Evidence-Based Management of Spinal Conditions in the Elite Athlete.

Spinal injuries are common and are a significant burden in the professional athlete population. From single-level disk herniation to career-ending fractures, the consequences of these conditions vary widely. Both contact and noncontact injuries can substantially affect the health and performance of elite athletes competing in a variety of sports. The nature and severity of these injuries have great influence on the prospects for full recovery and successful return to play. Common spinal injuries, management decisions, and return to play prospects are important considerations in the professional athlete population.

Transcription of the Streptococcus pyogenes hyaluronic acid capsule biosynthesis operon is regulated by previously unknown upstream elements.

The important human pathogen Streptococcus pyogenes (group A Streptococcus [GAS]) produces a hyaluronic acid (HA) capsule that plays critical roles in immune evasion. Previous studies showed that the hasABC operon encoding the capsule biosynthesis enzymes is under the control of a single promoter, P1, which is negatively regulated by the two-component regulatory system CovR/S. In this work, we characterize the sequence upstream of P1 and identify a novel regulatory region controlling transcription of the capsule biosynthesis operon in the M1 serotype strain MGAS2221. This region consists of a promoter, P2, which initiates transcription of a novel small RNA, HasS, an intrinsic transcriptional terminator that inefficiently terminates HasS, permitting read-through transcription of hasABC, and a putative promoter which lies upstream of P2. Electrophoretic mobility shift assays, quantitative reverse transcription-PCR, and transcriptional reporter data identified CovR as a negative regulator of P2. We found that the P1 and P2 promoters are completely repressed by CovR, and capsule expression is regulated by the putative promoter upstream of P2. Deletion of hasS or of the terminator eliminates CovR-binding sequences, relieving repression and increasing read-through, hasA transcription, and capsule production. Sequence analysis of 44 GAS genomes revealed a high level of polymorphism in the HasS sequence region. Most of the HasS variations were located in the terminator sequences, suggesting that this region is under strong selective pressure. We discovered that the terminator deletion mutant is highly resistant to neutrophil-mediated killing and is significantly more virulent in a mouse model of GAS invasive disease than the wild-type strain. Together, these results are consistent with the naturally occurring mutations in this region modulating GAS virulence.

Sagittal alignment after lumbar interbody fusion: comparing anterior, lateral, and transforaminal approaches.

STUDY DESIGN: Retrospective radiographic analysis. OBJECTIVE: To determine which lumbar interbody technique is most effective for restoring lordosis, increasing disk height, and reducing spondylolisthesis. SUMMARY OF BACKGROUND DATA: Lumbar interbody fusions are performed in hopes of increasing fusion potential, correcting deformity, and indirectly decompressing nerve roots. No published study has directly compared anterior, lateral, and transforaminal lumber interbody fusions in terms of ability to restore lordosis, increase disk height, and reduce spondylolisthesis. MATERIALS AND METHODS: Lumbar interbody fusion techniques were retrospectively compared in terms of improvement of lordosis, disk height, and spondylolisthesis between preoperative and follow-up lateral radiographs. RESULTS: A total of 220 consecutive patients with 309 operative levels were compared by surgery type: anterior (184 levels), lateral (86 levels), and transforaminal (39 levels). Average follow-up was 19.2 months (range, 1-56 mo), with no statistical difference between the groups. Intragroup analysis showed that the anterior (4.5 degrees) and lateral (2.2 degrees) groups significantly improved lordosis from preoperative to follow-up, whereas the transforaminal (0.8 degrees) group did not. Intergroup analysis showed that the anterior group significantly improved lordosis more than both the lateral and transforaminal groups. The anterior (2.2 mm) and lateral (2.0 mm) groups both significantly improved disk height more than the transforaminal (0.5 mm) group. All 3 groups significantly reduced spondylolisthesis, with no difference between the groups. CONCLUSIONS: After lumbar interbody fusion, improvement of lordosis was significant for both the anterior and lateral groups, but not the transforaminal group. Intergroup analysis showed the anterior group had significantly improved lordosis compared to both the other groups. The anterior and lateral groups had significantly increased disk height compared to the transforaminal group. All the 3 groups significantly reduced spondylolisthesis, with no difference between the groups.

Staphylococcus aureus nuclease is an SaeRS-dependent virulence factor.

Several prominent bacterial pathogens secrete nuclease (Nuc) enzymes that have an important role in combating the host immune response. Early studies of Staphylococcus aureus Nuc attributed its regulation to the agr quorum-sensing system. However, recent microarray data have indicated that nuc is under the control of the SaeRS two-component system, which is a major regulator of S. aureus virulence determinants. Here we report that the nuc gene is directly controlled by the SaeRS two-component system through reporter fusion, immunoblotting, Nuc activity measurements, promoter mapping, and binding studies, and additionally, we were unable identify a notable regulatory link to the agr system. The observed SaeRS-dependent regulation was conserved across a wide spectrum of representative S. aureus isolates. Moreover, with community-associated methicillin-resistant S. aureus (CA MRSA) in a mouse model of peritonitis, we observed in vivo expression of Nuc activity in an SaeRS-dependent manner and determined that Nuc is a virulence factor that is important for in vivo survival, confirming the enzyme's role as a contributor to invasive disease. Finally, natural polymorphisms were identified in the SaeRS proteins, one of which was linked to Nuc regulation in a CA MRSA USA300 endocarditis isolate. Altogether, our findings demonstrate that Nuc is an important S. aureus virulence factor and part of the SaeRS regulon.

Family practice enhancements for patients with severe mental illness.

Individuals with severe mental health disorders experience difficulty maneuvering the complexity encountered in primary care (PC). This study describes the impact of three components of primary care practice enhancements on: changes in missed appointments, changes in health outcomes, number of ER visits and hospitalization days, and perceptions of integrated care. Missed PC appointments: baseline to post practice enhancement changed from 42 to 11, statistically significant (p < .01). Changes in health outcomes: SF-12 scores had no significant change nor did ER utilization and hospitalization; however, outcomes are low-base rate and assessment period was short. Integration of care: liaison was most helpful in accessing and navigating PC, educating and reconciling medication lists. Behavioral health staff voiced relief regarding access and felt better informed. Strategies focusing on increasing communication, staff education, and reducing barriers to access and receipt of PC may improve integration and continuity of care.

Characterization of a new cytotoxin that contributes to Staphylococcus aureus pathogenesis.

Staphylococcus aureus is an important pathogen that continues to be a significant global health threat because of the prevalence of methicillin-resistant S. aureus strains (MRSA). The pathogenesis of this organism is partly attributed to the production of a large repertoire of cytotoxins that target and kill innate immune cells, which provide the first line of defence against S. aureus infection. Here we demonstrate that leukocidin A/B (LukAB) is required and sufficient for the ability of S. aureus, including MRSA, to kill human neutrophils, macrophages and dendritic cells. LukAB targets the plasma membrane of host cells resulting in cellular swelling and subsequent cell death. We found that S. aureus lacking lukAB are severely impaired in their ability to kill phagocytes during bacteria-phagocyte interaction, which in turn renders the lukAB-negative staphylococci more susceptible to killing by neutrophils. Notably, we show that lukAB is expressed in vivo within abscesses in a murine infection model and that it contributes significantly to pathogenesis of MRSA in an animal host. Collectively, these results extend our understanding of how S. aureus avoids phagocyte-mediated clearance, and underscore LukAB as an important factor that contributes to staphylococcal pathogenesis.

Spinal Injuries in the Overhead Athlete.

PURPOSE OF REVIEW: Treatment of overhead athletes requires a systematic approach that will make an accurate diagnosis, deliver effective treatment, and make timely and safe return to sport. RECENT FINDINGS: New data has shown success rates and return to play effectiveness after different types of cervical and lumbar surgery. Cervical foraminotomy has been shown to have the highest rate and fastest return to play, but with the highest incidence of need for revision surgery. Cervical artificial disc replacement has shown promising results in the general population and is being done more commonly in elite athletes, but has an unknown risk for failure. Cervical fusion is a well-established and effective treatment, but has the longest healing time and risk for adjacent level pathology. In the lumbar spine, discectomy has a long and proven track record, fusion is rarely performed but can be effective, and artificial disc replacement is extremely rare in an elite athlete. An effective and comprehensive approach can diagnose, treat, and return overhead athletes to competitive play.

Data-Driven Dose-Volume Histogram Prediction.

PURPOSE: To evaluate dose-volume histogram (DVH) prediction from prior radiation therapy data. METHODS AND MATERIALS: An Oncospace radiation therapy database was constructed including images, structures, and dose distributions for patients with advanced lung cancer. DVH data was queried for total lungs, esophagus, heart, and external body contours. Each query returned DVH data for the N-most similar organs at risk (OARs) based on OAR-to-planning-target-volume (PTV) geometry via the overlap volume histogram (OVH). The DVHs for 5, 20, and 50 of the most similar OVHs were returned for each OAR for each patient. The OVH(0cm) is the relative volume of the OAR overlapping with the PTV, and the OVH(2cm) is the relative volume of the OAR 2 cm away from the PTV. The OVH(cm) and DVH(%) queried from the database were separated into interquartile ranges (IQRs), nonoutlier ranges (NORs) (equal to 3 × IQR), and the average database DVH (DVH-DB) computed from the NOR data. The ability to predict the clinically delivered DVH was evaluated based on percentiles and differences between the DVH-DB and the clinical DVH (DVH-CL) for a varying number of returned patient DVHs for a subset of patients. RESULTS: The ability to predict the clinically delivered DVH was excellent in the lungs and body; the IQR and NOR were <4% and <16%, respectively, in the lungs and <1% and <5%, respectively, in the body at all distances less than 2 cm from the PTV. For 21/23 patients considered, the differences in lung DVH-DB and DVH-CL were <4.6% and in 14/23 cases, <3%. In esophagus and heart, the ability to predict DVH-CL was weaker, with mean DVH differences >10% for 12/23 esophagi and 10/23 hearts. In esophagus and heart queries, the NOR was often 10% to 100% volume in dose ranges between 0% and 50% of prescription, independent of the number of patients queried. CONCLUSIONS: Using prior data to predict clinical dosimetry is increasingly of interest, but model- and data-driven methods have limitations if based on limited data sets. This study's results showed that prediction may be reasonable in organs containing tumors with known overlap, but for nonoverlapped OARs, planning preference and plan design may dominate the clinical dose.

The implementation of Good For The Neighborhood: a participatory community health program model in four minority underserved communities.

To describe the participatory approach used to develop "Good For The Neighborhood" (GFTN), a community program to improve the health of four underserved communities. A core program was developed involving a "park and stay" approach to impact four underserved predominately minority communities (two predominately African American, 1 predominately Latino, and the Seneca Nation of Indians). The core program includes health screenings, risk assessments, health education, and exposure to health services. An extensive tracking and evaluation system was developed to determine participation and impact on the community. Multi-methods (key informant interviews, focus groups, surveys) were implemented to gain feedback from community partners and participants as to how to adopt the program to meet the needs of the community. GFTN has been sustained for over 3 years and has reached over 3,500 predominately minority individuals in four communities with 1/3 of participants engaging regularly in the program. The program has evolved in the four communities to meet specific needs. A "park and stay" approach in partnership with the community has led to a strong program that community partners and residents embrace. Community ownership and social networking, including word-of-mouth from residents is essential to establishing a successful program.

Cervical Disc Herniations, Radiculopathy, and Myelopathy.

The key to successful treatment of elite athletes is optimizing the medical care at every step: injury prevention and sport-specific training; comprehensive history and physical examination; high-quality and complete diagnostic studies; accurate diagnosis; control and completion of rehabilitation program; minimally invasive, safe, and effective surgeries; risk assessment for return to sport; guided and gradual return to sport; and continued rehabilitation and exercise program after return to sport.

The Management of Acute Lumbar Stress Reactions of the Pedicle and Pars in Professional Athletes Playing Collision Sports.

Acute stress reactions in the lumbar spine most commonly occur in athletes at the pars interarticularis followed by the pedicle. These reactions occur as a result of repetitive microtrauma from supraphysiological loads applied to the lumbar spine. Characteristic motions such as trunk extension and twisting are also thought to play a role and may be sport-specific. Other risk factors include increased lumbar lordosis, hamstring and thoracolumbar fascia tightness, and abdominal weakness. On physical examination, pain is typically reproduced with lumbar hyperextension. Currently, magnetic resonance imaging or nuclear imaging remain the most sensitive imaging modalities for identifying acute lesions. In the elite athlete, management of these conditions can be challenging, particularly in those playing collision sports such as American football, hockey, or rugby. Nonoperative treatment is the treatment of choice with rehabilitation programs focused on pain-free positioning and progressive strengthening. Operative treatment is rare, but may be warranted for patients symptomatic for >12 months. Specialized diagnosis protocols as well as treatment and return to play guidelines from 4 physicians treating elite athletes playing collision sports are presented and reviewed.

Asymptomatic Spinal Cord Compression: Is Surgery Necessary to Return to Play.

Advising athletes with asymptomatic cervical canal stenosis on their return to active play is a topic of considerable debate, with no definitive guidelines in place. Once cervical canal stenosis is identified, often through imaging following other injuries, it is difficult to predict the risk of future injury upon return to play in both contact and collision sports. Consequently, the decision can be a complicated one for the athlete, family, and physician alike. In this article, we identify radiographical and magnetic resonance imaging (MRI)-based criteria that may distinguish athletes "at-risk" for more severe consequences due to asymptomatic cervical canal stenosis from those who are safe to return to play. Using a Torg-Pavlov ratio <0.7 and MRI metrics, namely a minimal disc-level canal diameter <8 mm, a cord-to-canal area ratio >0.8, or space available for the cord <1.2 mm, can help when making these difficult decisions. Counseling can be a critical asset to patients with cervical stenosis who have had a previous episode of cervical cord neuropraxia, especially when they are involved in high-risk sports such as American football and rugby. We believe that while this remains an area of continued concern and controversy, improved MRI criteria will be a useful springboard for further studies, especially in the elite athlete population.

Updated Return-to-Play Recommendations for Collision Athletes After Cervical Spine Injury: A Modified Delphi Consensus Study With the Cervical Spine Research Society.

BACKGROUND: Previous studies have attempted to establish return-to-play (RTP) guidelines in collision sport athletes after cervical spine injury; however, recommendations have been limited by scant high-quality evidence and basic consensus survey methodologies. OBJECTIVE: To create relevant clinical statements regarding management in collision sport athletes after cervical spine injury, and establish consensus RTP recommendations. METHODS: Following the modified Delphi methodology, a 3 round survey study was conducted with spine surgeons from the Cervical Spine Research Society and National Football League team physicians in order to establish consensus guidelines and develop recommendations for cervical spine injury management in collision sport athletes. RESULTS: Our study showed strong consensus that asymptomatic athletes without increased magnetic resonance imaging (MRI) T2-signal changes following 1-/2- level anterior cervical discectomy and fusion (ACDF) may RTP, but not after 3-level ACDF (84.4%). Although allowed RTP after 1-/2-level ACDF was noted in various scenarios, the decision was contentious. No consensus RTP for collision athletes after 2-level ACDF was noted. Strong consensus was achieved for RTP in asymptomatic athletes without increased signal changes and spinal canal diameter >10 mm (90.5%), as well as those with resolved MRI signal changes and diameter >13 mm (81.3%). No consensus was achieved in RTP for cases with pseudarthrosis following ACDF. Strong consensus supported a screening MRI before sport participation in athletes with a history of cervical spine injury (78.9%). CONCLUSION: This study provides modified Delphi process consensus statements regarding cervical spine injury management in collision sport athletes from leading experts in spine surgery, sports injuries, and cervical trauma. Future research should aim to elucidate optimal timelines for RTP, as well as focus on prevention of injuries.

"Bashing" of medical specialties: students' experiences and recommendations.

BACKGROUND AND OBJECTIVES: Exposure to non-constructive criticism of medical specialties is believed to be fairly common among medical students. Better understanding of this "bashing" phenomenon is needed to promote greater professionalism in medical education and student interest in primary care careers. This study examines exposure and reactions to bashing among third-year medical students in a public university. METHODS: A survey assessing amount, sources, targets, and nature of perceived bashing was completed by 105 students. Three open-ended questions elicited students' experiences, opinions, and recommendations. RESULTS: Students perceived that bashing of other specialties occurred during all clerkships; the most were perceived during the surgery clerkship, for which 87.5% reported such bashing. Specialties perceived as the object of bashing were family medicine (72%), general internal medicine (40%), psychiatry (39%), and general surgery (36%). Sixty-seven percent of students reported personally receiving non-constructive criticism about their preferred specialty. Seventy-nine percent believed bashing was unprofessional behavior. Strategies suggested by respondents to decrease bashing included increasing awareness, highlighting the interdisciplinary nature of medicine, and evaluating professionalism. CONCLUSIONS: Medical students perceived bashing of medical specialties, recognized it as unprofessional behavior, and would be receptive to interventions to reduce bashing. Findings suggest a need to address bashing as part of professionalism curricula in medical training.

Return to Play After Anterior Cervical Discectomy and Fusion in Professional Athletes.

BACKGROUND: Data are limited on return to play after anterior cervical discectomy fusion (ACDF) in professional athletes. PURPOSE: To determine the rate and time of return to play among professional athletes after ACDF. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study involved the prospective and retrospective review of patient charts and diagnostic studies as well as an internet search to collect data on a consecutive series of professional athletes who underwent cervical fusion by 1 of the 2 senior authors between 1982 and 2016. Demographic data included sport, preoperative symptoms and radiologic findings, date of surgery, level of surgery, postoperative symptoms and radiologic findings, and confounding factors (eg, other orthopaedic injuries). An internet search engine was used to determine date of return to play and length of career after surgery. RESULTS: A total of 27 ACDFs were performed on 26 professional athletes: 12 National Football League athletes, 5 National Hockey League athletes, 5 Major League Baseball athletes, 3 National Basketball Association athletes, and 1 Major League Soccer athlete. Twenty-six procedures (96.3%) showed clinical and radiographic evidence of fusion, and 20 of 25 eligible players returned to play (80%). At the conclusion of this study, 2 players were still in the rehabilitation phase and expected to return at the start of the next National Football League season. The mean time to return to play in a professional game was 9.5 months (range, 5.0-20.2 months). Of 15 players who returned to play but had retired by the time of this study, the mean career length after fusion was 3.2 years (range, 0.1-8.0 years). Clinical follow-up ranged from 1 to 96 months, with a mean of 22.1 months and mode of 11 months. CONCLUSION: After single-level ACDF, 80% of professional athletes were able to return to sport at approximately 9 months. The study findings will help athletes, physicians, and teams better predict outcome after ACDF surgery.

The impacts of subsidized health insurance on employees' use of preventive health services.

This study presents an uncontrolled preliminary evaluation of a pilot health insurance subsidy program and addresses whether provision of subsidized insurance that required employee contribution had an impact upon preventive health utilization among small businesses and their employees. Self-report questionnaires were mailed to the employees; these included questions on use of preventive health services before and after enrollment in the subsidy program. The analysis was stratified by self-reported prior enrollment in an insurance program to compare employees with and without prior health insurance. The findings suggest significant increases in health service utilization among the previously uninsured. Regular checkups more than doubled (p < .0001), as did the number of individuals receiving regular blood work (p < .0001). Nearly twice the number of individuals filled regular prescriptions after enrollment in the subsidy program as compared with before (p < .0001). This study suggests that employees of small businesses are willing to contribute to the cost of a health insurance premium, and once insured are more likely to use preventive services. A model of shared cost responsibility is an effective way to provide affordable insurance to small-business employees, thus increasing preventive services in these populations.

Piperazine-based CCR5 antagonists as HIV-1 inhibitors. IV. Discovery of 1-[(4,6-dimethyl-5-pyrimidinyl)carbonyl]- 4-[4-[2-methoxy-1(R)-4-(trifluoromethyl)phenyl]ethyl-3(S)-methyl-1-piperazinyl]- 4-methylpiperidine (Sch-417690/Sch-D), a potent, highly selective, and orally bioavailable CCR5 antagonist.

The nature and the size of the benzylic substituent are shown to be the key to controlling receptor selectivity (CCR5 vs M1, M2) and potency in the title compounds. Optimization of the lead benzylic methyl compound 3 led to the methoxymethyl analogue 30, which had excellent receptor selectivity and oral bioavailability in rats and monkeys. Compound 30 (Sch-417690/Sch-D), a potent inhibitor of HIV-1 entry into target cells, is currently in clinical trials.

Microscopic lumbar discectomy results for 60 cases in professional and Olympic athletes.

BACKGROUND CONTEXT: There is no documented information indicating time for return to play after lumbar discectomy in professional and Olympic athletes. PURPOSE: To determine the rate of return to sport and the average time of recovery in elite athletes undergoing microscopic lumbar discectomy (MLD). STUDY DESIGN: Between 1984 and 1998, the senior author performed 60 MLDs on 59 professional and Olympic athletes with lumbar herniated nucleus pulposus. PATIENT SAMPLE: Sixty consecutive MLDs performed on professional and Olympic athletes were reviewed. OUTCOME MEASURES: The rate of return and the average time to return to sport were determined. Also, the distribution of pain and presence of neurologic deficits were recorded. METHODS: A retrospective review was performed. RESULTS: Follow-up indicated that all but 7 of the 60 cases had returned to their sport, including one who underwent a second MLD for a herniation at an adjacent level. The average time from surgery to return was 5.2 months for the entire group, with a range of 1 to 15 months. CONCLUSION: MLD was effective in correcting the problems that forced the athletes to seek help, and the time to return often depends on factors other than their medical condition. Postoperatively, a complete trunk stabilization rehabilitation program was effective in returning these athletes to a high level of competition.

Measurements of lumbopelvic lordosis using the pelvic radius technique as it correlates with sagittal spinal balance and sacral translation.

BACKGROUND CONTEXT: Maintenance of normal lumbar lordosis is important in the treatment of spinal disorders. Many attempts have been made to quantify normal sagittal spinal alignment and lordosis using a C7 plumb line and segmental angulations of the spinal vertebrae. Little attention has been given to pelvic compensation as it correlates to lumbar lordosis and overall sagittal spinal alignment. Better methods of measuring lordosis, which correlate with sagittal spinal balance and pelvic compensation, are needed in treating patients with spinal disorders. PURPOSE: To determine the correlation between lumbopelvic lordosis, pelvic rotation and sagittal spinal balance and standardize a method for measuring lumbopelvic lordosis, sacral translation, and sagittal spinal alignment. STUDY DESIGN: Sagittal alignments using the C7 plumb line, Cobb angles, sacral plumb line and the pelvic radius (PR) technique were used to measure standing 36-inch lateral radiographs of patients with various spinal disorders. PATIENT SAMPLE: A review of the records identified 62 patients with various spinal pathologies presenting to the (RGW) spine clinic that had standing lateral spine radiographs. Only radiographs that allowed positive identification of the C7 vertebral body, the entire thoracolumbar spine, the sacrum and both femoral heads were studied. These criteria allowed inclusion of 28 subjects in this study. The final population had 12 women and 16 men with an average age of 52 years (SD, 16.6 years; range, 20 to 84 years). OUTCOME MEASURES: No outcomes measures were used in this study. METHODS: Measurements for sagittal spinal balance and lumbopelvic lordosis were made on 36-inch standing lateral radiographs of adult patients. Measurements included the C7 plumb line, segmental angulations of spinal vertebrae (Cobb angles), sacral translation and the PR technique for lumbopelvic lordosis. Data were analyzed for significant correlation between lumbopelvic lordosis, sagittal spinal balance, sacral translation and total segmental lumbar lordosis using the Cobb method. RESULTS: Our population averaged 50 degrees of total segmental lumbar lordosis from L1 to S1 (SD, 14.3; maximum, 89.5; minimum, 17.9). Nearly 75% of total segmental lumbar lordosis measured from L1 to S1 can be accounted for through the L4 to S1 superior end plates and 47% through L5 to S1 superior end plates in our population. Total segmental lumbar lordosis correlated with total thoracic kyphosis (r=0.45, p=.008). Total segmental lumbar lordosis measured by the Cobb method significantly correlated with sagittal spinal balance (r=-0.35, p=.022) and sacral translation (r=0.41, p=.016). Measurements for lumbopelvic lordosis significantly correlated with sagittal spinal balance (r=-0.33, p=.042), sacral translation (r=-0.70, p=.00002) and total segmental lumbar lordosis (r=0.82, p<.000001). Measurements for sacral translation and sagittal spinal balance also correlated significantly (r=0.35, p=.034). CONCLUSIONS: Sacral translation, the C7 plumb line and lumbopelvic lordosis are useful measures for sagittal spinal balance. Lumbopelvic lordosis and sacral translation can be correlated to the sagittal spinal balance. Understanding these measurements and the range of lumbopelvic compensation can be extremely helpful in treating patients with spinal pathology and in avoidance of flatback deformity. Application of these measures would be especially helpful in the treatment of patients with spinal fusion, degenerative spondylosis, disc disease, fractures, and in the prevention of sagittal malalignment.