Magnetic resonance imaging grading of interspinous ligament degeneration of the lumbar spine and its relation to aging, spinal degeneration, and segmental motion

Establishment of a risk prediction model for residual low back pain in thoracolumbar osteoporotic vertebral compression fractures after percutaneous kyphoplasty

OBJECTIVE

This study aims to identify potential independent risk factors for residual low back pain (LBP) in patients with thoracolumbar osteoporotic vertebral compression fractures (OVCFs) following percutaneous kyphoplasty (PKP) treatment. Additionally, we aim to develop a nomogram that can accurately predict the occurrence of residual LBP.

METHODS

We conducted a retrospective review of the medical records of thoracolumbar OVCFs patients who underwent PKP treatment at our hospital between July 2021 and December 2022. Residual LBP was defined as the presence of moderate or greater pain (VAS score ≥ 4) in the low back one day after surgery, and patients were divided into two groups: the LBP group and the non-LBP group. These patients were then randomly allocated to either a training or a validation set in the ratio of 7:3. To identify potential risk factors for residual LBP, we employed lasso regression for multivariate analysis, and from this, we constructed a nomogram. Subsequently, the predictive accuracy and practical clinical application of the nomogram were evaluated through a receiver operating characteristic (ROC) curve, a calibration curve, and a decision curve analysis (DCA).

RESULTS

Our predictive model revealed that five variables-posterior fascial oedema, intravertebral vacuum cleft, time from fracture to surgery, sarcopenia, and interspinous ligament degeneration-were correlated with the presence of residual LBP. In the training set, the area under the ROC was 0.844 (95% CI 0.772-0.917), and in the validation set, it was 0.842 (95% CI 0.744-0.940), indicating that the model demonstrated strong discriminative performance. Furthermore, the predictions closely matched actual observations in both the training and validation sets. The decision curve analysis (DCA) curve suggested that the model provides a substantial net clinical benefit.

CONCLUSIONS

We have created a novel numerical model capable of accurately predicting the potential risk factors associated with the occurrence of residual LBP following PKP in thoracolumbar OVCFs patients. This model serves as a valuable tool for guiding specific clinical decisions for patients with OVCFs.

Intervertebral disc degeneration relates to biomechanical changes of spinal ligaments

BACKGROUND CONTEXT

The ligamentum flavum (LF), the inter- and supraspinous ligament (ISL&SSL) and the intertransverse ligament (ITL) are relevant spinal structures for segmental stability. The biomechanical effect of degeneration and aging on their biomechanical properties remains largely unknown.

PURPOSE

The aim of this study was to assess the material properties of the ITL, ISL&SSL and LF and to correlate parameters of biomechanical function with LF-thickness, intervertebral disc (IVD) degeneration and age.

STUDY DESIGN

Biomechanical cadaveric study.

METHODS

MRI- and CT-scans of 50 human lumbar segments (Th12-L5) were used to assess the ISL (acc. to Keorochana), the grade of IVD degeneration (acc. to Pfirrmann) and to quantify LF-thickness. The ITL, ISL&SSL and LF were resected in the neutral position of the spinal segment with a specifically developed method to conserve initial strain. Ramp to failure testing was performed (0.5 mm/s) to record initial tension, slack length, stiffness and ultimate strength. The relationship between the biomechanical characteristics and age and radiological parameters were analyzed. There are no study-specific conflicts of interest and no external funding was received for this study.

RESULTS

With aging, a significant reduction in initial tension (r=-0.5, p<.01) and ultimate strength (r=-0.41, p<.01) of the LF was observed, while the effect on LF-stiffness and the characteristics of the other ligaments was non-significant. IVD-degeneration was correlated with a significant reduction in stiffness (r=-0.47, p=.001; r=-0.36, p=.01) and ultimate strength (r=-0.3, p=.04; r=-0.36, p=.01) of the LF and ISL&SSL respectively and a significant reduction in initial tension (r=-0.4, p<.01) of the LF. For the ITL, no significant correlation was observed. Comparing Pfirrman 2 to 5, this reduction was 40% to 80% for stiffness 60% to 70% for ultimate strength and 88% for initial tension of the LF. ISL&SSL-stiffness between Kerorochana grade A and D differed significantly (p=.03), while all other comparisons were non-significant (p>.05). LF-thickness did not correlate with the biomechanical properties of the LF (p>.05).

CONCLUSIONS

Aging is primarily related to biomechanical changes to the LF. IVD-degeneration is related to a relevant reduction in stiffness and ultimate strength of the LF and ISL&SSL, with a similar trend for the ITL. The ISL-specific Keorochana grading system provides only minimal biomechanical information and LF-thickness does not provide biomechanical information.

CLINICAL SIGNIFICANCE

Patient age and the degenerative state of the IVD can be used to evaluate the biomechanical characteristics of the dorsal spinal ligaments, which can be helpful in selecting the optimal surgical procedure (e.g. in decompression surgery) for a specific situation.

Ultrasound-guided, direct suprainguinal injection for fascia iliaca block for total hip arthroplasty: A retrospective study

BACKGROUND

Peripheral regional block combined with general anesthesia might be a preferable anesthetic regimen for elderly patients undergoing total hip arthroplasty.

AIM

To investigate whether ultrasound-guided, direct suprainguinal injection for fascia iliaca block accelerated recovery after general anesthesia and relieved postoperative pain after total hip arthroplasty.

METHODS

Patients who underwent total hip arthroplasty under general anesthesia in 2015 or 2019 at The Second Affiliated Hospital of Xuzhou Medical University were retrospectively analyzed. The patients were grouped based on whether preoperative suprainguinal fascia iliaca block was performed or not. The time to tracheal extubation and time spent in the post-anesthesia care unit (PACU), intraoperative remifentanil dosage, fentanyl consumption in the PACU, postoperative cumulative fentanyl consumption within 48 h after operation, visual analogue scale at rest and during movement on the first and second days after surgery, and adverse reactions were compared.

RESULTS

Thirty-one elderly patients who underwent total hip arthroplasty were included in the study (block group, n = 16; no-block group, n = 15). The visual analog scale scores at rest and during movement on the first and second days were significantly lower in the block group than in the no-block group (all P < 0.05). Compared with the no-block group, the intraoperative remifentanil dosage was lower, the time to tracheal extubation and the time spent in the PACU were shorter in the block group (all P < 0.01). Fentanyl consumption in the PACU and postoperative cumulative fentanyl consumption in 48 h after operation were lower in the block group (all P < 0.01). The incidence of dizziness was higher in the no-block group than in the block group (P = 0.037).

CONCLUSION

Ultrasound-guided, direct suprainguinal injection for fascia iliaca block led to faster recovery after general anesthesia and early postoperative pain relief in elderly patients undergoing total hip arthroplasty.

Anatomical and Biomechanical Study of the Lumbar Interspinous Ligament

Objective

The lumbar interspinous ligaments (ISLs) are thin and short fibers connecting adjacent spinous processes. However, their morphology is variably described and their biomechanics are not well understood. Therefore, the purpose of this study was to assess the anatomy and biomechanics of the lumbar ISL.

Materials and Methods

Five fresh frozen cadaveric specimens were dissected posteriorly to reveal and study the lumbar ISL. Measurements of the ligaments included the anterior vertical height (length A), the posterior vertical height (length P), and the length (length H) at each lumbar level. Next, 17 lumbar vertebral levels from 6 cadaveric specimens were used for tensile strength testing. The ISLs were subjected to vertically controlled increasing manual tension. The force necessary to disrupt the ISL was recorded.

Results

All the ISLs ran horizontally in an anterior-posterior direction with a slight curve. The average of length A, length P, and length H on the right sides was 9.82, 9.57, and 20.12 mm, respectively. The average of length A, length P, and length H on the left sides was 11.56, 12.01, and 21.42 mm, respectively. The mean tensile strength of the ISL was 162.33 (N) at L1/2, 85.67 (N) at L2/3, and 79 (N) at L3/4. There was a significant difference in the tensile force between L1/2 and L2/3 and L1/2 and L3/4 (P < 0.05). The ligaments became weaker with a descent along the lumbar levels.

Conclusion

The results of this study might help surgeons understand pathology/trauma of the lumbar vertebral region.

Imaging of Degenerative and Infectious Conditions of the Spine

: Imaging is important in the evaluation of patients with degenerative disease and infectious processes. There are numerous conditions that can manifest as low back pain (LBP) or neck pain in a patient, and in many cases, the cause may be multifactorial. Clinical history and physical examination are key components in the evaluation of such patients; however, physical examination has variable sensitivity and specificity. Although studies have demonstrated that uncomplicated acute LBP and/or radiculopathy are self-limited conditions that do not warrant any imaging, neuroimaging can provide clear anatomic delineation of potential causes of the patient's clinical presentation. Various professional organizations have recommendations for imaging of LBP, which generally agree that an imaging study is not indicated for patients with uncomplicated LBP or radiculopathy without a red flag (eg, neurological deficit such as major weakness or numbness in lower extremities, bowel or bladder dysfunction, saddle anesthesia, fever, history of cancer, intravenous drug use, immunosuppression, trauma, or worsening symptoms). Different imaging modalities have a complementary role in the diagnosis of pathologies affecting the spine. In this review, we discuss the standard nomenclature for lumbar disk pathology and the utility of various clinical imaging techniques in the evaluation of LBP/neck pain for potential neurosurgical management. The imaging appearance of spinal infections and potential mimics also is reviewed. Finally, we discuss advanced neuroradiological techniques that offer greater microstructural and functional information.

ABBREVIATIONS

ADC, apparent diffusion coefficientDTI, diffusion tensor imagingDWI, diffusion-weighted imagingDOM, diskitis-osteomyelitisLBP, low back painMRM, magnetic resonance myelographySNA, spinal neuroarthropathySPECT, single-positron emission computed tomographySTIR, short tau inversion recovery.

Lumbar ganglion cyst: Nosology, surgical management and proposal of a new classification based on 34 personal cases and literature review

AIM

To analyze different terms used in literature to identify lumbar extradural cysts and propose a common scientific terminology; to elaborate a new morphological classification of this pathology, useful for clinical and surgical purposes; and to describe the best surgical approach to remove these cysts, in order to avoid iatrogenic instability or treat the pre-existing one.

METHODS

We retrospectively reviewed 34 patients with symptomatic lumbar ganglion cysts treated with spinal canal decompression with or without spinal fixation. Microsurgical approach was the main procedure and spinal instrumentation was required only in case of evident pre-operative segmental instability.

RESULTS

The complete cystectomy with histological examination was performed in all cases. All patients presented an improvement of clinical conditions, evaluated by Visual Analogic Scale and Japanese Orthopaedic Association scoring.

CONCLUSION

Spinal ganglion cysts are generally found in the lumbar spine. The treatment of choice is the microsurgical cystectomy, which generally does not require stabilization. The need for fusion must be carefully evaluated: Pre-operative spondylolisthesis or a wide joint resection, during the operation, are the main indications for spinal instrumentation. We propose the terms “ganglion cyst” to finally identify this spinal pathology and for the first time its morphological classification, clinically useful for all specialists.

Lumbar spondylosis, lumbar spinal stenosis, knee pain, back muscle strength are associated with the locomotive syndrome: Rural population study in Japan

OBJECTIVES

To comprehensively investigate the clinical and physical factors associating with locomotive syndrome (Loc-S); the locomotorium-disability for daily life.

METHODS

647 volunteers participated (247 males, 400 females, Age: 58.4 ± 11.0, BMI: 22.5 ± 3.3). Three self-assessment questionnaires were administered: 1) "25-question Geriatric Locomotive Function Scale" (GFLS-25) for evaluating Loc-S (GLFS-25 ≥ 16 defined as Loc-S); 2) "diagnostic support tool for LSS" (LSS-DST) for evaluating the prevalence of lumbar spinal stenosis (LSS); 3) Knee injury and Osteoarthritis Outcome Score (KOOS). Plain radiographs of the bilateral knees and lumbar spine were evaluated, and the severity of lumbar spondylosis (LS) and knee osteoarthritis (KOA) defined by Kellgren-Lawrence grade. Bone status was evaluated by using the osteo-sono assessment index (OSI) at the calcaneus. Isometric muscle strength of trunk and leg (Nm/kg, both extension and flexion) were evaluated. Linear regression analysis was performed to elucidate the factors concerned with GFLS-25 including age, sex, and BMI.

RESULTS

Thirty-nine subjects (6.0%, 13 males, 26 females) were defined as having Loc-S. Single regression model showed that age, height, BMI, skeletal muscle mass, OSI, LSS, KOOS, the severity of LS and KOA, and trunk- and leg-muscle strength were correlated with the degree of GLFS-25. Stepwise multiple regression model showed that sex, height, LSS, KOOS, the severity of LS, and back muscle strength were significantly correlated with that of GLFS-25.

CONCLUSION

In this cross-sectional study, pain status associated with LSS and knee joint, structural severity for LS, and back muscle strength primarily affected the degree of GFLS-25. For managing Loc-S, we must pay more intensive attention to these factors.

Effect of Concentration on Median Effective Dose (ED50) for Motor Block of Intrathecal Plain Bupivacaine in Elderly Patients

Background

The aim of the study was to determine the median effective dose (ED₅₀) for motor block of various concentrations of intrathecally administered plain bupivacaine.

Material/Methods

Between 2011 and 2013, 64 patients aged ≥70 years, undergoing transurethral, or lower limb surgery with combined spinal and epidural anesthesia in a single hospital were enrolled. The patients were randomized into 3 groups to receive intrathecal 0.75% bupivacaine (Group 1), 0.375% bupivacaine (Group 2) or 0.25% bupivacaine (Group 3). Spinal anesthesia was achieved using injections of up-and-down doses of 0.75%, 0.375%, or 0.25% plain bupivacaine. The first patient in each group received 7.5 mg bupivacaine, and the testing interval was set at 0.75 mg. The efficacy of motor block in both legs was determined using a modified Bromage and a hip motor function scale. The ED₅₀ for motor block was estimated according to the Dixon’s up-and-down method.

Results

The ED₅₀ for motor block of bupivacaine was 6.10 (95% CI 5.58–6.66) mg in Group 1, 6.04 (95% CI 5.82–6.28) mg in Group 2, and 5.43 (95% CI 5.19–5.67) mg in Group 3. There were significant differences in the ED₅₀ for motor block among the groups (P=0.008).

Conclusions

The ED₅₀ doses for motor block with 3 bupivacaine concentrations were significantly different in elderly patients; the ED₅₀ dose of 0.75% bupivacaine being significantly higher than that of 0.25% bupivacaine.

Age-related Changes in Maximum Pelvic Anteversion and Retroversion Angles Measured in the Sitting Position

[Purpose] The purpose of this study was to investigate the relationship between age and the maximum pelvic anteversion and retroversion angles, as well as the associated pelvic range of motion, measured in a sitting position with free knee movement. [Subjects] A total of 132 healthy volunteers (74 women, 58 men; age range, 20–79 years) were divided into six groups based on age (20–29, 30–39, 40–49, 50–59, 60–69, and 70–79 years). [Methods] The maximum pelvic anteversion and retroversion angles were measured manually five times by a goniometer in a sitting position that allowed free movement of the knee joints. [Results] There was a significant effect of age group on the maximum pelvic anteversion and retroversion angles and pelvic range of motion (the difference between these angles). There was a significant correlation between age and the maximum pelvic anteversion angle, maximum pelvic retroversion angle, and pelvic range of motion. [Conclusion] The maximum pelvic anteversion and retroversion angles and pelvic range of motion were significantly correlated with age. The maximum pelvic anteversion angle and pelvic range of motion were most affected by age.

Comparison of hemodynamics after combined spinal-epidural anesthesia between decubitus and sitting positions in aged patients undergoing total hip replacement

OBJECTIVE

To compare the hemodynamics after combined spinal-epidural anesthesia (CSEA) between decubitus and sitting positions in aged patients undergoing total hip replacement.

METHODS

A total of 80 aged patients who underwent CSEA for elective total hip replacement were randomly divided into a decubitus position group (group D) and a sitting position group (group S; each group with 40 patients). In group D, 10 mg of 0.5% bupivacaine were given into the subarachnoid space in decubitus position. In group S, 10 mg of 0.5% bupivacaine were given into the subarachnoid space in the sitting position, which was maintained for 1 min, after which the patients were in decubitus position. In both groups, the sensory block levels and changes in hemodynamics were assessed.

RESULTS

The mean arterial blood pressure was significantly higher in group S than in group D at each time point within 30 min after anesthesia. There were no significant differences in heart rate between the two groups at each time point. There was also no significant difference in the level of sensory block between the two groups 20 min after the administration of CSEA.

CONCLUSION

For aged patients undergoing total hip replacement, CSEA is safer and more effective in the sitting position than in decubitus position.

Nucleus pulposus cells expressing hBMP7 can prevent the degeneration of allogenic IVD in a canine transplantation model

We have previously explored the possibilities of allogenic intervertebral disc (IVD) curing disc degeneration disease in clinical practice. The results showed that the motion and stability of the spinal unit was preserved after transplantation of allogenic IVD in human beings at 5-year follow-up. However, mild degeneration was observed in the allogenic transplanted IVD cases. In this study, we construct the biological tissue engineering IVD by injecting the nucleus pulposus cells (NPCs) expressing human bone morphogenetic protein 7 (hBMP7) into cryopreserved IVD, and transplant the biological tissue engineering IVD into a beagle dog to investigate whether NPCs expressing hBMP7 could prevent the degeneration of the transplanted allogenic IVDs. At 24 weeks after transplantation, MRI scan showed that IVD allografts injected NPCs expressing hBMP7 have a slighter signs of degeneration than IVD allografts with NPCs or without NPCs. The range of motion of left-right rotation in the group without NPCs was bigger than that of two cells injection group. PKH-26-labeled cells were identified at IVD allograft. The study demonstrated that NPCs expressing hBMP7 could survive at least 24 weeks and prevent the degeneration of the transplanted IVD. This solution might have a potential role in preventing the IVD allograft degeneration in long time follow-up.

Effect of position changes after spinal anesthesia with low-dose bupivacaine in elderly patients: sensory block characteristics and hemodynamic changes

Background

The purpose of this study is to compare the anesthetic characteristics in elderly patients who remain in sitting position for 2 min compared with patients that are placed in supine position after induction of spinal anesthesia.

Methods

Fifty-seven patients scheduled for transurethral surgery were randomized to assume supine position immediately after 6.5 mg hyperbaric bupivacaine were injected (L group) or to remain in the sitting position for 2 minutes before they also assumed the supine position (S group). Analgesic levels were assessed bilaterally, using pin-prick. Motor block was scored using a 12-point scale. The mean arterial pressure and heart rate were also recorded.

Results

Sensory block levels were significantly lower at all time points for the L group. However, there were no significant differences in the degree of the motor block and hemodynamic changes between the two groups. However, in the L group, ephedrine or atropine were administered to three patients.

Conclusions

We concluded that performing a spinal anesthesia in sitting position was technically easier and induced less hypotension.

mild® Lumbar Decompression for the Treatment of Lumbar Spinal Stenosis

More than 1.2 million people are undergoing treatment for lumbar spinal stenosis (LSS) in the United States. Yet, therapeutic options for these patients are limited to either conservative treatments or highly invasive surgeries. A new image-guided interlaminar decompression procedure, mild®, offers significant relief for many of these patients by debulking dorsal element hypertrophy while preserving structural stability. mild can be performed without general anesthesia and offers a short recovery period. A meta-analysis of four clinical patient series from multiple institutions in the United States evaluated over 250 patients for safety and clinical efficacy of the mild procedure. Clinical efficacy was evaluated at baseline and at three-month follow-up using validated patient reported outcomes (PRO) instruments including the ten-point Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). Acute safety and patient outcomes was compared to the Spine Patient Outcomes Research Trial (SPORT). No device or procedure-related serious adverse events (SAEs) have been recorded with the mild procedure. Outcome metrics for patients treated with mild demonstrated statistically significant symptomatic improvement over baseline. When compared to open surgery, mild efficacy results compare favorably, and complication rates are much lower. mild is a safe and effective procedure that decompresses LSS in a minimally invasive manner while preserving the structural stability of the spine.