POPOVICH, encoding a C2H2 zinc-finger transcription factor, plays a central role in the development of a key innovation, floral nectar spurs, in Aquilegia.

The evolution of novel features, such as eyes or wings, that allow organisms to exploit their environment in new ways can lead to increased diversification rates. Therefore, understanding the genetic and developmental mechanisms involved in the origin of these key innovations has long been of interest to evolutionary biologists. In flowering plants, floral nectar spurs are a prime example of a key innovation, with the independent evolution of spurs associated with increased diversification rates in multiple angiosperm lineages due to their ability to promote reproductive isolation via pollinator specialization. As none of the traditional plant model taxa have nectar spurs, little is known about the genetic and developmental basis of this trait. Nectar spurs are a defining feature of the columbine genus Aquilegia (Ranunculaceae), a lineage that has experienced a relatively recent and rapid radiation. We use a combination of genetic mapping, gene expression analyses, and functional assays to identify a gene crucial for nectar spur development, POPOVICH (POP), which encodes a C2H2 zinc-finger transcription factor. POP plays a central role in regulating cell proliferation in the Aquilegia petal during the early phase (phase I) of spur development and also appears to be necessary for the subsequent development of nectaries. The identification of POP opens up numerous avenues for continued scientific exploration, including further elucidating of the genetic pathway of which it is a part, determining its role in the initial evolution of the Aquilegia nectar spur, and examining its potential role in the subsequent evolution of diverse spur morphologies across the genus.

Genetic architecture underlying variation in floral meristem termination in Aquilegia.

Floral organs are produced by floral meristems (FMs), which harbor stem cells in their centers. Since each flower only has a finite number of organs, the stem cell activity of an FM will always terminate at a specific time point, a process termed floral meristem termination (FMT). Variation in the timing of FMT can give rise to floral morphological diversity, but how this process is fine-tuned at a developmental and evolutionary level is poorly understood. Flowers from the genus Aquilegia share identical floral organ arrangement except for stamen whorl number (SWN), making Aquilegia a well-suited system for investigation of this process: differences in SWN between species represent differences in the timing of FMT. By crossing A. canadensis and A. brevistyla, quantitative trait locus (QTL) mapping has revealed a complex genetic architecture with seven QTL. We explored potential candidate genes under each QTL and characterized novel expression patterns of select loci of interest using in situ hybridization. To our knowledge, this is the first attempt to dissect the genetic basis of how natural variation in the timing of FMT is regulated, and our results provide insight into how floral morphological diversity can be generated at the meristematic level.

Landscape Genomics to Enable Conservation Actions: The California Conservation Genomics Project.

The California Conservation Genomics Project (CCGP) is a unique, critically important step forward in the use of comprehensive landscape genetic data to modernize natural resource management at a regional scale. We describe the CCGP, including all aspects of project administration, data collection, current progress, and future challenges. The CCGP will generate, analyze, and curate a single high-quality reference genome and 100-150 resequenced genomes for each of 153 species projects (representing 235 individual species) that span the ecological and phylogenetic breadth of California's marine, freshwater, and terrestrial ecosystems. The resulting portfolio of roughly 20 000 resequenced genomes will be analyzed with identical informatic and landscape genomic pipelines, providing a comprehensive overview of hotspots of within-species genomic diversity, potential and realized corridors connecting these hotspots, regions of reduced diversity requiring genetic rescue, and the distribution of variation critical for rapid climate adaptation. After 2 years of concerted effort, full funding ($12M USD) has been secured, species identified, and funds distributed to 68 laboratories and 114 investigators drawn from all 10 University of California campuses. The remaining phases of the CCGP include completion of data collection and analyses, and delivery of the resulting genomic data and inferences to state and federal regulatory agencies to help stabilize species declines. The aspirational goals of the CCGP are to identify geographic regions that are critical to long-term preservation of California biodiversity, prioritize those regions based on defensible genomic criteria, and provide foundational knowledge that informs management strategies at both the individual species and ecosystem levels.

Comparative transcriptomics of early petal development across four diverse species of Aquilegia reveal few genes consistently associated with nectar spur development.

BACKGROUND: Petal nectar spurs, which facilitate pollination through animal attraction and pollen placement, represent a key innovation promoting diversification in the genus Aquilegia (Ranunculaceae). Identifying the genetic components that contribute to the development of these three-dimensional structures will inform our understanding of the number and types of genetic changes that are involved in the evolution of novel traits. In a prior study, gene expression between two regions of developing petals, the laminar blade and the spur cup, was compared at two developmental stages in the horticultural variety A. coerulea 'Origami'. Several hundred genes were differentially expressed (DE) between the blade and spur at both developmental stages. In order to narrow in on a set of genes crucial to early spur formation, the current study uses RNA sequencing (RNAseq) to conduct comparative expression analyses of petals from five developmental stages between four Aquilegia species, three with morphologically variable nectar spurs, A. sibirica, A. formosa, and A. chrysantha, and one that lacks nectar spurs, A. ecalcarata. RESULTS: Petal morphology differed increasingly between taxa across the developmental stages assessed, with petals from all four taxa being indistinguishable pre-spur formation at developmental stage 1 (DS1) and highly differentiated by developmental stage 5 (DS5). In all four taxa, genes involved in mitosis were down-regulated over the course of the assessed developmental stages, however, many genes involved in mitotic processes remained expressed at higher levels later in development in the spurred taxa. A total of 690 genes were identified that were consistently DE between the spurred taxa and A. ecalcarata at all five developmental stages. By comparing these genes with those identified as DE between spur and blade tissue in A. coerulea 'Origami', a set of only 35 genes was identified that shows consistent DE between petal samples containing spur tissue versus those without spur tissue. CONCLUSIONS: The results of this study suggest that expression differences in very few loci are associated with the presence and absence of spurs. In general, it appears that the spurless petals of A. ecalcarata cease cell divisions and enter the cell differentiation phase at an earlier developmental time point than those that produce spurs. This much more tractable list of 35 candidates genes will greatly facilitate targeted functional studies to assess the genetic control and evolution of petal spurs in Aquilegia.

Disruption of the petal identity gene APETALA3-3 is highly correlated with loss of petals within the buttercup family (Ranunculaceae).

Absence of petals, or being apetalous, is usually one of the most important features that characterizes a group of flowering plants at high taxonomic ranks (i.e., family and above). The apetalous condition, however, appears to be the result of parallel or convergent evolution with unknown genetic causes. Here we show that within the buttercup family (Ranunculaceae), apetalous genera in at least seven different lineages were all derived from petalous ancestors, indicative of parallel petal losses. We also show that independent petal losses within this family were strongly associated with decreased or eliminated expression of a single floral organ identity gene, APETALA3-3 (AP3-3), apparently owing to species-specific molecular lesions. In an apetalous mutant of Nigella, insertion of a transposable element into the second intron has led to silencing of the gene and transformation of petals into sepals. In several naturally occurring apetalous genera, such as Thalictrum, Beesia, and Enemion, the gene has either been lost altogether or disrupted by deletions in coding or regulatory regions. In Clematis, a large genus in which petalous species evolved secondarily from apetalous ones, the gene exhibits hallmarks of a pseudogene. These results suggest that, as a petal identity gene, AP3-3 has been silenced or down-regulated by different mechanisms in different evolutionary lineages. This also suggests that petal identity did not evolve many times independently across the Ranunculaceae but was lost in numerous instances. The genetic mechanisms underlying the independent petal losses, however, may be complex, with disruption of AP3-3 being either cause or effect.

Technical Note on the Role of Kambin's Triangle in the Evolution of Total Joint Replacement of the Lumbar Spine.

We provide a historical and technical perspective on the evolution of Kambin's triangle as a safe working corridor for percutaneous access to the intervertebral disc to an anatomically expanded space to accommodate and facilitate open lumbar total joint replacement. The nearly 6-decade progression from intradiscal access in the intact lumbar spine to an enlarged working space following facetectomy to accommodate a transforaminal lumbar interbody fusion, and eventual further expansion via pedicle vertebral body osteotomy to support motion preservation with total joint replacement, represents a unique evolutionary pathway in surgical technique development. For each of these steps in evolution, we detail and provide the historical context of the corresponding surgical modifications required to expand the original anatomical boundaries of Kambin's triangle. It is postulated that the introduction of machine learning technologies coupled with innovations in robotics, materials science, and advanced imaging will further accelerate and refine the adaptation of more complex, precise, and efficacious surgical procedures to treat spinal degeneration via this working corridor.

Are We Finally Ready for Total Joint Replacement of the Spine? An Extension of Charnley's Vision.

Professor Sir John Charnley has been rightfully hailed as a visionary innovator for conceiving, designing, and validating the Operation of the Century-the total hip arthroplasty. His groundbreaking achievement forever changed the orthopedic management of chronically painful and dysfunctional arthritic joints. However, the well-accepted surgical approach of completely removing the diseased joint and replacing it with a durable and anatomically based implant never translated to the treatment of the degenerated spine. Instead, decompression coupled with fusion evolved into the workhorse intervention. In this commentary, the authors explore the reasons why arthrodesis has remained the mainstay over arthroplasty in the field of spine surgery as well as discuss the potential shift in the paradigm when it comes to treating degenerative lumbar disease.

Loss of staminodes in Aquilegia jonesii reveals a fading stamen-staminode boundary.

The modification of fertile stamens into sterile staminodes has occurred independently many times in the flowering plant lineage. In the genus Aquilegia (columbine) and its closest relatives, the two stamen whorls closest to the carpels have been converted to staminodes. In Aquilegia, the only genetic analyses of staminode development have been reverse genetic approaches revealing that B-class floral identity genes are involved. A. jonesii, the only species of columbine where staminodes have reverted to fertile stamens, allows us to explore the genetic architecture of staminode development using a forward genetic approach. We performed QTL analysis using an outcrossed F2 population between A. jonesii and a horticultural variety that makes fully developed staminodes, A. coerulea 'Origami'. Our results reveal a polygenic basis for staminode loss where the two staminode whorls are under some level of independent control. We also discovered that staminode loss in A. jonesii is not complete, in which staminode-like traits sometimes occur in the inner fertile stamens, potentially representing a fading boundary of gene expression. The QTLs identified in this study provide a map to guide future reverse genetic and functional studies examining the genetic basis and evolutionary significance of this trait.

Spatiotemporal reconstruction of the Aquilegia rapid radiation through next-generation sequencing of rapidly evolving cpDNA regions.

Aquilegia is a well-known model system in the field of evolutionary biology, but obtaining a resolved and well-supported phylogenetic reconstruction for the genus has been hindered by its recent and rapid diversification. Here, we applied 454 next-generation sequencing to PCR amplicons of 21 of the most rapidly evolving regions of the plastome to generate c. 24 kb of sequences from each of 84 individuals from throughout the genus. The resulting phylogeny has well-supported resolution of the main lineages of the genus, although recent diversification such as in the European taxa remains unresolved. By producing a chronogram of the whole Ranunculaceae family based on published data, we inferred calibration points for dating the Aquilegia radiation. The genus originated in the upper Miocene c. 6.9 million yr ago (Ma) in Eastern Asia, and diversification occurred c. 4.8 Ma with the split of two main clades, one colonizing North America, and the other Western Eurasia through the mountains of Central Asia. This was followed by a back-to-Asia migration, originating from the European stock using a North Asian route. These results provide the first backbone phylogeny and spatiotemporal reconstruction of the Aquilegia radiation, and constitute a robust framework to address the adaptative nature of speciation within the group.

Pollinator shifts drive increasingly long nectar spurs in columbine flowers.

Directional evolutionary trends have long garnered interest because they suggest that evolution can be predictable. However, the identification of the trends themselves and the underlying processes that may produce them have often been controversial. In 1862, in explaining the exceptionally long nectar spur of Angraecum sesquipedale, Darwin proposed that a coevolutionary 'race' had driven the directional increase in length of a plant's spur and its pollinator's tongue. Thus he predicted the existence of an exceptionally long-tongued moth. Though the discovery of Xanthopan morgani ssp. praedicta in 1903 with a tongue length of 22 cm validated Darwin's prediction, his 'race' model for the evolution of long-spurred flowers remains contentious. Spurs may also evolve to exceptional lengths by way of pollinator shifts as plants adapt to a series of unrelated pollinators, each with a greater tongue length. Here, using a species-level phylogeny of the columbine genus, Aquilegia, we show a significant evolutionary trend for increasing spur length during directional shifts to pollinators with longer tongues. In addition, we find evidence for 'punctuated' change in spur length during speciation events, suggesting that Aquilegia nectar spurs rapidly evolve to fit adaptive peaks predefined by pollinator morphology. These findings show that evolution may proceed in predictable pathways without reversals and that change may be concentrated during speciation.

In Vitro Wear of a Novel Vitamin E Crosslinked Polyethylene Lumbar Total Joint Replacement.

BACKGROUND: A novel, lumbar total joint replacement (TJR) design has been developed to treat degeneration across all three columns of the lumbar spine (anterior, middle, and posterior columns). Thus far, there has been no in vitro studies that establish the preclinical safety profile of the vitamin E-stabilized highly crosslinked polyethylene (VE-HXLPE) lumbar TJR relative to historical lumbar anterior disc replacement for the known risks of wear and impingement faced by all motion preserving designs for the lumbar spine. QUESTIONS/PURPOSE: In this study we asked, (1) what is the wear performance of the VE-HXLPE lumbar TJR under ideal, clean conditions? (2) Is the wear performance of VE-HXLPE in lumbar TJR sensitive to more aggressive, abrasive conditions? (3) How does the VE-HXLPE lumbar TJR perform under impingement conditions? METHOD: A lumbar TJR with bilateral VE-HXLPE superior bearings and CoCr inferior bearings was evaluated under clean, impingement, and abrasive conditions. Clean and abrasive testing were guided by ISO 18192-1 and impingement was assessed as per ASTM F3295. For abrasive testing, CoCr components were scratched to simulate in vivo abrasion. The devices were tested for 10 million cycles (MC) under clean conditions, 5 MC under abrasion, and 1 MC under impingement. RESULT: Wear rates under clean and abrasive conditions were 1.2 ± 0.5 and 1.1 ± 0.6 mg/MC, respectively. The VE-HXLPE components demonstrated evidence of burnishing and multidirectional microscratching consistent with microabrasive conditions with the cobalt chromium spherical counterfaces. Under impingement, the wear rates ranged between 1.7 ± 1.1 (smallest size) and 3.9 ± 1.1 mg/MC (largest size). No functional or mechanical failure was observed across any of the wear modes. CONCLUSIONS: Overall, we found that that a VE-HXLPE-on-CoCr lumbar total joint replacement design met or exceeded the benchmarks established by traditional anterior disc replacements, with wear rates previously reported in the literature ranging between 1 and 15 mg/MC. CLINICAL RELEVANCE: The potential clinical benefits of this novel TJR design, which avoids long-term facet complications through facet removal with a posterior approach, were found to be balanced by the in vitro tribological performance of the VE-HXLPE bearings. Our encouraging in vitro findings have supported initiating an FDA-regulated clinical trial for the design which is currently under way.

Evolution of spur-length diversity in Aquilegia petals is achieved solely through cell-shape anisotropy.

The role of petal spurs and specialized pollinator interactions has been studied since Darwin. Aquilegia petal spurs exhibit striking size and shape diversity, correlated with specialized pollinators ranging from bees to hawkmoths in a textbook example of adaptive radiation. Despite the evolutionary significance of spur length, remarkably little is known about Aquilegia spur morphogenesis and its evolution. Using experimental measurements, both at tissue and cellular levels, combined with numerical modelling, we have investigated the relative roles of cell divisions and cell shape in determining the morphology of the Aquilegia petal spur. Contrary to decades-old hypotheses implicating a discrete meristematic zone as the driver of spur growth, we find that Aquilegia petal spurs develop via anisotropic cell expansion. Furthermore, changes in cell anisotropy account for 99 per cent of the spur-length variation in the genus, suggesting that the true evolutionary innovation underlying the rapid radiation of Aquilegia was the mechanism of tuning cell shape.

Adaptive radiations: from field to genomic studies.

Adaptive radiations were central to Darwin's formation of his theory of natural selection, and today they are still the centerpiece for many studies of adaptation and speciation. Here, we review the advantages of adaptive radiations, especially recent ones, for detecting evolutionary trends and the genetic dissection of adaptive traits. We focus on Aquilegia as a primary example of these advantages and highlight progress in understanding the genetic basis of flower color. Phylogenetic analysis of Aquilegia indicates that flower color transitions proceed by changes in the types of anthocyanin pigments produced or their complete loss. Biochemical, crossing, and gene expression studies have provided a wealth of information about the genetic basis of these transitions in Aquilegia. To obtain both enzymatic and regulatory candidate genes for the entire flavonoid pathway, which produces anthocyanins, we used a combination of sequence searches of the Aquilegia Gene Index, phylogenetic analyses, and the isolation of novel sequences by using degenerate PCR and RACE. In total we identified 34 genes that are likely involved in the flavonoid pathway. A number of these genes appear to be single copy in Aquilegia and thus variation in their expression may have been key for floral color evolution. Future studies will be able to use these sequences along with next-generation sequencing technologies to follow expression and sequence variation at the population level. The genetic dissection of other adaptive traits in Aquilegia should also be possible soon as genomic resources such as whole-genome sequencing become available.

Intrathecal Fentanyl With a Myofascial Plane Block in Open Lumbar Surgeries: A Case Series.

BACKGROUND: Acute postoperative pain control after lumbar surgery is imperative to minimizing long-term narcotic use and associated adverse sequela. The safety of intrathecal morphine for postoperative pain management in spine surgery has been investigated; however, to date, no studies have investigated the safety of intrathecal fentanyl with a myofascial plane (MP) block in lumbar procedures. OBJECTIVE: To assess the safety profile of intrathecal fentanyl with a MP block administered during lumbar surgery and the subsequent utilization of postoperative intravenous opioids. METHODS: An intraoperative intrathecal injection of fentanyl and a MP block was administered in 40 patients undergoing open lumbar reconstructive surgery. The procedure performed was an open decompression with lumbar total joint reconstruction at 1 to 3 lumbar levels. Postoperative complications including urinary retention, respiratory depression, and need for IV opioid use were recorded. RESULTS: Postoperatively, none of the study patients required IV opioid medication for supplemental pain control. Thirty-six patients (85%) were discharged same day or before 23 hours postoperatively. No intrathecal fentanyl-related perioperative complications were noted. None of the 40 listed patients experienced urinary retention or delayed respiratory depression. One patient (2%) experienced orthostatic hypotension at postoperative day 1, which resolved on discontinuation of oral oxycodone. CONCLUSION: Intrathecal fentanyl and MP block may be a safe option for perioperative pain control and may reduce the need for supplemental intravenous opioids without increased risk of respiratory depression, urinary retention, or other side effects. Further studies are necessary to compare the efficacy of intrathecal fentanyl with other analgesia techniques.

Non-pollinator selection for a floral homeotic mutant conferring loss of nectar reward in Aquilegia coerulea.

Here, we describe a polymorphic population of Aquilegia coerulea with a naturally occurring floral homeotic mutant, A. coerulea var. daileyae, where the characteristic petals with nectar spurs are replaced with a second set of sepals. Although it would be expected that this loss of pollinator reward would be disadvantageous to the mutant, we find that it has reached relatively high frequency (∼25%) and is under strong, positive selection across multiple seasons (s = 0.17-0.3) primarily due to reduced floral herbivory. We identify the underlying locus (APETALA3-3) and multiple causal loss-of-function mutations indicating an ongoing soft sweep. Elevated linkage disequilibrium around the two most common causal alleles indicates that positive selection has been occurring for many generations. Lastly, genotypic frequencies at AqAP3-3 indicate a degree of positive assortative mating by morphology. Together, these data provide both a compelling example that large-scale discontinuous morphological changes differentiating taxa can occur due to single mutations and a particularly clear example of linking genotype, phenotype, and fitness.

Impact of Cervical Disc Arthroplasty vs Anterior Cervical Discectomy and Fusion on Driving Disability: Post Hoc Analysis of a Randomized Controlled Trial With 10-Year Follow-Up.

BACKGROUND: Driving an automobile requires the ability to turn the neck laterally. Anecdotally, patients with multilevel fusions often complain about restricted turning motion. The purpose of this study was to compare the effectiveness of cervical disc arthroplasty (CDA) with anterior cervical discectomy and fusion (ACDF) on driving disability improvement at 10-year follow-up after a 2-level procedure. METHODS: In the original randomized controlled trial, patients with cervical radiculopathy or myelopathy at 2 levels underwent CDA or ACDF. The driving disability question from the Neck Disability Index was rated from 0 to 5 years preoperatively and up to 10 years postoperatively. Severity of driving disability was categorized into "none" (score 0), "mild" (1 or 2), and "severe" (3, 4, or 5). Score and severity were compared between groups. RESULTS: Out of 397 patients, 148 CDA and 118 ACDF patients had 10-year follow-up. Driving disability scores were not different between the groups preoperatively (CDA: 2.65; ACDF: 2.71, P = 0.699). Postoperatively, the scores in the CDA group were significantly lower than those in the ACDF group at 5 (0.60 vs 1.08, P ≤ 0.001) and 10 years (0.66 vs 1.07, P = 0.001). Mean score improvement in the CDA group was significantly greater than the ACDF group at 10-year follow-up (-1.94 vs -1.63, P = 0.003). The majority of patients reported severe driving disability (CDA: 56.9%, ACDF: 58.0%, P = 0.968) before surgery. After surgery, a greater proportion of patients in the CDA group had neck pain-free driving compared with the ACDF group at 5 (63.3% vs 41.8%, P < 0.001) and 10 years (61.8% vs 41.2%, P = 0.003). CONCLUSION: In patients with cervical radiculopathy/myelopathy and 2-level disease, CDA provided greater improvements in driving disability as compared with ACDF at 10-year follow-up. This is the first report of its kind. This finding may be attributable to preservation of motion associated with CDA. CLINICAL RELEVENCE: This study provides valuable information regarding the improvement of driving disability after both CDA and ACDF. It demonstrates that both procedures result in significant improvements, with CDA resulting in even better improvements than ACDF, up to 10 year follow-up.

Are we there yet? Tracking the development of new model systems.

It is increasingly clear that additional 'model' systems are needed to elucidate the genetic and developmental basis of organismal diversity. Whereas model system development previously required enormous investment, recent advances including the decreasing cost of DNA sequencing and the power of reverse genetics to study gene function are greatly facilitating the process. In this review, we consider two aspects of the development of new genetic model systems: first, the types of questions being advanced using these new models; and second, the essential characteristics and molecular tools for new models, depending on the research focus. We hope that researchers will be inspired to explore this array of emerging models and even consider developing new molecular tools for their own favorite organism.

Seated Lateral X-ray Is a Better Stress Radiograph of the Lumbar Spine Compared to Standing Flexion.

STUDY DESIGN: Prospective lumbar radiograph analysis. OBJECTIVE: To compare changes in lumbar lordosis in standing flexion versus seated lateral radiographs. METHODS: Standing lateral, standing flexion, and seated lateral X-rays of the lumbar spine were obtained in patients presenting with low back pain. Trauma, tumor, and revision cases were excluded. Changes in global lumbar as well as segmental lordosis were measured in each position. RESULTS: Seventy adult patients were reviewed. Overall, the greatest changes in lordosis were seen at L4-S1 in both the seated and flexion X-rays (12.5° and 6.3°, respectively). Greater kyphosis was seen in seated versus flexion X-rays (21.6° vs 15.8°); changes in lordosis from L1-L3 were similar in both positions, with little change seen at these levels (approximately 5° to 7°). On subgroup analysis, these differences were magnified in analyzing only patients that moved at least 20° globally, and there were no significant differences between sitting and flexion in "stiff" patients that moved less than 20° globally. CONCLUSION: Greater lumbar kyphosis was seen in the seated position compared to standing flexion, especially from L4-S1. Given these results we suggest the use of seated lateral X-rays to dynamically assess the lumbar spine. These findings may also guide future research into the mechanism and clinical relevance of a stiff versus mobile lumbar spine, as well as into the sensitivity of seated X-rays in detecting instability.

A novel lumbar total joint replacement may be an improvement over fusion for degenerative lumbar conditions: a comparative analysis of patient-reported outcomes at one year.

BACKGROUND CONTEXT: Effective alternatives to lumbar fusion for degenerative conditions have remained elusive. Anterior total disc replacement does not address facet pathology or central/recess stenosis, resulting in limited indications. A posterior-based motion-preserving option that allows for neural decompression, facetectomy, and reconstruction of the disc and facets may have a role. PURPOSE: The purpose was to compare one-year patient-reported outcomes for a novel, all-posterior, lumbar total joint replacement (LTJR - replacing both the disc and facet joints) against transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar conditions warranting fusion (degenerative spondylolisthesis, recurrent disc herniation, severe foraminal stenosis requiring facet removal, and adjacent segment degeneration). STUDY DESIGN/SETTING: A retrospective analysis of prospectively collected data comparing outcomes for LTJR patients to TLIF patients at an academic teaching hospital. PATIENT SAMPLE: Analysis was conducted on 156 adult TLIF patients who were propensity matched to the 52 LTJR patients for a total sample of 208. OUTCOME MEASURES: Self-reported Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain were compared preoperatively, 3 months and 1 year after surgery. METHODS: The implant is a motion-preserving lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral transforaminal approach with complete facetectomies. Adult patients with degenerative lumbar pathology undergoing either LTJR or open TLIF were analyzed. These degenerative conditions included: grade 1 degenerative spondylolisthesis, recurrent disc herniation, adjacent segment disease, disc degeneration with severe foraminal stenosis). Trauma, tumor, grade 2 or higher spondylolisthesis, spinal deformity, and infection cases were excluded. Propensity score matching was performed to ensure parity between the cohorts. Multivariable regression analyses were done to compare the 1-year results as measured by 3 different standards to assess procedure success. RESULTS: At 3 months, both the LTJR and TLIF cohorts showed significant and similar improvements in ODI and NRS back and leg pain. At 1 year, the LTJR cohort showed continued improvement in ODI and NRS back pain, while the TLIF group showed a plateau for ODI, back and leg pain. In a series of three multivariable logistic regressions, LTJR was shown to provide 3.3 times greater odds of achieving the minimal clinical symptom state in disability and pain (ODI <20%, NRS back and leg pain <2) and 2.4 and 4.1 times greater odds of achieving substantial clinical benefit (18% reduction in ODI) and minimal clinically important difference (30% reduction in ODI) as compared to TLIF. CONCLUSIONS: Here we present a comparative analysis for the first 52 patients undergoing a novel, posterior-based LTJR for the lumbar spine versus TLIF for degenerative pathology. The approach for the LTJR allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. At 1 year, the LTJR cohort showed significant improvement in ODI and NRS back and leg pain as compared to TLIF. These results suggest that wide neural decompression combined with motion preservation using this novel LTJR may represent a viable alternative to TLIF for treating certain degenerative conditions. A prospective controlled trial is under development to further evaluate the efficacy, safety, and durability of this procedure.

Loading of the lumbar spine during transition from standing to sitting: effect of fusion versus motion preservation at L4-L5 and L5-S1.

BACKGROUND CONTEXT: Transition from standing to sitting significantly decreases lumbar lordosis with the greatest lordosis-loss occurring at L4-S1. Fusing L4-S1 eliminates motion and thus the proximal mobile segments maybe recruited during transition from standing to sitting to compensate for the loss of L4-S1 mobility. This may subject proximal segments to supra-physiologic flexion loading. PURPOSE: Assess effects of instrumented fusion versus motion preservation at L4-L5 and L5-S1 on lumbar spine loads and proximal segment motions during transition from standing to sitting. STUDY DESIGN: Biomechanical study using human thoracolumbar spine specimens. METHODS: A novel laboratory model was used to simulate lumbosacral alignment changes caused by a person's transition from standing to sitting in eight T10-sacrum spine specimens. The sacrum was tilted in the sagittal plane while constraining anterior-posterior translation of T10. Continuous loading-data and segmental motion-data were collected over a range of sacral slope values, which represented transition from standing to different sitting postures. We compared different constructs involving fusions and motion preserving prostheses across L4-S1. RESULTS: After L4-S1 fusion, the sacrum could not be tilted as far posteriorly compared to the intact spine for the same applied moment (p<.001). For the same reduction in sacral slope, L4-S1 fusion induced 2.9 times the flexion moment in the lumbar spine and required 2.4 times the flexion motion of the proximal segments as the intact condition (p<.001). Conversely, motion preservation at L4-S1 restored lumbar spine loads and proximal segment motions to intact specimen levels during transition from standing to sitting. CONCLUSIONS: In general, sitting requires lower lumbar segments to undergo flexion, thereby increasing load on the lumbar disks. L4-S1 fusion induced greater moments and increased flexion of proximal segments to attain a comparable seated posture. Motion preservation using a total joint replacement prosthesis at L4-S1 restored the lumbar spine loads and proximal segment motion to intact specimen levels during transition from standing to sitting. CLINICAL SIGNIFICANCE: After L4-S1 fusion, increased proximal segment loading during sitting may cause discomfort in some patients and may lead to junctional breakdown over time. Preserving motion at L4-S1 may improve patient comfort and function during activities of daily living, and potentially decrease the need for adjacent level surgery.