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Journal: Spine


A pooled patient-level analysis of two multicenter randomized controlled trials and one multicenter single-arm prospective trial.

Concepts: Randomized controlled trial,, Joint, Minimally invasive, Sacroiliac joint, Joints



STUDY DESIGN.: A retrospective cohort. OBJECTIVE.: To describe physical therapy utilization following primary care consultation for low back pain (LBP) and evaluate associations between the timing and content of physical therapy and subsequent health care utilization and costs. SUMMARY OF BACKGROUND DATA.: Primary care management of LBP is highly variable and the implications for subsequent costs are not well understood. The importance of referring patients from primary care to physical therapy has been debated, and information on how the timing and content of physical therapy impact subsequent costs and utilization is needed. METHODS.: Data were extracted from a national database of employer-sponsored health plans. A total of 32,070 patients with a new primary care LBP consultation were identified and categorized on the basis of the use of physical therapy within 90 days. Patients utilizing physical therapy were further categorized based on timing (early [within 14 d] or delayed)] and content (guideline adherent or nonadherent). LBP-related health care costs and utilization in the 18-months following primary care consultation were examined. RESULTS.: Physical therapy utilization was 7.0% with significant geographic variability. Early physical therapy timing was associated with decreased risk of advanced imaging (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32), surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) compared with delayed physical therapy. Total medical costs for LBP were $2736.23 lower (95% CI: 1810.67, 3661.78) for patients receiving early physical therapy. Physical therapy content showed weaker associations with subsequent care. CONCLUSION.: Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. Further research is needed to clarify exactly which patients with LBP should be referred to physical therapy; however, if referral is to be made, delaying the initiation of physical therapy may increase risk for additional health care consumption and costs.

Concepts: Health care, Health care provider, Medicine, Spinal disc herniation, Classification of Pharmaco-Therapeutic Referrals, Illness, Opioid, Massage


STUDY DESIGN.: Prospective radiographical analysis of cranial center of mass (CCOM), C2, and C7 plumb lines in young and elderly asymptomatic individuals. OBJECTIVE.: To establish a normal range for craniosagittal balance for both young and elderly asymptomatic individuals. SUMMARY OF BACKGROUND DATA.: Global sagittal balance must account for the position of the head in relation to the spine and pelvis. The C7 plumb line defines thoracolumbar sagittal balance and has been shown to have significant impact on patient outcomes. However, the C7 plumb line fails to take into consideration the position of the head in relation to the pelvis. METHODS.: A total of 100 asymptomatic 20- to 40-year-old patients and 100 asymptomatic 60- to 80-year-old patients were enrolled. Standing plain radiographs of 14 × 36 in were obtained. CCOM, C2, and C7 plumb lines were drawn and measured from the superoposterior endplate of S1. RESULTS.: A total of 78 asymptomatic 20- to 40-year-old patients and 62 asymptomatic 60- to 80-year-old patients had adequate radiographs. The mean plumb line values in the 20- to 40-year-old patients and 60- to 80-year-old patients, respectively, were as follows; CCOM 9.0 mm (SD, 31.5 mm) and 41.2 mm (SD, 35.7 mm); C2 -2.7 mm (SD, 32.7 mm) and 32.1 mm (SD, 33.6 mm); and C7 -16.4 mm (SD, 31.5 mm) and 10.6 mm (SD, 27.8 mm). One-way analysis of variance and Student t tests confirmed that these mean plumb line values were significantly different between young and elderly patients (P < 0.001). The change at each level over time was highly correlated with the other levels (r > 0.97; P < 0.001) as did the degree of change between groups (r > 0.90, P < 0.001). CONCLUSION.: Spinopelvic alignment in conjunction with CCOM has increased our understanding of spinal balance by including the head and may better represent true global spinal balance. CCOM is an easily measured parameter by using the nasion-inion technique.

Concepts: Variance, Mass, Arithmetic mean, Normal distribution, Lead, Analysis of variance, Normative, Plumb-bob


STUDY DESIGN.: Retrospective case series. OBJECTIVE.: This report provides long-term follow-up on athletes who have sustained a cervical spinal cord contusion. Their magnetic resonance (MR) image is correlated with clinical signs and symptoms. Mechanism of injury and a hypothesis of etiology are reported. SUMMARY OF BACKGROUND DATA.: Current return-to-play criteria for athletes who sustain a cervical cord contusion are based on expert opinion only. Decision making for this clinical situation in athletes carries significant clinical, legal, and economic ramifications. The natural history, clinical correlation, and effect of surgery for athletic cervical cord contusions have not been established. The mechanism of injury for this entity has historically emphasized axial loading. METHODS.: The case histories, physical examination, and MR images were reviewed for 4 professional athletes. All athletes had documented cervical cord contusions. None of the athletes had an acute disc herniation, fracture, instability, or focal cord compression. All athletes were contacted by telephone to assess symptoms at a minimum follow-up of 2 years after injury. RESULTS.: All 4 athletes had congenital stenosis, defined as lack of CSF signal around the cord on an MR image. All underwent anterior fusions at the level of their contusion. In follow-up, 2 athletes developed new contusions: one more than 5 years later, adjacent to a fusion; and 1, 2 years later, not adjacent to his previous fusion. No athlete developed permanent neurological sequelae. The presence of a contusion did not correlate with athletes' signs and symptoms. The mechanism of injury was hyperextension. CONCLUSION.: It is hypothesized that the horizontal facet orientation of the C3-C4 level, congenital stenosis, and relative hypermobility in extension are the contributing factors in the cause of this clinical entity. An anterior fusion at the C3-C4 level seems to be the most reliable method of preventing or delaying the return of symptoms. Return-to-play guidelines should emphasize the athletes' history of symptoms in context with their MR image because there is poor correlation between the finding of a contusion and the clinical presentation. Recurrence of symptoms is common and the long-term consequences of repeated episodes remain unknown.

Concepts: Spinal cord, Symptom, Magnetic resonance imaging, Medical diagnosis, Medical signs, Correlation and dependence, Pearson product-moment correlation coefficient, Medical sign


Study Design. A descriptive study of the association between demographic factors, and physical characteristics, and degenerative lumbar spinal stenosis (DLSS).Objective. To shed light on the association of socioeconomic parameters and physical characteristics with DLSS.Summary of Background Data. Lumbar spinal stenosis is a prevalent and disabling condition in the aging population. DLSS is considered to be the most common type and is essentially associated with disc disease, facet joint arthrosis, ligamentum flavum thickening and osteophyte formation. While there is ample information regarding the association between BMI, cardiovascular disorders, smoking habits and disc disease, very little is known about their association with DLSS. Data on the association of body physique (e.g., height and weight) and DLSS are limited.Methods. Two sample populations were studied. The first included 165 individuals with DLSS (mean age 64 ± 9.9 years) and the second 180 individuals without spinal stenosis related symptoms (mean age 62.5 ± 12.6 years). An evaluation of the cross-sectional area of the dural sac and degenerative listhesis for all participants was performed on CT lumbar spine images, utilizing Philips EBW station (Brilliance 64, Philips Medical System, Cleveland Ohio). All participants were interviewed in order to obtain demographic, physical and health data. Independent T- test, Mann-Whitney and Chi-square tests were used to determine the association between parametric and non-parametric variables and DLSS. Logistic regression analysis was carried out in order to reveal predicting variables for DLSS.Results. Stenosis females were significantly heavier and shorter compared to their counterparts in the control group. We also noticed that they delivered babies more often than those in the control group. Prevalence of individuals suffering from diabetes mellitus was significantly higher in the stenosis males compared to control group. In the stenosis group, the frequencies of individuals engaged in heavy manual labor (males) and housekeeping (females) were significantly higher compared to their counterparts in the control group.Conclusions. Heavy manual labor and diabetes mellitus in males and housekeeping (females) play major roles in the genesis of DLSS.

Concepts: Regression analysis, Logistic regression, Disease, Diabetes mellitus, Demography, Population, Non-parametric statistics, Spinal stenosis


STUDY DESIGN.: Meta-analysis on mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion. OBJECTIVE.: To compare mid- to long-term outcomes and complications of the most commonly used instrumentation systems in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA.: A meta-analysis of mid- to long-term results of different methods of instrumentation, including the most currently used all-pedicle screw construct, is lacking. METHODS.: A structured literature review was conducted for studies concerning management of patients with adolescent idiopathic scoliosis with instrumented posterior fusion. Pooled means, standard deviations, and sample sizes were either identified or calculated on the basis of the results of each study. RESULTS.: Meta-analyses were performed on outcomes from 27 studies. Overall, 1613 patients who had been treated with Harrington rods, 361 patients who had undergone Cotrel-Dubousset instrumentation, and 298 patients who managed with all-pedicle screw constructs were reviewed. The mean follow-up was 14.9 years. Cotrel-Dubousset and pedicle screw instrumentations achieved a significantly greater degree of correction of the thoracic curve than Harrington rods (40.3° vs. 14.7°; P < 0.001 and 21.9° vs. 14.7°; P = 0.005, respectively). Cotrel-Dubousset technique achieved a significantly higher degree of correction than all-pedicle screw construct in both the thoracic (40.3° vs. 21.9°, respectively; P < 0.001) and lumbar curves (37.2° vs. 16°, respectively; P < 0.001). Similarly, Cotrel-Dubousset construct achieved a greater correction of both thoracic kyphosis (33.5° vs. 23°, respectively; P < 0.001) and lumbar lordosis (46° vs. 50.7°, respectively; P = 0.002) than pedicle screws. All-pedicle screw fixation was associated with the lower risk of pseudarthrosis, infection, neurological deficit, and reoperation. CONCLUSION.: This study confirms the negative effect of Harrington rods on sagittal alignment. We further found that the degree of correction in the coronal and sagittal planes was higher after Cotrel-Dubousset instrumentation than all-pedicle screw fixation. All-pedicle screw constructs offered the lower risk of mid- to long-term complications and revision surgery.

Concepts: Vertebral column, Scoliosis, Lordosis, Spinal fusion, Kyphosis, Scheuermann's disease, Kyphoscoliosis, Harrington implant


STUDY DESIGN.: Prospective case series study. OBJECTIVE.: To study the effect of percutaneous thoracoplasty-only procedure on curve pattern in mature adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA.: The rib hump prominence on the convex side is the major cosmetic concern among patients with AIS. Thoracoplasty combined with spinal fusion is a commonly used procedure in scoliosis. However, there are no studies regarding the effect of isolated thoracoplasty procedure on curve pattern in skeletally matured patients with AIS. METHODS.: The study involved 7 skeletally matured female patients with AIS. The convex rib hump deformity was measured preoperatively using hump height and hump angle. We performed thoracoplasty without spinal fusion in patients with the Cobb angle less than 40° but with prominent hump deformity. Thoracoplasty was performed percutaneously using 1 or 2 transverse incisions along the rib hump, and apex portions of the deformed ribs were resected. The Cobb angle was measured before surgery, immediately after surgery, and at final follow-up visit. In all cases, clinical satisfaction was assessed using the Scoliosis Research Society Instrument (SRS-22 questionnaires) and trunk appearance perception scale before surgery and at final follow-up visit. RESULTS.: The mean patient age was 20.24 years and an average of 4 ribs were resected. The mean preoperative hump height and hump angle of 38.14 mm and 14.14° improved to 11.70 mm and 11.42° respectively, after surgery (P = 0.018 and 0.042). Preoperative and the final follow-up mean Cobb angles were 35.43° and 45.00°, respectively (P = 0.028). On average, the mean thoracic curve progressed by 9.57°. Preoperative Scoliosis Research Society Instrument SRS-22 questionnaires and trunk appearance perception scale scores of 4.09 and 2.57 respectively improved to and 4.26 and 3.66 after surgery (P = 0.126 and 0.014). CONCLUSION.: Percutaneous thoracoplasty-only procedure gives significant rib humps correction and satisfactory clinical outcome. However, progression of the curve was observed after surgery. This suggests that the convex ribs function as a buttress for curve progression.

Concepts: Vertebral column, Scoliosis, Arithmetic mean, Paul Randall Harrington, Scoliosis Research Society, Thorax, Spinal fusion, Case series


STUDY DESIGN.: This is a case report. OBJECTIVE.: To report a case of soft-tissue reaction to wear debris and osteolysis around a pedicle screw after posterior spine fusion in a pediatric patient. SUMMARY OF BACKGROUND DATA.: Posterior spine fusion with instrumentation is a standard procedure for stabilization and curve correction in patients with scoliosis. Late operative site pain accounts for the highest frequency of reoperation. Debris accumulation for steel and titanium constructs occurs at the pedicle screw-rod junction. Cellular reaction to metal wear may be responsible for osteolysis and aseptic loosening around spinal implants. METHODS.: A 14-year-old male patient with neurofibromatosis and right thoracic scoliosis of 50° underwent posterior spine fusion from T2 to T10. The postoperative course was complicated by continuous pain, and imaging studies demonstrated hardware failure, requiring a revision and subsequent development of a perihilar opacity of unknown origin. Further studies demonstrated hypermobility with adjacent soft-tissue reactivity and inflammation surrounding the right T5 transpedicle screw. RESULTS.: After hardware removal, the patient’s recovery was uneventful. Six months later, a repeated computed tomographic scan demonstrated resolution of the previously described soft-tissue mass and a satisfactory fusion of the thoracic spine. CONCLUSION.: Metal wear debris can form in pediatric patients during the healing process after spinal fusions or when pseudarthrosis is present. Clinically, this manifests as back pain with a possible aseptic inflammatory abscess. Hardware removal can achieve resolution of symptoms and regression of inflammation.

Concepts: Patient, Vertebral column, Scoliosis, Right-wing politics, Thoracic vertebrae, Conservatism, Spinal fusion, Reactionary


Study Design. Retrospective case control study.Objective. To evaluate the effectiveness of bracing in patients with Chiari malformation-associated scoliosis (CMS) following posterior fossa decompression (PFD).Summary of Background Data. The effectiveness of bracing has been poorly studied in CMS patients who have received PFD.Methods. A retrospective study was conducted on 22 CMS patients who received brace treatment for their scoliosis following PFD. Forty-four age- and gender-matched IS patients who received bracing served as the control group. The bracing outcome was considered a failure if the curve worsened ≥ 6°; otherwise, the treatment was considered to be successful.Results. The age and Risser grade were similar between the CMS and IS patients at brace initiation. The initial curve magnitude of CMS patients (mean, 32.9° ± 6.3°; range, 20°-45°) was marginally significantly larger than that of the IS patients (mean, 29.6° ± 6.4°; range, 20°-45°). Until the final follow-up, a ≥ 6° worsening of the major curve occurred in 8 CMS patients (36%) and in 15 IS patients (34%). Overall, 7 CMS patients (32%) and 13 IS patients (30%) underwent spinal fusion surgery. No significant differences were observed between the two groups in the surgery rates or the bracing success rates (P>0.05). In the CMS patients, neither the performance of syringosubarachnoid shunting nor the extent of tonsillar descent correlated with the bracing outcomes, whereas a double major curve pattern was found to be predictive for the failure of bracing.Conclusion. Brace treatment subsequent to PFD is effective in preventing curve progression for 64% of CMS patients, which is comparable to the rate that is observed in IS patients. Double major curve pattern may be a risk factor in predicting treatment failure in CMS patients.

Concepts: Scientific method, Vertebral column, Scoliosis, The Age, Retrospective, Major, Spinal fusion, Scheuermann's disease