Total Spine Research Articles

Association between Hypertension, Antihypertensive Drugs, and Osteoporosis in Postmenopausal Syrian Women: A Cross-Sectional Study.

Background Osteoporosis and hypertension are frequent and often coexisting diseases among the elderly. Recent studies suggested that both diseases may share the same etiopathology. Moreover, the treatment of hypertension can affect the bone mineral density and worsen osteoporosis. The aim of this cross-sectional study was to assess the prevalence of low bone mass and osteoporosis in postmenopausal Syrian women and investigate their relationship with hypertension and antihypertensive drugs. Methods 813 postmenopausal women were involved in this cross-sectional study, aged between 40 and 96 yrs. Their menopause duration ranged between 1 and 43 yrs. Bone mineral density was measured using a dual-energy X-ray absorptiometry at the total lumbar spine (L1-L4) and left hip. T-score values were used to determine the diagnosis of osteoporosis. The existence of HTN was defined as blood pressure ≥130/85 mmHg or a history of hypertension medication. Results Using the world health organization criteria, 24% had osteoporosis and 45.2% had low bone mass. The incidence of osteoporosis and low bone mass significantly increased with age and menopause duration and decreased with BMI. Prevalence of hypertension was almost equal among the women who had or did not have osteoporosis. However, hypertensive women who used thiazides or beta blockers had higher values of total lumbar BMD compared with the women who did not. Conclusion Hypertension in postmenopausal Syrian women aged over 40 was not found to be associated with osteoporosis. However, the mean total lumbar BMD of the hypertensive women who took thiazide diuretics or beta blocker was found to be increased significantly comparing to the women who did not take either.

Reliability of a radiation-free, noninvasive and computer-assisted assessment of the spine in children with cerebral palsy

PurposeThe radiation-free, noninvasive and computer-assisted Spinal Mouse® (SM) is a reliable and valid measuring instrument for functional analysis of the pediatric spine. The aim of this study was to examine the intra-rater reliability of the SM measurements in children with cerebral palsy (CP) and to investigate differences after a 1 week of the rehabilitation program.MethodsA total of 168 SM investigations in the sagittal plane and frontal plane at three measurement times from a sample of 28 children (n = 10 girls, age 9.7 ± 3.1 years) with CP were eligible for evaluation. For the verification of reliability, the measurement results from the first and second measurement times (t1, t2) were used at intervals of 1 day. In addition, differences after the rehabilitation program the patients underwent (t3) were evaluated using the measurement results of the first and third measurements (5-day interval).ResultsThe results show good to excellent intra-rater reliability for the SM measurements, both in the sagittal and in the frontal plane (ICC values = 0.69–0.99). Furthermore, significant changes may occur after only 1 week of therapeutic intervention for total spinal inclination (t1: 12.82 ± 5.40, t3: 11.11 ± 5.60, p = 0.014, Cohen’s d = 0.43) and spine length (t1: 401.75 ± 69.05, t3: 409.25 ± 63.58, p = 0.030, Cohen’s d = 0.43).ConclusionsSM can be used to generate reliable values for functional analysis of the spine in children with CP. Furthermore, significant posture differences can be demonstrated by therapeutic interventions, especially in the spine inclination (Inc) and spine length (SL).Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Effect of Extra Virgin Olive Oil and Traditional Brazilian Diet on the Bone Health Parameters of Severely Obese Adults: A Randomized Controlled Trial

Dietary interventions can stabilize and/or reverse bone mass loss. However, there are no reports on its effects on bone mineral density (BMD) in severely obese people, despite the vulnerability of this group to bone loss. We examine the effect of extra virgin olive oil supplementation and the traditional Brazilian diet (DieTBra) on BMD and levels of calcium, vitamin D, and parathyroid hormone (PTH) in severely obese adults. A randomized controlled trial followed-up with severely obese adults (n = 111, with mean body mass index 43.6 kg/m2 ± 4.5 kg/m2) for 12 weeks. Study participants received either olive oil (52 mL/day), DieTBra, or olive oil + DieTBra (52 mL/day + DieTBra). BMD was assessed by total spine and hip dual-energy X-ray absorptiometry. After interventions, BMD means for total spine (p = 0.016) and total hip (p = 0.029) were higher in the DieTBra group than in the olive oil + DieTBra group. Final mean calcium levels were higher in the olive oil group compared to the olive oil + DieTBra group (p = 0.026). Findings suggest that DieTBra and extra virgin olive oil have positive effects on bone health in severely obese adults. The major study was registered at ClinicalTrials.gov (NCT02463435).

Magnetic resonance tomography for the early detection of occult fractures of the spinal column in patients with ankylosing spondylitis

PurposeThe purpose of this study was to determine the extent to which magnetic resonance imaging (MRI) performed in patients with ankylosing spondylitis (AS) after low- and no-energy trauma leads to an improved diagnosis and, as a result, to a change in the therapeutic strategy.MethodsAll patients with AS, who underwent surgery after minor traumas (low-energy traumas, LETs) and patients without trauma history (NET: no-energy trauma), were retrospectively analysed. The diagnostic and planned surgical procedure was examined initially and again after total spine MRI in patients with persistent and/or new complaints.ResultsOne hundred and thirty-six patients with AS after trauma were surgically treated. A total of 92 patients with LETs and 12 patients with NETs were included. After initial diagnostics (CT and X-ray) were performed in 15.4% of the patients with LET or NET (n = 16), we found occult fractures on MRI scans. In ten of these patients (6 LET, 4 NET) in which a previous decision was made to follow conservative therapy, no fracture indication was found on CT or X-ray. Two fracture heights were observed in six patients who experienced LET. However, on X-ray and CT, the fractures were only visible at one height. All fractures were treated surgically with stabilization and decompression if indicated.ConclusionConsidering the high percentage of our patient population with occult fractures, we recommend supplementing the basic diagnostic procedures with an MRI of the entire spinal column in patients with painful spinal column findings after minor trauma and for those with persistent pain without trauma.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Is there cervical spine muscle weakness in patients with Hirayama disease? A morphological study about cross-sectional areas of muscles on MRI.

Patients with Hirayama disease (HD) present with a larger range of neck flexion and show signs of cervical spine instability. Cervical spine stability largely relies on cervical spine muscles. The purpose of this study was to compare the cross-sectional areas (CSAs) of cervical spine muscles between patients with HD and healthy controls, providing some insights into whether there is cervical spine muscle weakness and incongruence in HD patients. In this retrospective study, cervical spine muscles CSAs of 44 HD patients, as well as that of 44 age- and sex-matched healthy counterparts, were measured on the T2-weighted axial MR images. The ratios of cervical spine muscles CSA to the corresponding vertebral body areas, defined as R-CSAs, and the flexor/extensor CSA ratios were computed and compared between two groups. Compared with healthy counterparts, R-CSAs of total cervical spine muscles, total extensors, superficial extensors, and deep flexors were significantly lower in HD patients. HD patients also demonstrated a significantly greater superficial flexor/superficial extensor CSA ratio than the healthy counterparts, indicating a mismatch between superficial flexors CSA and superficial extensors CSA in HD patients. In this pioneering study, HD patients had decreased size in most cervical spine muscles and a mismatch between CSAs of superficial flexor and that of superficial extensors. These results indicate generalized weakness and incongruence of cervical spine muscles, which may predispose cervical spine of HD patients to a less stable situation. These slides can be retrieved under Electronic Supplementary Material.

Management of spinal dural arterio venous fistula with peri-medullar drainage

Introduction: Spinal Dural Arterio Venous Fistula (SDAVF) is an arteriovenous communication on the spinal dura with peri-medullar venous drainage. It is a curable cause of myelopathy and the most common form of spinal arterio venous malformation (AVM). The average age of revelation is the fifth decade; it is a diagnostic and therapeutic emergency.
 Materials and methods: This is a retrospective study conducted in the neuro surgical department of CHU Bab El Oued in Algiers during a five years time from November 2013 to September 2018. We assessed the clinical status of patients according to the Aminoff-Logue disability score before and after surgery. All patients did a total spine MRI followed by a Medullar angiography which facilitated the pin-pointing of the exact location of the dural fistula. The mean follow-up is 30 months.
 Results: There were five males and two females, all of them older than 45 years of age. At the admission, patients presented with signs of neurological deficits. After the diagnosis of SDAVF the surgical intervention consisted of a disconnection of the arteriovenous communication by coagulation and section of the fistula at the foot of the vein after a laminectomy. Functional rehabilitation was prescribed for all patients and they were regularly followed-up.
 Conclusion: Treatment of AVF is surgical or endovascular. Results depend largely on preoperative neurological status.

Validation of the recently developed Total Disability Index: a single measure of disability in neck and back pain patients.

Neck and back pain are highly prevalent conditions that account for major disability. The Neck Disability Index (NDI) and Oswestry Disability Index (ODI) are the two most common functional status measures for neck and back pain. However, no single instrument exists to evaluate patients with concurrent neck and back pain. The recently developed Total Disability Index (TDI) combines overlapping elements from the ODI and NDI with the unique items from each. This study aimed to prospectively validate the TDI in patients with spinal deformity, back pain, and/or neck pain. This study is a retrospective review of prospectively collected data from a single center. The 14-item TDI, derived from ODI and NDI domains, was administered to consecutive patients presenting to a spine practice. Patients were assessed using the ODI, NDI, and EQ-5D. Validation of internal consistency, test-retest reproducibility, and validity of reconstructed NDI and ODI scores derived from TDI were assessed. A total of 252 patients (mean age 55 years, 56% female) completed initial assessments (back pain, n = 115; neck pain, n = 52; back and neck pain, n = 55; spinal deformity, n = 55; and no pain/deformity, n = 29). Of these patients, 155 completed retests within 14 days. Patients represented a wide range of disability (mean ODI score: 36.3 ± 21.6; NDI score: 30.8 ± 21.8; and TDI score: 34.1 ± 20.0). TDI demonstrated excellent internal consistency (Cronbach's alpha = 0.922) and test-retest reliability (intraclass correlation coefficient = 0.96). Differences between actual and reconstructed scores were not clinically significant. Subanalyses demonstrated TDI's ability to quantify the degree of disability due to back or neck pain in patients complaining of pain in both regions. The TDI is a valid and reliable disability measure in patients with back and/or neck pain and can capture each spine region's contribution to total disability. The TDI could be a valuable method for total spine assessment in a clinical setting, and its completion is less time consuming than that for both the ODI and NDI.

Caregiver Patient Reported Outcomes Measurement Information System (PROMIS) profiles in patients undergoing total joint arthroplasty and spine surgery: a prospective observational cohort study

Background/ObjectiveThe role of caregiver psychosocial characteristics and their relation to postsurgical caregiving capability remains unclear. The objective of this study was to explore caregiver psychosocial variables following surgery of patients...

The effect of simulated sheep grazing on male and female reproductive performance in Caragana microphylla Lam. (Leguminosae)

Understanding the reproductive response of host plants to herbivores is important in grazing ecology and grassland management. Simulated grazing experiments were conducted to determine the influence of different grazing intensities on reproductive performance of a shrub, Caragana microphylla Lam. The total leaf mass, total flower mass, total flower mass allocation, and single flower mass allocation decreased with increased grazing intensity. The total spine mass, single flower mass and total spine mass allocation increased with increased grazing intensity. The stem mass, stem mass allocation and total leaf mass allocation had not significant change with the increasing grazing intensity. Under heavy grazing treatments, the host plants significantly decreased their investment in reproduction and increased investment in physical defense organs. Although there were no significant differences in the number of ovules among different grazing intensities, herbivory negatively affected reproductive performance, including the number of flowers, the number of pollen grains per flower, the number of ripe seeds and the rate of pod-set in host plants. These results indicate that there are trade-offs among vegetative and reproductive and defensive organs. Compared with male reproduction, female reproductive performance was less sensitive to herbivory and grazing intensity. Moreover, pollen grains from heavily browsed plants seemed to be less likely to sire pods and ripe seeds than those from unbrowsed plants, indicating that herbivory not only decreased pollen production, but also adversely affected pollen performance.

Bone mark changes after an eight-month intervention in an osteogenic sport and in physical education in low-income children

Summary Aim Regular physical activity and/or sports practice play an important role in peak bone mass. However, the role of different physical-sportive approaches on bone health is not fully understood, especially in low-income children. The aim of this study was to analyze the changes in bone markers (bone mineral density–BMD and bone metabolism) promoted by two different exercise programs (osteogenic sport and Physical Education–PE) in low-income children. Methods An 8-month intervention program in children (8.07 ± 1.38 years at baseline) was conducted in two groups, Martial Arts (G1, n = 14) and PE (G2, n = 12). BMD was obtained by dual energy X-ray absorptiometry. To determine bone metabolism, serum osteocalcin and alkaline phosphatase (ALP) were collected as indicators of bone formation. General Linear Model (GLM) - ANOVA was used to analyze longitudinal effects in repeated measures with adjustments for maturational stages, calcium consumption and serum vitamin D. Results The within the groups analysis highlighted significant differences for BMD at the arms and spine, and for serum ALP for both groups. After the interventions, G1 presented significant changes in BMD of the total body, femoral neck, proximal total femur and spine (P ≤ 0.05), while G2 presented statistically significant changes in serum ALP levels. The group × time analysis showed significant differences in BMD at the arms (Δ% G1 = 8.1 vs. Δ% G2 = 3.7), and at the spine (Δ% G1 = 5.7 vs. Δ% G2 = 5.0). and in serum ALP (Δ% G1 = 61.1 vs. Δ% G2 = 171.0). Conclusion Both exercise programs increased BMD in the arms and the spine and increased serum alkaline phosphatase levels of low-income children, even after adjustments for potential confounders.

Ethnic differences in craniofacial and upper spine morphology between European and Asian children with skeletal Class III malocclusion

The aims of this study were to analyze differences in craniofacial and upper cervical spine morphology, including posterior cranial fossa and growth prediction signs between European and Asian skeletal Class III children, and to analyze associations between morphologic deviations in the upper cervical spine and craniofacial characteristics. A total of 60 skeletal Class III children, 19 Danes and 41 Koreans, were included. Upper spine morphology, Atlas dimensions, and craniofacial morphology, including posterior cranial fossa and growth prediction signs, were assessed on lateral cephalograms. Differences and associations were analyzed by multiple linear and logistic regression analyses adjusted for age and gender. In the craniofacial morphology, the inclination of the maxilla (NSL/NL, P<0.05) and the shape of the posterior cranial fossa (s-d, d-p, p-iop; P<0.01 and P<0.0001, respectively) were significantly different between the 2 groups. There was no significant difference in upper cervical spine morphology and Atlas dimensions between the groups. Fusion was significantly associated with the sagittal jaw relationship (P<0.05), and the total upper spine deviations were significantly associated with some growth prediction signs (P<0.05, P<0.01). Atlas dimensions were significantly associated with the prognathia of the mandible (P<0.05), posterior cranial fossa (P<0.01, P<0.0001), and some growth prediction signs (P<0.05, P<0.01). Upper spine morphology and Atlas dimensions may provide valuable information for predicting jaw growth and craniofacial morphology in Class III malocclusion.

Performance of On-Call Radiology Residents in Interpreting Total Spine MRI Studies for the Detection of Spinal Cord Compression or Cauda Equina Compression.

OBJECTIVE. Accurate diagnosis of spinal cord compression (SCC) or cauda equina compression (CEC) is important in the emergency setting so management decisions may be made promptly. The purpose of this study is to evaluate the performance of on-call radiology residents in interpreting total spine MRI studies for the detection of SCC or CEC. MATERIALS AND METHODS. On-call radiology residents' preliminary interpretation of total spine MRI studies performed over a period of two and half years were evaluated. Agreements and disagreements were determined for SCC (defined as severe spinal stenosis with compression of the spinal cord and lack of surrounding CSF), CEC (defined as > 75% narrowing of the lumbar canal and lack of CSF in the thecal sac), and the presence of other significant findings that might impact clinical management. Studies with true-positive, true-negative, false-positive, and false-negative findings were identified. RESULTS. SCC or CEC was present in 72 of the 295 studies with preliminary interpretations done by on-call residents. The sensitivity and specificity for detecting SCC or CEC were 93.1% and 98.2%, respectively. Sensitivity was higher for 3rd- and 4th-year residents (97.7%) than for 2nd-year residents (86.2%). Other significant findings were present in 34 of the 295 studies. The overall sensitivity and specificity for the detection of other significant findings were 85.3% and 100.0%, respectively. The level of training did not affect the detection of other significant findings. CONCLUSION. The overall sensitivity of on-call radiology residents' interpretation of total spine MR images for the detection of SCC or CEC was high, improving with their level of training. However, residents' sensitivity was slightly less for the detection of other significant findings. Resident performance can be further improved with focused training and the use of a preliminary interpretation template.

Trends in Spine Surgery Training During Neurological and Orthopaedic Surgery Residency: A 10-Year Analysis of ACGME Case Log Data.

Spine surgery training in the United States currently involves residency training in neurological or orthopaedic surgery. Because of different core residency surgical requirements, the volume of spine surgery procedures may vary between the 2 residencies. We reviewed the Accreditation Council for Graduate Medical Education resident case logs for both orthopaedic surgery and neurological surgery for exposure to spine surgery procedures for the graduating years of 2009 to 2018. The average number of spine surgery procedures performed during that 10-year period was 433.8 for neurosurgery residents and 119.5 for orthopaedic surgery residents (p < 0.01). From 2009 to 2018, neurosurgery residents saw an increase of 26.5% in spine surgery procedures (from 389.6 to 492.9 procedures), whereas orthopaedic surgery residents saw a decrease of 41.3% (from 141.1 to 82.8 procedures). The 10-year average percentage of total spine procedures among all total surgical cases was 33.5% for neurosurgery residents compared with 6.2% for orthopaedic surgery residents (p < 0.01). This percentage decreased for both neurosurgery residents (35.8% in 2009 to 31.3% in 2018) and orthopaedic surgery residents (7.2% in 2009 to 4.9% in 2018). Neurosurgical residents performed 3.6 times more total spine procedures than orthopaedic surgery residents on average, a number that increased from 2.8-fold in 2009 to 6.0-fold in 2018. The case volume of spine surgery procedures varies greatly, with higher rates for neurological surgery and lower rates for orthopaedic surgery residencies, with an increasing discrepancy over time. Although case volume alone cannot solely determine quality of training, it is one measure to assess opportunities to develop optimal spine education around a certain accepted volume of surgical patient care. Not accounted for here are additional postgraduate spine cases performed by orthopaedic surgery residents who pursue spine fellowship training (an additional 300 to 500 cases). The results described herein may help to explore the various needs of and differences between residents seeking to pursue careers in spine as well as the role of spine surgery fellowships currently and in the future.

The Impact of Serum C-peptide Level on Bone Mineral Density in Postmenopausal Type 2 Diabetic Women.

Objective: Recent studies suggested that c-peptide had biological activity on bone metabolism. We aimed to evaluate the impact of c-peptide level on bone mineral density (BMD) in postmenopausal type 2 diabetic women.&#x0D; Methods: Thirty-five insulin naïve type 2 diabetic postmenopausal women were included in our prospective cohort study. Fasting and random c-peptide, parathyroid hormone (PTH), vitamin D, insulin, alkaline phosphatase level (ALP) levels and BMD were evaluated.&#x0D; Results: The mean age of patients was 61.8±8.56 years. The mean fasting c-peptide, random c-peptide and insulin levels were 3.0±1.24, 7.7±3.7 and 13.9±11.2 µIU/ml, respectively. The mean femoral neck (FN-BMD) and total lumbar spine bone mineral density (L-BMD) were 0.787±0.127 and 0.919±0.122 g/cm2, respectively. C-peptide level was associated with total hip BMD (p&lt;0.05) but this relation disappeared after regression analysis adjusted for confounders. A negative correlation between PTH level and FN-BMD was found (p=0.01). Total hip BMD and L-BMD were negatively correlated with age (p=0.01 and p=0.02, respectively). A positive association between DPP4 inhibitor treatment and total hip BMD was observed (p=0.03).&#x0D; Conclusions: We observed a positive association between total hip BMD and serum c-peptide level. However, this relationship disappeared in multiple linear regression analysis. Further studies are necessary to evaluate the impact of c-peptide level on the risk of osteoporosis in T2DM.

NATURAL HISTORY OF LUMBAR CANAL STENOSIS: CLINICAL ASPECTS AND SAGITTAL BALANCE

ABSTRACT Objective To compare the sagittal alignment (SA) parameters in individuals with LCS and surgical indication with a control group and to study the correlations between SA parameters and ODI, VAS and EQ-5D in individuals with LCS and surgical indication. Methods In this multicenter cross-sectional case-control study, the individuals were allocated as follows. A stenosis group (SG) composed by patients with LCS confirmed by magnetic resonance imaging with surgical indication, treated between July 2010 and August 2016 and a control group (CG), without LCS. All subjects underwent anamnesis, completed the Health-related Quality of Life (HRQoL) and total spine radiographs were taken. Clinical data, HRQoL and radiographic parameters were correlated. Results Sixty-four individuals formed the SG and 14 the CG. The SG had higher values of mean age, coronal imbalance, sagittal vertical axis (SVA), pelvic tilt (PT), sacrofemoral distance (SFD), overhang (OH), PI-LL mismatch, Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for pain and smaller thoracic kyphosis (TK), total (TLPL) and regional lumbopelvic lordosis (RLPL) in all vertebrae, sagittal offset (SO) in all evaluated vertebrae and EuroQol-5D (EQ-5D) with p &lt;0.05. In the SG, the only significant correlations (p &lt;0.05) were between TK and ODI and EQ-5D; all the other sagittal parameters did not correlated with VAS, ODI or EQ-5D. Conclusion SG had SA parameters altered in relation to CG. There was a direct correlation between decrease in TK and worsening of ODI and EQ-5D in SG. Level of evidence: III; Case Control Study.

The Effect of Bracing on Spinopelvic Rotation and Psychosocial Parameters in Adolescents with Idiopathic Scoliosis.

Study DesignRetrospective study.PurposeTo evaluate the effect of bracing on spinopelvic rotation and psychosocial parameters in adolescents with idiopathic scoliosis (AIS).Overview of LiteratureComplex three-dimensional deformity in AIS is proposed to influence the spinopelvic parameters and psychosocial condition in adolescents; however, few studies have quantitatively evaluated these parameters.MethodsThirty AIS who were prescribed a brace were included in the study. The patients’ standing postero-anterior and total spine radiographs were used to measure the primary curve Cobb angle, vertebral rotation, and pelvic rotation. Apical vertebral rotation (AVR), upper AVR, and lower AVR were measured using the Nash-Moe method. Pelvic rotation was determined using the left-to-right hemipelvic width ratio. The curve pattern was classified as per the Lenke classification system. In all, 14 patients had a type I curve, five had type II, six had type III, one had type IV, and four had type V curves. Brace compliance was subjectively evaluated by interviewing the patients and their parents. The health-related quality of life (HRQOL) and stress level of the recruited patients were assessed using the Brace Questionnaire and Bad Sobernheim Stress Questionnaire, respectively.ResultsThe Cobb angle significantly decreased with at least 6 months of brace use. AVR correction changed significantly; however, no such results were observed for upper and lower AVR. Pelvic rotation and psychosocial parameters were not significantly affected by brace use. No statistically significant correlation was observed between brace compliance and curve correction.ConclusionsThe Cobb angle and AVR are crucial measurements that help evaluate the treatment efficacy in AIS with small curves who undergo brace treatment. HRQOL and pelvic axial rotation are not influenced by the brace treatment.

The associations among lead exposure, bone mineral density, and FRAX score: NHANES, 2013 to 2014.

Lead exposure has been suspected as a risk factor for osteoporosis. However, in epidemiological studies, the association between environmental lead exposure and bone health were inconsistent. With the decrease of lead exposure in recent decades, we evaluated the association between lead exposure and bone mineral density (BMD) in the general US population in this study. We analyzed data on 1859 adults (aged ≥40 years) from the National Health and Nutrition Examination Survey (NHANES) conducted in 2013-2014 to determine the relationship among lead exposure measured by both blood and urine lead concentration, BMD of total spine and femur, and FRAX score in a cross-sectional study. In premenopausal women, the results showed a 1-unit increase in natural log-transformed blood and urine lead levels was associated with a decrease in total femur BMD of 0.061 g/cm2 (S.E. = 0.015; p = 0.001) and 0.046 g/cm2 (S.E. = 0.018; p = 0.020), respectively. Moreover, in premenopausal women, a 1-unit increase in natural log-transformed blood level was associated with a decrease in total spine BMD of 0.054 g/cm2 (S.E. = 0.019; p = 0.013). Both FRAX scores were positively correlated with blood and urine lead levels in subjects without fractures, while the 10-year hip fracture risk score was positively associated with lead exposure in subjects with a history of fracture or vertebral fracture. In conclusion, lead exposure was associated with decreased total femur and spine BMD, and FRAX score in the general US population. Further research is needed to elucidate the causal relationship among lead exposure, BMD, and fracture risk.

P3. Perioperative immunonutrition in spine and total joint surgery

BACKGROUND CONTEXT In the current era of adding value to health care, modifiable risk factors have become a major focus. Quality and outcomes are now measured, reported, and tied to reimbursement. Recent studies in orthopedic surgery and spine surgery have shown nutritional status to be one of the most significant risk factors for post-operative complications. Our purpose for this study is to evaluate if perioperative nutritional support can reduce post-operative complications and improve outcomes in orthopedic and spine surgery patients. PURPOSE To evaluate if perioperative nutritional support with immunonutrition containing arginine, glutamine, omega 3 fatty acids, and nucleotides can reduce post-operative complications and improve outcomes in orthopedic and spine surgical patients. STUDY DESIGN/SETTING For a 12-month period from November 2016 to October 2017 we prospectively collected data for inpatient total joint replacements and spine surgeries occurring at two hospitals. Surgeries were performed by one of two fellowship trained Orthopedic spine surgeons. PATIENT SAMPLE A total of 125 patients were included. Patients were excluded from the study if they were receiving radiation, or chemotherapy, at the time of surgery or were non compliant with the nutritional protocol. Included patients were adults over the age of 18 undergoing elective spine or total joint replacement surgery OUTCOME MEASURES Postoperative complications, readmissions, reoperations were recorded. Number needed to treat and absolute risk reduction were calculated to evaluate results. METHODS Data were prospectively collected for inpatient total joint replacements and spine surgeries for 12 months beginning November 2016 and ending October 2017. All patients were followed a minimum of 90 days after surgery. The immunonutrition group was instructed to consume two 8 oz bottles of Ricochet Nutrition (Revive Medical, Brighton, MO USA) each day for 6 days before, and 6 days after, surgery. Outcome data was collected on reoperations, readmissions, and complications including: surgical site infections, Pneumonia, UTI, sepsis, and acute MI. RESULTS A total of 125 patients (62 in immunonutrition group and 63 in the control group) were included and no difference was found between the two groups regarding surgery type, comorbidities, sample size, and demographics. The control group had a total of 8 patients with complications after surgery: 1 pneumonia, 3 UTIs, 1 incisional hernia, and 2 deep surgical site infections. There was a total of 3 reoperations and 4 readmissions in the control group. The immunon trition group had no reoperations, no readmissions, and no complications. CONCLUSIONS Our study provides strong evidence that perioperative immunonutrition (containing Arginine, Glutamine, Omega 3 FAs and Nucleotides) reduces complications, reoperations and readmission for inpatient orthopedic and spine surgery patients.; Patient optimization prior to surgery should include optimizing nutritional status with immunonutrition. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

113. Segmental contribution to total cervical flexion-extension motion before and after cervical disc arthroplasty (CDA): influence of prosthesis design

BACKGROUND CONTEXT As a healthy cervical spine undergoes motion from extension to flexion, individual motion segments move synchronously throughout the arc of motion. The contribution of an individual spinal segment as a fraction of the total motion of the cervical spine (termed here the segmental motion fraction) depends on the flexibility of the spinal segment, but remains nearly constant in healthy segments with small variations around the average value during the arc of motion. Hypermobility, indicative of an unstable motion segment, will cause the segmental motion fraction to deviate substantially from the average value over a portion of the arc of motion. Segmental motion fraction analysis offers a bridge between motion response measured in the laboratory and in vivo kinematic assessment. PURPOSE To investigate: (1) motion contributed by individual spinal segments (C5-C6 and C6-C7) as a fraction of total cervical spine motion through the arc of motion from extension to flexion, and (2) how cervical disc prosthesis design may influence segmental motion contribution. STUDY DESIGN/SETTING Biomechanical study of CDA using Mobi-C and M6-C prostheses. PATIENT SAMPLE Sixteen human cervical spine specimens (C3-T1, 43±6 years). OUTCOME MEASURES Segmental and total cervical motion throughout the arc of motion in flexion-extension (F-E). METHODS We tested 16 human C3-T1 spine specimens under physiologic loads; first intact, after implantation of cervical disc prosthesis by an arthroplasty-trained surgeon at C5-C6 (1-level), and then at C5-C6 and C6-C7 (2-level). The Mobi-C and M6-C disc prostheses were used for 1- and 2-level implantations in eight specimens each. F-E motion was assessed before and after CDA. Quality of motion was assessed using the contribution made by each index segment toward the motion of the C3-T1 cervical spine during the F-E arc of motion. RESULTS Intact: In the intact specimens (N=16), The C5-C6 and C6-C7 segments contributed on average 23%±2.5% and 21%±3.0%, respectively, towards the total F-E motion of C3-T1 specimens. Peak deviations from the average contributions were 12%±6.1% and 14%±9.8%, respectively. M6-C (N=8): After disc replacement using the M6-C prosthesis, the contributions towards the C3-T1 F-E motion by the C5-C6 and C6-C7 segments changed to 23%±4.0% and 22%±3.8%, respectively. The peak deviations from the average contributions were 16%±3.9% and 16%±6.5%, respectively. Mobi-C (N=8): After disc replacement using the Mobi-C prosthesis, the contributions towards the C3-T1 F-E motion by the C5-C6 and C6-C7 segments changed to 23%±4.3% and 18%±6.5%, respectively. The peak deviations from the average contributions were 36%±23% and 53%±31%, respectively. CONCLUSIONS The M6-C artificial disc restored physiologic quality of motion such that the implanted C5-C6 and C6-C7 segments continued to function in harmony with the other segments of the cervical spine as before arthroplasty. The average motion contribution and the peak deviations from the average after CDA remained nearly unchanged from the healthy intact values. Conversely, the Mobi-C prosthesis, while maintaining average motion contributions similar to the pre-implantation values, demonstrated large deviations in motion contribution over the F-E arc of motion in 10 of 16 implanted segments. This behavior was attributed to the locking of the prosthesis over a portion of the arc of F-E motion in these implanted segments. Such nonphysiologic implant kinematics could lead to excessive wear of the prosthesis, and motion- and stress-shielding at adjacent segments. FDA DEVICE/DRUG STATUS Mobi C Cervical disc prosthesis (Approved for this indication), M6 C Cervical disc prosthesis (Investigational/Not approved)

Trends in Spine Surgery Training During Neurological and Orthopedic Surgery Residency: A Ten-Year Analysis of ACGME Case Log Data

Abstract INTRODUCTION Spine surgery training in the United States currently involves residency training in neurological or orthopedic surgery. Due to different core residency surgical requirements, volume of spine surgery procedures may vary between the two residencies. METHODS The Accreditation Council of Graduate Medical Education resident case logs for both orthopedic surgery and neurological surgery were reviewed for exposure to spine surgery procedures for the graduating years of 2009 to 2018. RESULTS The average number of spine surgery procedures performed during that 10-yr period was 433.8 for neurosurgery residents and 119.5 for orthopedic surgery residents (P &lt; .01). From 2009 to 2018, neurosurgery residents saw an increase of 26.5% in spine surgery procedures from 389.6 to 492.9 procedures whereas orthopedic surgery residents saw a decrease of 41.3% from 141.1 to 82.8 procedures. The 10-yr average percentage of total spine procedures of all total surgical cases was 33.5% for neurosurgery residents compared to 6.2% for orthopedic surgery residents (P &lt; .01). This percentage decreased both for neurosurgery residents (35.8% in 2009 to 31.3% in 2018) and orthopedic surgery residents (7.2% in 2009 to 4.9% in 2018). Neurosurgical residents performed on average 3.6 times more total spine procedures than orthopedic surgery residents, a number that increased from 2.8-fold in 2009 to 6.0-fold in 2018. CONCLUSION Case volume of spine surgery procedures vary greatly with higher rates for neurological and lower for orthopedic surgery residencies, with an enlarging increasing discrepancy over time. Although case volume alone cannot solely determine quality of training, it is one measure to assess opportunities to develop optimal spine education around a certain accepted volume of surgical patient care. The results found here may help to explore various needs and differences between residents seeking to pursue careers in spine, and the role of spine surgery fellowships currently and in the future.