Spine Position Research Articles

A Comparative Dose-Escalation Analysis for the Head and Neck Reirradiation Patients with and without Appropriate DICOM Based Dose-Volume Information of Primary Radiotherapy

<h3>Purpose/Objective(s)</h3> This study aims to compare the dose-escalation between two groups of head and neck reirradiation patients with or without availability of appropriate DICOM based dose-volume and planning information of primary RT <h3>Materials/Methods</h3> A total of 89 patients who received reirradiation for recurrent/second primary head and neck cancers between 2019-21 was included in the present study. Patients were categorized in two groups, with (D-group) and without (ND-Group) the DICOM based primary radiotherapy (RT1) information in planning system. For first group RT1 and re-irradiation (ReRT) in the present institution, for second group only ReRT in the present institution. For the D group, the dose to 0.2cc volume (D0.2cc) to the spine, brainstem, and optic apparatus was converted into structures in the RT1CT and these structures along with target volumes are copied to ReRTCT using deformable registration. Serial Structures in RT1CT and ReRTCT were merged to get the resultant structure with an intersection of D0.2 cc. A treatment plan was created using the baseline prescription (BRx) was defined by the treating physician. Further, a dose escalation (DERx) plan was created (66Gy/33fr for gross disease and 60Gy/30fr for post operative cases) respecting serial structures tolerance dose. For the ND group, no dose escalation was attempted over the BRx plan. <h3>Results</h3> 57 and 32 patients listed in D and ND-group. ReRT techniques were VMAT=72; IMRT=11, 3DCRT=6. For RT1, dose in D and ND groups 61±5.6 Gy and 30-66 Gy respectively. ReRT BRx doses for D and ND group were 52.5±10.7Gy and 50.6±6.9Gy (ΔDose=1.9±12.7 Gy). Dose escalated plan (DERx) was possible for 51 patients in D-Group with a mean DERx of 59.2±6.2Gy, and ΔDERx 6.7±12.4Gy from BRx plans. The maximum dose escalation from BRx was 21 Gy (D-Group). For 5 patients, dose escalation was not accepted for treatment due to other comorbidities, reducing actually delivered ΔDERx to 6.2± 14.4Gy. The average dose difference between D and ND-group were 8.6±9.3 Gy and 8.1±11.8 Gy on planned and accepted dose escalation. The spatial position of RT1 and ReRT Spine 0.2cc dose was within 5 mm only in 2 cases; for rest of the patients RT1 spine dose was not a big challenge for ReRT planning. It was possible to achieve the combined RT1 and ReRT Spine (<50Gy), Brainstem and Optic apparatus (<54 Gy) dose for 97% patients for D-group. For 86% cases Spine is the only challenged serial OAR for ReRT. <h3>Conclusion</h3> BRx was uniform for both the groups indicating the consistency in the institutional prescription policy. Appropriate dose mapping using DICOM information between RT1 and ReRT allows moderate to high dose escalation in recurrent Head neck re-irradiation which was otherwise not possible. Linear addition of maximum dose, without considering its spatial position, for serial structures (spine, brainstem) between RT1 and ReRT reduces dose escalation possibility as seen in the ND group and could not reach up to the recommended dose of 60/66Gy.

Dynamic Radiographs Are Unreliable to Assess Arthrodesis Following Cervical Fusion: A Modeled Radiostereometric Analysis of Cervical Motion.

In vitro study. The purpose of the present study was to utilize an idealized cervical spine model to determine whether the parallax effect or changes in the position of the spine relative to the x-ray generator influence intervertebral motion parameters on dynamic cervical spine radiographs. The utility of flexion-extension radiographs in clinical practice remains in question due to poor reliability of the parameters utilized to measure motion. A cervical spine model with tantalum beads inserted into the tip of each spinous process was utilized to measure interspinous process distance (IPD) on plain radiographs. The model was then manipulated to alter the generator angle and generator distance, and the IPD was measured. The impact of individual and combined changes in these parameters on IPD was assessed. Multivariate analysis was performed to identify independent drivers of variability in IPD measurements. Isolated changes in the generator distance and generator angle and combined changes in these parameters led to significant changes in the measured IPD at each intervertebral level in neutral, flexion, and extension, which, in many instances, exceeded an absolute change of >1mm or >2mm. Multivariate analysis revealed that generator distance and generator angle are both independent factors impacting IPD measurements that have an additive effect. In an idealized cervical spine model, small clinically feasible changes in spine position relative to the x-ray generator produced substantial variability in IPD measurements, with absolute changes that often exceeded established cutoffs for determining the presence of pathologic motion across a fused segment. This study further reinforces that motion assessment on dynamic radiographs is not a reliable method for determining the presence of an arthrodesis unless these sources of variability can be consistently eliminated. 3.

38. Integration of intramuscular pressure with novel muscle activation strategies in a spine model

<h3>BACKGROUND CONTEXT</h3> The unstable nature of the spine motivates the use of optimization and electromyography (EMG) methods to estimate its individual muscles force activation. Conventionally, muscles are modelled as force vectors negating enclosed constituents such as intramuscular pressure (IMP), a parameter that has been previously shown to influence muscle performance. <h3>PURPOSE</h3> The purpose of this research was to leverage a novel, validated and fully representative finite elements (FE) model of the spine, inclusive of an accurate representation of IMP defined as a fluid-structure continuum, to explore muscle activation strategies subject to equilibrium static spinal stability constraints. <h3>STUDY DESIGN/SETTING</h3> The FE spine model previously developed by the authors, was validated toward its context of use in exploring activation strategies. The FE model consisted of the thoracic and lumbar vertebral bodies (VBs), intervertebral discs (IVDs), major spine muscles inclusive of their IMP (modelled as fluid-structure continuum), thoracolumbar fascia (TLF) tissue, and a model of the IAP similar to that of IMP, which all added up to a total of 273 tissues. <h3>METHODS</h3> Toward exploring the model's validity, three conventional strategies governing minimizing muscle effort, minimizing IVD compressive forces and maintaining stability at all costs were first investigated. All strategies were subject to an equilibrium static stability constraint whereby the activation strategy aimed to retrieve the spine's initial position after a validated, 30 N.m flexion moment, was applied as an external perturbation. Lastly, two novel IMP-based strategies were devised and explored, that is, minimizing and maximizing IMP. Under physiological muscle force and vertebral displacements constraints, activation strategies were quantified and compared in terms of their ability to maintain an equilibrium static spine position. <h3>RESULTS</h3> Validation efforts proved successful whereby the conventional strategies dictated efficacy in muscular activations whilst maintaining an equilibrium stable spine position, as quantified by vertebral displacements, with a maximum difference of 9.8% from documented data. On the other hand, the minimum IMP novel strategy showed that to maintain a high equilibrium stability, minimum individual muscle forces and IMP of 75N and 50 mmHg, respectively, were sufficient. Lastly, excessive increase in IMP, as dictated by the maximum novel IMP strategy, resulted with a compartmental pressure of up to 93 mmHg between muscles, as well as high tensional TLF forces reaching 56.9N. <h3>CONCLUSIONS</h3> This research concluded on the capabilities of FE models to investigate IMP-based activation strategies governed by stability constraints, as shown by the validation results of the conventional strategies investigated. In addition, the requirements of the minimum IMP strategy to achieve stability supported the role of muscles in achieving efficient mobility and stable joints—in other words, maximizing muscular endurance while maintaining a stable spine position. Lastly, the excessive activation of IMP showed a key role of muscles sharing radial loads with surrounding tissues. This led to a build-up of compartmental pressure between muscles, putting the TLF under higher tensional forces, and thus alluding to another role of the TLF which is to passively store loads. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

36. Assessment of static spine stability and relative implications of trunk muscles, thoracolumbar fascia and intra-abdominal pressure

<h3>BACKGROUND CONTEXT</h3> The spine is an inherently unstable structure due to the numerous degrees of freedom it possesses. Yet, its static spinal stability is believed to be maintained by the actions of muscle activations combined with their intramuscular pressure (IMP), intra-abdominal pressure (IAP) generated by the abdominal muscles, and the passive engagement of the thoracolumbar fascia (TLF). Nonetheless, previous studies provide little information about the relative contribution of these tissues. <h3>PURPOSE</h3> The purpose of this research was to leverage a novel, validated and fully representative finite elements (FE) model of the spine to explore the relative actions of spinal muscles, TLF, IMP and IAP, as well as their collective efforts to achieve equilibrium static spinal stability. <h3>STUDY DESIGN/SETTING</h3> A novel, validated and comprehensive FE spine model was previously developed by the authors, which was applied to the current study. The model put forth includes accurate continuum models of all thoracic and lumbar vertebral bodies (VBs), intervertebral discs (IVDs), major spine muscles inclusive of their IMP (modelled as fluid-structure continuum), TLF tissue and a model of the IAP (modeled strategy like IMP). <h3>METHODS</h3> Equilibrium static stability was assessed as the ability of select tissues to restore the spine's initial position after an external perturbation is applied. For this reason, a previously validated spinal perturbation of 350N flexion force was applied at the first thoracic vertebra. Case studies including each tissue on its own, as well as combinations, were investigated. For each scenario, in-planar lumbar VBs final displacements, after tissue activations and applying the perturbation, were recorded in efforts of quantifying equilibrium static stability. Muscle activation was based on validated EMG muscle forces while IAP was introduced as an increasing pressure of 67 mmHg (9 kPa) maximum value in an abdominal cavity. <h3>RESULTS</h3> With the upright spine position being the initial stable position, the application of the 350N perturbation on the model inclusive of only the VBs and IVDs was identified as the most unstable position. Thereafter, activating the IAP, muscles, and TLF contributed individually to 24%, 53.8%, and 77% equilibrium static stabilities, respectively. Furthermore, combined tissues stability results fell between 60% and 93%, with 93% being the result of all tissues activated together to their maximum physiological capability. Another worthwhile finding was the approximately 46% drop in IMP developed by spinal muscles on the passive engagement of the TLF, suggesting its role in stabilizing and preventing excessive muscles pressurization. <h3>CONCLUSIONS</h3> This research concluded that the included muscles, combined with their IMP, IAP and TLF, are major spine stabilizers, contributing to 93% of the spine's equilibrium static stability, as defined in this paper. The TLF in particular, one of the strongest passive tissues in the back, showed to be capable of storing excessive loads, potentially as a protective measure. This was supported by the observed resultant forces at the TLF-VBs connection points, which summed up to around 244N acting opposite to applied perturbation. Lastly, results of this study may assist to better understand the notion of equilibrium static spinal stability as literature and previous studies are still pressing for more representative spine models able to assess other modes of stability. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The Measured Effects of Isometric Loading in a Flexed vs Neutral Lumbar Spinal Position: A Case Report

Abstract: The common understanding that loaded lumbar flexion is a positional hazard and a possible cause for injury has recently been disputed by certain fractions of the manual medicine and exercise science community [1]. Although a polarizing subject, this case study set out to investigate the first hand subjective experience of loaded lumbar flexion on an actual experienced world champion strength athlete. The research question driving this case report was “Does an isometric load applied to a flexed lower back cause more tightness, general discomfort OR pain than that same load applied to a neutral spine?”. A null hypothesis and an Alternative hypothesis was established. For set 1, the participant performed a 30kg dumbbell weighted isometric 45-degree angled hip hinge in lumbar “macro-flexion”. 3 markers were used to gather subjective feedback. The lifter was instructed to notify the researchers verbally when the onset of tightness, general discomfort, and pain began – each marker was assigned a time. Marker 1; tightness was felt at the 12 second mark. Marker 2; general discomfort was experienced at 49 seconds and marker 3; pain occurred from the 85 second mark, which reached a 7/10 VAS score before stopping at 98 seconds. Additionally, the patient experienced residual LBP following the session. After a 1-week wash out period, the participant performed set 2, a 30kg dumbbell weighted isometric 45-degree angled hip hinge with a “relatively neutral” lumbar position. The lifter exceeded set 1’s max time of 98 seconds experiencing no onset of tightness, general discomfort or pain. The patient did not experience any on-going pain after the session either. The results conclude that a “relatively neutral” lumbar spinal position during a loaded isometric hip hinge was less provocative across all 3 markers. Conversely, set 1 showed a very provocative response, with a rapid early onset of tightness, general discomfort and pain - of which the pain lingered beyond the sessions duration. A strong association between loaded lumbar macro-flexion and the onset of tightness, discomfort and pain was observed in this case study – however, more high quality research is required to reach stronger conclusion.

Effect of seat tilting on biomechanics of L4 in tractor drivers

The tilting of the tractors' seat during deep tillage operations affects the drivers' sitting position, which can lead to lumbar spine injuries. To investigate the effect of seat tilting on the driver's L4 biomechanics, we built a tractor-driver musculoskeletal model in AnyBody™. The maximum activity of the driver's erector spinae at different tilted angles were measured by sEMG and compared with the simulation results to validate the model. The spatial position of the driver's spine at different tilted angles were obtained by 3 D motion capture. The model simulated the driver's spine posture during the actual tilt and investigated the effects of different tilted angles and vibration on the biomechanics of the driver's L4 . The results showed that as the tilt angle of the tractor increased, the load on the driver's L4 also increased, especially the shear force increased at a faster rate than the axial and normal forces, with the shear force on the driver's L4 increasing from 0 N to 138.7 N when the tractor was tilted from 0° to 15°. When vibration was applied to the musculoskeletal model, the maximum value of the shear force on the driver became progressively greater as the angle of tilt of the tractor increased. Overall, tilting the tractor can have a large impact on the biomechanics of the driver's L4, and tilting the tractor may be an important cause of lumbar spine injuries for tractor drivers.

A prospective study using an individualized nomogram to predict the success rate of external cephalic version

To establish a clinical-based nomogram for predicting the success rate of external cephalic version (ECV) through a prospective study. This was a single-center prospective study that collected eligible breech pregnant women. 152 participants were enrolled in the training cohort, who received ECV procedures performed by a single operator. We used the training cohort to establish regression equations and prediction models. These variables include maternal factors (age, operation gestational age, pre-pregnancy BMI (Body Mass Index), operation BMI, BMI increase, multipara), ultrasound factors (fetal weight estimation, amniotic fluid index, placental location, type of breech presentation, spinal position), and anesthesia. Univariate and multivariable analyses were used to screen the factors affecting the success of ECV. A nomogram scoring model was established based on these factors. And C-index, DCA (Decision Curve Analysis) and calibration curve, Hosmer–Lemeshow test was used to verify the prediction effect of the model. Finally, 33 participants were enrolled in the testing cohort who received ECV with an unrestricted operator. We used C-index, DCA (decision curve analysis), and Hosmer–Lemeshow to verify the application value of the prediction model. The calibration curves and ROC curves of both the training cohort and testing cohort are plotted for internal and external validation of the model. The ECV success rate of the training cohort was 62.5%. Univariate analysis showed that the predictors related to the success rate of ECV were age, BMI increase value, AFI (amniotic fluid index), breech type, placental location, spinal position, anesthesia, and multipara. The prediction thresholds of the corresponding indexes were calculated according to the Youden index. Multivariate logistic regression analysis showed that BMI increase ≥ 3.85 kg/m2, AFI ≥ 10.6 cm, anesthesia, multipara, and non-anterior placenta were independent predictors of ECV success. Through the internal and external validation, it is confirmed that the model has a good calibration and prediction ability. Our nomogram has a good ability to predict the success rate of ECV.

Does the Rigid External Distraction Device Alter Maxillary Pitch in Cleft Maxillary Distraction?

The rigid external distraction (RED) device is reported to have the ability to three-dimensionally reposition the maxilla. The purpose of this study is to assess the ability of RED to intentionally alter the maxillary pitch. Retrospective cohort study. Institutional practice. A retrospective chart review was completed over the past 12 years and a total of 50 patients met the inclusion criteria. Cephalometric changes and alteration in palatal plane angle. Cephalometric analysis of standardized landmarks was completed on calibrated, standardized lateral cephalograms. Pre-distraction and post-consolidation variables were compared via a two-tailed paired t-test. The mean age at surgery of 12.2 ± 3.2 years. Through distraction osteogenesis (DO), the maxilla was moved anteriorly with a mean distraction distance of 8.4 ± 4.8 mm. The mean change in the angles sella-nasion-A-point angle (SNA), sella-nasion-B-point angle (SNB), and A-point-nasion-B-point angle (ANB) were 10.2 ± 4.8, 0.9 ± 2.7, and 9.3 ± 4.1, respectively. The mean change in the palatal plane angle was −4.4 ± 3.7. The mean change in the vertical position of the anterior nasal spine (ANS) and posterior nasal spine (PNS) in relation to the Frankfort horizontal (FH) were −2.0 ± 4.1 mm and 1.7 ± 3.8 mm, respectively. This study documents short-term findings of RED in a large cleft lip and palate (CLP) population. Despite positioning of distraction eyelets superior to the theoretical center of resistance, a counterclockwise (CCW) rotation of the palatal plane occurred. This suggests that adjunctive methods of vector control should be considered if clockwise (CW) rotation of the palatal plane is intended with the RED device.

The immediate effect of simulating leg-length discrepancy on spinal posture and pelvic position: a cross-over designed study

ABSTRACT Leg-length discrepancy (LLD) is a common condition that may cause posture changes and clinical consequences. Rasterstereography is a valid and reliable method that analyzes posture without radiation exposure and invasive procedures. This study aimed to assess the immediate effect of artificial LLD on pelvic position and spinal posture in athletes. Twenty-four elite karate athletes (14 men, 10 women) were included in the study. Sagittal imbalance, coronal imbalance, pelvic obliquity, pelvic torsion angle, thoracic kyphosis angle and lumbar lordosis angle were measured at different artificial LLD heights (5 –10 –15 –20 mm). Statistical analysis was performed with One-Way ANOVA with repeated measures or Friedman test. In cases where there were significant differences, pairwise comparisons were performed with least significant differences (LSD) test or Wilcoxon signed rank test. There were statistically significant differences in pelvic obliquity (p = 0.001), pelvic torsion (p = 0.001) and lumbar lordosis (p = 0.001) with varying LLD. However, there was no significant difference in sagittal imbalance, coronal imbalance and thoracic kyphosis angle. It has been observed that even a 5-mm LLD causes pelvic position and spinal posture changes. Future studies detecting these changes in populations with LLD via rastersterography may prevent possible musculoskeletal disorders.

Reproducibility of Deep-Inspiration Breath Hold treatments on Halcyon™ performed using the first clinical version of AlignRT InBore™: Results of CYBORE study

Background and purposeTo investigate the reproducibility of deep-inspiration breath hold (DIBH) breast cancer treatments on Halcyon™ performed using the first clinical version of AlignRT InBore™ (Vision RT Ltd., London, UK), a Halcyon’s SGRT dedicated solution. Materials and methodsThe ease and feasibility of DIBH treatments was retrospectively investigated for the initial 22 left breast cancer patients treated on Halcyon™ using AlignRT InBore™. Setup time, Cone beam computed tomography (CBCT) imaging and analysis time as well as overall treatment time were recorded. Online and offline review of CBCT images was undertaken to verify the compliance of breast, heart, spine, sternum and diaphragmatic domes positions. ResultsMean duration of patient setup, CBCT analysis and overall treatment time were 4 min, 1.1 min and 14 min respectively. Online review of 520 CBCT acquisitions by therapists showed minimal positioning shifts with AlignRT InBore™ guidance with mean value of vertical, longitudinal, and lateral shifts of 1.7 mm, −1.7 mm, and −0.2 mm respectively. Meanwhile, offline review of 115 CBCTs by the radiation oncologist, showed reproducible breath hold (BH) with average deviation of breast, heart, spine, sternum and diaphragmatic domes respectively within 2.4 mm, 2.9 mm, 3.3 mm, 3.2 mm and 4.5 mm in magnitude. ConclusionAlignRT InBore™ allows for accurate and reproducible DIBH on Halcyon™ with breast and heart organs’ positions within 3 mm in magnitude of expected position and fully compliant with planning margins (5 mm anisotropic CTV-PTV margins).

CORR Insights®: Altered Cervical Spine Position Results in Decreased Shoulder Rotation Strength.

CORR Insights®: Altered Cervical Spine Position Results in Decreased Shoulder Rotation Strength.

Alternative methods for skeletal maturity estimation with the EOS scanner-Experience from 934 patients.

BackgroundHand-wrist bone age assessment methods are not possible on typical EOS 2D/3D images without body position modifications that may affect spinal position. We aimed to identify and assess lesser known bone age assessment alternatives that may be applied retrospectively and without the need for extra imaging.Materials and methodsAfter review of 2857 articles, nine bone age methods were selected and applied retrospectively in pilot study (thirteen individuals), followed by evaluation of EOS images of 934 4-24-year-olds. Difficulty of assessment and time taken were recorded, and reliability calculated.ResultsFive methods proved promising after pilot study. Risser ‘plus’ could be applied with no difficulty in 89.5% of scans (836/934) followed by the Oxford hip method (78.6%, 734/934), cervical (79.0%, 738/934), calcaneus (70.8%, 669/934) and the knee (68.2%, 667/934). Calcaneus and cervical methods proved to be fastest at 17.7s (95% confidence interval, 16.0s to 19.38s & 26.5s (95% CI, 22.16s to 30.75s), respectively, with Oxford hip the slowest at 82.0 s (95% CI, 76.12 to 87.88s). Difficulties included: regions lying outside of the image—assessment was difficult or impossible in upper cervical vertebrae (46/934 images 4.9%) and calcaneus methods (144/934 images, 15.4%); position: lower step length was associated with difficult lateral knee assessment & head/hand position with cervical evaluation; and resolution: in the higher stages of the hip, calcaneal and knee methods.ConclusionsHip, iliac crest and cervical regions can be assessed on the majority of EOS scans and may be useful for retrospective application. Calcaneus evaluation is a simple and rapidly applicable method that may be appropriate if consideration is given to include full imaging of the foot.

Reduction of Work-Related Musculoskeletal Disorders in Plastic Surgeons by Introduction of a Posture Training Device.

Plastic surgeons have an increased risk for the development of musculoskeletal disorders because of frequent poor ergonomics of the operating room. This study characterizes selected plastic surgery procedures, with an attempt to identify high-risk procedures and procedural components as well as the impact of biofeedback on surgical ergonomics. A commercially available posture training device was used to initially record neck and spine positioning and later to send biofeedback to prompt surgeons to correct posture. Device data were correlated with in-person observations to characterize factors associated with more time spent in the slouched/nonneutral cervical and thoracic spine posture. The proportion of time spent in the upright position during surgery was significantly different among male and female participants, level of training, participant height, in the sitting versus nonsitting positioning (P < 0.001), with loupes use, and if there was more than an 8-inch height difference between 2 participants (mean, 0.70 ± 0.285). Using the device intervention, all participants spent a larger proportion of operating time upright. Half of these improvements in posture were statistically significant. While in feedback mode, participants experienced shorter and more frequent periods of slouching/nonneutral posture. When comparing the same participant performing the same procedure with and without device biofeedback, 72.2% of participants spent more time in the upright/neutral posture during the surgery when the device was sending feedback. Biofeedback devices used in the operating room can lead to improved surgical posture, which may translate to reduction of workplace injuries, and overall physician health. This study found that a commercially available posture training device and sitting stools in the operating room could significantly improve physician cervical and thoracic spine posture.

MRI and Anatomical Determinants Affecting Neuroforaminal Stenosis Evaluation: A Descriptive Observational Study.

PurposeNeuroforaminal stenosis (NFS), a narrowing of the intervertebral foramen, is a cause of disability in the aging population. Formal magnetic resonance imaging (MRI) classification of NSF has been developed recently and contradictory findings have been reported. This study aims to assess whether in-plane, anatomically conformed two-dimensional (2D) views of the neuroforamen characterize NFS more accurately than traditional axial, coronal, and sagittal views in healthy individuals with and without simulated scoliosis.Patients and methodsThis observational study was approved by the designated institutional review board at our academic tertiary care center. Four volunteers underwent lumbar spine MRI twice, once in the supine position and once with intentionally introduced hip tilt. The latter resulted in lumbar curvature mimicking positioning errors approximating degenerative lumbar scoliosis. Anatomically oriented cuts such as axial with endplate correction and coronally obliqued parasagittals, also called coronal obliques, were performed. Standard sagittal and axial views were also performed in both the supine and rotated groups.ResultsCoronal oblique and anatomically oriented axial views demonstrated the highest correlation with true neuroforaminal caliber. Deviation from anatomical congruence resulted in false measurements of neuroforaminal size. The hip-tilt studies produced MR that were less favorable to characterization of the caliber of neuroforamina. Coronal sections demonstrated reliability only when performed at the mid-pedicular lines. Standard axial views were reliable only when taken at the upper one-third of the neuroforamen. Coronal oblique views demonstrated superiority when evaluating consecutive neuroforamen on one image compared to non-obliqued parasagittal slices.ConclusionTo minimize error in neuroforaminal analysis, imaging specialists should perform anatomically oriented cuts to conform to individual patient anatomy. When this cannot be performed due to a patient’s spine rotation or position, the MRI reader should view oblique, axial, and coronal images simultaneously and dynamically for proper foraminal characterization.

Hubungan Posisi Spinal Blok Anestesi Dengan Terjadinya Retensi Urine Pasca Anestesi Di Ruang IBS RSUD dr. H. Jusuf SK Provinsi Kalimantan Utara

Background: Post spinal anesthesia complications, one of which is urinary retention, it is an inabity of the bladder to partially of completely empty urine during urination. In performing injections on the subarachnoid can be done on the patient in a sitting position on the surgery table or in a tilted/lateral decubitus position. Objective: To analyze the corellation between spinal position an the occurrence of post-anesthesia urinary retention, with the inclusion criteria of patients undergoing spinal block anesthesia in sitting position. Research Methods: The design of this research is analytical observation with a cross sectional approach, sampling using pusposive sampling technique. The number of samples as many as 42 people, the sample was taken in the Central Surgical Installation Room of RSUD dr. H. Jusuf SK. Collecting data using observation sheets that have been prepared and given instructions on how to fill them, regarding the patient’s sitting position in spinal surgery, that is the sitting position with both legs straight or sitting sitting position with both knees flexed, as well as the patient’s ability to urinate after spinal surgery, which is less than 8 hours or more than 8 hours after spinal surgery. From the study, the were 16 respondents who experienced post-spinal urinary retention, 13 respondents who received a spinal sitting position with both legs straight and 3 respondents who received a spinal sitting position with both knees flexed. Result: Statistical test using chi square, obtained P value = 0.715, thus P value &gt; alpha (0.05), so Ho is accepted, it means that it can be concluded that there is no correllation between spinal anesthesia block position and the ccurance of post-anesthesia urinary retention.

Altered Cervical Spine Position Results in Decreased Shoulder Rotation Strength.

Strength testing of shoulder rotation is commonly used in clinical examinations of the shoulder. People prone to shoulder injury, such as overhead athletes and manual trade workers, place their shoulders under tremendous amounts of stress when the cervical spine is in nonneutral positions. If these nonneutral cervical spine positions result in decreased shoulder strength, it may help explain the etiology of the high prevalence of shoulder injuries in these populations. Given standard clinical strength assessments are performed with a neutral cervical spine, an investigation into the effects of cervical spine rotation is warranted. We sought to compare isokinetic shoulder rotation strength while in a neutral position with rotated cervical spine positions, specifically (1) with the cervical spine rotated contralaterally with the shoulder elevated in the frontal plane and (2) with the cervical spine rotated ipsilaterally and the shoulder elevated in the scapular plane. A convenience sample of 52 individuals (height 170 ± 10 cm; weight 73 ± 18 kg, age 21 ± 2 years; 18 males, 34 females), without shoulder or cervical spine pathology participated in this study. Participants were screened for eligibility via questionnaire. Concentric shoulder internal and external rotation torque was measured through a 90° arc on an isokinetic dynamometer with the shoulder elevated 90° in the frontal plane, and again 45° anterior to the frontal plane (scapular plane). Two repetitions were performed in a single testing session with the participant's cervical spine in neutral in both planes, maximally rotated contralaterally in the frontal plane, and maximally rotated ipsilaterally with the shoulder in the scapular plane; the second repetition was used for analysis. The testing order was randomized. Data were imported into a platform for statistical parametric mapping analysis (a technique that allows data from the entire arc of motion to be compared with data from another arc to identify differences in the wave form) to compare strength between positions throughout 90° arc of motion. Rotating the cervical spine contralaterally with the shoulder in the frontal plane resulted in a decrease in external (2.24 Nm or 12% average difference; p < 0.001) and internal (2.22 Nm or a 6% average difference; p = 0.02) rotation strength with the forearm within 15° and 20° of the vertical position. Rotating the cervical spine ipsilaterally with the shoulder in the scapular plane resulted in a decrease in external rotation strength (1.27 Nm or a 6% average difference; p < 0.001) throughout nearly all the motion, with peaks approximately 20° and 60° from the horizontal position, and internal rotation strength (1.78 Nm or 5% average difference; p < 0.001) the last 60° towards the horizontal position. Patient populations who require strenuous use of their shoulders in altered cervical spine positions may be at increased risk for injury from decreased shoulder rotator strength. Clinicians should assess shoulder strength in the position the patient requires to use their shoulder because cervical spine position may cause weakness that would be missed in standard testing positions.

A retrospective analysis comparing set up errors from standard versus customised headrests for head and neck radiotherapy

IntroductionIn response to advice from The National Institute for Health and Care Excellence (1) to reduce hospital visits during COVID-19, standard headrests were introduced for head and neck radiotherapy within Northern Centre for Cancer Care (NCCC). The standard headrest requires one mould room appointment compared to 3 appointments with customised headrests. MethodsTwo groups of 10 patients treated between December 2019 and June 2020 were retrospectively analysed by 1 observer. Groups were stratified according to age, sex and tumour site. One group had customised headrest and the other had standard headrest. Five hundred and forty seven cone beam computed tomography images were reviewed. A 6 Degree of Freedom match was performed then chin, shoulder and spine position were assessed using dosimetrist drawn structures. Structures out of the tolerance were recorded. A chi-squared test was used for statistical analysis. ResultsThe out of tolerance chin position count recorded was 21 for customised headrest and 36 for standard headrest, p-value 0.046. The shoulder position count was 13 for customised headrest and 77 for standard headrest p-value <0.001. The spine position count was 3 for CHR and 21 for standard headrest, p-value <0.001. This means the headrests compared are not equivalent in terms of set up reproducibility. Overall the standard headrest group had 10 set-up re-scans and no set up re-scans were recorded in the customised headrest group. ConclusionFewer hospital visits with SHR reduce patient exposure to COVID-19. However, CHR provided a more reliable level of immobilisation in this study. Implications for practiceThe radiotherapy service will be reviewed in line with these findings.

Influence of Nonsyndromic Bicoronal Synostosis and Syndromic Influences on Orbit and Periorbital Malformation.

Oculoorbital disproportion in patients with craniosynostosis has similarities and dissimilarities between syndromic and nonsyndromic cases. The authors hypothesized that these two conditions have specific individual influences as they relate to development of the orbital and periorbital skeletons. A total of 133 preoperative computed tomography scans (nonsyndromic bicoronal synostosis, n = 38; Apert syndrome bicoronal synostosis subtype, n = 33; Crouzon syndrome bicoronal synostosis subtype, n = 10; controls, n = 52) were included. Craniometric and volumetric analyses related to the orbit and periorbital anatomy were performed. Orbital cavity volume was mildly restricted in nonsyndromic bicoronal synostosis (7 percent, p = 0.147), but more so in Apert and Crouzon syndromes [17 percent (p = 0.002) and 21 percent (p = 0.005), respectively]. The sphenoid side angle in Apert syndrome was wider than when compared to Crouzon syndrome (p = 0.043). The ethmoid side angle in Apert patients, however, was narrower (p = 0.066) than that in Crouzon patients. Maxilla anteroposterior length was more restricted in Apert syndrome than Crouzon syndrome (21 percent, p = 0.003) and nonsyndromic cases (26 percent, p < 0.001). The posterior nasal spine position was retruded in Crouzon syndrome (39 percent, p < 0.001), yet the anterior nasal spine position was similar in Apert and Crouzon syndromes. Orbit and periorbital malformation in syndromic craniosynostosis is likely the combined influence of syndromic influences and premature suture fusion. Apert syndrome expanded the anteriorly contoured lateral orbital wall associated with bicoronal synostosis, whereas Crouzon syndrome had more infraorbital rim retrusion, resulting in more severe exorbitism. Apert syndrome developed maxillary hypoplasia, in addition to the maxillary retrusion, observed in Crouzon syndrome and nonsyndromic bicoronal synostosis patients. Risk, II.

Comparison of the ultra-sound-guided peri-capsular nerve group block (Peng block) and the Peng block with the lateral femoral cutaneous nerve block (LFCN) for the fractured hip surgeries – an aprospective, double-blinded randomised study

Background and Aims:We hypothesised that blocking the lateral femoral cutaneous nerve (LFCN) separately may provide an additional advantage to the peri-capsular nerve group (PENG) block in terms of duration of analgesia and patient comfort. Therefore, we conducted a prospective, double-blinded, randomised study comparing the effect of PENG with that of the PENG Plus LFCN block on the duration of analgesia in fractured hip surgery. Rest and Dynamic pain scores for 24 hours were recoded as primary objectives. The duration of analgesia, the time of administration of the block until numerical rating scale (NRS) ≥ 4, the ease of spinal positioning, and side effects were recorded as secondary outcomes.Methods:A total of 124 patients of age group 18 to 80 years, American Society of Anesthesiologists grade 1–3, were randomised into two groups. The ultra-sound-guided PENG block with ropivacaine 0.5% 30 ml and dexamethasone 8 mg was given in group A and ropivacaine 0.5% 25 ml and 5 ml at LFCN separately was given in group B. The NRS after 20 minutes, 25 minutes, and 30 minutes was noted. The ease of spinal positioning was also noted. The NRS at 4, 6, 8, 12, and 24 hours was noted in resting and movement. Any side effects were documented and treated as a hospital protocol. All patients were given a combined spinal epidural with injection bupivacaine 0.5 per cent 1.6 ml with fentanyl 20 µg. Injection paracetamol 1 gram was added 8 hourly in both the groups as a part of multi-modal analgesia. Injection tramadol 25 mg was given if NRS exceeded 4 through a patient-controlled analgesia only bolus dose, a lock-out of 10 minutes, 4 hourly, limit 100 mg, as rescue analgesia.Results:NRS at rest and movement in group A (PENG) mean [inter-quartile range (IQR)] = 3 (3-2), group B (PENG+LFCN) 2 (2-1), respectively. Time to first analgesic request mean (IQR) group A 9.04 (12.5-0), group B 12.12 (14-0), ease of spinal positioning group A 3 (3-2), group B 3 (3-2).Conclusion:The PENG block is an effective block for fractured hip surgeries in providing ease of spinal positioning and post-operative analgesia, and if PENG is combined with the LFCN block, the post-operative analgesia is enhanced by increasing the duration and reduction in the pain score.TableNRS at rest and movement in both groups at 24 hMedian (IQR) P NRS at rest at 24 h Group A3 (3-2)0.00001 Group B2 (3-2)0.0026NRS at movement at 24 h Group A3 (3-3)0.00001 Group B2.5 (3-2)0.00092

Is the lateral tibial spine a reliable landmark for planning tibial or femoral valgus osteotomies?

IntroductionA valgus osteotomy around the knee is a conservative procedure performed to unload the medial tibiofemoral compartment. However, the optimal postoperative alignment target remains controversial. Many studies have applied a “Fujisawa point” at 62.5%. The results of recent studies suggest decreasing the range of the mechanical axis target correction to 50–55%. The primary purpose of this study was to define the mean position of the lateral tibial spine in healthy patients from a reproducible 3-dimensional (3D) analysis. The study hypothesis was that the apex of the lateral tibial spine was a reliable and reproducible landmark for planning valgus osteotomies and preventing overcorrections. Materials and methodsThe study included 1140 patients: 560 women and 580 men, with a mean age of 61.7±16.5 years (18–98) and a mean body mass index (BMI) of 24.9±4.9kg/m2 (13.3–54.6). This analysis was done with the Stryker Orthopaedics Modeling and Analytics (SOMA) system which uses a database of computed tomography (CT) scans and 3D bone models. A statistical assessment was performed to determine the mean position of the lateral tibial spine. These measurements were then compared according to ethnicity, sex, age, BMI, knee side (right and left) and the overall mechanical axis of the leg. ResultsThe mean tibial plateau width was 72.9±5.7mm (59.1–91.1). The mean position of the lateral tibial spine was 53.6±1.1% (48.9–57.2). The mean position of the medial tibial spine was 48.4±2.5% (43.6–56.1) while the center of the tibial spines was 51.0±1.5% (46.4–56.1). Africans had a significantly more lateral mean tibial spine position than Asians (54.7% vs. 53.3%, p=0.001), Caucasians (54.7% vs. 53.7%, p=0.002) and Middle Easterners (54.7% vs. 53.6%, p=0.034). ConclusionThe lateral tibial spine is a simple and reproducible bony landmark. This landmark can be used when planning valgus osteotomies aiming for a “Fujisawa point” at 54%. Level of evidenceIV.