Lumbar X-ray Research Articles

Ultrasound Aided Vertebral Level Localization for Lumbar Surgery

Localization of the correct vertebral level for surgical entry during lumbar hernia surgery is not straightforward. In this paper, we develop and evaluate a solution using free-hand 2-D ultrasound (US) imaging in the operation room (OR). Our system exploits the difference in spinous process shapes of the vertebrae. The spinous processes are pre-operatively outlined and labeled in a lateral lumbar X-ray of the patient. Then, in the OR the spinous processes are imaged with 2-D sagittal US, and are automatically segmented and registered with the X-ray shapes. After a small number of scanned vertebrae, the system robustly matches the shapes, and propagates the X-ray label to the US images. The main contributions of our work are: we propose a deep convolutional neural network-based bone segmentation algorithm from US imaging that outperforms state of the art methods in both performance and speed. We present a matching strategy that determines the levels of the spinal processes being imaged. And lastly, we evaluate the complete procedure on 19 clinical data sets from two hospitals, and two observers. The final labeling was correct in 92% of the cases, demonstrating the feasibility of US-based surgical entry point detection for spinal surgeries.

Short-term effectiveness of transforaminal unilateral approach for bilateral decompression in lumbar interbody fusion for the treatment of lumbar spinal stenosis

To assess the clinical application value of tranforaminal unilateral approach for bilateral decompression by comparing the short-term effectiveness of bilateral decompression via unilateral approach of intervertebral foramen with via small surgical incision of bilateral spinous process in lumbar interbody fusion for the treatment of lumbar spinal stenosis. Between July 2014 and June 2015, 48 patients with lumbar spinal stenosis underwent decompression and internal fixation by unilateral approach in 24 cases (trial group) and by bilateral small incision approach in 24 cases (control group). There was no significant difference in gender, age, disease duration, disease type, involved segment, combined medical diseases, preoperative level of creatine phosphokinase (CPK), the visual analogue scale (VAS), and Oswestry disability index (ODI) between 2 groups ( P>0.05). The operation time, intraoperative blood loss, postoperative drainage, hospitalization time, and the incidence of complications were recorded. The CPK levels were evaluated at 1, 3, and 7 days after operation. VAS score and ODI were used to evaluate the effectiveness, and lumbar X-ray film or CT scanning to determine the intervertebral bony fusion. There was no significant difference in operation time, intraoperative blood loss, and hospitalization time between 2 groups ( P>0.05), but significant difference was found in postoperative drainage ( t=5.547, P=0.000). At 1 day after operation, the level of CPK in the trial group was significantly lower than that in the control group ( t=3.129, P=0.005), but there was no significant difference at 3 and 7 days after operation between 2 groups ( P>0.05). The patients were followed up 12-24 months (mean, 17 months). All the wounds healed primarily. Heart failure occurred in 1 case of the trial group, and cerebrospinal fluid leakage and pulmonary infection, and nerve root injury occurred in 1 case of the control group respectively. There was no significant difference in the incidence of complications between 2 groups ( χ2=0.273, P=0.602). The interbody fusion rate was 95.8% (23/24) in the trial group and was 91.7% (22/24) in the control group, showing no significant difference ( χ2=0.356, P=0.551). No cage sink, dislocation or plate and screw loosening and breakage was found in 2 groups. No adjacent segment degeneration occurred during the follow-up, and there was no change of scoliosis and lumbar sagittal curvature. At 3, 6, and 12 months after operation, the VAS score and ODI were significantly improved when compared with the preoperative scores in 2 groups ( P<0.05), and the VAS score and ODI of the trial group were significantly better than those of control group ( P<0.05). The bilateral decompression via unilateral approach of intervertebral foramen and small surgical incision of bilateral spinous process in lumbar interbody fusion have satisfactory efficacy for the treatment of lumbar spinal stenosis, but the tranforaminal unilateral approach has the advantages of less trauma, avoidance of bilateral muscle stripping and soft paraspinal muscle injury, retention of posterior spinal structure, faster postoperative recovery, shorter hospital stay and good short-term effectiveness.

Associations between disc space narrowing, anterior osteophytes and disability in chronic mechanical low back pain: a cross sectional study

BackgroundRadiographic features of lumbar disc degeneration (LDD) are common findings in patients with chronic mechanical low back pain; however, its role in disability and intensity of pain is debatable. This study aims to investigate the associations of the x-ray features of LDD and lumbar spondylolisthesis with severity of disability and intensity of pain.MethodsA cross-sectional study was conducted on 439 patients with chronic mechanical low back pain who attended the rheumatology clinic, National Hospital of Sri Lanka, Colombo, from May 2012 to May 2014. Severity of disability was measured using Modified Oswestry Disability Index and intensity of pain was assessed using numeric rating scale (0–100). X-ray features of LDD (disc space narrowing, anterior osteophytes and overall LDD) and spondylolisthesis were assessed in lateral recumbent lumbar x-rays (L1/L2 to L5/S1) and graded by a consultant radiologist blinded to clinical data. Generalised linear model with linear response was used to assess the associations of x-ray features of LDD with severity of disability and intensity of pain adjusting for age, gender, body mass index and pain radiating into legs.ResultsMean age was 48.99 ± 11.21 and 323 (73.58%) were females. 87 (19.82%) were obese. Mean severity of disability was 30.95 ± 13.67 and mean intensity of pain was 45.50 ± 20.37. 69 (15.72%), 26 (5.92%) and 85 (19.36%) patients had grade 2 disc space narrowing, anterior osteophytes and overall LDD, respectively. 51 (11.62%) patients had lumbar spondylolisthesis. Grade of disc space narrowing and overall LDD were not associated with severity of disability or intensity of pain. The presence of lumbar spondylolisthesis was associated with severity of disability. Female gender and pain radiating into legs were associated with severity of disability and intensity of pain. Advancing age was associated with x-ray features of LDD and lumbar spondylolisthesis.ConclusionsLumbar spondylolisthesis is associated with severity of disability in patients with chronic mechanical low back pain. Associations of x-ray features of LDD with severity of disability and intensity of pain are inconclusive. Female gender and pain radiating into legs are significant confounders.

Extreme lateral channel debridement and fusion combined with posterior fixation for lumbar spinal tuberculosis

To investigate the effectiveness of extreme lateral channel debridement and fusion combined with posterior fixation for lumbar spinal tuberculosis. A retrospective analysis was made on the clinical data of 17 patients with lumbar spinal tuberculosis undergoing extreme lateral channel debridement and fusion combined with posterior fixation between December 2008 and December 2014. There were 10 males and 7 females, aged 20-69 years (mean, 42.6 years). The disease duration was 1-6 months (mean, 3.4 months). The involved segments included L 1, 2 in 5 patients, L 2, 3 in 6 patients, L 3, 4 in 3 patients, and L 4, 5 in 3 patients. Based on American Spinal Injury Association (ASIA) classification, there were 2 cases of grade C, 13 cases of grade D, and 2 cases of grade E. The visual analogue scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and Barthel index were used to evaluate the effectiveness, and the improvement rate of JOA score and Barthel index was calculated at the same time. Lumbar X-ray film and CT were taken regularly to evaluate lumbar kyphotic Cobb angle correction and bony fusion. The operation was successfully performed in 17 patients, and pathological examination showed tuberculosis. All cases were followed up 24-48 months (mean, 35.3 months). Lumbar X-ray film and CT showed that necrotic bone and abscess were cleared completely, and lumbar kyphosis correction was satisfactorily in all cases. Bony fusion was achieved within 6 months, and clinical cure was obtained within 18 months in all cases; no recurrence was found during follow-up period. No loosening or breakage of internal fixation was observed. At last follow-up, ASIA classification was recovered to grade D and grade E from grade C in 2 cases, to grade E from grade D in 11 cases and had no change in 2 cases (grade D). Two cases of ASIA grade E showed no neurological deficit. The VAS score, JOA score, Barthel index, and lumbar kyphotic Cobb angle were significantly improved at 2 weeks after operation and at last follow-up when compared with preoperative ones ( P<0.05). At last follow-up, the improvement rate of JOA score was 75.2%±6.2% and the improvement rate of Barthel index was 75.7%±10.8%. To use extreme lateral channel debridement and fusion combined with posterior fixation is an effective treatment for lumbar spinal tuberculosis.

Abdominal aortic calcification on a plain X-ray and the relation with significant coronary artery disease in asymptomatic chronic dialysis patients

BackgroundCoronary artery disease (CAD) is common in asymptomatic chronic dialysis patients and plays an important role in their poor survival. Early identification of these high-risk patients could improve treatment and reduce mortality. Abdominal aortic calcification (AAC) has previously been associated with CAD in autopsy studies. Since the AAC can be quantified easily using a lateral lumbar X-ray we hypothesized that the extent of AAC as assessed on a lateral lumbar X-ray might be predictive of the presence of significant CAD in dialysis patients.MethodsAll patients currently enrolled in the ICD2 trial without a history of CABG or a PCI with stent implantation were included in this study. All patients underwent CT-angiography (CTA) and a lateral X-ray of the abdomen. AAC on X-ray was quantified using a previously validated scoring system whereupon the association between AAC and the presence of significant CAD was assessed.ResultsA total of 90 patients were included in this study (71% male, 67 ± 7 years old). Forty-six patients were found to have significant CAD. AAC-score was significantly higher in patients with CAD (10.1 ± 4.9 vs 6.3 ± 4.6 (p < 0.05). Multivariate regression analysis revealed that AAC score is an independent predictor for the presence of CAD with a 1,2 fold higher risk per point increase (p < 0.01). The AAC score has a sensitivity of 85% and a specificity of 57% for the presence of significant CAD.ConclusionThis study shows that abdominal aortic calcification as assessed on a lateral lumbar X-ray is predictive for the presence of significant coronary artery disease in asymptomatic dialysis patients. This simple, non-invasive and cheap screening method could contribute to early identification of patients eligible for further screening of CAD.Trial registrationNTR948, registered 10-4-2007 ; ISRCTN20479861, registered 2-5-2007

Clinical value of one-level oblique lateral interbody fusion in the treatment of degenerative lumbar disc diseases

Objective To evaluate the clinical outcomes of one-level oblique lateral interbody fusion (OLIF) for the treatment of degenerative lumbar diseases. Methods A total of 36 patients, 11 males and 25 females with ages from 32 to 75 (average 55.2 ± 13.6 years), underwent one-level OLIF with or without posterior pedicle screw-rod instrumentations from October 2014 to May 2016. The index diagnosis was discogenic back pain in 15 cases, and spondylolisthesis with or without segmental instability in 21 cases. The distribution of operative level was 30 cases at L4/5 and 6 cases at L3/4. The changes of serum level of creatinine kinase was measured 1 and 3 days post-operatively, and compared to that of the pre-operative one. Clinical outcomes were evaluated using visual analogue scale (VAS) and Oswestry disability questionnaire (ODI) scores. Lumbar X-ray was taken and the clinical outcomes were re-assessed. Results 25 in the 36 patients underwent supplementary posterior pedicle screw-rod instrumentation with OLIF procedures. The operation lasted for 46-175 min, with a mean duration of (112±43) min. Blood loss during the operation was 30-180 ml, with a mean of (63 ± 35) ml. Average length of stay was (4.5±2.1) d, ranging from 3-7 d. Serum level of creatinine kinase was (63.5±16.8) IU/L before operation, (416.8±152.1) IU/L 1 day after operation, (112.4±37.5) IU/L 3 days after operation. The VAS and ODI score decreased from (8.3±2.3) pre-operatively to (1.6±0.4) 6 months post-operatively, and from (69.2±17.5) to (10.7±2.7), respectively. The total incidence of complications was 25%, including 8.3% of intra-operative complications (3 cases of cage subsidence) and 16.7% of post-operative ones. The latter consisted of ipsilateral hip flexor weakness in 1, ipsilateral anterior thigh pain in 1, contralateral pain in flexion of hip in 1, ipsilateral sympathetic chain injury in 1, and pain in area of iliac bone donor site in 2. All symptoms were released or disappeared during follow-up. Conclusion OLIF as a novel technique for spinal surgical management showed excellent short-term outcomes. Clinical results with long-term follow-up are required. Key words: Lumbar vertebrae; Spinal fusion; Clinical protocols

A Clinical Prospective Observational Cohort Study on the Prevalence and Primary Diagnostic Accuracy of Occult Vertebral Fractures in Aged Women with Acute Lower Back Pain Using Magnetic Resonance Imaging.

Background Elderly female patients complaints of acute low back pain (LBP) may involve vertebral fracture (VF), among which occult VF (OVF: early-stage VF without any morphological change) is often missed to be detected by primary X-ray examination. The current study aimed to investigate the prevalence of VF and OVF and the diagnostic accuracy of the initial X-ray in detecting OVF. Method Subjects were elderly women (>70 years old) complaining of acute LBP with an accurate onset date. Subjects underwent lumbar X-ray, magnetic resonance imaging (MRI), and bone mineral density (BMD) measurement at their first visit. The distribution of radiological findings from X-ray and magnetic resonance imaging (MRI) as well as the calculation of the prevalence of VF and OVF are investigated. Results The prevalence of VF among elderly women with LBP was 76.5% and L1 was the most commonly injured level. Among VF cases, the prevalence of OVF was 33.3%. Furthermore, osteoporotic patients tend to show increased prevalence of VF (87.5%). The predictive values in detecting VF on the initial plain X-ray were as follows: sensitivity, 51.3%; specificity, 75.0%; and accuracy rate, 56.7%. Conclusions Acute LBP patients may suffer vertebral injury with almost no morphologic change in X-ray, which can be detected using MRI.

Unilateral approach for microchannel percutaneous bilateral decompression of lumbar spinal stenosis

Objective To evaluate the clinical outcomes and operative techniques of microscopic bilateral decompression for lumbar spinal canal stenosis via the unilateral paramedian approach with tubular retractor system. Methods A retrospective study was conducted to analyze 35 patients with central lumbar spinal canal stenosis who were admitted to Department of Neurosurgery, Affiliated Union Hospital, Fujian Medical University from November 201l to May 2015. Bilateral spinal canal decompression was performed using microchannel percutaneous system through unilateral paraspinal approach and under intraoperative electroneurophysiological monitoring (IOEM). Data including surgical incision, operation time, blood loss volume and IOEM were analyzed. Creatine kinase(CK-MM) levels were measured 1 day before surgery and l day, 3 day as well as 5 days postoperatively. The Japanese Orthopedic Association (JOA) and Visual Analog Scale (VAS) scores were documented at l day preoperatively, and postoperatively at day 1, day 3, day 5, month 1, month 3, month 6 and month 12 months . Lumbar magnetic resonance imaging, computed tomography (CT), and X-ray scan were conducted preoperatively and at 1 month, 6 month and the last follow-up postoperatively. Results The operations were all successfully accomplished with no cases of nerve injury, cerebrospinal fluid leakage (CSFL), postoperative infection or death. The surgical incisions measured 1.5-1.8 cm, the operations lasted 65-110 min, and blood loss volumes were estimated between 8 to 35 ml. The CK-MM level was increased to(461.2±32.6)IU/ml 1 day post-op. with a statistically significant difference compared with pre-op. (P 0.05). At the 12-month follow-up, the JOA score was elevated from (13.4±3.7) to (28.1±0.8)(P<0.05) and the VAS score decreased from (6.9±1.1) to (0.4±0.5)(P<0.05). Postoperative examination of MRI indicated sufficient nerve decompression.No lumbar spinal instability or scoliosis was observed. Conclusion Microscopic bilateral decompression through microelectrode percutaneous approach seems effective for central lumbar spinal canal stenosis with sufficient nerve decompression and less injuries of paraspinal muscles, facet joints, spinous processes and ligaments. This technique offers the advantage of postoperative stability and preserved lumbar mobility. Key words: Lumbar vertebrae; Spinal stenosis; Microsurgery; Unilateral approach; Bilateral decompression

Tuberculous spondylitis diagnosed through Xpert MTB/RIF assay in urine: a case report.

BackgroundExtrapulmonary tuberculosis (EPTB) is associated with high rates of morbidity and mortality. Diagnosis of EPTB is challenging in resource-limited settings due to difficulties in obtaining samples, as well as the paucibacillarity of the specimens. Skeletal tuberculosis accounts for 10–35 % of EPTB cases, with vertebral osteomyelitis (Pott’s disease) representing 50 % of the cases. We present two cases of suspected Pott’s disease, diagnosed through GeneXpert MTB/RIF assay in urine at a rural Tanzanian hospital.Case PresentationCase IA 49-year old male, HIV-1 positive, on co-formulated tenofovir disoproxil fumarate/lamivudine/efavirenz since 2009 and CD4 counts of 205 cells/μL (13 %). He presented with lower back pain and progressive lower limb weakness for two weeks prior to admission. The physical examination revealed bilateral flaccid paraplegia with reduced reflexes, but otherwise unremarkable findings. A lateral lumbar X-ray showed noticeable reduction of intervertebral space between L4 and L5, and a small calcification in the anterior longitudinal ligament between L4 and L5, being compatible with focal spondylosis deformans but inconclusive with regard to tuberculous spondylitis. An abdominal ultrasound showed normal kidneys, bladder and prostate gland. The urinalysis and complete blood counts (CBC) were normal. M. Tuberculosis was detected through GeneXpert MTB/RIF in centrifuged urine, with no resistance to rifampicin.Case IIA 76-year old female, HIV-1 negative, presented with lower back pain and progressive weakness and numbness of the lower limbs for two months prior to admission. The physical examination revealed paraplegia, but otherwise unremarkable findings. The lumbosacral X-ray findings were compatible with spondylosis deformans of the lumbar spine and possible tuberculous spondylitis in L3-L4. The abdominal and renal ultrasound showed normal kidneys and bladder. The urinalysis and CBC were normal. M. Tuberculosis was detected through GeneXpert MTB/RIF in centrifuged urine, with no resistance to rifampicin.ConclusionWe report two cases of suspected tuberculous spondylitis diagnosed through Xpert MTB/RIF in urine samples from a rural Tanzanian hospital. Urine testing using Xpert MTB/RIF reflects disseminated disease and renal involvement, and may offer a feasible additional diagnostic approach for Pott’s disease in rural Africa.

Correlations between the feature of sagittal spinopelvic alignment and facet joint degeneration: a retrospective study.

BackgroundSagittal spinopelvic alignment changes associated with degenerative facet joint arthritis have been assessed in a few studies. It has been documented that patients with facet joint degeneration have higher pelvic incidence, but the relationship between facet joint degeneration and other sagittal spinopelvic alignment parameters is still disputed. Our purpose was to evaluate the correlation between the features of sagittal spinopelvic alignment and facet joint degeneration.MethodsImaging data of 140 individuals were retrospectively analysed. Lumbar lordosis, pelvic tilt (PT), pelvic incidence (PI), sacral slope, and height of the lumbar intervertebral disc were measured on lumbar X-ray plates. Grades of facet joint degeneration were evaluated from the L2 to S1 on CT scans. Spearman’s rank correlation coefficient and Student’s t-test were used for statistical analyses, and a P-value <0.05 was considered statistically significant.ResultsPI was positively associated with degeneration of the facet joint at lower lumbar levels (p < 0.001 r = 0.50 at L5/S1 and P = 0.002 r = 0.25 at L4/5). A significant increase of PT was found in the severe degeneration group compared with the mild degeneration group: 22.0° vs 15.7°, P = 0.034 at L2/3;21.4°vs 15.1°, P = 0.006 at L3/4; 21.0° vs 13.5°, P = 0.000 at L4/5; 20.8° vs 12.1°, P = 0.000 at L5/S1.ConclusionOur results indicate that a high PI is a predisposing factor for facet joint degeneration at the lower lumbar spine, and that severe facet joint degeneration may accompany with greater PT at lumbar spine.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-016-1193-6) contains supplementary material, which is available to authorized users.

Clinical outcomes of poly ether ether ketone rods and pedicle screw system for lumbar degenerative diseases

Objective To explore the reliability and validity of poly ether ether ketone (PEEK) rods and pedicle screw system for lumbar degenerative diseases. Methods Sixty-three patients, including 23 men and 40 women with the mean age of 56.2±5.1 years (range,35-75 years), treated by PEEK rods pedicle screw system from September 2012 to March 2013 were retrospectively recruited. Fusion procedure were performed in 10 patients, with 2 cases at L3, 4, 5 cases at L4, 5, 3 cases at L5S1; nonfusion procedure were performed in 17 patients, with 4 cases at L3, 4, 10 cases at L4, 5, 3 cases at L5S1; hybrid procedure were performed in 36 patients, with 22 case fusion at L4, 5 and nonfusion at L3, 4, with 2 cases fusion at L3, 4 and nonfusion at L4, 5, with 12 cases fusion at L5S1 and nonfusion at L4,5. Clinical effects were evaluated via Japanese Orthopedics Association (JOA) score and Oswestry disfunction index (ODI) at 3 months, 6 months and 24 months postoperatively. Disc heights were measured by disc height index on lateral lumbar radiograph. Range of motion (ROM) was measured by extension-flexion lumbar X-ray. Three-dimensional CT reconstruction was achieved to observe the integrity of PEEK rods at the final follow-up. Results The mean follow-up were 23.4±3.3 months. The mean operation time were 110±17 min in the fusion group, 98±22 min in the non-fusion group and 121± 25 min in the hybrid group. The mean blood loss were 270±85 ml in the fusion group, 255±72 ml in the non-fusion group and 316±80 ml in the hybrid group. The JOA score improved from 10.5±2.6 preoperatively to 24.0±3.1 at the final follow-up in the fusion group, from 10.3±2.2 to 24.3±3.4 in the non-fusion group and from 11.1±2.3 to 23.9±3.3 in the hybrid group (P<0.05). The ODI decreased from 51.8%±10.3% preoperatively to 14.1%±3.7% at the final follow-up in the fusion group, from 52.2%± 11.1% to 13.2%±3.2% in the non-fusion group and from 53.4%±9.2% to 13.8%±2.5% in the hybrid group. There was no significantly statistical difference in the disc height index at 3 months, 6 months and 24 months postoperatively compared with that at preoperative. The ROM decreased from 8.8°±1.8° preoperatively to 2.2°±0.3° at the final follow-up (P<0.05). One case demonstrated cage migration at one month follow-up, bony fusion in situ at 3 months follow-up, and the patient had no related symptoms during the follow-up. No screw loosening or breakage and rods breakage was observed during the follow-up. Conclusion PEEK rods and pedicle screw system for lumbar degenerative diseases by fusion, nonfusion and hybrid procedure can achieve considerable clinical outcome with low complication rate. Key words: Lumbar vertebrae; Intervertebral disc degeneration; Spinal stenosis; Spinal fusion; Internal fixators

Biomarkers Associated with Vascular Calcification in Peritoneal Dialysis.

♦ Vascular calcification is strongly associated with cardiovascular disease and mortality. However, some factors related to vascular calcification in patients with end-stage renal disease receiving peritoneal dialysis (PD) remain unknown. This study aimed to evaluate the associations of osteoprotegerin (OPG), osteopontin (OPN), osteocalcin (OCN), fibroblast growth factor 23 (FGF-23), magnesium, and phosphate clearance with vascular calcification in PD subjects, assessed by plain radiographs. ♦ Simple vascular calcification scores (SVCS) obtained from plain X-rays of the pelvis and hands, and the Kauppila Index (KI) from lateral lumbar X-rays were assessed in 76 adults receiving PD for ≥ 6 months (43 women, median age 39 years, median time on PD 1.4 years). Levels of OPG, OPN, OCN, and FGF-23 were determined by luminometry. ♦ Serum OPG levels were higher in subjects with vascular calcification (n = 22 with SVCS > 3; n = 19 with KI > 7) compared with those with less calcification (p < 0.001). Spearman's correlation coefficients between OPG and SVCS and KI were r = 0.49 and r = 0.51, respectively (both p < 0.001). Subjects with vascular calcification had significantly lower renal phosphate clearance. Multiple regression analysis showed that vascular calcification assessed by SVCS was associated with age (r = 0.2, p = 0.042), diabetes mellitus (r = 2.4, p < 0.001), body mass index (BMI) (r = 0.09, p = 0.037), and OPG (r = 0.22, p = 0.001). Vascular calcification assessed by KI was associated with age (r = 0.16, p < 0.001), time on PD (r = 0.54, p = 0.001) and OPG (r = 0.08, p = 0.04). Osteocalcin, OPN, FGF-23, and magnesium were not associated with vascular calcification. ♦ Higher levels of OPG were consistently associated with vascular calcification in subjects on PD.

Evaluating Sagittal Balance with Lumbopelvic Parameters: A Single-Center Performance Improvement Project

Introduction Neutral sagittal balance is key for painless upright posture and a large offset of sagittal balance may cause low back pain and correlates with impaired quality of life. Lumbar sagittal balance can easily be assessed on a standing X-ray, however, it is still a new concept to many spine specialists and radiologists. Materials and Methods A performance improvement program was developed to enable radiologists and neurosurgeons to quickly assess lumbar sagittal balance. Baseline knowledge and reporting were analyzed. Clinical tools to measure lumbar sagittal balance were taught with a 30-minute presentation. Following this, a spine surgeon helped colleagues measure their first patients. Results At baseline, 42% of 75 patients showed problems with lumbar sagittal balance but basic knowledge of sagittal balance was low: only 10% of pre- and post-treatment X-ray reports and only 1% of neurosurgical reports included information on sagittal balance. The 30-minute presentation empowered the target audience with the clinical skills to measure, interpret, and report lumbar sagittal balance on a standing X-ray. Intermittent encouragement and support from a spine surgeon helped colleagues to evaluate lumbar sagittal balance in their patients. In the first three months following the presentation, the neurosurgeons documented pelvic parameters in 48% of patients (14 of 29) and the radiologists reported the pelvic parameters on all new lumbar X-rays. Assessing and reporting sagittal balance has become a routine procedure beyond the study period and has led to more profound understanding of deformity induced pain and disability, not only by doctors, but also by patients to whom the origin of their back pain can be explained. Conclusions A short teaching presentation on a poorly known yet important clinical concept enables radiologists and spine specialists to easily measure and interpret heretofore underused information from the standing lumbar X-ray. Performance improvement programs are a valuable educational intervention for surgeons and to engage teams in interdisciplinary learning.

Better Height Restoration and Kyphosis Correction of Osteoporotic Vertebral Compression Fractures Using Intravertebral Reduction Devices (SpineJack): One Year Follow Up

Background Transpedicular cement augmentation has became a significant treatment for osteoporotic vertebral compression fractures with the evident effect of pain-relief. However, height restoration and kyphosis correction of the spinal column following transpedicular cement augmentation are not satisfying. SpineJack, one of intravertebral reduction devices, has been proved to has better height restoration and kyphosis correction in a cadaveric study. It also has been reported to has good outcomes for treating spine trauma. However, for treating osteoporotic vertebral compression in the elderly, the role of SpineJack is still unknown. This clinical study was conducted to compare the radiological and clinical outcomes between transpedicular cement augmentation with/without SpineJack for osteoporotic vertebral compression fracture in the elderly. Materials and Methods 75 patients with osteoporotic vertebral compression were included and treated with transpedicular cement augmentation with/without SpineJack during Sep. 2013- May. 2015. The radiological outcomes, including the anterior, central, posterior body height, and kyphotic angle, were measured on flexion/extension lateral lumbar X-ray at the time points of pre-operatively, post-operatively 1 week, 3 month, 6 month, and 1 year. The clinical outcomes, including VAS for pain, SF-36, complications were recorded by reviewing the charts retrospectively. The incidences of adjacent and non-adjacent fracture in both groups were also recorded. Results 36 patients was treated with SpineJack and 39 without SpineJack (Vertebroplasty group). The age, bone marrow density, body mass index, sex ratio, fracture level, the use of steroid and anti-osteoporosis medication were comparable in two groups (p &gt; 0.05). The pre/post- VAS for pain, SF-36, or complication was similar in two groups(p &gt; 0.05). The incidences of adjacent and non-adjacent fracture were also comparable in both group (p &gt; 0.05). The restoration of anterior/middle body height and kyphotic angle in SpineJack group were significantly better than that in Vertebroplaty group at post-op 1 week, 3m, 6m, and one year (p &gt; 0.05). The restorations maintained at least for 1 year in SpineJack group (p &gt; 0.05), while the restorations in Vertebroplasty groups only maintained for 3 months. Conclusion Based on this study, height restoration and kyphosis correction were significantly better in the SpineJack group at least for one year for treating osteoporotic compression fractures in the elderly.

Abdominal aortic calcification in patients with CKD

BackgroundAbdominal aortic calcification (AAC) is independently associated with cardiovascular events in dialysis patients and in the general population. However, data in non-dialysis chronic kidney disease (CKD) patients are limited. We analyzed determinants and prognostic value of AAC in non-dialysis CKD patients.MethodsWe included patients with CKD not receiving renal replacement therapy from the MASTERPLAN study, a randomized controlled trial that started in 2004. In the period 2008–2009, an X-ray to evaluate AAC was performed in a subgroup of patients. We studied AAC using a semi-quantitative scoring system by lateral lumbar X-ray. We used baseline and 2-year data to find determinants of AAC. We used a composite cardiovascular endpoint and propensity score matching to evaluate the prognostic value of AAC.ResultsIn 280 patients an X-ray was performed. In 79 patients (28 %) the X-ray showed no calcification, in 62 patients (22 %) calcification was minor (<4), while 139 patients (50 %) had moderate or heavy calcification (≥4). Older age, prior cardiovascular disease, higher triglyceride levels, and higher phosphate levels were independent determinants of a calcification score ≥4. AAC score ≥4 was independently associated with cardiovascular events, with a hazard ratio of 5.5 (95 % confidence interval 1.2–24.8).ConclusionsAssessment of AAC can identify CKD patients at higher cardiovascular risk, and may provide important information for personalized treatment. Whether this approach will ultimately translate into better outcomes remains to be answered.

Protective Effect of Myo-Inositol Hexaphosphate (Phytate) on Abdominal Aortic Calcification in Patients With Chronic Kidney Disease

The aim of this study was to evaluate the relationship between physiological levels of myo-inositol hexaphosphate (phytate) and cardiovascular (CV) calcification in patients with chronic kidney disease (CKD). This was a prospective cross-sectional study conducted from December 2012 to June2013. Sixty-nine consecutive patients with CKD who were not undergoing renal replacement therapy. All subjects were given lateral lumbar X-rays to quantify abdominal aortic calcification (AAC). Clinical laboratory analyses and phytate food frequency questionnaires were also performed. Phytate urinary excretion, estimated phytate consumption (based on food frequency questionnaire) and AAC score. Patients were divided into two groups based on median abdominal aortic calcification (AAC) score: no/mild AAC (AAC≤6, n=35) and moderate/severe AAC (AAC>6, n=34). Patients with no/mild AAC were younger, had lower pulse pressure, greater dietary intake of phytate, greater urinary phytate and the prevalence of prior CV disease was significantly lower compared to patients with moderate/severe AAC. Among the top 10 phytate-rich foods, lentil consumption was significantly greater in patients with no/mild AAC than in those with moderate/severe AAC. Multivariate logistic regression analysis indicated that age, prior CV disease, urinary phytate (or lentil consumption) were independently associated to AAC. Our results suggest that adequate consumption of phytate can prevent AAC in patients with CKD. Further prospective studies must be performed to elucidate the benefits of a phytate-rich diet and the associated risk of phosphorus bioavailability in these patients.

The Infiniti Plus ultrasound needle guidance system improves needle visualization during the placement of spinal anesthesia.

The Infiniti Plus ultrasound needle guidance system improves needle visualization during the placement of spinal anesthesia.

Hypovitaminosis D and Low Bone Mineral Density in Inflammatory Bowel Disease Patients

Background: Increasing evidences suggest that hypovitaminosis D can play an important role in immuno-mediated diseases, such as Inflammatory Bowel Diseases (IBD). The hypovitaminosis D is an established risk factor for the development of osteopenia, osteoporosis and pathological fractures. Studies have reported a correlation between hypovitaminosis D, disease history and clinical features in Crohn's Disease (CD) and Ulcerative Colitis (UC). The aim of this study is to evaluate the vitamin D serum levels and the prevalence of bone mineral density (BMD) alterations in a population of Italian IBD patients and to correlate the prevalence of hypovitaminosis D with disease history and clinical features. Method: Between October 2013 and November 2014 we enrolled patients from our center that were affected by UC or CD. Exclusion criteria were age below 18 and over 60, concomitant vitamin D replacement therapy and concomitant gastrointestinal or endocrinological diseases which may alter vitamin D metabolism. All patients underwent 25-OH-vitamin D, ESR, C-reactive protein (CRP), PTH, serum calcium and phosphorus, β-CTX, alkaline phosphatase (bone isoenzyme) plasma assay and bone mass density (BMD) evaluation by lumbar and femoral dual-energy X-ray absorptiometry (DXA) scan. Both measurements were made at the same time, during the autumn and winter months. Following 2012 Osteoporosis Italian Society Guidelines, we defined as hypovitaminosis D plasmatic values <30 ng/mL, vitamin D levels were considered as insufficient if between 20 and 30 ng/ mL and deficient if <20 ng/mL. We collected data regarding patients’ life habits and clinical history, disease course and disease clinical activity at enrollment. For BMD evaluation T-score and/or Z-score were calculated for each patient at lumbar (L1-L4) and femoral neck level, and the diagnosis of osteopenia or osteoporosis was made according to international guidelines. Results: We enrolled 88 patients (62 CD, 26 UC); median age at enrollment was 42 years for CD and 43 years for UC. Mean Body Mass Index (BMI) was 22.6 in CD and 23.7 in UC patients. Age at diagnosis was 29.8 years for CD and 33.5 years for UC, with mean disease duration of 12.8 years for CD and 9.1 years for UC.Hypovitaminosis D was observed in 84.1% of the patients. Of these, 31.8% had insufficient vitamin D levels, whereas 57.3% deficient. Mean vitamin D level was 20.4 ng/mL, but there was no difference with respect to sex or disease type. Indeed, there was no correlation between hypovitaminosis D and disease duration or patients age at diagnosis. A statistically significant correlation was found between hypovitaminosis D and history of steroid-dependancy (p=0.03), need of therapy with anti- TNF-α drugs (p=0.01) and cigarette smoke habit in CD patients (p=0.01). In CD patients we also found a correlation, at the limit of statistical significance (p=0.05), between hypovitaminosis D, high CRP values and HarveyBradshaw Index (HBI) at enrollment.70 patients underwent the lumbar DXA analysis, 67 the femoral DXA. Lumbar BMD was found to be below the normal range in 37.1% of the patients, suggesting that 24.2% and 12.9% were affected by osteopenia or osteoporosis, irrespective of sex and disease type (CD or UC). Similarly, femoral BMD was below the normal range for age in 43.3% of the patients. This figure is consistent with osteopenia or osteoporosis in 34.3% and 9%, irrespective of sex and disease type and femoral Z-score that was found significantly lower in CD than UC patients (p=0.03). Reduced BMD correlated with lower BMI and hypovitaminosis D. Conclusion: In our study we found a high prevalence of hypovitaminosis D in an IBD population irrespective of patients' sex, type and duration of disease. Our data show a strong correlation between hypovitaminosis D and a more aggressive disease course in terms of history of steroiddependancy, need of therapy with anti TNF-α drugs and smoke habit in CD patients. Hypovitaminosis D may play a crucial role in causing a more severe clinical behavior of IBD. Alteration of bone metabolism is a concern in IBD patients. We observed a high prevalence of BMD alterations in both men and women affected by UC and CD, even if of young age and with a short disease duration, irrespective of the type of IBD. Such patients may be prescribed lumbar and femoral, especially in cases of hypovitaminosis D and low BMI. This would allow an early diagnosis of BMD alterations, to start specific therapy and to prevent further complications.

Do Trunk Muscles Affect the Lumbar Interbody Fusion Rate?: Correlation of Trunk Muscle Cross Sectional Area and Fusion Rates after Posterior Lumbar Interbody Fusion Using Stand-Alone Cage.

ObjectiveAlthough trunk muscles in the lumbar spine preserve spinal stability and motility, little is known about the relationship between trunk muscles and spinal fusion rate. The aim of the present study is to evaluate the correlation between trunk muscles cross sectional area (MCSA) and fusion rate after posterior lumbar interbody fusion (PLIF) using stand-alone cages.MethodsA total of 89 adult patients with degenerative lumbar disease who were performed PLIF using stand-alone cages at L4–5 were included in this study. The cross-sectional area of the psoas major (PS), erector spinae (ES), and multifidus (MF) muscles were quantitatively evaluated by preoperative lumbar magnetic resonance imaging at the L3–4, L4–5, and L5–S1 segments, and bone union was evaluated by dynamic lumbar X-rays.ResultsOf the 89 patients, 68 had bone union and 21 did not. The MCSAs at all segments in both groups were significantly different (p<0.05) for the PS muscle, those at L3–4 and L4–5 segments between groups were significantly different (p=0.048, 0.021) for the ES and MF muscles. In the multivariate analysis, differences in the PS MCSA at the L4–5 and L5–S1 segments remained significant (p=0.048, 0.043 and odds ratio=1.098, 1.169). In comparison analysis between male and female patients, most MCSAs of male patients were larger than female's. Fusion rates of male patients (80.7%) were higher than female's (68.8%), too.ConclusionFor PLIF surgery, PS muscle function appears to be an important factor for bone union and preventing back muscle injury is essential for better fusion rate.

Effective dose reduction in spine radiographic imaging by choosing the less radiation-sensitive side of the body

Background ContextX-ray absorption is highest in the organs and tissues located closest to the radiation source. The photon flux that crosses the body decreases from the entry surface toward the image receptor. The internal organs absorb x-rays and shield each other during irradiation. Therefore, changing the x-ray projection angle relative to the patient for specific spine procedures changes the radiation dose that each organ receives. Every organ has different radiation sensitivity, so irradiation from different sides of the body changes the biological influence and radiation risk potential on the total body, that is the effective dose (ED). PurposeThe study aimed to determine the less radiation-sensitive sides of the body during lateral and anterior-posterior (AP) or posterior anterior (PA) directions. Study DesignThe study used exposure of patient phantoms and Monte Carlo simulation of the effective doses. Patient SampleCalculations for adults and 10-year-old children were included because the pediatric population has a greater lifetime radiation risk than adults. Outcome MeasuresPediatric and adult tissue and organ doses and ED from cervical, thoracic, and lumbar x-ray spine examinations were performed from different projections. MethodsStandard mathematical phantoms for adults and 10-year-old children, using PCXMC 2.0 software based on Monte Carlo simulations, were used to calculate pediatric and adult tissue and organ doses and ED. The study was not funded. The authors have no conflicts of interest to declare. ResultsSpine x-ray exposure from various right (RT) LAT projection angles was associated with lower ED compared with the same left (LT) LAT projections (up to 28% and 27% less for children aged 10 and adults, respectively). The PA spine projections showed up to 64% lower ED for children aged 10 and 65% for adults than AP projections. The AP projection at the thoracic spine causes an excess breast dose of 543.3% and 597.0% for children aged 10 and adults, respectively. ConclusionsRadiation ED in spine procedures can be significantly reduced by performing x-ray exposures through the less radiation-sensitive sides of the body, which are PA in the frontal position and right lateral in the lateral position.