Offset sublaminar hook is an efficient tool for the prevention of distal junctional failure after kyphotic deformity correction

PURPOSE

To assess the radiological outcomes and complications focusing on distal junctional failure (DJF) of adult spinal deformity patients who underwent thoracolumbar fixation with the use of offset sublaminar hooks (OSH) distally.

METHODS

Retrospective review of a prospective, multicenter adult spinal deformity database (2 sites). Inclusion criteria were age of at least 18 years, presence of a spinal deformity with thoraco-lumbar instrumentation ending distally with OSH (pelvis excluded), with minimum 2 years of follow-up. Demographic data, spinopelvic parameters, functional outcomes and complications were collected. Data was analyzed using descriptive statistics. Statistical significance was set to p < 0.05.

RESULTS

32 patients met the inclusion criteria, with the main etiologies being Scheuermann kyphosis and post-traumatic kyphosis. There was a significant correction of thoracic or thoraco-lumbar kyphosis (from 83° to 45° in case of posterior column osteotomy, p < 0.001, and from 49° to 11° in case of a three-column osteotomy, p < 0.001). DJF occurred in 9.3% of the patients including 1 patient who presented distal hook dislodgement and 2 patients who presented a compression fracture below the lowest instrumented vertebra. Oswestry Disability Index score improved in the majority of the patients (from 34.3 to 18.1, p < 0.05).

CONCLUSIONS

This is the first paper to propose offset sublaminar hook as a safe and efficient tool for protection of the distal end of the construct in kyphotic ASD surgery when not going down to the pelvis. It showed satisfactory radiological and clinical outcome with an acceptable rate of complications and no distal junctional failure that required revision surgery.

Subcutaneous and Topical Tranexamic Acid Use During Rhytidectomy

OBJECTIVE

Tranexamic acid is a potential rhytidectomy adjunct; however, its route of administration, benefits, and safety remain a topic of debate. The purpose of this study is to analyze the effects of topical and subcutaneous TXA during rhytidectomy.

METHODS

This is a retrospective, 3-arm analysis of a single surgeon's practice from Aug. 2019 to Nov. 2023. 175 consecutive patients underwent rhytidectomy; 55 did not receive TXA (8/2019-12/2020), 65 received intraoperative topical 25 mg/mL TXA (1/2021-7/2022), and 55 received subcutaneous 5 mg/mL TXA (7/2022-11/2023). Measured outcomes included drain output, bruising, operative time, estimated blood loss, and complications.

RESULTS

Subcutaneous and topical TXA had similar drain outputs (11.32 mL vs. 12.98 mL, respectively) and bruising scores (20.93 vs. 22.12, respectively). These were significantly less than the control group (24.05 mL, p < 0.001 and 36.28, p < 0.001, respectively). The subcutaneous group operative time (196.13 min) was less than the topical and control groups (212.72 min, p = 0.01; 207.90 min, p = 0.037, respectively) in patients who underwent rhytidectomy with platysmaplasty. EBL and seroma formation in the subcutaneous TXA group were significantly less than the control (23.92 mL vs. 31.67 mL, p = 0.011; 3.60% vs. 18.18%, p = 0.03, respectively). Hematoma, epidermolysis, and infection rates were similar between all groups.

CONCLUSION

Both topical and subcutaneous TXA use during rhytidectomy are associated with reduced postoperative drain output and bruising without an increased risk of complications. Subcutaneous TXA has the added associated benefit of decreasing operative time, EBL, and seroma formation.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:1685-1690, 2025.

Biomechanical Evaluation of a C1-C2 Posterior Arch Screw Construct

Study DesignIn-vitro biomechanical study.ObjectivesInjuries or degenerative conditions can lead to atlantoaxial instability requiring fixation. We aim to assess and compare the biomechanics of a C1-C2 posterior arch and translaminar screw construct against the Harms procedure for posterior atlantoaxial fixation on a human cadaveric model.MethodsNine human cadaveric cervical specimens from occiput to C3 (C0-C3) were used for range of motion (ROM) testing. Each specimen was tested for 4 configurations: 1. Intact, 2. Destabilized, 3. Harms construct, 4. C1-C2 posterior arch screw (PAS) construct. A pure moment of 1.5 Nm was applied, and ROM of the C1-C2 segment was measured in flexion-extension, lateral bending, and axial rotation.ResultsThe Harms group showed a decrease in ROM in all modes (P < 0.021), and the PAS group showed a decrease in ROM in flexion-extension and lateral bending (P < 0.002), but not in lateral bending (P = 0.176). Compared to the intact condition, Harms showed increased ROM for flexion-extension (P = 0.012), and PAS did not (P = 0.258). In lateral bending, both constructs did not significantly reduce ROM (P > 0.058). In axial rotation, both constructs showed a significant increase in ROM (P < 0.002). There was no significant difference in ROM when comparing Harms with PAS in flexion-extension (P = 1.000), lateral bending (P = 0.163), or axial rotation (P = 1.000).ConclusionsThe study demonstrates that a C1-C2 PAS construct restores or increases biomechanical stability compared to the intact condition. C1-C2 PAS offers similar biomechanical stability compared to the Harms construct.

The presence of abnormal palpatory findings in the sacrococcygeal area is correlated with chronic pelvic pain: a cross-sectional study

OBJECTIVE

This study examines the prevalence of abnormal palpatory findings (APFs) in the different pelvic areas among individuals with chronic pelvic pain syndrome (CPP-CPPS) and assesses correlations between APFs and clinical and psychosocial symptoms.

METHODS

In this cross-sectional study, 326 participants (162 CPP-CPPS patients, 164 controls) underwent a standardized palpatory assessment of the sacroiliac, sacrococcygeal, and pelvic floor regions. The manual procedure was performed by two expert physiotherapists with a certification in osteopathic manipulation, following a consensus training. We assessed symptom severity and psychosocial variables using the NIH Chronic Prostatitis Symptom Index (NIH-CPSI), the Hospital Anxiety and Depression Scale (HADS), and the Fear Avoidance Belief Questionnaire (FABQ). Correlation analyses explored relationships between APFs, the presence of pain, and psychosocial variables.

RESULTS

APFs were significantly associated with CPP/CPPS, particularly in the sacrococcygeal (r = 0.609, p < 0.01) and pelvic floor (r = 0.620, p < 0.01) regions, indicating a moderate-to-strong correlation. The multivariate analysis confirmed that sacrococcygeal APFs (OR 3.02, 95% CI 1.96-4.65, p < 0.001) and pelvic floor APFs (OR 2.99, 95% CI 1.87-4.78, p < 0.001) were independently associated with CPP/CPPS, whereas sacroiliac findings showed a weak correlation. The correlations between APFs and psychosocial issues (anxiety, depression, fear-avoidance) were weak (r = 0.25).

CONCLUSIONS

Sacrococcygeal and pelvic floor APFs appear to be important clinical markers of CPP/CPPS. Their presence may help identify patients who could benefit from targeted manual therapy as part of multimodal management. Further research should evaluate the prognostic value of these findings.

How to view the effectiveness of spinal deformity surgery for adult degenerative scoliosis in octogenarian population? A comprehensive analysis and judgment

This study aims to explore the connections between risk factors and clinical outcomes in octogenarian patients diagnosed with adult degenerative scoliosis (ADS). A total of 394 patients participated in this study, with 206 individuals in the younger group and 188 in the octogenarian group. We meticulously gathered patient demographics, including basic information, comorbidities, radiographic data, clinical scoring systems, and details on medical and surgical complications as well as revision surgeries. Univariable linear regression analysis revealed positive correlations between age and several postoperative outcomes: Sagittal vertical axis (SVA) (B = -0.572, P = 0.001), Oswestry Disability Index (ODI) (B = 0.145, P < 0.001), and Japanese Orthopaedic Association (JOA) score (B = 0.035, P < 0.001). Additionally, a positive relationship was observed between age and both proximal junctional kyphosis (PJK) (B = 0.055, P = 0.039) and internal fixation loosening (B = 0.253, P < 0.001). Receiver operator characteristic (ROC) curve analysis indicated that the age threshold values for predicting PJK and internal fixation loosening were 71.5 and 79.5, respectively. In octogenarian patients with ADS, the cost associated with spinal deformity surgery is accompanied by a greater incidence of surgical complications. Compared to younger patients, surgical intervention tends to be more effective at enhancing objective motor functions while having a lesser impact on the subjective experiences of octogenarian patients.

Effects of new assembled titanium mesh cage on the improvement in biomechanical performance of single-level anterior cervical corpectomy and fusion: a finite element analysis

BACKGROUND

Anterior cervical corpectomy and fusion (ACCF) with Traditional Titanium Mesh Cages (TTMCs) can lead to complications such as cage subsidence, dysphagia, and implant-related issues. These complications suggest that the biomechanical stability of ACCF with TTMC may be insufficient. This study aims to evaluate whether a New Assembled Titanium Mesh Cage (NTMC) can improve the biomechanical performance after ACCF.

METHODS

ACCF procedures using both TTMC and NTMC models were constructed and compared. The range of motion (ROM) of the surgical segments and stress peaks in various regions including the endplate, bone-screw interface, facet joints, and adjacent intervertebral discs were analyzed.

RESULTS

The use of NTMC significantly reduced the postoperative ROM of the surgical segments by 80.7%-82.0% compared to ACCF with TTMC. Additionally, stress peaks at the endplate, bone-screw interface, and facet contact force (FCF) were higher in ACCF with TTMC compared to NTMC. TTMC also induced higher stress peaks in the C3/4 and C6/7 intervertebral discs (ranging from 0.2009-6.961 MPa and 0.2477-4.735 MPa, respectively), followed by the NTMC (ranging from 0.1322-3.820 MPa and 0.2227-4.104 MPa, respectively).

CONCLUSIONS

The utilization of NTMC, which includes enlarged spacers and emulates endplate geometries, effectively reduces the risks of cage subsidence and instrument-related complications in ACCF. Furthermore, ACCF with NTMC also decreases the risks of dysphagia, facet joint degeneration, and adjacent disc degeneration during the follow-up period by altering the fixing method while maintaining construct stability.

Impact of Preoperative Anemia on Hospital Costs in Children and Adolescents Undergoing Pediatric Spinal Deformity Surgery

BACKGROUND CONTEXT

Preoperative anemia is associated with the need for red blood cell (RBC) transfusion and extended hospital stays in pediatric patients undergoing spinal deformity surgery.

PURPOSE

This study sought to identify excess hospital costs associated with preoperative anemia in this population.

DESIGN

Retrospective review of linked procedure records from prospectively maintained institutional databases.

PATIENT SAMPLE

Patients aged 2 to 18 years old who underwent posterior spinal fusion surgery at our institution from 2017 to 2023 were identified through procedure-related data collected as part of the National Surgical Quality Improvement Program and Pediatric Health Information Systems databases.

OUTCOME MEASURES

The primary outcome measure was total hospital costs, as derived from billed services and the hospital's department level costs-to-charge ratios, with RBC transfusion as a mediating outcome.

METHODS

Linear regression estimated the association between preoperative anemia and increased hospital costs, adjusting for age, sex, American Society of Anesthesiologists physical status classification, number of spinal levels fused, and surgical duration. The unified framework for mediation and interaction identified whether RBC transfusion was a significant mediator of this association.

RESULTS

Of 672 patients, 10.6% (n = 71) were anemic on preoperative testing. Higher median total hospital costs were seen for those with preoperative anemia than those without ($49,370 vs $41,044; p < 0.001). Linear regression on log-transformed cost data indicated that those with anemia had 18.0% (95% CI: 4.5% - 33.2%; p = 0.008) higher total hospital costs after adjustment for covariates, highlighting 95% confidence in a cost excess of at least $2,448 in anemic patients. RBC transfusion was more common in anemic patients (63.4% vs 46.8%, p = 0.008) and significantly mediated the observed association with costs.

CONCLUSIONS

Preoperative anemia is independently associated with increased healthcare costs during the surgical treatment of spinal deformity in children, with anemic patients incurring thousands of dollars of additional costs driven in part by those associated with RBC transfusion. Depending on the expense and efficacy of hemoglobin optimization strategies, these findings highlight the potential for a cost-effective intervention to treat preoperative anemia in vulnerable populations.

Enhanced Recovery After Surgery Protocol in Patients With Adult Spinal Deformity: A Systematic Review and Meta-Analysis

Study DesignSystematic review and meta-analysis.ObjectivesPerioperative interventions in Enhanced recovery after surgery (ERAS) protocols for managing adult spinal deformity (ASD) patients vary widely across institutions without widespread standardization. This study aims to evaluate the various interventions performed in ERAS protocols and the impact of these protocols on postoperative outcomes following ASD surgery.MethodsA comprehensive systematic review was conducted following PRISMA guidelines. Studies that addressed the implementation of ERAS protocol for thoraco-lumbar corrective surgery were included. We conducted a meta-analysis on postoperative outcomes, where possible, calculating the pooled standardized mean difference between conventional care (pre-ERAS) and ERAS pathways (post-ERAS).ResultsOut of 63 articles, 8 were included in the systematic review. Common interventions in the ERAS protocols included: (1) preoperative anesthesia-related risk assessment and multidisciplinary assessment, (2) intraoperative tranexamic acid (TXA) administration and continuous monitoring of lab data, and (3) postoperative early mobilization and early nutritional support. Multimodal analgesia plans were commonly observed in many of the ERAS protocols. Although meta-analysis demonstrated no significant difference in length of stay (LOS) between the groups, the post-ERAS group generally tended to exhibit lower rates of readmission and medical complications, and reductions in total opioid consumption.ConclusionsThe goals of ERAS protocols for ASD surgery often address preoperative optimization, intraoperative stress minimization, and postoperative recovery facilitation. While the implementation of the ERAS protocol has shown improvements in postoperative outcomes, further studies are required to standardize the ERAS protocol for ASD surgery and enhance the impact on multiple postoperative outcomes.

Manual Therapy for Cervical Radiculopathy: Effects on Neck Disability and Pain - A Systematic Review and Network Meta-Analysis

Objective

To evaluate the application effects of different manual therapy approaches in the treatment of cervical radiculopathy using a network meta-analysis.

Methods

Prospective randomized controlled trials on manual therapy for cervical radiculopathy published in PubMed, the Cochrane Library, and Embase databases were retrieved. The neck disability index and visual analogue scale for neck pain were collected and subjected to network meta-analysis.

Results

A total of 8 eligible studies involving 632 participants with a mean age range of 40-47 years were included. The intervention duration ranged from 4 to 6 weeks. Three intervention groups were defined: Group C (exercise and other therapies without manual therapy), Group M (manual therapy without traction), and Group MT (manual therapy with traction). Larger circles indicate more patients, and thicker lines show more studies comparing interventions. Group M had the highest probability (68.1%) of improving the neck disability index, followed by Group MT (29.1%), with Group C the lowest (2.8%). Compared to Group C, neck disability index scores improved by 0.58 (95% CI: -0.17, 1.33) in Group M and by 0.36 (95% CI: -0.39, 1.11) in Group MT. The difference between Group M and Group MT was not significant (0.22, 95% CI: -0.59, 1.03). For neck pain (visual analogue scale score), Group M had the highest probability (59.5%) of improvement, followed by Group MT (39.6%), with Group C the lowest (0.9%). Compared to Group C, the visual analogue scale score improved by 0.74 (95% CI: -0.04, 1.52) in Group M and by 0.61 (95% CI: -0.18, 1.40) in Group MT. The difference between Group M and Group MT was not significant (0.13, 95% CI: -0.72, 0.98). Egger's regression test showed no apparent publication bias.

Conclusion

Manual therapy is an effective approach for improving neck pain and neck disability index in patients with cervical radiculopathy, but more evidence-based support is needed regarding the use of cervical traction.

Warning line for preventing bone cement leakage in surgery involving percutaneous kyphoplasty for osteoporotic vertebral compression fractures

Background

Percutaneous kyphoplasty (PKP) has achieved good clinical efficacy in the treatment of Osteoporotic vertebral compression fractures (OVCFs). However, how to reduce the bone cement leakage rate and improve safety during PKP surgery remains an urgent issue to be addressed in clinical practice. Therefore, the aim of this study was to identify a line, called the "warning line", to determine whether there is leakage of bone cement during PKP surgery.

Methods

From February 2018 to September 2022, 88 patients and 106 vertebral bodies with OVCFs treated with PKP by a single surgeon at our center were included in the study. Clinical general data were recorded. Vertebral bodies with bone cement reaching the apex of the posterior margin depression without leakage were designated Group A, whereas those with leakage were designated Group B. The posterior vertebral wall was divided into three equal parts in the postoperative three-dimensional CT scans, and the leakage rates at different positions of the posterior vertebral wall were analysed. In Group A without leakage, line b, called the warning line, was marked as the apex of cement diffusion.

Results

All 88 patients successfully underwent surgery, with a significant decrease in the postoperative VAS score. No neurological complications occurred. Bone cement leakage rate was 58.5%. There were 44 vertebral bodies in Group A and 62 in Group B. No significant differences were found between the two groups in terms of age, bone density, balloon pressure, contrast dose, or cement volume (P > 0.05). The bone cement leakage rates in the upper third, middle third, and lower third of the posterior vertebral wall were 25%, 61.1%, and 66.7%, respectively, with statistically significant differences (P < 0.05). In Group A without leakage, the warning line was approximately 6.8% of the sagittal diameter from the posterior vertebral margin.

Conclusions

PKP is a relatively safe treatment for OVCFs. Most bone cement leakage occurs in the middle and lower thirds of the posterior vertebral wall. When the apex of cement diffusion remains anterior to the warning line in PKP surgery, the posterior vertebral wall cement leakage rate is low.

Effect of tranexamic acid in spine surgeries: a systematic review and network meta-analysis

Background

Severe blood loss during spine surgery increases the need for blood transfusion. Transfusion carries the risks of infection, complications, and postoperative morbidity; therefore, minimizing these risks is crucial for all surgical patients.

Methods

A comprehensive literature search was conducted in PubMed, Cochrane, and EMBASE to find studies examining the effect of tranexamic acid (TXA) on spine surgeries in patients who received blood transfusion. We used the mean difference (MD) and 95% credible intervals (CrI) to analyze continuous outcomes, such as intraoperative blood loss, postoperative blood loss, hemoglobin drop, and length of hospital stay. To evaluate categorical outcomes, such as blood transfusion rate and complication rate, the odds ratios (OR) and 95% CrI were determined.

Results

A total of 38 randomized controlled trials were included, evaluating six outcomes across 10 treatment groups. Low-dose intravenous (IV) TXA combined with temperature intervention (15 mg/kg) significantly reduced intraoperative blood loss compared with placebo [MD: -112.0; 95% CrI: -211.0 to -14.9, surface under the cumulative ranking curve (SUCRA): 78.37%]. The administration of more than two doses of TXA significantly reduced intraoperative blood loss (MD: -101.0, 95% CrI: -161.0 to -44.1, SUCRA: 77.65%) and postoperative blood loss (MD: -177.0, 95% CrI: -275.0 to -92.4, SUCRA: 85.66%) compared with placebo. Both treatments significantly impacted the hemoglobin drop and blood transfusion rate.

Conclusions

Low-dose IV TXA with temperature intervention and the combined use of TXA significantly improved blood loss, hemoglobin drop, and blood transfusion rate during spine surgeries. Further studies involving larger populations are warranted and should be carefully designed to determine the potential risk of complications.

Systematic Review Registration

www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024531557, identifier: CRD42024531557.

Lumbosacral anatomy is unique in pediatric spondylolysis

PURPOSE

To determine whether patients with L5 spondylolysis have different lumbosacral anatomy compared to patients without L5 spondylolysis.

METHODS

Computed tomography (CT) scans of pediatric patients with isolated L5 spondylolysis were identified and matched 1:4 (age, sex, BMI) to patients without spondylolysis. Sagittal parameters assessed included sacral slope angle, sacral table angle, L4-S1 and L5-S1 Cobb angles, the horizontal angle of the L5 pars interarticularis, the distances between the L4 inferior articular process (IAP) and the S1 superior articular process (SAP) and their respective individual distances to the L5 pars. Coronal parameters assessed included the percent subluxation of L4 IAP below the facet joint.

RESULTS

1084 CT scans were reviewed. 32 patients with isolated L5 spondylolysis were identified and matched to 122 patients without spondylolysis. The horizontal angle of the L5 pars was greater in spondylolysis patients (142.5 ± 10.2 vs. 119.9 ± 5.9, p < 0.05). There was less distance (mm) between L4 IAP and S1 SAP (11.3 ± 3.9 vs. 14.7 ± 2.9, p < 0.05) and less distance (mm) from both L4 IAP (2.6 ± 1.7 vs. 5.4 ± 2.2, p < 0.05) and S1 SAP (0.7 ± 0.4 vs. 1.5 ± 0.7, p < 0.05), respectively, to the L5 pars in the spondylolysis group. Pearson's analyses revealed that a larger horizontal angle of the L5 pars was strongly associated with spondylolysis (0.59).

CONCLUSION

Pediatric patients with L5 spondylolysis have a significantly more horizontal L5 pars that is closer to both the L4 IAP and S1 SAP.

Influence of variations of craniovertebral junction anatomy on safe C1 lateral mass and C2 pedicle screw insertion: a cadaveric and radiologic study

PURPOSE

The aim of the present study is to analyze the feasibility of a new optimized C1 lateral mass and C2 pedicle screw method that has a suitable trajectory for a range of anatomical variations to decrease the risk of vertebral artery injury.

METHODS

The craniovertebral junction of 17 cadavers (34 sides) were dissected after performing thin-cut computed tomography. The screw entry points, targets, angles, and lengths of the trajectories were performed for C1 lateral mass and C2 pedicle. We particularly focused on the morphometric features and the safety of trajectories in cadavers with vascular and bony variations.

RESULTS

For the C1 lateral mass, the ideal medial and cranial angles were 13.4° ± 1.0° and 14.7° ± 1.1°, respectively. For the C2 pedicle screw, the cranial and medial angles were 27.7° ± 1.4° and 20.4° ± 1.5°, respectively. High-riding vertebral arteries (HRVA) were observed in 35.3% of all cadavers. The incidence of an arcuate foramen was 47% among all sides and its coexistence with an HRVA among all cadavers was 23.5%.

CONCLUSION

Preoperative pedicle-oriented radiological evaluation is crucial before C1 lateral mass and C2 pedicle screw placement because of the high incidence of bony and vascular variations. Using our safe C2 pedicle trajectory, a longer and safer screw course that preserves the vertebral artery can be achieved with a more feasible cranial angle, even with HRVAs, with the exception of narrow pedicle anatomy.

Potential causes of iatrogenic intraoperative bleeding during C1 surgeries: a CT 3D rendering study

BACKGROUND

Iatrogenic intraoperative bleeding during C1 surgeries is difficult to manage.

PURPOSE

To investigate the potential causes of iatrogenic intraoperative bleeding in atlas surgeries.

STUDY DESIGN

This was a retrospective study, observational cohort of patients with DICOM.

PATIENT SAMPLE

High-resolution head and neck computed tomography angiography (CTA) images from 551 subjects were included.

OUTCOME MEASURES

Ponticulus posticus (POPO), vertebral artery (VA), venous plexus communication.

METHODS

Three dimension rendering was utilized in the present study. Potential arterial bleeding was evaluated based on the variation in the VA and the polymorphism of the POPO over the groove for VA (GVA). The communication of the venous plexus in the occipitoatlantal region was investigated to assess the venous hemorrhage.

RESULTS

Among the 551 atlases examined, POPOs were identified on 155 sides, resulting in a prevalence of 14.07% (155/1102). These POPOs (n=155) were reclassified into four types: tiny spur (54.84%), long spur (7.10%), ossified bridge (30.32%), and ossified canal (7.74%). In 42.92% (473/1102) of cases, the VA did not directly contact the sulci of the GVA, creating space for the passage of the rich venous plexus that drained intracranial venous blood outflow to various extracranial layers. Moreover, in 12.7% of the subjects, the study revealed the presence of additional foramens in the posterior lamina of C1, which served as a conduit for the communicating vein CONCLUSION: The potential underestimation of polymorphism in POPOs and VAs can lead to arterial bleeding, whereas a lack of understanding of the intricate condylar emissary venous plexus can result in venous hemorrhage. To mitigate iatrogenic hemorrhage during C1 surgeries, a preoperative HEAD AND NECK CTA is recommended, and heightened caution should be exercised during dissection in the lateral half of the C1 lamina. Furthermore, unknown causes of intraoperative bleeding may arise during the posterior C1 approach; modifications should be considered based on the specific circumstances encountered.

Spinal Cord Stimulation for Intractable Pain Caused by Sacroiliac Joint Dysfunction: A Case Report

Sacroiliac joint dysfunction is one of the causes of lower back pain, and although it has characteristic pain locations and aggravating factors, it is difficult to diagnose and is often overlooked. A case of relief of typical pain symptoms due to sacroiliac joint dysfunction by spinal cord stimulation is presented. A 60-year-old woman presented with severe chronic pain in the left lumbar, lower buttock, iliac, and groin areas that worsened even when sitting for short periods, as well as numbness in the right lower extremity. The patient had chronic lower back pain since experiencing acute lumbosacral sprains in her 20s and 40s, and her symptoms worsened without any trigger in her 60s. Standard imaging examinations showed no lesions that could be causing the pain, and blood tests showed no inflammation or other abnormalities. Although pharmacological treatment did not provide sufficient analgesia, sacroiliac joint block provided a significant analgesic effect, leading to a definitive diagnosis of sacroiliac joint dysfunction. A spinal cord stimulation trial was performed using percutaneous 8-contact leads placed at the thoracic vertebra 8-11 level, and pain relief was confirmed. One month later, 2 new percutaneous 16-contact leads and an implantable pulse generator were implanted simultaneously. One month after implantation, the visual analog scale and the quick inventory of depression symptomatology scores decreased dramatically from 83 to 8 and from 16 to 4, respectively. In addition, the numbness of the right lower extremity disappeared. These analgesic effects were sustained for 12 months.

Pearls and pitfalls in imaging of axial spondyloarthritis for rheumatologists

This review provides key insights into sacroiliitis imaging, covering anatomy, imaging techniques, and interpretation. It focuses on normal physiological changes in young to middle-aged women, children, and the elderly that can resemble sacroiliitis. We emphasize the importance of distinguishing between active and structural lesions, as highlighted in the recent ASAS-SPARTAN standardized magnetic resonance imaging protocol. Physicians should be aware that bone marrow oedema signals on magnetic resonance imaging, a hallmark of active inflammation in axial spondyloarthritis, can also be observed in young to middle-aged women, especially postpartum, even without spondyloarthritis. Paediatric sacroiliac joints may show changes mimicking inflammation due to ongoing bone growth. Furthermore, degenerative changes in the sacroiliac joint are common with advancing age and can be mistaken for sacroiliitis or interpreted as structural changes. The presence of accessory sacroiliac joints, prone to degeneration, further complicates diagnosis. Accurate interpretation requires considering these normal variations to avoid misdiagnosing spondyloarthritis. Collaboration between clinicians and radiologists is crucial, especially when encountering atypical or clinically inconsistent findings.

A comparative biomechanical study of a non-threaded triangular titanium implant versus a fully threaded screw: assessing pullout strength of two sacroiliac joint fixation implant designs

Background

Considering that implant backout is a recognized mode of failure, evaluating the pullout strength is critical for assessing anchoring efficacy. The Sacrix® fully threaded screw (TS) was designed specifically for Less Exposure Spine Surgery (LESS) to reduce incision size, surgical time, and blood loss, using two implants for sacroiliac joint (SIJ) fixation. This study compares the Sacrix® design with the SI-Bone iFuse non-threaded triangular titanium implant (TTI) design, which is widely regarded as the industry standard, and represents the first comparative biomechanical pullout strength study of these implant designs currently used in SIJ fusions.

Methods

We conducted mechanical static axial pullout tests on three 7.0 mm × 45 mm iFuse non-threaded TTIs and six 8.0 mm × 40 mm Sacrix® fully TS embedded in polyurethane foam blocks. An INSTRON 8874 Bi-Axial Tabletop Servohydraulic Dynamic Testing System was used to perform the tests by applying a 2.5 kN axial load.

Results

The effective surface areas of the iFuse non-threaded TTI and Sacrix® fully threaded TS were comparable, measuring 294.15 and 289.81 mm2, respectively. The TS exhibited a significantly higher mean static axial pullout strength of 814.90 N [standard deviation (SD), ±99.428 N] compared to the TTI 200.14 N (SD, ±14.428 N). Statistical analyses, including Welch's t-test and Mann-Whitney U test, revealed significant differences in pullout strength between the two implants (P<0.05). Variance analysis confirmed the differences in pullout strength variances between the implants (P=0.040), suggesting that the variability in pullout strength was distinct for each implant.

Conclusions

The Sacrix® fully threaded TS demonstrated a threefold increase in pullout strength compared with the SI-Bone iFuse non-threaded TTI, suggesting that future SIJ fusion designs should favor threaded over non-threaded implants for improved anchoring capability.

Validation of the AOSpine-DGOU Osteoporotic Fracture Classification - Effect of Surgical Experience, Surgical Specialty, Work-Setting and Trauma Center Level on Reliability and Reproducibility

Study DesignCross-sectional survey.ObjectivesA cornerstone of classification systems is good reliability amongst different groups of classification users. Thus, the aim of this international validation study was to assess the reliability of the new AO Spine DGOU Osteoporotic Fracture Classification (OF classification) stratified by surgical specialty, work-setting, work-experience, and trauma center level.Methods320 spine surgeons were asked to rate 27 cases according to the OF classification at 2 time points, 4 weeks apart (assessment 1 and 2) in this online-webinar based validation process. The kappa statistic (κ) was calculated to assess the inter-observer reliability and the intra-rater reproducibility.ResultsA total of 7798 (90.3%) ratings were recorded in assessment 1 and 6621 (76.6%) ratings in assessment 2. Global inter-rater reliability was moderate in both assessments (κ = 0.57; κ = 0.58). Participants with a work-experience of >20 years showed the highest inter-rater agreement in both assessments globally (κ = 0.65; κ = 0.67). Participants from a level-1 trauma center showed the highest agreement (κ = 0.58), whereas participants working at a tertiary trauma center showed higher grade of agreement in the second assessment (κ = 0.66). Participants working in academia showed the highest agreement in assessment 2 (κ = 0.6). Surgeons with academic background and surgeons employed by a hospital showed substantial intra-rater agreement in the second assessment.ConclusionsThe AO Spine-DGOU Osteoporotic Fracture Classification showed moderate to substantial inter-rater agreement as well as intra-rater reproducibility regardless of work-setting, surgical experience, level of trauma center and surgical specialty.

Cooled radiofrequency ablation provides extended clinical utility in the management of chronic sacroiliac joint pain: 12-month follow-up results from the observational phase of a randomized, multicenter, comparative-effectiveness crossover study

INTRODUCTION

Sacroiliac joint (SIJ) pain comprises up to 30% of cases of mechanical low back pain (LBP), the leading cause of disability worldwide. Despite sacral lateral branch cooled radiofrequency ablation (CRFA) showing efficacy in clinical trials, there is a lack of comparative-effectiveness long-term follow-up.

METHODS

In this randomized, multicenter, comparative-effectiveness study, 210 patients with injection-confirmed SIJ pain who responded to prognostic lateral branch blocks were randomly assigned to receive CRFA of the L5 dorsal ramus and S1-S3/4 lateral branches or standard medical management (SMM) consisting of pharmacotherapy, physical therapy, injections, and integrative therapies. Patients were followed up at 1, 3, 6, 9, and 12 months, with participants reporting unsatisfactory SMM outcomes being allowed to crossover (XO) and receive CRFA at 3 months. The primary outcome measure was the mean change in average LBP score on a 0-10 Numeric Rating Scale (NRS), with secondary outcomes including measures of quality of life (QoL) and function. A responder was defined as a participant who experienced a ≥30% or ≥2-point decrease in average daily NRS pain score coupled with a score ≥5 out of 7 (moderately better) on the Patient Global Impression of Change scale.

RESULTS

At 12 months, the mean NRS pain score declined from a baseline of 6.4±1.4 to 3.5±2.6, with 57.4% (35/61) of participants in the randomized CRFA cohort experiencing a ≥2-point or 30% decrease in average LBP from baseline. In the crossover cohort, 35/63 (55.6%) subjects had the same experience 12 months following the XO procedure; in the XO group, the mean LBP decreased from 6.1±1.5 to 3.4±2.5. Patients also experienced clinically meaningful improvements in QoL via EuroQoL-5D-5L at 12 months (mean change of +0.22±0.27 in the originally-treated CRFA group and +0.21±0.33 in the XO group). Oswestry Disability Index (ODI) scores also improved by 12.4%±14.7 (CRFA) and 13.7%±17.1 (XO) from baseline at study-end. No serious adverse events related to the CRFA procedure were reported.

CONCLUSION

CRFA in patients with SIJ pain provided clinically significant and sustained improvements for 12 months following a single CRFA treatment, regardless of previous SMM treatment.

TRIAL REGISTRATION NUMBER

NCT03601949.

The influence of cement-bone composite material on the biomechanical properties of cervical partial vertebral osteotomy fusion surgery

By establishing micro finite element models of cement-bone composite materials and fusion surgery models (C4-C7), the mechanical properties of cement-bone composite materials (Polymethyl methacrylate (PMMA) and a mixture of PMMA and calcium phosphate bone cement (PMMA/CPC)) were analyzed, and the influence of bone cement on the biomechanical properties of anterior cervical discectomy fusion surgery with partial vertebral osteotomy was evaluated. The results revealed that compared with bone cement, the elastic modulus of cement-bone composite material decreased, the PMMA/CPC+bone (osteoporosis) decreased by 73.65% compared to PMMA/CPC. Furthermore, compared with the PMMA/CPC+bone (osteoporosis), the mechanical properties of the PMMA/CPC+bone (osteoporosis) composite material are closer to those of healthy cancellous bone, exhibiting a lower elastic modulus and higher strain compatibility. This study suggests that choosing PMMA/CPC as a reinforcement material may be more beneficial for cervical fusion surgery in patients with osteoporosis.

A Muscle-Driven Spine Model for Predictive Simulations in the Design of Spinal Implants and Lumbar Orthoses

Knowledge of realistic loads is crucial in the engineering design process of medical devices and for assessing their interaction with the spinal system. Depending on the type of modeling, current numerical spine models generally either neglect the active musculature or oversimplify the passive structural function of the spine. However, the internal loading conditions of the spine are complex and greatly influenced by muscle forces. It is often unclear whether the assumptions made provide realistic results. To improve the prediction of realistic loading conditions in both conservative and surgical treatments, we modified a previously validated forward dynamic musculoskeletal model of the intact lumbosacral spine with a muscle-driven approach in three scenarios. These exploratory treatment scenarios included an extensible lumbar orthosis and spinal instrumentations. The latter comprised bisegmental internal spinal fixation, as well as monosegmental lumbar fusion using an expandable interbody cage with supplementary posterior fixation. The biomechanical model responses, including internal loads on spinal instrumentation, influences on adjacent segments, and effects on abdominal soft tissue, correlated closely with available in vivo data. The muscle forces contributing to spinal movement and stabilization were also reliably predicted. This new type of modeling enables the biomechanical study of the interactions between active and passive spinal structures and technical systems. It is, therefore, preferable in the design of medical devices and for more realistically assessing treatment outcomes.

Role of tranexamic acid (TXA) in plastic and reconstructive surgery: A national perspective

PURPOSE

Despite the widespread use of tranexamic acid (TXA) in plastic surgery, guidelines for the safe and effective administration have yet to be established. The present study reports the current practices of TXA usage in plastic and reconstructive surgery procedures among members of the American Society of Plastic Surgeons (ASPS).

METHODS

An online survey was distributed to all active members of the ASPS. The survey was organized into three general parts: (1) demographic data and practice profiles; (2) familiarity, perceptions, and experience with TXA in various plastic surgery fields including craniofacial surgery, aesthetic surgery, burn care, microsurgery, and Mohs surgery; and (3) TXA dosage, mode, and time of administration.

RESULTS

Five hundred two ASPS members completed the survey (21% response rate). Among the respondents, TXA use was most common in aesthetic surgery (90.3%), craniofacial surgery (78.2%), and breast reconstruction (61.8%). The most common procedures performed under TXA were facial procedures, including facelift (83.6%), neck lift (77.1%), forehead and browlift (54.8%), and rhinoplasty (55.0%). TXA administration protocols in aesthetic procedures included IV bolus (52.3%) and topical administration (50.5%). The most common IV bolus dose was 1 g (43.2%) and the most common TXA solution concentration was 3% (36.0). A total of 92.4% of respondents reported that they had never observed any TXA-related complications.

CONCLUSIONS

The results reflect the widespread use of TXA among ASPS members, the preferred administration protocols in plastic surgery, and TXA's efficacy and favorable safety profile across a wide range of procedures.

Nutrient foramina of human fibula: morphometric analysis and clinical relevance

BACKGROUND

The fibula, situated laterally in the leg, receives vital nutrition through nutrient arteries during embryonic bone growth and early ossification. This study aims to assess the direction, distance, location, number, and foraminal index of nutrient foramina in dry fibulae from the South Indian population.

MATERIALS AND METHODS

A descriptive cross-sectional analysis involved 63 dry adult human fibulae sourced from the Department of Anatomy, Saveetha Medical College and Hospital, Thandalam. Parameters like fibula length, location, number, and direction of vascular foramina were recorded. Statistical analyses were performed on morphometric data and foraminal index.

RESULTS

The mean fibula length was 34.68 ± 2.11 cm. Among the fibulae, 88.88% had a single nutrient foramen, 4.76% had dual foramina, and 6.34% lacked nutrient foramina. Most single foramina were found on the medial crest (66.66%), followed by between the medial crest and posterior border (20.63%). Nutrient foramina were primarily located in Zone II (87.30%), followed by Zone III (11.11%) and Zone I (1.58%). Directionally, 85.71% pointed downward, while 14.28% pointed upward. The mean foraminal index was 40.85 ± 6.78, ranging from 32.57 to 56.25.

CONCLUSION

Zone II, particularly on the medial crest, was the most prevalent location for vascular foramina in the fibula. Dual foramina occurred in 6.34% of cases. This precise anatomical knowledge is valuable for various medical professionals, including anthropologists, forensic experts, radiologists, plastic surgeons, and orthopedic surgeons, especially in procedures involving vascularized fibular bone grafts.

Surgical and non-surgical management of spondylolisthesis: a comprehensive review

Spondylolisthesis is a spinal condition characterized by the forward or backward displacement of a vertebral body, most commonly affecting the lower lumbar spine. It can be classified into different types, with isthmic and degenerative being the most prevalent. Early diagnosis is essential to initiate appropriate treatment based on symptom severity, degree of slippage, and neurological deficits. Non-surgical management is the first-line approach for low-grade spondylolisthesis (Grade I-II) and includes physical therapy, activity modification, pain management with nonsteroidal anti-inflammatory drugs or epidural steroid injections, and, in some cases, bracing. While most patients experience symptom relief with conservative treatment, those with progressive neurological deficits, severe pain, or significant instability may require surgery. Surgical options typically include decompression for nerve compression and fusion to stabilize the spine. The choice between decompression alone and decompression with fusion remains controversial, particularly in degenerative spondylolisthesis without initial instability. Posterior lumbar interbody fusion and transforaminal lumbar interbody fusion are the most performed techniques, with minimally invasive surgery gaining popularity due to its less aggressive impact on tissues and faster recovery. Long-term follow-up is necessary to monitor for complications such as adjacent segment disease, pseudarthrosis, or reoperation rate. Advances in imaging, surgical navigation, and regenerative medicine are important for the future of spondylolisthesis treatment, but current management remains centered on optimizing patient outcomes through individualized care and evidence-based treatment selection.

Multi-level spondylolysis at Egiin Gol: A case from Xiongnu period Mongolia

OBJECTIVE

This paper presents and discusses the aetiology of an extreme case of multi-level spondylolysis with unique presentation.

MATERIALS

The affected individual is an adult male from Xiongnu period (209 BCE to 93 CE) Egiin Gol, northern Mongolia.

METHODS

Analyses were limited to macroscopic and non-invasive methods.

RESULTS

Seven complete spondylolytic clefts were documented on four vertebrae between T12 and L4, with only one located on L4, where most cases of spondylolysis occur, and four defects had atypical morphology. Evidence of spondylolisthesis was also observed.

CONCLUSIONS

Congenital susceptibility to spondylolysis, combined with a physically demanding lifestyle, likely account for the condition's unusual manifestation.

SIGNIFICANCE

The significance of this case its severity (one of the most extreme documented from archaeological contexts) and unusual presentation (location of the clefts and their atypical morphology).

LIMITATIONS

Only a small sample (< 30) of Xiongnu period human remains were available for comparison.

SUGGESTIONS FOR FURTHER RESEARCH

Interpretations from this case study would benefit from a more extensive analysis of spondylolysis, biomechanical stress, and acute trauma on the nomadic pastoral populations of northern Mongolia, including those pre-dating and post-dating the Xiongnu.

Prevalence and Characteristics of Lumbar Spondylolysis in White and Black Patients

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To the best of our knowledge, the prevalence of lumbar spondylolysis in white and black populations has never been studied using computed tomography (CT). The purpose of this study was to examine and compare the prevalence and characteristics of lumbar spondylolysis in white and black patients.

METHODS

This study is a cross sectional study. Patients aged 20-79 who underwent abdominal and pelvic CT for trauma screening in the New York City area and whose race was classified as "white" and "black" on the questionnaire were recruited to the study. A total of 1200 white patients (600 women, 600 men) and 1200 black patients (600 women, 600 men) were included for the analysis. The presence of lumbar spondylolysis, level, unilateral/bilateral, and the presence of spondylolisthesis at lumbar spondylolysis level were evaluated using CT.

RESULTS

The prevalence of lumbar spondylolysis was 3.0% (n = 36) for white patients and .8% (n = 10) for black patients, with 3.3% (n = 20) and 1.0% (n = 6) for white and black females, respectively; and 2.7% (n = 16) and .7% (n = 4) for white and black males, respectively. The prevalence of lumbar spondylolysis was significantly higher in white patients compared with that in black patients (P < .0001). Lumbar spondylolysis was at L5 in 44/46 patients (95.7%) and bilateral in 41/46 patients (89.1%). Spondylolisthesis at lumbar spondylolysis level was found in 40/46 patients (87.0%).

CONCLUSIONS

The prevalence of lumbar spondylolysis was 3.0% for white patients and .8% for black patients. The prevalence of lumbar spondylolysis was significantly higher in white patients compared with that in black patients.

Correlation analysis of global sagittal alignment of the spine in cases of low-grade degenerative lumbar spondylolisthesis

PURPOSE

Disruptions in global sagittal spinal alignment can lead to changes in global sagittal spinal alignment, often manifesting as sagittal malalignment, where the trunk shifts forward. We proposed that these alignment changes are linked to degenerative lumbar spondylolisthesis (DS). The objective was to assess global spinal alignment in low-grade DS using sagittal vertical axis (SVA) classification.

METHODS

The patients with DS were categorized into three groups based on the adult spinal deformity classification: type I, defined by a SVA of less than 40 mm; type II, with an SVA ranging from 40 mm to 95 mm; and type III, where the SVA is 95 mm or greater. The study compared age and various sagittal parameters among these groups, including thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI).

RESULTS

Notable differences were observed between type I and type II, as well as between type I and type III, whereas no substantial variation was detected between type II and type III. Additionally, PI increased with advancing type classification, with a distinct contrast observed between type I and type III.

CONCLUSION

A high PI is a key risk factor for worsening SVA in DS, and it may contribute to the initiation and progression of the condition.

Fixation of the Sacroiliac Joint: A Cadaver-Based Concurrent-Controlled Biomechanical Comparison of Posterior Interposition and Posterolateral Transosseous Techniques

OBJECTIVE

Our study aimed to compare the posterior interposition technique against the posterolateral transosseous technique in the same cadaver specimens.

METHODS

Computer and cadaver models of 2 fixation techniques were developed. The computer model was constructed to analyze bone volume removed during implant placement and the bony surface area available for fusion. The cadaver model included quasi-static multidirectional bending flexibility and dynamic fatigue loading. Relative motions between the sacrum and ilium were measured intact, after joint destabilization, after fixation with direct-posterior and posterolateral techniques, and after 18,500 cycles of fatigue loading. Relative positions between each implant and the sacrum and ilium were measured after fixation and fatigue loading to ascertain the quality of the bone-implant interface. The 2 techniques were randomized to the left and right sacroiliac joints of the same cadavers.

RESULTS

The posterior interposition technique removed less bone volume and facilitated a larger surface area available for bony fusion. Posterior interposition significantly reduced the nutation/counternutation motion of the sacroiliac joint (42% ± 8%) and reduced it more than the posterolateral transosseous technique (14% ± 4%). Upon fatigue loading, the posterior interposition implant maintained the bone-implant interface across all specimens, while the posterolateral transosseous implant migrated or subsided in 20%-50% of specimens.

CONCLUSION

Posterior interposition fixation of the sacroiliac joint reduces joint motion. The amount of fixation from the posterior technique is superior and more durable than the amount of fixation achieved by the posterolateral technique.

MRI-based endplate bone quality scores outperform vertebral bone quality scores in predicting adjacent segment disease following transforaminal lumbar interbody fusion

PURPOSE

This study aims to (1) evaluate whether the endplate bone quality (EBQ) scores can independently predict adjacent segment disease (ASD); and (2) judge the predictive value of EBQ compared to vertebral bone quality (VBQ) for ASD after single-level transforaminal lumbar interbody fusion (TLIF).

METHODS

A single-center retrospective analysis was conducted of patients undergoing single-level TLIF for degenerative spinal disease from 2014 to 2020. Demographic, surgery, and radiographic data were collected. Logistic regression was used to identify independent risk factors for ASD. Furthermore, a receiver operating curve (ROC) analysis was conducted to evaluate the predictive efficacy of the EBQ score and VBQ score.

RESULTS

The rate of ASD was 16.4% at a minimum 24-month follow-up. Significant risk factors for ASD were higher VBQ score (OR = 3.418, 95%CI: 1.297-9.008, P = 0.013), higher EBQ score (OR = 2.469, 95%CI: 1.085-5.621, P = 0.031), and higher adjacent segment Pfirrmann grade (OR = 2.866, 95%CI: 1.765-4.653, P<0.001). The diagnostic accuracy of VBQ and EBQ for distinguishing ASD were 0.806 (95%CI: 0.728-0.883) and 0.835 (95%CI: 0.757-0.912). The optimal threshold of VBQ scores was 2.926 (sensitivity: 90.6%, specificity: 62.0%) and of EBQ was 3.511 (sensitivity: 90.6%, specificity: 71.8%).

CONCLUSION

Higher VBQ and EBQ scores are both independent risk factors of ASD after single-segment TLIF surgery, and EBQ scores perform better in predicting ASD. When EBQ > 3.511, there is a considerable risk of ASD.

A Mid-Term Result of the Treatment of Intra-Articular Calcaneal Fractures with the Use of Intramedullary Nailing

Background: Intra-articular calcaneal fracture (CF) treatment is associated with a high risk of complications, but closed reduction and internal fixation (CRIF) is a minimally invasive alternative for treatment. Methods: Forty-eight patients treated with CRIF and CALCAnail® due to intra-articular CF between 2016 and 2021 were analyzed to check union time, complication rate, and functionality after the intervention. Functional and pain outcomes were assessed, including the Maryland Foot Score (MFS), American Orthopedic Foot & Ankle Society (AOFAS) scale questionnaires, and the numerical pain scale (NRS) at mid-term follow-ups 2-5 years after the intervention. Results: Intervention increased median Böhler's angle from 21.5° to 32° (p < 0.01). The median bone union time was 12 weeks. The risk of malunion was higher in patients with Sanders type 4 (RR = 2.28; 95% CI 1.11-4.72) and those operated on later than the 2nd day after injury (RR = 2.1; 95% CI 1.08-4.09). Patients with at least one of the comorbidities (nicotinism, diabetes, obesity) had a higher risk of intensive pain (NRS > 3) 2-5 years after surgery (RR = 1.69; 95% CI 1.06-2.68), and 84% were satisfied with their treatment. Other complications included complex regional pain syndrome in two patients (4%), malunion in three (6%), and surgical site infection in two (4%). The MFS had a median score of 85 points, while that of the AOFAS was 82 points. Conclusions: CRIF, with the use of the CALCAnail® implant, allows doctors to restore anatomical relationships around the subtalar joint, resulting in good clinical and functional results.

Anatomy of the diaphragmatic crura and other paraspinal structures relevant to en-bloc spondylectomy for lumbar spine tumours

INTRODUCTION

En-bloc spondylectomy in the lumbar spine is a challenging procedure mainly due to a complex prevertebral anatomy. The aim of our study is to describe the anatomy of the diaphragmatic crura and surrounding vascular and neural structures which may be iatrogenically injured during the surgical resection.

MATERIALS AND METHODS

Ten embalmed specimens were meticulously dissected. Widths of the diaphragmatic crura, abdominal aorta, cisterna chyli, thoracic duct, sympathetic trunks, and inferior vena cava as well as their distances from the midline were measured at nine levels (L1 to L4 vertebra and adjacent intervertebral discs).

RESULTS

The right crus was attached to the L2-L4 vertebral bodies and L2/3 intervertebral disc, while the left crus inserted onto L1-L3 vertebrae. The thoracic duct arose commonly at the level of L2 vertebra and overlaid the right crus at the L3 vertebra and L2/3-disc levels. The cisterna chyli was present in 70% of specimens and overlapped with the left crus at the same levels. Both sympathetic trunks emerged underneath the crura at the L1/2 discs or L1 vertebra level. The aorta overlapped with the crura at all levels.

CONCLUSION

The L3 level appears to be the riskiest for spondylectomy due to the overlap of both diaphragmatic crura with the thoracic duct and cisterna chyli, respectively. Spondylectomy at the L2 level also brings the risk of lymphatic structures injury while injury to the left sympathetic trunk may be the main issue at the L1 level.

The management of odontoid fractures through the lens of evolution in classification schemes: A systematic review with illustrative case examples

Introduction

Odontoid fractures account for approximately 15% of all cervical spine fractures. Despite numerous classification systems, controversy persists regarding the ideal treatment of these fractures, especially in elderly and medically frail patients.

Research question

This article aims to provide a systematic review of odontoid fracture classifications and assess their clinical applicability.

Material and methods

A systematic literature review was conducted in PubMed, Embase, and Cochrane databases using the terms "odontoid", "fracture", and "classification". Articles published between 1974 and 2024 were analyzed and those containing odontoid fracture classifications were included.

Results

Four hundred and fifty-seven articles were identified, and 32 were selected for detailed investigation. Seven articles were selected after reviewing the full text, and four additional articles cited in the references were included, from which two were published before 1974. A total of eleven classification systems were found in the literature. The classifications were based on the position and direction of the fracture line, displacement, angulation, embryology, and odontoid anatomy. The AO Spine Classification System was among the more recent frameworks reviewed and analyzes the presence of ligamentous injury or translation.

Discussion and conclusions

Anderson and D'Alonzo, Roy-Camille, Grauer, and the AO Spine Classification System are the most commonly applied in clinical practice. However, existing systems lack specific considerations for osteoporosis and the medical frailty of elderly patients, who constitute a substantial portion of cases. Future classification systems should address these factors to better guide treatment for this population.

Management of extremity and pelvic fractures in earthquake: our observations and recommendations

BACKGROUND

Earthquakes frequently cause injuries to the musculoskeletal system. Studies conducted after earthquakes often report on injured limbs, fractures, and surgeries. This study aimed to enhance preparedness for future earthquakes by acquiring knowledge about the prevalence of fractures and the relationship between fracture types and injury mechanisms.

METHODS

A retrospective analysis was conducted on medical records of patients with fractures admitted to our hospital following the 2023 Kahramanmaraş Earthquake. Patients with fractures resulting from traffic accidents or other causes unrelated to earthquakes were excluded. The recorded data included age, gender, fracture site, fracture type, mechanism of injury, date, duration of surgery, and peak creatine kinase (CK) level. The injury mechanisms were classified into four main categories: injured by falling objects, falling while running, falling from height, and being trapped under rubble. The study investigated the relationship between fractures and other factors.

RESULTS

The study included 185 patients with a mean age of 39.62 ± 20.83 years. The most frequent mechanism of injury was being trapped under rubble. In total, there were 214 fractures, with pelvic fractures being the most common (21.50% of all fractures). Tibia fractures were the most common fractures in the lower extremities (15.89%). Women had a significantly higher occurrence of pelvic fractures (33.3%) compared to men (14.5%) (p = 0.003). The frequency of pelvic fractures significantly increased as age decreased (p = 0.007). Patients with pelvic fractures had a significantly greater peak CK concentration (p = 0.006). Open fractures were more common in the first few days, and Kirschner wires were the first treatment applied at a mean of 74 h and external fixators at a mean of 94.3 h.

CONCLUSION

Injuries from falling objects from roofs and jumping from heights are important in earthquakes. In addition to lower extremity fractures, pelvic fractures are common in earthquake disasters. Most pelvic fractures are simple lateral compression fractures and it is important to follow the patients for crush syndrome in the first days instead of focusing on definitive fracture treatment. Open fractures should be prioritized for fracture surgery within the first few days. External fixators and Kirschner wires are recommended. Closed fractures should be treated conservatively and definitive surgical procedures should be postponed to the following weeks.

Autologous Bone Graft Harvest Technique Using Reamer-Irrigator-Aspirator for 2-Stage Revision Anterior Cruciate Ligament Reconstruction

Autologous or allograft bone grafting is commonly used for bone restoration in the setting of revision anterior cruciate ligament (ACL) reconstruction owing to bone loss or malpositioned or osteolytic tunnels. For significant defects, staged procedures with initial bone grafting to the femoral and/or tibial tunnels is occasionally required. In this setting, allograft shows variable rates and quality of healing and can incur increased expense. Historical techniques of autograft harvest are associated with limited graft volume and donor-site morbidity. Our technique of retrograde femoral autograft harvest shows excellent volume and quality of graft; minimal morbidity; operative expediency; and rapid, quality tunnel filling to facilitate an anatomic second-stage revision ACL reconstruction. Intramedullary bone graft harvest using a Reamer-Irrigator-Aspirator has shown efficacy for typical use in the setting of nonunion, particularly among orthopaedic trauma surgeons. Advantages of using the RIA 2 (Reamer-Irrigator-Aspirator) system (DePuy Synthes) for autologous bone graft harvest include lower donor-site morbidity, greater bone graft volume, decrease in number and size of incision sites, shorter harvest time, and efficacious healing. The goal of this procedure is to obtain an adequate amount of autologous bone graft using a minimally invasive device, RIA 2, safely and efficiently for a 2-stage revision ACL reconstruction.

Ligamentous ankle injuries in relation to the morphology of the incisura fibularis: A systematic review

IMPORTANCE

Ligamentous ankle lesions are among the most frequent sports injuries. One of the key intrinsic stabilizers of the ankle joint is the incisura fibularis (IF), as it interlocks the distal tibia and fibula. Despite an abundant amount of studies related to ligamentous ankle injuries, scant attention has been given to the specific role of the IF morphology.

OBJECTIVE

We systematically reviewed all literature focused on the relation between ligamentous ankle lesions and IF morphology.

EVIDENCE REVIEW

A systematic literature search was conducted on PubMed, Embase, and Web of Science according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021282862). In general, search terms were related to ankle and syndesmosis trauma/instability in combination with morphology parameters of the IF. Studies categorizable as original research (randomized controlled trial or observational) were included. Studies concerning degenerative ankle disease and cadavers were excluded.

FINDINGS

Thirteen studies were confirmed eligible and consisted of a prospective cohort (n ​= ​1), retrospective comparative (n ​= ​10), and observational (n ​= ​2) study design. Several studies have found an increased number of ankle ligament injuries and a higher incidence of chronic ankle instability in association with a shallow IF depth. In addition, statistically significant differences in incisura height and angle were also noted: a shorter incisura and more obtuse angle were more present in patients with ankle ligament injuries.

CONCLUSION AND RELEVANCE

Most studies found distinct characteristics of the IF morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement. However, not all studies could identify this association and presented a heterogeneous methodological quality. Therefore, further prospective studies are warranted to clarify the relationship between the IF morphology and ligamentous ankle injuries.

LEVER OF EVIDENCE

Level III, systematic review.

3d-printed sacral reconstruction prosthesis from multiscale topology optimization: A comprehensive numerical assessment of mechanical stability

Sacral chordoma, an invasive tumor, necessitates surgical removal of the tumor and the affected region of the sacrum, disrupting the spinopelvic connection. Conventional reconstruction methods, relying on rod and screw systems, often face challenges such as rod failure, sub-optimal stability, and limited osseointegration. This study proposes a novel design for a porous-based sacral reconstruction prosthesis. The design framework involves a two-step topology optimization (TO) process. The first TO step is utilized to obtain the external shape of a patient-specific prosthesis, while the second TO step determines varied density fields. These fields are later integrated with graded Gyroid structures to generate the porous-based sacral prosthesis. Finite element simulations reveal several benefits of the newly developed device. Firstly, considering only solid-based TO tends to result in a highly rigid spinal movement, which may not be entirely favorable. However, the porous-based technique allows for a wider design space, enabling the sacral device's stiffness to be more comprehensively engineered. Secondly, with porous integration, the prosthesis shows potential for promoting bone integration over time, thereby providing further biological fixation and improving long-term structural stability. Thirdly, the porous-based prosthesis outperforms conventional methods such as four-rod reconstruction (FRR) and four-rod plus anterior column reconstruction (FRACR) by reducing maximum von Mises stress in the instruments by approximately 50-80 %. In summary, this study demonstrates how a two-step TO framework can create a superior sacral prosthesis, enhancing its mechanical performance and impact on spinopelvic stability. This suggests potential improvement for similar orthopedic devices in the future.

Complicated Diverticulitis: A Rare Long-Term Complication After Esophagectomy With Colon Interposition

Colon interposition, a rare esophageal reconstructive procedure, can lead to late complications such as diverticulitis in the transplanted colon segment. This case involves a 65-year-old man who presented with a neck swelling 60 years after a colon interposition following caustic ingestion. A diagnosis of diverticulitis with an abscess was confirmed on a computed tomography scan after an initial diagnosis of diverticulitis, and subsequent abscess drainage was performed. Despite the development of a colocutaneous fistula, it closed spontaneously after eight weeks. The pathophysiology involves altered colonic conditions postsurgery. Management includes antibiotics and drainage, but treatment for such fistulas remains uncertain, requiring a tailored approach.

Sacroiliac joint auricular surface morphology modulates its mechanical environment

The sacroiliac joint (SIJ) exhibits significant variation in auricular surface morphology. This variation influences the mechanics of the SIJ, a central node for transmitting mechanical energy from upper body to lower limbs and vice versa. The impact of the auricular surface morphology on stress and deformation in the SIJ remains poorly understood to date. Computed tomography scans obtained from 281 individuals were included to extract the geometry of the pelvic ring. Then, the auricular surface area, SIJ cartilage thickness, and total SIJ cartilage volume were identified. Based on these reconstructions, 281 finite element models were created to simulate SIJ mechanical loading. It was found that SIJ cartilage thickness only weakly depended on age or laterality, while being strongly sex sensitive. Auricular surface area and SIJ cartilage volume depended weakly and non-linearly on age, peaking around menopause in females, but without significant laterality effect. Larger SIJs, characterized by greater auricular area and cartilage volume, exhibited reduced stress and deformation under loading. These findings highlight the significant role of SIJ morphology in its biomechanical response, suggesting a potential link between morphological variations and the risk of SIJ dysfunction. Understanding this relationship could improve diagnosis and targeted treatment strategies for SIJ-related conditions.

Patient outcomes: One-stage vs. two-stage lumbar surgery for symptomatic low-grade spondylolisthesis: A quality outcomes database study

OBJECTIVE

Controversy exists regarding treatment of symptomatic low-grade spondylolisthesis (LGS). Both one- and two-stage fusions are commonly performed, but it is unclear if one approach is superior. We aim to compare the satisfaction rates and patient-reported outcomes (PROs) in patients with LGS undergoing one- versus two-stage lumbar spine surgery.

METHODS

The Quality Outcomes Database was queried for patients with Grades I and II spondylolisthesis who underwent one- (n = 3223) or two-stage (n = 325), 1-2 level lumbar fusion. Demographics, comorbidities, symptom burden, and PROs were extracted and compared. Outcomes included Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), Quality-Adjusted Life Year (QALY), and satisfaction index. Minimal clinically important difference (MCID) values for VAS back pain, VAS leg pain, ODI, and QALY were 1.6, 1.7, 14.3, and 0.2, respectively. Patients with pre-existing scoliosis or kyphosis, missing data, and revision procedures were excluded. Categorical variables were compared with a Chi-square test; continuous variables were assessed for normality with a Shapiro Wilk test and compared with a Mann-Whitney U or Student's t-test.

RESULTS

No significant differences were noted for baseline characteristics, except for a lower mean age, percentage of female patients, and prevalence of osteoporosis in the two-stage cohort (58 ± 12.4 vs 62 ± 11.6 years; 50 % vs 62 %; 3.0 % vs 7.1 %, respectively; p < 0.01). The average surgery length was longer in the two-stage cohort (p < 0.01). A significantly higher percentage of patients returned to baseline activities within 3 months postoperatively following one-stage procedures (43 % vs. 29 %, p < 0.01), irrespective of whether they had Grade 1 or Grade 2 spondylolisthesis. Comparable proportions of patients achieved the MCID for PROs, with no significant differences in satisfaction indices observed at 3, 12, and 24 months postoperatively, regardless of preoperative spondylolisthesis grade.

CONCLUSIONS

Patients receiving one and two-stage procedures for symptomatic LGS had similar rates of satisfaction and PROs. More research is necessary to define the benefits of two-stage approaches given their increased time, cost, and risk profile.

Successful Secondary Reconstruction and Dental Rehabilitation for a Maxillary Bone Defect With Discontinuity After Partial Maxillectomy: A Case Report

Secondary reconstruction of the maxillary defect with discontinuity after partial maxillectomy is extremely challenging due to extensive, severe adhesions between the maxillary sinus membrane and oral mucosa, resulting in no space for the grafted bone and a lack of soft tissue to cover the graft. This case reports a 23-year-old female patient who underwent secondary reconstruction for a bone defect caused by a partial maxillectomy to remove an ameloblastoma that had invaded the maxillary sinus. We incised the existing soft tissue ridge at the bone defect and extensive adhesions below the maxillary sinus to create space for the grafted bone and to form an adequate buccal flap. To ensure the grafted bone's stability and to support the surrounding soft tissues, a cortical bone from the iliac crest was placed beneath the sinus membrane, with cancellous bone grafted underneath, and a titanium mesh was applied at the alveolar region. This approach allowed robust bone regeneration at the graft site, demonstrating dense, well-integrated new bone formation that facilitated successful implant treatment with good primary stability for 2 implants. This surgical approach, when indicated, can be less invasive than vascularized bone grafts.

Preoperative Optimization Strategies in Elective Spine Surgery

» Although spine surgery is effective in reducing pain and improving functional status, it is associated with unacceptably high rates of complications, thus necessitating comprehensive preoperative patient optimization.» Numerous risk factors that can impact long-term surgical outcomes have been identified, including malnutrition, cardiovascular disease, osteoporosis, substance use, and more.» Preoperative screening and personalized, evidence-based interventions to manage medical comorbidities and optimize medications can enhance clinical outcomes and improve patient satisfaction following spine surgery.» Multidisciplinary team-based approaches, such as enhanced recovery after surgery protocols and multidisciplinary conferences, can further facilitate coordinated care from across specialties and reduce overall hospital length of stay.

Phase-specific changes in hip joint loading during gait following sacroiliac joint fusion: Findings from a finite element analysis

BACKGROUND

Low back pain affects over 80 % of adults, with sacroiliac joint dysfunction accounting for 15-30 % of these cases. Sacroiliac fusion is a surgical procedure for refractory joint pain. While the biomechanics of the joint and its fusion relative to the spinal column are well-known, the hip-spine relationship post-fusion remains unclear. Understanding the biomechanical state following fusion can enhance patient recovery and optimize surgical outcomes. This study uses finite element analysis to assess hip joint biomechanics following sacroiliac joint fusion.

METHODS

CTs of a 55-year-old male were used to create a biomechanical model, validated against a cadaveric study. Three triangular titanium alloy implants were placed across the sacroiliac joint in a unilateral and bilateral configuration. The model, loaded with pelvis and hip joint kinematics during a gait cycle, calculated joint reaction forces, contact stress and area on the hip joint across various gait phases.

FINDINGS

Hip joint contact stresses varied with fixation configurations and gait phases. Unilateral right fusion reduced joint reaction forces by 2 % but increased contact stress by 3.7 %. Bilateral fusion increased joint reaction forces by 6.7 % and contact stress by 3.25 %, with higher stress during foot flat and heel off phases compared to unilateral fixation.

INTERPRETATION

Fusion alters hip loading patterns during specific gait phases, with bilateral fusion producing the highest stresses during foot flat and heel off. These findings may suggest the need for fusion-specific rehabilitation protocols and warrants further investigation of long-term joint health outcomes.

Biomechanical Evaluation of the Effect of MIS and COS Surgical Techniques on Patients with Spondylolisthesis using a Musculoskeletal Model

Background

The biomechanical impacts of Conventional Open Surgery (COS) versus Minimally Invasive Surgery (MIS) fusion techniques on adjacent segments and their potential role in developing Adjacent Segment Disease (ASD) remain uncertain for spondylolisthesis.

Objective

This study aimed to investigate the impact of MIS and COS fusion surgeries on adjacent spinal segments for spondylolisthesis, through on muscle injury and developing ASD.

Material and Methods

This prospective and non-randomized controls study used a validated musculoskeletal model to compare the biomechanical effects of COS and MIS L4/L5 fusion surgery on patients with spondylolisthesis. The model incorporated kinematic data from 30 patients who underwent each surgery. A sitting task was simulated to model post-operative muscle atrophy, and the analysis focused on changes in biomechanics of adjacent spinal segments.

Results

Lumbar flexion was significantly greater (201%) in MIS vs. COS, despite similar pelvic tilt. Consequently, Lumbopelvic Rhythm (LPR) also increased in MIS (133%). Both techniques altered inter-segmental moments. While inter-joint load was higher in COS, only the lower joint's compressive load was significantly greater (67%). Additionally, MIS required lower overall muscle force with reduced loads and passive moment on spinal joints compared to COS.

Conclusion

This study demonstrates that MIS fusion preserves physiological LPR better than COS. MIS maintains normal spinal curvature and maintains lumbar lordosis. While open surgery can lead to abnormal curvature and increased muscle forces to compensate for spinal stability. The study emphasizes the importance of paraspinal muscles in influencing spinal load distribution during MIS compare to COS.

Risk factors and treatment strategies for adjacent segment disease following spinal fusion (Review)

Adjacent segment disease (ASD) is a significant clinical complication following cervical and lumbar spinal fusion surgery, characterized by the degeneration of spinal segments adjacent to the fused area. The present literature review aimed to elucidate the risk factors contributing to ASD and to evaluate current and emerging treatment strategies. Epidemiological data indicate that patient‑related factors such as age, pre‑existing spinal degeneration and comorbidities, along with surgical factors including the type of fusion, instrumentation and alignment correction, play pivotal roles in ASD development. Biomechanical alterations post‑fusion further exacerbate the risk. The underlying mechanisms of ASD involve changes in spinal kinematics and disc degeneration, driven by inflammatory and degenerative processes. Diagnostic modalities, such as magnetic resonance imaging and computed tomography scans, are essential for early detection and accurate diagnosis. Preventive strategies emphasize meticulous preoperative planning, advanced surgical techniques and postoperative rehabilitation. Treatment approaches range from conservative methods such as physical therapy and pharmacological interventions to surgical solutions, including revision surgeries and the use of motion‑preserving technologies. Emerging therapies, particularly in regenerative medicine, show promise in mitigating ASD. The present review underscored the necessity of a multidisciplinary approach to optimize patient outcomes and highlighted the need for ongoing research to address gaps in the current understanding of ASD in both cervical and lumbar regions.

Outcome comparison of rotational ankle fractures: Supination external rotation versus pronation external rotation

BACKGROUND

Ankle fractures are among the most common types of fractures in the orthopaedic field, and the Lauge-Hansen classification is commonly used to categorize rotational ankle fractures. This study evaluated and compared the clinical and radiological outcomes of surgically treated supination external rotation (SER) and pronation external rotation (PER) injuries of grades III or IV.

METHODS

We retrospectively reviewed and enrolled 104 patients who underwent open reduction and internal fixation for SER or PER injuries classified as Grades III or IV between January 2016 and December 2021, all performed at a single center. Of these, 72 belonged to the SER group and 32 to the PER group. The average postoperative follow-up durations were 31.3 months (range, 24 to 74) for the SER group and 32.1 months (range, 24 to 71) for the PER group. Clinical and radiological outcomes were assessed 24 months after surgery and compared between the two groups. Details of concomitant surgical procedures performed and postoperative complications were also evaluated.

RESULTS

All clinical outcome variables, including the Foot and Ankle Outcome Score, Visual Analog Scale for pain, and ankle range of motion, were comparable between the two groups. Similarly, no statistically significant differences were observed in the development of post-traumatic arthritis or in the frequency of syndesmotic widening 24 months postoperatively. However, the time required for fibular union was significantly longer in the PER group, taking 5.6 ± 2.2 months compared to 3.4 ± 1.3 months in the SER group on average (p < 0.001).

CONCLUSIONS

Our study demonstrated that both types of rotational ankle fractures can achieve equivalent clinical and radiological outcomes with surgical treatment. Given the prolonged time to fibular union in the PER group, careful monitoring during postoperative follow-up is required.

Contraction ratio of multifidus and erector spinae muscles in unilateral sacroiliac joint pain: A cross-sectional trial

Sacroiliac joint (SIJ) pain is one of the most prevalent reasons for disability, it affects the contraction ratio of the muscles of the back. Imaging is critical for diagnosing back muscles. The purpose of this study was to look at changes in the muscle contraction ratio of the lumbar multifidus (LM) and erector spinae (ES) in unilateral SIJ pain. This research included 60 individuals (30 with unilateral SIJ pain and 30 healthy people (who served as matching controls). The contraction ratio of back muscles such as ES and LM was assessed using real-time ultrasonography, and the results were compared between the affected and non-affected sides in patients with unilateral SIJ pain, and healthy participants as well. In the study group, the contraction ratio of ES and LM muscles on the non-affected side was significantly higher than on the affected side (p < 0.05). as well as a significant increase in contraction ratio of the ipsilateral side (affected matched control side) LM of the healthy group compared with that of the non-affected side of the study group (p < 0.001), while there was no significant difference in contraction ratio of the contralateral (unaffected matched control side) ES of the healthy group compared with that of the non-affected side of the study group. The results of this trial demonstrate that patients with unilateral SIJ pain exhibited a substantially lower muscle contraction ratio in the ES and LM of the affected side than the non-affected side in the study group, as well as a significant increase in the contraction ratio of the ES and MF on the ipsilateral side of the control group compared with that of the study group. However, there was no significant change in the contraction ratio of the contralateral ES in healthy individuals compared to the non-affected side of the study group. The findings of the study may help in designing an appropriate exercise program to deal with patients with SIJ pain.

Cost-utility of lumbar interbody fusion surgery: A systematic review

BACKGROUND CONTEXT

Lumbar interbody fusion (LIF) is a common surgical intervention for treating lumbar degenerative disorders. Increasing demand has contributed to ever-increasing healthcare expenditure and economic burden. To address this, cost-utility analyses (CUAs) compare value in the context of patient outcomes. CUAs quantify health improvements using quality-adjusted life years (QALYs), allowing decision-makers to determine procedure value.

PURPOSE

While there is a growing body of literature assessing LIF value, a comprehensive synthesis of LIF CUAs is lacking. This systematic review aims to address this gap by assessing all available CUAs of LIF techniques, to support evidence-based practices that improve outcomes and promote efficient resource use.

STUDY DESIGN

Systematic review.

STUDY SAMPLE

This study sample consisted of adult patients with lumbar degenerative conditions specifically treated with lumbar interbody fusion, including grade I or II degenerative spondylolisthesis, lumbar spinal stenosis, disc degeneration, and spondylosis, with or without low back and/or leg pain.

OUTCOME MEASURES

Direct (healthcare) and indirect (non-healthcare) costs, cost sources and calculation methods, utility scores, QALY gain, cost-utility, incremental cost-effectiveness ratios, and willingness-to-pay thresholds. Outcomes were reported as median and interquartile ranges (IQR).

METHODS

A systematic review was conducted following PRISMA guidelines. PubMed, Web of Science, and Embase were searched from inception to October 23, 2023, for CUAs reporting QALYs and costs of LIF procedures. Relevant studies were selected and data extracted. Subgroup analyses compared minimally invasive versus open surgery and anterior versus posterior approaches. Study quality was assessed using the CHEC-Extended tool. Quantitative meta-analysis was not performed due to methodological heterogeneity.

RESULTS

Out of 2047 identified studies, 14 met inclusion criteria. The mean CHEC-Extended score was 72.1%. Most studies reported on TLIF (n=11) and utilized EQ-5D questionnaire to calculate utility (n=9). Direct costs were sourced from institutional databases, Medicare, DRGs, Redbook, and a variety of other sources. Most indirect costs were estimated from productivity loss. TLIF demonstrated the highest median QALY gain over 1 year (0.43, IQR 0.121-0.705), while PLIF was highest over 2 years (1.33). ALIF was most favorable over 1 year ($30901/QALY) and OLIF was most favorable over 2 years ($11187/QALY). PLIF, TLIF, and LLIF exhibited similar cost-utility over 2 years ($44383, $45628, $48576/QALY). MIS was substantially favorable to OS at 1 year ($42635 vs. $226304), though similar at 2 years ($48576 vs. $45628/QALY). Anterior approach was favorable to posterior approach at 1 year ($30901.5 vs. $81038) and 2 years ($29881.9 vs. $44383). Cost-utility comparisons substantially varied and were sensitive to utility measures, study methodology, cost sourcing, and follow-up duration.

CONCLUSIONS

This is the first systematic review to comprehensively assess CUAs of all LIF approaches in the existing literature. While certain approaches, such as ALIF and OLIF, may demonstrate favorable outcomes, these conclusions are limited by high methodological heterogeneity and a limited study pool. By addressing existing gaps in study design and reporting, future comparative cost-utility research can better inform evidence-based decision-making and optimize the value of spinal surgical care.

GAIT ASSESSMENT IN ANKLE FRACTURES WITH SYNDESMOSIS LESIONS UNDERGOING SURGERY

INTRODUCTION

The three-dimensional evaluation of patients in the gait laboratory is a diagnostic method that is gaining ground in various orthopedic pathologies and, in the case of ankle fractures, can more accurately detail the degree of joint limitation.

OBJECTIVE

To present the importance of laboratory gait studies in the postoperative period of ankle fractures associated with syndesmosis ligament injuries, increasing the arsenal for assessing whether the surgical approach and outcome were satisfactory.

METHODS

Case series of 13 patients who underwent surgical treatment for ankle fractures associated with syndesmosis injuries, evaluated postoperatively in the gait clinic using the BTS GAITLAB hardware program. Kinetic and kinematic data using a three-dimensional movement system were collected and analyzed.

RESULTS

Alterations were found in the Temporal and Spatial Parameters and in the Statistical Angles of the lower limb joints, comparing the operated limb with the non-operated limb.

CONCLUSION

The results of the study suggest that, despite subtle variations between the limbs assessed, the program was able to identify these differences in a significant way, demonstrating that gait assessments bring great benefits in understanding biomechanical limitations, and make more effective and individualized rehabilitation protocols possible. Level of evidence IV, Case series.

Influence of cervical muscle strength and pain severity on functional balance and limits of stability in elderly individuals with chronic nonspecific neck pain: a cross-sectional study

BACKGROUND

Chronic nonspecific neck pain (CNSNP) is a common musculoskeletal disorder, particularly in the elderly, leading to reduced cervical muscle strength, impaired functional balance, and decreased postural stability. This study investigated the correlation between cervical muscle strength, functional balance, and limits of stability (LOS) in elderly individuals with CNSNP. Additionally, it assessed the moderating effect of pain severity on the relationship between cervical muscle strength and these balance outcomes.

METHODS

A prospective study included a total of 186 participants, including 93 with CNSNP and 93 asymptomatic individuals, were recruited. Cervical flexor and extensor muscle strength were assessed using an ergoFET hand-held dynamometer. Functional balance was measured using the Berg Balance Scale (BBS) and Timed Up and Go (TUG) test, while LOS were evaluated using the Iso-Free machine.

RESULTS

Individuals with CNSNP exhibited significantly lower cervical flexor strength (32.45 ± 5.67 N vs. 40.75 ± 5.20 N, p < 0.001) and extensor strength (28.30 ± 6.05 N vs. 36.90 ± 5.90 N, p < 0.001) compared to asymptomatic individuals. Functional balance was also poorer in the CNSNP group, with lower BBS scores (47.85 ± 4.20 vs. 53.65 ± 3.85, p < 0.001) and slower TUG times (11.30 ± 2.05 s vs. 8.45 ± 1.80 s, p < 0.001). Cervical muscle strength showed moderate to strong positive correlations with LOS (r = 0.56 to 0.62, p < 0.001) and BBS (r = 0.48 to 0.53, p < 0.001). Pain severity significantly moderated the relationship between cervical muscle strength and functional balance (β = 0.20, p = 0.045) as well as LOS (β = 0.22, p = 0.038), suggesting that higher pain levels diminish the positive effects of muscle strength on balance.

CONCLUSION

Cervical muscle strength plays a crucial role in maintaining functional balance and postural stability in elderly individuals with CNSNP. Pain severity moderates the relationship between cervical muscle strength and balance outcomes, emphasizing the importance of integrating muscle strengthening and pain management in rehabilitation programs for elderly individuals with CNSNP to optimize postural control and minimize fall risk.