Trabecular texture analysis of CT images in the relationship with spinal fracture

PURPOSE

To evaluate age-related changes in trabecular texture and bone mineral density (BMD) and to determine the usefulness of texture analysis in the assessment of the risk of fracture.

MATERIALS AND METHODS

The vertebral trabecular BMD was measured in 209 women aged 18-86 years. Run length analysis was applied to computed tomographic images obtained with 2-mm section thickness. The width of the trabecula (T-texture) and the width of the intertrabecular space (I-texture) were calculated.

RESULTS

I-texture significantly increased with age in women 50 years of age or older (P < .0001). Women with fracture had significantly lower BMD (P < .0001 at 60-69 years, P < .05 at 70-79 years) and significantly higher I-texture (P < .05 at 60-69 years, P < .01 at 70-79 years). For fracture risk, BMD had the highest sensitivity and I-texture had the highest specificity in women aged 60-69 years; I-texture had the highest sensitivity and specificity in women aged 70-79 years.

CONCLUSION

Texture analysis was helpful in the assessment of fracture risk, especially in elderly women.

Standardized way for imaging of the sagittal spinal balance

Nowadays, conventional or digitalized teleradiography remains the most commonly used tool for the study of the sagittal balance, sometimes with secondary digitalization. The irradiation given by this technique is important and the photographic results are often poor. Some radiographic tables allow the realization of digitalized spinal radiographs by simultaneous translation of X-ray tube and receptor. EOS system is a new, very low dose system which gives good quality images, permits a simultaneous acquisition of upright frontal and sagittal views, is able to cover in the same time the spine and the lower limbs and study the axial plane on 3D envelope reconstructions. In the future, this low dose system should take a great place in the study of the pelvispinal balance. On the lateral view, several pelvic (incidence, pelvic tilt, sacral slope) and spinal (lumbar lordosis, thoracic kyphosis, Th9 sagittal offset, C7 plumb line) parameters are drawn to define the pelvispinal balance. All are interdependent. Pelvic incidence is an individual anatomic characteristic that corresponds to the "thickness" of the pelvis and governs the spinal balance. Pelvis and spine, in a harmonious whole, can be compared to an accordion, more or less compressed or stretched.

A retrospective case-control study assessing the role of trabecular bone score in postmenopausal Caucasian women with osteopenia: analyzing the odds of vertebral fracture

This case-control study assessed whether the trabecular bone score (TBS), determined from gray-level analysis of DXA images, might be of any diagnostic value, either alone or combined with bone mineral density (BMD), in the assessment of vertebral fracture risk among postmenopausal women with osteopenia. Of 243 postmenopausal Caucasian women, 50-80 years old, with BMD T-scores between -1.0 and -2.5, we identified 81 with osteoporosis-related vertebral fractures and compared them with 162 age-matched controls without fractures. Primary outcomes were BMD and TBS. For BMD, each incremental decrease in BMD was associated with an OR = 1.54 (95% CI = 1.17-2.03), and the AUC was 0.614 (0.550-0.676). For TBS, corresponding values were 2.53 (1.82-3.53) and 0.721 (0.660-0.777). The difference in the AUC for TBS vs. BMD was statistically significant (p = 0.020). The OR for (TBS + BMD) was 2.54 (1.86-3.47) and the AUC 0.732 (0.672-0.787). In conclusion, the TBS warrants a closer look to see whether it may be of clinical usefulness in the determination of fracture risk in postmenopausal osteopenic women.

A method for analysis of back shape in scoliosis

The shape of the back is an important factor in the clinical assessment of various spinal disorders, in particular scoliosis. A method of analysis of back surface shape is described which was designed to present most of the numerical parameters needed to assess the progress of the disease as it affects body shape. Measurements of back surface shape and manually marked anatomical landmarks were taken from a television/computer surface measurement system in which a plane of light was scanned over the back and from moiré topographs. The anatomical landmarks were used to define reference planes from which successive analyses were matched. Asymmetry in the transverse plane was illustrated by horizontal cross-sections and skin surface angles. The lateral deformity was shown by an estimate of the line of the vertebral bodies beneath the skin, derived by adding an extra lateral displacement to the palpated positions of the spinous processes, proportional to the rotation of the skin in the transverse plane. This model was used to estimate vertebral end-plate angles and Cobb angles. Lateral sections showed kyphosis and lordosis. Correlations of Lateral Asymmetry from the surface shape analysis with Cobb angle from X-ray measurements in three groups of patients (totalling 119 subjects) were in the range r = 0.77 to r = 0.94, p less than 0.0001. The analysis has reduced follow-up X-ray examinations at the Nuffield Orthopaedic Centre because it indicates quantitatively and with complete safety both lateral asymmetry and deformity in the transverse plane.

Standing-up of a healthy subject and a paraplegic patient

The joint torques in hip, knee and ankle were measured during the standing-up of a healthy subject. Force plate and stroboscopic photography were used in the experiment. It has been observed that the time courses of particular joint torques depend on the kind of standing-up. On the basis of these results a standing-up procedure for paraplegic patients was proposed. With the use of electrical stimulation to both paralyzed knee extensors and through use of the arm support, a completely paraplegic patient was able to rise independently from the wheel-chair. The same dual-channel stimulation also provides knee locking during standing of spinal cord injured patients.

The determinants of bone mineral density in Chinese men--results from Mr. Os (Hong Kong), the first cohort study on osteoporosis in Asian men

Mr. Os (Hong Kong) is the first study to address the risk factors for osteoporosis in Asian men. A standardized, structured interview and dual X-ray densitometry (DEXA) were performed on 2,000 Chinese men aged 65-92. By multiple regression, the following factors were found to be positively associated with BMD at both the total hip and the spine: body weight, grip strength and a history of diabetes mellitus. The following factors were found to be negatively associated with BMD at both the total hip and spine: cigarette smoking, a history of gastrectomy or bowel resection, current use of inhaled steroid and a history of fracture after 50 years. Moreover, a history of chronic obstructive pulmonary disease (COPD) was negatively associated with BMD at the total hip, and age, the use of an alpha-blocker, thiazide diuretic and nitrate were associated with a higher BMD at the spine. A total of 21.8% of the variance in total hip and 31.5% of the variance in total spine BMD was accounted for in the multivariate analysis.

Articular tropism and stability of the lumbar spine

Lumbar intervertebral joints were subjected to compressive and shear forces calculated to simulate walking with a heavy pack on the back. The joints with articular tropism were found to rotate toward the side of the more oblique facet. The mechanics relating the orientation of the articular facets with joint forces and stability of the lumbar spine are discussed.

Idiopathic scoliosis. Natural history

This study reviews the prognostic factors in curve progression in untreated idiopathic scoliosis patients followed an average of 40 years. A select group of 54 patients with 67 curves with complete radiographs from initial presentation, skeletal maturity, 30-year follow-up and 40-year follow-up were analyzed for radiographic factors leading to curve progression. Analysis of these patients confirmed that the radiographic factors identified at skeletal maturity leading to curve progression apply to the skeletally immature patient as well.

2000 Volvo Award winner in biomechanical studies: Monitoring in vivo implant loads with a telemeterized internal spinal fixation device

STUDY DESIGN

Implant loads were measured in 10 patients using telemeterized internal spinal fixation devices.

OBJECTIVE

To determine the postoperative temporal course of implant loads.

SUMMARY OF BACKGROUND DATA

Little information exists regarding the temporal course of loads on internal spinal fixation devices.

METHODS

The telemeterized internal spinal fixator allows the measurement of three force components and three moments acting in the fixator. Implant loads were determined in up to 20 measuring sessions for different activities, including walking, standing, sitting, lying in the supine position, and lifting an extended leg while in the supine position.

RESULTS

Implant loads often increased shortly after anterior interbody fusion was performed. Several patients retained the same high level even after fusion had taken place. This explains the reason why screw breakage sometimes occurs more than half a year after implantation. The time of fusion could not be pinpointed from the loading curves.

CONCLUSIONS

The results show that fixators may be highly loaded even after fusion has occurred. A flexion bending moment acts on the implant even with the body in a relaxed lying position. This means that already shortly after the anterior procedure, the shape of the spine is not neutral and unloaded, but slightly deformed, which loads the fixators. Pedicle screw breakage more than half a year after insertion does not prove that anterior interbody fusion has not occurred.

Normal bone density of the wrist and spine and increased wrist fractures in girls with Turner's syndrome

Turner's syndrome is associated with multiple skeletal abnormalities, including osteoporosis. We evaluated the hypothesis that girls with Turner's syndrome may have deficient bone density before the expected age of pubertal onset (9-13 yr) by comparing the bone mineral content of the wrist and lumbar spine in 78 girls with Turner's syndrome (4-13 yr old) and 28 normal prepubertal girls who were matched for age, bone age, body mass index, or height age. The bone mineral content of the wrist and spine was measured by single photon absorptiometry (SPA) and dual photon absorptiometry (DPA), respectively. SPA values for girls with Turner's syndrome vs. normal subjects (4-6.9, 7-9.9, and 10-12.9 yr old) were (mean +/- SD) 0.27 +/- 0.05 vs. 0.36 +/- 0.05, 0.35 +/- 0.06 vs. 0.41 +/- 0.06, and 0.41 +/- 0.05 vs. 0.45 +/- 0.03 g/cm2, respectively. SPA values in the Turner's syndrome girls were decreased compared to those in normal prepubertal girls, matched for age (P less than 0.0001), bone age, (P less than 0.001), and body mass index (BMI; P less than 0.0001), but not for height age. DPA values for girls with Turner's syndrome vs. normal girls in the same age categories were 0.65 +/- 0.06 vs. 0.70 +/- 0.09, 0.77 +/- 0.08 vs. 0.79 +/- 0.09, and 0.83 +/- 0.12 vs. 0.78 +/- 0.07 g/cm2. DPA values in Turner's syndrome girls (as a group) were decreased compared to those in normal prepubertal girls matched for age (P less than 0.05) and BMI (P less than 0.02), but not for bone age or height age. The annual incidence rate of wrist fractures in Turner's syndrome girls (9.1 of 1000) was significantly increased compared to the reported annual incidence rate in normal children (3.5 of 1000; P less than 0.003). We conclude that prepubertal-aged girls with Turner's syndrome (less than 13 yr old) have normal bone density for height age, but significantly decreased bone density of the wrist for chronological age, bone age, and BMI. They also have significantly more wrist fractures than normal girls, but it is not clear that this is related to their bone density.

Growth and progression of adolescent idiopathic scoliosis in girls

The progression velocity of scoliosis was studied for 535 consecutive girls with untreated adolescent idiopathic scoliosis. At the first visit the mean age of the patients was 13.9 years (range 9-19 years), the mean magnitude of the major curves was 23.4 degrees (range 5-60 degrees), and that of the minor curves 16.4 degrees (range 0-49 degrees). The median follow-up time was 1.1 years (mean 1.4, range 0.5-6.3 years). The right thoracic curves were most progressive. In the major left thoracic and left lumbar curve types, initial minor curves progressed faster than major curves. The scoliosis progressed faster in patients with minor thoracic kyphosis. In these patients major right thoracic curves were more common. The progression of scoliosis was clearly dependent on the growth velocity, also, the greater the curve at the first visit, the greater was the progression. The progression was most notable with a growth velocity of >or=2 cm/year, at ages between 9 and 13 years, bone ages between 9 and 14 years, Risser signs 0-1, and between 0.5-2 years before menarche.

Effects of chondroitinase ABC and chymopapain on spinal motion segment biomechanics. An in vivo biomechanical, radiologic, and histologic canine study

STUDY DESIGN

The biomechanical effects of chondroitinase ABC and chymopapain related to spinal segmental instability were investigated using a canine model, as well by as radiologic and histologic analyses.

OBJECTIVES

To evaluate the biomechanical, radiologic, and histologic affects on the lumber intervertebral disc of chondroitinase ABC compared with chymopapain.

SUMMARY OF BACKGROUND DATA

No study on the biomechanical effects of chondroitinase ABC has been reported.

METHODS

Forty-eight lumbar intervertebral discs in eight beagles were randomly assigned to three groups and received one of three materials: chondroitinase ABC, chymopapain, or buffered saline, using a lateral percutaneous procedure. One week after injection, the animals were killed and the lumbar spinal motion segments were removed. Spinal segmental instability after chemonucleolysis was evaluated in spinal motion segments without posterior elements. Radiologic and histologic changes were also investigated.

RESULTS

Spinal segmental instability and disc space narrowing were more greater in the chymopapain group than in the chondroitinase ABC group. Destruction of nucleus and anulus proteoglycans, indicated by loss of safranin-O staining, was less intense in chondroitinase ABC-injected discs.

CONCLUSIONS

Chondroitinase ABC results in less spinal segmental instability, disc space narrowing, and destruction of proteoglycans in intervertebral disc matrix than chymopapain.

Relative osteopenia after treatment for acute lymphoblastic leukemia

Osteoporosis in adult life is associated with a significant morbidity and may be predisposed to by osteopenia and failure to reach peak bone mass in childhood. Children treated for acute lymphoblastic leukemia (ALL) may be at risk of osteopenia as a result of previous therapy or as a consequence of the disease process itself. Dual energy x-ray absorptiometry measurements of bone mineral content (BMC) for the whole body and at the lumbar spine and hip were taken in 35 (14 male) long-term survivors of ALL and compared with results in 20 (10 male) survivors of other malignancies and 31 (17 male) healthy sibling controls. The measured BMC was expressed as a percentage of a predicted value derived from the control group and based on the variables that had influence upon it. BMC (%) was reduced at the spine in the ALL group compared with controls [92.4 (8.0)% versus 100.4 (9.7)%, respectively; p < 0.005] and at the hip compared with both other malignancies and controls [89.0 (11.5)% versus 96.1 (11.7)% and 100.4 (9.2)%, respectively; p < 0.0005]. Increasing length of time off therapy was associated with a significant increase in %BMC at both the spine and the hip. For the spine, this association was significantly different between the ALL group and other malignancies, suggesting that any gain in %BMC after therapy was slower in children treated for ALL. Both exercise capacity and levels of physical activity were correlated with %BMC at the hip (r = 0.44, p < 0.001 and r = 0.29, p < 0.01, respectively). Previous exposure to methotrexate, ifosfamide, and bleomycin was associated with a reduction in %BMC at the spine. Exposure to 6-mercaptopurine and cisplatin was associated with a reduction at the hip. In conclusion, children treated for ALL are osteopenic. The mechanism is probably multifactorial but is partially related to previous chemotherapy, limited exercise capacity, and relative physical inactivity.

Decreased axial bone mineral density in perimenopausal women with rheumatoid arthritis--a population based study

OBJECTIVES

Although periarticular osteoporosis is a well-recognised phenomenon in rheumatoid arthritis (RA), there is considerable controversy over whether RA is associated with more generalised osteoporosis. The aetiology of this bone loss is probably multifactorial, including both life-style risk factors and disease-related determinants. Population-based studies on bone mineral density (BMD) in RA have not previously been conducted, and the purpose of the present cross-sectional population-based study was to determine whether patients with RA are at an increased risk of having osteoporosis. Furthermore, the determinants of BMD in RA patients were investigated.

METHODS

BMD at the spine and femoral neck was measured in 143 women with RA. The control group consisted of 1611 women with no disease or taking any drugs known to affect bone metabolism. The study population was a random stratified sample from the Kuopio Osteoporosis Study, which included all perimenopausal women aged 47-56 years residing in Kuopio Province, Eastern Finland in 1989 (n = 14,220). The mean age of the patients at the time of densitometry was 53.7 years.

RESULTS

The mean (SD) spinal and femoral neck BMD was significantly lower in patients with RA compared with controls [spine: 1.067 (0.161) v 1.129 (0.157) g/cm2, p < 0.001; femoral neck: 0.851 (0.136) v 0.932 (0.123) g/cm2, p < 0.001]. Analysis of variance showed that at the spine the difference was significant only in patients having corticosteroid treatment, whereas at the femoral neck patients with non-steroid treatment also had significantly lower BMD. When confounding factors were corrected, no significant difference could be found between non-steroid and corticosteroid treated patients with RA, suggesting that the independent effect of corticosteroids on BMD is only minimal. Multiple regression analysis found age, weight and functional grade to be significant predictors of spinal BMD (R2 = 0.403, p < 0.001). In the femoral neck weight, cumulative corticosteroid dose and functional grade were significant predictors of BMD (R2 = 0.410, p < 0.001).

CONCLUSIONS

RA is associated with generalised osteoporosis. The physical impairment and body weight are the major determinants of both spinal and femoral bone mass in RA patients. The cumulative corticosteroid dose was also a significant determinant of femoral neck BMD. However, the independent effect of corticosteroids is questionable because the use of corticosteroids may be an indicator of more severe disease.

Pain-related fear is associated with avoidance of spinal motion during recovery from low back pain

STUDY DESIGN

A longitudinal assessment of the association between pain-related fear and joint motions in 36 participants with subacute low back pain.

OBJECTIVES

To determine how the psychologic construct of pain-related fear maps to motor behavior in standardized reaching tasks.

SUMMARY OF BACKGROUND DATA

Pain-related fear is a significant predictor of avoidance behavior and occupational disability in individuals with low back pain. However, it is not currently known how pain-related fear maps to motor behavior.

METHODS

Participants with an episode of subacute LBP were tested at 3, 6, and 12 weeks following pain onset. Participants performed reaching tasks at comfortable and fast-paced movement speeds to 3 targets (high, middle, low) located in a midsagittal plane. Three-dimensional joint motions of the thoracic spine, lumbar spine, and hip were recorded using an electromagnetic tracking device. Group differences in joint excursions were assessed using 2 groups (high pain-related fear, low pain-related fear) x 3 times (3, 6, 12 weeks) x 2 movement speeds (comfortable, fast paced) x 3 target heights (high, middle, low) MANOVAs.

RESULTS

Individuals with high pain-related fear had smaller excursions of the lumbar spine for reaches to all targets at 3 and 6 weeks, but not at 12 weeks following pain onset.

CONCLUSION

Individuals with high pain-related fear adopt alternative movement strategies and avoid motion of the lumbar spine when performing a common reaching movement. Identifying how pain-related fear maps to actual motor behavior (i.e., alternative movement strategies) is a crucial first step in determining how pain-related fear and motor behavior interact to promote or delay recovery from acute low back pain.

Instant vertebral assessment: a noninvasive dual X-ray absorptiometry technique to avoid misclassification and clinical mismanagement of osteoporosis

The presence of a vertebral fracture significantly increases the risk of future fracture, classifies a patient with "clinical" osteoporosis, and usually results in treatment for osteoporosis. However, the majority of vertebral fractures are silent, and lateral X-rays (the standard method for identification) are not routinely obtained. Instant vertebral assessment (IVA), a technology that utilizes dual X-ray absorptiometry (DXA), provides rapid assessment of vertebral fractures and is highly correlated with vertebral fractures, as assessed on standard lateral spine X-rays. To assess the role of IVA in patient management, we examined standard bone mineral density (BMD) of the spine, total hip, and femoral neck and spine IVA by DXA in 482 participants screened for an osteoporosis study, who had no previous knowledge of vertebral fractures. Using World Health Organization (WHO) guidelines, subjects were classified using BMD at the spine, total hip, femoral neck, or any combination of these central sites. In addition, we considered subjects as osteoporotic if they had vertebral fractures independent of low bone density. We found that vertebral fractures assessed by IVA were present in 18.3% of asymptomatic postmenopausal women recruited for this study. The sensitivity of BMD alone to diagnose osteoporosis based on either a vertebral fracture or low BMD using WHO criteria ranged from 40 to 74%. This means that between 26 and 60% of osteoporotic individuals could have potentially been missed. Furthermore, 11.0-18.7% of clinically osteoporotic individuals would have been classified as normal by BMD criteria alone. We conclude that IVA is a useful adjunct in the clinical identification of osteoporosis and may prevent mismanagement of osteoporotic patients.

Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people

Spinal mobility and back extensor strength (BES) are important in determining quality of life (QOL) for elderly people. However, the impact of spinal factors on falls remains unclear. The purpose of this study was to clarify spinal factors related to falls in elderly people, including deformity of spinal curvature, spinal mobility and BES. Subjects comprised 92 elderly people divided into 3 groups: subjects without a history of falls or fear of falls (Non-falls group, n = 40); subjects with a history of fear of falls or requiring any support when walking (Fear of falls group, n = 36); and subjects with a history of falls (Falls group, n = 16). Kyphotic angles and mobility of the thoracic and/or lumbar spine, and spinal inclination were measured using a computer-assisted device. Postural imbalance was evaluated using a computerized stabilometer. Isometric BES was also measured. Angle of lumbar kyphosis, spinal inclination, and postural imbalance were significantly higher in the Falls group (p < 0.05) compared to those in the Non-falls group. Mobility of the lumbar spine and BES were significantly lower in the Falls group (p < 0.05) than in the Non-falls group. Multiple logistic regression analysis after adjusting for age, gender, height, and body weight showed grip strength (p = 0.0028), BES (p = 0.0052), lumbar kyphosis (p = 0.0057), spinal inclination (p = 0.0378), mobility of lumbar spine (0.027), and mobility of spinal inclination (p = 0.0282) were significantly associated with presence/absence of falls in elderly individuals.

A prospective study of bone loss in menopausal Australian-born women

Two hundred and twenty-four women (74 pre-, 90 peri-, 60 post-menopausal), aged 46-59 years, from a population-based cohort participated in a longitudinal study of bone mineral density (BMD). BMD was measured by dual-energy X-ray absorptiometry (DXA) at the lumbar spine and femoral neck and the time between bone scans was on average 25 (range 14-41) months. The aim of the study was to assess changes in BMD in relation to changes in normal menopausal status. During the study period women who were between 3 and 12 months past their last menstrual period (n = 22, late perimenopausal) at the time of the second bone scan had a mean (SE) annual change in BMD of -0.9% (0.4%) at the lumbar spine and -0.7% (0.6%) at the femoral neck (both p < 0.05 compared with women who remained premenopausal). In the women who became postmenopausal (n = 42) the mean annual changes in BMD were -2.5% (0.2%) at the lumbar spine and -1.7% (0.2%) at the femoral neck (both p < 0.0005), and in the women who remained post-menopausal (n = 60) they were -0.7% (0.2%) per year and -0.5% (0.3%) per year respectively (both p < 0.05), compared with women who remained premenopausal. In the 1-3 years after the final menstrual period (FMP) there was greater bone loss from the lumbar spine than the femoral neck (p < 0.05). In women who were menstruating at the time of the second bone scan and whose FMP could be dated prospectively (n = 35), higher baseline oestradiol levels were associated with less lumbar spine bone loss (p < 0.005). In the women who remained postmenopausal there was an association between baseline body mass index (BMI) and percentage change per year in femoral neck BMD (p < 0.05), such that women with higher BMI had less bone loss. In conclusion, during the time of transition from peri- to post-menopause, women had accelerated BMD loss at both the hip and spine.

Low back pain

Low back pain is a common, frequently recurring condition that often has a nonspecific cause. Most nonspecific acute low back pain will improve within several weeks with or without treatment. The diagnostic workup should focus on evaluation for evidence of systemic or pathologic causes. Psychosocial distress, poor coping skills, and high initial disability increase the risk for a prolonged disability course. All patients with acute or chronic low back pain should be advised to remain active. The treatment of chronic nonspecific low back pain involves a multidisciplinary approach targeted at preserving function and preventing disability. Surgical referral is indicated in the presence of severe or progressive neurologic deficits or signs and symptoms of cauda equina syndrome.

Spine: posture, mobility and pain. A longitudinal study from childhood to adolescence

A longitudinal study was undertaken to analyse the development of posture and spinal mobility during growth and its relationship to low back pain and sports activities. A total of 90 children were examined at 5-6 years of age and re-examined at 15-16. Sagittal configuration and mobility were measured using Debrunner's kyphometer. Information about pain and activities was acquired by interview with the parents of the 5- to 6-year-olds and by a questionnaire to the 15- to 16-year-olds. Posture changed significantly during the study period: thoracic kyphosis increased by 6 degrees and lumbar lordosis increased by 6 degrees. The relationship between kyphosis and lordosis was independent of gender at age 5-6, but kyphosis in relation to lordosis was significantly lower in girls among the 15- to 16-year-olds. The total sagittal mobility of the spine decreased significantly during the 10-year study period: in the thoracic spine by as much as 27 degrees and in the lumbar spine by 4 degrees. About one-third of the children at the age of 15-16 years stated that they had occasional low back pain. This complaint was more frequent in those stating they had suffered some type of back injury, but low back pain was not related to gender, regular physical training, posture or spinal mobility. The results of the study showed that kyphosis and lordosis increased and mobility decreased in the 90 children who were examined both at age 5-6 and 15-16 years. The relationship between kyphosis and lordosis decreased in girls but not in boys. Occasional low back pain was reported by 38% of the children at the age of 15-16 years, but back pain was not related to posture, spinal mobility or physical activity.

The influence of spine and trunk deformity on preoperative idiopathic scoliosis patients' health-related quality of life questionnaire responses

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To determine the influence of spine and trunk deformity on preoperative idiopathic scoliosis patients' health-related quality of life questionnaire responses.

SUMMARY OF BACKGROUND DATA

Management recommendations for patients with idiopathic scoliosis during adolescence are based heavily on spine deformity and to some extent trunk deformity magnitude. However, the manner in which these objective measures influence the patients' perception of their condition is unclear.

METHODS

Of 67 consecutive preoperative patients, 61 (91%) had completed the Scoliosis Research Society-22 health-related quality of life questionnaire and had been studied with posterior exposure surface topography. Their average age was 15 years, 6 months (range 10 years, 10 months-20 years, 10 months), and the average maximum Cobb was 63 degrees (range 40-137 degrees). Correlations between spine and trunk deformity measures and Scoliosis Research Society-22 scores were determined by the Pearson correlation coefficient, with P < 0.01 considered significant.

RESULTS

For the study group, spine deformity (Cobb) correlated significantly only with Scoliosis Research Society-22 function (r = -0.39, P = 0.0022) domain. Neither coronal nor transverse plane trunk deformity composite scores correlated with any Scoliosis Research Society-22 scores. The Hump Index component of the transverse plane Suzuki Hump Sum composite score was the only trunk measurement to correlate significantly (function r = -0.45, P = 0.003; self image, r = -0.36, P = 0.0040). The strongest correlations occurred when the single thoracic curves, King classifications III and IV, were combined: Cobb versus function r = -0.53, P = 0.0027; Cobb versus self-image r = -0.46, P = 0.0099; and Hump Index versus function r = -0.60, P = 0.0005. There were no significant correlations between either spine deformity or any trunk deformity measure with Scoliosis Research Society-22 responses for either the double or thoracolumbar curve pattern groups.

CONCLUSION

Both spine and upper thoracic transverse plane trunk deformity significantly influenced preoperative idiopathic scoliosis patients' perception of function and self-image, but not pain or mental health. However, in spite of a fairly rigorous standard of proof, P < or = 0.01, the significant r values ranged from -0.33 to -0.68, suggesting that there are factors other than spine and trunk deformity influencing the idiopathic scoliosis patients' health-related quality of life questionnaire responses. Future studies are necessary to define these factors.

Sagittal spino-pelvic alignment in adults: The Wakayama Spine Study

OBJECTIVES

To establish the normal values of spino-pelvic alignment and to clarify the effect of age-related changes using large, community-based cohorts.

METHODS

In this study, data from 1461 participants (466 men, 995 women) were analyzed. On lateral standing radiographs, the following parameters were measured: thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), and C7 sagittal vertical axis (SVA). All values are expressed as the mean±standard deviation. The Spearman rank correlation coefficient was used to examine correlations between variables of spino-pelvic parameters. Finally, we analyzed the relationship between age and spino-pelvic parameters. Therefore, we entered values for the body mass index (BMI), SVA, TK, and PI-LL into a multiple regression model to adjust for potential confounding factors.

RESULTS

The SVA, TK, and PT increased with age, and LL decreased with age. Regarding sex differences, the TK was statistically significantly larger in men than in women, and LL, PT, and PI were statistically significantly smaller in men than in women. Correlation coefficients between the SVA and TK, between the SVA and PI-LL, and between TK and PI-LL were none, strong, and weak, respectively. Results of multiple regression analysis between age and spino-pelvic parameters showed that the standardized partial regression coefficients for the SVA, TK, and PI-LL were 0.17, 0.30, and 0.23, respectively, in men and 0.29, 0.32, and 0.23, respectively, in women.

CONCLUSIONS

We found that all parameters were significantly associated with age in men and women. The SVA, TK, and PT increased with age, and LL decreased with age. Results of multiple regression analysis also demonstrated that the SVA, TK, and PI-LL are related to age. Indeed, the PI-LL value increased with age. In this study, a more excessive PI-LL mismatch was shown, indicating an increased risk of spinal malalignment. Differences in the absolute values of spino-pelvic parameters in each sex were small yet statistically significant. Thus, further study should be performed to corroborate this finding.

The effect of modifying patient-preferred spinal movement and alignment during symptom testing in patients with low back pain: a preliminary report

OBJECTIVE

To examine the effect on symptoms of modifying patient-preferred movements and alignments of the lumbar spine during patient examination.

DESIGN

Repeated-measures study in which patients with low back pain (LBP) participated in a standardized examination that included tests of symptoms with various movements and positions.

SETTING

Six university-affiliated outpatient physical therapy clinics and the local community.

PARTICIPANTS

Five trained physical therapists examined a total of 185 patients (102 women, 83 men; mean age, 41.89+/-13.29 y) with LBP. The majority of patients had multiepisode, chronic LBP.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The examination included tests of symptoms with various alignments and movements in several different positions. Seven tests were designated as primary tests. Tests that increased symptoms were followed immediately by a secondary test in which (1) patient-preferred lumbar spine movement was modified or (2) the lumbar spine was positioned in a neutral alignment. Patients reported the effect of the secondary test on symptoms relative to their symptoms with the primary test. Three responses were possible: symptoms increased, remained the same, or decreased.

RESULTS

Eighty-three percent of the patients reported an increase in symptoms with 1 or more of the 7 primary tests. Ninety-five percent who reported an increase in symptoms with at least 1 of the primary tests reported a decrease in symptoms with 1 or more of the 7 secondary tests. The majority of patients reported a decrease in symptoms when the spinal movement or alignment was modified for 6 of the 7 secondary tests.

CONCLUSIONS

Modifying the symptom-provoking movements and alignments of the spine during symptom testing resulted in a decrease in symptoms for the majority of patients. Information about specific modifications that provide relief of LBP symptoms is important because it can be used to design a treatment program that focuses on training a patient to modify the same movements and alignments in their everyday activities.

Comparison of methods for the assessment of postural load on the back

A questionnaire, a self-administered log, and an observational method were simultaneously applied in the workplace of 35 mechanical repair men to assess exposure to strenuous postures and movements of the back. The average duration of time spent in a standing position was considerably underrated by the workers, while the duration of sitting was strongly overrated when compared with the ratings obtained with the observational method. The workers' ratings of duration with a bent or rotated trunk was two to four times lower than the observed duration. The estimate of the average number of lifts performed per hour was more than four times higher in the questionnaire than in the log. The same striking difference was found for the frequency of bending or rotating of the trunk. These results suggest that the reliability of questionnaire methods for the assessment of postural load in epidemiologic studies is probably not very high.

Review of spinal pseudomeningoceles and cerebrospinal fluid fistulas

Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fistulas are uncommon extradural collections of CSF that may result from inadvertent tears in the dural-arachnoid layer, traumatic injury, or may be congenital in origin. Most pseudomeningoceles are iatrogenic and occur in the posterior lumbar region following surgery. The true incidence of iatrogenic pseudomeningoceles following laminectomy or discectomy is unknown; however, the authors of several published reports suggest that the incidence of lumbar pseudomeningoceles following laminectomy or discectomy is between 0.07% and 2%. Pseudomeningoceles are often asymptomatic, but patients may present with recurrence of low-back pain, radiculopathy, subcutaneous swelling, or with symptoms of intracranial hypotension. Very rarely, they present with delayed myelopathy. Although magnetic resonance imaging is the neurodiagnostic study of choice, computerized tomography myelography and radionuclide myelographic study may be helpful diagnostic tools in some cases. Analysis of suspect fluid for Beta2 transferrin may be a useful adjunctive study. Treatment options include close observation for spontaneous resolution, conservative measures such as bed rest and application of an epidural blood patch, lumbar subarachnoid drainage, and definitive surgical repair.