An Exploration of Low Back Beliefs of Male Pre-Professional and Professional Dancers

BACKGROUND

Globally, male dancers are affected by low back pain (LBP) up to 2.5 times more than female dancers. While female dancers' beliefs around LBP and dance-specific low back movements exist, no research has explored male dancers' beliefs. This study aimed to (1) examine the low back beliefs of Australian male professional and pre-professional dancers, and (2) determine if beliefs toward common low back movements and lifting differed when current LBP or history of disabling LBP (DLBP) were considered.

METHODS

40 male dancers (mean age [SD] 26.9 years [7.9]) from a range of dance backgrounds (all participating in ballet) were recruited to complete a cross-sectional survey comprising a beliefs questionnaire considering dance-specific movement and lifting tasks, the Back Pain Attitudes Questionnaire (Back-PAQ) and the Athletic Fear Avoidance Questionnaire (AFAQ). Primary analysis included initial descriptives, a repeated measures ANOVA for movement-specific beliefs and visual thematic analysis for written responses within the belief's questionnaire. Secondary subgroup analysis included independent T-tests for those with/without current LBP and those with/without a history of DLBP.

RESULTS

Fourteen dancers reported current LBP and 30 reported a history of DLBP. Dancers held generally negative beliefs toward the low back (Back-PAQ mean 123.1 ± 9.7) with neither subgroup demonstrating significant between-group difference (P < .05). Dance-specific flexion movements were seen as safer than extension movements (P < .05), and more extended-spine lifting was seen as safer than more flexed-spine lifting (P < .05). Dancers experiencing current LBP held less positive beliefs surrounding some dance-specific movements.

CONCLUSIONS

Dancers hold negative general beliefs toward the low back irrespective of current or historical DLBP, however their beliefs surrounding dance-specific movements were relatively positive. Dancers' beliefs surrounding some movements were affected by the presence of current LBP, in particular an arabesque and a fish dive.

Clinical and Radiographic Outcomes of Repair of Spondylolitic Spondylolisthesis Through Direct Pars Repair

STUDY DESIGN

A retrospective chart review.

OBJECTIVE

The objective of this study is to investigate whether direct pars repair achieves bone healing and symptom relief in patients with spondylolitic spondylolisthesis.

SUMMARY OF BACKGROUND DATA

While most cases of spondylolysis can be managed nonoperatively, a small percentage of patients require surgical intervention. The outcome of direct pars repair through a standard pedicle-screw with wiring technique is controversial in patients with lumbar spondylolitic spondylolisthesis.

MATERIALS AND METHODS

Medical records of patients who had undergone an open surgical pars repair were retrospectively reviewed. Standard demographic and surgical parameters were collected. All patients underwent a primary repair of the pars with an autograft or bone morphogenetic protein and instrumentation using a pedicle-screw with spinous process wiring. At 6 to 12 months after the surgery, patient's pain symptoms, and postoperative computed tomography (CT) scans were independently reviewed to assess healing; which was graded as nonunion, partial union, or solid union.

RESULTS

There were 68 patients identified (33 male and 35 female), with an average age of 18.6 years. The mean estimated blood loss was 139 ml, and the mean length of hospital stay was 3.7 days. CT evaluation revealed 35 (52%) solid unions, 21 (31%) partial unions, and 12 (18%) nonunions requiring revisions. Thirty-four (50%) patients had no postoperative pain, 24 (35%) had mild pain, and 10 (15%) had persistent pain. The majority of patients with nonunions on CT had mild or persistent pain. Patients with no or mild pain tended to be younger than those with persistent pain (17.5 vs. 24.6 yr, P =0.163).

CONCLUSION

This study demonstrated a partial or complete union rate of 82% and a postoperative persistent pain rate of 15%. These figures are comparable to the previous study, and this pedicle-screw with wiring technique can be worth trying before interbody fusion for spondylolytic spondylolisthesis to preserve anatomical lumbar motion.

The Efficacy of Noninvasive Ventilation in Patients Affected by Rett Syndrome With Hypoventilation

BACKGROUND

Rett syndrome is a progressive neurological disorder associated to several comorbidities that contribute significantly to impair lung function. Respiratory morbidity represents a major cause of death in this population. Little is known about the benefit of noninvasive ventilation.

METHODS

We retrospectively enrolled patients with Rett syndrome who underwent a pneumological evaluation combined with a cardiorespiratory polygraphy and/or a pulse oximetry and capnography from 2012 to 2022.

RESULTS

Medical records of 11 patients with Rett syndrome, mean age 13 ± 6 years, were evaluated. Most patients presented with both epilepsy and scoliosis. Five patients showed a pathologic sleep study and/or impaired night gas exchange: mean obstructive apnea-hypopnea index was 4 ± 3 events/hour; mean and minimal SpO2 were, respectively, 93% ± 2% and 83% ± 6%, while mean and maximal transcutaneous carbon dioxide monitoring (PtcCO2) were, respectively, 51 ± 5 mm Hg and 55 ± 8 mm Hg; and mean oxygen desaturation index was 13 ± 11 events/hour. These patients started noninvasive ventilation with clinical benefit and improved gas exchange mostly in terms of PtcCO2 (mean PtcCO2 51 ± 5 mm Hg before and 46 ± 6 mm Hg after noninvasive ventilation).

CONCLUSIONS

Noninvasive ventilation is a suitable option for patients with Rett syndrome.

Sleep and socio-occupational functioning in adults with serious mental illness: A systematic review

Sleep is a crucial factor influencing mental health and quality of life. Individuals with serious mental illness (SMI) often experience significant sleep problems. This can further exacerbate their symptoms and impact their socio-occupational functioning (SOF) (the extent to which a person is able to engage in 'self-care and activities of daily living, communication, interpersonal relations, instrumental living skills, and work'). Despite the well-established bidirectional relationship between sleep and mental health, the specific association between sleep and SOF in the context of SMI remains underexplored. A systematic review was conducted. Comprehensive searches in PubMed and PsycNet yielded 832 results. After applying inclusion criteria, 24 studies were included in the narrative synthesis. Study characteristics and key findings were extracted for analysis. Collectively, studies investigated sleep quality, satisfaction, duration, disturbance, specific disorders, and objectively-recorded sleep parameters across various study designs. Studies included a total population of 10,938, utilising a range of sleep and SOF outcome measures. Nearly all studies indicated that worsened sleep was associated with reduced SOF in SMI populations. The review supports the potential role of improved sleep as a route to improved SOF in SMI populations. This has clear implications for research and clinical care for patients with SMI.

Pediatric cervical spine instability: evolving concepts

The pediatric cervical spine is structurally and biomechanically unique in comparison to adults. Guidelines to assess for cervical spine instability and standard of care treatments in the pediatric population have yet to be delineated. This is due to the rarity of the condition and the lack of multicenter data published on the topic. Our review explores the biomechanics of the pediatric cervical spine and highlights evolving concepts/research over the last several decades, with special attention to the Down syndrome and complex Chiari malformation cohorts.

Virtual Reality for Subacute Pain After Orthopedic Traumatic Musculoskeletal Injuries: A Mixed Methods Pilot Study

OBJECTIVES

Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (eg, pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed-methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating principles of mindfulness and cognitive-behavioral therapy, for pain self-management at home following orthopedic injury.

METHODS

We enrolled 10 adults with acute orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham health care system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and hypothesized mechanisms (pain self-efficacy, mindfulness, and coping).

RESULTS

The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients.

DISCUSSION

The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries.

Preoperative expectations of patients with degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network

BACKGROUND

Despite an abundance of literature on degenerative cervical myelopathy (DCM), little is known about preoperative expectations of these patients.

PURPOSE

The primary objective was to describe patient preoperative expectations. Secondary objectives included identifying patient characteristics associated with high preoperative expectations and to determine if expectations varied depending on myelopathy severity.

STUDY DESIGN

This was a retrospective study of a prospective multicenter, observational cohort of patients with DCM.

PATIENT SAMPLE

Patients who consented to undergo surgical treatment between January 2019 and September 2022 were included.

OUTCOMES MEASURES

An 11-domain expectation questionnaire was completed preoperatively whereby patients quantified the expected change in each domain.

METHODS

The most important expected change was captured. A standardized expectation score was calculated as the sum of each expectation divided by the maximal possible score. The high expectation group was defined by patients who had an expectation score above the 75th percentile. Predictors of patients with high expectations were determined using multivariable logistic regression models.

RESULTS

There were 262 patients included. The most important patient expectation was preventing neurological worsening (40.8%) followed by improving balance when standing or walking (14.5%), improving independence in everyday activities (10.3%), and relieving arm tingling, burning and numbness (10%). Patients with mild myelopathy were more likely to select no worsening as the most important expected change compared to patients with severe myelopathy (p<.01). Predictors of high patient expectations were: having fewer comorbidities (OR -0.30 for every added comorbidity, 95% CI -0.59 to -0.10, p=.01), a shorter duration of symptoms (OR 0.92, 95% CI 0.35-1.19, p=.02), no contribution from "failure of other treatments" on the decision to undergo surgery (OR 1.49, 95% CI 0.56-2.71, p=.02) and more severe neck pain (OR 0.19 for 1 point increase, 95% CI 0.05-0.37, p=.01).

CONCLUSIONS

Most patients undergoing surgery for DCM expect prevention of neurological decline, better functional status, and improvement in their myelopathic symptoms. Stopping neurological deterioration is the most important expected outcomes by patients.

Spinopelvic morphology impacts on postoperative proximal junctional kyphosis in congenital scoliosis with thoracolumbar hemivertebrae

PURPOSE

It aims to investigate the lumbar and pelvic morphology in congenital scoliosis with thoracolumbar hemivertebrae and its impact on proximal junctional kyphosis (PJK) incidence after hemivertebra resection and short fusion.

METHODS

23 congenital scoliosis patients with thoracolumbar hemivertebra aged between 10 and 18 years were enrolled in the retrospective study. Spinopelvic sagittal parameters were analyzed on whole-spine standing lateral radiographs preoperatively, one-week postoperatively and at the final follow-up. Pearson correlations were calculated for local kyphosis (LK), lumbar and pelvic morphology parameters. Binary logistic regression and receiver operating characteristics (ROC) curve analysis were performed to identify the risk factors for PJK.

RESULTS

Thoracolumbar hemivertebra caused LK of 29.2° ± 17.3°, an increased lumbar lordosis (LL) (-64.7° ± 16.3°), lower LL apex (52.2% at L5), and small pelvic incidence (PI) (36.8° ± 6.6°). LK was correlated with lumbar morphology parameters, including LL (r = - 0.837), upper arc of LL (LLUA) (r = - 0.879), thoracolumbar kyphosis (TLK) (r = 0.933), thoracic kyphosis (TK) (r = 0.762) and TK apex (TKA) (r = - 0.749). Surgical treatment improved the lumbar morphology, but not pelvic morphology. At the final follow-up, LL had returned to its preoperative value (p = 0.158). PJK occurred in 30.4% of cases as a compensatory mechanism. Preoperatively, significant differences of parameters between non-PJK and PJK groups were observed in LK and TLK. Binary logistic regression identified three independent risk factors for PJK: preoperative LLA (OR = 0.005, 95%CI = 0.000-0.287, p = 0.011), preoperative TLK (OR = 1.134, 95%CI = 1.001-1.286, p = 0.048), and preoperative lumbar lordosis morphology type (OR = 5.507, 95%CI = 1.202-25.227, p = 0.028). However, residual LK after surgery was not correlated with PJK incidence. ROC curve analysis verified that preoperative TLK > 22.59° was associated with increased PJK incidence after surgery.

CONCLUSIONS

Lumbar morphology changes as a compensatory mechanism beneath the thoracolumbar hemivertebra. However, a stable pelvis tends to allow the LL to return to its preoperative value. PJK occurred as a cranial compensatory mechanism for increasing LL and corrected TLK. A larger TLK (> 22.59°) was an independent risk factor for PJK incidence in patients with type 2 and 3A lumbar lordosis morphology.

Analysis of the reliability of KEOPS version 2 for the measurement of coronal and sagittal parameters in spinal deformity

BACKGROUND

The purpose of the study is to evaluate the updated version of this software in patients with various spinal deformity.

METHODS

Sixty patients were included in this study and were divided into three categories: 20 patients with AIS, 20 patients with ASD, and 20 patients having undergone corrective surgery for spinal deformity. The measurements were performed by two senior and two junior orthopedic surgery residents, and were done at two points in time separated by a 3-week interval with the cases being randomized every time to reduce the risk of memory bias. Measured parameters included coronal, sagittal, global alignment parameters, and pelvic parameters.

RESULTS

When assessing the inter- and intra-observer reliability across all the groups of patients, none of the coefficients was smaller than 0.8 with a very high level of agreement. The standard error ranged from 0.7° to 1.5° demonstrating a high level of accuracy. Fairly similar results were seen when the groups were divided into the three categories except for the post-operative groups where a strong and not perfect level of agreement was reported.

CONCLUSION

This is the first study to assess the reproducibility of the new version of KEOPS, showing a very high agreement in all measurements. In the post-operative group, although it showed a strong agreement, the lower performance can be explained by the presence of surgical material making it harder to identify the anatomical landmarks accurately. Nevertheless, we can recommend the usage of this software in a clinical setting.

Immobilization protocols for the treatment of cervical spine fracture: a scoping review

BACKGROUND

Current protocols on cervical immobilization postcervical spine fracture are widely accepted in the acute rehabilitation of older adults, however consensus on its overall effectiveness remains lacking.

PURPOSE

Summarize information from original studies on available cervical immobilization protocols following a cervical fracture and to answer the questions; Which types of study designs have been used to assess the effectiveness of these protocols? What are the currently reported cervical immobilization protocols following cervical fracture in adults? What is the effectiveness of these protocols? What adverse events are associated with these protocols?

STUDY DESIGN

Scoping review was performed.

PATIENT SAMPLE

Searches were performed on the following online databases from inception to February 23, 2023: EMBASE, MEDLINE, CINAHL, and CENTRAL. Databases were searched for articles pertaining to collar use post cervical spine fracture.

OUTCOME MEASURES

Effectiveness of the cervical fracture immobilization protocols was the primary outcome, examined by various measures including union rates and disability indexes.

METHODS

4 databases were searched; EMBASE, MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) beginning on February 23, 2023, where 5,127 studies were yielded and 32 were extracted based on studies of adults (≥18 years) with a diagnosis of a cervical fracture (C0-C7) managed with a rigid external orthosis to prevent instability and surgery (collar, or cervicothoracic orthosis). Risk of bias was assessed using the guidelines set out by the Joanna Briggs Institute.

RESULTS

This scoping review yielded low-level prospective (18%) and retrospective (69%) cohort studies, case-control studies (3%), and case series (6%) from 1987 to 2022, patient age ranged from 14 to 104 years. Findings were difficult to summarize based on the lack of randomized controlled trials, leading to no clear conclusions drawn on the presence of standardized cervical immobilization protocols with no information on the duration of treatment or transition in care. Most included articles were retrospective cohort studies of poor to moderate quality, which have significant risk of bias for intervention questions. The effectiveness of these protocols remains unclear as most studies evaluated heterogeneous outcomes and did not present between-group differences. Mortality, musculoskeletal (MSK) complications, and delayed surgery were common adverse events associated with cervical collar use.

CONCLUSION

This scoping review highlights the need for higher levels of evidence as there is currently no standardized immobilization protocol for cervical spine fractures as a primary treatment, the effectiveness of cervical immobilization protocols is unclear, and mortality, MSK complications, and delayed surgery are common adverse events. No sources of funding were used for this scoping review.

An osteopathic orientation to interprofessional education

CONTEXT

The osteopathic tenets may serve as a useful guideline for an interprofessional program. There is an alignment between the osteopathic tenets and the concept of interprofessional education (IPE). IPE occurs when students from two or more professions work with each other to collaborate or improve healthcare outcomes. Holistic treatment is fundamental in both instances, and the interrelatedness of structure and function requires acknowledgment of all healthcare professionals' roles in treating a patient. IPE allows students to gain a better understanding of their own professional roles and the roles of their fellow healthcare providers in treating patients more effectively.

OBJECTIVES

The objectives of this analysis are to evaluate the ability of an interprofessional summer workshop/lecture utilizing an osteopathic focus to educate students from different healthcare colleges about the interconnectedness of the systems of the human body and how working with a team-based approach will ultimately benefit their collective patients. A secondary objective was to determine the students' perceptions before and after the lecture/workshop to see if there were any perceived differences among students in different healthcare professions at either time.

METHODS

This was a retrospective data analysis conducted on pretest/posttest surveys completed by 73 incoming students from six different healthcare colleges participating in the Summer Preparedness and Readiness Course (SPaRC), held annually at Western University of Health Sciences (WUHS) in Pomona, California. Analysis was conducted on responses collected during the SPaRC programs of 2013, 2016, and 2019. Participants were given surveys containing five questions scored on a five-point Likert scale. The surveys were given before and after an integrated lecture/hands-on workshop presented at SPaRC that reviewed multiple studies showing the utility of connecting the healthcare professions to best treat a patient.

RESULTS

A total of 73 students responded to both the prelecture and postlecture surveys. When the number of positive scores were totaled from students from all colleges, there was an increase in positive responses from 190 (52.2 %) in prelecture surveys when compared to 336 (92.3 %) in postlecture surveys. A Wilcoxon signed-rank test suggested that the lecture workshop elicited a significant improvement in scores from prelecture to postlecture for all students (Z=-6.976, p=0.000). Median scores improved from 3.60 at baseline to 4.40 after the lecture/workshop. Secondary analysis conducted utilizing Kruskal-Wallis H to examine the differences between the responses of the different colleges prelecture and postlecture showed no significant differences prelecture (H [6]=7.58, p=0.271) and a significant difference between postlecture answers (H [6]=14.04, p=0.029). A series of post hoc independent Kruskal-Wallis H analyses was conducted to identify where differences were, and the only identifiable difference after Bonferroni corrections was between students from the Doctor of Osteopathic Medicine college and the Physician Assistant's college after the lecture/survey (p=0.041).

CONCLUSIONS

An interprofessional program with the osteopathic principles of focusing on body unity and relatedness of structure and function may serve as a helpful tool for uniting healthcare professionals in their ultimate goal of better serving their patients.

A multicenter evaluation of the time and travel burden on families with children treated for early-onset scoliosis

PURPOSE

Patients who undergo growth-friendly (GF) treatment for early-onset scoliosis (EOS) undergo multiple clinical and surgical encounters. We sought to quantify the associated temporal and travel burden and estimate subsequent cost.

METHODS

Four centers in an international study group combined data on EOS patients who underwent surgical GF treatment from 2006 to 2021. Data collected included demographics, scoliosis etiology, GF implant, encounter type, and driving distance. We applied 2022 IRS and BLS data or $0.625/mile and $208.2/day off work to calculate a relative financial burden.

RESULTS

A total of 300 patients were analyzed (55% female). Etiologies were: congenital (33.3%), idiopathic (18.7%), neuromuscular (30.7%), and syndromic (17.3%). The average age at the index procedure was 5.5 years. For the 300 patients, 5899 encounters were recorded (average 18 encounters/patient). Aggregate encounter types were 2521 clinical office encounters (43%), 2045 surgical lengthening encounters (35%), 1157 magnetic lengthening encounters (20%), 149 spinal fusions (3%), and 27 spinal fusion revisions (0.5%). When comparing patients by scoliosis etiology or by GF implant type, no significant differences were noted in the total number of encounters or average travel distance. Patients traveled a median round trip distance of 158 miles/encounter between their homes and treating institutions (range 2.4-5654 miles), with a cumulative median distance of 2651 miles for the entirety of their treatment (range 29-90,552 miles), at an estimated median cost of $1656.63. The mean number of days off work was 18 (range 3-75), with an associated loss of $3643.50 in income.

CONCLUSION

Patients with EOS averaged 18 encounters for GF surgical treatment. These patients and their families traveled a median distance of 158 miles/encounter, with an estimated combined mileage and loss of income of $5300.

Effect of Core Exercises on Clinical and Functional Outcomes After Total Knee Arthroplasty in Individuals With Knee Osteoarthritis: A Systematic Review

BACKGROUND

Core muscles constitute the centre of the kinetic chain, and core exercises have been effective in improving outcomes in many postsurgical lower extremity musculoskeletal conditions. However, the literature on the implementation of core exercises after TKA has not been summarised.

OBJECTIVE

The objective was to review the evidence on the effect of core exercises on clinical and functional outcomes after TKA in individuals with knee osteoarthritis (OA).

METHODS

PubMed, Scopus, CINAHL, Web of Science, the Cochrane Library, and ProQuest databases were explored with appropriate keywords for studies published on the effect of core exercises on TKA from inception to 1 April 2024. Two authors independently screened the titles and abstracts and full-texts, and a third author solved the discrepancies. Risk of bias assessment was done with the Joanna Briggs Critical Appraisal tool. The final articles were systematically summarised.

RESULTS

A total of 1485 records were retrieved. Sixty-four articles were included for screening full-texts, and four articles were ultimately included. Core exercises were administered for three to 6 weeks. The administration of core exercises along with the standard knee rehabilitation programme significantly improved balance, mobility, knee function, transverse abdominis muscle thickness, transversus abdominis contraction, and quality of life after TKA (p < 0.05).

CONCLUSIONS

Core exercises can be administered as an adjunct to standard rehabilitation programs to improve clinical and functional outcomes after TKA. However, there is a dearth of literature in this domain, and more studies are warranted.

TRIAL REGISTRATION

PROSPERO Registration Number: CRD42024542992.

How do implants overlying the spine influence "The Law of Diminishing Returns" in early-onset scoliosis patients?

PURPOSE

The "law of diminishing returns" (LODR) in early-onset scoliosis (EOS) is well-known. We hypothesized that previously observed variations between constructs may be related to the lateral distance that each construct lies from the spine. We therefore sought to determine whether the curve magnitude improvement and spinal length gains for distraction-based constructs in EOS are positively correlated with the collinearity of the spine and the convex-sided implant on posteroanterior radiographs.

METHODS

A prospectively-collected, multicenter EOS registry was queried for all patients who underwent non-fusion, distraction-based instrumentation surgery. Post-index radiographs were graded from 1 to 5 based on amount of overlap between the convex-sided rod and the apical vertebra. Grade 1: convex rod is lateral to convex-sided pedicle; Grade 2: overlaps the convex-sided pedicle; Grade 3: lies between pedicles; Grade 4: overlaps concave-sided pedicle; Grade 5: medial to concave-sided pedicle. ANOVA assessed the correlations between post-index overlap grade and change in (a) curve magnitude and (b) T1-T12 height. Multivariable regression modeling further assessed these associations.

RESULTS

284 patients met all selection criteria and were included. On ANOVA, post-index grade was associated with curve magnitude (p <0.001) and T1-12 height (p = 0.028) change. Better curve correction and height change were associated with higher grade. On regression modeling, curve correction (R = 0.574) and T1-T12 height change (R = 0.339) remained significantly associated with grade when controlling for time, anchor locations, age, underlying diagnosis, and pre-index curve magnitude.

CONCLUSION

More apical overlap by the convex rod was associated with better spinal deformity control and improved height gain.

LEVEL OF EVIDENCE III

Therapeutic.

Measurement Error, Minimal Detectable Change, and Minimal Clinically Important Difference of the Short Form-36 Health Survey, Hospital Anxiety and Depression Scale, and Pain Numeric Rating Scale in Patients With Chronic Pain

In both pain research and clinical practice, patient-reported outcome measures are used to assess dimensions of health. Interpreting these instruments requires understanding their measurement error and what magnitude of change has subjective importance for patients. This study estimated the standard error of measurement, 1-year minimal detectable change, and 1-year minimal clinically important difference (MCID) for the Short Form-36 Health Survey physical component summary and mental component summary, the Hospital Anxiety and Depression Scale subscales for anxiety symptoms and depression symptoms, and the numeric rating scale for past-week average pain intensity. MCIDs for these instruments have not previously been estimated in a large sample of chronic pain patients participating in interdisciplinary pain rehabilitation. Data were drawn from the Swedish Quality Registry for Pain Rehabilitation (n = 8,854 patients). MCID was estimated as average change and change difference based on 3 different anchors. MCID estimates were 2.62 to 4.69 for Short Form-36 Health Survey physical component summary, 4.46 to 6.79 for Short Form-36 Health Survey mental component summary, .895 to 1.48 for numeric rating scale, 1.17 to 2.13 for anxiety symptoms in the Hospital Anxiety and Depression Scale, and 1.48 to 2.54 for depression symptoms in the Hospital Anxiety and Depression Scale. The common assumption of an identical standard error of measurement for pre- and post-treatment measurements was not always applicable. When estimating MCID, researchers should select an estimation method and anchor aligned with the study's context and objectives. PERSPECTIVE: This article presents estimates of MCID and minimal detectable change for several commonly used patient-reported outcome measures among patients with chronic pain. These estimates can help clinicians and researchers to determine when a measured health improvement is subjectively important to the patient and greater than measurement error.

Percutaneous endoscopic interlaminar discectomy for high-grade migrated lumbar disc herniation: clinical efficacy and safety assessment

PURPOSE

This study aimed to assess the clinical effectiveness and safety of percutaneous endoscopic interlaminar discectomy (PEID) in the management of high-grade migrated Lumbar disc herniation (LDH).

METHODS

A total of 328 patients who underwent PEID for high-grade migrated LDH between May 2020 and January 2023 in our hospital were selected. Patients were categorized into high-grade migrated group and low-grade migrated group according to preoperative MRI findings. The preoperative and postoperative evaluations of clinical outcomes, such as Visual Analogue Scale (VAS) for lower backs and legs, Oswestry Disability Index (ODI), and modified MacNab criteria for surgical success, were compared between groups.

RESULTS

No statistically significant differences were found in hospitalization time, surgery time, intraoperative hemorrhage, number of intraoperative fluoroscopies, or incision length between the two groups. The lower back and leg VAS scores and ODI exhibited a statistically significant decrease in both groups across all postoperative time intervals. However, the difference between the two groups was not statistically significant. Postoperative nerve root stimulation symptoms were reported in two and three cases in the high-grade migrated group and low-grade migrated group, respectively. One patient in the high-grade migrated group underwent reoperation due to re-herniation at the same segment. There was no significant difference in the rate of excellent-good cases between the two groups, with an overall rate of 94.7%.

CONCLUSION

In treating high-grade migrated disc herniation, PEID offers advantages such as reduced trauma, small incision, quicker recovery and satisfactory clinical safety and efficacy.

Prevalence and Biopsychosocial Factors Associated With a Current Episode of Low Back Pain Among Adults With a Previous History of Low Back Pain: A Cross-sectional Study of Market Traders in an African Population

Low back pain (LBP) is the leading cause of years lived with disability globally, with Nigeria having one of the greatest burdens. A current episode of LBP is important in Nigeria, but the associated factors are unknown. This cross-sectional study investigated the prevalence, biomechanical, and psychosocial factors associated with a current episode of LBP among 700 adult market traders with previous LBP in an urban Nigerian population. Descriptive, bivariate, and multivariate analyses were conducted. The prevalence of a current episode of LBP was 76.4%. Factors associated with an increased risk of a current episode of LBP in a decreasing order of importance were exposure to biomechanical factors (aggregate [total] score) (odds ratio [OR] = 1.535; 95% confidence interval [CI] = 1.398-1.685); anxiety (OR = 1.182; 95% CI = 1.089-1.282); fear-avoidance beliefs (physical activity) (OR = 1.139; 95% CI = 1.029-1.261); fear-avoidance beliefs (work) (OR = 1.105; 95% CI = 1.047-1.165); while factors associated with a reduced risk of a current episode of LBP were ability to take breaks in the job in addition to scheduled breaks (OR = .430; 95% CI = .240-.773) and ability to control the order and pace of tasks (OR = .477; 95% CI = .236-.965). Occupational biomechanical and psychosocial factors were associated with a current episode of LBP in logistic regression models explaining 52.7% and 73.1% of the variation in a current episode of LBP. Occupational biomechanical factors, particularly handling large and bulky objects at arm's length and kneeling and squatting, produced the greatest risk of a current episode of LBP. PERSPECTIVE: Occupational biomechanical factors, occupational psychosocial factors, and personal psychosocial factors such as anxiety and fear-avoidance beliefs are associated with a current episode of LBP in Nigeria. Pragmatic public health and occupational health initiatives that modify exposure to these factors may be required in Nigeria.

Pediatric Intraoperative Neurophysiological Monitoring and Long-Term Outcomes in a Developing Country

PURPOSE

Pediatric intraoperative neurophysiological monitoring (IONM) has been shown to be effective in preventing and reversing postoperative neurological deficits in developed countries. There are currently no published studies from developing countries that describe neurophysiological findings and postoperative outcomes. Our study aims to address these gaps in children undergoing neurosurgical procedures in a single center.

METHODS

We conducted a retrospective study of case series of children who underwent IONM (2014-2020) in the State of Mexico, Mexico. Sociodemographic characteristics, IONM modalities, changes during procedures, and short-term and long-term postoperative results were recorded. Descriptive statistics were used.

RESULTS

We included 35 patients (≤18 years of age), 57% (20/35) boys. A relative increase of up to 5 times in the use of IONM is observed from 2014 (5.7%) to 2020 (25.7%) in our center. The most frequent preoperative pathologies were located at the infratentorial cranium (40%), followed by the spine and spinal cord (37.1%). The IONM modalities were as follows: free-running EMG 94.3%, transcranial electrical stimulation motor-evoked potentials 91.4%, somatosensory-evoked potentials 85.7%, triggered EMG 28.6%, EEG 25.7%, and visual-evoked potentials 5.7%. Only in 8.3%, we did not obtain sufficient evoked potential baseline signals. At 24 hours postoperatively true negatives were 100%. Long-term follow-up was completed in 22/35 (63%) at 3 months, 12/35 (34.2%) at 6 months, and 5/35 (14.3%) at 12 months with progressive motor and sensory improvement.

CONCLUSIONS

Pediatric multimodal IONM in neurosurgeries from a single center in a developing country is mainly used in pathologies of the posterior fossa, spine, and spinal cord, with true negatives in 100% of those monitored, preventing and avoiding postoperative sequelae.

Safety and efficacy of robotic anti-reflux surgery in geriatric patients: a comparative analysis

INTRODUCTION

As our population ages, older adults are being considered for anti-reflux surgery (ARS). Geriatric patients typically have heightened surgical risk, and literature has shown mixed results regarding postoperative outcomes. We sought to evaluate the safety and efficacy of robotic ARS in the geriatric population.

METHODS

We conducted a single-institution review of ARS procedures performed between 2009 and 2023. Patients ≥ 65 were assigned to the geriatric cohort. We compared operative details, lengths of stay (LOS), readmissions, reoperations, and complications between the two cohorts. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL) survey and review of clinic notes were used to evaluate ARS efficacy.

RESULTS

628 patients were included, with 190 in the geriatric cohort. This cohort had a higher frequency of diabetes (16.3% vs 5.9% p < 0.0001), hypertension (50.0% vs 21.5% p < 0.0001), and heart disease (17.9% vs 2.3% p < 0.0001). Geriatric patients were more likely to exhibit hiatal hernias on imaging (51.6% vs 34.2% p < 0.0001) and were more likely to have large hernias (30.0% vs 7.1% p < 0.0001). Older adults were more likely to undergo Toupet fundoplications (58.4% vs 41.3%, p < 0.0001), Collis gastroplasties (9.5% vs 2.7% p < 0.0001), and relaxing incisions (11.6% vs 1.4% p < 0.0001). Operative time was longer for geriatric patients (132.0 min vs 104.5 min p < 0.0001). There were no significant differences in LOS, readmissions, or reoperations between cohorts. Geriatric patients exhibited lower rates of complications (7.4% vs. 14.6%, p = 0.011), but similar complication grades. Both groups had significant reduction in symptom scores from preoperative values. There were no significant differences in the reported symptoms between cohorts at any follow-up timepoint.

CONCLUSION

Geriatric robotic ARS patients tend to do as well as younger adults regarding postoperative and symptomatic outcomes, despite presenting with larger hiatal hernias and shorter esophagi. Clinicians should be aware of possible need for lengthening procedures or relaxing incisions in this population.

Prediction of adolescent idiopathic scoliosis with machine learning algorithms using brain volumetric measurements

Background

It is known that neuroanatomical and neurofunctional changes observed in the brain, brainstem and cerebellum play a role in the etiology of adolescent idiopathic scoliosis (AIS). This study aimed to investigate whether volumetric measurements of brain regions can be used as predictive indicators for AIS through machine learning techniques.

Methods

Patients with a severe degree of curvature in AIS (n = 32) and healthy individuals (n = 31) were enrolled in the study. Volumetric data from 169 brain regions, acquired from magnetic resonance imaging (MRI) of these individuals, were utilized as predictive factors. A comprehensive analysis was conducted using the twelve most prevalent machine learning algorithms, encompassing thorough parameter adjustments and cross-validation processes. Furthermore, the findings related to variable significance are presented.

Results

Among all the algorithms evaluated, the random forest algorithm produced the most favorable results in terms of various classification metrics, including accuracy (0.9083), AUC (0.993), f1-score (0.970), and Brier score (0.1256). Additionally, the most critical variables were identified as the volumetric measurements of the right corticospinal tract, right corpus callosum body, right corpus callosum splenium, right cerebellum, and right pons, respectively.

Conclusion

The outcomes of this study indicate that volumetric measurements of specific brain regions can serve as reliable indicators of AIS. In conclusion, the developed model and the significant variables discovered hold promise for predicting scoliosis development, particularly in high-risk individuals.

Malignant character of an ossified posterior longitudinal ligament in a hyperflexion injury: A case report

The present study reports the case of a 50-year-old obese male with ankylosing spondylitis, Scheuermann's kyphosis. The patient was asymptomatic concerning the ectopic ossification of the posterior longitudinal ligament (OPLL) at the cervical spine; he developed quadriparesis and respiratory insufficiency following minor head trauma. Even though trauma to the cervical spine in patients with OPLL is common, to the best of our knowledge, this is the first reported case of an extensive osteophyte with a lethal outcome after syncope. In rare occasions, it may be present with syncope and potentially lethal outcomes, particularly when precipitated by trauma. Therefore, the management of OPLL with significant canal stenosis should not be unnecessarily delayed.

Which North American spine society disc herniation morphology descriptors are most associated with improvements in clinical outcomes after microdiscectomy?

Background

The North American Spine Society (NASS) assembled the first ever comprehensive naming system for describing lumbar disc disease, including lumbar disc herniation. The objectives of this study were (1) to determine which NASS descriptors are most predictive of independent patient-reported outcomes after microdiscectomy and (2) to identify the inter-rater reliability of each NASS descriptor.

Methods

Adult patients (≥18 years) who underwent a lumbar microdiscectomy from 2014-2021 were retrospectively identified. Patient-reported outcome measures (PROMs) were collected at preoperative, 3-month, and 1-year postoperative time points. Lumbar disc herniations were evaluated and classified on preoperative MRI using the NASS lumbar disc nomenclature specific to disc herniation.

Results

About 213 microdiscectomy patients were included in the final analysis. Herniation descriptors exhibiting the greatest reliability included sequestration status (κ=0.83), axial disc herniation area (κ=0.83), and laterality (κ=0.83). The descriptor with the lowest inter-rater reliability was direction of migration (κ=0.53). At 3 months, a sequestered herniation was associated with lower odds of achieving the minimal clinically important difference (MCID) for ODI (p=.004) and MCS (p=.032). At 12 months, a similar trend was observed for Oswestry Disability Index (ODI) MCID achievement (p=.001). At 3 months, a herniation with larger axial area was a predictor of MCID achievement in ODI (p=.004) and the mental component summary (MCS) (p=.009). Neither association persisted at 12 months; however, larger axial disc herniation area was able to predict MCID achievement in the Visual Analogue Scale (VAS) leg (p=.031) at 12 months.

Conclusions

The utility of the NASS nomenclature system in predicting postoperative outcomes after microdiscectomy has yet to be studied. We showed that sequestration status and disc area are both reliable and able to predict the odds of achieving MCID in certain clinical outcomes at 3 months and 12 months after surgery. Hence, preoperative imaging analysis of lumbar disc herniations may be useful in accurately setting patient expectations.

Remineralization of lytic spinal metastases after radiation therapy - A retrospective cohort study comparing conventional external beam radiation therapy with stereotactic ablative body radiation

Introduction

Osteolytic spinal metastases (SM) have a higher risk of fracture. In this study we aim to confirm the remineralization of lytic SM after radiation therapy. Secondary the influence of SBRT compared to cEBRT and tumor type will be analyzed.

Methods

A retrospective cohort study was performed.

Results

87 patients, 100 SM were included. 29 received SBRT, 71 cEBRT. Most common primary tumors were breast (35 %), lung (26 %) and renal (11 %). Both cEBRT and SBRT resulted in a significant increase of bone mineral density (BMD) (83.76 HU ± 5.72 → 241.41 HU ± 22.58 (p < 0.001) and 82.45 ± 9.13 → 179.38 ± 47.83p = 0.026). There was a significant increase in absolute difference of BMD between the SM and reference vertebrae (p < 0.001). There was no significant difference between SBRT and cEBRT. There was no increase of BMD in renal lytic SM after radiation therapy (pre-treatment: 85.96 HU ± 19.07; 3 m 92.00 HU ± 21.86 (p = 0.882); 6 m 92.06 HU ± 23.94 (p = 0.902); 9 m 70.44 HU ± 7.45 (p = 0.213); 12 m 98.08 HU ± 11.24 (p = 0.740)). In all other primary tumors, a significant increase of BMD after radiation therapy was demonstrated (p < 0,05).

Conclusion

We conclude that the BMD of lytic SM increases significantly after radiation therapy. Lytic SM of primary renal tumors are the exception; there is no significant remineralization of renal lytic SM after radiation therapy. There is no benefit of SBRT over cEBRT in this remineralization. These findings should be taken into account when deciding on surgery in the potentially unstable group defined by the spinal instability neoplastic score.

An Intervention to Improve Mental and Physical Health of Undergraduate Nursing Students

BACKGROUND

Nursing students experience poorer mental and physical health relative to students in other health-related disciplines and young adults of similar age outside post-secondary school. Compromised mental and physical health has numerous negative impacts on nursing students and can result in burnout and development of chronic diseases.

PURPOSE

To determine whether an asynchronous online yoga intervention would improve mental and physical health of students.

METHODS

An asynchronous online 6-week yoga intervention was carried out between January and December 2021, using a pre/post design. Participants' symptoms of depression, anxiety, stress, and self-compassion were assessed using the Depression, Anxiety, and Stress Scale and Self-Compassion Scale and core endurance was assessed using the Mackenzie Core Endurance Test prior to commencement and at the conclusion of the program.

RESULTS

Of 114 participants, 68 completed the online program and pre and post measures showed that the mean depression, anxiety, stress, self-compassion and core endurance scores improved significantly (p<0.001) between baseline and study completion.

CONCLUSION

A six-week virtual yoga program significantly improved mental and physical health of undergraduate nursing students. Targeted modifications to the yoga program might enhance participant retention.

Single-Level Anterolateral and Posterior Interbody Fusion Techniques are Associated With Equivalent Long-Term Lumbar Reoperations

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

This study compares reoperation rates and complications following single-level anterior lumbar interbody fusion (ALIF)/lateral lumbar interbody fusion (LLIF) and transforaminal lumbar interbody fusion (TLIF)/posterior lumbar interbody fusion (PLIF).

SUMMARY OF BACKGROUND DATA

ALIF, LLIF, TLIF, and PLIF are widely used for degenerative disc disease. Lumbar interbody fusions have high rates of reoperation, primarily related to adjacent segment pathology and pseudarthrosis.

MATERIALS AND METHODS

The PearlDiver database was queried for patients (2010-2021) who had single-level ALIF/LLIF or TLIF/PLIF with same-day, single-level posterior instrumentation. ALIF/LLIF were combined, and similarly, TLIF/PLIF were combined, given how these operations are indistinguishable from Current Procedural Terminology coding. All patients were followed for ≥2 years and excluded if they had spinal traumas, fractures, infections, or neoplasms before surgery. The two cohorts, ALIF/LLIF and TLIF/PLIF, were matched 1:1 based on age, sex, Elixhauser-comorbidity index, smoking status, and diabetes. The primary outcome was the incidence of all-cause subsequent lumbar operations. Secondary outcomes included 90-day surgical complications.

RESULTS

After 1:1 matching, each cohort contained 14,070 patients. All-cause subsequent lumbar operations were nearly identical at five-year follow-up (9.4% ALIF/LLIF vs. 9.5% TLIF/PLIF, P =0.91). Survival analysis using all-cause subsequent lumbar operations as the endpoint showed an equivalent 10-year survival rate of 86.0% (95%CI: 85.2-86.8). Within 90 days, TLIF/PLIF had more infections (1.3% vs. 1.7%, P =0.007) and dural injuries (0.2% vs. 0.4%, P =0.001). There was no difference in wound dehiscence, hardware complications, or medical complications.

CONCLUSION

As utilized in real-world clinical practice, single-level anterolateral versus posterior approaches for interbody fusion have no effect on long-term reoperation rates.

Detection and Characterization of Endplate Structural Defects on CT: A Diagnostic Accuracy Study

STUDY DESIGN

Diagnostic test study.

OBJECTIVE

To determine the reliability and validity or diagnostic accuracy of two previously described endplate structural defect (EPSD) assessment methods.

SUMMARY OF BACKGROUND DATA

Studies of EPSD may further the understanding of pathoanatomic mechanisms underlying back pain. However, clinical imaging methods used to document EPSD have not been validated, leaving uncertainty about what the observations represent.

MATERIALS AND METHODS

Using an evaluation manual, 418 endplates on CT sagittal slices obtained from 19 embalmed cadavers (9 men and 10 women, aged 62-91 yr) were independently assessed by two experienced radiologists and a novice for EPSD using the two methods. The corresponding micro-CT (µCT) from the harvested T7-S1 spines were assessed by another independent rater with excellent intra-rater reliability (k=0.96).

RESULTS

Inter-rater reliability was good for the presence (k=0.60-0.69) and fair for specific phenotypes (k=0.43-0.58) of EPSD. Erosion, for which the Brayda-Bruno classification lacked a category, was mainly (82.8%) classified as wavy/irregular, while many notched defects (n=15, 46.9%) and Schmorl's nodes (n=45, 79%) were recorded as focal defects using Feng's classification. When compared to µCT, endplate fractures (n=53) and corner defects (n=28) were routinely missed on CT. Endplates classified as wavy/irregular on CT corresponded to erosion (n=29, 21.2%), jagged defects (n=21, 15.3%), calcification (n=19, 13.9%), and other phenotypes on µCT. Some focal defects on CT represented endplate fractures (n=21, 27.6%) on µCT. Overall, with respect to the presence of an EPSD, there was a sensitivity of 70.9% and a specificity of 79.1% using Feng's method, and 79.5% and 57.5% using Brayda-Bruno's method. Poor to fair inter-rater reliability (k=0.26-0.47) was observed for defect dimensions.

CONCLUSION

There was good inter-rater reliability and evidence of criterion validity supporting assessments of EPSD presence using both methods. However, neither method contained all needed EPSD phenotypes for optimal sensitivity, and specific phenotypes were often misclassified.

Optical Marker-Based Motion Capture of the Human Spine: A Scoping Review of Study Design and Outcomes

Biomechanical analysis of the human spine is crucial to understanding injury patterns. Motion capture technology has gained attention due to its non-invasive nature. Nevertheless, traditional motion capture studies consider the spine a single rigid segment, although its alignment changes during movement. Moreover, guidelines that indicate where markers should be placed for a specific exercise do not exist. This study aims to review the methods used to assess spine biomechanics using motion capture systems to determine the marker sets used, the protocols used, the resulting parameters, the analysed activities, and the characteristics of the studied populations. PRISMA guidelines were used to perform a Scoping Review using SCOPUS and Web of Science databases. Fifty-six journal and conference articles from 1997 to 2023 were considered for the analysis. This review showed that Plug-in-Gait is the most used marker set. The lumbar spine is the segment that generates the most interest because of its high mobility and function as a weight supporter. Furthermore, angular position and velocity are the most common outcomes when studying the spine. Walking, standing, and range of movement were the most studied activities compared to sports and work-related activities. Male and female participants were recruited similarly across all included articles. This review presents the motion capture techniques and measurement outcomes of biomechanical studies of the human spine, to help standardize the field. This work also discusses trends in marker sets, study outcomes, studied segments and segmentation approaches.

Asymmetrical atrophy of the paraspinal muscles in patients undergoing unilateral lumbar medial branch radiofrequency neurotomy

ABSTRACT

Lumbar medial branch radiofrequency neurotomy (RFN), a common treatment for chronic low back pain due to facet joint osteoarthritis (FJOA), may amplify paraspinal muscle atrophy due to denervation. This study aimed to investigate the asymmetry of paraspinal muscle morphology change in patients undergoing unilateral lumbar medial branch RFN. Data from patients who underwent RFN between March 2016 and October 2021 were retrospectively analyzed. Lumbar foramina stenosis (LFS), FJOA, and fatty infiltration (FI) functional cross-sectional area (fCSA) of the paraspinal muscles were assessed on preinterventional and minimum 2-year postinterventional MRI. Wilcoxon signed-rank tests compared measurements between sides. A total of 51 levels of 24 patients were included in the analysis, with 102 sides compared. Baseline MRI measurements did not differ significantly between the RFN side and the contralateral side. The RFN side had a higher increase in multifidus FI (+4.2% [0.3-7.8] vs +2.0% [-2.2 to 6.2], P = 0.005) and a higher decrease in multifidus fCSA (-60.9 mm 2 [-116.0 to 10.8] vs -19.6 mm 2 [-80.3 to 44.8], P = 0.003) compared with the contralateral side. The change in erector spinae FI and fCSA did not differ between sides. The RFN side had a higher increase in multifidus muscle atrophy compared with the contralateral side. The absence of significant preinterventional degenerative asymmetry and the specificity of the effect to the multifidus muscle suggest a link to RFN. These findings highlight the importance of considering the long-term effects of lumbar medial branch RFN on paraspinal muscle health.

The Effectiveness of Instruction on Lumbar Spine Thrust Joint Manipulation Task Performance

INTRODUCTION

Uncertainty exists regarding the best method for teaching thrust joint manipulation (TJM) to student physical therapists. The purpose of this study was to compare the effectiveness of Peyton's 4-step (P4) approach with the "see one, do one" (S1D1) approach for teaching students to perform a lumbar spine TJM task in an academic setting. Secondary objectives were to compare the effects of each instructional approach on students' attitudes and beliefs toward spinal TJM and on their motivation to learn to perform lumbar spine TJM.

REVIEW OF LITERATURE

The S1D1 approach is used in the health care professions for teaching clinical tasks to students. It is unclear whether the P4 approach may better prepare students to practice TJM.

SUBJECTS

Student physical therapists.

METHODS

Using a factorial quasi-experimental design, an equal number of students were assigned to a P4 or S1D1 instruction group for the TJM task. Students' performance accuracy, time, and outcome performing TJM in an academic setting were measured. Paper surveys were used to collect data about students' attitudes and beliefs toward spinal TJM and their motivation to learn TJM. A generalized estimating equations approach was used for data analysis.

RESULTS

Fifty-eight students (29 per group) completed the study. There was an interaction between the instruction group and time on task performance accuracy favoring the P4 approach (P = .03). There was no interaction between the instruction group and task performance time, task performance outcome, attitudes and beliefs toward spinal TJM, or motivation to learn TJM (all P > .19).

DISCUSSION AND CONCLUSION

The P4 approach more effectively improved student accuracy when performing the TJM task in an academic setting than the S1D1 approach. However, no differences between instruction were found for performance time or outcome. Students reported a favorable perception of learning lumbar spine TJM. These preliminary results suggest that instructors may use the P4 approach to improve students' TJM procedural knowledge before task practice. However, limitations of the study may affect the internal validity and generalizability of results.

Clinical and radiological outcome of stand-alone percutaneous pedicle screw fixation (SAPF) versus minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). A propensity-matched cohort study

In adult patients affected by degenerative disc disease with lumbar instability and chronic low back pain, spine surgery with lumbar fixation aims to reduce segmental instability and pain. Different techniques have been developed, but the optimal surgical technique remains controversial. No studies have compared the clinical and radiological outcomes between stand-alone pedicle screw fixation (SAPF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). This was a retrospective study. All patients who underwent surgery for single-level L4-L5 or L5-S1 lumbar stenosis, associated with minor lumbar instability and treated with SAPF or MI-TLIF techniques were included in the study. Data were collected preoperatively and at 24 monts follow-up. Clinical primary outcomes were Oswestry Disability Index (ODI) and Numerical Rating Scale (NRS). Secondary outcomes were patient satisfaction, walking ability and self reported back and leg pain. In addition, perioperative data and complications were recorded. Segmental lordosis (L4-L5 and L5-S1) and overall lumbar lordosis (L1-S1) were measured on lumbar X-Rays preoperatively and at least 24 months postoperatively. 277 patients were firstly identified. Baseline data and a minimum of two-year follow-up were available for 62 patients. After the propensity score matching, 44 patients (22 patients in the SAPF group and 22 patients in the MI-TLIF group) were matched. At 24 months follow-up, no difference between the two groups of patients in NRS (p = 0.11) and ODI scores (p = 0.21) were observed. Patients' satisfaction at follow-up was also not significantly different between the two groups. In both groups, a significant improvement in the walked distance was observed after surgery (p = 0.05) while no difference was observed regarding the type of surgery performed (p = 1.00). No differences were found in the pre- and post-operative median lumbar lordosis (p = 0.91 and p = 0.67) and the same findings were observed for lumbar segmental lordosis (p = 0.65 and p = 0.41 respectively). Significant improvements in ODI and NRS-scores were recorded after 24 months follow-up with both SAPF and MI-TLIF. No significant differences in postoperative PROMs and patients' satisfaction were observed between the groups. The results of our study indicate no superiority of either surgical technique concerning pain and functional outcomes after 24 months.

Impact of pelvic anteversion on spinopelvic alignment in an asymptomatic population: a dynamic perspective of standing and sitting

BACKGROUND CONTEXT

A subgroup of patients with pelvic anteversion can present with an unusually large degree of lumbar lordosis (LL), a highly sloped sacrum, and a relatively small pelvic incidence (PI). Prior to lumbar surgery, it can be important to consider such unique sagittal alignment. However, until now, there has been a lack of a predictive model considering different pelvic alignments. Furthermore, the dynamic characteristics of an anteverted pelvis (AP) subgroup have also been unclear.

PURPOSE

To build linear predictive formulas for LL that take pelvic anteversion into consideration and to explore the dynamic characteristics of an AP subgroup.

STUDY DESIGN

Monocentric, cross-sectional study.

PATIENT SAMPLE

Five hundred sixty-five asymptomatic Chinese men and women between the ages of 18 and 80 years.

OUTCOME MEASURES

Sagittal parameters including LL, lumbar lordosis minus thoracic kyphosis (LL-TK), PI, pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), sacral slope (SS), sacral slope divided by pelvic incidence (SS/PI), sagittal vertical axis (SVA), thoracic kyphosis (TK), and T1 (first thoracic vertebra) pelvic angle (TPA) were measured on whole spine radiographs obtained with participants in standing and sitting positions.

METHODS

All participants underwent radiography in the standing position; 235 of them underwent additional radiography in the sitting position to allow measurement of sagittal parameters. The participants with pelvic anteversion were placed in an AP (anteverted pelvis) group. Sagittal parameters were compared between the AP group and the non-AP group, and predictive formulas for LL based on PI were created in both groups. In addition, changes in sagittal parameters from standing to sitting were compared in the AP group and a PI-matched control group.

RESULTS

Of the 565 participants, 171 (30.3%) had pelvic anteversion. In comparison with the non-AP group, the AP group presented with larger LL, a larger SS, and a smaller PT, with relatively small PI. The predictive formulas for LL were LL=0.60° × PI+21.60° (R2=0.268; p<.001) in the whole cohort, LL=0. 83×PI+18.75° (R2=0.427; p<.001) in AP group, and LL=0.79°×PI+9.66° (R2=0.451; p<.001) in the non-AP group. In moving from standing to sitting, the AP group presented with a larger decrease in SS and LL compared with the control group, indicating different patterns of spinopelvic motion.

CONCLUSIONS

In the cohort examined, 30.3% present with pelvic anteversion. Those with AP present with unique characteristics of spinopelvic alignment. In moving from standing to sitting, they exhibit different patterns of spinopelvic motion. We found that identifying the degree of anteversion in each person improves the accuracy of linear models for predicting the degree of LL, which in turn can make plans for spine surgery more accurate.

Surgical treatment of refractory low back pain using implanted BurstDR spinal cord stimulation (SCS) in a cohort of patients without options for corrective surgery: Findings and results from the DISTINCT study, a prospective randomized multi-center-controlled trial

Background

Low back pain (LBP) is a highly prevalent, disabling condition affecting millions of people. Patients with an identifiable anatomic pain generator and resulting neuropathic lower extremity symptoms often undergo spine surgery, but many patients lack identifiable and/or surgically corrective pathology. Nonoperative treatment options often fail to provide sustained relief. Spinal cord stimulation (SCS) is sometimes used to treat these patients, but the lack of level 1 evidence limits its widespread use and insurance coverage. The DISTINCT RCT study evaluates the efficacy of passive recharge burst SCS compared to conventional medical treatment (CMM) in alleviating chronic, refractory axial low back pain.

Methods

This prospective, multicenter, randomized, study with an optional 6-month crossover involved patients who were not candidates for lumbar spine surgery. The primary and secondary endpoints evaluated improvements in low back pain intensity (NRS), back pain-related disability (ODI), pain catastrophizing (PCS), and healthcare utilization. Patients were randomized to SCS therapy or CMM at 30 US study sites.

Results

The SCS arm reported an 85.3% NRS responder rate (≥ 50% reduction) compared to 6.2% (5/81) in the CMM arm. After the 6M primary endpoint, SCS patients elected to remain on assigned therapy and 66.2% (49/74) of CMM patients chose to trial SCS (crossover). At the 12M follow-up, SCS and crossover patients reported 78.6% and 71.4% NRS responder rates. Secondary outcomes indicated significant improvements in ODI, PCS, and reduced healthcare utilization. Six serious adverse events were reported and resolved without sequelae.

Conclusion

DISTINCT chronic low back pain patients with no indication for corrective surgery experienced a significant and sustained response to burst SCS therapy for up to 12 months. CMM patients who crossed over to the SCS arm reported profound improvements after 6 months. This data advocates for a timely consideration of SCS therapy in patients unresponsive to conservative therapy.

Preoperative Mobile Health Data Improve Predictions of Recovery From Lumbar Spine Surgery

BACKGROUND AND OBJECTIVES

Neurosurgeons and hospitals devote tremendous resources to improving recovery from lumbar spine surgery. Current efforts to predict surgical recovery rely on one-time patient report and health record information. However, longitudinal mobile health (mHealth) assessments integrating symptom dynamics from ecological momentary assessment (EMA) and wearable biometric data may capture important influences on recovery. Our objective was to evaluate whether a preoperative mHealth assessment integrating EMA with Fitbit monitoring improved predictions of spine surgery recovery.

METHODS

Patients age 21-85 years undergoing lumbar surgery for degenerative disease between 2021 and 2023 were recruited. For up to 3 weeks preoperatively, participants completed EMAs up to 5 times daily asking about momentary pain, disability, depression, and catastrophizing. At the same time, they were passively monitored using Fitbit trackers. Study outcomes were good/excellent recovery on the Quality of Recovery-15 (QOR-15) and a clinically important change in Patient-Reported Outcomes Measurement Information System Pain Interference 1 month postoperatively. After feature engineering, several machine learning prediction models were tested. Prediction performance was measured using the c-statistic.

RESULTS

A total of 133 participants were included, with a median (IQR) age of 62 (53, 68) years, and 56% were female. The median (IQR) number of preoperative EMAs completed was 78 (61, 95), and the median (IQR) number of days with usable Fitbit data was 17 (12, 21). 63 patients (48%) achieved a clinically meaningful improvement in Patient-Reported Outcomes Measurement Information System pain interference. Compared with traditional evaluations alone, mHealth evaluations led to a 34% improvement in predictions for pain interference (c = 0.82 vs c = 0.61). 49 patients (40%) had a good or excellent recovery based on the QOR-15. Including preoperative mHealth data led to a 30% improvement in predictions of QOR-15 (c = 0.70 vs c = 0.54).

CONCLUSION

Multimodal mHealth evaluations improve predictions of lumbar surgery outcomes. These methods may be useful for informing patient selection and perioperative recovery strategies.

Advancements in defensive medicine research: Based on current literature

To investigate and comprehend the evolving research hotspots, cutting-edge trends, and frontiers associated with defensive medicine. The original data was collected from the Web of Science core collection and then subjected to a preliminary retrieval process. Following screening, a total of 654 relevant documents met the criteria and underwent subsequent statistical analysis. Software CiteSpace was employed for conducting a customized visual analysis on the number of articles, keywords, research institutions, and authors associated with defensive medicine. The defensive medicine research network was primarily established in Western countries, particularly the United States, and its findings and conceptual framework have significantly influenced defensive medicine research in other regions. Currently, quantitative methods dominated most studies while qualitative surveys remained limited. Defensive medicine research mainly focused on high-risk medical specialties such as surgery and obstetrics. Research on defensive medicine pertained to the core characteristics of its conceptual framework. An in-depth investigation into the factors that give rise to defensive medicine is required, along with the generation of more generalizable research findings to provide valuable insights for improving and intervening in defensive medicine.

Novel Calcium Phosphate Promotes Interbody Bony Fusion in a Porcine Anterior Cervical Discectomy and Fusion Model

STUDY DESIGN

Experimental porcine anterior cervical discectomy and fusion (ACDF) model: a proof-of-concept study.

OBJECTIVE

The effect of monetite synthetic bone graft (SBG) containing calcium pyrophosphate and β-tricalcium phosphate on cervical spinal fusion in a noninstrumented two-level large animal model.

SUMMARY OF BACKGROUND DATA

ACDF is the gold standard surgical technique for the treatment of degenerative cervical spinal diseases. However, pseudarthrosis associated with increased patient morbidity occurs in ∼2.6% of the surgeries. SBG may enhance bony fusion and subsequently decrease the risk of pseudarthrosis. Recent studies on monetite-based SBGs for use in large cranial defects in humans have shown promising bone healing results, necessitating further investigation of their use in cervical spinal fusion.

MATERIALS AND METHODS

Four adult female Danish Göttingen minipigs received partial cervical anterior discectomy and intervertebral defects at an upper and lower level. One defect was filled with SBG, and the other was left empty. Bony fusion was evaluated using computed tomography (CT) at three-month intervals for 12 months. Fifteen months postsurgery, the animals were euthanized for further ex vivo qualitative histopathologic and micro-CT evaluations. Fusion rates were compared using the Fisher exact test at each time point.

RESULTS

Increased interbody bony fusion rates were observed at SBG levels (4/4) compared with control levels (0/4) evaluated by CT at 6 and 9 months postsurgery ( P =0.029). Fusion was observed at all SBG levels 12 months postsurgery and at only one control level. Histopathologic evaluation confirmed high-quality interbody bony fusion at all SBG levels and fusion by spondylosis at one control level.

CONCLUSION

This proof-of-concept study provides preliminary evidence of a novel, calcium pyrophosphate-containing, and β-tricalcium phosphate-containing monetite SBG that promotes bony fusion compared with a negative control in a clinically relevant porcine model of ACDF.

YouTube as a Source of Patient Information for Cubital Tunnel Syndrome: An Analysis of Video Reliability, Quality, and Content

BACKGROUND

This study seeks to examine the reliability, quality, and content of YouTube videos on cubital tunnel syndrome, on which there is presently a paucity of information.

METHODS

The top 50 unique YouTube videos by relevance resulting from the Boolean search term "cubital tunnel + cubital tunnel syndrome" were identified, with video properties for analysis including source, upload date, duration, views, and comments. Content was assessed using the Journal of American Medical Association (JAMA) criteria, the Global Quality Score (GQS), and a "Cubital Tunnel-Specific Score" (CTSS).

RESULTS

The average video saw 72 108 ± 199 362 views, with videos produced by allied (nonphysician) health professionals demonstrating the highest mean views (111 789 ± 294 471 views). Videos demonstrated low mean JAMA scores (2.4/4 ± 0.7), GQS (2.8/5 ± 1.3), and CTSS (7.5/21 ± 4.3), with academic and nonacademic physician videos demonstrating significantly greater mean GQS and CTSS scores when compared with videos by allied health professionals. Positive independent predictors for GQS included academic sources (β = 1.871), nonacademic physician sources (β = 1.651), and video duration (β = 0.102), which were likewise positive predictors for CTSS (β = 4.553, 4.639, 0.374). Content relating to surgical techniques or approaches for cubital tunnel decompression had the greatest CTSS scores (11.2 [4.2]).

CONCLUSIONS

YouTube is a source of highly accessible information on cubital tunnel syndrome, although the average video presents generally poor and inadequate information. Directing patients toward higher quality video resources can be a meaningful component of patient education.

Global utilization of biportal spinal endoscopy: Case series on management of lumbar pathology in Soddo, Ethiopia

INTRODUCTION

Biportal spinal endoscopy is a safe and cost-effective methodology for the management of lumbar pathology in rural underserved hospitals that have standard orthopaedic arthroscopic equipment, but lack access to microscopy.

METHODS

This is a case series noting 1-year outcomes from 5 patients managed with biportal spinal endoscopy during an 11-day mission trip to Soddo, Ethiopia in November 2022. Surgical complications, postoperative assessments, and patient-reported outcomes (PROs) were retrospectively collected and analyzed. Surgical techniques and equipment utilized were shared with residents and faculty at the hospital.

RESULTS

Five Ethiopian patients (4:1, female:male) with no prior spine surgery history elected to undergo biportal surgery for the diagnoses of lumbar stenosis and disc herniation, averaging 31 years of age with Body-Mass-Indices (BMI) <35. Two patients underwent endoscopic discectomy, and three patients underwent endoscopic unilateral laminotomy and bilateral decompression (ULBD). There were no complications. No postoperative functional deficits, infections, readmissions, revisions, or wound dehiscences were noted at 12 months follow-up. VAS-back and VAS-leg scores improved to <2/10 for 80 % of patients. All patients returned to work/activities of daily living. No patients required postoperative pain management beyond the 2-week post-operative follow-up.

CONCLUSION

With these five patients, we found that biportal spinal endoscopy can be safely applied in rural hospital settings with limited resources. This supports biportal spinal endoscopy as a viable minimally invasive modality for the management of lumbar pathology. For hospitals with limited resources, but access to arthroscopic equipment, biportal spinal endoscopy is a feasible option.

LEVEL OF EVIDENCE

IV.

Subcutaneous Oxytocin Injection Reduces Heat Pain: A Randomized-Controlled Trial

Oxytocin (OT) is a neuropeptide broadly implicated in social relationships and behavior. OT also exerts antinociceptive and pain-reducing effects in both humans and rodents. Recent research in rodents demonstrates that these effects can be peripheral and local. In human studies, intravenous OT has reduced visceral pain, and subcutaneous injection of OT has reduced postsurgical pain. However, the local effects of subcutaneous OT on experimental pain have not been studied. We conducted a 2-session crossover study during which healthy adults received a subcutaneous injection of synthetic OT (4 mcg/2 mL) or saline placebo (isotonic saline 2 mL), in a randomized and double-blinded manner. Eighteen participants completed full study procedures. We hypothesized that 10 minutes after injection, OT would reduce measures of acute mechanical pain, pressure pain, and heat pain perception. Subcutaneous OT significantly reduced ratings of heat pain intensity and unpleasantness (both P < .01), but did not alter mechanical pain, pressure pain, or heat pain threshold (all P > .05). Changes in heat pain were observed only on the injected arm and not on the contralateral arm, confirming a localized mechanism. These findings confirm the ability of OT in or near the skin to modulate nociceptive processes in cutaneous tissues in human adults, opening exciting avenues for further mechanistic research as well as potential clinical applications for acute pain. PERSPECTIVE: This randomized-controlled trial showed that a subcutaneous injection of OT could reduce perception of heat pain tested with a thermode. OT did not alter mechanical or pressure pain or thresholds for perceiving heat pain. These findings are relevant to scientists and clinicians seeking nonaddictive local drug treatments for pain.

Two-stage surgery for large sacrococcygeal chordomas: How I do it

Sacrococcygeal chordoma is a malignant, slow-growing, and locally aggressive bone tumor. A wide surgical margin is recommended to prevent local recurrence and metastasis. This disease tends to cause massive defects when rectal resection and sacrectomy are required. Therefore, soft tissue reconstruction is required and a pedicled vertical rectus abdominis muscle flap (VRAM) is a viable option. Important anatomical landmarks, advantages and limitations are discussed and the procedure is described step by step. This case report presents a two-stage operation with an anterior rectal resection and VRAM flap harvest followed by a complementary posterior approach with sacrectomy and soft tissue reconstruction: approach and results. The wound completely healed in six weeks. Three years after surgery, no local recurrence or distal metastasis was detected. This two-stage strategy presents a viable and safe option for large sacrococcygeal chordomas.

Automated magnetic resonance imaging-based grading of the lumbar intervertebral disc and facet joints

Background

Degeneration of both intervertebral discs (IVDs) and facet joints in the lumbar spine has been associated with low back pain, but whether and how IVD/joint degeneration contributes to pain remains an open question. Joint degeneration can be identified by pairing T1 and T2 magnetic resonance imaging (MRI) with analysis techniques such as Pfirrmann grades (IVD degeneration) and Fujiwara scores (facet degeneration). However, these grades are subjective, prompting the need to develop an automated technique to enhance inter-rater reliability. This study introduces an automated convolutional neural network (CNN) technique trained on clinical MRI images of IVD and facet joints obtained from public-access Lumbar Spine MRI Dataset. The primary goal of the automated system is to classify health of lumbar discs and facet joints according to Pfirrmann and Fujiwara grading systems and to enhance inter-rater reliability associated with these grading systems.

Methods

Performance of the CNN on both the Pfirrmann and Fujiwara scales was measured by comparing the percent agreement, Pearson's correlation and Fleiss kappa value for results from the classifier to the grades assigned by an expert grader.

Results

The CNN demonstrates comparable performance to human graders for both Pfirrmann and Fujiwara grading systems, but with larger errors in Fujiwara grading. The CNN improves the reliability of the Pfirrmann system, aligning with previous findings for IVD assessment.

Conclusion

The study highlights the potential of using deep learning in classifying the IVD and facet joint health, and due to the high variability in the Fujiwara scoring system, highlights the need for improved imaging and scoring techniques to evaluate facet joint health. All codes required to use the automatic grading routines described herein are available in the Data Repository for University of Minnesota (DRUM).

Recent advances in small molecule Nav 1.7 inhibitors for cancer pain management

The dorsal root ganglion (DRG) is the primary neuron responsible for transmitting peripheral pain signals to the central nervous system and plays a crucial role in pain transduction. Modulation of DRG excitability is considered a viable approach for pain management. Neuronal excitability is intricately linked to the ion channels on the neurons. The small and medium-sized DRG neurons are chiefly engaged in pain conduction and have high levels of TTX-S sodium channels, with Nav1.7 accounting for approximately 80% of the current. Voltage-gated sodium channel (VGSC or Nav) blockers are vital targets for the management of central nervous system diseases, particularly chronic pain. VGSCs play a key role in controlling cellular excitability. Clinical research has shown that Nav1.7 plays a crucial role in pain sensation, and there is strong genetic evidence linking Nav1.7 and its encoding gene SCN9A gene to painful disorders in humans. Many studies have shown that Nav1.7 plays an important role in pain management. The role of Nav1.7 in pain signaling pathways makes it an attractive target for the potential development of new pain drugs. Meanwhile, understanding the architecture of Nav1.7 may help to develop the next generation of painkillers. This review provides updates on the recently reported molecular inhibitors targeting the Nav1.7 pathway, summarizes their structure-activity relationships (SARs), and discusses their therapeutic effects on painful diseases. Pharmaceutical chemists are working to improve the therapeutic index of Nav1.7 inhibitors, achieve better analgesic effects, and reduce side effects. We hope that this review will contribute to the development of novel Nav1.7 inhibitors as potential drugs.

Facet deflection and strain are dependent on axial compression and distraction in C5-C7 spinal segments under constrained flexion

Background

Facet fractures are frequently associated with clinically observed cervical facet dislocations (CFDs); however, to date there has only been one experimental study, using functional spinal units (FSUs), which has systematically produced CFD with concomitant facet fracture. The role of axial compression and distraction on the mechanical response of the cervical facets under intervertebral motions associated with CFD in FSUs has previously been shown. The same has not been demonstrated in multi-segment lower cervical spine specimens under flexion loading (postulated to be the local injury vector associated with CFD).

Methods

This study investigated the mechanical response of the bilateral inferior C6 facets of thirteen C5-C7 specimens (67±13 yr, 6 male) during non-destructive constrained flexion, superimposed with each of five axial conditions: (1) 50 N compression (simulating weight of the head); (2-4) 300, 500, and 1000 N compression (simulating the spectrum of intervertebral compression resulting from neck muscle bracing prior to head-first impact and/or externally applied compressive forces); and, (5) 2 mm of C6/C7 distraction (simulating the intervertebral distraction present during inertial loading of the cervical spine by the weight of the head). Linear mixed-effects models (α = 0.05) assessed the effect of axial condition.

Results

Increasing amounts of intervertebral compression superimposed on flexion rotations, resulted in increased facet surface strains (range of estimated mean difference relative to Neutral: maximum principal = 77 to 110 με, minimum principal = 126 to 293 με, maximum shear = 203 to 375 με) and angular deflection of the bilateral inferior C6 facets relative to the C6 vertebral body (range of estimated mean difference relative to Neutral = 0.59° to 1.47°).

Conclusions

These findings suggest increased facet engagement and higher load transfer through the facet joint, and potentially a higher likelihood of facet fracture under the compressed axial conditions.

Transabdominal ultrasonography-guided biofeedback training for pelvic floor muscles integrated with stabilization exercise improved pregnancy-related pelvic girdle pain and disability: a randomized controlled trial

OBJECTIVES

Investigate effects of integrated training for pelvic floor muscles (PFM) with and without transabdominal ultrasonography (TAUS) imaging-guided biofeedback in postpartum women with pregnancy-related pelvic girdle pain (PPGP).

DESIGN

Three-arm, single-blinded randomized controlled trial SETTING: University laboratory PARTICIPANTS: Fifty-three postpartum women with PPGP randomized into stabilization exercise with TAUS-guided biofeedback (BIO+EXE), exercise (EXE), and control (CON) groups.

INTERVENTIONS

The BIO+EXE and EXE groups underwent an 8-week exercise program, with the BIO+EXE group receiving additional TAUS-guided biofeedback for PFM training during the first 4 weeks. The CON group only received a pelvic educational session.

MAIN OUTCOME MEASURES

Primary outcomes included self-reported pain (numeric rating scale) and disability (pelvic girdle questionnaire). Secondary outcomes included functional tests (active straight leg raising [ASLR] fatigue, timed up-and-go, and 6-meter walking tests) and muscle contractibility indicated by muscle thickness changes for abdominal muscles and bladder base displacement for PFM (ultrasonographic measures).

RESULTS

The BIO+EXE group had lower pain [1.8 (1.5) vs. 4.4 (1.5), mean difference -2.6, 95% confidence interval (CI) -3.9 to -1.2] and disability [14% (10) vs. 28% (21), mean difference -14, 95% CI -25 to -2] and faster walking speed [3.1 seconds (1) vs. 3.3 seconds (1), mean difference -0.2, 95% CI -1.0 to -0.2] than the CON group. The EXE group only had lower pain intensity compared to the CON group [2.7 (2.0) vs. 4.4 (1.5), mean difference -1.7, 95% CI -3.1 to -0.4]. No significant differences were observed among groups in timed up-and-go, ASLR fatigue, or muscle contractibility.

CONCLUSIONS

Integrated training for PFM and stabilization with TAUS-guided biofeedback seems to be beneficial for reducing pain and disability in postpartum women with PPGP. CONTRIBUTION OF THE PAPER.

Radiofrequency echographic multi-spectrometry-based measurement of bone mineral density in patients with severe motor and intellectual disability: An opportunity for patients with severe scoliosis and hip dislocation

Purpose

Radiofrequency echographic multi-spectrometry (REMS) is an ultrasound technology currently used for the densitometric evaluation of osteoporosis and has been validated against dual-energy X-ray absorptiometry. However, the use of REMS for bone densitometry in patients with severe motor and intellectual disabilities (SMID) remains to be reported. This study aimed to investigate whether REMS technology can be used for densitometric evaluation of osteoporosis in patients with SMID with hip dislocation and severe scoliosis.

Methods

Sixty-five patients with SMID, who resided in a long-term care facility and received comprehensive medical and rehabilitation care, underwent REMS scans of the femoral neck and/or lumbar spine. Data regarding anthropometric parameters (height and weight), bone mineral density (BMD), clinical diagnostic classification, physical ability, presence of scoliosis and hip dislocation, and frontal radiographs of both hip joints were obtained.

Results

We included 29 men and 34 women (mean age: 52.6 years). All patients underwent successful scanning at either the femoral neck (82.5 %) or lumbar spine (95.2 %). BMD measurements obtained using REMS revealed low values, with a mean BMD, T-score, and Z-score of 0.67 g/cm2, -2.39 standard deviation (SD), and - 1.38 SD, respectively, at the femoral neck and 0.66 g/cm2, -2.70 SD, and - 1.87 SD, respectively, at the lumbar spine. The average Cobb angle of the lumbar spine was 34.0°; furthermore, dislocation rates did not significantly differ between those with and without successful BMD measurements (p = 0.073). Lumbar BMD T-scores were significantly correlated with femoral neck BMD T-scores (p < 0.001, r = 0.530).

Conclusion

All patients with SMID were able to undergo measurements of either spinal or femoral neck BMD; furthermore, 77.7 % of the patients underwent measurements at both the lumbar spine and femur. Our data suggest that REMS is useful for measuring BMD in patients with SMID who are residing in institutions.

Diverse and multifunctional roles for perlecan (HSPG2) in repair of the intervertebral disc

Perlecan is a widely distributed, modular, and multifunctional heparan sulfate proteoglycan, which facilitates cellular communication with the extracellular environment to promote tissue development, tissue homeostasis, and optimization of biomechanical tissue functions. Perlecan-mediated osmotic mechanotransduction serves to regulate the metabolic activity of cells in tissues subjected to tension, compression, or shear. Perlecan interacts with a vast array of extracellular matrix (ECM) proteins through which it stabilizes tissues and regulates the proliferation or differentiation of resident cell populations. Here we examine the roles of the HS-proteoglycan perlecan in the normal and destabilized intervertebral disc. The intervertebral disc cell has evolved to survive in a hostile weight bearing, acidic, low oxygen tension, and low nutrition environment, and perlecan provides cytoprotection, shields disc cells from excessive compressive forces, and sequesters a range of growth factors in the disc cell environment where they aid in cellular survival, proliferation, and differentiation. The cells in mechanically destabilized connective tissues attempt to re-establish optimal tissue composition and tissue functional properties by changing the properties of their ECM, in the process of chondroid metaplasia. We explore the possibility that perlecan assists in these cell-mediated tissue remodeling responses by regulating disc cell anabolism. Perlecan's mechano-osmotic transductive property may be of potential therapeutic application.

Artificial neural network analysis of factors affecting functional independence recovery in patients with lumbar stenosis after neurosurgery treatment: An observational cohort study

Background and aim

Lumbar spinal stenosis (LSS) is a leading cause of low back pain and lower limbs pain often associated with functional impairment which entails the loss or the impairment of independence in older adults. Conservative treatment is effective in a small percentage of patients, while a significant percentage undergo surgery, even if often without a complete resolution of clinical symptoms and motor deficits. The aim of the study is to identify clinical and demographic prognostic factors characterising the patients who would benefit most from surgical treatment in relation to the functional independence recovery using an innovative approach based on an artificial neural network.

Methods

Adult patients with LSS and indication of neurosurgical treatment were enrolled in the study. Clinical evaluation was performed in the preoperative-phase (into the 48 h before surgery) and after two months. Clinical battery investigated the motor, functional, cognitive, behavioural, and pain status. Demographics and clinical characteristics were analysed via Artificial Neural Network (ANN) using 24 input variables, 2 hidden layers and a single final output layer to predict the outcome. ANN results were compared with those of a multiple linear regression.

Results

108 patients were included in the study and 90 of them [66.5 ± 12.8 years; 27.8 % F] were submitted to surgery treatment and completed longitudinal evaluation. Statistically significant improvement was recorded in all clinical scales comparing pre- and post-surgery. The ANN results showed a prediction ability up to 81 %. Disability, functional limitations, and pain concerning clinical assessment and stature, onset and age about demographic characteristics are the main variables impacting on surgical outcome.

Conclusions

ANN can support clinical decision making, using clinical and demographic characteristics of patients with LSS identifying the characteristics of those who might benefit more from the surgical treatment in terms of global functional recovery.

Cryopreserving the intact intervertebral disc without compromising viability

Background

Tissue cryopreservation requires saturation of the structure with cryoprotectants (CPAs) that are also toxic to cells within a short timeframe unless frozen. The race between CPA delivery and cell death is the main barrier to realizing transplantation banks that can indefinitely preserve tissues and organs. Unrealistic cost and urgency leaves less life-threatening ailments unable to capitalize on traditional organ transplantation systems that immediately match and transport unfrozen organs. For instance, human intervertebral discs (IVD) could be transplanted to treat back pain or used as ex vivo models for studying regenerative therapies, but both face logistical hurdles in organ acquisition and transport. Here we aimed to overcome those challenges by cryopreserving intact IVDs using compressive loading and swelling to accelerate CPA delivery.

Methods

CPAs were tested on bovine nucleus pulposus cells to determine the least cytotoxic solution. Capitalizing on our CPAs Computed Tomography (CT) contrast enhancement, we imaged and quantified saturation time in intact bovine IVDs under different conditions in a bioreactor. Finally, the entire protocol was tested, including 1 week of frozen storage, to confirm tissue viability in multiple IVD regions after thawing.

Results

Results showed cryopreserving medium containing dimethyl sulfoxide and ethylene glycol gave over 7.5 h before cytotoxicity. While non-loaded IVDs required over 3 days to fully saturate, a dynamic loading protocol followed by CPA addition and free-swelling decreased saturation time to <5 h. After cryopreserving IVDs for 1 week with the optimized CPA and permeation method, all IVD regions had 85% cell viability, not significantly different from fresh unfrozen controls.

Conclusions

This study created a novel solution to a roadblock in IVD research and development. Using post-compression swelling CPA can be delivered to an intact IVD over 20× more quickly than previous methods, enabling cryopreservation of the IVD with no detectable loss in cell viability.

Physiologic Osseous Remodeling of the Anterior Wall of the Spinal Canal after Anterior Cervical Corpectomy and Fusion: A Retrospective Observational Study

BACKGROUND

 Anterior cervical corpectomy and fusion (ACCF) has been widely used in the treatment of cervical spondylotic myelopathy (CSM), ossification of posterior longitudinal ligament (OPLL), cervical trauma, and other cervical diseases, but few studies have reported the osseous and physiologic remodeling of the anterior wall of the spinal canal following ACCF. In this study, we analyze that remodeling process and its influence on titanium mesh cage (TMC) subsidence.

METHODS

 We performed a clinical and radiologic analysis of consecutive patients treated with ACCF. Growth rates (GRs) reflecting the extent of remodeling of the remnants of the resected vertebral bodies were measured. We compared the computed tomography (CT) scans taken immediately and at least 1 year after surgery, and a literature review was conducted.

RESULTS

 In all, 48 patients underwent ACCF at a mean age of 61.5 ± 12.0 years. The median follow-up was 36 months, and 159 CT images were analyzed. The GR values of the remnants of the vertebral bodies on CT images immediately and 1 year after surgery were 0.505 ± 0.077 and 0.650 ± 0.022 (p < 0.001), respectively, and the GR value at ≥4 years was 1. Axial CT scans showed that remodeling starts from the lateral remnants of the resected vertebral bodies, finally reaching the center. When fusion of the vertebral bodies and the titanium cage was complete during the first year after ACCF, osteogenesis and remodeling were initiated in the osseous anterior wall of the spinal canal. The remodeling of the osseous anterior wall of the spinal canal was completed at the fourth year after surgery, without recompressing the spinal cord, as seen on both axial and lateral CT scans. According to the literature review, there was no TMC subsidence at more than 4 years after surgery.

CONCLUSION

 The anterior wall of the spinal canal undergoes osseous remodeling after ACCF. The process is complete in the fourth year after surgery and prevents TMC subsidence.