Lumbar Radiographs Research Articles

Progression of Aortic Calcification in Stage 4–5 Chronic Kidney Disease Patients Transitioning to Dialysis and Transplantation

Background and Aims: Abdominal aortic calcification (AAC) is common in chronic kidney disease (CKD) patients and associated with increased mortality. Comparative data on the AAC score progression in CKD patients transitioning from conservative treatment to different modalities of renal replacement therapy (RRT) are lacking and were examined. Methods: 150 study patients underwent lateral lumbar radiograph to study AAC in the beginning of the study before commencing RRT (AAC1) and at 3 years of follow-up (AAC2). We examined the associations between repeated laboratory tests taken every 3 months, echocardiographic and clinical variables and AAC increment per year (ΔAAC), and the association between ΔAAC and outcomes during follow-up. Results: At the time of AAC2 measurement, 39 patients were on hemodialysis, 39 on peritoneal dialysis, 39 had a transplant, and 33 were on conservative treatment. Median AAC1 was 4.8 (0.5–9.0) and median AAC2 8.0 (1.5–12.0) (p < 0.0001). ΔAAC was similar across the treatment groups (p = 0.19). ΔAAC was independently associated with mean left ventricular mass index (LVMI) (log LVMI: β = 0.97, p = 0.02) and mean phosphorus through follow-up (log phosphorus: β = 1.19, p = 0.02) in the multivariable model. Time to transplantation was associated with ΔAAC in transplant recipients (per month on the waiting list: β = 0.04, p = 0.001). ΔAAC was associated with mortality (HR 1.427, 95% confidence interval 1.044–1.950, p = 0.03). Conclusion: AAC progresses rapidly in patients with CKD, and ΔAAC is similar across the CKD treatment groups including transplant recipients. The increment rate is associated with mortality and in transplant recipients with the time on the transplant waiting list.

Single and Multilevel Lumbar Total Disc Replacement Adjacent to L5-S1 ALIF (Lumbar Hybrid): 6 Years of Follow-up

Single and multilevel lumbar arthroplasty has had excellent results, but the L5-S1 level frequently has pathology that precludes arthroplasty. This study evaluated clinical outcomes and sagittal range of motion (ROM) of operated levels and adjacent motion segments in single- and multiple-level ProDisc-L above a simultaneous L5-S1 fusion (hybrid) after a 2- to 6-year follow-up. In this prospective cohort study, 46 patients underwent simultaneous lumbar total disc replacement (TDR) at one to three levels and anterior lumbar interbody fusion (ALIF) at L5-S1. Twenty-three patients had L5-S1 ALIF + L4-5 TDR, 19 patients had L5-S1 ALIF + two-level TDR, and 4 patients had L5-S1 ALIF + three-level TDR. Oswestry disability index (ODI) and visual analog scores (VAS) of patient satisfaction (VAS-S) and pain (VAS-P) were recorded. Sagittal motion on pre- and postoperative lumbar radiographs at each operative segment and adjacent segment was acquired. Patients were evaluated preoperatively and at 6 weeks, 3 months, 6 months, and annually for 24 to 72 months postoperatively. For clinical results, there were no differences among the groups for age, gender, body mass index, tobacco use, or worker's compensation status. At 2-6 years postoperation, all patients had significant reductions in ODI and VAS scores. For radiographic results, at the nonsurgical level adjacent to the TDR + ALIF constructs, the mean preoperative ROM was 9.40 ± 1.80° compared with 10.50 ± 2.25° postoperatively. The mean preoperative ROM at levels undergoing TDR was 10.4 ± 2.71° versus 12.6 ± 2.25° postoperatively. There was no statistically significant difference in ROM at each prosthetic motion segment between patients receiving one-, two-, or three-level TDR. The mean preoperative ROM at the L5-S1 segment to undergo fusion was 2.4 ± 2.44°, with all patients having a postoperative ROM of 0.00°. Multilevel TDR above an L5-S1 ALIF (hybrid procedure) preserves ROM at the individual TDR levels and does not reduce the fusion rate of the L5-S1 fused level. Most significantly, the nonoperative adjacent level maintains its preoperative ROM at 2-6 years postoperatively.

146. A novel vertebral numbering system for identifying congenital anomalies of the spine using full spine radiographs with the EOS imaging system

<h3>BACKGROUND CONTEXT</h3> The numbering of vertebral transitional anatomy can be challenging and controversial. Disagreement exists on how to best report anomalous vertebra and which imaging modality (CT, MRI, X-ray, etc) is most consistent. For these reasons, there is often a discrepancy in the numbering of transitional levels between radiologists and surgeons. Moreover, correlating levels identified intraoperatively by fluoroscopy with inconsistently numbered vertebrae on preoperative MRI or CT is arduous. Errors in numbering can have devastating implications for patients. A simple and accurate vertebral numbering system that can be applied to routine imaging is needed. <h3>PURPOSE</h3> The purpose of this study was to describe a novel and more simplified vertebral numbering system that can be used amongst surgeons and radiologists. <h3>STUDY DESIGN/SETTING</h3> A retrospective imaging study analyzing full-length spine X-rays was performed with the approval of a Colorado Multiple Institutional Review Board (COMIRB protocol:17-1920). <h3>PATIENT SAMPLE</h3> A total of 5,422 images were obtained that included all adult patients who presented to the Spine Center at the University of Colorado and obtained full-spine X-rays using the EOS imaging system between January 31st of 2018 and March 31st of 2020. Images from the same patient at multiple time points were excluded and 3,250 unique patient images were included in our study. After the initial period of data collection, 103 images were excluded from the final analysis due to poor image quality or missing image files. <h3>OUTCOME MEASURES</h3> Total presacral mobile segments were identified and counted using 24 as the number found in conventional spinal anatomy. The total number of ribs were counted for each patient including hypoplastic ribs, and the level of the first-ribbed vertebrae and last-ribbed vertebrae were recorded. <h3>METHODS</h3> Image analysis was conducted by five experienced researchers. The results were reviewed and verified by the senior authors. Any disagreements were reviewed and resolved by two board-certified musculoskeletal radiologists. Final results were evaluated and a novel vertebral numbering system with the lowest probability of error was agreed upon. <h3>RESULTS</h3> In our study cohort, 91.1% (2,868/3,147) demonstrated the conventional 24 presacral mobile segments, whereas 3.3% (104) had 23 presacral mobile segments, 5.5% (174) had 25, and 0.03% (1) had 26. Transitional anatomy, as defined by a number of presacral segments other than 24, was noted in 8.8% (279) of the total number of patients. Within this same group, the majority (94.6%; 2,976) had 12 ribs (including hypoplastic ribs), 4.5% (143) had 11 ribs, and 0.88% (28) had 13 ribs. Just 3.5% (112) had incomplete or hypoplastic ribs. Furthermore, 1.8% (56) of patients had both transitional anatomy and an abnormal number of ribs, with the pattern of transitional anatomy and 11 ribs being the most common combination identified. Considering the first nonribbed vertebrae as the first lumbar vertebrae yielded the lowest probability of a numbering error. <h3>CONCLUSIONS</h3> We are proposing a novel vertebral numbering system that yields the lowest probability of error in reporting anomalous anatomy which can be applied to routine cervical, thoracic, and lumbar radiographs. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P45. The predictive value of a novel site-specific MRI-based bone quality assessment, endplate bone quality (EBQ), for Severe Cage Subsidence among patients undergoing standalone lateral lumbar interbody fusion

<h3>BACKGROUND CONTEXT</h3> Methods to measure bone quality using opportunistic imaging have recently been developed, including quantitative computed tomography (QCT), which allows for site-specific volumetric bone mineral density (vBMD) measurement, such as pedicles or endplates. Studies have shown these site-specific QCT measurements had more predictive value for site-specific complications than standard L1/2 measurements. Recently, MRI-based assessments of the vertebral bone quality (VBQ), which measures trabecular bone quality, were also introduced. However, there have been few studies that investigate the association between site-specific MRI bone assessment and osteoporosis related complications in patients undergoing lumbar interbody fusion. In this work, we created a novel site-specific MRI-based assessment of the endplate bone quality (EBQ) and assessed its predictive value for severe cage subsidence following standalone lateral lumbar interbody (SA-LLIFF) fusion. <h3>PURPOSE</h3> The purpose is to introduce a novel MRI-based site-specific bone quality assessment, EBQ, and investigate the predictive value of EBQ for severe cage subsidence after SA-LLIF compared with standard VBQ. <h3>STUDY DESIGN/SETTING</h3> A retrospective observational study at a single academic institution. <h3>PATIENT SAMPLE</h3> Patients undergoing SA-LLIF between 2008-2019 with available preoperative CT and T1-weighted MRIs of the lumbar spine as well as postoperative lumbar radiographs or CTs. <h3>OUTCOME MEASURES</h3> Severe cage subsidence (Grade 2 or 3) within 5-14 month after SA-LLIF. <h3>METHODS</h3> We retrospectively reviewed the records of SA-LLIF patients. Cage subsidence was assessed using the classification of Marchi et al. and severe cage subsidence was defined as grade 2 or 3. We measured VBQ as shown in the original article by Ehresman et al. EBQ was measured using preoperative non-contrast T1-weighted MRIs of the lumbar spine. The regions of interest were the subchondral bones of upper and lower endplates at the operated level, and the average signal intensity of both endplates was divided by that of the cerebrospinal fluid space at the level of L3. As a confounding factor, vBMD was measured using asynchronous QCT. Bivariate and multivariable analysis with generalized linear mixed models were performed with setting binary severe subsidence as the outcome. Statistical significance was set at p=0.05. The quality of fit was assessed using Akaike's information criterion. <h3>RESULTS</h3> A total of 205 levels in 89 patients were included in the final analysis. There were 50 levels (24.4%) which demonstrated severe subsidence. QCT-vBMD was significantly lower in severe subsidence group (Mean (SD) 97.4 (34.4) vs 110.1(33.4), p=0.021). Both VBQ and EBQ were significantly higher in severe subsidence group (VBQ: Mean (SD) 2.67 (1.08) vs 2.39 (0.44), p=0.010; EBQ Mean (SD) 5.09 (2.20) vs 4.31 (1.09), p=0.001). In multivariate analyses adjusted with QCT-vBMD, EBQ showed significant association with severe cage subsidence (OR (95% confidential interval) = 1.94 (1.36-3.63), p=0.038), whereas VBQ only showed a marginal trend (p=0.071). The EBQ based prediction model for severe subsidence showed better goodness of fit compared to VBQ based model. (AIC EBQ 190 vs VBQ 192). <h3>CONCLUSIONS</h3> We introduced a novel MRI-based site-specific bone quality assessment. High EBQ was an independent factor for severe cage subsidence after SA-LLIF and the EBQ-based model showed better goodness of fit compared to VBQ-based model. Given the availability of preoperative MRIs, EBQ assessment prior to SA-LIFF may provide insight into a patient's risk for severe subsidence. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

74. Novel artificial intelligence algorithm can accurately and independently measure spinopelvic parameters

<h3>BACKGROUND CONTEXT</h3> Preoperative and postoperative sagittal plane assessment is crucial in both spinal deformity and degenerative pathologies. Sagittal malalignment is a well-established cause of poor patient reported outcomes. There is a growing need for an automated analysis tool that measures pelvic parameters with speed, precision and reproducibility without relying on user identified landmarks. A new AI algorithm has been developed to measure important radiographic parameters independently. <h3>PURPOSE</h3> The analysis of sagittal alignment by measuring spinopelvic parameters has been widely adopted among spine surgeons globally. The currently available spine measurement software programs require users to identify several landmarks prior to calculating parameters, making them time consuming and more reliant upon user experience. This study evaluates and demonstrates that an algorithm based on artificial intelligence (AI) can independently determine spinopelvic parameters. This allows for precise radiographic measurement without time-intensive human input. We hypothesize that the novel, fully automatic method will have a high agreement with human measurements for lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS). <h3>STUDY DESIGN/SETTING</h3> Evaluation of the inter-rater reliability and mean error between radiographic measurements of the AI algorithm and expert human raters. Radiographs were retrospectively reviewed from a single site, multisurgeon center. <h3>PATIENT SAMPLE</h3> In this study, preoperative and postoperative X-rays were evaluated in 100 patients undergoing a lumbar fusion procedure. <h3>METHODS</h3> From a total of 200 lateral lumbar radiographs (preoperative and postoperative images from 100 patients undergoing fusion) 5 independent observers (4 spinal surgeons, 1 senior researcher) digitally measured LL, PI, PT and SS. Their parameters were compared with AI algorithm generated parameters. Mean error (95% confidence interval, standard deviation) and inter-rater reliability were assessed using 2-way mixed, single-measure intraclass correlation (ICC). ICC values larger than 0.75 were considered excellent. <h3>RESULTS</h3> The novel algorithm's spinopelvic parameter ICC values were excellent in 98% of preoperative and in 95% of postoperative radiographs (PreOp range: 0.85–0.92, PostOp range: 0.81–0.87). Exemplarily, mean errors are smallest for the PI (PreOp: -0.5° [95%-CI: -1.5°–0.6°]; PostOp: 0.0° [-1.1°–1.2°]) and largest for LL (1.3° [0.3°–2.4°]; 3.8° [2.5°–5.0°]). <h3>CONCLUSIONS</h3> Novel AI algorithm automated spinopelvic parameter measurements from spine radiographs have a high degree of accuracy comparable to digital measurements by experts. This algorithm can improve physician workflow efficiency and reduce inter-rater and intra-rater measurement errors <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Factors affecting disc angle restoration in oblique lateral interbody fusion at L5–S1

BACKGROUND CONTEXTOptimal restoration of the L5–S1 disc angle (DA) is an important surgical goal in spinal reconstructive surgery. Anterior approach is beneficial for L5–S1 DA reconstruction and fusion. However, factors associated with a greater DA restoration in oblique lateral interbody fusion (OLIF) at L5–S1 have not been studied. PURPOSEThis study aimed to identify factors that aid in achieving a greater DA in OLIF at L5–S1. STUDY DESIGN/SETTINGA retrospective analysis. PATIENT SAMPLEThis study involved 61 consecutive patients who underwent OLIF at L5–S1 for lumbar degenerative disease and were followed for more than 1 year. Patients with incomplete data or posterior column osteotomy at L5–S1 were excluded. OUTCOME MEASURESThe L5–S1 DA was measured preoperatively, postoperatively, and at the last follow-up on standing lateral lumbar radiographs. The associations between demographics and/or surgical and/or radiological factors and the L5–S1 DA at the last follow-up were analyzed using multiple regression analysis. METHODSDemographics and surgical factors were reviewed from the medical records with respect to age, sex, body mass index, bone mineral density, diagnosis, surgery level, cage parameters (cage lordotic angle and height), laminectomy performed and/or not performed, estimated blood loss, operative time, configuration of the left common iliac vein. Radiological factors were measured with respect to sagittal parameters, the L5–S1 disc parameters, and the postoperative cage parameters. RESULTSThe mean preoperative DA at L5–S1 was 5.4±5.0°, which increased to 18.9±5.6° postoperatively (p<.001) and was maintained as 16.5±5.9° at the last follow-up (p<.001). The preoperative DA, end plate lesions, anterior spur, facet joint osteoarthritis, or cage position at L5–S1 did not affect the DA at the last follow-up (all p>.05). Multiple regression analysis showed four independent variables, including increased age, increased cage lordotic angle, laminectomy performed, and absence of cage subsidence as the factors associated with the greater DA at L5–S1. CONCLUSIONSOLIF at L5–S1 showed favorable DA restoration regardless of the preoperative conditions. To achieve a greater DA, surgeons should try to distract the anterior disc space for insertion of a larger lordotic cage. Laminectomy during posterior fixation is recommended for achieving additional DA restoration.

Minimally invasive transforaminal lumbar interbody fusion using the biportal endoscopic techniques versus microscopic tubular technique

BACKGROUND CONTEXTMinimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with microscopic tubular technique is an established surgical procedure with several potential advantages, including decreased surgical-related morbidity, reduced length of hospital stay, and accelerated early rehabilitation. A recently introduced biportal endoscopic technique for spine surgery presents familiar surgical anatomy and can be conducted using a conventional approach with a minimal footprint; it is also applicable to TLIF. PURPOSETo compare the clinical and radiological outcomes of biportal endoscopic technique transforaminal lumbar interbody fusion (BE-TLIF) and microscopic tubular technique transforaminal lumbar interbody (MT-TLIF) in patients with single- or two-segment lumbar spinal stenosis with or without spondylolisthesis. STUDY DESIGNA retrospective cohort study. PATIENT SAMPLEOne hundred two participants with neurogenic intermittent claudication or lumbar radiculopathy with single- or two-level lumbar spinal stenosis with or without spondylolisthesis. OUTCOME MEASURESClinical outcomes were assessed using the visual analog scale (VAS) score for the back and leg pain, Oswestry Disability Index (ODI), and the Short Form-36 health survey Questionnaire (SF-36). Demographic data, operative data (total operation time, estimated blood loss, amount of surgical drain, postoperative transfusion, and length of hospital stay), and laboratory results (plasma hemoglobin, serum creatine phosphokinase, and C-reactive protein) were also evaluated. The fusion rate was assessed using the Bridwell interbody fusion grading system. Postoperative complications were also noted. METHODSPatients were divided into two groups: group A (BE-TLIF) and group B (MT-TLIF). The clinical outcomes, including VAS-Back and VAS-Leg, ODI, and SF-36 scores, were evaluated at 1 month, 6 months, and 1 year after surgery. Differences in demographics, operative data, and the laboratory and radiological results were assessed between the two groups. The fusion rate was assessed using standard standing lumbar radiographs and computed tomography scans conducted 1 year after surgery. RESULTSSeventy-nine patients were analyzed in this study, 47 from group A and 32 from group B. Demographic and operative data were comparable for both the groups. The VAS-Back and SF-36 scores were more significantly improved in group A than in group B at 1 month after surgery. However, there were no significant differences between groups for the mean VAS-Back, VAS-Leg, ODI, and SF-36 scores at 1year after the surgery. Although the total operation time was significantly longer in group A, the estimated blood loss and the amount of surgical drainage was significantly higher in group B (p < .001). There were no between-group differences for the fusion rate and postoperative complications. CONCLUSIONBoth BE-TLIF and MT-TLIF provided equivalent and favorable clinical outcomes and fusion rates. Further large-scale, randomized, controlled trials with long-term follow-ups are warranted.

How does a non-optimal tube potential influence radiation dose to the patient in lumbar spine radiography?

IntroductionWhen comparing the radiation dose to the patient, the lumbar spine has one of the highest dose values in general radiography, therefore the procedure needs to be optimised. The aim of this study was to investigate the effect of a non-optimal tube potential (66 kV) during anteroposterior (AP) lumbar spine radiography on the radiation dose received by the patient compared with the radiation dose when an optimal tube potential (79 kV) is used, in accordance with European guidelines. MethodsThis retrospective study involved 100 patients referred for lumbar radiography in two different diagnostic departments. Half of the patients were admitted to a department which used optimal tube potential and the other half to the department which used non-optimal tube potential for AP lumbar spine radiography protocols. The height and weight of the patients were collected to calculate the body mass index (BMI) of the patients. The image field size and dose area product (DAP) values were collected after each imaging session. The effective dose and selected organ dose were calculated using the PCXMC 2.0 program. ResultsThe results showed that a non-optimal tube potential resulted in a significant increase in the DAP value by 360% (p < 0.001) and a significant increase in the effective dose by 160% (p < 0.001). Dose to selected organs due to non-optimal tube potential increased from 107% (breasts) up to 631% (prostate) (p < 0.001). The images were not assessed using visual grading characteristics (VGC) analysis, but the radiologists evaluated all the images appropriate for diagnostic reading. ConclusionBased on our study's stated results, we can conclude that optimal tube potential use is essential to achieve the ALARA principle. Implications for practiceThe study shows the effect of a non-optimal tube potential on the radiation dose received by the patient during radiography of the lumbar spine. This could influence possible diagnostic departments to consider protocol optimisation due to the high radiation dose received by the patient.

POS-504 Kauppila Score for Abdominal Aortic Calcification and Its Correlation with Carotid Intima Media Thickness among Dialyzed Patients

Carotid intima-media thickness (cIMT) was a predictor for cardiocerebrovascular mortality among dialyzed patients. Kauppila Score was a system for quantification of abdominal aortic calcification (AAC) on lateral lumbar radiograph and was also highly associated with cardiovascular risk. Latest guideline suggested lateral abdominal radiograph to detect the presence or absence of vascular calcification in patients with chronic kidney disease-mineral bone disorders which prevalent among dialyzed patients.

Opportunistic use of dual-energy X-ray absorptiometry to evaluate lumbar scoliosis.

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. 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. 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. 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.

Lumbar Spine Sagittal Mismatch Deformity Negatively Affects Total Knee Arthroplasty Outcomes.

There is currently a paucity of data regarding the potential relationships between preexisting spinal deformity and clinical outcomes following total knee arthroplasty (TKA). We sought to expand upon this deficit. We hypothesize that lumbar sagittal mismatch deformity (MD) will correlate with a decrease in functional outcomes after TKA. This retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure sagittal parameters of interest: pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, and deformity mismatch. Ninety-four TKAs were subsequently available for inclusion and divided into two groups: those with MD as defined by |PI-LL| > 10 degrees and those without MD. The following clinical outcomes were compared between the groups: total postoperative arc of motion (AOM), incidence of flexion contracture, and need for manipulation under anesthesia (MUA). In total, 53 TKAs met the MD criteria, while 41 did not have MD. There were no significant differences in demographics, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with MD were more likely to have MUA (p = 0.026), ROM <0 to 120 (p < 0.001), a decreased AOM by 16 degrees (p < 0.001), and a flexion contracture postoperatively (p = 0.01). Preexisting MD may adversely affect clinical results following TKA. Statistically and clinically significant decreases in postoperative ROM/AOM, increased likelihood of flexion contracture, and increased need for MUA were all noted in those with MD. This is a Level 3 study.

Comparison of the Effectiveness of Three Lumbosacral Orthoses on Early Spine Surgery Patients: A Prospective Cohort Study.

ObjectiveTo compare the convenience and effectiveness of the existing lumbosacral orthoses (LSO) (classic LSO and Cybertech) and a newly developed LSO (V-LSO) by analyzing postoperative data.MethodsThis prospective cohort study was performed from May 2019 to November 2019 and enrolled and analyzed 88 patients with degenerative lumbar spine disease scheduled for elective lumbar surgery. Three types of LSO that were provided according to the time of patient registration were applied for 6 weeks. Patients were randomized into the classic LSO group (n=31), Cybertech group (n=26), and V-LSO group (n=31). All patients were assessed using the Oswestry Disability Index (ODI) preoperatively and underwent plain lumbar radiography (anteroposterior and lateral views) 10 days postoperatively. Lumbar lordosis (LS angle) and frontal imbalance were measured with and without LSO. At the sixth postoperative week, a follow-up assessment with the ODI and orthosis questionnaire was conducted.ResultsNo significant differences were found among the three groups in terms of the LS angle, frontal imbalance, ODI, and orthosis questionnaire results. When the change in the LS angle and frontal imbalance toward the reference value was defined as a positive change with and without LSO, the rate of positive change was significantly different in the V-LSO group (LS angle: 41.94% vs. 61.54% vs. 83.87%; p=0.003).ConclusionThe newly developed LSO showed no difference regarding its effectiveness and compliance when compared with the existing LSO, but it was more effective in correcting lumbar lordosis.

Association of maximal stress ergometry performance with troponin T and abdominal aortic calcification score in advanced chronic kidney disease

BackgroundCardiac biomarkers Troponin T (TnT) and N-terminal pro-B-type natriuretic peptide (proBNP) and abdominal aortic calcification score (AAC) are associated with cardiovascular events and mortality in patients with chronic kidney disease (CKD). The effects of cardiac biomarkers and AAC on maximal exercise capacity in CKD are unknown and were studied.MethodsOne hundred seventy-four CKD 4–5 patients not on maintenance dialysis underwent maximal bicycle ergometry stress testing, lateral lumbar radiograph to study AAC, echocardiography and biochemical assessments.ResultsThe subjects with proportional maximal ergometry workload (WMAX%) less than 50% of the expected values had higher TnT, proBNP, AAC, left ventricular end-diastolic diameter, left ventricular mass index, E/e’ and pulse pressure, and lower global longitudinal strain compared to the better performing patients. TnT (β = − 0.09, p = 0.02), AAC (β = − 1.67, p < 0.0001) and diabetes (β = − 11.7, p < 0.0001) remained significantly associated with WMAX% in the multivariable model. Maximal ergometry workload (in Watts) was similarly associated with TnT and AAC in addition to age, male gender, hemoglobin and diastolic blood pressure in a respective multivariate model.AAC and TnT showed fair predictive power for WMAX% less than 50% of the expected value with AUCs of 0.70 and 0.75, respectively.ConclusionsTnT and AAC are independently associated with maximal ergometry stress test workload in patients with advanced CKD.Trial registrationhttp://www.ClinicalTrials.gov NCT04223726.

ISSLS Prize in Bioengineering Science 2021: in vivo sagittal motion of the lumbar spine in low back pain patients—a radiological big data study

We investigated the flexion-extension range of motion and centre of rotation of lumbar motion segments in a large population of 602 patients (3612 levels), and the associations between lumbar motion and other parameters such as sex, age and intervertebral disc degeneration. Lumbar radiographs in flexion-extension of 602 patients suffering from low back pain and/or suspect instability were collected; magnetic resonance images were retrieved and used to score the degree of disc degeneration for a subgroup of 354 patients. Range of motion and centre of rotation were calculated for all lumbosacral levels with in-house software allowing for high degree of automation. Associations between motion parameters and age, sex, spinal level and disc degeneration were then assessed. The median range of motion was 6.6° (range 0.1-28.9°). Associations between range of motion and age as well as spinal level, but not sex, were found. Disc degeneration determined a consistent reduction in the range of motion. The centre of rotation was most commonly located at the centre of the lower endplate or slightly lower. With progressive degeneration, centres of rotation were increasingly dispersed with no preferential directions. This study constitutes the largest analysis of the in vivo lumbar motion currently available and covers a wide range of clinical scenarios in terms of age and degeneration. Findings confirmed that ageing determines a reduction in the mobility independently of degeneration and that in degenerative levels, centres of rotation are dispersed around the centre of the intervertebral space.

Knowledge of and adherence to radiographic guidelines for low back pain: a survey of chiropractors in Newfoundland and Labrador, Canada

BackgroundLow back pain (LBP) rarely requires routine imaging of the lumbar spine in the primary care setting, as serious spinal pathology is rare. Despite evidence-based clinical practice guidelines recommending delaying imaging in the absence of red flags, chiropractors commonly order imaging outside of these guidelines. The purpose of this study was to survey chiropractors to determine the level of knowledge, adherence to, and beliefs about, clinical practice guidelines related to the use of lumbar radiography for LBP in Newfoundland and Labrador (NL), Canada.MethodsA cross-sectional survey of chiropractors in NL (n = 69) was conducted between May and June 2018, including questions on demographics, awareness of radiographic guidelines, and beliefs about radiographs for LBP. We assessed behavioural simulation using clinical vignettes to determine levels of adherence to LBP guideline recommendations.ResultsThe response rate was 77% (n = 53). Half of the participants stated they were aware of current radiographic guideline recommendations, and one quarter of participants indicated they did not use guidelines to inform clinical decisions. The majority of participants agreed that x-rays of the lumbar spine are useful for patients with suspected pathology, are indicated when a patient is non-responsive to 4 weeks of conservative treatment for LBP, and when there are neurological signs associated with LBP. However, a small proportion indicated that there is a role for full spine x-rays (~ 21%), x-rays to evaluate patients with acute LBP (~ 13%), and that patient expectations play a role in decision making (4%). Adherence rate to radiographic guidelines measured using clinical vignettes was 75%.ConclusionsWhile many chiropractors in this sample reported being unsure of specific radiographic guidelines, the majority of respondents adhered to guideline recommendations measured using clinical vignettes. Nonetheless, a small proportion still hold beliefs about radiographs for LBP that are discordant with current radiographic guidelines. Future research should aim to determine barriers to guideline uptake in this population in order to design and evaluate tailored knowledge translation strategies to reduce unnecessary LBP imaging.

Pathomechanism and prevention of further surgery after posterior decompression for lumbar spinal canal stenosis in patients with diffuse idiopathic skeletal hyperostosis

BACKGROUND CONTEXTDiffuse idiopathic skeletal hyperostosis (DISH) is a risk factor for further surgery after posterior decompression without fusion for patients with lumbar spinal canal stenosis (LSS). However, a strategy to prevent revision surgery has not been described. PURPOSEThe aim of this study was to review clinical and imaging findings in LSS patients with DISH extending to the lumbar segment and to propose countermeasures for prevention of revision surgery. STUDY DESIGNA retrospective study. PATIENTS SAMPLEA total of 613 consecutive patients with LSS underwent posterior decompression without fusion at our hospital and had a minimum follow-up period of 2 years. We defined patients with DISH bridging to the lumbar segment as L-DISH cases (group D, n=111), and those without as non-L-DISH cases (group N, n=502). OUTCOME MEASUREDemographic data including the rate of revision surgery, neurological examination using Japanese Orthopaedic Association score, radiological studies comprised plain lumbar radiography, CT, and high-resolution MRI were assessed. METHODSClinical features and imaging findings were compared in patients with and without L-DISH. Revision surgery and surgical procedures (conventional laminotomy or lumbar spinous process-splitting [split] laminotomy) were examined in the two groups. No funding was received for this study. RESULTSL-DISH from L2 to L4 was a risk factor for disc degeneration such as a vacuum phenomenon and for further surgical treatment. The rate of revision surgery was higher in group D than in group N (9.0% vs. 4.0%, p=.026). There was no significant difference in this rate for patients in groups D and N who underwent conventional laminotomy; however, for those who underwent split laminotomy, the rate was significantly higher in group D (16.7% vs. 2.1%, p=.0006). Furthermore, the rate of revision surgery after split laminotomy at a lower segment adjacent to L-DISH was significantly higher than that after conventional laminotomy (37.5% vs. 7.7%, p=.037). CONCLUSIONSA negative impact of lumbar spinous process-splitting laminotomy was found, especially with decompression at a lower segment adjacent to L-DISH. In such cases, surgery sparing the osteoligamentous structures at midline, including the spinous process and supra- and interspinous ligaments, should be selected.

Accuracy and Reliability of Standing Lateral Lumbar Radiographs for Measurements of Spinopelvic Parameters.

Retrospective observational study. To assess the accuracy and reliability of standing lateral lumbar radiographs for measurements of spinopelvic parameters, compared with whole-spine EOS® images. Lateral lumbar radiographs are commonly used for measurements of spinopelvic parameters. However, variable magnifications by fan-beam x-ray projection at margins may cause measurement errors. Fifty consecutive patients with standing lateral lumbar radiographs and whole-spine EOS® images were retrospectively reviewed from March to July in 2019. Two orthopedic surgeons (observers) independently measured the spinopelvic parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL) on the computers. These spinopelvic parameters of each patient were measured twice on both lateral lumbar radiograph and EOS® image by two observers with the usage of Surgimap software. The measurement difference and agreement of each parameter value between lateral lumbar radiographs and EOS® images were analyzed by paired t test and the interclass correlation coefficient (ICC) respectively. Intra- and inter-observer's reliabilities of both imaging methods were assessed by ICC. The measurement difference of each spinopelvic parameter on EOS® images and lateral lumbar radiographs was less than 1° on average. Only the measurement difference of PI value revealed statistically significant (P = 0.020) with 0.9° discrepancy (95% confidential interval: 0.2-1.6), which indicated no clinical significance. The ICC values of lateral lumbar radiographs and EOS® images were more than 0.870 (range, 0.872-0.976), thus showed good to excellent measurement agreement between both imaging methods. All the ICC values for evaluating intra- and inter-observer reliability were greater than 0.960 (range, 0.963-0.993), indicating excellent reliability for observer's measurements. Measurements of spinopelvic parameters (PI, PT, SS, and LL) on standing lateral lumbar radiographs are accurate and reliable, which are comparable to whole-spine EOS® images.Level of Evidence: 3.

Factors Predictive of Radiographic Progression in Ankylosing Spondylitis.

Using a longitudinal observational cohort of ankylosing spondylitis (AS) patients, we sought to identify progression rates and factors predictive of spinal progression. As a secondary aim, we analyzed the effect of tumor necrosis factor inhibitor (TNFi) treatment on radiographic progression. AS patients who had baseline and follow-up cervical and lumbar radiographs were included in the study. Radiographic damage was assessed by the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). A change of 2 mSASSS units in 2 years was defined as progression. The characteristics of the study group such as demographic, clinical, laboratory, and treatment history were collected. There were 350 patients in the study. The mean ± SD mSASSS increased from 9.3 ± 15.8 units at baseline to 17.7 ± 21.7 units by the sixth year. Mean ± SD changes in mSASSS between the years 0 to 2, 2 to 4, and 4 to 6 were 1.23 ± 2.68, 1.47 ± 2.86, and 1.52 ± 3.7 units, respectively. Overall, 24.3% of the group progressed over 2 years. Male sex (hazard ratio [HR] 2.46 [95% confidence interval (95% CI) 1.05, 5.76]), the presence of baseline damage (HR 7.98 [95% CI 3.98, 16]), increased inflammatory markers (log C-reactive protein level HR 1.35 [95% CI 1.07, 1.70]), and TNFi use (HR 0.82 [95% CI 0.70, 0.96]) were predictive of radiographic progression. There was a 20% reduction in the rate of progression with TNFi. Male sex, the presence of baseline damage, active disease state, and higher inflammatory markers confer a high risk for disease progression. Treatment with TNFi showed a disease-modifying effect by slowing the rate of radiographic progression.

Serum Sortilin Is Associated with Coronary Artery Calcification and Cardiovascular and Cerebrovascular Events in Maintenance Hemodialysis Patients

Objective: To analyze the role of serum sortilin in coronary artery calcification (CAC) and cardiovascular and cerebrovascular events (CCE) in maintenance hemodialysis (MHD) patients. Methods: One hundred eleven patients with MHD ≥3 months were included in this study. The general data, clinical features, hematological data, and medication history of the patients were recorded. Eighty-five cases were examined by vascular color Doppler ultrasound, cardiac color Doppler ultrasound, lateral lumbar radiography, and coronary artery calcification score. The patients were followed up for a median time of 45 months. The primary endpoint was CCE or death from a vascular event, and the role of sortilin in this process was analyzed. Results: Among 85 MHD patients, 51 cases (60.00%) had different degrees of CAC. There were significant differences in diabetes, dialysis time, serum phosphorus, calcium-phosphorus product, medical history of phosphate binders, sortilin, and carotid artery plaque between 4 different degrees of calcification groups (p < 0.05). Logistic regression analysis showed that diabetes (OR = 5.475; 95% CI: 1.794–16.71, p = 0.003), calcium-phosphorus product (OR = 2.953; 95% CI: 1.198–7.279, p = 0.019), and sortilin (OR = 1.475 per 100 pg/mL; 95% CI: 1.170–1.858, p = 0.001) were independent risk factors for CAC. During the follow-up, 28 cases of 111 patients (25.23%) suffered from CCE. There were significant differences in CCE between mild, moderate, and severe CAC groups and noncalcification groups (p < 0.05). Cox regression analysis showed that diabetes mellitus (HR 3.424; 95% CI: 1.348–8.701, p = 0.010), CAC (HR 5.210; 95% CI: 1.093–24.83, p = 0.038), and serum sortilin (HR = 8.588; 95% CI: 1.919–38.43, p = 0.005) were independent risk factors for CCE. Besides, we proposed a cutoff value of 418 pg/mL for serum sortilin level, which was able to predict the occurrence of CCE with 75.0% sensitivity and 71.9% specificity. The area under the curve was 0.778 (95% CI: 0.673–0.883). Conclusion: Sortilin is newly found to be independently associated with CAC and CCE in MHD patients.

Study of Patients with Bilateral Knee Osteoarthritis Undergoing Total Knee Replacement Procedure with Coexisting Lumbar Spondylosis Symptoms.

Study DesignThis is a prospective cohort study involving patients who were followed for 2 years after total knee replacement (TKR) to determine changes in lumbar spine and knee symptoms.PurposeThe objectives of this study were to determine the percentage of patients undergoing bilateral TKR who present with coexisting lumbar spine problems and determine if TKR relieves lumbar spine symptoms.Overview of LiteratureNo studies quantify the percentage of TKR patients who experience relief of lumbar spine symptoms after TKR surgery.MethodsThe study included 200 patients (164 females, 36 males) undergoing primary TKR. Follow-up was performed at 4 weeks, 3, 6, 12, and 24 months. Lumbar spine and knee symptom improvements were assessed using the Oswestry Disability Index (ODI) and Oxford Knee Score, respectively.ResultsAll 200 patients undergoing bilateral TKR presented with radiographic lumbar spine degenerative pathology; 60% (n=120) of the patients presented with moderate to severe clinical symptoms of lumbar spondylosis, including 54% (n=108) with degenerative lumbar spondylosis and lumbar canal stenosis and 6% (n=12) with degenerative spondylolisthesis. Of the 120 patients who presented with lumbar spine problems, 90% (n=108) reported improvement in their symptoms; the ODI score improved from 42.5%±4.1% preoperative score to 15.6%±2.3% postoperative score (p-value<0.001). Of the 12 patients with no improvement, 10 patients underwent percutaneous procedures for their lumbar spine pathology with good results, one patient underwent surgery, and one declined any intervention.ConclusionsA significant number of patients (60%) undergoing bilateral TKR also present with symptomatic lumbar spine problems. Patients with mild to moderate lumbar spine degenerative symptoms and no associated severe radiating pain on activity are more likely to experience relief of their symptoms post-TKR.