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The relationship between spinal alignment and activity of paravertebral muscle during gait in patients with adult spinal deformity: a retrospective study. BMC Musculoskelet Disord 2023; 24:2. [PMID: 36597097 PMCID: PMC9808926 DOI: 10.1186/s12891-022-06121-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Spinal alignment in patients with adult spinal deformity (ASD) changes between rest and during gait. However, it remains unclear at which point the compensated walking posture breaks down and how muscles respond. This study used time-synchronized electromyography (EMG) to investigate the relationship between dynamic spinal alignment and muscle activity during maximum walking duration to reveal compensation mechanisms. METHODS This study collected preoperative three-dimensional gait analysis data from patients who were candidates for corrective surgery for ASD from April 2015 to May 2019. We preoperatively obtained dynamic spinal alignment parameters from initiation to cessation of gait using a motion capture system with time-synchronized surface integrated EMG (iEMG). We compared chronological changes in dynamic spinal alignment parameters and iEMG values 1) immediately after gait initiation (first trial), 2) half of the distance walked (half trial), and 3) immediately before cessation (last trial). RESULTS This study included 26 patients (22 women, four men) with ASD. Spinal sagittal vertical axis distance during gait (SpSVA) increased over time (first vs. half vs. last, 172.4 ± 74.8 mm vs. 179.9 ± 76.8 mm vs. 201.6 ± 83.1 mm; P < 0.001). Cervical paravertebral muscle (PVM) and gluteus maximus activity significantly increased (P < 0.01), but thoracic and lumbar PVM activity did not change. Dynamic spinal alignment showed significant correlation with all muscle activity (cervical PVM, r = 0.41-0.54; thoracic PVM, r = 0.49-0.66; gluteus maximus, r = 0.54-0.69; quadriceps, r = 0.46-0.55) except lumbar PVM activity. CONCLUSION Spinal balance exacerbation occurred continuously in patients with ASD over maximum walking distance and not at specific points. To maintain horizontal gaze, cervical PVM and gluteus maximus were activated to compensate for a dynamic spinal alignment change. All muscle activities, except lumbar PVM, increased to compensate for the spinal malalignment over time.
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Schell TL, Krueger D, Binkley N, Hetzel S, Bernatz JT, Anderson PA. Opportunistic use of dual-energy X-ray absorptiometry to evaluate lumbar scoliosis. Arch Osteoporos 2021; 16:38. [PMID: 33624177 DOI: 10.1007/s11657-021-00898-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 01/21/2021] [Indexed: 02/03/2023]
Abstract
Low bone mineral density is associated with spinal deformity. Dual-energy X-ray absorptiometry (DXA), a modality that assesses bone density, portends a theoretical means to also assess spinal deformity. We found that DXA can reliably assess spine alignment. DXA may permit surveillance of spine alignment, i.e., scoliosis in the clinical setting. PURPOSE Osteoporosis and scoliosis are interrelated disease processes. Dual-energy X-ray absorptiometry (DXA), used to assess bone density, can also be used to evaluate spinal deformity since it captures a posteroanterior (PA) image of the lumbar spine. We assessed the use of DXA to evaluate lumbar spine alignment. METHODS A lumbar spine DXA phantom was used to assess the effects of axial and sagittal plane rotation on lumbar bone mineral content (BMC), density (BMD), and L1-L4 Cobb angle measurements. Using two subject cohorts, intra- and inter-observer reliability and validity of using DXA for L1-L4 Cobb angle measurements in the coronal and sagittal planes were assessed. RESULTS Axial and sagittal plane rotation greater than 15° and 10°, respectively, significantly reduced measured BMD and BMC; there was minimal effect on Cobb angle measurement reliability. In human subjects, excellent intra- and inter-observer reliability was observed using lumbar PA DXA images for Cobb angle measurements. Agreement between Cobb angles derived from lumbar PA DXA images and AP lumbar radiographs ranged from good to excellent. The mean difference in Cobb angles between supine lumbar PA DXA images and upright AP lumbar radiographs was 2.8° in all subjects and 5.8° in those with scoliosis. CONCLUSIONS Lumbar spine rotation does not significantly affect BMD and BMC within 15° and 10° of axial and sagittal plane rotation, respectively, and minimally affects Cobb angle measurement. Spine alignment in the coronal plane can be reliably assessed using lumbar PA DXA images.
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Affiliation(s)
- Trevor L Schell
- Department of Orthopedics and Rehabilitation, Medical Foundation Centennial Building, University of Wisconsin, 1685 Highland Ave, 6th floor, Madison, WI, 53705-2281, USA
| | - Diane Krueger
- Osteoporosis Clinical Research Program, University of Wisconsin, 2870 University Avenue, Madison, WI, 53705, USA
| | - Neil Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin, 2870 University Avenue, Madison, WI, 53705, USA
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin, 207G WARF Office Building, 610 Walnut Street, Madison, WI, 53726, USA
| | - James T Bernatz
- Department of Orthopedics and Rehabilitation, Medical Foundation Centennial Building, University of Wisconsin, 1685 Highland Ave, 6th floor, Madison, WI, 53705-2281, USA
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, Medical Foundation Centennial Building, University of Wisconsin, 1685 Highland Ave, 6th floor, Madison, WI, 53705-2281, USA.
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Is the Cranial Sagittal Vertical Axis (Cr-SVA) a Better Midterm Predictor of Clinical Results Than C7-SVA in Adult Patients Operated on Spinal Deformity After a Minimum 2-Year Follow-Up? Clin Spine Surg 2021; 34:E32-E38. [PMID: 32568865 DOI: 10.1097/bsd.0000000000001034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 05/22/2020] [Indexed: 01/22/2023]
Abstract
STUDY DESIGN This is nonconcurrent prospective study approved by the Institutional Research Ethics Committee. OBJECTIVE The purpose of this study is to determine if the cranial sagittal vertical axis (Cr-SVA) measured in full spine standing radiographs is a better predictor of clinical results than the C7 sagittal vertical axis (C7-SVA) in adult patients operated on spinal deformity with a minimum 2-year follow-up after surgery. SUMMARY OF BACKGROUND DATA The Cr-SVA has recently been described as a better predictor of health-related quality of life outcomes than the C7-SVA for patients with adult spinal deformity (ASD) before undergoing surgery. This has not been confirmed in patients after ASD surgery. METHODS Inclusion criteria were age at surgery more than 25 years and a minimum 2-year follow-up after a ≥5 level fusion for ASD. Full-length standing lateral radiographs (including nasion-inion line, spine, and femoral heads) and Scoliosis Research Society 22 Questionnaire and SF36 questionnaires were available for every patient at the final follow-up. The distance from the Cr-SVA to the posterior corner of S1 (Cr-SVA-S) and to the centers of the hip (Cr-SVA-H) was measured and also the C7-SVA, lumbar lordosis, pelvic incidence, pelvic tilt, and PI-LL. RESULTS Sixty-five patients (58 female individuals) operated on ASD in a single institution were included. Age at surgery was 61 years (26-67). The mean follow-up was 53 months (24-120). Spearman rank-order test showed several significant correlations. After multivariable analysis, only Cr-SVA-S and age persisted as predictors for Scoliosis Research Society (SRS) image scores, Cr-SVA-H for SRS satisfaction, Cr-SVA-H and age for SRS total scores, Cr-SVA-H and age for SF36 Physical Function, Cr-SVA-S for SF36 Role Physical, Cr-SVA-H for SF36 Bodily Pain, and Cr-SVA-H for SF36 Role Emotional. CONCLUSIONS The Cr-SVA measured in full spine standing radiographs seems to be a better predictor of health-related quality of life outcomes than the C7-SVA for adults operated on spinal deformity >2 years after surgery.
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Kirilov N, Kirilova E, Todorov S, Nikolov N. Effect of the lumbar scoliosis on the results of dual-energy X-ray absorptiometry. Orthop Rev (Pavia) 2020; 12:8477. [PMID: 32391137 PMCID: PMC7206360 DOI: 10.4081/or.2020.8477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 04/16/2020] [Indexed: 11/23/2022] Open
Abstract
One of the most common causes of lumbar scoliosis in adults is the decreased bone mineral density (BMD). The scoliosis in the lumbar spine has a known effect over the dual-energy X-ray absorptiometry (DXA) scan results. The objective of this study is to assess the influence of the lumbar scoliosis on the results of the DXA scan of the lumbar spine. 1019 women aged ≥40 years underwent a DXA scan of the spine. Age, weight, height, total BMD, total Tscore of the lumbar spine were recorded. The angle of the lumbar scoliosis (Cobb’s angle) was measured from the DXA scan image using a DICOM software. The incidence of lumbar scoliosis in the current study accounts to 12.3%. Women with scoliosis showed significantly higher incidence of discrepancy in BMD T-scores between the adjacent vertebrae by more than 1 SD compared to women without scoliosis, (p=0.046). DXA results of subjects with scoliosis require more detailed evaluation of the T-scores of each vertebra to make a prompt decision about the final diagnosis.
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Affiliation(s)
| | - Elena Kirilova
- Department of Rheumatology, University Hospital "Dr. Georgi Stranski", Pleven, Bulgaria
| | | | - Nikolay Nikolov
- Department of Rheumatology, University Hospital "Dr. Georgi Stranski", Pleven, Bulgaria
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Bailey JF, Sparrey CJ, Williams FMK, Curran PF, Lotz JC, Kramer PA. The Effect of Parity on Age-Related Degenerative Changes in Sagittal Balance. Spine (Phila Pa 1976) 2020; 45:E210-E216. [PMID: 31513113 DOI: 10.1097/brs.0000000000003234] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Evaluate the effects of parity (number of births) on measures of sagittal posture in elderly women. The long-term objective of this study is to identify and mitigate factors contributing to age-related postural deformity in older adults. SUMMARY OF BACKGROUND DATA Adult spinal deformity is a prevalent condition that often requires costly surgical management. Females are disproportionately represented in spinal deformity surgical cases with up to 90% of patients being women. The potential contributions of pregnancy on postural degeneration have only begun to be acknowledged and require further study. METHODS Two hundred eight women with standing lateral radiographs were selected from the TwinsUK register. Parity information was extracted from questionnaires. Sagittal balance measurements (thoracic kyphosis, lumbar lordosis [LL], pelvic incidence [PI]) were collected and PI-LL mismatch was calculated. One-way analysis of variance tests were done between three separate age categories for measures of sagittal balance and parity and stepwise multivariate regression was done for PI-LL. RESULTS Both age and PI-LL mismatch significantly differed between parity categories. PI-LL was on average 7.0° ± 2.5° greater in multiparous (3+ births) subjects than in nulliparous subjects (P < 0.01). Parity did not have an independent relationship with lumbar disc degeneration, lumbar bone mineral density, or any of the individual sagittal balance parameters (P > 0.05 for all), except for PI-LL. From a subanalysis of the effect of parity on sagittal alignment within twin pairs, we found that within pair differences in parity associate with within pair differences in thoracic kyphosis. CONCLUSION This study established correlations between measures of spinal curvature in older women and parity for the first time. Longitudinal research is required to establish a causative relationship. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Jeannie F Bailey
- Department of Orthopedic Surgery, University of California, San Francisco, CA
| | - Carolyn J Sparrey
- School of Mechatronics Systems Engineering, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Frances M K Williams
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - Patrick F Curran
- Department of Orthopedic Surgery, University of California, San Francisco, CA
| | - Jeffrey C Lotz
- Department of Orthopedic Surgery, University of California, San Francisco, CA
| | - Patricia A Kramer
- Departments of Orthopedics and Sports Medicine and Anthropology, University of Washington, Seattle, WA
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Choi UY, Kang JI, Park JY, Kuh SU, Chin DK, Kim KS, Cho YE, Kim KH. Residence could influence the surgical outcome after corrective surgery in adult spinal deformity: comparison study between urban and rural area in Korea. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2216-2222. [PMID: 31240439 DOI: 10.1007/s00586-019-06042-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 05/06/2019] [Accepted: 06/16/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Numerous factors affect the surgical outcomes in patients with adult spinal deformity (ASD). However, no study has examined the relationship between residence and physical factors and surgical outcomes in patients with ASD. Here, we analysed the impact of residence and physical factors on the post-operative outcomes of patients with ASD residing in urban (U) and rural (R) environments. METHODS We retrospectively reviewed data from patients who had undergone ASD surgery with sacropelvic fixation at a single institution between June 2011 and May 2017 with a minimum 1 year follow-up. We divided the patients into two groups (U and R). Preoperative demographic data were reviewed, and radiographic parameters were measured preoperatively, immediately postoperatively, at 1, 3, and 6 months, and at the final follow-up. The L4 axial paraspinal muscles were measured preoperatively using magnetic resonance imaging. RESULTS There were 25 and 34 patients in the U and R groups, respectively. Both groups had similar preoperative demographic and radiological parameters. There were no differences between the groups in post-operative radiographic parameters, clinical outcomes, and complications, but proximal junctional kyphosis (PJK) was significantly higher in the R group. Additionally, muscle mass in the multifidus and erector spinae was lower in the R than in the U group. CONCLUSIONS Patient residence influenced PJK in patients with ASD. Mass reduction in the trunk extensor muscle is an important and existing risk factor for PJK. Surgeons should be aware of this information for preoperative counselling, informed consent, and post-operative education of patients with ASD. These slides can be retrieved from Electronic Supplementary Material.
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Affiliation(s)
- Un-Yong Choi
- Department of Neurosurgery, CHA Bundang Medical Center, CHA University School of Medicine, Gyeonggi-do, Seongnam-Si, 13496, Republic of Korea
| | - Ji-In Kang
- Department of Neurosurgery, Gangnam Severance Hospital, Spine and Spinal Cord Institute, Yonsei University College of Medicine, 211 Eonjuro Gangnam-gu, Seoul, 135-720, South Korea
| | - Jeong-Yoon Park
- Department of Neurosurgery, Gangnam Severance Hospital, Spine and Spinal Cord Institute, Yonsei University College of Medicine, 211 Eonjuro Gangnam-gu, Seoul, 135-720, South Korea
| | - Sung-Uk Kuh
- Department of Neurosurgery, Gangnam Severance Hospital, Spine and Spinal Cord Institute, Yonsei University College of Medicine, 211 Eonjuro Gangnam-gu, Seoul, 135-720, South Korea
| | - Dong-Kyu Chin
- Department of Neurosurgery, Gangnam Severance Hospital, Spine and Spinal Cord Institute, Yonsei University College of Medicine, 211 Eonjuro Gangnam-gu, Seoul, 135-720, South Korea
| | - Keun-Su Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Spine and Spinal Cord Institute, Yonsei University College of Medicine, 211 Eonjuro Gangnam-gu, Seoul, 135-720, South Korea
| | - Yong-Eun Cho
- Department of Neurosurgery, Gangnam Severance Hospital, Spine and Spinal Cord Institute, Yonsei University College of Medicine, 211 Eonjuro Gangnam-gu, Seoul, 135-720, South Korea
| | - Kyung-Hyun Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Spine and Spinal Cord Institute, Yonsei University College of Medicine, 211 Eonjuro Gangnam-gu, Seoul, 135-720, South Korea.
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Liu G, Tan JH, Yang C, Ruiz J, Wong HK. A Computed Tomography Analysis of the Success of Spinal Fusion Using Ultra-Low Dose (0.7 mg per Facet) of Recombinant Human Bone Morphogenetic Protein 2 in Multilevel Adult Degenerative Spinal Deformity Surgery. Asian Spine J 2018; 12:1010-1016. [PMID: 30322256 PMCID: PMC6284119 DOI: 10.31616/asj.2018.12.6.1010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 05/22/2018] [Indexed: 01/08/2023] Open
Abstract
Study Design Retrospective cohort study. Purpose To report on spinal fusion assessment using computed tomography (CT) after adult spinal deformity (ASD) surgery using ultra-low dose recombinant human bone morphogenetic protein 2 (RhBMP-2). Overview of Literature The reported dose of RhBMP-2 needed for successful spinal posterolateral fusion in ASD ranges from 10 to 20 mg per spinal level. This study reports the use of ultra-low dose of RhBMP-2 (0.07 mg per facet) to achieve spinal fusion in multilevel ASD surgery. Methods Consecutive patients who underwent ASD surgery using ultra-low dose RhBMP-2 were recruited. Routine postoperative CT analysis for spinal fusion was performed by two spine surgeons. Inter-observer agreement was calculated for facet fusion (FF) and interbody fusion (IBF) at 6 and 12 months after the procedure. Results Six consecutive ASD patients with a mean age of 62 years (28–72 years) were examined. Each patient received a total dose of 12 mg with an average dose of 0.69±0.2 mg (0.42–1 mg) per single FF and 1.38±0.44 mg (0.85–2 mg) for IBF. Total 131 FF and 15 IBF were examined in the study, with 88 FFs and nine IBFs being analyzed specifically at 6 months after the surgery. FF and IBF reported by surgeons A and B at 6 months were 97.7% vs. 91.9% FF, respectively (κ=0.95) and 100% vs. 100% IBF, respectively (κ=1). Two patients underwent longitudinal follow-up CT at 12 months, and the FF rates reported by surgeons A and B were 100% vs. 95.8%, respectively (κ=0.96). Five out of nine facet (56%) non-unions were identified at the cross-links. The remaining four facet pseudarthrosis were noted at 1–2 spinal levels caudal to the cross-links. At the final clinical follow-up, there was no rod breakage, deformity progression, neurological deficit, or symptom recurrence. The Oswestry Disability Index improved by an average of 32.8±6.3, while the mental component summary of the 36-item Short-Form Health Survey improved by an average of 4.7±2.1, and physical component summary improved by an average of 10.5±2.1. Conclusions To our knowledge, this is the first study to report a CT that defined 92%–98% FF and 100% IBF using the lowest reported dose of RhBMP-2 in multilevel ASD surgery. The use of ultra-low dose RhBMP-2 reduces the RhBMP-2 related complications and healthcare costs.
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Affiliation(s)
- Gabriel Liu
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Jun Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Changwei Yang
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - John Ruiz
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Hee-Kit Wong
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
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Lumbosacral Transitional Vertebra-Related Low Back Pain: Resolving the Controversy. Asian Spine J 2018; 12:407-415. [PMID: 29879766 PMCID: PMC6002172 DOI: 10.4184/asj.2018.12.3.407] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/18/2017] [Accepted: 10/30/2017] [Indexed: 12/02/2022] Open
Abstract
Study Design Case control study. Purpose The association of lumbosacral transitional vertebra (LSTV) with low back pain (LBP) is controversial, as is the role of occupational physical activity and radiological spinal abnormalities suggestive of other spinal disorders (OSDs) such as spinal degeneration and instability. This study aimed to determine if any association of LSTV with LBP exists. If so, the association of the level of physical activity and presence of OSD with LSTV-related LBP was determined. Overview of Literature The cause of LBP has been linked to proximal level disc degeneration, arthritic pseudoarticulation between LSTV and the sacral ala, facet joint degeneration, and nerve root compression due to a broadened transverse process. LSTV associated with LBP is present among individuals who are involved in high-level physical activity, including military recruits and athletes. Methods This was an unmatched study comprising 372 cases and 224 controls consecutively recruited with clinical and radiographic documentation. The relationship between LSTV and LBP was analyzed, and the effects of LSTV and OSD on this relationship were also assessed and statistically controlled. Results The presence of LSTV (p =0.039) was significantly associated with LBP, and the presence of OSD was associated with LTSV-related LBP, after statistically controlling for the level of physical activity (p =0.024). The level of physical activity was not associated with LBP. Demographic analysis revealed female predominance with an advanced age (>45 years) among those with LSTV-related LBP who have OSD. Conclusions The presence of LSTV was associated with an increased prevalence of LBP. This association was probably due to the confounding effect of OSD. The level of occupational physical activity was not associated with LSTV-related LBP. We speculate that advanced age and female sex caused the spurious association of LSTV with LBP in our study, rendering LSTV-related LBP controversial in published literature.
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Kunkle WA, Madden M, Potts S, Fogelson J, Hershman S. Validity of a smartphone protractor to measure sagittal parameters in adult spinal deformity. Spine J 2017; 17:1559-1564. [PMID: 28818564 DOI: 10.1016/j.spinee.2017.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/07/2017] [Accepted: 06/16/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Smartphones have become an integral tool in the daily life of health-care professionals (Franko 2011). Their ease of use and wide availability often make smartphones the first tool surgeons use to perform measurements. This technique has been validated for certain orthopedic pathologies (Shaw 2012; Quek 2014; Milanese 2014; Milani 2014), but never to assess sagittal parameters in adult spinal deformity (ASD). This study was designed to assess the validity, reproducibility, precision, and efficiency of using a smartphone protractor application to measure sagittal parameters commonly measured in ASD assessment and surgical planning. PURPOSE This study aimed to (1) determine the validity of smartphone protractor applications, (2) determine the intra- and interobserver reliability of smartphone protractor applications when used to measure sagittal parameters in ASD, (3) determine the efficiency of using a smartphone protractor application to measure sagittal parameters, and (4) elucidate whether a physician's level of experience impacts the reliability or validity of using a smartphone protractor application to measure sagittal parameters in ASD. STUDY DESIGN/SETTING An experimental validation study was carried out. METHODS Thirty standard 36″ standing lateral radiographs were examined. Three separate measurements were performed using a marker and protractor; then at a separate time point, three separate measurements were performed using a smartphone protractor application for all 30 radiographs. The first 10 radiographs were then re-measured two more times, for a total of three measurements from both the smartphone protractor and marker and protractor. The parameters included lumbar lordosis, pelvic incidence, and pelvic tilt. Three raters performed all measurements-a junior level orthopedic resident, a senior level orthopedic resident, and a fellowship-trained spinal deformity surgeon. All data, including the time to perform the measurements, were recorded, and statistical analysis was performed to determine intra- and interobserver reliability, as well as accuracy, efficiency, and precision. Statistical analysis using the intra- and interclass correlation coefficient was calculated using R (version 3.3.2, 2016) to determine the degree of intra- and interobserver reliability. RESULTS High rates of intra- and interobserver reliability were observed between the junior resident, senior resident, and attending surgeon when using the smartphone protractor application as demonstrated by high inter- and intra-class correlation coefficients greater than 0.909 and 0.874 respectively. High rates of inter- and intraobserver reliability were also seen between the junior resident, senior resident, and attending surgeon when a marker and protractor were used as demonstrated by high inter- and intra-class correlation coefficients greater than 0.909 and 0.807 respectively. The lumbar lordosis, pelvic incidence, and pelvic tilt values were accurately measured by all three raters, with excellent inter- and intra-class correlation coefficient values. When the first 10 radiographs were re-measured at different time points, a high degree of precision was noted. Measurements performed using the smartphone application were consistently faster than using a marker and protractor-this difference reached statistical significance of p<.05. CONCLUSIONS Adult spinal deformity radiographic parameters can be measured accurately, precisely, reliably, and more efficiently using a smartphone protractor application than with a standard protractor and wax pencil. A high degree of intra- and interobserver reliability was seen between the residents and attending surgeon, indicating measurements made with a smartphone protractor are unaffected by an observer's level of experience. As a result, smartphone protractors may be used when planning ASD surgery.
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Affiliation(s)
- William Aaron Kunkle
- Department of Orthopedic Surgery, Broward Health Medical Center, 1600 South Andrews Ave, Fort Lauderdale, FL 33316, USA.
| | - Michael Madden
- Department of Orthopedic Surgery, Broward Health Medical Center, 1600 South Andrews Ave, Fort Lauderdale, FL 33316, USA
| | - Shannon Potts
- Department of Mathematics, University of Southern California, 3620 South Vermont Ave, KAP 104, Los Angeles, CA 90089, USA
| | - Jeremy Fogelson
- Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Stuart Hershman
- Department of Orthopedic Surgery, Yawkey Center for Outpatient Care, Massachusetts General Hospital, 55 Fruit St, Suite 3A, Boston, MA 02114, USA
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Lin YC, Huang TS, Wu JS, Cheung YC, Huang YH, Sung CM, Juan YH, Chen FP, Ni Mhuircheartaigh JM. Are bilateral decubitus views necessary in assessing for vertebral compression fractures using DXA vertebral fracture assessment? Osteoporos Int 2017; 28:2377-2382. [PMID: 28488133 DOI: 10.1007/s00198-017-4040-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED The purpose of this study is to assess the differences in VFA diagnostic accuracy when using bilateral decubitus views and whether diagnostic accuracy is affected by scoliosis. Our findings show that the current practice of performing only one side is valid; however, bilateral views can improve specificity in scoliosis. INTRODUCTION The diagnostic accuracy of vertebral fracture assessment (VFA) can be influenced by poor patient position and scoliosis. This study aims to assess the differences in VFA diagnostic accuracy for right and left lateral decubitus views and the effect of scoliosis. METHODS One hundred fourteen postmenopausal women received right and left lateral thoracolumbar spine dual-energy VFA and radiography. Cobb angles were measured from the posteroanterior absorptiometry image, and lumbar spine radiography was the standard reference for vertebral fracture and also provides the levels investigated. McNemar's test was used to compare accuracy between the two decubitus position and Fisher's exact test was used for patients with and without scoliosis. RESULTS Forty-two vertebral fractures (VFs) were identified. There was no significant difference in sensitivity (p = 0.125) or specificity (p = 0.866) between the left lateral decubitus (64.3, 97.2%) and right lateral decubitus (76.2, 91.1%), respectively, views. Scoliotic patients had a significantly worse specificity (92.7 vs 98.1%, p = 0.003) than patients without scoliosis; however, a combination of both decubitus positions significantly improved specificity (p < 0.001). CONCLUSION Right and left side lateral decubitus views have excellent agreement with radiography and similar diagnostic accuracy in the detection of VFs. Thus, the current practice of performing only one side is valid. With scoliosis, bilateral decubitus views can improve the specificity of detecting VF; however, this would increase radiation dose.
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Affiliation(s)
- Y-C Lin
- Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung and Chang Gung University, 222 Maijin Road, Keelung, Taiwan
- Keelung Osteoporosis Prevention and Treatment Center, Keelung, Taiwan
| | - T-S Huang
- Keelung Osteoporosis Prevention and Treatment Center, Keelung, Taiwan
- Department of General Surgery, Chang Gung Memorial Hospital, 222 Maijin Road, Keelung, Taiwan
- Department of Chinese Medicine, College of Medicine, Chang Gung University, Kuei-Shan, Taoyuan, Taiwan
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - J S Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Y-C Cheung
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou/Taoyuan and Chang Gung University, 5 Fu-Shin Street, Kuei-Shan, Taoyuan, 333, Taiwan
| | - Y-H Huang
- Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung and Chang Gung University, 222 Maijin Road, Keelung, Taiwan
| | - C-M Sung
- Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung and Chang Gung University, 222 Maijin Road, Keelung, Taiwan
| | - Y-H Juan
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou/Taoyuan and Chang Gung University, 5 Fu-Shin Street, Kuei-Shan, Taoyuan, 333, Taiwan
| | - F-P Chen
- Keelung Osteoporosis Prevention and Treatment Center, Keelung, Taiwan.
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Keelung and Chang Gung University, 222 Maijin Road, Keelung, Taiwan.
| | - J M Ni Mhuircheartaigh
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA
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