Selection, Prescription, and Progression of Exercises for the Lumbar Spine: an Evidence-based Systematic Biomechanical Approach

Abstract Background As rates of advanced imaging for lower back pain continue to increase, there is a need to ensure appropriateness of imaging. The goal of this project was to reduce the number of inappropriate MRI and CT requests for lower back pain patients and facilitate appropriate imaging by developing a combined imaging appropriateness checklist for lumbar spine MRI and CT. Methods In prior work, we developed and adopted individual evidence-based lumbar spine MRI and CT checklists into the radiology requisition process. In the current project, a combined checklist was developed and trialed in one of the former Saskatchewan health regions (Five Hills) beginning in May 2018. Using statistical process control (SPC), control charts compared monthly number of imaging requests pre- and post-checklist implementation from May 2017 to February 2020. Monthly number of lumbar spine MRI and CT requisitions in the nearby former Saskatchewan Regina Qu’Appelle Health Region, in which the combined checklist was not trialed, were also plotted and compared as a balancing measure. Results In Five Hills, a shift (decrease) was observed in the monthly number of lumbar spine MRI requisitions seven months following the implementation of the combined checklist. However, the monthly number of lumbar spine CT requisitions did not change significantly. In the Regina Qu’Appelle Health Region, there was a shift (increase) in the monthly number of lumbar spine MRI requisitions, while the monthly number of lumbar spine CT requests decreased after the implementation of the combined checklist. Conclusions The combined checklist with evidence-based indications for lumbar spine MRI and CT imaging in lower back pain patients appeared to reduce the complexity associated with two previous individual checklists and facilitate imaging appropriateness. Accountable benefits may include the reduction of radiation exposure as a result of unnecessary and repeated imaging and reduction in wait times for CT and/or MRI.

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Lumbar spine surgery positioning complications: a systematic review

Neurosurgical FOCUS ◽

10.3171/2015.7.focus15268 ◽

2015 ◽

Vol 39 (4) ◽

pp. E16 ◽

Cited By ~ 23

Author(s):

Michael F. Shriver ◽

Valerie Zeer ◽

Vincent J. Alentado ◽

Thomas E. Mroz ◽

Edward C. Benzel ◽

...

Keyword(s):

Systematic Review ◽

Lumbar Spine ◽

Prone Position ◽

Spine Surgery ◽

Web Of Science ◽

Lumbar Spine Surgery ◽

Evidence Based ◽

Inclusion Criteria ◽

Lateral Decubitus ◽

Intraoperative Positioning

OBJECT There are a variety of surgical positions that provide optimal exposure of the dorsal lumbar spine. These include the prone, kneeling, knee-chest, knee-elbow, and lateral decubitus positions. All are positions that facilitate exposure of the spine. Each position, however, is associated with an array of unique complications that result from excessive pressure applied to the torso or extremities. The authors reviewed clinical studies reporting complications that arose from positioning of the patient during dorsal exposures of the lumbar spine. METHODS MEDLINE, Scopus, and Web of Science database searches were performed to find clinical studies reporting complications associated with positioning during lumbar spine surgery. For articles meeting inclusion criteria, the following information was obtained: publication year, study design, sample size, age, operative time, type of surgery, surgical position, frame or table type, complications associated with positioning, time to first observed complication, long-term outcomes, and evidence-based recommendations for complication avoidance. RESULTS Of 3898 articles retrieved from MEDLINE, Scopus, and Web of Science, 34 met inclusion criteria. Twenty-four studies reported complications associated with use of the prone position, and 7 studies investigated complications after knee-chest positioning. Complications associated with the knee-elbow, lateral decubitus, and supine positions were each reported by a single study. Vision loss was the most commonly reported complication for both prone and knee-chest positioning. Several other complications were reported, including conjunctival swelling, Ischemic orbital compartment syndrome, nerve palsies, thromboembolic complications, pressure sores, lower extremity compartment syndrome, and shoulder dislocation, highlighting the assortment of possible complications following different surgical positions. For prone-position studies, there was a relationship between increased operation time and position complications. Only 3 prone-position studies reported complications following procedures of less than 120 minutes, 7 studies reported complications following mean operative times of 121–240 minutes, and 9 additional studies reported complications following mean operative times greater than 240 minutes. This relationship was not observed for knee-chest and other surgical positions. CONCLUSIONS This work presents a systematic review of positioning-related complications following prone, knee-chest, and other positions used for lumbar spine surgery. Numerous evidence-based recommendations for avoidance of these potentially severe complications associated with intraoperative positioning are discussed. This investigation may serve as a framework to educate the surgical team and decrease rates of intraoperative positioning complications.

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