vertebrae, measured by a special subequal ultrasound method developed by the research group. The experimental results have been evaluated by using special software for analyzing ultrasound pictures. More than 3500 ultrasound pictures of 400 lumbar segments of 155 patients have been measured and evaluated. RESULTS: As for the results, at the end of the treatment, elongation of lumbar segments has been demonstrated practically in 60% of patients without and in 75% of patients with extra weights. The mean extension of a lower lumbar segment after a 20 minutes long weight-bath treatment is about 1.2-1.4 mm, while with extra weights it is about 1.3-1.6 mm, in the average of the deformed segments only. In the average of all segments, the above mean extensions are 0.7-0.9 mm, and with extra weights yield 0.8-1.4 mm. CONCLUSIONS: Just being suspended in water, due to the decompression, even without any extra weights, significant extension has been registered: a mean value of 1.0-1.2 mm per segments for the deformable, and 0.4-0.6 mm for all segments. The 20 minutes long treatment time in itself has a significant effect: the average additional extension is 0.2-0.4 mm per segments without, and about 0.5 mm with extra weights. The deformation capacity of lumbar segments decreases with increasing age of patients. Elongations increase with increasing body height. Body weight shows different tendency depending on the sudden elastic and time-dependent viscous deformations. Significant difference has been observed in reaction time of male and female patients: female patients react later, however the final traction effect seems to be equal.

A PROSPECTIVE RANDOMIZED CONTROLLED STUDY OF VAX-D AND TENS FOR THE TREATMENT OF CHRONIC LOW BACK PAIN.
Neurol Res. 2001 Oct;23(7):780-4. Sherry E, Kitchener P, Smart R. Sydney University, NSW, Australia.

Low back pain is one of the most significant medical and socioeconomic problems in modern society. International guidelines call for evidence-based management for the pain and disability associated with musculoskeletal disorders. The purpose of this randomized controlled trial is to address the question of efficacy and appropriateness of vertebral axial decompression (VAX-D) therapy, a new technology that has been shown in clinical research to create negative intradiscal pressures, and has been shown to be effective in treating patients presenting with chronic low back pain (> 3 months duration) with associated leg pain. Successful outcome was defined as a 50% reduction in pain utilizing a 10 cm Visual Analog Pain Scale and an improvement in the level of functioning as measured by patient-nominated disability ratings. Patients were randomly assigned to VAX-D or to TENS which was used as a control treatment or placebo. The TENS treatment demonstrated a success rate of 0%, while VAX-D demonstrated a success rate of 68.4% (p < 0.001). A statistically significant reduction in pain and improvement in functional outcome was obtained in patients with chronic low back pain treated with VAX-D.

Orthopaedic Primary Care Centre, Dinslaken, Germany.
Werners R, Pynsent PB, Bulstrode CJ. PMID: 10457578 [PubMed - indexed for MEDLINE]

STUDY DESIGN: A randomized trial designed to compare interferential therapy with motorized lumbar traction and massage management for low back pain in a primary care setting. OBJECTIVE: To measure and compare the outcome of interferential therapy and management by motorized lumbar traction and massage. SUMMARY OF BACKGROUND DATA: Management of low back pain by interferential therapy and motorized lumbar traction and massage is common in Germany. No reports of previous randomized trials for the outcome from interferential therapy were found. METHODS: Consenting patients were randomly assigned into one of two groups. A pretreatment interview was performed by the patient using a computer-based questionnaire. It also incorporated the Oswestry Disability Index and a pain visual analog scale. Management consisted of six sessions over a 2- to 3-week period. Oswestry Disability Indexes and pain visual analog scale scores also were obtained immediately after and at 3 months after treatment. RESULTS: A total of 152 patients were recruited. The two treatment groups had similar demographic and clinical baseline characteristics. The mean Oswestry Disability Index before treatment was 30 for both groups (n = 147). After treatment, this had dropped to 25, and, at 3 months, were 21 (interferential therapy) and 22 (motorized lumbar traction and massage). The mean pain visual analog scale score before treatment was 50 (interferential therapy) and 51 (motorized lumbar traction and massage). This had dropped, respectively, to 46 and 44 after treatment and to 42 and 39 at 3 months. CONCLUSIONS: This study shows a progressive fall in Oswestry Disability Index and pain visual analog scale scores in patients with low back pain treated with either-interferential therapy or motorized lumbar traction and massage. There was no difference in the improvement between the two groups at the end of treatment. Although there is evidence from several trials that traction alone is ineffective in the management of low back pain, this study could not exclude some effect from the concomitant massage.

MULTIPLE INDEPENDENT, SEQUENTIAL, AND SPONTANEOUSLY RESOLVING LUMBAR INTERVERTEBRAL DISC HERNIATIONS: A CASE REPORT.
Spine. 2002 Mar 1;27(5):549-53. Reyentovich A, Abdu WA. Dartmouth Medical School, Hanover New Hampshire, USA. William.a.abdu@hitchcock.org

STUDY DESIGN: A case report is presented. OBJECTIVE: To highlight the potential for spontaneous resolution of large extruded intervertebral lumbar disc herniations in a patient with three independent herniations. SUMMARY OF BACKGROUND DATA: The most effective methods of treatment for lumbar intervertebral disc herniations remain in question. This is partly because the potential for intrinsic spontaneous resolution is not understood, and because many believe that large extruded lumbar intervertebral disc herniations require surgical intervention. This case report addresses both issues. METHODS: A case is reported and the literature is reviewed. RESULTS: In the patient described, multiple independent lumbar intervertebral disc herniations resolved spontaneously both clinically and radiographically with nonoperative treatment. CONCLUSIONS: Not only is the question concerning the cause of disc herniation unresolved, but the best methods of treatment also are generally unclear. This case report documents a patient with the intrinsic capability not only to herniate multiple lumbar intervertebral discs, but also to resolve them clinically and anatomically. Extruded lumbar intervertebral disc herniations may be treated without surgery, as highlighted by this case report. The immunohistologic pathomechanism for resorption remains unclear.

LUMBAR SPINE TRACTION: EVALUATION OF EFFECTS AND RECOMMENDED APPLICATION FOR TREATMENT.
Krause M, Refshauge KM, Dessen M, Boland R. Wentworth Falls Physiotherapy, Rehabilitation and Sports Injuries Centre, Sydney, Australia.

Despite the widespread use of traction, little is known of the mode of effect, and application remains largely anecdotal. The efficacy of traction is also unclear because of generally poor design of the clinical trials to date, and because subgroups of patients most likely to benefit have not been specifically studied. These observations prompted this review, the purposes of which are to evaluate the mechanisms by which traction may provide benefit and to provide rational guidelines for the clinical application of traction. Traction has been shown to separate the vertebrae and it appears that large forces are not required. Vertebral separation could provide relief from radicular symptoms by removing direct pressure or contact forces from sensitised neural tissue. Other mechanisms proposed to explain the effects of traction (e.g. reduction of disc protrusion or altered intradiscal pressure) have been shown not to occur. We conclude that traction is most likely to benefit patients with acute (less than 6 weeks' duration) radicular pain with concomitant neurological deficit. The apparent lack of a dose-response relationship suggests that low doses are probably sufficient to achieve benefit. Copyright 2000 Harcourt Publishers Ltd.

The object of this study was to examine the effect of vertebral axial decompression on pressure in the nucleus pulposus of lumbar discs. Intradiscal pressure measurement was performed by connecting a cannula inserted into the patient's L4-5 disc space to a pressure transducer. The patient was placed in a prone position on a VAX-D therapeutic table and the tensionometer on the table was attached via a pelvic harness. Changes in intradiscal pressure were recorded at resting state and while controlled tension was applied by the equipment to the pelvic harness. Intradiscal pressure demonstrated an inverse relationship to the tension applied. Tension in the upper range was observed to decompress the nucleus pulposus significantly, to below -100 mm Hg.

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