Lateral Lumbar Radiographs Research Articles

Deep learning system assisted detection and localization of lumbar spondylolisthesis.

Objective: Explore a new deep learning (DL) object detection algorithm for clinical auxiliary diagnosis of lumbar spondylolisthesis and compare it with doctors' evaluation to verify the effectiveness and feasibility of the DL algorithm in the diagnosis of lumbar spondylolisthesis. Methods: Lumbar lateral radiographs of 1,596 patients with lumbar spondylolisthesis from three medical institutions were collected, and senior orthopedic surgeons and radiologists jointly diagnosed and marked them to establish a database. These radiographs were randomly divided into a training set (n = 1,117), a validation set (n = 240), and a test set (n = 239) in a ratio of 0.7 : 0.15: 0.15. We trained two DL models for automatic detection of spondylolisthesis and evaluated their diagnostic performance by PR curves, areas under the curve, precision, recall, F1-score. Then we chose the model with better performance and compared its results with professionals' evaluation. Results: A total of 1,780 annotations were marked for training (1,242), validation (263), and test (275). The Faster Region-based Convolutional Neural Network (R-CNN) showed better precision (0.935), recall (0.935), and F1-score (0.935) in the detection of spondylolisthesis, which outperformed the doctor group with precision (0.927), recall (0.892), f1-score (0.910). In addition, with the assistance of the DL model, the precision of the doctor group increased by 4.8%, the recall by 8.2%, the F1-score by 6.4%, and the average diagnosis time per plain X-ray was shortened by 7.139s. Conclusion: The DL detection algorithm is an effective method for clinical diagnosis of lumbar spondylolisthesis. It can be used as an assistant expert to improve the accuracy of lumbar spondylolisthesis diagnosis and reduce the clinical workloads.

Abdominal aortic calcification assessed on standard lateral lumbar radiographs as a screening tool for impaired bone status in spine surgery.

The aim of this study was to determine whether the presence of abdominal aortic calcification (AAC) can predict patient bone status, represented by volumetric bone mineral density (vBMD) assessed with quantitative computed tomography (QCT). Patients undergoing lumbar fusion surgery at a tertiary care center between 2014 and 2021, with a preoperative lumbar CT-scan and lateral lumbar radiographs were retrospectively reviewed. A semi-quantitative measurement method for AAC (AAC 4, 8 and 24) was performed. QCT measurements were made for L1 and L2. Patients were divided into two groups depending on whether AAC was present. A one-way analysis of covariance was conducted to adjust for age. A multiple linear regression model was used to test if age, sex, BMI, diabetes, hypertension, smoking and presence of AAC could predict the vBMD. A receiver operating characteristic (ROC) analysis was conducted for predicting impaired bone status. 267 patients with a median age of 65.1years and BMI of 29.8kg/m2 were analyzed, 59.6% of patients had AAC. The group comparison showed that vBMD was significantly lower in patients with the presence of AAC (97.8mg/cm3 vs. 121.5mg/cm3). Age (β = - 0.360; p < 0.001) and presence of AAC (β = -0.206; p = 0.005) significantly predict vBMD as independent variables. Impaired bone status could be discriminated using AAC 4, 8 and 24 (cut off value 0.5) with a sensitivity of 70.1% and a specificity of 60.2%. The presence of AAC may identify patients at risk for impaired bone status. Preoperative evaluation of standard lumbar radiographs could be used as a potential diagnostic tool in assessing bone status.

Abdominal aortic calcification is independently associated with increased atrophy and fatty infiltration of the lumbar paraspinal muscles: a retrospective cross-sectional study.

Aortic abdominal calcification (AAC) is associated with spine-related conditions, such as lower back pain and reduced bone mineral density. Similar to peripheral vascular disease, AAC possibly reduces blood flow to the lumbar posterior paraspinal muscles (PPM) which may lead to atrophy and increased fatty infiltration. Imaging of patients with lower back pain was analyzed. AAC was assessed on lateral lumbar radiographs according to the Kauppila classification. The cross-sectional area of the PPM was measured on a T2-weighted axial MRI sequence and the functional cross-sectional area (fCSA) and fatty infiltration (FI) were calculated with custom software. The association of AAC and FI as well as AAC and fCSA was assessed by multivariable linear regression, adjusted for age, sex, body mass index (BMI), diabetes, and smoking. Two hundred and thirty patients (47.8% female) with a median age of 60years (IQR 48-68) were analyzed. In patients, without AAC the median FI of the PPM was 33.3% (IQR 29.1-37.6%), compared to 44.6% (IQR 38.5-54.3%) in patients with AAC (p < 0.001). In the multivariable linear regression, both fCSA and FI of the PPM were significantly and independently associated with the degree of AAC (p = 0.037 and p = 0.015, respectively). This is the first study to demonstrate a significant and independent association between AAC and PPM morphology. The results of this study improve our understanding of the interaction between AAC and spinal musculature, with AAC being a reason for atrophy of the PPM.

Soluble urokinase plasminogen activator receptor is associated with cardiovascular calcification in peritoneal dialysis patients.

Cardiovascular disease (CVD) is an important cause of morbidity and mortality in peritoneal dialysis (PD) patients. Cardiovascular calcification (CVC) is highly prevalent in PD patients and could predict their cardiovascular mortality. Soluble urokinase plasminogen activator receptor (suPAR) is closely associated with coronary artery calcification in hemodialysis patients and is an important predictor of CVD. However, the role of suPAR in PD patients is poorly understood. We investigated the relationship between serum suPAR and CVC in PD patients. Abdominal aortic calcification (AAC) was assessed by lateral lumbar radiography, coronary artery calcification (CAC) by multi-slice computed tomography, and cardiac valvular calcification (ValvC) by echocardiography. CVC was defined as confirmed presence of calcification in one site (AAC, CAC, or ValvC). Patients were divided into CVC group and non-CVC group. Demographic characteristics, biochemical variables, comorbidities, PD regimen, serum suPAR, and medication were compared between the two groups. Logistic regression was conducted to determine association between serum suPAR and presence of CVC. The receiver-operator curve (ROC) was plotted to calculate the area under the curve (AUC) for suPAR to identify CVC and ValvC. Of 226 PD patients, 111 (49.1%) had AAC, 155 (68.6%) had CAC, and 26 (11.5%) had ValvC. There were significant differences in age, BMI, diabetes, white blood cell, phosphorus, hs-CRP, suPAR, time on dialysis, total volume of dialysate, ultrafiltration, volume of urine, and Kt/V between CVC and non-CVC group. Serum suPAR was associated with CVC by multivariate logistic regression analysis in PD patients, especially in elderly patients. The levels of serum suPAR were closely related to the degree of AAC, CAC, and ValvC in PD patients. The incidence of CVC was higher in patients with higher levels of suPAR. The ROC curve showed that serum suPAR had a predictive value for CVC (AUC = 0.651), especially for ValvC (AUC = 0.828). Cardiovascular calcification is prevalent in PD patients. High levels of serum suPAR are associated with cardiovascular calcification in PD patients, especially in elderly patients.

What is the fate of the adjacent segmental angles 6 months after single-level L3–4 or L4–5 lateral lumbar interbody fusion?

Background ContextLateral lumbar interbody fusion (LLIF) is an effective technique for fusion and sagittal alignment correction/maintenance. Studies have investigated the impact on the segmental angle and lumbar lordosis (and pelvic incidence-lumbar lordosis mismatch), however not much is documented regarding the immediate compensation of the adjacent angles. PurposeTo evaluate acute adjacent and segmental angle as well as lumbar lordosis changes in patients undergoing a L3–4 or L4–5 LLIF for degenerative pathology. Study Design/SettingRetrospective cohort study. Patient SamplePatients included in this study were analyzed pre- and post-LLIF performed by one of three fellowship-trained spine surgeons, 6 months following surgery. Outcome MeasuresPatient demographics (including body mass index, diabetes diagnosis, age, and sex) as well as VAS and ODI scores were measured. Lateral lumbar radiograph parameters: lumbar lordosis (LL), segmental lordosis (SL), infra and supra-adjacent segmental angle, and pelvic incidence (PI). MethodsMultiple regressions were applied for the main hypothesis tests. We examined any interactive effects at each operative level and used the 95% confidence intervals to determine significance: a confidence interval excluding zero indicates a significant effect. ResultsWe identified 84 patients who underwent a single level LLIF (61 at L4–5, 23 at L3–4). For both the overall sample and at each operative level, the operative segmental angle was significantly more lordotic postop compared to preop (all ps≤.01). Adjacent segmental angles were significantly less lordotic postop compared to pre-op overall (p=.001). For the overall sample, greater lordotic change at the operative segment led to more compensatory reduction of lordosis at the supra-adjacent segment. At L4–5, more lordotic change at the operative segment led to more compensatory lordosis reduction at the infra-adjacent segment. ConclusionThe present study demonstrated that LLIF resulted in significant increase in operative level lordosis and a compensatory decrease in supra- and infra-adjacent level lordosis, and subsequently no significant impact on spinopelvic mismatch.

Pubic Symphysis to Sacrococcygeal Joint: A Poor Correlate to Other Spinopelvic Measurements

BackgroundThe hip-spine relationship is increasingly recognized as critical for optimizing stability following total hip arthroplasty (THA). However, these measurements are not routinely obtained during THA workup. It has been suggested that insight can be gained from supine antero-posterior pelvis radiograph, measuring the distance from the superior border of the pubic symphysis to the sacro-coccygeal joint (PSCD). This study assessed the correlation between PSCD and lateral lumbar radiographic metrics in a cohort of preoperative THA patients. MethodsWe retrospectively evaluated 250 consecutive patients who underwent THA with preoperative supine antero-posterior pelvis and lateral lumbar radiographs. The mean age was 68 years (range, 42 to 89), 61% were women, and the mean body mass index was 30 kg/m2 (range, 19 to 52). Two reviewers measured PSCD, pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), and lumbar lordosis (LL). Inter-observer reliability was calculated for all measurements, and correlation coefficients were calculated for PSCD with respect to PT, SS, PI, and LL. ResultsCorrelations between PSCD and lumbar radiographic metrics were all statistically significant, except for PI in men but graded as “weak” or “very weak” for men and women, respectively, as follows: PT = −0.30 (P < .01) and −0.46 (P < .01); SS = 0.27 (P < .01) and 0.22 (P < .01); PI = −0.04 (P = .70) and −0.19 (P = .02); and LL = 0.45 (P < .01) and 0.30 (P < .01). Inter-observer reliability was graded as “strong” for every metric. ConclusionThe PSCD was weakly correlated with all evaluated lateral lumbar radiographic metrics in both sexes, despite strong inter-observer reliability. Therefore, PSCD cannot reliably serve as a proxy for evaluating the hip-spine relationship.

Relationship between the gross motor function classification system and hip and lumbar spine development in children with spastic cerebral palsy

To investigate the relationship among the gross motor function classification system (GMFCS)and the development of hip joint and lumbar spine in children with spastic cerebral palsy. The clinical data of 125 children with spastic cerebral palsy admitted from January 2018 to July 2021 were retrospectively analyzed. There were 85 males and 40 females, aged from 4 to 12 years old with an average of (8.4±2.9) years. According to GMFCS, the patients were divided into gradeⅠ, Ⅱ, Ⅲ and Ⅳ groups. There were 27 cases in gradeⅠgroup, 40 cases in gradeⅡgroup, 35 cases in grade Ⅲ group and 23 cases in grade Ⅳ group. The migration percentage(MP), central edge angle(CE), neck-shaft angle(NSA), acetabular index(AI) were measured by the radiograph of pelvis, abnormal parameters were selected to evaluate the relationship between different GMFCS grades and hip joint development. Lumbar sagittal Cobb angle, lumbar sacral angle, lumbar lordosis index and apical distance were measured by lateral lumbar radiographs to evaluate the relationship between different GMFCS grades and lumbar spine development. ①Among the 125 spastic cerebral palsy children, there were 119 cases of pelvic radiographs that met the measurement standards. In the four groups with gradeⅠ, Ⅱ, Ⅲ, Ⅳ, MP was (22.72±3.88), (26.53±4.36), (33.84±4.99), and (49.54±7.87)%, CE was(30.10±6.99) °, ( 22.92±4.19) °, ( 17.91±5.50) °, and (-0.70±17.33)°, AI was (16.41±2.77) °, (20.46±4.63) °, (23.76±5.10) °, and ( 29.15±7.35)°, respectively, there were significant differences between the two comparisons (P<0.05). And the higher GMFCS grade, the greater MP and AI, and the smaller CE.The NSA was(142.74±10.03) °, (148.66±9.09) °, (151.66±10.52) °, and (153.70±8.05)° in four groups with gradeⅠ, Ⅱ, Ⅲ, Ⅳ, respectively. The differences between the two comparisons of the GMFCS gradeⅠgroup and the other three groups were statistically significant (P<0.05). NSA of GMFCSⅠgroup was significantly lower than that of the others, there was no significant difference among other groups(P>0.05). ② Among the 125 spastic cerebral palsy children, there were 88 cases of lumbar spine radiographs that met the measurement standards. ③The lumbar sagittal Cobb angle was(32.62±11.10) °, (29.86±9.90) °, (31.70±11.84) °, and (39.69±6.80)° in the four groups with gradeⅠ, Ⅱ, Ⅲ, Ⅳ, respectively;GMFSS of grade Ⅳ group was significantly higher than that of other three groups, there was significant difference between the two comparisons (P<0.05);there were no significant differences between other groups (P>0.05). In the four groups with gradeⅠ, Ⅱ, Ⅲ, Ⅳ, the lumbosacral angle was (31.02±9.91) °, ( 26.57±9.41) °, (28.08±8.56) °, and ( 27.31±11.50)°, the lumbar lordosis index was (4.14±12.89), (8.83±13.53), (13.00±11.78), and (10.76±9.97) mm, the arch apex distance was (9.50±6.80), (6.68±3.20), (7.16±4.94), and (6.62±4.13) mm, respectively, there were no significant differences between the two comparisons(P>0.05). ①In children with GMFCS gradeⅠ-Ⅳ, the higher the GMFCS grade, the worse the hip develops. ② Children with GMFCS grade Ⅲ-Ⅳ may be at greater risk for lumbar kyphosis.

Abdominal aortic calcification score can predict all-cause and cardiovascular mortality in maintenance hemodialysis patients

Purpose Abdominal aortic calcification (AAC) assessed by using standard lateral lumbar radiographs can be graded, and composite summary scores (range, 0–24) have been shown to be highly predictive of subsequent cardiovascular morbidity and mortality in hemodialysis (HD) patients. However, few studies have sought to determine the optimal AAC score cutoff values for the prediction of mortality among HD patients. Methods This retrospective cohort study included 408 hemodialysis patients. AAC severity was quantified by the AAC score, which was measured by lateral lumbar radiography with complete follow-up data from January 2015 to December 2021. We used receiver operating characteristic (ROC) analysis to find the cutoff AAC value for the prediction of mortality. The Kaplan–Meier method was used to analyze all-cause and cardiovascular mortality. Results The cutoff calcification score for the prediction of mortality was 4.5 (sensitivity, 67.3%; specificity, 70.4%). The patients with AAC scores above 4.5 had significantly higher all-cause (log-rank p < 0.001) and cardiovascular (log-rank p < 0.001) mortality rates than those with AAC scores below 4.5. In the multivariate regression analyses, an AAC score above 4.5 was a significant factor associated with all-cause mortality (HR: 2.079, p = 0.002) and cardiovascular mortality (HR: 2.610, p < 0.001). Conclusions AAC is a reliable aortic calcification marker. HD patients with an AAC score > 4.5 have significantly elevated all-cause and cardiovascular mortality compared with those with an AAC score ≤ 4.5. AAC was a better predictor than cardiac valve calcification for mortality in HD patients.

Unravelling the hip-spine dilemma from the CHECK-cohort: is sagittal pelvic morphology linked to radiographic signs of femoroacetabular impingement?

To date the aetiology of femoroacetabular impingement (FAI) is still not completely understood. There are mechanical theories that suggest symptomatic FAI is linked to sagittal pelvic morphology and spinopelvic-femoral dynamics. The aim of this study is to evaluate the relation of sagittal pelvic morphology and orientation to radiographic signs of FAI. Additionally, we test whether the relation between FAI and spinopelvic parameters differs in osteoarthritic hips. From a prospective, observational cohort study, 1002 patients between 45 and 65 years old with a first episode of knee or hip pain were followed for 8 years. All patients who had lateral lumbar radiographs and clinical and radiographic follow-up of the hips were included in the present study. Range of internal rotation of the hip as well as radiographic signs of FAI (alpha and Wiberg angle) and presence of hip osteoarthritis (Kellgren and Lawrence) were systematically measured at baseline. Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS)) were measured at 8-year follow-up. Associations between PI, PT, SS and FAI parameters were tested using generalised estimating equations. 421 subjects, 842 hips, were included. No significant relations between PI, PT or SS and alpha or Wiberg angle were found. Comparison of hips with and without radiological sign(s) of FAI showed no differences in PI, PT or SS. There was no relation between range of internal rotation of the hip and spinopelvic parameters. Sagittal pelvic morphology and orientation are not related to the presence of radiological signs of FAI in this study population.

Novel artificial intelligence algorithm: an accurate and independent measure of spinopelvic parameters.

The analysis of sagittal alignment by measuring spinopelvic parameters has been widely adopted among spine surgeons globally, and sagittal imbalance is a well-documented cause of poor quality of life. These measurements are time-consuming but necessary to make, which creates a growing need for an automated analysis tool that measures spinopelvic parameters with speed, precision, and reproducibility without relying on user input. This study introduces and evaluates an algorithm based on artificial intelligence (AI) that fully automatically measures spinopelvic parameters. Two hundred lateral lumbar radiographs (pre- and postoperative images from 100 patients undergoing lumbar fusion) were retrospectively analyzed by board-certified spine surgeons who digitally measured lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope. The novel AI algorithm was also used to measure the same parameters. To evaluate the agreement between human and AI-automated measurements, the mean error (95% CI, SD) was calculated and interrater reliability was assessed using the 2-way random single-measure intraclass correlation coefficient (ICC). ICC values larger than 0.75 were considered excellent. The AI algorithm determined all parameters in 98% of preoperative and in 95% of postoperative images with excellent ICC values (preoperative range 0.85-0.92, postoperative range 0.81-0.87). The mean errors were smallest for pelvic incidence both pre- and postoperatively (preoperatively -0.5° [95% CI -1.5° to 0.6°] and postoperatively 0.0° [95% CI -1.1° to 1.2°]) and largest preoperatively for sacral slope (-2.2° [95% CI -3.0° to -1.5°]) and postoperatively for lumbar lordosis (3.8° [95% CI 2.5° to 5.0°]). Advancements in AI translate to the arena of medical imaging analysis. This method of measuring spinopelvic parameters on spine radiographs has excellent reliability comparable to expert human raters. This application allows users to accurately obtain critical spinopelvic measurements automatically, which can be applied to clinical practice. This solution can assist physicians by saving time in routine work and by avoiding error-prone manual measurements.

Change in prevalence of vertebral fractures over two decades: a Japanese medical examination-based study.

Although remarkable progress has been made in osteoporosis treatment over the last two decades, no study has reported the change in the prevalence of vertebral fractures (VFs) during this time. This study aimed to compare the prevalence and pattern of VFs at three time points from 1997 to 2019 in a Japanese medical examination-based study. The participants of this study were inhabitants of a typical Japanese mountain village who participated in these surveys at three time points: 1997 (group A), 2009 or 2011 (group B), and 2019 (group C). The age- and sex-adjusted groups were defined as groups A', B', and C', respectively (39 men and 85 women; mean age 73.6-74.0years old). The type and extent of deformities of the prevalent fractures from T4 to L4 on the lateral thoracic and lumbar spine radiographs were semiquantitatively evaluated. The prevalence of VFs has significantly decreased over the past two decades. In group A, the percentages of thoracic level, biconcave type, and severe deformity of VFs were significantly higher than expected. The bone mineral density of the participants increased significantly over time. The treatment rate for osteoporosis in participants with osteoporosis has improved over the past two decades. This study demonstrated that the prevalence of VFs has decreased, and the pattern of VFs has changed over the last two decades in a typical Japanese mountain village due to multifactorial improvements in skeletal fragility, including improvement in osteoporosis treatment rate.

Clinical efficacy of transforaminal endoscopic lumbar discectomy for lumbar degenerative diseases: A minimum 6-year follow-up.

BackgroundTransforaminal Endoscopic Lumbar Discectomy (TELD) is widely applied for lumbar degenerative disease (LDDs) and satisfactory short-term outcomes have been achieved. However, the mid-term and long-term follow-up of this technique is still lacking.ObjectiveTo retrospectively analyze the mid-term clinical efficacy of TELD for single-level LDD and its effect on intervertebral disc degeneration with a minimum of 6-year follow-up.Methods64 patients with single-level LDDs (lumbar disc herniation, lumbar spinal stenosis) who underwent TELD under local anesthesia in our department from December 2014 to December 2015 were observed. Visual analog scale (VAS), Japanese Orthopaedic Association evaluation treatment (JOA) score and Oswestry Disability Index (ODI) were calculated and compared before operation, 3 months after operation, 6 months after operation, 1 year after operation and at the last follow-up. Disc Height (DH), disc range of motion (ROM) and disc degeneration on standard lumbar lateral radiographs before operation and at the last follow-up were determined. Recurrence rate and operation-related complications during follow-up were recorded.Results64 cases were followed up for 6.4 ± 0.1 years. There were no complications such as infection, epidural hematoma and nerve root injury. 1 patient (1.67%) was found to have dural rupture and cauda equina hernia during the operation. There were significant differences in VAS, JOA, ODI between preoperative and postoperative 3 months, 6 months, 1 year and last follow-up (P < 0 01), VAS, JOA, ODI at 3 months after operation were different from 6 months after operation (P < 0 05), and there were significant differences compared with preoperative, 1 year after operation and last follow up (P < 0 01). VAS, JOA and ODI at 6 months after operation were significantly different from those before operation (P < 0.01), but not significantly different from those at 1 year after operation and the last follow-up (P > 0.05). There was no significant difference in DH, ROM and the Pfirrmann grade of intervertebral disc preoperative and the last follow-up. During the follow-up period, 3 patients (4.69%) were recurrent, 13 patients (20.31%) had various degrees of postoperative dysesthesia (POD), and 3 patients (4.69%) had various degrees of muscle weakness.ConclusionTELD has a satisfactory mid-term efficacy, and has no significant effect on the DH, the stability of the intervertebral disc space, or on intervertebral disc degeneration. However, as expected, TELD was associated with some complications including recurrent disc herniation and POD.

Vascular calcification of the abdominal aorta has minimal impact on lumbar spine bone density in patients with chronic kidney disease

Dual-energy X-ray absorptiometry (DXA) measurements are sensitive to artifacts from surrounding tissues. This study investigates the impact of abdominal aortic calcification (AAC) on bone mineral density (BMD) in patients with chronic kidney disease (CKD). In 88 patients with CKD stage G5D, lumbar spine BMD was measured in both anterior-posterior (AP) and lateral DXA projections. AAC was determined from lateral lumbar radiographs. Median age was 51 ± 14 years, and 61 % were men. AAC was present in 59 %. There was no difference in lumbar spine BMD between patients with and without AAC (AP: 0.823 vs. 0.806 g/cm 2 , p = 0.66). The ΔBMD between AP and lateral projections was similar in patients with and without AAC (13.4 ± 6.7 % vs. 11.5 ± 6.3 %; difference 1.9 %, 95 % CI −0.9 to 4.7 %, p = 0.18). When comparing single vertebrae at levels with high vs. low degree of AAC within the same individual, there was no difference in BMD (AP: 0.827 ± 0.202 vs. 0.818 ± 0.291 g/cm 2 , p = 0.78), nor in the ΔBMD between AP and lateral projections (12.9 ± 8.1 % vs. 14.3 ± 8.3 %, p = 0.12). We could not detect an impact of AAC on lumbar spine BMD. These findings challenge the dogma that lumbar spine BMD by DXA is unreliable due to widespread AAC in patients with CKD. • Low BMD is a risk factor for fractures in chronic kidney disease. • Lumbar spine BMD bias by aortic calcification is often cited as a concern. • Anterior-posterior and lateral lumbar spine BMD were compared in this study. • No impact of aortic calcification on lumbar spine BMD was detected. • Any effect of aortic calcification on BMD is likely of limited clinical relevance.

Utility of Flexion-Extension Radiographs with Brackets and Magnetic Resonance Facet Fluid for the Assessment of Lumbar Instability in Degenerative Lumbar Spondylolisthesis

To propose a new standardized technique for evaluating lumbar stability in degenerative lumbar spondylolisthesis using lumbar lateral flexion-extension radiographs with brackets and magnetic resonance facet fluid. A retrospective analysis of 57 patients diagnosed with lumbar (L4-5) spondylolisthesis was performed. We analyzed lateral flexion-extension radiographs obtained with a bracket (LFEB) and without a bracket (LFE). Sagittal translation, segmental angulation, posterior opening, lumbar instability, and changes in lumbar lordosis were compared using functional radiographs. The mean width and maximum width of the facet fluid, mean facet joint length, and facet fluid index (FFI) of the 2 groups were compared using sagittal translation. The average value of sagittal translation was 1.68 ± 0.96mm in LFE and 3.07 ± 1.29mm in LFEB, and the difference was significant (P < 0.05). Segmental angulation, posterior opening, and changes in lumbar lordosis were significantly greater in LFEB than in LFE. The instability detection rate was 14.0% in LFE and 35.1% in LFEB. The FFI, maximum width, and mean width were significantly increased in the unstable lumbar spondylolisthesis group compared with the stable group in LFEB. The FFI and maximum width of the facet fluid were significantly increased in the unstable lumbar spondylolisthesis group compared with the stable group in LFE. Lumbar lateral flexion-extension radiographs with brackets can standardize the operation process and provide sufficient hyperflexion and hyperextension images. The width of the facet fluid and FFI are significant factors in the evaluation of lumbar stability in patients with lumbar spondylolisthesis.

Serum osteocalcin concentration as an independent biomarker of osteoporosis in patients with chronic kidney disease.

Osteocalcin, an osteoblast-derived hormone, is associated with the development of osteoporosis and arteriosclerosis in the general population. However, its role on the pathogenesis of osteoporosis and vascular calcification in patients with chronic kidney disease (CKD) is unclear. Here, we investigated the connection between osteocalcin, bone mineral density (BMD), and abdominal aortic calcification (AAC) in CKD patients. In total, 95 patients with stage 2 to stage 5 CKD were enrolled. Serum osteocalcin levels were measured using an electrochemiluminescence immunoassay. BMD was determined by dual-energy X-ray absorptiometry, and AAC scores were generated from lateral lumbar radiograph findings. 95 patients were assigned into normal bone density (30.5%, n = 29), osteopenia (45.3%, n = 43), and osteoporosis (24.2%, n = 23) groups. The osteoporosis group was characterized by older age, higher female-to-male ratio, phosphorous levels, calcification scores, osteocalcin levels, and intact parathyroid hormone (PTH) levels, while with lower hemoglobin levels as compared to normal and osteopenia groups. Multivariate multinominal regression analysis showed age, female sex, intact PTH, and serum osteocalcin level were independent determinants of osteoporosis severity in CKD patients. Furthermore, serum osteocalcin level is positively correlated to intact PTH in multivariate linear regression model, indicating that osteocalcin might be a bone turnover marker in patients with CKD. Multivariate stepwise linear regression analysis revealed that age, diabetes mellitus, poorer renal function, rather than osteocalcin, have independent associations with AAC score. Elevated serum osteocalcin levels could be considered as a marker of osteoporosis rather than that of vascular calcification in patients with CKD.

Association of Serum Osteoprotegerin Level With Myocardial Injury and Cardiovascular Calcification in Chronic Kidney Disease Patients.

BackgroundChronic kidney disease has emerged as a significant independent risk factor for cardiovascular disease. Cardiovascular calcification is an active process involving a complex interaction of inducers and inhibitors. High sensitivity cardiac troponin T assay detects troponin T with higher sensitivity and precision at an earlier point of time than the conventional assays, and is associated with poor outcomes. Serum osteoprotegerin is classed as an inhibitory factor for cardiovascular calcification. It is involved in the pathological processes of vascular damage and linked to the excess cardiovascular morbidity. The aim of the present study was to evaluate the extent of cardiovascular calcification and serum high sensitivity cardiac troponin T level, and their association with serum osteoprotegerin level in patients with chronic kidney disease stages 3–5.Methods90 chronic kidney disease patients were enrolled in this study, and they were divided into two groups: group (1) included 45 non-dialysis-dependent chronic kidney disease patients (stages 3–5) and group (2) included 45 chronic hemodialysis patients. Each group further subdivided according to the presence of cardiovascular calcification into subgroup A and B. Vascular calcifications were assessed by lateral lumbar, pelvis and hands X-ray radiographs. Valvular calcification was assessed by echocardiography. Serum cardiac troponin T was measured by high sensitivity assay and serum osteoprotegerin was measured by ELISA.ResultsCardiovascular calcification distribution was 22.2% in group (1) and 33.3% in group (2). Serum osteoprotegerin and troponin T in calcification groups (1A and 2A) were significantly higher than non-calcification groups (1B and 2B; P < 0.001). Osteoprotegerin correlated positively with high sensitivity cardiac troponin T (rs = 0.72, P < 0.001). cardiovascular calcification correlated positively with osteoprotegerin, troponin T, and phosphorus. osteoprotegerin and phosphorus were significant independent predictors of cardiovascular calcification at cut-off values ≥4.6 ng/L and ≥6.95 mg/dl, respectively (P < 0.001). Serum phosphorus and creatinine were independent predictors of osteoprotegerin (P < 0.001 and 0.048, respectively).ConclusionOsteoprotegerin is strongly associated with cardiovascular calcification and high sensitivity cardiac troponin T. In addition, there is a positive association between calcification and troponin T. This suggests a role for osteoprotegerin in the pathogenesis and risk stratification of cardiovascular calcification and myocardial injury in chronic kidney disease patients with a potential role as a therapeutic target.

Association between bone mineral metabolism and vascular calcification in end-stage renal disease

BackgroundDevelopment of vascular calcification is accelerated in patients with end-stage renal disease. In addition to traditional risk factors of cardiovascular disease (CVD) abnormal bone and mineral metabolism together with many other factors contribute to the excess cardiovascular burden in patients on dialysis. Aortic calcification score and coronary calcification score are predictive of CVD and mortality. The aim of this study was to evaluate the possible relationship between arterial calcification and bone metabolism.MethodsThirty two patients on dialysis were included. All patients underwent a bone biopsy to assess bone histomorphometry and a 18F-NaF PET scan. Fluoride activity was measured in the lumbar spine (L1 – L4) and at the anterior iliac crest. Arterial calcification scores were assessed by computerized tomography for quantification of coronary artery calcification score and lateral lumbar radiography for aortic calcification score.ResultsThis study group showed high prevalence of arterial calcification and 59% had verified CVD. Both CAC and AAC were significantly higher in patients with verified CVD. Only 22% had low turnover bone disease. There was a weak association between fluoride activity, which reflects bone turnover, measured in the lumbar spine, and CAC and between PTH and CAC. There was also a weak association between erosion surfaces and AAC. No significant association was found between calcification score and any other parameter measured.ConclusionsThe results in this study highlight the complexity, when evaluating the link between bone remodeling and vascular calcification in patients with multiple comorbidities and extensive atherosclerosis. Several studies suggest an impact of bone turnover on development of arterial calcification and there is some evidence of reduced progression of vascular calcification with improvement in bone status. The present study indicates an association between vascular calcification and bone turnover, even though many parameters of bone turnover failed to show significance. In the presence of multiple other factors contributing to the development of calcification, the impact of bone remodeling might be diminished.Trial registrationThe study is registered in ClinicalTrials.gov protocol registration and result system, ID is NCT02967042. Date of registration is 17/11/2016.

A pilot study on deep learning-based grading of corners of vertebral bodies for assessment of radiographic progression in patients with ankylosing spondylitis.

Background:Radiographs are widely used to evaluate radiographic progression with modified stoke ankylosing spondylitis spinal score (mSASSS).Objective:This pilot study aimed to develop a deep learning model for grading the corners of the cervical and lumbar vertebral bodies for computer-aided detection of mSASSS in patients with ankylosing spondylitis (AS).Methods:Digital radiographic examination of the spine was performed using Discovery XR656 (GE Healthcare) and Digital Diagnost (Philips). The disk points were detected between the bodies using a key-point detection deep learning model from the image obtained in DICOM (digital imaging and communications in medicine) format from the cervical and lumbar spinal radiographs. After cropping the vertebral regions around the disk point, the lower and upper corners of the vertebral bodies were classified as grade 3 (total bony bridges) or grades 0, 1, or 2 (non-bridges). We trained a convolutional neural network model to predict the grades in the lower and upper corners of the vertebral bodies. The performance of the model was evaluated in a validation set, which was separate from the training set.Results:Among 1280 patients with AS for whom mSASSS data were available, 5,083 cervical and 5245 lumbar lateral radiographs were reviewed. The total number of corners where mSASSS was measured in the cervical and lumbar vertebrae, including the upper and lower corners, was 119,414. Among them, the number of corners in the training and validation sets was 110,088 and 9326, respectively. The mean accuracy, sensitivity, and specificity for mSASSS scoring in one corner of the vertebral body were 0.91604, 0.80288, and 0.94244, respectively.Conclusion:A high-performance deep learning model for grading the corners of the vertebral bodies was developed for the first time. This model must be improved and further validated to develop a computer-aided tool for assessing mSASSS in the future.

Artificial intelligence X-ray measurement technology of anatomical parameters related to lumbosacral stability

PurposeTo develop a deep learning-based model for measuring automatic lumbosacral anatomical parameters from lateral lumbar radiographs and compare its performance to that of attending-level radiologists. MethodsA total of 1791 lateral lumbar radiographs were collected through the PACS system and used to develop the deep learning-based model. Landmarks for the four used parameters, including the lumbosacral lordosis angle (LSLA), lumbosacral angle (LSA), sacral horizontal angle (SHA), and sacral inclination angle (SIA), were identified and automatically labeled by the model. At the same time, the measurement results were obtained through landmarks on the test set compared to manual measurements as the reference standard. Statistical analyses of the Percentage of Correct Key Points (PCK), intra-class correlation coefficient (ICC), Pearson correlation coefficient, mean absolute error (MAE), root mean square error (RMSE), and Bland-Altman plots were performed to evaluate the performance of the model. ResultsThe mean differences between the reference standard and the model for LSLA, LSA, SHA, and SIA, were 0.39°, 0.09°, 0.13°, and 0.12°, respectively. A strong correlation and consistency between the four parameters were found between the model and reference standard (ICC = 0.92–0.98, r = 0.92–0.97, MAE = 1.35–1.84, RMSE = 1.82–2.51), while with statistically significant difference for LSLA (p = 0.02). ConclusionsThe presented model revealed clinically equivalent measurements in terms of accuracy, while superior measurements were obtained in terms of cost-effectiveness, reliability, and reproducibility. The model may help clinicians improve their understanding and evaluation of lumbar diseases and LBP from a quantitative perspective in practical work. (ChiCTR2100048250).

P011 Radiological pattern in juvenile onset Spondylarthritis differ from the adult onset spondylarthritis

Abstract Background Spondylarthritis (SpA) is a chronic inflammatory disease of the axial spine that may be affect the peripheral joints. SpA occurs predominantly in adulthood: Adult onset Ankylosing Spondylitis (AoAS). However, it can occur earlier in childhood (≤16 years old), also termed as juvenile onset Ankylosing Spondylitis (JoAS). In the second group, delay in diagnosis may lead to further structural damage. The aim of our study was to compare the differences in radiographic features between JoAS and AoAS. Methods We conducted a retrospective study in our department of rheumatology of Kassab Institute of orthopedics, including patients diagnosed with SpA according to the ASAS criteria (≥17 years at symptom onset) or to the ILAR criteria (≤16 years at symptom onset). Were not included AS patients whose disease onset was ≥ 45 years. Sociodemographic as well as disease characteristics were recorded. The lateral cervical and lumbar spine radiographs were used to assess structural damage by the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) and The Bath Ankylosing Radiologic Index (BASRI). The total score of mSASSS and BASRI vary between 0–72 and 0–16 respectively with higher scores indicating evolved structural damage. Radiographic features were then compared between AoAS and JoAS. The level of significance was fixed for a P &amp;lt; 0.05. Results Of 140 AS patients, 40 had JoAS and 100 had AoAS. The average age at disease onset was 12.4 ± 3 [8–16] and 25.4 ± 10.1 [17–42] respectively (P &amp;lt; 0.001). The disease duration was 10.6 years [1–44]. The average current age was 25.3 ± 10.2 [9–59] and 32.5 ± 7.5 [18–46] (P &amp;lt; 0.001). The JoAS group showed a more frequent onset with peripheral joint involvement than the AoAS group (80% vs 50%,P = 0.001). Similarly, hip involvement was more frequent among JoAS patients (57.7% vs 25%, P = 0.000). There was no significant differences between the two groups regarding the mean mSASSS score, the total BASRI score and the BASRI score for the sacroiliac joints (P = 0.9, P = 0.49, P = 0.06 respectively). Similarly, there was no differences in the mean spine BASRI score between the two groups, although there was a trend of higher scores among AoAS patients (3.2 vs 3.9, P = 0.15 respectively). On the contrary, JoAS patients had a significantly higher BASRI score for the hip than AoAS patients (2.4 vs 1.3, P = 0.000). Conclusion Our study showed that JoAS patients are more likely to suffer from early hip damage than AoAS patients. The spine BASRI was similar between the two groups despite the shorter disease duration in the juvenile group. This highlights the need for screening for hip involvement and for a closer monitoring in this subset of children.