Assessing clinical trunk change with surface topography: anterior scoliosis correction as a model to evaluate curve progression.

PURPOSE: Previous work has suggested that surface topography can be used for repeated measurements of deformity during curve monitoring following an initial radiograph. Changes in deformity during natural curve progression may be subtle. An important preemptive question to answer is whether topography can follow a large change in spine deformity, as in scoliosis correction. We assess the ability of surface topography to track the evolution of spine deformity during anterior scoliosis correction relative to traditional radiographs. Anterior scoliosis correction was chosen for this analysis because it changes the shape of the trunk without leaving a surgical scar and muscle atrophy along the posterior spine. METHODS: Following IRB approval, 18 patients aged 14.6 ± 2.0 years at surgery were enrolled in a retrospective review of coronal radiographs and topographic scans acquired before and after scoliosis correction. Radiographic and topographic measures for the coronal curve angle before and after surgery were compared. RESULTS: Surface topography estimates correlate with radiographic measures of the pre- (r = 0.7890, CI = [0.4989 0.9201], p < 0.00001), postsurgical (r = 0.7485, CI = [0.4329 0.9006], p = 0.0004), and the change in the coronal curve angle (r = 0.6744, CI = [0.3028 0.8680], p = 0.0021) due to surgery. CONCLUSIONS: We provide evidence open for further extension that topography can follow changes in the coronal curve angle comparably to radiographs. LEVEL OF EVIDENCE: Level IV.

Musculoskeletal Workforce Needs: Are Physician Assistants and Nurse Practitioners the Solution? AOA Critical Issues.

Growth estimates and demographic shifts of the population of the United States foreshadow a future heightened demand for musculoskeletal care. Although many articles have discussed this growing demand on the musculoskeletal workforce, few address the inevitable need for more musculoskeletal care providers. As we are unable to increase the number of orthopaedic surgeons because of restrictions on graduate medical education slots, physician assistants (PAs) and nurse practitioners (NPs) represent one potential solution to the impending musculoskeletal care supply shortage. This American Orthopaedic Association (AOA) symposium report investigates models for advanced practice provider integration, considers key issues affecting PAs and NPs, and proposes guidelines to help to assess the logistical and educational possibilities of further incorporating NPs and PAs into the orthopaedic workforce in order to address future musculoskeletal care needs.

Scoliosis Research Society members attitudes towards physical therapy and physiotherapeutic scoliosis specific exercises for adolescent idiopathic scoliosis.

BACKGROUND: Attitudes regarding non-operative treatment for adolescent idiopathic scoliosis (AIS) may be changing with the publication of BRAiST. Physiotherapeutic Scoliosis Specific Exercises (PSSE) are used to treat AIS, but high-quality evidence is limited. The purpose of this study is to assess the attitudes of members of the Scoliosis Research Society towards PSSE. METHODS: A survey was sent to all SRS members with questions on use of Physical Therapy (PT) and PSSE for AIS. RESULTS: The majority of the 263 respondents were from North America (175, 67 %), followed by Asia (37, 14 %) and Europe (36, 14 %). The majority of respondents (166, 63 %) prescribed neither PT nor PSSE, 28 (11 %) prescribed both PT and PSSE, 39 (15 %) prescribe PT only and 30 (11 %) prescribe PSSE only. PT was prescribed by 67 respondents, as an adjunct to bracing (39) and in small curves (32); with goals to improve aesthetics (27) and post-operative outcomes (25). Of the 196 who do not prescribe PT, the main reasons were lack of evidence (149) and the perception that PT had no value (112). PSSE was prescribed by 58 respondents. The most common indication was as an adjunct to bracing (49) or small curves (41); with goals to improve aesthetics (36), prevent curve progression (35) and improve quality of life (31). Of the respondents who do not prescribe PSSE, the main reasons were lack of supporting research (149), a perception that PSSE had no value (108), and lack of access (63). Most respondents state that evidence of efficacy may increase the role of PSSE, with 85 % (223 of 263) favoring funding PSSE studies by the SRS. CONCLUSION: The results show that 22 % of the respondents use PSSE for AIS, skepticism remains regarding the benefit of PSSE for AIS. Support for SRS funded research suggests belief that there is potential benefit from PSSE and the best way to assess that potential is through evidence development.

Lumbar Spondylolysis and Spondylolisthesis in Down Syndrome: A Cross-sectional Study at One Institution.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVES: To describe lumbar spondylolysis and spondylolisthesis and establish their prevalence in individuals with Down syndrome. SUMMARY OF BACKGROUND DATA: Orthopedic problems in Down syndrome are variable and numerous. Lumbar spondylolysis and spondylolisthesis may be common conditions in Down syndrome. However, there has been a paucity of data on the association of these conditions in the published literature. METHODS: A retrospective review of 110 patients with Down syndrome seen at a single institution from 2000 through 2012 was performed. Medical records, X-rays, and physician dictations were carefully reviewed to establish a detailed database of the study population. RESULTS: Of the 110 patients in the study, 20 exhibited spondylolysis (unilateral, n = 11; bilateral, n = 9), whereas 38 had lumbar spondylolisthesis (isthmic, n = 9; dysplastic, n = 2; degenerative, n = 27). No gender difference was noted (p ≥ .7732). Fifteen patients reported low back pain (LBP) and/or leg pain. There was no significant association between LBP, leg pain, and spondylolysis (p = .9232). Both of these symptoms were highly predictive of lumbar spondylolisthesis, however (p = .0006). No significant findings were noted in pelvic parameters (pelvic incidence, sacral slope, pelvic tilt, or lumbar lordosis) in this study. CONCLUSIONS: The prevalence of spondylolysis and spondylolisthesis in individuals with Down syndrome may be as high as 18.7% and 32.7%, respectively, significantly higher than in the non-Downs population. Etiopathogenesis of these conditions in Down syndrome does not appear to be related to pelvic parameters. Low back pain and leg pain may be more predictive of spondylolisthesis in Down syndrome than in the general population. Therefore, it is recommended that individuals with Down syndrome and LBP and/or leg pain be evaluated for lumbar spondylolisthesis.

A review of orthostatic blood pressure regulation and its association with mood and cognition.

AIMS: This paper will review literature that examines the psychological and neuropsychological correlates of orthostatic blood pressure regulation. RESULTS: The pattern of change in systolic blood pressure in response to the shift from supine to upright posture reflects the adequacy of orthostatic regulation. Orthostatic integrity involves the skeletal muscle pump, neurovascular compensation, neurohumoral effects and cerebral flow regulation. Various physiological states and disease conditions may disrupt these mechanisms. Clinical and subclinical orthostatic hypotension has been associated with impaired cognitive function, decreased effort, reduced motivation and increased hopelessness as well as dementia, diabetes mellitus, and Parkinson's disease. Furthermore, inadequate blood pressure regulation in response to orthostasis has been linked to increased depression and anxiety as well as to intergenerational behavioral sequalae. CONCLUSIONS: Identifying possible causes and consequences of subclinical and clinical OH are critical in improving quality of life for both children and older adults.

The use of the T1 sagittal angle in predicting overall sagittal balance of the spine.

BACKGROUND CONTEXT: A balanced sagittal alignment of the spine has been shown to strongly correlate with less pain, less disability, and greater health status scores. To restore proper sagittal balance, one must assess the position of the occiput relative to the sacrum. The assessment of spinal balance preoperatively can be challenging, whereas predicting postoperative balance is even more difficult. PURPOSE: This study was designed to evaluate and quantify multiple factors that influence sagittal balance. STUDY DESIGN: Retrospective analysis of existing spinal radiographs. METHODS: A retrospective review of 52 adult spine patient records was performed. All patients had full-column digital radiographs that showed all the important skeletal landmarks necessary for accurate measurement. The average age of the patient was 53 years. Both genders were equally represented. The radiographs were measured using standard techniques to obtain the following parameters: scoliosis in the coronal plane; lordosis or kyphosis of the cervical, thoracic, and lumbar spine; the T1 sagittal angle (angle between a horizontal line and the superior end plate of T1); the angle of the dens in the sagittal plane; the angle of the dens in relation to the occiput; the sacral slope; the pelvic incidence; the femoral-sacral angle; and finally, the sagittal vertical axis (SVA) measured from both the dens of C2 and from C7. RESULTS: It was found that the SVA when measured from the dens was on average 16 mm farther forward than the SVA measured from C7 (p<.0001). The dens plumb line (SVA(dens)) was then used in the study. An analysis was done to examine the relationship between SVA(dens) and each of the other measurements. The T1 sagittal angle was found to have a moderate positive correlation (r=0.65) with SVA(dens), p<.0001, indicating that the amount of sagittal T1 tilt can be used as a good predictor of overall sagittal balance. When examining the other variables, it was found that cervical lordosis had a weak correlation (r=0.37) with SVA(dens) that was unexpected, given that cervical lordosis determines head position. Thoracic kyphosis also had a weak correlation (r=0.26) with SVA(C1), which was equally surprising. Lumbar lordosis had a slightly higher correlation (r=0.38), p=.006, than the cervical or thoracic spine. A multiple regression was run on the data to examine the relationship that all these independent variables have on SVA(dens). SPSS (SPSS, Inc., Chicago, IL, USA) was used to create a regression equation using the independent variables of T1 sagittal angle, cervical lordosis, thoracic kyphosis, lumbar lordosis, sacral slope, pelvic incidence, and femoral-sacral angle and the dependent variable of SVA(dens). The model had a strong correlation (r=0.80, r(2)=0.64) and was statistically significant (p<.0001). The T1 sagittal angle was the variable that had the strongest correlation with the SVA(dens) Spearman r=0.65, p<.0001, followed by pelvic incidence, p=.002, and lumbar lordosis, p=.006. We also observed that when the T1 tilt was higher than 25°, all patients had at least 10 cm of positive sagittal imbalance. In addition, patients with negative sagittal balance had mostly low T1 tilt values, usually lower than 13°. The other variables were not shown to have a statically significant influence on SVA. CONCLUSIONS: This analysis shows that many factors influence the overall sagittal balance of the patient, but it may be the position of the pelvis and lower spine that have a stronger influence than the position of the upper back and neck. Unfortunately, to our knowledge, there are no studies to date that have established a normal sagittal T1 tilt angle. However, our analysis has shown that when the T1 tilt was higher than 25°, all patients had at least 10 cm of positive sagittal imbalance. It also showed that patients with negative sagittal balance had mostly low T1 tilt values, usually below 13° of angulation. The T1 sagittal angle is a measurement that may be very useful in evaluating sagittal balance, as it was the measure that most strongly correlated with SVA(dens). It has its great utility where long films cannot be obtained. Patients whose T1 tilt falls outside the range 13° to 25° should be sent for full-column radiographs for a complete evaluation of their sagittal balance. On the other hand, a T1 tilt within the above range does not guarantee a normal sagittal balance, and further investigation should be performed at the surgeon's discretion.

A comparison of magnetic and radiographic imaging artifact after using three types of metal rods: stainless steel, titanium, and vitallium.

BACKGROUND CONTEXT: After spinal fusion surgery, postoperative management often includes imaging with either computed tomography (CT) or magnetic resonance imaging (MRI) to assess the spinal canal and nerve roots. The metallic implants used in the fusion can cause artifact that interferes with this imaging, reducing their diagnostic value. Stainless steel is known to produce large amounts of artifact, whereas titanium is known to produce significantly less. Other alloys such as vitallium are now being used in spinal implants, but their comparison to titanium and stainless steel has not been well documented in the orthopedic literature. Titanium is a desirable metal because of its light weight and lower production of artifact on imaging, although it is not as stiff as stainless steel. Vitallium is proposed as a replacement for titanium because it has stiffness similar to stainless steel, while still being as light as titanium. PURPOSE: The purpose of this study was to compare the amount of artifact produced on MRI and CT by three types of spinal implants: stainless steel, titanium, and vitallium. STUDY DESIGN: A prospective experimental design was used to compare three types of spinal implants used in posterior spinal fusion surgery. OUTCOME MEASURES: The resulting images were evaluated by a radiologist to measure the amount of artifact (in millimeters) and by an orthopedic surgeon to assess the diagnostic quality (on a Likert scale). METHODS: A porcine torso was used for repeated MRI and CT scans before and after implantation with pedicle screws and rods made of the three metals being studied. RESULTS: Images produced after the insertion of vitallium rods and titanium screws as well as those with titanium rods and screws were found to have less artifact and a better overall diagnostic quality than those produced with stainless steel implants. Overall, there was not a difference between the amount of artifact in the spinal images with vitallium and titanium rods, with the exception of a few trials that showed small but statistically significant differences between the two metals, where titanium had slightly better images. CONCLUSIONS: If vitallium rods are used in posterior spinal surgery in place of implants made of titanium or stainless steel, any postoperative imaging of the spine using MRI or CT should have amounts of artifact that are similar to titanium and better than stainless steel.