European Spine Journal最新文献

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.

Purpose: The study's aim was to characterize the variations in spinopelvic alignment among an asymptomatic population and to establish a classification system for this alignment. Additionally, it sought to formulate predictive formulas for lumbar lordosis (LL) based on pelvic incidence (PI) to enhance the accuracy of spinal balance assessments.

Methods: This cross-sectional study included 726 asymptomatic individuals. Sagittal parameters were assessed through radiographic evaluation. Participants were categorized into clusters using K-means clustering. A decision tree incorporating PI and sacral slope (SS) was utilized to define the classification criteria. Linear regression models were developed to predict LL and PT, integrating the newly established classification.

Results: The sample was evenly divided into three clusters with distinct PI and LL averages. Cluster-specific predictive formulas for LL and SS were generated, highlighting the importance of spinopelvic alignment in spinal balance. For instance, in one cluster, the formula for LL was LL = 0.68*PI + 24.82, indicating a moderate correlation.

Conclusion: The research successfully identified different patterns of sagittal balance and developed cluster-specific predictive formulas for LL based on PI. The findings underscore the significance of recognizing the anteverted pelvic subgroup for improving the precision of LL and SS predictions, which is vital for spinal surgery planning and achieving optimal sagittal balance.

Purpose: The low positive rate of microorganism culture and nonspecific clinical manifestations increase the difficulty of diagnosing spinal infection. To date, no studies have reported differences in radiological manifestations between fungal spondylitis (FS) and brucellar spondylitis (BS). This may lead to severe misdiagnosis. In this study, we aimed to investigate the typical radiological features of these two types of spondylitis and evaluate the application of computed tomography (CT) values in their diagnosis.

Methods: A total of 59 elderly patients with 119 infected vertebrae were included. 44 patients with 91 infected vertebrae were included in the BS group, and 15 patients with 28 infected vertebrae were included in the FS group. Differences in radiological features and parameters were compared by using the Mann-Whitney U test, χ² test or Fisher's exact test. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic efficiency of the radiological parameters and CT values.

Results: Framework destruction was a typical imaging feature in patients with FS (p < 0.001). In contrast, patients with BS were more prone to concave destruction (p = 0.002), corner destruction (p = 0.010) and severe marginal osteosclerosis (p < 0.001). The longitudinal erosion ratio (AUC = 0.948) and CT value (AUC = 0.789) exhibited excellent diagnostic utility.

Conclusions: The degree of bone destruction and severity of osteosclerosis significantly differed between the two types of spondylitis. Measuring the CT value and erosion ratio facilitates increased diagnostic accuracy and efficiency.

Purpose: Ageing, long illness duration, and poor preoperative Japanese Orthopaedic Association (JOA) score were reported to be risk factors for residual pain after cervical ossification of the posterior longitudinal ligament (cOPLL). In this study, we focused on residual neuropathic pain (NeP) and aimed to elucidate risk factors for residual NeP after cOPLL.

Methods: Total of 234 patients who underwent cOPLL surgery were included. NeP was evaluated using painDETECT (PDQ) and Spine painDETECT (SPDQ) questionnaires. Score of ≥ 13 / ≥ 0 was defined as NeP for PDQ/SPDQ. Patient backgrounds factors, preoperative radiographic factors and surgical factors were reviewed, and comparisons between the NeP(+) and NeP(-) groups were made. Independent risk factors for residual NeP were evaluated using multiple logistic regression analysis.

Results: Prevalence of residual NeP after cOPLL was 22.6% on PDQ and 55.1% on SPDQ. Preoperative JOA score was significantly lower in the NeP(+) group for PDQ compared with that in the NeP(-) group. Additionally, cervical lordosis angle was significantly lower in the NeP(+) group for SPDQ compared with that in the NeP(-) group. Following multiple logistic regression analysis, poor preoperative JOA score was identified as a risk factor for NeP on the PDQ. Poor preoperative JOA score and low cervical lordosis angle were identified as risk factors using the SPDQ.

Conclusions: We found high prevalence of residual NeP after cOPLL. Patients with a poor preoperative JOA score and low cervical lordosis angle might be at risk for residual NeP after surgery evaluated by PDQ or SPDQ and should be monitored with greater care after surgery.

Purpose: The diagnosis of adolescent lumbar spondylolysis typically requires computed tomography (CT) imaging; however, concerns regarding medical radiation exposure have emerged. With recent advancements in magnetic resonance imaging (MRI), it has become possible to acquire CT-like images using an MR bone imaging approach. This study aimed to investigate whether MR bone imaging can be utilised as a substitute for CT in evaluating the fracture line in patients with adolescent spondylolysis.

Methods: We included 24 patients (28 levels) diagnosed with adolescent lumbar spondylolysis between June and August 2023. In addition to the usual MRI, MR bone imaging and CT scans of the affected area were performed. Two raters evaluated the fracture lines on sagittal images and determined their presence or absence. For statistical analysis, we calculated the sensitivity, specificity, and accuracy of MR bone imaging using CT as the reference standard. Furthermore, we assessed intra- and inter-observer agreement using Cohen's Kappa coefficient.

Results: This study included 42 fractured pars and 14 non-fractured pars interarticularis controls. The sensitivity, specificity, and accuracy of MR bone imaging were 0.846, 1.00, and 0.893, respectively, for rater A and 0.789, 1.00, and 0.857, respectively, for rater B. The intra-observer agreement rates were 0.841 and 0.769 for raters A and B, respectively. Inter-observer agreement rates were 1.00 for CT and 0.875 for MR bone imaging.

Conclusion: Our results show that MR bone imaging can detect fracture lines in adolescent lumbar spondylosis at a level comparable to that of CT in clinical settings.