The Safety and Efficacy of Tranexamic Acid in Adult Spinal Deformity Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVES: Major spinal corrective surgeries can be associated with critical intra-operative blood loss. The objective of this systematic review and meta-analysis was to assess the safety and efficacy of tranexamic acid (TXA), a commonly used antifibrinolytic agent, in adult spinal deformity (ASD) surgery, defined as fusion of five or more levels. METHODS: Articles from PubMed, Embase, Cochrane, and clinicaltrials.gov were screened using PRISMA guidelines through December 2018. Thromboembolic events, blood loss, and transfusion levels were primary outcomes of interest. Randomized controlled trials (RCTs) and observational studies (OBSs) with adult patients (≥ 18 years) were included. Continuous variables were analyzed using mean difference (MD) and categorical variables were analyzed using Peto odds ratio (OR), via random effects models. RESULTS: Of the 604 articles screened, seven studies (two RCTs and five cohort studies) were included. Incidence of thromboembolic events was not statistically significantly different between TXA (1 event/19) and placebo (0 events/13) in the RCT (Peto OR = 1.41, 95% CI 0.05-37.2; 32 patients; 1 study) and in the OBSs (TXA [2 events/135] vs control [0 events/72]; Peto OR = 1.09, 95% CI 0.16-7.61; p-heterogeneity = 0.85; 207 patients; 3 studies). Data from OBSs showed that the pooled MD was statistically significantly lower in the TXA group compared with the control group for intraoperative blood loss (MD: - 620.2 mL, 95% CI - 1066.6 to - 173.7; p-heterogeneity = 0.14; 228 patients; 4 studies) and total transfusion volume (MD: - 958.2 mL, 95% CI - 1867.5 to - 49.0; p-heterogeneity = 0.23; 93 patients; 2 studies). CONCLUSION: In this meta-analysis, TXA was not significantly associated with increased risk of thromboembolic events but was associated with lower intraoperative blood loss and lower total transfusion volumes in ASD surgery.

[Estimation of the influence of the design of school backpacks to posture regulation in children with different posture conditions].

There was performed the study of the characteristics of the regulation of vertical posture in 42 children of 8-10 years old using school bags of different designs. According to medical examination 25 children have normal posture and 17 children had kyphotic one. The stability of the posture was estimated according to the average variance and the average velocity of the total center of gravity of the body, the area of the ellipse, and the quality of the equilibrium function with computer stabilography. Three models of school bags were used - with traditional, ergonomic and orthopedic back support. Vertical posture stability for children with impaired posture without school bag and when used with traditional and ergonomic back were significantly lower in comparison with children with normal posture. When the orthopedic back was used the stability impairment of the vertical posture in children with kyphotic posture was not observed. It is concluded that for the prevention of spinal deformity for students with kyphotic posture orthopedic school bags should be used.

The effects of backward adjustable thoracic support in wheelchair on spinal curvature and back muscle activation for elderly people.

OBJECTIVES: To investigate the effects of backward adjustable thoracic support on spinal curvature and back muscle activation during wheelchair sitting. METHODS: Twenty elderly people were recruited for this study. The backward adjustable thoracic support sitting posture was compared with the slumped, normal, and lumbar support sitting postures. Spinal curvatures (pelvic, lumbar, and thoracic angles) and muscle activations of 4 back muscles on both sides (maximal voluntary isometric contraction of the lumbar multifidus, lumbar erector spinae, iliocostalis lumborum pars thoracis, and thoracic erector spinae at T9) were measured and compared between the different sitting postures using one-way analysis of variance with repeated measures. RESULTS: The backward adjustable thoracic support sitting posture showed a relatively neutral pelvic tilt (-0.32±4.80°) when compared with the slumped (22.84±5.27°) and lumbar support (-8.97±3.31°) sitting postures (P<0.001), and showed relatively higher lumbar lordosis (-23.38±6.50°) when compared with the slumped (14.77±7.83°), normal (0.44±7.47°), and lumbar support (-16.76±4.77°) sitting postures (P<0.05). It also showed relatively lower back muscle activity when compared with the normal and lumbar support sitting postures (P<0.05). CONCLUSIONS: The backward adjustable thoracic support sitting concept was suggested because it maintains a more neutral pelvic tilt, higher lumbar lordosis, and lower back muscle activation, which may help maintain a better sitting posture and reduce the risk of back pain.

Post-laminectomy deformities / Deformidades pós-laminectomia / Deformidades post-laminectomía

Objective: To present the deformities and evaluate the results of their treatment. Methods: Retrospective study of patients with deformity following surgical access to the spinal canal. Fifteen patients who met the inclusion criteria were included. Patients without complete data in medical records were excluded. Results: Fourteen patients underwent surgical treatment and one patient received conservative treatment with vest type TLSO. The average angle of kyphosis correction was 87° preoperatively to 38° postoperatively, while the associated scoliosis correction was 69° preoperatively to 23° postoperatively. Conclusions: The prevention of deformity should be emphasized to avoid laminectomy alone, while laminoplasty should be the procedure of choice for canal access in surgeries where there is no need for resection of the posterior elements. .

Objetivos: Apresentar as deformidades e avaliar os resultados de seu tratamento. Métodos: Estudo retrospectivo de pacientes portadores de deformidade após cirurgia de acesso ao canal vertebral. Incluíram-se quinze pacientes que satisfaziam os critérios de inclusão. Foram excluídos os pacientes que não apresentavam dados completos no prontuário. Resultados: Quatorze pacientes foram submetidos a tratamento cirúrgico e um paciente ao tratamento conservador com colete do tipo OTLS. A correção angular média da cifose foi de 87° no pré-operatório para 38° após a cirurgia, enquanto a correção da escoliose associada foi de 69° no pré-operatório para 23° no pós-operatório. Conclusões: A prevenção da deformidade deve ser enfatizada evitando-se a laminectomia isolada, enquanto a laminoplastia deve ser o procedimento de escolha para acesso ao canal nas cirurgias em que não há necessidade de ressecção dos elementos posteriores. .

Objetivo: Presentar las deformidades y evaluar los resultados de su tratamiento. Métodos: Estudio retrospectivo de los pacientes con deformidad después del acceso quirúrgico al canal espinal. Quince pacientes que cumplían los criterios de inclusión fueron incluidos. Se excluyeron los pacientes que no tenían dados completos en la historia clínica. Resultados: Catorce pacientes fueron sometidos a tratamiento quirúrgico y un paciente recibió tratamiento conservador con ortesis OTLS. La corrección de la cifosis angular promedio fue de 87° antes de la operación a 38o después de la cirugía, mientras que la escoliosis asociada fue de 69° antes de la operación a 23° después de la operación. Conclusiones: La prevención de la deformidad debe ser destacada para evitar laminectomía solo, mientras que laminoplastia debe ser el procedimiento de elección para el acceso al canal durante la cirugía donde no hay necesidad de resección de los elementos posteriores. .

Cervical spine curvature during simulated rear crashes with energy-absorbing seat.

BACKGROUND CONTEXT: Epidemiological studies indicate potential benefits of the Whiplash Protection System (WHIPS) for reducing neck injury risk. PURPOSE: Our goal was to evaluate cervical spine curvature during simulated rear crashes of a Human Model of the Neck (HUMON) within a WHIPS seat with fixed head restraint (HR). STUDY DESIGN: In vitro biomechanical study. METHODS: The HUMON consisted of a human neck specimen mounted to the torso of BioRID II (Denton ATD, Inc., Milan, OH, USA) and carrying a surrogate head stabilized with muscle force replication. The HUMON was subjected to simulated rear crashes in a WHIPS seat (n=6) at 9.9, 12.0, and 13.3 g and in a seat with no WHIPS or HR (n=6) at 11.5 g. Statistical tests (p<.05) determined significant increases in spinal motion peaks during the crashes with WHIPS relative to physiologic and significant differences in spinal curvature peaks between WHIPS (12.0 g) and no WHIPS or HR (11.5 g). RESULTS: The WHIPS absorbed crash energy during the initial 75 milliseconds, while peak lower cervical spine (LCS) extension occurred as late as 179 milliseconds. The average C7/T1 rotation peaks during the 13.3-g rear crashes with WHIPS significantly exceeded physiologic by 95% in flexion (4.3° vs. 2.2°) and more than 225% in extension (9.8° vs. 3.0°). The WHIPS caused a significant reduction in average peak normalized LCS extension as compared with no WHIPS or HR (1.2 vs. 3.7). CONCLUSIONS: Although the peak LCS extension was significantly reduced due to WHIPS as compared with no WHIPS or HR, it exceeded physiologic as the cervical spine maintained a prolonged S-shaped curvature. Nonphysiologic LCS motion may occur even if head/HR contact occurs early, and injury is possible before head/HR contact even with a modern energy-absorbing seat. Future whiplash-reduction systems will most likely integrate active injury prevention systems with advanced features such as accident avoidance technology.

[Prevention of spine deformities in adolescents due to inadequate posture].

INTRODUCTION: The spine deformities tend to increase, and in 90% of children they change the quality of life. The aim of this study was to determine the percents of spinal deformity in our population of adolescents, and long bad posture in and out of school as a factor for its increase. MATERIAL AND METHODS: The study included 124 adolescents attending High Musical School in Bitola and Skopje, who underwent four standard spine tests and an interview. RESULTS: According to the test 3, 50% of the examined adolescents in Bitola and 69% in Skopje had the postural spine deformity, the average being 59.5%. The results obtained by the questionnaire showed that 50% of adolescents did not have any physical activity out of school, the longest daily activity, lasting four hours, in 48% of the examinees was practising their musical instruments; 40% of the examinees spent two hours watching TV or using the computer, whereas 18% did not use any of them at all. CONCLUSION: The bad spine posture tends to deteriorate in adolescents and the factor influencing this result should be established by studies aimed at determining the effects of physical activity on reducing such deformities, since the specific type of their education induces the risk of developing pain and early degenerative changes of the spine, which are predominant in the professionals.

Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.

Balloon kyphoplasty and percutaneous vertebroplasty are relatively recent procedures in the treatment of painful vertebral fractures. There are, however, still some uncertainties about the incidence and treatment strategies of pulmonary cement embolisms (PCE). In order to work out a treatment strategy for the management of this complication, we performed a review of the literature. The results show that there is no clear diagnostic or treatment standard for PCE. The literature research revealed that the risk of a pulmonary embolism ranges from 3.5 to 23% for osteoporotic fractures. In cases of asymptomatic patients with peripheral PCE we recommend no treatment besides clinical follow-up; in cases of symptomatic or central embolisms, however, we recommend to proceed according to the guidelines regarding the treatment of thrombotic pulmonary embolisms, which includes initial heparinization and a following 6-month coumarin therapy. In order to avoid any types of embolisms, both procedures should only be performed by experienced surgeons after critical determination of the indications.

Sagittal spinal posture after Pilates-based exercise in healthy older adults.

STUDY DESIGN: Longitudinal, repeated-measures study. OBJECTIVE: The aim of this study was to determine changes in sagittal spinal posture in older adults during standing and sitting after a Pilates-based exercise program. SUMMARY OF BACKGROUND DATA: Pilates exercise is purported to improve posture, however, few peer-reviewed articles are available to provide scientific support. Most previous studies were conducted in young dancers, and the effect of Pilates exercise on spinal posture in older adults remained unclear. METHODS: Thirty-four healthy older adults aged over 60 years volunteered for this study. A two-dimensional PEAK Motus motion analysis system was used to measure sagittal spinal angles. Participants were tested on 2 occasions before the exercise program to establish a baseline measure, and undertook a supervised Pilates-based exercise program twice weekly for 10 weeks. Participants were tested on another 2 occasions, immediately after the exercise program, and after a short-term follow-up. RESULTS: Baseline measures in both standing and sitting postures remained unchanged except for the lumbar spine angle in sitting. Immediately after the Pilates-based exercise program, older adults stood with slightly decreased thoracic flexion and sat with slightly increased lumbar extension. No significant differences were found during the follow-up period. CONCLUSION: The individually designed Pilates-based exercise program was feasible for healthy older adults, and the high attendance rate supports the suitability of the exercise program over a long period. Considering the variability of the baseline measure, small improvement was only observed in the thoracic kyphosis during standing. The long-term effect of Pilates exercise requires further investigation.

Faulty posture and style of life in young adults.

UNLABELLED: Study was aimed to determine the incidence of postural faults, level of physical activity and their possible relationship in young adults. Material included 100 subjects recruited randomly among students of Medical University of Silesia (54F aged 20-28, mean=22.9, SD=2.11 and 46M aged 20-29, mean=25.1, SD=1.86). Posture was examined according to modified Klapp protocol. For thoracic kyphosis and lumbar lordosis, values of 30 degrees +/-2 were considered as normal. ATR exceeding 5 degrees was considered as scoliosis. Physical activity was evaluated with a questionnaire, admitting 1 point for each hour of physical labour and 2 points for each hour of sport activity per week. Statistical analysis was based on the one-way ANOVA test. Postural faults were widespread in assessed group. Most common was lumbar hypolordosis (71.0%, 48.1%F and 97.8%M) and thoracic hyperkyphosis (58.0%, 53.7%F and 63.0%M). Scoliosis was observed in 54.0% (50%F and 58.7%M). Physical activity in assessed group was high, with 71% of cases (76%F and 62.5%M) within range of mean value +/- 1SD. Level of activity in men was significantly higher than women (mean 20.25 vs. 6.28 points, p<0.05). Significant dependence of postural faults and physical activity was not observed. CONCLUSIONS: Young adults prefer active way of life. Postural faults are widespread among young adults. Correlation between level of physical activity and postural faults was not observed.

Dicas dos especialistas: coluna – corrija sua postura

Traz, em forma de perguntas e respostas, informações para o público geral sobre como melhorar a postura. Com ilustrações comparativas entre o que se fazer e o que não fazer.

Indoor heated swimming pools: the vulnerability of some infants to develop spinal asymmetries years later.

Evidence reported in an earlier paper suggests that infants introduced to indoor heated swimming pools in the first year of life show an association with spinal asymmetries including progressive adolescent idiopathic scoliosis (AIS) and in normal subjects vertical spinous process asymmetry. Indoor heated swimming pools may contain a risk factor that predisposes some infants to develop such spinal asymmetries years later. What the risk factor(s) may be and its possible portal of entry into the infant's body are unknown and possibilities are examined. New teenage controls were obtained after mothers of AIS patients mentioned that they had taken their child to an infant swim class. In a further group of 18 normal teenagers introduced to an indoor heated swimming pool in the first year of life, 15 had vertical spinous process asymmetry. This prevalence of 83% of those at risk confirms our previous observation of vertical spinous process asymmetry in 61% of teenagers who were introduced to indoor heated swimming pools in the first year of life. Subject to confirmation of our observations consideration should be given to chemical risk factors, possible portals of entry, toxicology, environmental epigenomics and disease susceptibility to altered spinal development. If the risk factor is confirmed there may ultimately be a place for the prevention of AIS in some subjects.

Exercise within lower body negative pressure partially counteracts lumbar spine deconditioning associated with 28-day bed rest.

Astronauts experience spine deconditioning during exposure to microgravity due to the lack of axial loads on the spine. Treadmill exercise in a lower body negative pressure (LBNP) chamber provides axial loads on the lumbar spine. We hypothesize that daily supine LBNP exercise helps counteract lumbar spine deconditioning during 28 days of microgravity simulated by bed rest. Twelve sets of healthy, identical twins underwent 6 degrees head-down-tilt bed rest for 28 days. One subject from each set of twins was randomly assigned to the exercise (Ex) group, whereas their sibling served as a nonexercise control (Con). The Ex group exercised in supine posture within a LBNP chamber for 45 min/day, 6 days/wk. All subjects underwent magnetic resonance imaging of their lumbar spine before and at the end of bed rest. Lumbar spinal length increased 3.7 +/- 0.5 mm in the Con group over 28-day bed rest, whereas, in the Ex group, lumbar spinal length increased significantly less (2.3 +/- 0.4 mm, P = 0.01). All lumbar intervertebral disk heights (L5-S1, L4-5, L3-4, L2-3, and L1-2) in the Con group increased significantly over the 28-day bed rest (P < 0.05). In the Ex group, there were no significant increases in L5-S1 and L4-5 disk heights. Lumbar lordosis decreased significantly by 3.3 +/- 1.2 degrees during bed rest in the Con group (P = 0.02), but it did not decrease significantly in the Ex group. Our results suggest that supine LBNP treadmill exercise partially counteracts lumbar spine lengthening and deconditioning associated with simulated microgravity.

[Treatment of multi-segmental spinal tuberculosis by using focal debridement and internal fixation with CD rod].

OBJECTIVE: To study the clinical results of focal debridement and primary internal fixation with CD rod in treatment of multi-segmental spinal tuberculosis. METHODS: From July 1999 to November 2002, 16 patients with multi-segmental spinal tuberculosis were given focal debridement and primary internal fixation with CD rod trans sick vertebra. There were 9 males and 7 females, aging from 21 to 59 years. The course of disease was 2 to 11 months. The locations of lesion were T6-T11 in 11 patients and T10-L2 in 5 patients. The involved vertebral bodies were 3 segments in 13 patients, 4 or more than 4 segments in 3 patients. There were 5 cases of Pott's paralysis (according to Frankel classification system: 3 cases of degree C, 2 cases of degree D) and 4 cases of kyphosis and 2 cases of collapse. Focal debridement and internal fixation was performed in 1 or 2 incisions according to concrete conditions. RESULTS: All patients were followed up 11 months (6 months-3 years), spinal tuberculosis was completely cured and the grafted bones were fused in all 16 patients. All patients obtained primary healing of the incision. Postoperative complication met with cerebrospinal fluid leakage in 1 case. After 6 months, 5 cases of paraplegia recovered. The kyphosis was corrected partly. No loose and dislocation of the nails and rods was found. CONCLUSION: Focal debridement and primary internal fixation with CD rod can stabilize involved spinal segments, prevent and correct local deformity, and improve its curative ratio and fused ratio of grafted bone.

Management of iatrogenic flat-back syndrome.

Iatrogenic loss of lordosis is now frequently recognized as a complication following placement of thoracolumbar instrumentation, especially with distraction instrumentation. Flat-back syndrome is characterized by forward inclination of the trunk, inability to stand upright, and back pain. Evaluation of the deformity should include a full-length lateral radiograph obtained with the patient's knees and hips fully extended. The most common cause of the deformity includes the use of distraction instrumentation in the lumbar spine and pseudarthrosis. Surgical treatment described in the literature includes opening (Smith-Petersen) osteotomy, polysegmental osteotomy, and closing wedge osteotomy. The authors will review the literature, cause, clinical presentation, prevention, and surgical management of flat-back syndrome.

[Effect of physical and athletic activity on spinal deformities due to osteoporosis]. / Utjecaj fizicke i sportske aktivnosti na osteoporotske deformacije kraljezaka.

Physical activity is associated with increased bone mass and reduced risk of hip fracture. However, scarce are data from population samples concerning the effect of level of physical and sport activity on the risk of osteoporotic vertebral deformity. The aim of the study was to determine the amount of physical and sport activity and to relate it to occurrence of vertebral deformity in older population. In total 425 subjects (269 women and 156 men) age 50 and above, were recruited from a population frame sample, as a random sample of city of Zagreb. An interviewer-administered questionnaire was used to get information about level of physical and sport activity in three different age periods (15-24 years, 25-49 years and 50 years and above), and the amount of time spent walking or cycling each day. Lateral thoracolumbar radiographs were taken using standardised procedure. Radiographs were evaluated morphometrically and the presence of vertebral deformity was defined according to method of McCloskey and al., with an alternative approach for defining normal values using iterative algorithm described by Melton and al. Vertebral deformities were found in 50 (11.8%) subjects. Men were more involved in sports activities in all three life periods, and had heavier overall physical activity from 15-24 years. Although results suggest possible decreased risk for vertebral deformity with stronger physical activity in the first life period, no significant association was found between physical or sport activity and vertebral deformities, even when possible confounding factors were taken in account. Current walking or cycling, adjusted for possible confounders, did not change the risk for vertebral deformities, too. Various confounding factor, different from those taken in account for this study or inadequately large sample for sport activity could have influence the results. We conclude that men are more physically active in younger age, and overall do more sports. Warning is the fact that appreciable proportion of men and women do not do any sport activity. We could not confirm that level of physical or sport activity, as well as regular walking or cycling was significantly important for occurrence of vertebral deformities. Prospective studies are needed in order to understand better the epidemiology and the role of possible risk factors of osteoporotic vertebral deformities in our population, which can help us in planning programs of prevention.