European Spine Journal最新文献

Purpose: Intervertebral disc degeneration progresses with normal aging; yet common disc grading schemes do not account for age. Degeneration progression also varies between spine levels and is similarly not accounted for by current grading schemes. These limitations inhibit differentiation between discs with normal and expected aging (non-pathological) and discs with accelerated degeneration (which may be pathological). We sought to develop a statistical model to quantify normal age and spine level dependent disc degeneration.

Methods: Eighty-four asymptomatic adult subjects ranging evenly from 18 to 83 years old underwent magnetic resonance imaging (MRI) of the lumbar spine. Subject traits, MRI-derived disc geometry, and MRI biomarkers of T2 relaxation time were evaluated and used to develop a statistical model to predict effective disc age, the age at which normal aging would produce a disc's observed phenotype.

Results: After evaluating several models, a 4-predictor model utilizing 1) subject height, 2) nucleus pulposus T2 relaxation time, 3) disc mid-sagittal area and 4) disc 3D volume, optimally estimated effective disc age. The effective age closely tracked true age for spine levels L1-L5 (R² ≈ 0.7, RMSE ≈ 10 years) and moderately tracked true age for L5-S1 (R² = 0.4, RMSE = 14 years). The uncertainty in the effective disc age prediction was ± 3 years as assessed by fivefold cross validation.

Conclusion: We offer a data-driven, quantitative tool to quantify normal, expected intervertebral disc aging. This effective age model allows future research to target discs with accelerated degeneration.

Background: Patients with atlantoaxial dislocation combined with atlas occipitalization often present with variations in the anatomy of the vertebral artery and bone, posing potential risks during the implantation of the C2 pedicle screws during surgery.

Objective: Based on comprehensive preoperative imaging evaluation, this study investigates the blood supply, course, and relationship with bone of the vertebral artery in patients with atlantoaxial dislocation combined with atlas occipitalization, aiming to provide reference for safe implantation of internal fixation.

Methods: Imaging data of 77 patients with atlantoaxial dislocation combined with atlas occipitalization from October 2015 to December 2023 at the First Affiliated Hospital of the University of Science and Technology of China were collected, including CT, CT angiography, and MRI. The blood supply, course, and relationship with surrounding structure of the vertebral artery were analyzed using PACS and RadiAnt software.

Results: There were 18 males and 59 females, with an average age of 48.5 ± 10.5 years (range: 17-71 years). Forty-one cases (53.2%) were associated with congenital C2-3 fusion(Klippel-Feil syndrome). Vertebral artery blood supply was predominantly unilateral (including single blood supply) in 56 cases (72.7%), with left-sided predominance (62.5%). Segment V3 course variations of the vertebral artery were common, with 47 cases (35.6%) not entering the transverse foramen of C1. High-riding vertebral arteries were present in 36 cases (46.8%), with 22 cases (61.1%) associated with congenital C2-3 fusion. The average width of the axis pedicle on the high-riding side was 2.13 ± 1.2 mm, and the height of the isthmus was ≤ 5 mm, with an average of 2.55 ± 1.07 mm. There was a loose gap on the lateral side of the vertebral artery within the transverse foramen, with an average of 2.1 mm, and the corresponding width of the subarachnoid space on the inner side of the axis pedicle was 3.48 mm.

Conclusion: Comprehensive preoperative imaging evaluation can reduce the risk of vertebral artery injury during surgery in patients with congenital atlantoaxial dislocation combined with atlas occipitalization, and provide feasible and optimized internal fixation solutions.

Purpose: This study aimed to investigate the differences in postural control effects due to plantar flexor fatigue between individuals with chronic low back pain (CLBP) and healthy controls.

Method: A total of 36 individuals with CLBP and 36 healthy participants took part in the study. Postural stability was evaluated using a force plate before and after a fatigue protocol that involved heel raises. Center-of-pressure (CoP) data were recorded during quiet standing on a rigid surface with eyes open (EO), a rigid surface with eyes closed (EC), and a foam surface with eyes closed (FC). Measurements included mean velocity, the area of the 95% confidence ellipse, and the standard deviation of velocity in both the anteroposterior and mediolateral directions.

Results: After fatigue, individuals with CLBP exhibited greater variability in sway velocity in the mediolateral direction on the foam surface with eyes closed (p = 0.035) and a larger sway area in the eyes closed condition (p = 0.027) compared to healthy controls. All participants demonstrated increased postural sway after fatigue in the more challenging task (EC) compared to the easier task (EO) (p < 0.01). However, the reduction in postural stability due to plantar flexor fatigue was not influenced by the increased difficulty of the postural task in the foam condition compared to the EO condition (p > 0.05).

Conclusions: Localized fatigue in the plantar flexor muscles negatively affected postural control in both CLBP and healthy groups, with a more significant impact observed in individuals with CLBP. This effect was particularly pronounced when visual input was removed.

Purpose: This systematic review aimed to identify predictors of brace treatment outcomes for adolescents or adults with idiopathic scoliosis.

Methods: Four databases including MEDLINE, EMBASE, Web of Science, and CINAHL were searched. Free text and indexed terms identifying the populations, predictions analyses and key outcomes were combined to search the literature. Pairs from eight independent reviewers conducted abstracts and full-text screening, and data extraction. The Quality in Prognostic Studies (QUIPS) tool was used to assess the risk of bias (ROB). Strength of evidence summary statements were formulated based on the risk of bias and the consistency of the research findings.

Results: The search found 2224 articles. After screening, seven articles were included. Only one article showed low ROB, while the others showed moderate ROB. All articles reported on patient-related outcome measurements (PROMS) of quality of life (QOL). Only one parameter achieved limited strength of evidence; shorter treatment time from one study predicted better long-term SRS-22 total scores. For other predictors, the level of evidence was unclear. Other predictors of long-term outcomes (> 1 year follow-up), from only 1 study on each outcome, were: larger Cobb angle predicted worse Spinal Appearance Questionnaire (SAQ) chest scores and worse depression; higher age predicted better SAQ curve scores, larger apical translations predicted worse SAQ shoulders and chest scores; a passive introverted personality or an active outgoing (MPI) character type predicted worse SRS-22 satisfaction; higher BMI predicted better SAQ curve, Rolland-Morris questionnaire (RMQ) lumbosacral pain, Quebec Back Pain Disability Scale (QDS) moving scores, and worse SRS-22 total; larger vital capacity predicted better QDS score; longer bracing (total) predicted worse depression; negative parental attitudes predicted worse depression; higher Strengths and Difficulties Questionnaire emotional symptoms, peer problems, prosocial behavior, and total scores predicted worse depression. Poor compliance from one short-term follow-up study predicted worse change of brace questionnaire (BRQ) for health perception, pain, physical and emotional functioning, and total scores. Moderate evidence from two studies with low and moderate RoB showed that age and Cobb angle did not predict long-term total SRS-22 score for prediction.

Conclusion: Eleven parameters predicted bracing outcomes, but most studies presented moderate risk of bias. Only one parameter, longer treatment time, with limited strength of evidence was predictive of better long-term SRS-22 total scores. Since most findings still present an unclear level of evidence, common weaknesses were identified to encourage design of high-quality studies predicting bracing outcomes.

Background context: Cauda Equina Syndrome (CES) is an emergency clinical syndrome with correlating radiological evidence of spinal compression. Urgent recognition and treatment is key. In many units, it lacks a clear pathway of investigation and referral, despite a constantly expanding evidence base for its management.

Purpose: The aim of this article is to provide a systematic review of currently available guidelines internationally, and also an up-to-date review of current key evidence on topics central to the accurate assessment and investigation of CES.

Study design: A systematic review of the literature was carried out to identify all previously published or proposed pathways internationally for CES.

Methods: Included articles were reviewed and data extracted and collected in excel format. Data extracted included year of publication, author, time to MRI in pathway, inclusion or exclusion of post void residual measurement and specific cauda equina red flags used. An evidentiary review was also carried out on key topics including digital rectal examination.

Results: Following removal of duplicates a total of 307 articles underwent title and abstract screening from which 9 were eventually included for data extraction. All included papers recommended urgent MRI with the presence of red flag findings. Red flags included in all papers were perianal/perineal/saddle sensory disturbance and bladder or bowel dysfunction of varying specifications. 8/9 papers included radicular/sciatic pain, 5/9 included new motor weakness, 4/9 included DRE findings and PVR was included in 5/9 papers. PVR and DR examinations retain clinical significance.

Conclusion: While specific guidelines show minor variability, overall the current literature presents a consensus that in cases of suspected cauda equina syndrome MRI should be carried out on an urgent basis.

Objective: To determine the risk factors for mechanical complications (MC) following corrective surgery for degenerative scoliosis through a machine learning (ML) algorithm.

Methods: Patients with degenerative scoliosis who received corrective surgery were enrolled. A total of 213 cases were ultimately included and randomized into the training set (70%) and test set (30%) to develop the machine learning-based algorithm. The demographic data, comorbidities, regional and global radiographic parameters, paraspinal muscle (PSM) fat infiltration rate (FI%), and vertebral bone quality (VBQ) score were analyzed.

Results: A total of 101 patients (47.4%) had MC, including 46 patients with proximal junctional kyphosis or failure (PJK/PJF), 7 patients with distal junctional kyphosis or failure (DJK/DJF), and 25 patients with rod or screw breakage. In the testing set, Gaussian Naive Bayes (GNB) exhibited the highest AUC at 0.77, while Random Forest (RF) exhibited the highest PRC at 0.63. GNB, RF, and Logistic Regression (LR) models all achieved an accuracy of 0.69, while RF exhibited the highest sensitivity at 0.60 and lowest Brier score of 0.20. Shapley Additive Explanation (SHAP) analysis identified higher FI% of PSM, elevated VBQ score, higher preoperative T1-pelvic angle (T1PA), and postoperative lordosis maldistribution as major risk factors for MC. Based on RF model, local interpretable model-agnostic explanations (LIME) visualization was successfully developed for individual risk calculation.

Conclusion: The RF and GNB models showed the best overall performance. Both RF and GNB models identified top-ranked/major risk factors including higher paraspinal muscle fat infiltration, elevated VBQ score, higher preoperative T1PA angle, and postoperative lordosis maldistribution providing valuable insights for surgical decision-making.

Purpose: The rate of lumbar spine surgeries has increased and the postoperative course is influenced not only by physical but also psychological factors. Patients with pre-existing psychological disorders appear to be more likely to develop anxiety and depression, these factors could negatively affect pain perception, disability, and quality of life. A systematic review and metanalysis were performed to determinate which psychological factors impact on spinal postoperative clinical outcomes and how it can influence postoperative clinical outcomes in patients undergoing spinal surgery.

Methods: A Systematic literature review was performed on the following databases: PubMed/ MEDLINE, Scopus, Psychinfo and Web of Science on October 2022. The quality of the included studies was assessed using the ROBINS-E tool (Risk Of Bias In Non-randomized Studies - of Exposures). This review was registered at Prospero CRD42022380777. Meta-analysis was performed to compare back pain, leg pain disability, quality of life between the group of patients with psychological issues and control groups as continuous outcomes.

Results: Of the identified 1756 studies, eventually 13 studies were included with a total of 5364 patients. Our results suggest that patients affected by anxiety and depression report worse back pain (MD 0.40, 95% CI 0.20 to 0.62, p = 0.0001) and disability (MD 9.58 95% CI 2.67 to 16.48, p = 0.007) levels after spine surgery than patients with healthy mental status. Instead quality of life and leg pain don't show significant differences between the two groups.

Conclusion: Our findings demonstrate a correlation between presence of mental disease and the worsening of post-surgical clinical outcomes. Anxiety and depressive symptoms can influence pain and disability symptoms during the postoperative phase.

Purpose: This study aimed to investigate the associations between electromyography (EMG) activity and key muscle quality parameters, including cross-sectional area (CSA), functional cross-sectional area (FCSA), fat area (FA), and fat infiltration (FI), in individuals with chronic low back pain (cLBP) and those without back pain (no-BP). The objective was to explore how variations in muscle quality affect muscle activation patterns in the erector spinae (ES) and multifidus (MF) muscles during a standardized lifting task in both groups.

Methods: A total of 102 participants were enrolled, comprising 60 individuals with cLBP and 42 without back pain. Muscle activation was measured using a bipolar wireless EMG system during the performance of a 10 kg lifting task. Magnetic resonance imaging (MRI) was utilized to assess muscle quality indicators (CSA, FCSA, FA, and FI) at the L3 level for the ES muscle and the L5 level for the MF muscle. Linear regression models were applied to examine the associations between EMG activity and muscle quality metrics, with adjustments for age, sex, and body mass index (BMI).

Results: In the no-BP group, significant negative associations were found between CSA, FCSA, and EMG activity in the ES muscles (p < 0.05). However, in the cLBP group, no significant associations were observed between CSA or FCSA and EMG activity. Instead, there was a significant negative association between EMG activity and FA/FI in the ES muscles of the cLBP group (p < 0.05).

Conclusion: Muscle quality, particularly fat infiltration, appears to have a greater impact on the amplitude of muscle activities in cLBP patients compared to CSA and FCSA. In contrast to the no-BP group, CSA and FCSA were not significantly associated with muscle activation in the cLBP group, highlighting the need for rehabilitation strategies focused on reducing fat infiltration to improve muscle performance in these patients.

Purpose: To compare the maternal and obstetric health outcomes between pregnant AIS patients treated surgically (AIS surgery), pregnant AIS patients treated conservatively (AIS conservative), and pregnant healthy controls.

Methods: A systematic review and meta-analysis were conducted according to the PRISMA guidelines (PROSPERO: CRD42023439219). PubMed, EMBASE, Scopus, and Cochrane Collaboration Library databases were searched for relevant studies. The risk ratios (RR) and mean differences (MD) were calculated for dichotomous and continuous variables. Heterogeneity was assessed using the chi2 and I2 tests. A fixed-effects or random-effects model was used based on heterogeneity results.

Results: Nine studies involving 4718 women were included. The frequency of caesarean section was higher in the AIS surgery group than in the healthy controls (RR 1.54, 95% CI 1.19 to 1.99), but not compared to the AIS conservative group (RR 1.28, 95% CI 0.96 to 1.69). Patients in the AIS surgery group were more likely to receive general anesthesia during caesarean section than were healthy controls (RR 11.69, 95% CI 3.03 45.13). Patients in the AIS surgery group reported more back pain during pregnancy than healthy controls (RR 4.02, 95% CI 1.20 to 13.49), but not compared to the AIS conservative group (RR 0.81, 95% CI 0.58 1.15). The AIS surgery group had worse scores on the SRS-22 pain and function domains than the healthy controls. There were no differences in marital status or the number of children between the groups.

Conclusion: Pregnant AIS patients treated surgically may have a higher risk of caesarean section and more back pain during pregnancy compared to healthy controls. The AIS surgery group also had worse scores on the SRS-22 pain and function domains than the healthy controls. However, there were no differences in marital status or number of children between the groups.

Objective: Intervertebral disc (IVD)-related pathology is associated with integrity of cartilaginous endplate (CEP), bony endplate (BEP) and their junction. However, ultrastructural details of the CEP, BEP and IVD and their interplay with disc degenerative features such as fissures and calcification are understudied. The current study aimed to ultra structurally explore CEP-BEP junction to IVD features.

Methods: Fifty-nine lumbar motion segments from 13 male human cadavers (range, 21-80 years of age) were analyzed macroscopically, histologically and through scanning electron microscope. The fissures present in CEP & IVD and gaps at the junction of CEP-BEP & CEP-IVD were measured and correlated with calcification, vascular channels and disc degeneration. Energy-dispersive X-ray analysis (EDX) provided the elemental composition of the CEP, BEP and IVD.

Results: Ultrastructural analysis revealed gaps at the CEP-BEP junction which were occasionally bridged by fine fibrillar adhesions. These junctional gap-width were in significant positive correlation with age (p = 0.001), spinal-level (p = 0.01), severity of disc degeneration (p < 0.001) and IVD calcification (p < 0.001). The vascular channels of BEP around the CEP were in significant positive correlation with age (p = 0.003), junctional gap-width (p < 0.001) & severity of disc degeneration (p < 0.001). EDX distribution of calcium in CEP was also associated significantly with junctional gap-width & vascularity (p = 0.03, p = 0.04, respectively).

Conclusion: This is the first study to ultrastructurally assess and map lumbar CEP, BEP and IVD in humans, noting discovery of specific phenotypic patterns of intradiscal calcification, fissures, vascularity and degeneration severity as associated with novel anatomical structures of "adhesion bridges and gaps" which are implicated in marked inflammation and pain.