Effect of asymptomatic intervertebral flexion patterns on lumbar disc pressure: A finite element analysis study.

Movement patterns may be a factor for manipulating the lumbar load, although little information is yet available in the literature about the relationship between this variable and intervertebral disc pressure (IDP). A finite element model of the lumbar spine (49-year-old asymptomatic female) was used to simulate intervertebral movements (L2-L5) of 127 asymptomatic participants. The data from participants that at least completed a simulation of lumbar vertebral movement during the first 53% of a movement cycle (flexion phase) were used for further analyses. Then, for each vertebral angular motion curve with constant spatial peaks, different temporal patterns were simulated in two stages: (1) in lumbar pattern exchange (LPE), each vertebral angle was simulated by the corresponding vertebrae of other participants data; (2) in vertebral pattern exchange (VPE), vertebral angles were simulated by each other. The k-mean algorithm was used to cluster two groups of variables; peak and cumulative IDP, in both stages of simulations (i.e., LPE and VPE). In the second stage of the simulation (VPE), Kendall's tau was utilized to consider the relationship between different temporal patterns and IDPs for each individual lumbar level. Cluster analyses showed that the temporal movement pattern did not exhibit any effect on the peak IDP while the cumulative IDP changed significantly for some patterns. Earlier involvement in lumbar motion at any level led to higher IDP in the majority of simulations. There is therefore a possibility of manipulating lumbar IDP by changing the temporal pattern with the same ROM, in which optimal distribution of the loads among lumbar levels may be applied as preventive or treatment interventions. Evaluating load benefits, such as load, on biomechanically relevant lumbar levels, dynamically measured by quantitative fluoroscopy, may help inform interventional exercises.

Spinal alignment and surgical correction in the aging spine and osteoporotic patient.

Background: The aging spine often presents multifaceted surgical challenges for the surgeon because it can directly and indirectly impact a patient's spinal alignment and quality of life. Elderly and osteoporotic patients are predisposed to progressive spinal deformities and potential neurologic compromise and surgical management can be difficult because these patients often present with greater frailty. Methods: This was a literature review of spinal alignment changes, preoperative considerations, and spinal alignment considerations for surgical strategies. Results: Many factors impact spinal alignment as we age including lumbar lordosis flexibility, hip flexion, deformity, and osteoporosis. Preoperative considerations are required to assess the patient's overall health, bone mineral density, and osteoporosis medications. Careful radiographic assessment of the spinopelvic parameters using various classification/scoring systems provide the surgeon with goals for surgical treatment. An individualized surgical strategy can be planned for the patient including extent of surgery, surgical approach, extent of the constructs, fixation techniques, vertebral augmentation, ligamentous augmentation, and staging surgery. Conclusions: Surgical treatment should only be considered after a thorough assessment of the patient's health, deformity, bone quality and corresponding age matched alignment goals. An individualized treatment approach is often required to tackle the deformity and minimize the risk of hardware related complications and pseudarthrosis. Anabolic agents offer a promising benefit in this patient population by directly addressing and improving their bone quality and mineral density preoperatively and postoperatively.

Alignment in motion: Fall risk in spine patients and the effect of vision, support surface, and adaptation on the cone of economy.

Background: Several assessment tools have been developed to estimate a patient's likelihood risk of falling. None of these measures estimate the contributions of the visual, vestibular, and somatosensory systems to fall risk, especially in patients with degenerative lumbar spine disease. Methods: Degenerative lumbar spine patients with radiculopathy (LD) and healthy subjects who were 35-70 years old without spine complaints were recruited. Patient reported outcome measures (PROMs) were collected prior to testing. Fall risk assessment was completed using Computer Dynamic Posturography (CDP), a computer-controlled balance machine that allows cone of economy (CoE) and cone of pressure (CoP) measurements. All patients completed Sensory Organization Tests (SOT) which include normal and perturbed stability, both with and without visual cues. Results: In total, 43 spine patients and 12 healthy controls were included, with mean age 57.8 years, 39.5% females, and mean BMI of 29.3 kg/m2. Nearly all CoE and most CoP dimensions were found to be larger in LD patients compared to controls across nearly all subtests (p<.05), with the largest dimensions generally observed in the surrounding and support sway testing condition. In LD patients, ODI and PROMIS Pain Interference were negatively correlated with CoE and CoP measurements (p<.05). Conclusions: In this prospective study, body sway was assessed as a function of CoE and CoP using the CDP system and was found to be elevated in spine patients, especially when they experienced increasing levels of visual and vestibular stimulation. The ability to identify the primary drivers of balance disorders is essential in spine patients and may be helpful in the development of a patient-specific treatment plan, which may in the future aid with fall-prevention initiatives.

Multidevice spinal cord stimulation trials: shared decision making in the era of multiple neuromodulation paradigms.

Aim: There is a lack of evidence-based standards for matching spinal cord stimulation (SCS) paradigm to individual patients. We aim to determine the feasibility and safety of a new alternative trial strategy, a sequential multidevice trial.Materials & methods: A retrospective analysis was performed on 116 patients who underwent SCS trials, single device or sequential multidevice (tonic and high-frequency), for chronic low back pain to assess feasibility and compare trial-to-implantation rate and explantation rate.Results: Multidevice SCS trials are feasible and safe. There was no statistically significant difference in the trial-to-implantation and explantation rates between the two groups.Conclusion: Multidevice SCS trial, prioritizing patient preference, may serve as an alternative trial strategy to improve long-term success of SCS.

Spinal cord stimulation plays an important role in the management of chronic low back pain refractory to conventional treatment. The current standard of practice is to try one device for 3­7 days prior to implantation. In the setting of increasing number of device options, we believe that a new trial method may be necessary to improve patient exposure to different options, thus improving informed decisions based on their personal experiences. Our study supports that this new trial method with different devices is feasible and safe.

Percutaneous lumbopelvic fixation is effective in the management of unstable transverse sacral fractures.

OBJECTIVES: Historically, fractures causing lumbopelvic dissociation have been managed with open lumbosacral fusion and instrumentation. Our aim was to evaluate outcomes and complications following surgical management of unstable transverse sacral fractures with percutaneous lumbopelvic fixation. METHODS: Design: Retrospective case series. SETTING: Academic Single Center, Level I Trauma Center. Patient Selection Criteria: Patients with lumbopelvic dissociation undergoing surgery. Outcome Measures and Comparisons: Patient demographics, mechanism of injury, ISS, associated injuries, radiographic classification (Roy-Camille), patient-reported outcomes (PROMIS PI, PF, D, and ODI), and complications were collected. RESULTS: 27 patients were enrolled with an average follow-up of 18.7 ± 17.6 months and age of 54.4 ± 25.1 years. All patients underwent lumbar pedicle screw and iliac screw placement. Sacral laminectomy was performed if the patient had a preoperative neurological deficit. Patients were counseled on instrumentation removal at 6-12 months. 67 % of patients sustained a fall, and 33 % were involved in an MVA. 52 % were Roy-Camille Type 2, and 32 % and 20 % were Types 1 and 3, respectively. The mean EBL was 261 ± 400 ml. 37 % required concurrent sacral laminectomy. There were no intraoperative complications and four postoperative complications, including surgical site infection, rod dislodgment, and deep venous thrombosis. 63 % underwent removal of instrumentation after fracture healing. ODI scores significantly improved from 6 weeks post-op (35.5 ± 4.5) to one-year follow-up (18.3 ± 9.6, p = 0.005), two-year follow-up (20.3 ± 10.0, p = 0.03), and final follow-up (16.4 ± 8.8, p = 0.002). Statistically significant improvements were observed in the PROMIS PI, PF, and D domains (p < 0.05). CONCLUSION: Our study demonstrates that lumbopelvic instrumentation leads to successful management of unstable transverse sacral fractures, with improvement in PRO. The combination of percutaneous instrumentation without arthrodesis did not result in any fracture non-union. LEVEL OF EVIDENCE: Level IV.

Fully automated determination of robotic pedicle screw accuracy and precision utilizing computer vision algorithms.

Historically, pedicle screw accuracy measurements have relied on CT and expert visual assessment of the position of pedicle screws relative to preoperative plans. Proper pedicle screw placement is necessary to avoid complications, cost and morbidity of revision procedures. The aim of this study was to determine accuracy and precision of pedicle screw insertion via a novel computer vision algorithm using preoperative and postoperative computed tomography (CT) scans. Three cadaveric specimens were utilized. Screw placement planning on preoperative CT was performed according to standard clinical practice. Two experienced surgeons performed bilateral T2-L4 instrumentation using robotic-assisted navigation. Postoperative CT scans of the instrumented levels were obtained. Automated segmentation and computer vision techniques were employed to align each preoperative vertebra with its postoperative counterpart and then compare screw positions along all three axes. Registration accuracy was assessed by preoperatively embedding spherical markers (tantalum beads) to measure discrepancies in landmark alignment. Eighty-eight pedicle screws were placed in 3 cadavers' spines. Automated registrations between pre- and postoperative CT achieved sub-voxel accuracy. For the screw tip and tail, the mean three-dimensional errors were 1.67 mm and 1.78 mm, respectively. Mean angular deviation of screw axes from plan was 1.58°. For screw mid-pedicular accuracy, mean absolute error in the medial-lateral and superior-inferior directions were 0.75 mm and 0.60 mm, respectively. This study introduces automated algorithms for determining accuracy and precision of planned pedicle screws. Our accuracy outcomes are comparable or superior to recent robotic-assisted in vivo and cadaver studies. This computerized workflow establishes a standardized protocol for assessing pedicle screw placement accuracy and precision and provides detailed 3D translational and angular accuracy and precision for baseline comparison.

The Longitudinal Effects of Posterior Spinal Fusion with Derotation on Axial Deformity in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To characterize the change in angle of trunk rotation (ATR), axial vertebral rotation (AVR), and body surface rotation (BSR) in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with en-bloc derotation across multiple postoperative visits. SUMMARY OF BACKGROUND DATA: Previous research has documented ATR, AVR, and BSR correction for AIS patients after surgery. However, there is a lack of evidence on the sustainability of this correction over time. METHODS: This was a retrospective study from a single-center prospective surface topographic registry of patients with AIS, age 11-20 at time of surgery, who underwent PSF with en-bloc derotation. Patients with previous spine surgery were excluded. ATR was measured with a scoliometer, AVR through EOS radiographic imaging, and BSR via surface topographic scanning, Data collection occurred at: preoperative, six-week, three-month, six-month, one-year, and two-year postoperative visits. BSR and AVR were tracked at the preoperative apical vertebral level, and the level with maximum deformity, at each respective timepoint. Generalized estimating equations models were used for statistical analysis. Covariates included age, sex, and body mass index. RESULTS: 49 patients (73.4% female, mean age 14.6±2.2 years, mean preoperative coronal curve angle 57.9°±8.5, and 67% major thoracic) were evaluated. ATR correction was significantly improved at all postoperative timepoints and there was no significant loss of correction. AVR Max and AVR Apex were significantly improved at all timepoints but there was a significant loss of correction for AVR Apex between the six-week and one-year visit (P=0.032). BSR Max achieved significant improvement at the three-month visit. BSR Apex was significantly improved at the three-month and one-year visit. CONCLUSION: ATR and AVR demonstrated significant axial plane correction at two-years postoperative in patients undergoing PSF for AIS. BSR did not maintain significant improvement by the two-year visit.

Novel Surface Topographic Assessment of Lung Volume and Pulmonary Function Tests in Idiopathic Scoliosis: A Preliminary Study.

OBJECTIVE: Severe spinal deformity results in restrictive pulmonary disease from thoracic distortions and lung-volume limitations. Though spirometry and body plethysmography are widely accepted tests for pulmonary function tests (PFTs), they are time-consuming and require patient compliance. This study investigates whether surface topographic [surface topography (ST)] measurements of body volume difference (BVD) and torso volume difference between maximum inhale and exhale correlate to values determined on PFTs. METHODS: This study included patients with idiopathic scoliosis and thoracic/thoracolumbar curves ≥40 degrees. Patients received ST scans, clinical examinations, and EOS biplanar radiographs on the same day. PFTs were performed within 3 months of ST/radiographic analysis. Univariate linear regression analysis was used to examine relationships between BVD, PFT values, and mean curves. RESULTS: Sixteen patients (14.6 ± 2.2 y, 69% females) with idiopathic scoliosis and mean thoracic/thoracolumbar curves of 62 degrees ± 15˚ degrees (45 degrees to 93 degrees) were assessed. BVD displayed statistically high-positive positive correlations with forced vital capacity ( R = 0.863, P < 0.0001), forced expiratory volume in 1 second ( R = 0.870, P < 0.001), vital capacity ( R = 0.802, P < 0.0001), and TLC ( R = 0.831, P < 0.0001. Torso volume difference showed similarly high positive correlations to forced vital capacity, forced expiratory volume in 1 second, vital capacity, and TLC, but not residual volume. No correlations emerged between the mean thoracic/thoracolumbar curve and BVD or PFT values. CONCLUSION: This study strongly endorses further investigation into ST scanning as an alternative to traditional PFTs for assessing pulmonary volumes. The noncontact and noninvasive nature of ST scanning presents a valuable alternative method for analyzing thoracic volume, particularly beneficial for patients unable to cooperate with standard PFTs. LEVEL OF EVIDENCE: Level II-prognostic.

Efforts to Improve Diversity, Equality, and Inclusion in Sports Medicine via Community Engagement Initiatives Within American Cities Divided by Racial, Social, and Economic Factors.

Although the twenty-first century has seen major advances in evidence-based medicine to improve health, athletic performance, and injury prevention, our inability to implement these best practices across underserved American communities has limited the impact of these breakthroughs in sports medicine. Rochester, NY is stereotypical of American communities in which an economically challenged racially diverse urban center with grossly underperforming public schools is surrounded by adequately resourced predominantly Caucasian state-of-the-art education systems. As these great disparities perpetuate and further degrade our society in the absence of interventions, the need for community engagement initiatives is self-evident.

Clinical Improvement After Lumbar Fusion: Using PROMIS to Assess Recovery Kinetics.

STUDY DESIGN: Retrospective review of a single institution cohort. OBJECTIVE: The goal of this study is to identify features that predict delayed achievement of minimum clinically important difference (MCID) following elective lumbar spine fusion using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. SUMMARY OF BACKGROUND DATA: Preoperative prediction of delayed recovery following lumbar spine fusion surgery is challenging. While many studies have examined factors impacting the achievement of MCID for patient-reported outcomes in similar cohorts, few studies have assessed predictors of early functional improvement. METHODS: We retrospectively reviewed patients undergoing elective one-level posterior lumbar fusion for degenerative pathology. Patients were subdivided into two groups based on achievement of MCID for each respective PROMIS domain either before six months ("early responders") or after six months ("late responders") following surgical intervention. Multivariable logistic regression analysis was used to determine features associated with odds of achieving distribution-based MCID before or after six months follow up. RESULTS: 147 patients were included. The average age was 64.3±13.0 years. At final follow-up, 57.1% of patients attained MCID for PI and 72.8% for PF. However, 42 patients (49.4%) reached MCID for PI by six months, compared to 44 patients (41.1%) for PF. Patients with severe symptoms had the highest probability of attaining MCID for PI (OR 10.3; P =0.001) and PF (OR 10.4; P =0.001) Preoperative PROMIS symptomology did not predict early achievement of MCID for PI or PF. Patients who received concomitant iliac crest autograft during their lumbar fusion had increased odds of achieving MCID for PI (OR 8.56; P =0.001) before six months. CONCLUSION: Our study demonstrated that the majority of patients achieved MCID following elective one-level lumbar spine fusion at long-term follow-up, although less than half achieved this clinical benchmark for each PROMIS metric by six months. We also found that preoperative impairment was not associated with when patients would achieve MCID. Further prospective investigations are warranted to characterize the trajectory of clinical improvement and identify the risk factors associated with poor outcomes more accurately.

The effect of a workplace wellness program on disability, function and pain in healthcare providers workers with low back pain-outcomes of 3040 academic health center employees.

PURPOSE: (1) Identification of musculoskeletal risk factors for healthcare providers suffering low back pain (LBP) and the creation of risk profiles for those individuals and (2) analyze the impact of a workplace wellness program on healthcare providers who suffer from low back pain. METHODS: A total of 3040 employees at an academic healthcare center underwent a computer-adaptive survey of health-related quality of life (HRQOL), biometric tests, and a disability and functional movement assessment as part of the workplace wellness program (WWP). Clinical interventions with a rehabilitation specialist were offered to employees identified as at risk for low back pain. Data collected were analyzed using descriptive methods and multivariable regressions to address the study objectives. RESULTS: Of the 3040 healthcare providers enrolled in this study, 77% identified with non-specific LBP with greater weakness, numbness, reduced flexibility, and physical activity. The major predictive risk factors for LBP were Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference score, PROMIS fatigue, previous work injury, flexibility, numbness, PROMIS social function, level of education, and BMI. Healthcare providers with LBP who completed the WWP improved in most dimensions of HRQOL and disability and functional outcomes. CONCLUSIONS: A high proportion of healthcare providers suffer from LBP as a result of the nature of their work. Disability and functional outcomes measurements and PROMIS results quantitatively assess healthcare providers with LBP. Organizations can develop injury mitigation programs to target employees at high risk of LBP using the risk factors we identify. Completion of the WWP was associated with improvements in disability, HRQOL and functional measures.

Exploring Correlations Between Pain and Deformity in Idiopathic Scoliosis With Validated Self-reported Pain Scores, Radiographic Measurements, and Trunk Surface Topographic Measurements.

BACKGROUND: Up to 75% of patients with idiopathic scoliosis (IS) report back pain, but the exact contributors are unclear. This study seeks to assess how pain correlates with demographics, radiographic and surface topographic (ST) measurements, and patient-reported outcome measures (PROMs) in patients with IS. METHODS: Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference (PI) and Scoliosis Research Society revised (SRS-22r) pain domain from an IRB approved prospectively collected registry containing patients 11 to 21 years old with IS were correlated (Spearman coefficients) with measurements from whole-body EOS radiography and ST scanning, PROMIS 1.0 PROMs, Trunk Appearance Perception Scale (TAPS), and SRS-22r domains. SRS-22r and PROMIS-PI were also compared between different sex, scoliosis severities, and primary curve locations with Mann-Whitney U or Kruskal-Wallis tests, and if significant differences were found, included with the 5 highest univariate correlated variables into stepwise multivariate linear regression models ( P <0.05 to enter, P >0.1 to remove) predicting SRS-22r pain and PROMIS-PI. RESULTS: One hundred and forty-nine patients (14.5 ± 2.0 y, body mass index 20.6 ± 4.1 kg/m 2 , 96 (64%) female, mean major coronal curve 40 ± 19 deg, range: 10 deg, 83 deg) reported mean PROMIS-PI of 42.2 ± 10.0 and SRS-22r pain of 4.4 ± 0.6. SRS-22r self-image was the most correlated variable with both SRS-22r pain (rho=0.519) and PROMIS-PI (rho=-0.594). Five variables, none of which were ST or radiographic measures, strongly predicted SRS pain domain (R=0.711, R2=0.505, N=138). Two variables (SRS-22r self-image and SRS-22r function) were utilized by a model correlated with PROMIS-PI (R=0.687, R2=0.463, N=124). CONCLUSIONS: SRS-22r function and self-image domains were more strongly correlated with SRS-22r pain and PROMIS-PI than any radiographic or ST measurements. LEVEL OF EVIDENCE: Level II-retrospective study.

Spine patient care with wearable medical technology: state-of-the-art, opportunities, and challenges: a systematic review.

BACKGROUND CONTEXT: Healthcare reforms that demand quantitative outcomes and technical innovations have emphasized the use of Disability and Functional Outcome Measurements (DFOMs) to spinal conditions and interventions. Virtual healthcare has become increasingly important following the COVID-19 pandemic and wearable medical devices have proven to be a useful adjunct. Thus, given the advancement of wearable technology, broad adoption of commercial devices (ie, smartwatches, phone applications, and wearable monitors) by the general public, and the growing demand from consumers to take control of their health, the medical industry is now primed to formally incorporate evidence-based wearable device-mediated telehealth into standards of care. PURPOSE: To (1) identify all wearable devices in the peer-reviewed literature that were used to assess DFOMs in Spine, (2) analyze clinical studies implementing such devices in spine care, and (3) provide clinical commentary on how such devices might be integrated into standards of care. STUDY DESIGN/SETTING: A systematic review. METHODS: A comprehensive systematic review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA) across the following databases: PubMed; MEDLINE; EMBASE (Elsevier); and Scopus. Articles related to wearables systems in spine healthcare were selected. Extracted data was collected as per a predetermined checklist including wearable device type, study design, and clinical indices studied. RESULTS: Of the 2,646 publications that were initially screened, 55 were extensively analyzed and selected for retrieval. Ultimately 39 publications were identified as being suitable for inclusion based on the relevance of their content to the core objectives of this systematic review. The most relevant studies were included, with a focus on wearables technologies that can be used in patients' home environments. CONCLUSIONS: Wearable technologies mentioned in this paper have the potential to revolutionize spine healthcare through their ability to collect data continuously and in any environment. In this paper, the vast majority of wearable spine devices rely exclusively on accelerometers. Thus, these metrics provide information about general health rather than specific impairments caused by spinal conditions. As wearable technology becomes more prevalent in orthopedics, healthcare costs may be reduced and patient outcomes will improve. A combination of DFOMs gathered using a wearable device in conjunction with patient-reported outcomes and radiographic measurements will provide a comprehensive evaluation of a spine patient's health and assist the physician with patient-specific treatment decision-making. Establishing these ubiquitous diagnostic capabilities will allow improvement in patient monitoring and help us learn about postoperative recovery and the impact of our interventions.

Spine Surgeons Social Dilemma: Benefits and Risks of Social Media for Spine Surgery Practice in the 21st Century.

STUDY DESIGN: Cross-sectional observational. BACKGROUND: The use of social media by providers can enhance patient education, complement offline information, facilitate patient support, stimulate brand building, and strengthen the organization's market position. Risks of social media include, but are not limited to, a lack of quality, reliability, misrepresentation of credentials, influence of hidden and overt conflicts of interest, content that may jeopardize patient privacy, HIPAA regulations, and physicians' credentials and licensure. Physicians' use of social media may also expose him/her to lawsuits if providing specific medical advice on media platforms. OBJECTIVE: To document the social media presence of a broad cohort of spine surgeons, and to discuss the benefits and risks of a social media presence. METHODS: Cross-sectional observational of 325 Spine Surgeons from 76 institutions across the US. Description statistic and Pearson's correlation were used to investigate the relationships between the variables. RESULTS: Out of the 325 surgeons, 96% were male with an average age of 51.5 ± 10.7 years and 14.1 ± 9.6 years of experience. The frequency of social media use included 57.2% of surgeons had professional LinkedIn, 17.8% had professional Facebook, and less than 16% had other social media platforms. When combining all platforms together, 64.6% of all surgeons had at least one professional social media platform. 64.0% of these surgeons had no social media activity in the past 90 days, while 19.4% and 10.9% were active once and twice a month, respectively. Surgeon age (P = 0.004), years in practice (P < 0.001), and practice type (P < 0.001) were strongly correlated with social media activity. CONCLUSIONS: Given the scarcity of research on this topic and the novelty of the platforms, social media and online services continue to be utilized at a low level by spine surgeons. Issues regarding the risks of privacy issues with social media users continue to be a concern among medical professionals adopting this technology. This can largely be mitigated with the combination of physician education and informed consent from patients. The ability to connect with patients directly, and provide access to high-quality education and information will be of considerable benefit to our field well into the future.

The H Laminectomy: Technical Description and Clinical Experience From the First 85 Patients.

BACKGROUND: Over the years, lumbar laminectomy has been widely employed by spinal surgeons for many purposes throughout the spinal canal. The Misonix BoneScalpel relies on ultrasonic energy and allows the surgeon to make precise osteotomies while protecting collateral or adjacent soft tissue structures. Amplification of electric impulses allows the blade in the BoneScalpel to oscillate at very high frequencies, which thus allow it to cut bone with immense amounts of heat, which are then tempered with copious irrigation to prevent overheating. The purpose of this study is to outline and detail an innovative technique while providing insight into the technique's clinical application in a variety of spine surgeries. METHODS: Data were retrospectively collected from medical charts and surgical reports from February 2018 to July 2021 for each surgery in which the ultrasonic scalpel was used to perform the H laminectomy. Baseline demographic information was recorded, including age, gender, laminectomy indication, and the number of levels of laminectomy. RESULTS: A total of 85 patients (64 women, 21 men) were included in this study. The mean age of the patients was 63.7 years. Of those patients, 42.4% underwent H laminectomy for degenerative stenosis without instrumentation, 31.8% for degenerative stenosis with instrumentation, 9.4% for traumatic injuries, and 7.1% for revision surgery with instrumentation. Approximately 55% of patients underwent laminectomy of 2 or more levels, while the rest underwent single-level laminectomy. No patients had a dural tear or cerebrospinal fluid (CSF) leak as a result of the BoneScalpel. CONCLUSIONS: The H laminectomy is another safe and effective way to perform a lumbar laminectomy. The technique has not been previously reported in the literature. No patients experienced a dural tear or CSF leak from the BoneScalpel using the H laminectomy technique. This technique affords the surgeon enhanced control of the dura-ligamentum interface. Even if the surgeon is not very experienced with the BoneScalpel, this technique provides an inherent safety mechanism with constant visualization/tactile feedback of the tip of the instrument and osteotome.

Is Golf a Contact Sport? Protection of the Spine and Return to Play After Lumbar Surgery.

STUDY DESIGN: Narrative review. OBJECTIVE: To address the gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing. METHODS: This review did not involve patient care or any clinical prospective or retrospective review of patient information and thus did not warrant institutional review board approval. The available literature of PubMed, Medline, and OVID was utilized to review the existing literature. RESULTS: Studies have shown that the forces through the lumbar spine in the modern-era golf swing are like other contact sports. Methods of protecting the lumbar spine include proper swing mechanics, abdominal and paraspinal musculature strengthening and flexibility as well as physical fitness. There are a variety of treatment options available to treat lumbar spine pathology each with a different return to play recommendations from doctors in the field. CONCLUSIONS: With the introduction of a high impact, modern-era swing to the game of golf, the pathology is seen in the lumbar spine of both young, old, professional, and amateur golfers with low back pain are similar to other athletes in contact sports. Surgery is effective in returning athletes to a similar level of play even though no protocols exist for an effective and safe return. There have been many studies conducted to determine appropriate treatment and return to play for these injuries, but there is a gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing. As return to competitive play is important, especially with professional golfers, studies combining the use of swing mechanics changes, rehabilitation regimens and the type of surgery performed would be able to provide some insight into this topic now that golf may begin to be considered a contact sport.

Balance effort, Cone of Economy, and dynamic compensatory mechanisms in common degenerative spinal pathologies.

BACKGROUND: Changes in balance are common in individuals with spinal disorders and may cause falls. Balance efficiency, is the ability of a person to maintain their center of gravity with minimal neuromuscular energy expenditure, oftentimes referred to as Cone of Economy (CoE). CoE balance is defined by two sets of measures taken from the center of mass (CoM) and head: 1) the range-of-sway (RoS) in the coronal and sagittal planes, and 2) the overall sway distance. This allows spine caregivers to assess the severity of a patient's balance, balance pattern, and dynamic posture and record the changes following surgical intervention. Maintenance of balance requires coordination between the central nervous and musculoskeletal systems. RESEARCH QUESTION: To discern differences in balance effort values between common degenerative spinal pathologies and a healthy control group. METHODS: Three-hundred and forty patients with degenerative spinal pathologies: cervical spondylotic myelopathy (CSM), adult degenerative scoliosis (ADS), sacroiliac dysfunction (SIJD), degenerative lumbar spondylolisthesis (DLS), single-level lumbar degeneration (LD), and failed back syndrome (FBS), and 40 healthy controls were recruited. A functional balance test was performed approximately one week before surgery recorded by 3D video motion capture. RESULTS: Balance effort and compensatory mechanisms were found to be significantly greater in degenerative spinal pathologies patients compared to controls. Head and Center of Mass (CoM) overall sway ranged from 65.22 to 92.78 cm (p < 0.004) and 35.77-53.31 cm (p < 0.001), respectively in degenerative spinal pathologies patients and in comparison to controls (Head: 44.52 cm, CoM: 22.24 cm). Patients with degenerative spinal pathologies presented with greater trunk (1.61-2.98°, p < 0.038), hip (4.25-5.87°, p < 0.049), and knee (4.55-6.09°, p < 0.036) excursion when compared to controls (trunk: 0.95°, hip: 2.97°, and knee: 2.43°). SIGNIFICANCE: The results of this study indicate that patients from a wide variety of degenerative spinal pathologies similarly exhibit markedly diminished balance (and compensatory mechanisms) as indicated by increased sway on a Romberg test and a larger Cone of Economy (CoE) as compared to healthy controls. Balance effort, as measured by overall sway, was found to be approximately double in patients with degenerative spinal pathologies compared to healthy matched controls. Clinicians can compare CoE parameters among symptomatic patients from the different cohorts using the Haddas' CoE classification system to guide their postoperative prognosis.

Functional Ability Classification Based on Moderate and Severe Kinesophobia and Demoralization Scores in Degenerative Spine Patients.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: To assess the relationship of fear avoidance and demoralization on gait and balance and determine a threshold score for the Tampa Scale for Kinesophobia (TSK) and the Demoralization Scale (DS) that identifies spine patients with gait and balance dysfunction amplified by underlying psychological factors. SUMMARY OF BACKGROUND DATA: Fear avoidance and demoralization are crucial components of mental health that impact the outcomes in spine surgery. However, interpreting their effect on patient function remains challenging. Further establishing this correlation and identifying a threshold of severity can aid in identifying patients in whom a portion of their altered gait and balance may be amplified by underlying psychologic distress. METHODS: Four hundred five symptomatic spine patients were given the TSK and DS questionnaires. Patient's gait and balance were tested with a human motion capture system. A TSK score of 41 and a DS score of 30 were chosen as thresholds to classify moderate versus severe dysfunction based on literature and statistical analysis. RESULTS: Higher TSK and DS scores were correlated with worse walking speed (P < 0.001), longer stride time (P = 0.001), decreased stride length (P < 0.048), and wider step width (<0.001) during gait as well as increased sway across planes (P = 0.001) during standing balance. When classified by TSK scores >41, patients with more severe fear avoidance had slower walking speed (P < 0.001), longer stride time (P = 0.001), shorter stride length (P = 0.004), increased step width (P < 0.001), and increased sway (P = 0.001) compared with their lower scoring counterparts. Similarly, patients with DS > 30 had slower walking speed (P = 0.012), longer stride time (P = 0.022), and increased sway (P = 0.003) compared with their lower scoring counterparts. CONCLUSION: This study demonstrates that fear avoidance and demoralization directly correlate with worsening gait and balance. Furthermore, patients with TSK > 41 and DS > 30 have more underlying psychological factors that contribute to significantly worse function compared with lower scoring peers. Understanding this relationship and using these guidelines can help identify and treat patients whose gait dysfunction may be amplified by psychologic distress.Level of Evidence: 3.