Lumbar Radiographs Research Articles

Estimating lumbar bone mineral density from conventional MRI and radiographs with deep learning in spine patients.

This study aimed to develop machine learning methods to estimate bone mineral density and detect osteopenia/osteoporosis from conventional lumbar MRI (T1-weighted and T2-weighted images) and planar radiography in combination with clinical data and imaging parameters of the acquisition protocol. A database of 429 patients subjected to lumbar MRI, radiographs and dual-energy x-ray absorptiometry within 6 months was created from an institutional database. Several machine learning models were trained and tested (373 patients for training, 86 for testing) with the following objectives: (1) direct estimation of the vertebral bone mineral density; (2) classification of T-score lower than - 1 or (3) lower than - 2.5. The models took as inputs either the images or radiomics features derived from them, alone or in combination with metadata (age, sex, body size, vertebral level, parameters of the imaging protocol). The best-performing models achieved mean absolute errors of 0.15-0.16g/cm2 for the direct estimation of bone mineral density, and areas under the receiver operating characteristic curve of 0.82 (MRIs) - 0.80 (radiographs) for the classification of T-scores lower than - 1, and 0.80 (MRIs) - 0.65 (radiographs) for T-scores lower than - 2.5. The models showed good discriminative performances in detecting cases of low bone mineral density, and more limited capabilities for the direct estimation of its value. Being based on routine imaging and readily available data, such models are promising tools to retrospectively analyse existing datasets as well as for the opportunistic investigation of bone disorders.

Can abdominal aortic calcification detected on lateral lumbar radiography predict instrument-related complications in patients undergoing posterior lumbar fusion?

Objective: Abdominal aortic calcification (AAC) is well known as a useful and simple clinical indicator of the risk of fracture and cardiovascular disease. However, no studies have directly compared the postoperative implications of AAC in spinal surgery. The purpose of this study was thus to examine whether extended AAC (scores ≥5) negatively affected clinical outcomes after posterior lumbar fusion with instrumentation for degenerative lumbar stenosis or degenerative spondylolisthesis.Methods: The subjects comprised 101 consecutive patients with spinal stenosis or degenerative spondylolisthesis who underwent posterior lumbar fusion and instrumentation between January 2016 and January 2019 and were followed for over 2 years. Propensity score matching was employed to assemble patient groups with similar baseline characteristics. Postoperative complications and radiologic outcomes were compared between the groups (33 patients in each) divided by extended AAC score.Results: The incidence rates of junctional failure (6.1% vs. 30.3%, P=0.008) and screw-related complications (12.1% vs. 36.4%, P=0.019) were higher in the extended AAC group than in the mild AAC group. However, the rates of adjacent segment disease (24.2% vs. 36.4%, P=0.283) and revision (6.1% vs. 9.1%, P=0.642) were not significantly different between the 2 groups. In terms of postoperative medical complications, cardiovascular and cerebrovascular diseases were significantly more common in the extended AAC group than in the mild AAC group (0% vs. 15.2%, P=0.020).Conclusion: Extended AAC indicates increased risk for postoperative junctional failure and screw-related complications, regardless of age, osteoporosis, and comorbidities.

Endoscopic and microsurgical decompression for central lumbar spinal stenosis

Objective. To perform comparative analysis of the results of endoscopic and microsurgical decompression for lumbar spinal stenosis.Material and Methods. Design: Retrospective monocentric intra-cohort comparison of two groups of patients. The study included 99 patients aged 51–88 years with clinically significant lumbar spinal stenosis manifested by neurogenic intermittent claudication syndrome. Endoscopic decompression was performed in 51 patients, and microsurgical decompression – in 48 patients. To objectify and standardize clinical symptoms, walking distance in meters, pain syndrome and quality of life were assessed before and after surgery using standard scales and questionnaires (VAS, ODI). On the first day after surgery, back and lower limb pain were assessed, and during the observation period back and lower limb pain, quality of life and walking distance were assessed. Functional lumbar radiography was performed to exclude instability of the spinal motion segment. Using MRI, the cross-sectional area of the dural sac at the level of stenosis was measured before and after surgery. Clinical efficacy was assessed using the MCID (Minimal Clinical Important Difference) criterion. The results of the operation were followed-up for 12 months after the operation.Results. Blood loss in the endoscopic intervention group was less than in the microsurgical group. Pain in the lumbar spine and in the lower extremities decreased, and the cross-sectional area of the dural sac increased. In the first days after surgery, patients after endoscopic decompression had less severe back and lower extremity pain than patients after microsurgical decompression due to less soft tissue trauma. Pain syndrome in back 10–12 months after surgery was without statistically significant difference between the groups. Patients after endoscopic decompression had statistically significantly better quality of life according to ODI, lesser pain in the lower extremities according to VAS and longer walking distance than those in the microsurgical decompression group. Surgical treatment in both groups turned out to be effective, which is confirmed by MCID. The time of endoscopic intervention is significantly longer than that of microsurgical intervention. The length of the incision during endoscopic decompression is shorter than that of microsurgical decompression.Conclusion. A comparative analysis of the results of endoscopic and microsurgical decompression for degenerative central lumbar stenosis showed comparable effectiveness of both methods, including an increase in the spinal canal dimension and ensuring regression of clinical symptoms. The results of the comparison do not allow making a sufficiently substantiated judgment on the advantages of one of the methods, which dictates the need for further research.

Association of Abdominal Aortic Calcification and Clinical Outcomes in LDH Patients Treated with Endoscopic Lumbar Discectomy.

To determine any significant associations between abdominal aortic calcification (AAC) and clinical manifestations of pain symptoms following endoscopic lumbar discectomy. Patients sequentially presenting with a history of unilateral radiculopathy with or without back pain, and with magnetic resonance imaging (MRI)-confirmed diagnosis of posterolateral disc herniation between August 2021 and December 2023 were eligible for inclusion in the study. All patients underwent endoscopic discectomy at our center during the study period. AAC stages were classified based on the Kauppila classification system using lateral lumbar radiographs. Between August 2021 and December 2023 a total of 120 patients were included in the study for analysis, of whom 82 (68.3%) exhibited mild AAC and 38 (31.7%) had moderate-severe AAC. Analyses using the multivariate linear regression model revealed a significant correlation between AAC comorbidity and postoperative clinical outcomes. At 1 year post-surgery, the mean change in leg pain following endoscopic lumbar discectomy was significantly less for patients with moderate-severe AAC (5.0 points) than for patients with mild ACC (p < 0.001). Even after adjusting for relevant confounders, this difference remained significant. Similar results were also observed in the postoperative improvement of back pain, the Oswestry Disability Index score, and the physical functioning, role physical, and bodily pain components of the 36-item Short Form Health Survey questionnaire. There was no significant difference in the rate of repeat surgery or post-surgical new-onset back pain between patients with different levels of severity of AAC at 1 year post-surgery. There is a significant association between the severity of AAC and clinical outcomes among patients with lumbar disk herniation who underwent endoscopic lumbar discectomy. AAC may serve as a prognostic factor in predicting surgical outcomes and guiding management strategies for patients with lumbar disk herniation following endoscopic lumbar discectomy.

Subject-level spinal osteoporotic fracture prediction combining deep learning vertebral outputs and limited demographic data.

Osteoporotic vertebral fractures are common and morbid. Automated opportunistic screening for incidental vertebral fractures from radiographs, the highest volume imaging modality, could improve osteoporosis detection and management. We consider how to form patient-level fracture predictions and summarization to guide management, using our previously developed vertebral fracture classifier on segmented radiographs from a prospective cohort study of US men (MrOS). We compare the performance of logistic regression (LR) and generalized additive models (GAM) with combinations of individual vertebral scores and basic demographic covariates. Subject-level LR and GAM models were created retrospectively using all fracture predictions or summary variables such as order statistics, adjacent vertebral interactions, and demographic covariates (age, race/ethnicity). The classifier outputs for 8663 vertebrae from 1176 thoracic and lumbar radiographs in 669 subjects were divided by subject to perform stratified fivefold cross-validation. Models were assessed using multiple metrics, including receiver operating characteristic (ROC) and precision-recall (PR) curves. The best model (AUC-ROC = 0.968) was a GAM using the top three maximum vertebral fracture scores and age. Using top-ranked scores only, rather than all vertebral scores, improved performance for both model classes. Adding age, but not ethnicity, to the GAMs improved performance slightly. Maximal vertebral fracture scores resulted in the highest-performing models. While combining multiple vertebral body predictions risks decreasing specificity, our results demonstrate that subject-level models maintain good predictive performance. Thresholding strategies can be used to control sensitivity and specificity as clinically appropriate.

Abdominal Aorta Calcification Identified on DXA Scans and the Risk of Mortality in Adults.

Abdominal aortic calcification (AAC) on lateral lumbar radiographs increases the risk of cardiovascular events and mortality. However, data on the association between AAC detected in dual energy X-ray absorptiometry (DXA) and the risk of mortality in the general population are scarce. The present study was based on data from participants aged ≥40 years in the National Health and Nutrition Examination Survey (NHANES) cycle of 2013 to 2014. Vertebral assessment of lateral spine DXA scans was used to provide AAC measurements at vertebrae L1-L4. The extent of AAC was defined according to the Kauppila AAC-24 scores (0-1, 2-5, ≥6), and the NHANES 2019 public-use linked mortality files were used to assess mortality status. Of the 2,962 participants who were included in this study, with a mean age of 57.4 years and a median follow-up of 69.9 months, 252 (8.5%) died. Of the deaths, 84 (33.3%) occurred due to cardiovascular disease. The Cox proportional hazards models revealed that participants with AAC-24 scores ≥6 were 1.7 times more likely to die than those with AAC-24 scores 0-1 (Hazard ratio, 1.75; 95% confidence interval, 1.13-2.71). Moreover, older adults and women with AAC-24 scores ≥6 were 2.8 and 2.4 times more likely to die than their counterparts with AAC-24 scores 0-1, respectively. Conversely, a non-significant risk of cardiovascular mortality was found among participants with AAC-24 scores ≥6. The extent of AAC detected on vertebral fracture assessment DXA was associated with an increased risk of all-cause mortality in adults, particularly older adults and women.

Automatic measurement of anatomical parameters of the lumbar vertebral body and the intervertebral disc on radiographs by deep learning.

Lumbar spine disorders are one of the common causes of low back pain (LBP). Objective and reliable measurement of anatomical parameters of the lumbar spine is essential in the clinical diagnosis and evaluation of lumbar disorders. However, manual measurements are time-consuming and laborious, with poor consistency and repeatability. Here, we aim to develop and evaluate an automatic measurement model for measuring the anatomical parameters of the vertebral body and intervertebral disc based on lateral lumbar radiographs and deep learning (DL). A model based on DL was developed with a dataset consisting of 1,318 lateral lumbar radiographs for the prediction of anatomical parameters, including vertebral body heights (VBH), intervertebral disc heights (IDH), and intervertebral disc angles (IDA). The mean of the values obtained by 3 radiologists was used as a reference standard. Statistical analysis was performed in terms of standard deviation (SD), mean absolute error (MAE), Percentage of correct keypoints (PCK), intraclass correlation coefficient (ICC), regression analysis, and Bland-Altman plot to evaluate the performance of the model compared with the reference standard. The percentage of intra-observer landmark distance within the 3 mm threshold was 96%. The percentage of inter-observer landmark distance within the 3 mm threshold was 94% (R1 and R2), 92% (R1 and R3), and 93% (R2 and R3), respectively. The PCK of the model within the 3mm distance threshold was 94-99%. The model-predicted values were 30.22±3.01 mm, 10.40±3.91 mm, and 10.63°±4.74° for VBH, IDH, and IDA, respectively. There were good correlation and consistency in anatomical parameters of the lumbar vertebral body and disc between the model and the reference standard in most cases (R2=0.89-0.95, ICC =0.93-0.98, MAE =0.61-1.15, and SD =0.89-1.64). The newly proposed model based on a DL algorithm can accurately measure various anatomical parameters on lateral lumbar radiographs. This could provide an accurate and efficient measurement tool for the quantitative evaluation of spinal disorders.

Diagnostic models to predict structural spinal osteoarthritis on lumbar radiographs in older adults with back pain: Development and internal validation

ObjectiveIt is difficult for health care providers to diagnose structural spinal osteoarthritis (OA), because current guidelines recommend against imaging in patients with back pain. Therefore, the aim of this study was to develop and internally validate multivariable diagnostic prediction models based on a set of clinical and demographic features to be used for the diagnosis of structural spinal OA on lumbar radiographs in older patients with back pain. DesignThree diagnostic prediction models, for structural spinal OA on lumbar radiographs (i.e. multilevel osteophytes, multilevel disc space narrowing (DSN), and both combined), were developed and internally validated in the ‘Back Complaints in Older Adults’ (BACE) cohort (N ​= ​669). Model performance (i.e. overall performance, discrimination and calibration) and clinical utility (i.e. decision curve analysis) were assessed. Internal validation was performed by bootstrapping. ResultsMean age of the cohort was 66.9 years (±7.6 years) and 59% were female. All three models included age, gender, back pain duration and duration of spinal morning stiffness as predictors. The combined model additionally included restricted lateral flexion and spinal morning stiffness severity, and exhibited the best model performance (optimism adjusted c-statistic 0.661; good calibration with intercept −0.030 and slope of 0.886) and acceptable clinical utility. The other models showed suboptimal discrimination, good calibration and acceptable decision curves. ConclusionAll three models for structural spinal OA displayed lesuboptimal discrimination and need improvement. However, these internally validated models have potential to inform primary care clinicians about a patient with risk of having structural spinal OA on lumbar radiographs. External validation before implementation in clinical care is recommended.

Osteoporosis, spinal degenerative disorders, and their association with low back pain, activities of daily living, and physical performance in a general population

Osteoporosis, vertebral fractures, and spinal degenerative diseases are common conditions that often coexist in older adults. This study aimed to determine the factors influencing low back pain and its impact on activities of daily living (ADL) and physical performance in older individuals with multiple comorbidities. This cross-sectional study was part of a large-scale population-based cohort study in Japan, involving 1009 participants who underwent spinal magnetic resonance imaging (MRI) to assess cervical cord compression, radiographic lumbar spinal stenosis, and lumbar disc degeneration. Vertebral fractures in the thoracolumbar spine were evaluated using sagittal MRI with a semi-quantitative method. Bone mineral density was measured using dual-energy X-ray absorptiometry. Low back pain, Oswestry Disability Index (ODI), and physical performance tests, such as one-leg standing time, five times chair-stand time, maximum walking speed, and maximum step length, were assessed. Using clinical conditions as objective variables and image evaluation parameters as explanatory variables, multiple regression analysis showed that vertebral fractures were significantly associated with low back pain and ODI. Vertebral fractures and osteoporosis significantly impacted physical performance, whereas osteoporosis alone did not affect low back pain or ODI. Our findings contribute to new insights into low back pain and its impact on ADL and physical performance.

Artificial intelligence automatic measurement technology of lumbosacral radiographic parameters.

Currently, manual measurement of lumbosacral radiological parameters is time-consuming and laborious, and inevitably produces considerable variability. This study aimed to develop and evaluate a deep learning-based model for automatically measuring lumbosacral radiographic parameters on lateral lumbar radiographs. We retrospectively collected 1,240 lateral lumbar radiographs to train the model. The included images were randomly divided into training, validation, and test sets in a ratio of approximately 8:1:1 for model training, fine-tuning, and performance evaluation, respectively. The parameters measured in this study were lumbar lordosis (LL), sacral horizontal angle (SHA), intervertebral space angle (ISA) at L4-L5 and L5-S1 segments, and the percentage of lumbar spondylolisthesis (PLS) at L4-L5 and L5-S1 segments. The model identified key points using image segmentation results and calculated measurements. The average results of key points annotated by the three spine surgeons were used as the reference standard. The model's performance was evaluated using the percentage of correct key points (PCK), intra-class correlation coefficient (ICC), Pearson correlation coefficient (r), mean absolute error (MAE), root mean square error (RMSE), and box plots. The model's mean differences from the reference standard for LL, SHA, ISA (L4-L5), ISA (L5-S1), PLS (L4-L5), and PLS (L5-S1) were 1.69°, 1.36°, 1.55°, 1.90°, 1.60%, and 2.43%, respectively. When compared with the reference standard, the measurements of the model had better correlation and consistency (LL, SHA, and ISA: ICC = 0.91-0.97, r = 0.91-0.96, MAE = 1.89-2.47, RMSE = 2.32-3.12; PLS: ICC = 0.90-0.92, r = 0.90-0.91, MAE = 1.95-2.93, RMSE = 2.52-3.70), and the differences between them were not statistically significant (p > 0.05). The model developed in this study could correctly identify key vertebral points on lateral lumbar radiographs and automatically calculate lumbosacral radiographic parameters. The measurement results of the model had good consistency and reliability compared to manual measurements. With additional training and optimization, this technology holds promise for future measurements in clinical practice and analysis of large datasets.

#2224 Higher serum level of indoxyl sulfate is not associated with increased abdominal aorta calcification in patients on maintenance hemodialysis

Abstract Background and Aims Vascular calcification is strongly associated with an increase in all-cause and cardiovascular mortality, especially in patients with and stage renal disease. Results of numerous experimental studies have shown direct toxic effect of microbial-derived uremic toxins on vascular endothelial and smooth muscle cells which may contribute vascular calcification. Meanwhile, the effects of these metabolites on vascular remodeling in patients receiving dialysis treatment remains largely unclear. Here we aimed to investigate the relationship between serum level of the uremic toxin indoxyl sulfate and severity of abdominal aorta calcification (AAC) in patients on maintenance hemodialysis. Method This single-center, cross-sectional study included eighty (40 men, average age – 59,7±11,8 years) clinically stable patients receiving hemodialysis treatment for 52(21,3-120) months. 13(16,3%) participants had history of smoking, 27(33,8%) were diabetic, 63(78,8%) had high blood pressure, 17(21,3%) – previous history of ischemic heart disease, including 5(6,3%) suffered a myocardial infarction. Severity of AAC was determined by lateral lumbar radiography with Kauppila scoring. The total AAC score ranged from 0 to 24 points, and a higher AAC score indicated a more pronounced degree of calcification. Routine laboratory data were collected before hemodialysis session after fasting for 12 hours. Serum concentration of indoxyl sulfate was assessed by ELISA using commercially available kit (Cloud-Clone Corp., USA). Statistical analysis was performed with IBM SPSS Statistics 26 program. Non-parametric Spearman's rank correlation method was used to evaluate the associations between the studied parameters. Value of p &amp;lt;0.05 was considered statistically significant in all tests. Results Median serum indoxyl sulfate was 2,1(1,4-3,0) μmol/l (the same parameter in relatively healthy individuals without impaired renal function is 0,1(0-0,3) μmol/l, р˂0,001). Serum levels of calcium (Ca) was 2,27(2,1-2,5) mmol/l, ionized calcium (Ca++) – 1,15(1,1-1,3) mmol/l, phosphate (P) – 1,6(1,3-2,0) mmol/l, intact parathyroid hormone (iPTH) – 303(162,2-492,8) pg/ml, total cholesterol (TH) – 4,5(3,5-5,4) mmol/l, low-density lipoprotein (LDL) – 2,6(2,0-3,3) mmol/l. AAC score in hemodialysis participants was 4,5(0,0-9,0) and significantly correlated with age (r=0,693; р˂0,001), Ca (r=0,208; р=0,04) and iPTH (r=0,418; р=0,021) but not with other indicators, including indoxyl sulfate concentration (r=0,164; р=0,147). Conclusion Our preliminary results do not allow to consider the elevated level of indoxyl sulfate as a factor contributing to increased AAC in patients on maintenance hemodialysis. Further prospective studies in larger populations should clarify the true role of indoxyl sulfate in vascular remodeling in individuals with chronic kidney disease.

Abdominal Aortic Calcification is Associated with Degeneration of The Paraspinal Muscles - A Retrospective cross-sectional Study.

Retrospective cohort study. To analyze the relationship of abdominal aortic calcification (AAC) and a reduction in the cross-sectional area (CSA) and the fatty infiltration (FI) of the paravertebral muscles in patients undergoing lumbar fusion surgery. Both AAC and paraspinal muscle degeneration have been shown to be associated with poorer outcomes after surgical treatment of degenerative diseases of the lumbar spine. However, there is a lack of data on the association between AAC and paraspinal muscle changes in patients undergoing spine surgery. We retrospectively analyzed patients undergoing lumbar fusion for degenerative spinal pathologies. Muscular and spinal degeneration were measured on magnetic resonance imaging (MRI). AAC was classified on lateral lumbar radiographs. The association of AAC and paraspinal muscle composition was assessed by a multivariate regression analysis adjusted for age, sex, body mass index (BMI), comorbidities, and lumbar degeneration. A total of 301 patients was included. Patients with AAC showed significantly higher degrees of intervertebral disc and facet joint degeneration as well as higher total endplate scores at the L3/4 level. The univariable regression analysis showed a significant positive correlation between the degree of AAC and the FI of the erector spinae (b=0.530, P<0.001) and multifidus (b=0.730, P<0.001). The multivariable regression analysis showed a significant positive correlation between the degree of AAC and the FI of the erector spinae (b=0.270, P=0.006) and a significant negative correlation between the degree of AAC and the CSA of the psoas muscle (b=-0.260, P=0.003). This study demonstrates a significant and independent association between AAC and degeneration of the erector spinae and the psoas muscles in patients undergoing lumbar fusion. As both AAC and degeneration of paraspinal muscles impact postoperative outcomes negatively, preoperative assessment of AAC may aid in identifying patients at higher risk after lumbar surgery.

The Classification of Lumbar Spondylolisthesis X-Ray Images Using Convolutional Neural Networks.

We aimed to develop and validate a deep convolutional neural network (DCNN) model capable of accurately identifying spondylolysis or spondylolisthesis on lateral or dynamic X-ray images. A total of 2449 lumbar lateral and dynamic X-ray images were collected from two tertiary hospitals. These images were categorized into lumbar spondylolysis (LS), degenerative lumbar spondylolisthesis (DLS), and normal lumbar in a proportional manner. Subsequently, the images were randomly divided into training, validation, and test sets to establish a classification recognition network. The model training and validation process utilized the EfficientNetV2-M network. The model's ability to generalize was assessed by conducting a rigorous evaluation on an entirely independent test set and comparing its performance with the diagnoses made by three orthopedists and three radiologists. The evaluation metrics employed to assess the model's performance included accuracy, sensitivity, specificity, and F1 score. Additionally, the weight distribution of the network was visualized using gradient-weighted class activation mapping (Grad-CAM). For the doctor group, accuracy ranged from 87.9 to 90.0% (mean, 89.0%), precision ranged from 87.2 to 90.5% (mean, 89.0%), sensitivity ranged from 87.1 to 91.0% (mean, 89.2%), specificity ranged from 93.7 to 94.7% (mean, 94.3%), and F1 score ranged from 88.2 to 89.9% (mean, 89.1%). The DCNN model had accuracy of 92.0%, precision of 91.9%, sensitivity of 92.2%, specificity of 95.7%, and F1 score of 92.0%. Grad-CAM exhibited concentrations of highlighted areas in the intervertebral foraminal region. We developed a DCNN model that intelligently distinguished spondylolysis or spondylolisthesis on lumbar lateral or lumbar dynamic radiographs.

Can the Mismatch of Measured Pelvic Morphology vs. Lumbar Lordosis Predict Chronic Low Back Pain Patients?

Background: Measures of lumbar lordosis (LL) and elliptical modeling variables have been shown to discriminate between normal and chronic low back pain (CLBP) patients. Pelvic morphology influences an individual's sagittal lumbar alignment. Our purpose is to investigate the sensitivity and specificity of lumbar sagittal radiographic alignment and modeling variables to identify if these can discriminate between normal controls and CLBP patients. Methods: We conducted a computer analysis of digitized vertebral body corners on lateral lumbar radiographs of normal controls and CLBP patients. Fifty normal controls were attained from a required pre-employment physical examination (29 men; 21 women; mean age of 27.7 ± 8.5 years), with no history of low back pain, a normal spinal examination, no pathologies, anomalies, or instability. Additionally, 50 CLBP patients (29 men; 29.5 ± 8 years of age) were randomly chosen and matched to the characteristics of the controls. The inclusion criteria required no abnormalities on lumbar spine radiographs. The parameters included the following: ARA L1-L5 lordosis, ARA T12-S1 lordosis, Cobb T12-S1, b/a elliptical modelling ratio, sacral base angle (SBA), and S1 posterior tangent to vertical (PTS1). Two measures of pelvic morphology were determined for each person-the angle of pelvic incidence (API) and posterior tangent pelvic incidence angle (PTPIA)-and the relationships between API - ARA T12-S1, API - Cobb T12-S1, and API - ARA L1-5 was determined. Descriptive statistics and correlations among the primary variables were determined. The receiver operating characteristic curves (ROC curves) for primary variables were analyzed. Results: The mean values of LL were statistically different between the normal and CLBP groups (p < 0.001), indicating a hypo-lordotic lumbar spine for the CLBP group. The mean b/a ratio was lower in the chronic pain group (p = 0.0066). The pelvic morphology variables were similar between the groups (p > 0.05). API had a stronger correlation to the SBA and Cobb T12-S1 than PTPIA did, while PTPIA had a stronger correlation to the S1 tangent and ARA T12-S1 than API did. While CLBP patients had a stronger correlation of ARA T12-S1 and Cobb T12-S1 relative to the pelvic morphology, they also had a reduced correlation of ARA L1-L5 lordosis relative to their SBA and pelvic morphology measures. API - T12-S1, API - L1-L5, and API - Cobb T12-S1 were statistically different between the groups, p < 0.001. Using ROC curve analyses, it was identified that ARA L1-L5 lordosis of 36° and ARA T12-S1 of 68° have a good sensitivity and specificity to discriminate between normal and CLBP patients. ROC curve analyses identified that lordosis ARAT12-S1 < 68° (AUC = 0.83), lordosis ARAL1-L5 < 36° (AUC = 0.78), API - ARA T12-S1 < -18° (AUC = 0.75), API - ARAL1-L5 > 35° (AUC = 0.71), and API - Cobb T12-S1 < -5° (AUC = 0.69) had moderate to good discrimination between groups (AUC = 0.83, 0.78, 0.75, and 0.72). Conclusions: Pelvic morphology is similar between normal and CLBP patients. CLBP patients have an abnormal 'fit' of their API - ARAT12-S1 and L1-L5 lumbar lordosis relative to their pelvic morphology and sacral tilt shown as a hypolordosis.

Abdominal aortic calcification is an independent predictor of perioperative blood loss in posterior spinal fusion surgery.

Abdominal aortic calcification (AAC), often found incidentally on lateral lumbar radiographs, is increasingly recognized for its association with adverse outcomes in spine surgery. As a marker of advanced atherosclerosis affecting cardiovascular dynamics, this study evaluates AAC's impact on perioperative blood loss in posterior spinal fusion (PSF). Patients undergoing PSF from March 2016 to July 2023 were included. Estimated blood loss (EBL) and total blood volume (TBV) were calculated. AAC was assessed on lateral lumbar radiographs according to the Kauppila classification. Predictors of the EBL-to-TBV ratio (%EBL/TBV) were examined via univariable and multivariable regression analyses, which adjusted for parameters such as hypertension and aspirin use. A total of 199 patients (47.2% female) were analyzed. AAC was present in 106 patients (53.3%). AAC independently predicted %EBL/TBV, accounting for an increase in blood loss of 4.46% of TBV (95% CI 1.17-7.74, p = 0.008). This is the first study to identify AAC as an independent predictor of perioperative blood loss in PSF. In addition to its link to degenerative spinal conditions and adverse postoperative outcomes, the relationship between AAC and increased blood loss warrants attention in patients undergoing PSF.

Rancang Bangun Alat Bantu Fiksasi Pemeriksaan Radiografi Lumbal Oblik

Background: The oblique lumbar examination has been carried out. The position of object isn't object angle at 45° to the image receptor, but only estimate it. It caused not optimal image of scottie dog sign and spondylolysis (pressure in pars interarticularis). Therefore, an examination aid is needed to make it easier to obtain the position of the oblique lumbar object.Methods: This research design is a RnD study with the ADDIE model which is carried out with five stages, namely analysis, design, development, implementation, and evaluation. The data is carried out by observing, designing, testing, and analyzing whether there are artifacts.Results: An oblique lumbar radiographic examination fixation aid was produced from acrylic material with a thickness of 5 mm. Acrylic is shaped like a right-angled triangular prism building which has a longer base measuring 50 cm, width 42 cm, and height 25 cm. A rectangular base with a length of 50 cm is pressed against the patient's body so that the supporting part of the angled triangle that supports the patient's lumbar region or the patient's body does not shift during an oblique lumbar radiography examination. This tool has a mass dimension of 2.5kg.Conclusion: The design of the oblique lumbar radiographic examination fixation tool resembles a right-angled triangular prism with one side tilted at a 45 degree angle to adjust the position of the object so that it can obtain a good view of the Scottie dog sign to show part of the pars interarticularis.

‘Skip’ osteoporosis vertebral compression fractures caused by electrical injury: a case report and review of the literature

IntroductionElectrical injuries rarely result in fractures, such as long bone fractures and spinal fractures. A few articles have reported osteoporosis vertebral compression fractures (OVCFs) caused by electrical injuries. Here, we present a rare case of 37-year-old male suffering from the 9th thoracic (T9) and 5th lumbar (L5) OVCFs after receiving a electric shock.Case presentationA 37-year-old Han male experienced an electric shock (480 V direct current) at the working time and felt immediately serious back pain. He did not fall and lose consciousness. X-ray and magnetic resonance imaging showed acute OVCFs, as well as dual-energy X-ray absorptiometry indicated osteoporosis. Normal laboratory tests can avoid secondary osteoporosis resulting from metabolic diseases and tumors. Finally, he was diagnosed with acute discontinuous OVCFs (T9 and L5). The patient denied having a history of back pain, whereas, he had a history of smoking, alcohol abuse, and congenital heart disease (tetralogy of Fallot) were associated with osteoporosis. Considering no local kyphosis and < 50% anterior body compression, we selected conservative treatment for this patient. At a 1-year and 3-year follow-up, the lateral thoracic and lumbar radiography demonstrated no instability of the spine, and the back pain has been relieved.ConclusionsThis rare case reminds us the importance of consulting a detailed medical history when we encounter young patients receiving electrical injuries. Discontinuously OVCFs must not be overlooked, even though we encounter a young man.

Paralumbar Spine Disease as a Cause of Low Back Pain in Older Adults.

Introduction Low back pain (LBP) is a major contributor to decreases in the ability to perform activities of daily living (ADL) in older adults. Paralumbar spine disease (PLSD) is a common cause of LBP. We aimed to investigate the causes of LBP, including PLSD, among older adults. Methods Among 744 consecutive patients with LBP, 75 patients (10.1%) aged >80 years (25 males and 50 females) were included. The average patient age was 83.9 years. All patients were evaluated using lumbar magnetic resonance imaging (MRI) and radiography to diagnose the causes of LBP. PLSD was diagnosed based on clinical symptoms, palpation, and the effects of the block. Results Eleven patients (11/75, 14.7%) had acute osteoporotic vertebral fractures. Twenty-eight of the remaining 64 patients exhibited decreased LBP with oral medication, and six (6/75, 8.0%) exhibited lumbar spinal canal stenosis on MRI. PLSD was suspected in 19 of the remaining 30 cases based on clinical symptoms and palpation. Blocks were effective in 16 patients with PLSD, which involved superior cluneal nerve entrapment (SCN-E) in eight patients (10.7%), middle cluneal nerve entrapment (MCN-E) in nine patients (12.0%), sacroiliac joint (SIJ) pain in five patients (6.7%), and gluteus medius muscle (GMeM) pain in three patients (4.0%). The average numerical rating scale (NRS) scores for pain changed from 7.5 ± 1.5 before treatment to 1.3 ± 0.9 at discharge (p < 0.05). Conclusion Osteoporotic acute vertebral fracture (14.7%) was identified as the cause of LBP in older adults. Block therapy for PLSD may aid in the diagnosis and treatment of non-specific LBP.

Characteristics and standards of severe sagittal imbalance in adult patients with spinal deformities: a retrospective analysis

ObjectiveTo analyze the characteristics of “severe” dynamic sagittal imbalance (DSI) in patients with adult spinal deformity (ASD) and establish criteria for them.MethodsWe retrospectively analyzed 102 patients with ASD presenting four cardinal signs of lumbar degenerative kyphosis. All patients underwent deformity corrective surgery and were divided into three groups according to the diagnostic criteria based on the Oswestry disability index and dynamic features (△Timewalk: time until C7 sagittal vertical axis [C7SVA] reaches ≥ 20 cm after the start of walking) of sagittal imbalance. The paravertebral back muscles were analyzed and compared using T2-weighted axial imaging. We performed a statistically time-dependent spinopelvic sagittal parameter analysis of full standing lateral lumbar radiographs. Lumbar flexibility was analyzed using dynamic lateral lumbar radiography.ResultsThe patients were classified into the mild (△Timewalk ≥ 180 s, 35 patients), moderate (180 s > △Timewalk ≥ 30 s, 38 patients), and severe (△Timewalk < 30 s, 29 patients) groups. The back muscles in the severe group exhibited a significantly higher signal intensity (533.4 ± 237.5, p < 0.05) and larger area of fat infiltration (35.2 ± 5.4, p < 0.05) than those in the mild (223.8 ± 67.6/22.9 ± 11.9) and moderate groups (294.4 ± 214.7/21.6 ± 10.6). The analysis of lumbar flexibility revealed significantly lower values in the severe group (5.8° ± 2.5°, p < 0.05) than in the mild and moderate groups (14.2° ± 12.4° and 11.4° ± 8.7°, respectively). The severe group had significantly lower lumbar lordosis (LL, 25.1° ± 22.7°, p < 0.05) and Pelvic incidence-LL mismatch (PI-LL, 81.5° ± 26.6°, p < 0.001) than those of the mild (8.2° ± 16.3°/58.7° ± 18.8°) and moderate (14.3° ± 28.6°/66.8° ± 13.4°) groups. On receiver operating characteristic curve analysis, PI-LL was statistically significant, with an area under the curve of 0.810 (95% confidence interval) when the baseline was set at 75.3°. The severe group had more postoperative complications than the other groups.ConclusionsOur results suggest the following criteria for severe DSI: C7SVA > 20 cm within 30 s of walking or standing, a rigid lumbar curve < 10° on dynamic lateral radiographs, and a PI-LL mismatch > 75.3°.Level of evidence3.

The Short-Term Outcome of Transforaminal Epidural Steroid Injection in Patients with Radicular Pain Due to Foraminal Stenosis from Lumbar Isthmic Spondylolisthesis.

In this study, we evaluated the therapeutic outcomes of transforaminal epidural steroid injection (TFESI) in managing chronic radicular pain due to foraminal stenosis. Furthermore, we evaluated its effectiveness according to isthmic spondylolisthesis (IS) severity. We included 40 patients with radicular pain due to IS-derived foraminal stenosis in our study and treated them with TFESI. Two patients were lost during follow-up. Based on the lateral lumbar radiograph findings, we allocated the recruited patients with < 25% slippage by IS to Group 1 (n = 23) and those having 25-50% slippage to Group 2 (n = 15). The degree of pain was measured using a numeric rating scale (NRS) at pre-treatment and 1 and 2 months after TFESI. In 38 patients who completed the study, the NRS at pre-treatment was significantly reduced at the 1- and 2-month follow-ups. In the Group analysis, the NRS scores were significantly reduced after TFESI in both Groups 1 and 2, regardless of IS severity. However, the reduction in NRS scores 1 month after TFESI was significantly greater in Group 1 than in Group 2. Moreover, the rate of successful treatment outcomes was significantly higher (65.2%) in Group 1 than in Group 2 (26.7%). After TFESI, chronic radicular pain was significantly reduced regardless of IS severity, and its effect persisted for at least 2 months. However, its effect was superior when the vertebra slippage by IS was less than 25% compared to patients with 25%-50%.