Healthcare disparities in adolescent idiopathic scoliosis: the impact of socioeconomic factors on Cobb angle.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The aim of this study is to assess the role of insurance type, geographic socioeconomic status, and ethnicity in AIS disease severity in a state with mandated scoliosis screenings. Early detection of adolescent idiopathic scoliosis (AIS) is associated with reduced curve progression, surgical treatment, and long-term sequelae. Type of insurance, ethnicity, and socioeconomic status are important determinants in healthcare access. METHODS: Data were obtained for 561 AIS patients aged 10-18 years, living within a single county, and presenting to a single healthcare system for initial evaluation of AIS between 2010 and 2016 that met inclusion criteria. Demographic data including gender, age, self-reported ethnicity, insurance, and zip code were collected. Outcome measures included Cobb angle, curve severity, and referral delay. A single fellowship-trained pediatric orthopedic surgeon calculated presenting Cobb angle for each case. Zip code was used as a proxy for household income level. Independent sample t tests, analysis of variance and covariance, and χ2 analysis were used to determine the significant differences and correlations. RESULTS: Female patients (n = 326, CA = 22.4°) had significantly greater Cobb angle measurements compared with male patients (n = 117, CA = 18.1°). Patients with government-supported insurance had significantly higher Cobb angles (CA = 22.1°) than privately insured patients (CA = 19.2°) but were both classified within the "mild" range clinically, and are likely not clinically significant. There was no correlation between income level and Cobb angle. Referral delay and Cobb angle severity did not vary by age, income, or insurance. A χ2 analysis showed no association between Cobb angle and race. CONCLUSIONS: Cobb angle severity was not influenced by SES factors, including ethnicity and household income. LEVEL OF EVIDENCE: Level-II.

Thoracic kyphosis assessment in postmenopausal women: an examination of the Flexicurve method in comparison to radiological methods.

The Flexicurve ruler is an alternative method to radiographs for measuring thoracic kyphosis (curvature), but it is not certain that it is comparable. This study shows that Flexicurve can estimate radiographic vertebral centroid angles with less error than Cobb angles but that its accuracy would be inadequate for most clinical purposes. INTRODUCTION: The Flexicurve ruler provides a non-radiological method of measuring thoracic kyphosis (TK) that has moderately strong correlations with the gold-standard radiographic Cobb angle method, while consistently underestimating the TK angle. Cobb angles can include measurement errors that may contribute to poor agreement, particularly in older populations. The vertebral centroid angle could be a better radiographic reference method for the validation of Flexicurve. Using two separate radiographic measurements of TK, we examined the validity of Flexicurve. We aimed to ascertain the level of agreement between measures and to empirically explore reasons for between-method differences. METHODS: TK angles determined using Flexicurve and radiographic Cobb and vertebral centroid methods were compared using data from 117 healthy postmenopausal women (mean (SD) age 61.4 (7.0) years). Bland and Altman plots were used to assess differences between methods. Age, bone mineral density and body mass index were examined as characteristics that might explain any differences. RESULTS: Flexicurve angles were scaled prior to analysis. There was no statistically significant difference between angles produced by Flexicurve and vertebral centroid methods (MD - 2.16°, 95%CI - 4.35° to 0.03°) although differences increased proportionally with TK angles. Flexicurve angles were significantly smaller than radiographic Cobb angles and depending on the scaling method used, systematic error ranged between - 2.48° and - 5.19°. Age accounts for some of the differences observed (R2 < 0.08, p < 0.005). CONCLUSIONS: TK measured using the Flexicurve shows better agreement with the radiographic vertebral centroid method, but inaccuracy of the Flexicurve increases with increasing angle of kyphosis.

Morphometric semi-quantitative assessment of vertebral fractures in postmenopausal black women in Central Africa.

This prospective and multi-centric study assessed the lacking of pattern in fractured patients and features of vertebral fractures in postmenopausal black women living in central Africa. INTRODUCTION: Patients with osteoporosis commonly collapsed their vertebral body. This has been widely studied in Caucasians, Asians, and Americans and studies in black African are lacking. Our study was designed to establish a pattern of patients with fractures and determine the features of vertebral fractures in postmenopausal black women living in Central Africa. METHODS: A prospective and multi-centric study was conducted from June 2011 to June 2016, to assess the thoraco-lumbar-computed tomographic images of women. The menopausal statuses and anthropometric parameters (age, height, and weight) were collected. The body mass index and the Asset Poverty Index were evaluated. The reviews included a morphometric analysis of each vertebra that was rated according to the visual semi-quantitative system proposed by Genant et al. RESULTS: Four hundred thirty women aged 47-87 years old were included in this study. The mean age was 57 years old, and the mean menopause duration was 11.45 ± 6.6 years with extremes ranging from 2 to 37 years. The body mass indices were rated as overweight and obese in 80.8% of subjects and 54, 3% had high-API indices. Among the 4730 vertebrae analyzed, 529 (11.12%) were fractured, with 68.7% exhibited a cup-shaped deformation (biconcave), 19.8% had a wedge-shaped deformation, and 11.4% exhibited a cake (crush) deformation. Of the vertebras, 88.8% were grade 0, 5.5% grade 1, 5% grade 2, and 0.57% were grade 3. Of the women, 68.8% had one vertebra fractured and 31.2% had more than one fractured vertebrae. CONCLUSION: This study seemed to determine the pattern and features of vertebral fractures in black African women which may be useful for comparisons with the pattern of worldwide populations.

Concurrent validity of photogrammetric and inclinometric techniques based on assessment of anteroposterior spinal curvatures.

PURPOSE: The purpose of the study was to investigate correlations between parameters of anteroposterior spinal curvatures in the sagittal plane, measured with the use of photogrammetric technique and inclinometer in healthy elderly women. METHODS: Randomized study involved 50 females, ranging from 50 to 70 years of age (mean 62.26 ± 6.94); mean body mass index (BMI) 27.69 ± 4.79. The examined parameters included angle of inclination in lumbosacral spine (ALFA), thoracolumbar transition (BETA), upper thoracic segment (GAMMA), angle of lumbar lordosis (LLA) and thoracic kyphosis (TKA). Results obtained with gravitational inclinometer were compared with those identified with photogrammetry method. Statistical analyses were performed with Mann-Whitney U test, regression analysis and Bland-Altman analysis. RESULTS: In Mann-Whitney U test, with correction due to continuity, no statistically significant differences for any variable were found. Regression analysis was significant only for the variable of BETA angle. Bland-Altman coefficient for the respective angles was: ALFA 2.0%, BETA 4%, GAMMA 0%, LLA 2% and TKA 0%. CONCLUSIONS: The results acquired with gravitational inclinometer and with photogrammetric technique are comparable, as the parameters of anteroposterior spinal curvatures acquired with these two methods are found to be compatible in the case of measurements of lumbar lordosis and thoracic kyphosis.

Assessment of Breast Asymmetry in Adolescent Idiopathic Scoliosis Using an Automated 3D Body Surface Measurement Technique.

STUDY DESIGN: Cohort study. OBJECTIVES: To assess breast asymmetry (BA) directly with 3D surface imaging and to validate it using MRI values from a cohort of 30 patients with significant adolescent idiopathic scoliosis (AIS). Also, to study the influence of posture (prone vs standing) on BA using the automated method on both modalities. SUMMARY OF BACKGROUND DATA: BA is a common concern in young female patients with AIS. In a previous study using MRI, we found that the majority of patients with significant AIS experienced BA of up to 21% in addition to their chest wall deformity. MRI is costly and not always readily available. 3D surface topography, which offers fast and reliable breast acquisitions without radiation or distortion of the body surface, is an alternative method in the clinical setting. METHODS: Thirty patients with AIS were enrolled in the study on the basis of their thoracic curvature, skeletal and breast maturity, without regard to their perception of their BA. Each patient underwent two imaging studies of their torso: a 3D trunk surface topography and a breast MRI. An automated breast volume measuring method was proposed using a program developed with Matlab programming. RESULTS: Strong correlations were obtained when comparing the proposed method to the MRI on the left breast volumes (LBV) (r = 0.747), the right breast volumes (RBV) (r = 0.805) and the BA (r = 0.614). Using the same method on both imaging modalities also yielded strong correlation coefficients on the LBV (r = 0.896), the RBV (r = 0.939) and the BA (r = 0.709). CONCLUSIONS: The proposed 3D body surface automated measurement technique is feasible clinically and correlates very well with breast volumes measured using MRI. Additionally, breast volumes remain comparable despite being measured in different body positions (standing and prone) in a young cohort of AIS patients. LEVEL OF EVIDENCE: Level IV.

A multicenter, retrospective epidemiologic survey of the clinical features and management of bone metastatic disease in China.

BACKGROUND: Bone metastases are common in patients with advanced cancer. Bisphosphonates (BPs) could prevent or delay the development of skeleton-related events (SREs). The present study aimed to identify the clinical features of and treatment strategies for Chinese patients with bone metastases. METHODS: Consecutive cancer patients who had bone metastases and received BP treatment were enrolled. A questionnaire was developed to collect the patients' clinical data, as well as information on the diagnosis and management of bone metastases. Physicians' awareness of the guidelines and knowledge of the application of BP were also assessed. RESULTS: A total of 3223 patients with lung cancer (36.5%), breast cancer (30.9%), prostate cancer (8.5%), and gastrointestinal cancer (5.7%) were included in this study. The sites of bone metastases were the thoracic spine (56.0 %), lumbar spine (47.1%), ribs (32.6%), and pelvis (23.2%). The SRE frequency was the highest in patients with multiple myeloma (36.6%), followed by those with lung cancer (25.9%), breast cancer (20.2%), prostate cancer (18.2%), and gastrointestinal cancer (17.3%). Irradiation to the bone was the most frequent SRE (58% in lung cancer patients, 45% in breast cancer patients, and 48% in prostate cancer patients). Our survey also showed that 45.5% of patients received BP within 3 months after their diagnosis of bone metastases, whereas the remaining 54.5% of patients did not receive BP treatment until at least 3 months after their diagnosis of bone metastases. The SRE frequency in the former group was significantly lower than that in the latter group (4.0% vs. 42.3%, P < 0.05). In patients with more than 6 months of continuous BP treatment, the mean time to the first SRE was significantly longer than that in patients with less than 6 months of continuous BP treatment (7.2 vs. 3.4 months, P < 0.05). In addition, 12.2% of the physicians were not aware of the efficacy of BP in preventing and delaying SRE. Only half (52.3%) of the physicians agreed that the BP treatment should persist for at least 6 months unless it was intolerable. CONCLUSIONS: Our study suggested that prompt and persistent BP treatment was associated with a reduced risk of SREs. However, our survey also revealed that the proper application of BP was not as common as expected in China.

The validity and reliability of "Spinal Mouse" assessment of spinal curvatures in the frontal plane in pediatric adolescent idiopathic thoraco-lumbar curves.

PURPOSE: Radiological measurement has been accepted as the gold standard for evaluating scoliosis for many years. However, exposure of children to X-ray constitutes a major limitation of the radiological methods. Spinal Mouse (SM) is a safe, practical and easy to perform measurement of curvature in scoliosis, but its validity and reliability have not been investigated. The aim of this study was to investigate the validity and reliability of Cobb angle and SM measurements in children with adolescent idiopathic scoliosis (AIS). METHODS: Fifty-one patients with AIS who were followed up conservatively were included in the study. The mean age of the patients was 14.4 years (9-18 years). Frontal plane curvatures were evaluated with SM by 2 physiotherapists and the results were compared with radiological measurements. Radiological measurements were performed by 2 orthopedists. RESULTS: All the measurements were of the thoraco-lumbar curve and the mean value was 35.08° according to Cobb angle measurement. There was no difference between the interobserver measurements of SM (p = 0.256) while the Cobb degrees measured by the 2 orthopedists was different (p = 0.0001). We did not find a statistically significant difference between Cobb measurements and the SM measurements of observer 1 and 2 (p = 0.505). The interobserver and intraobserver agreement of the Cobb and SM measurements was excellent (ICC = 0.872-0.962). When the differences between the evaluations were compared, the interobserver SM differences were seen to be lower than the interobserver Cobb angle differences (p = 0.003). The agreement between the Cobb and SM measurements was higher for curves over 40°. We found a strong or very strong relationship between measurements made with the Cobb and SM methods (p < 0.0001). CONCLUSIONS: We conclude that SM can be used for research and patient follow-up in the clinic as a safe, reliable, quick, and easy to use method with no side effects although it cannot be the only factor to consider when determining the treatment plan of AIS patients.

Nonoperative Management in Neurologically Intact Thoracolumbar Burst Fractures: Clinical and Radiographic Outcomes.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The identification of factors that lead to the failure of nonoperative management in neurologically intact thoracolumbar burst fractures. SUMMARY OF BACKGROUND DATA: The treatment of thoracolumbar burst fractures (TLBF) can be controversial, particularly in the neurologically intact. Surgery for intact burst fractures has been advocated for early mobilization and a shorter hospital stay. These goals, however, have not always been achieved, rejuvenating an interest in nonoperative treatment. METHODS: Sixty-eight neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2), and a thoracolumbar injury classification and severity score (TLICS) of 2, were treated at our institution. Based on CT scans, patients were scored based on the load-sharing classification (LSC) scale. Initial treatment consisted of bracing in clamshell thoracolumbar orthosis and gradual mobilization. RESULTS: Owing to pain limiting mobilization, 18 patients failed nonoperative management and required instrumentation. Those who failed nonsurgical management were significantly more kyphotic (8° ± 10) and stenotic (52% ± 14%) than those successfully treated nonoperatively (3° ± 7 and 63 ± 12%, respectively). The LSC score of those undergoing surgery (6.9 ± 1.1) was also greater than those successfully treated nonoperatively (5.8 ± 1.3, P = 0.006). Length of hospitalization was longer, and hospital charges higher in those requiring surgery compared to the nonoperative group. At follow-up there was no difference between groups in the visual analog score for pain (VAS) or the Oswestry disability index. CONCLUSION: Owing to pain limiting mobilization, a quarter of neurologically intact patients with thoracolumbar burst fractures and a TLICS score of 2 failed nonsurgical management. The greater the kyphosis, stenosis, and fragmentation of the fracture, the more likely patients required surgery. In addition to the TLICS classification, other radiographic and clinical parameters should be included in selecting appropriate treatment strategy. The cost savings with nonoperative treatment of intact burst fractures, when appropriate, are significant.

An assessment system for evaluating the severity of thoracolumbar osteoporotic fracture and its clinical application: A retrospective study of 381 cases.

OBJECTIVE: We put forward an assessment system of thoracolumbar osteoporotic fracture (ASTLOF) evaluating the severity of thoracolumbar osteoporotic fracture. This study was to investigate its efficacy in guiding clinical practice. METHODS: Three hundred and eighty-one patients with thoracolumbar vertebral osteoporosis fracture admitted to the hospital from January 2010 to December 2011 were enrolled in the study. All cases were evaluated by ASTLOF including evaluation of morphological changes, MRI, bone mineral density and pain. The patients were treated with different methods according to ASTLOF score. All patients were followed up on a regular basis. The treatment results were assessed by VAS and ODI. RESULTS: All patients were followed up with an average of 20.1 (range: 6-30) months. There were 91 cases of ASTLOF score<4 points. Their average VAS score decreased from 8.0 ± 1.7 points to 2.0 ± 1.3 with statistical significance (P<0.05) and the average ODI score decreased from 69.5 ± 2.8 to 38.1 ± 1.5 (P<0.05). One hundred and thirty-two cases were with ASTLOF score=4, with the average VAS score decreased from 8.2 ± 1.4 to 1.9 ± 1.2 (P<0.05) and the average ODI score decreased from 71.5 ± 3.7 to 36.2 ± 2.5 (P<0.05). There were 158 cases of ASTLOF score ≥ 5, with the VAS score decreased from 8.0 ± 1.7 to 2.0 ± 1.3 and the ODI score decreased from 69.5 ± 2.8 to 38.1 ± 1.5. CONCLUSIONS: ASTLOF based on the severity of thoracolumbar osteoporotic fracture was suggested to be helpful in guiding clinical practice.

[Reckoning: Assessment of 21 years' work in spinal surgery]. / Számvetés: 21 éves gerincsebészeti tevékenység mérlege.

INTRODUCTION: Of the world-wide used Cotrel-Dubousset instrumentation and surgical technique providing breakthrough for the three-dimensional correction and multi-segmental fixation of spinal deformity surgery in Hungary is linked to the author's name, who carried out 1655 spine deformity surgeries in the last 21 years. AIM: The aim of the author was to discuss his own results in the field of spine surgery and compare his own data to those published in the international literature. METHOD: At the beginning hooks, followed by hybrid instrumentation with hooks in thoracic area and transpedicular screws in lumbar spine have been used for the segmental fixation. During the correction process, initially the classic derotation maneuver was used, followed by the translation and then the in situ bending techniques and, finally, a combination of the above three techniques have been applied. RESULTS: In addition to the restoration of normal sagittal balance, an average of 40.8° (SD, 25.9), a 65.5% correction was achieved in the frontal plane, which partly exceeds and partly consistent with the published international results. The incidence of inflammation (3.9%), and mechanical complications (1.7%) was similar to the international average, while the incidence of neurological complications (0.48%) was slightly lower than the average of international data. CONCLUSIONS: The author believes that the better correction results as compared to the international average could be due to the always consistent application of the Cotrel-Dubousset instrumentation correction philosophy based on the meticulous segmental analysis of spine deformities.

Assessment of autonomic function after acute spinal cord injury using heart rate variability analyses.

OBJECTIVES: Spinal cord injury (SCI) often results in severe dysfunction of the autonomic nervous system. C1-C8 SCI affects the supraspinal control to the heart, T1-T5 SCI affects the spinal sympathetic outflow to the heart, and T6-T12 SCI leaves sympathetic control to the heart intact. Heart rate variability (HRV) analysis can serve as a surrogate measure of autonomic regulation. The aim of this study was to investigate changes in HRV patterns and alterations in patients with acute traumatic SCI. METHODS: As soon as possible after SCI patients who met the inclusion criteria had 24 h Holter monitoring of their cardiac rhythm, additional Holter monitoring were performed 1, 2, 3 and 4 weeks after SCI. RESULTS: Fifty SCI patients were included. A significant increase in standard deviation of the average normal-to-normal (SDANN) sinus intervals was seen in the first month after injury (P=0.008). The increase was only significant in C1-T5 incomplete patients and in patients who did not experience one or more episodes of cardiac arrest. Significant lower values of Low Frequency Power, Total Power and the Low Frequency over High Frequency ratio were seen in the C1-T5 SCI patients compared with T6-T12 SCI patients. CONCLUSIONS: The rise in SDANN in the incomplete C1-T5 patients could be due to spontaneous functional recovery caused by synaptic plasticity or remodelling of damaged axons. That the autonomic nervous system function differs between C1-C8, T1-T5 and T6-T12 patients suggest that the sympathovagal balance in both the C1-C8 and T1-T5 SCI patients has yet to be reached.

Radiation-free spinometry adds to the predictive power of historical height loss in clinical vertebral fracture assessment.

UNLABELLED: After introducing radiation-free spinometry as a diagnostic tool to predict prevalent vertebral fractures, its validity and comparison with established tools such as historical height loss (HHL) was missing. This study shows that radiation-free spinometry is valid and its application adds predictive power to the ability of HHL to assess presence of vertebral fractures. INTRODUCTION: Recently, radiation-free spinometry was introduced to identify patients with vertebral fractures (VFs). The goals of this study were to validate previous findings and to test the predictive accuracy of radiation-free spinometry compared to the assessment of historical height loss (HHL). METHODS: We analyzed 304 patients [258 (85%) females (age range, 42-90 years) and 46 males (50-84 years)], including 108 patients with VFs. We performed receiver operator characteristic and net reclassification improvement (NRI) analyses to quantify the predictive power and the added predictive ability of radiation-free spinometry and HHL for VFs. RESULTS: The estimated odds ratios in the thoracic and the lumbar spine showed no significant differences compared to the previously published, except for the effect of thoracic kyphosis in region "Th12 + L4-5." Radiation-free spinometry and HHL were both moderately accurate to raise suspicion for VFs. According to the NRI, which is defined as the net sum of the predicted risk increase in individuals who have VFs and the predicted net risk decrease for those who have not, we found significant improvements in all regions of interest when HHL and radiation-free spinometry were used in combination (area under the curve (AUC) 0.729-0.788). CONCLUSION: Our results based on a new data set suggest validity of the prognostic score published previously. In addition, although our findings did not confirm our initial hypothesis that radiation-free spinometry alone performs superior to the assessment of HHL to predict VFs, we showed that radiation-free spinometry still adds predictive power to the ability of HHL to discriminate patients with VFs.

Gold fiducials are a unique marker for localization in the thoracic spine: a cost comparison with percutaneous vertebroplasty.

We present a unique application of the gold fiducial as a preoperative, radiographic marker placed in the thoracic spine and used for intraoperative localization. In comparison to percutaneous vertebroplasty marking of thoracic spinal levels with polymethyl methacrylate (PMMA) cement, implantation of the gold fiducial is technically facile with a minimal learning curve. The fiducial markers are also associated with significantly less financial resources. Following 2013 Current Procedural Terminology (CPT) coding, the cost of vertebroplasty under fluoroscopic guidance, $3195·43, or under computed tomography (CT) guidance, $3232·54, is more than double the cost of the gold fiducial implantation - $1237·55 and $1267·03, under similar imaging techniques, respectively. In the first description of gold fiducials in the thoracic spine, we conclude that the marker is a safe and cost-effective method for preoperative localization of the thoracic levels.

Inter-observer reproducibility of back surface topography parameters allowing assessment of scoliotic thoracic gibbosity and comparison with two standard postures.

The objective of this work was to analyze the inter-observer reproducibility of an upright posture designed to bring out the thoracic humps by folding the upper limbs. The effect of this posture on back surface parameters was also compared with two standard radiological postures. A back surface topography was performed on 46 patients (40 girls and 6 boys) with a minimum of 15° Cobb angle on coronal spinal radiographs. Inter-observer reliability was evaluated using the typical error measurement (TEM) and Intraclass Correlation Coefficient (ICC). Variations between postures were assessed using a Student's t test. The inter-observer reproducibility is good enough for the three postures. The proposed posture leads to significant changes in the sagittal plane as well as in the identification of thoracic humps. This study shows the reproducibility of the proposed posture in order to explore the thoracic humps and highlights its relevance to explore scoliosis with back surface topography systems.

Intra- and interobserver repeatability of the assessment of anteroposterior curvatures of the spine using Saunders digital inclinometer.

INTRODUCTION: According to the requirements of Evidence Based Medicine, every research tool and method should be subjected to reliability evaluation. A variety of inclinometers are used for the assessment of sagittal plane spinal curvatures in clinical practice. The aim of the study was to evaluate the intra- and interobserver repeatability of measurements of the anterior-posterior spinal curvatures taken with Saunders digital inclinometer. MATERIAL AND METHODS: The study involved 30 healthy subjects (5 males, 25 females) aged 20 to 35 years. The anteroposterior curvatures of the spine were measured in all subjects using a Saunders digital inclinometer. In order to evaluate the intraobserver repeatability of measurements, the results obtained by one investigator were compared. To evaluate interobserver repeatability, the results obtained by three investigators were compared. Additionally, the levels of reliability and measurement error were determined. RESULTS: The measurements conducted by one investigator showed good repeatability for sacral slope, lumbar lordosis, and thoracic kyphosis, including the angle of proximal (Th1-Th6) and distal (Th6-Th12) thoracic kyphosis (p>0.05). For measurements taken by three investigators, interobserver repeatability was achieved for thoracic kyphosis (p>0.05). The reliability of the measurements was good (Cronbach's alpha was 0.9> α ≥0.8), and the measurement error was between 2.8°-3.8°. CONCLUSIONS: The assessment of anteroposterior curvatures of the spine by one investigator provided good repeatability and reliability of measurements. Measurements performed by more than one investigator displayed partial repeatability. The value of the observational error should be taken into account in the interpretation of results of measurements performed with the Saunders inclinometer. The assessment of anteroposterior curvatures of the spine should be preceded by a verification of measurement reliability.

Vertebral fracture assessment by new dual-energy X-ray absorptiometry.

The aim of this study was to investigate the diagnostic performance of new dual-energy X-ray absorptiometry (DXA) technologies in the detection of vertebral fractures (VFs). Sixty-eight patients were submitted to DXA and conventional radiography (XR) on the same day. Lateral images of the spine were independently evaluated by three radiologists with different experience in skeletal imaging, in two sessions with 7 days between evaluations of the same anonymous images. The most expert physician repeated the analysis in a subsequent reading session after further 7 days. Results from expert XR evaluation were considered as gold standard. A semiquantitative approach was used to interpret images and morphometric analysis was performed when a VF was suspected. Seventy vertebrae (70/884, 7.9%) were excluded from the lesion-based analysis, as not evaluable: 11/70 (15.7%) missed by XR only, 56/70 (80.0%) missed by DXA only, 3/70 (4.3%) missed by both techniques (upper thoracic spine). Forty "true" fractures were detected (4.9% out of 814 vertebrae) in 26 patients (38.2% of the 68 studied patients). Twenty-five (62.5%) were mild fractures. DXA sensitivity and specificity were 70.0% and 98.3% on a lesion-based analysis, 73.1% and 90.5% on a patient-based analysis. Intra-observer agreement was excellent with no significant difference between the two techniques. Inter-observer agreement among the 3 observers was higher for XR (k=0.824 versus 0.720 in the detection of VFs, p=0.011). DXA accuracy was not influenced by radiologist experience; T4-L4 assessability as well as reproducibility and repeatability of the two techniques and accuracy of DXA were independent from sex, age, body mass index, grade of arthrosis. However DXA sensitivity was affected by mild VFs. Vertebral level did not affect the diagnostic performance with exception of vertebral body assessability. Latest improvements make VFs assessment by DXA competitive with traditional radiographic gold standard, providing consistent advantages and attractions. Few limitations still affect DXA performance and need to be overcome.

Vertebral fracture assessment in asymptomatic men and its impact on management.

INTRODUCTION: Recognition of vertebral fractures (VFs) change the patient's diagnostic classification, estimation of fracture risk, and threshold for pharmacological intervention. Vertebral fracture assessment (VFA) enables the detection of VFs in the same session as bone mineral density (BMD) testing. OBJECTIVE: To study prevalence and risk factors of VFs using VFA in asymptomatic men and measure its impact on patients' management. METHODS: We enrolled 791 men aged between 45 and 89 (mean age, weight and BMI of 62.4±8.6) (45 to 89) years, 74.9±12.7 (40 to 163) and 26.3±4.0 (16.6 to 43.8) kg/m(2), respectively. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. RESULTS: VFs were identified in 318 (40.3%): 206 (26.0%) had grade 1 and 112 (14.2%) had grade 2 or 3. As would be expected, the prevalence of VFA-detected fractures globally increased significantly with age and as BMI and BMD declined. A fracture was identified on VFA in 85 (32.4%) of men with normal BMD (6.9% had grade 2/3 VFs) and in 144 (35.8%) with osteopenia (11.7% had grade 2/3 VFs). Stepwise regression analysis showed that presence of VFs was independently related to the osteoporotic status (OR=4.761, 95%CI [2.956-7.668]; p<0.0001) and current smoking (OR=1.717, 95%CI [1.268-2.323]; p=0.002). CONCLUSION: Our results support the recommendation to enlarge the indications of VFA to all the men referred for DXA measurement.

A re-assessment of a combinatorial treatment involving Schwann cell transplants and elevation of cyclic AMP on recovery of motor function following thoracic spinal cord injury in rats.

This study was undertaken as part of the NIH "Facilities of Research-Spinal Cord Injury" project to support independent replication of published studies. Here, we repeated a study reporting that a combinatorial treatment with transplants of Schwann cells, systemic delivery of Rolipram to enhance cyclic AMP levels, and intra-spinal injections of dibutyryl cyclic AMP enhanced locomotor recovery in rats after contusion injuries at the thoracic level. We compared the following experimental groups: 1) rats that received Schwann cell transplants, systemic Rolipram, and injections of db-cyclic AMP (the combined treatment group that showed the greatest improvement in function); 2) rats that received Schwann cell transplants only and implantation of empty pumps as control; 3) rats that received Rolipram only and implantation of empty pumps as control, and 4) control rats that received no treatment other than the injection of DMEM into the spinal cord and implantation of empty pumps. The principal findings reported in Pearse et al. were not replicated in that the combined treatment group did not exhibit greater recovery on any of the measures, although the group that received Schwann cells only did exhibit enhanced recovery on several of the outcome measures. The failure of the combined treatment may be due in part to less successful engraftment of Schwann cells in our study vs. Pearse et al. Issues relating to failures to replicate, especially when effect size is small, are discussed.

The assessment of the postoperative spinal alignment: MRI adds up on accuracy.

INTRODUCTION: The sagittal profile of conventionally and surgically treated scoliotic spines is usually analyzed via lateral views of whole-spine X-rays in an upright position. Due to a more hypokyphotic configuration of scoliotic spines, the view onto the upper thoracic vertebrae is often difficult. We investigated whether additional supine MRI measurement supports valid kyphosis angle measurement. PATIENTS AND METHODS: Twenty patients with either short (n = 10, Halm-Zielke, VDS) or long spondylodesis (n = 10, dorsoventral) were assessed 5 years after surgery with standing radiographs and supine whole-spine MRI. RESULTS: Up to 90% of the upper thoracic vertebrae were invisible on radiographs, whereas MRI allowed visibility of almost many vertebrae. No significant difference in thoracal kyphosis angles could be observed in the comparison of X-ray and MRI data. CONCLUSION: Thoracal kyphosis measurement of postoperative spines in MRI is a valid diagnostic tool with reliability comparable to that of X-ray. These results cannot be transferred to lumbar lordosis measurement and transferred only partly to coronal COBB angle measurement.