Inter-observational analysis of computed tomography parameters to predict nonobvious posterior ligament complex injury in neurologically intact patients with thoracolumbar trauma.

Introduction: Assessing the integrity of the posterior ligament complex (PLC), as a key element in the characterization of an unstable Thoracolumbar fracture (TLF), is challenging, but crucial in the choice of treatment. Research question: How to create a reproducible score using combined parameters of Computed Tomography (CT) to predict nonobvious PLC injury. How CT parameters relate with PLC status. Material and methods: Retrospective analysis of neurologically intact patients with an acute traumatic TLF, who underwent CT and Magnetic Resonance Imaging (MRI) within 72 h, in the Emergency Department of a single institution between January 2016 and 2022. Four investigators rated independently 11 parameters on CT and PLC integrity on MRI. The interrater reliability of the CT parameters was evaluated, and two risk scores were created to predict PLC injury on CT using the coefficients of the multivariate logistic regression. Results: 154 patients were included, of which 62 with PLC injury. All CT measurements had excellent or good interrater reliability. Patients with Horizontal Fracture of the lamina or pedicle (HLPF), Spinous process fracture (SPF) and Interspinous Distance Widening (IDW) were positively associated with PLC injury (p < 0.001, p < 0.001 and p = 0.045, respectively). Risk Score 2 (RS2), which included only statistically significant variables, had a total of 75.9% of correct classifications (p < 0.001), with a sensitivity of 71.0% and specificity of 78.3% to estimate PLC injury detected in the MRI. Discussion and conclusion: Standardized procedures pre-established in the CT measurement protocol were effective. Identically to early findings, those three CT measurements showed a positive relation to PLC injury, thus enhancing the conclusions of previous studies. Comparing to the reliability of the CT findings above mentioned, the score was less precise.

The ideal patient positioning in spine surgery: a preventive strategy.

Patient positioning on the surgical table is a critical step in every spine surgery. The most common surgical positions in spine surgery are supine, prone and lateral decubitus. There are countless lesions that can occur during spine surgery due to patient mispositioning. Ulnar nerve and brachial plexus injuries are the most common nerve lesions seen in malpositioned patients. Devastating complications due to increased intraocular pressure or excessive abdominal pressure can also occur in prone decubitus and are real concerns that the surgical team must be aware of. All members of the surgical team (including surgeons, anesthesiologists and nurses) should know how to correctly position the patient, identify possible positioning errors and know how to avoid them in order to prevent postoperative morbidity. This work pretends to do a review of the most common positions during spine surgery, alert to errors that can happen during the procedure and how to avoid them.

Rehabilitation after cervical and lumbar spine surgery.

The total number of spine surgeries is increasing, with a variable percentage of patients remaining symptomatic and functionally impaired after surgery. Rehabilitation has been widely recommended, although its effects remain unclear due to lack of research on this matter. The aim of this comprehensive review is to resume the most recent evidence regarding postoperative rehabilitation after spine surgery and make recommendations. The effectiveness of cervical spine surgery on the outcomes is moderate to good, so most physiatrists and surgeons agree that patients benefit from a structured postoperative rehabilitation protocol and despite best timing to start rehabilitation is still unknown, most programs start 4-6 weeks after surgery. Lumbar disc surgery has shown success rates between 78% and 95% after 2 years of follow-up. Postoperative rehabilitation is widely recommended, although its absolute indication has not yet been proven. Patients should be educated to start their own postoperative rehabilitation immediately after surgery until they enroll on a rehabilitation program usually 4-6 weeks post-intervention. The rate of lumbar interbody fusion surgery is increasing, particularly in patients over 60 years, although studies report that 25-45% of patients remain symptomatic. Despite no standardized rehabilitation program has been defined, patients benefit from a cognitive-behavioral physical therapy starting immediately after surgery with psychological intervention, patient education and gradual mobilization. Formal spine rehabilitation should begin at 2-3 months postoperatively. Rehabilitation has benefits on the recovery of patients after spine surgery, but further investigation is needed to achieve a standardized rehabilitation approach.

The Influence of Schmorl Nodes in Spinal Sagittal Balance in Young Adults.

Objectives The present study aims to characterize the spinal balance (SB) in young adults with Schmorl nodes (SN). Methods A cross-sectional study was conducted on a sample of 47 young adults. Lumbar magnetic resonance imaging (MRI) was used to divide the patients into an SN group and a control group. Standing full spine radiographs were used to compare the spinopelvic SB parameters between groups: sagittal vertical axis, thoracic kyphosis, lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Results The LL and SS values were significantly lower in patients with SN when compared with the control group (54.5° versus 64.3°; 36.2° versus 41.4°, respectively). No significant differences were observed for the other parameters. Significant correlations were found in both groups between LL and SS; PI and PT; and PI and SS. Conclusions Young adults with SN have associated SB modifications, particularly lower LL and SS values, when compared with a control group. This flatter profile resembles that observed in patients with lower back pain and early disc pathology. We believe that SNs are relevant clinical findings that should prompt the study of the SB of a patient, as it may uncover variations associated with early disc degeneration. Level of Evidence III.

Long-Term Follow-Up of Anterior Spinal Fusion for Thoracolumbar/Lumbar Curves in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective patient series analysis with update of long-term data. OBJECTIVE: To define the long-term prognosis of the thoracolumbar/lumbar correction after selective anterior spinal fusion (ASF) in adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The ASF is a well-described procedure for the treatment of AIS. The correction reliability over time, the consequences in adjacent spinal levels and patient's quality of life are fundamental for the characterization of AIS treatment. METHODS: One hundred seven patients were submitted to single-rod ASF for thoracolumbar/lumbar (ThL/L) AIS between 1993 and 2016 in a single-surgeon experience. Seventy five were available for final follow-up evaluation 9 years ±4 (2-23) after surgery. A clinical and sequential radiographic evaluations were performed. RESULTS: The mean age at surgery was 16 years ±â€Š2.33 (14-20) and 94 (87%) were females. The mean final follow-up of the 75 patients available was 9 years ±â€Š4 (2-23). Sixty-five patients had a Lenke type 5C curve and 10 had a type 6C curve. The mean values of the Scoliosis Research Society 22 (SRS-22) questionnaire in Lenke 5C was 92 ±â€Š9 (71-109) and in Lenke 6C 90.3 ±â€Š9 (75-107). In Lenke 5C group, the mean preoperative ThL Cobb angle was 38.4°â€Š±â€Š9.3 (21-60) and the postoperative was 5.9°â€Š±â€Š4.5 (0-18; P < 0.001) being similar at the final follow-up (P > 0.05). In Lenke 6C group, the mean preoperative ThL Cobb angle was 58.6°â€Š±â€Š13.9 (40-90) and the postoperative ThL Cobb was 22.6°â€Š±â€Š14.5 (5-48, P < 0.001) being similar at the final follow-up (P > 0.05). The mean preoperative Thoracic (Th) Cobb angle was 39°â€Š±â€Š7.6 (30-50), the postoperative was 30.6°â€Š±â€Š10.1 (14-49, P < 0.008) and in the final follow-up was 29.3°â€Š±â€Š10.7 (11-48, P < 0.011). CONCLUSION: ASF is a safe procedure in the treatment of ThL/L with good long-term results and high rates of satisfaction among patients with AIS Lenke type 5C. The partial correction was frequent in Lenke type 6C despite the absence of progression in the non-instrumented curves. LEVEL OF EVIDENCE: 4.

Acetabular retroversion: Diagnosis and treatment.

Acetabular retroversion (AR) consists of a malorientation of the acetabulum in the sagittal plane. AR is associated with changes in load transmission across the hip, being a risk factor for early osteoarthrosis. The pathophysiological basis of AR is an anterior acetabular hyper-coverage and an overall pelvic rotation.The delay or the non-diagnosis of AR could have an impact in the overall management of femoroacetabular impingement (FAI). AR is a subtype of (focal) pincer deformity.The objective of this review was to clarify the pathophysiological, diagnosis and treatment fundaments inherent to AR, using a current literature review.Radiographic evaluation is paramount in AR: the cross-over, the posterior wall and ischial spine signs are classic radiographic signs of AR. However, computed tomography (CT) evaluation permits a three-dimensional characterization of the deformity, being more reliable in its recognition.Acetabular rim trimming (ART) and periacetabular osteotomy (PAO) are the best described surgical options for the treatment of AR.The clinical outcomes of both techniques are dependent on the correct characterization of existing lesions and adequate selection of patients. Cite this article: EFORT Open Rev 2018;3:595-603. DOI: 10.1302/2058-5241.3.180015.

Mesenchymal Stem Cell Secretome Improves Tendon Cell Viability In Vitro and Tendon-Bone Healing In Vivo When a Tissue Engineering Strategy Is Used in a Rat Model of Chronic Massive Rotator Cuff Tear.

BACKGROUND: Massive rotator cuff tears (MRCTs) represent a major clinical concern, especially when degeneration and chronicity are involved, which highly compromise healing capacity. PURPOSE: To study the effect of the secretome of mesenchymal stem cells (MSCs) on tendon cells (TCs) followed by the combination of these activated TCs with an electrospun keratin-based scaffold to develop a tissue engineering strategy to improve tendon-bone interface (TBi) healing in a chronic MRCT rat model. STUDY DESIGN: Controlled laboratory study. METHODS: Human TCs (hTCs) cultured with the human MSCs (hMSCs) secretome (as conditioned media [CM]) were combined with keratin electrospun scaffolds and further implanted in a chronic MRCT rat model. Wistar-Han rats (N = 15) were randomly assigned to 1 of 3 groups: untreated lesion (MRCT group, n = 5), lesion treated with a scaffold only (scaffold-only group, n = 5), and lesion treated with a scaffold seeded with hTCs preconditioned with hMSCs-CM (STC_hMSC_CM group, n = 5). After sacrifice, 16 weeks after surgery, the rotator cuff TBi was harvested for histological analysis and biomechanical testing. RESULTS: The hMSCs secretome increased hTCs viability and density in vitro. In vivo, a significant improvement of the tendon maturing score was observed in the STC_hMSC_CM group (mean ± standard error of the mean, 15.6 ± 1.08) compared with the MRCT group (11.0 ± 1.38; P < .05). Biomechanical tests revealed a significant increase in the total elongation to rupture (STC_hMSC_CM, 11.99 ± 3.30 mm; scaffold-only, 9.89 ± 3.47 mm; MRCT, 5.86 ± 3.16 mm; P < .05) as well as a lower stiffness (STC_hMSC_CM, 6.25 ± 1.74 N/mm; scaffold-only, 6.72 ± 1.28 N/mm; MRCT, 11.54 ± 2.99 N/mm; P < .01). CONCLUSION: The results demonstrated that hMSCs-CM increased hTCs viability and density in vitro. Clear benefits also were observed when these primed cells were integrated into a tissue engineering strategy with an electrospun keratin scaffold, as evidenced by improved histological and biomechanical properties for the STC_hMSC_CM group compared with the MRCT group. CLINICAL RELEVANCE: This work supports further investigation into the use of MSC secretome for priming TCs toward a more differentiated phenotype, and it promotes the tissue engineering strategy as a promising modality to help improve treatment outcomes for chronic MRCTs.

The Influence of Schmorl Nodes in Spinal Sagittal Balance in Young Adults / A Influência dos nódulos de Schmorl no equilíbrio sagital de adultos jovens

Abstract Objectives The present study aims to characterize the spinal balance (SB) in young adults with Schmorl nodes (SN). Methods A cross-sectional study was conducted on a sample of 47 young adults. Lumbar magnetic resonance imaging (MRI) was used to divide the patients into an SN group and a control group. Standing full spine radiographs were used to compare the spinopelvic SB parameters between groups: sagittal vertical axis, thoracic kyphosis, lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Results The LL and SS values were significantly lower in patients with SN when compared with the control group (54.5° versus 64.3°; 36.2° versus 41.4°, respectively). No significant differences were observed for the other parameters. Significant correlations were found in both groups between LL and SS; PI and PT; and PI and SS. Conclusions Young adults with SN have associated SB modifications, particularly lower LL and SS values, when compared with a control group. This flatter profile resembles that observed in patients with lower back pain and early disc pathology. We believe that SNs are relevant clinical findings that should prompt the study of the SB of a patient, as it may uncover variations associated with early disc degeneration. Level of Evidence III

Resumo Objetivos O presente estudo tem como objetivo caracterizar o equilíbrio sagital (SB, na sigla em inglês) espinhal em adultos jovens com nódulos de Schmorl (NS). Métodos Este é um estudo transversal de uma amostra composta por 47 adultos jovens. Ressonância magnética (RM) lombar foi usada para separar os pacientes em um grupo com NS e um grupo controle. Radiografias da coluna vertebral em pé foram usadas para comparar os parâmetros espinopélvicos do SB entre os grupos: eixo vertical sagital, cifose torácica, lordose lombar (LL), incidência pélvica (PI, na sigla em inglês), inclinação pélvica (PT, na sigla em inglês) e inclinação sacral (SS, na sigla em inglês). Resultados Os valores de LL e SS foram significativamente menores nos pacientes com NS em comparação com o grupo controle (54,5° versus 64,3°; 36,2° versus 41,4°, respectivamente). Não foram observadas diferenças significativas nos demais parâmetros. Os dois grupos apresentaram correlações significativas entre LL e SS, PI e PT e PI e SS. Conclusões Adultos jovens com NS apresentam modificações associadas ao SB, principalmente valores menores de LL e SS, em comparação com o grupo controle. Este perfil mais plano assemelha-se ao observado em pacientes com lombalgia e patologia discal em estágio inicial. Acreditamos que o NS seja um achado clínico relevante que deve levar ao estudo do SB de um paciente por poder revelar variações associadas aos primeiros estágios de degeneração discal. Nível de Evidência III

A new methodology for assessment of pectus excavatum correction after bar removal in Nuss procedure: Preliminary study.

PURPOSE: The objective is to present a new methodology to assess quantitatively the impact of bar removal on the anterior chest wall, among patients with pectus excavatum who have undergone the Nuss procedure, and present a preliminary study using this methodology. METHODS: We propose to acquire, for each patient, the surface of the anterior chest wall using a three-dimensional laser scanner at subsequent time points (short term: before and after surgery; long term: follow-up visit, 6months, and 12months after surgery). After surfaces postprocessing, the changes are assessed by overlapping and measuring the distances between surfaces. In this preliminary study, three time points were acquired and two assessments were performed: before vs after bar removal (early) and before vs 2-8weeks after bar removal (interim). In 21 patients, the signed distances and volumes between surfaces were computed and the data analysis was performed. RESULTS: This methodology revealed useful for monitoring changes in the anterior chest wall. On average, the mean, maximum, and volume variations, in the early assessment, were -0.1±0.1cm, -0.6±0.2cm, and 47.8±22.2cm3, respectively; and, in the interim assessment, were -0.5±0.2cm, -1.3±0.4cm, and 122.1±47.3cm3, respectively (p<0.05). Data analysis revealed that the time the bar was in situ was inversely and significantly correlated with postretraction and was a relevant predictor of its decrease following surgery (p<0.05). Additionally, gender and age suggested influencing the outcome. CONCLUSIONS: This methodology is novel, objective and safe, helping on follow-up of pectus excavatum patients. Moreover, the preliminary study suggests that the time the bar was in situ may be the main determinant of the anterior chest wall retraction following bar removal. Further studies should continue to corroborate and reinforce the preliminary findings, by increasing the sample size and performing long-term assessments. LEVELS OF EVIDENCE: III.

Variations of the soft tissue thicknesses external to the ribs in pectus excavatum patients.

BACKGROUND: Surgical repair of pectus excavatum (PE) has become more popular due to improvements in the minimally invasive Nuss procedure. The pre-surgical assessment of PE patients requires Computerized Tomography (CT), as the malformation characteristics vary from patient to patient. OBJECTIVE: This work aims to characterize soft tissue thickness (STT) external to the ribs among PE patients. It also presents a comparative analysis between the anterior chest wall surface before and after surgical correction. METHODS: Through surrounding tissue segmentation in CT data, STT values were calculated at different lines along the thoracic wall, with a reference point in the intersection of coronal and median planes. The comparative analysis between the two 3D anterior chest surfaces sets a surgical correction influence area (SCIA) and a volume of interest (VOI) based on image processing algorithms, 3D surface algorithms, and registration methods. RESULTS: There are always variations between left and right side STTs (2.54 ± 2.05 mm and 2.95 ± 2.97 mm for female and male patients, respectively). STTs are dependent on age, sex, and body mass index of each patient. On female patients, breast tissue induces additional errors in bar manual conception. The distances starting at the deformity's largest depression point at the SCIA are similar in all directions. Some diverging measures and outliers were found, being difficult to find similar characteristics between them, especially in asymmetric patients. CONCLUSION: The Nuss procedure metal bar must be modeled according to each patient's special characteristics. The studied relationships between STT and chest surface could represent a step forward to eliminate the CT scan from PE pre-surgical evaluation.