Ability of the Seventh Cervical Vertebra Wall Distance to Determine Mobility Deficits of Older Adults.

Thoracic hyperkyphosis could affect mobility and independence of older adults. However, there was no clear evidence on the use of the seventh cervical vertebra wall distance (C7WD), a practical measure for thoracic hyperkyphosis, to indicate mobility deficits relating to independence of these individuals. This study explored the ability of C7WD to determine mobility impairments in 104 older adults. Participants (average age of 74.1 ± 7.4 years) with various degree of thoracic kyphosis were cross-sectionally measured for their C7WD, mobility, and Cobb angle. The findings indicate that participants with thoracic hyperkyphosis (Cobb angle = 46.1 ± 5.2°) had significantly poorer mobility than those without thoracic hyperkyphosis (Cobb angle = 32.8 ± 5.9°, p < .05). A C7WD of ≥7.8 cm could indicate mobility deficits of the participants (sensitivity = 71%-92%, specificity = 75%-94%, and area under the curve >0.80). The findings confirm the ability of C7WD that could be clinically measured using rulers to indicate mobility deficits of older adults.

Influence of Sex and Body Mass Index on the Thoracic Kyphosis and Lumbar Lordosis.

OBJECTIVES: The purpose of this study was to assess the influence of sex and body mass index (BMI) on the thoracic kyphosis and lumbar lordosis of adolescents and to assess the reliability and agreement of the flexicurve method for these measurements. METHODS: The study included 217 adolescents of both sexes, aged between 11 and 15 years, who were students from municipal schools in the city of São José dos Campos in São Paulo. The measurement of thoracic kyphosis and lumbar lordosis angles was performed using the flexicurve method. Descriptive analysis of the data, analysis of covariance for comparison between groups (by BMI and sex), assessment of reliability, and intrarater agreement were analyzed. RESULTS: There was a significant difference between the groups by BMI and sex only for lumbar lordosis. The obese group had greater lumbar angles for both sexes (female sex: 32.6° ± 7.8° [eutrophic]; 37.7° ± 7.3° [obese]; male sex: 25.3° ± 7.3° [eutrophic]; 32.2° ± 7.3° [obese]). In the comparison between the sexes, the greatest lumbar angles were found in the female sex (female sex: 32.6° ± 7.8°; male sex: 25.3° ± 7.3°) among the eutrophic. Excellent intrarater reliability was found for thoracic kyphosis (intraclass correlation coefficient, 0.86) and moderate for lumbar lordosis (intraclass correlation coefficient, 0.72). CONCLUSION: Sex and BMI were associated with lumbar lordosis in adolescents and were greater in individuals with obesity and female individuals. The flexicurve method was reliable and accurate for the assessment of thoracic kyphosis and lumbar lordosis in adolescents.

Association of Core Muscle Endurance Times With Balance, Fatigue, Physical Activity Level, and Kyphosis Angle in Patients With Ankylosing Spondylitis.

BACKGROUND/OBJECTIVE: Core muscle endurance (CME), which is the ability of sustaining the activity of trunk muscles, has been shown to be lower in patients with ankylosing spondylitis (AS). The aim was to investigate the possible relationship between CME times and balance, fatigue, physical activity (PA) level, and thoracic kyphosis angle. METHODS: Fifty-one patients with AS with a mean age of 41.0 years (interquartile range, 25/75 years; 29.0/51.0 years) were included in the study. Core muscle endurance times were assessed by using trunk extension, trunk flexion, and side bridge tests. Overall stability index, anteroposterior stability index, mediolateral stability index, and limits of stability were evaluated with the Biodex Balance System. Fatigue and PA levels were surveyed using Fatigue Severity Scale and International Physical Activity Questionnaire, respectively. Thoracic kyphosis angle was measured by using a digital inclinometer. Additionally, CME times were compared for "high-fatigue" versus "low-fatigue" and as "low PA" versus "moderate/high PA" groups. Spearman correlation coefficients and Mann-Whitney U test were used for statistical analysis. RESULTS: Significant correlations were detected between overall stability index, anteroposterior stability index, Fatigue Severity Scale, International Physical Activity Questionnaire, and all CME tests (p < 0.05) and between mediolateral stability index and side bridge test (p < 0.05). Limits of stability correlated only with side bridge test (p < 0.05). Core muscle endurance significantly differed between high-fatigue and low-fatigue groups (p < 0.05), except trunk flexor test (p > 0.05). No significant differences were observed between low PA and moderate/high PA groups (p > 0.05), except side bridge test (p < 0.05). CONCLUSIONS: Core muscle endurance times seem to be related to PA level, fatigue, and balance but not with thoracic kyphosis angle. Assessing CME in patients with AS might help in planning individualized exercise programs.

Musculoskeletal abnormalities in a large international cohort of boys with 49,XXXXY.

49,XXXXY is the rarest X and Y chromosomal variation, with an incidence of 1 in 80,000-100,000 live male births and has been associated with numerous musculoskeletal abnormalities. Data was collected from an international cohort of boys with 49,XXXXY over 10 years. Children were evaluated by a multidisciplinary team consisting of a pediatric orthopedist, a neurogeneticist, a neurodevelopmentalist, and two physical therapists. Increased rates of torticollis (32.4%), hamstring tightness (42%), radioulnar synostosis (67.6%), pes planus (65.2%), and other foot abnormalities (86.9%) were observed. Several anomalies increased with age, specifically hamstring tightness, kyphosis, and scoliosis. The elucidation of the orthopedic profile of this population is necessary in order to provide healthcare providers with current medical information. This research further supports the necessity for the comprehensive multidisciplinary treatment of boys with 49,XXXXY.

Kyphosis and 3-year fall risk in community-dwelling older men.

Hyperkyhosis is thought to be a fall risk factor in older adults. This large study of older men found that fall risk increased with greater kyphosis measured with the blocks method, but did not find an association between kyphosis and falls when measured by the commonly used the Cobb angle method. INTRODUCTION: Research suggests an association between hyperkyphosis and falls in community-dwelling older adults, though this has not been investigated within large, population-based studies. This study sought to determine whether two measures of kyphosis prospectively predict fall risk over 3 years among older men. METHODS: Within the Osteoporotic Fractures in Men Study (MrOS), we conducted two 3-year prospective studies of 2346 and 2928 men. The first group had kyphosis measured by the Cobb angle at visit 1, while the second group had kyphosis assessed with the blocks method at visit 3; both groups then self-reported falls tri-annually for 3 years. Poisson regression with GEE was used to obtain relative risks (RR) of falls. RESULTS: The fall rates over 3 years were 651/1000 person-years among the visit 1 sample (mean age 74 ± 6 years) and 839/1000 person-years among the visit 3 sample (mean age 79 ± 5 years). In adjusted models of the visit 3 sample, the risk of falls was increased by 12% for each standard deviation increase (1.4 blocks) in the number of blocks required to achieve a neutral head and neck position (RR = 1.12, 95% CI = 1.06, 1.18). The Cobb angle was not associated with falls in the visit 1 sample. CONCLUSIONS: Although the Cobb angle did not predict falls in community-dwelling older men over 3 years, the blocks method of measuring kyphosis was predictive of falls in this population. This difference could be due to the Cobb angle's focus on thoracic kyphosis, whereas the blocks method may additionally capture abnormal cervical spine curvature.

Percutaneous versus open posterior stabilization in AOSpine type A3 thoracolumbar fractures.

BACKGROUND: The purpose of this retrospective cohort study was to compare treatment strategies of two level-one trauma centers regarding clinical and radiological outcomes focusing on non-osteoporotic AOSpine type A3 fractures of the thoracolumbar spine at levels T11 to L2. METHODS: Eighty-seven patients between 18 and 65 years of age that were treated operatively in either of two trauma centers were included. One treatment strategy includes open posterior stabilization whereas the other uses percutaneous posterior stabilization. Both included additional anterior fusion if necessary. Demographic data, McCormack classification, duration of surgery, hospital stay and further parameters were assessed. Owestry Disability Index (ODI), Visual Analog Scale (VAS) and SF-36 were measured for functional outcome. Bisegmental kyphosis angle, reduction loss and sagittal alignment parameters were assessed for radiological outcome. Follow up was at least 24 months. RESULTS: There was no significant difference regarding our primary functional outcome parameter (ODI) between both groups. Regarding radiological outcome kyphosis angle at time of follow up did not show a significant difference. Reduction loss at time of follow up was moderate in both groups with a significantly lower rate in the percutaneously stabilized group. Surgery time was significantly shorter for posterior stabilization and anterior fusion in the percutaneous group. Time of hospital stay was equal for posterior stabilization but shorter for anterior fusion in the open stabilized group. CONCLUSION: Both treatment strategies are safe and effective showing only minor loss of reduction. Clinical relevant differences in functional and radiographic outcome between the two surgical groups could not be demonstrated. TRIAL REGISTRATION: It was conducted according to ICMJE guidelines and has been retrospectively registered with the German Clinical Trials Registry (identification number: DRKS00015693, 07.11.2018).

The clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction in the treatment of Kümmell's disease.

BACKGROUND: Kümmell's disease is a special type of osteoporotic vertebral fracture that causes chronic low back pain and deformity, which seriously affects the living quality of patients. PVP is commonly used to treat osteoporotic vertebral fractures and can quickly relieve low back pain. So, the objective of this study was to analyze the clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction for the treatment of Kümmell's disease. METHODS: A retrospective analysis of patients with Kümmell's disease who underwent bipedicular percutaneous vertebroplasty was conducted from February 2016 to May 2018. Operative time, VAS, bone cement injection volume, cement leakage rate, compression improvement of vertebral front edge and vertebral center, and correction degree of kyphosis were collected and analyzed meticulously. RESULTS: The operative time was 45.33 ± 7.64 min. The volume of bone cement injected was 5.38 ± 1.33 ml. The compression improvement of vertebral front edge was 7.31 ± 1.21%. The compression improvement of vertebral center was 10.34 ± 1.15% and the correction degree of kyphosis was - 2.73 ± 0.31゜. Bone cement leakage occurred in 6 of 39 patients (15.38%), but no clinical symptoms were observed. The VAS scores were significantly lower at 1 day after the surgery, 6 months and at the last follow-up than before the surgery (P = 0.000, respectively). The VAS score was lower at the last follow-up than at 1 day after the surgery (P = 0.001). CONCLUSION: Bipedicular percutaneous vertebroplasty combined with postural reduction could achieve satisfactory analgesic effect in the treatment of Kümmell's disease, and restore the height of the vertebral body and improve kyphosis to some extent.

Is It Growth or Natural History? Increasing Spinal Deformity After Sanders Stage 7 in Females With AIS.

BACKGROUND: Accurate prognosis and treatment decisions in adolescent idiopathic scoliosis (AIS) demand a reliable radiographic marker of growth cessation. Specifically, Sanders Stage 7 (SS7) is a useful marker of spine growth cessation in females and is proposed as a bracing endpoint. The purpose of this study was to determine the amount of curve progression noted in female individuals with AIS after achieving SS7. We hypothesize that a subset of patients continues to progress at a greater rate than the natural history at SS7. METHODS: This retrospective review included female patients with AIS treated at a single institution from May 2008 to 2018. Patients required a hand radiograph demonstrating SS7 and concurrent spine radiograph measuring <50 degrees, plus 2-year follow-up spine radiograph. Curve types were categorized by the modified Lenke Classification. Risser grade, menarche, height, weight, and bracing data were collected. Progression was defined as an increase of the main curve ≥5 degrees. Comparison between groups was analyzed using independent t tests and χ or Fisher exact tests as appropriate. Binary logistic regressions were used to construct a model predictive of progressing beyond 50 degrees or undergoing surgery. RESULTS: A total of 89 patients met inclusion criteria, average main curve magnitude 33 degrees (SD 9) at SS7 and 38 degrees (SD 11) at 2-year follow-up. Forty-five (51%) patients progressed ≥5 degrees and 17 (19%) progressed at least 10 degrees. Seventy patients had curves <40 degrees at SS7 and 22 (31%) progressed to >40 degrees at 2 years. Eleven (12%) patients progressed to >50 degrees or had surgery at 2-year follow-up. Receiver operating characteristic curve analysis identified a threshold of 39.5 degrees curvature at SS7 associated with progression to >50 degrees or surgery (area under the curve=0.94, P<0.001, sensitivity=100%, specificity=87%). Patients with initial curves >40 degrees did have additional height gained (2.1 cm; SD 1.5), but this was not different than those <40 degrees, P>0.05. In addition, no other variables had statistically significant association with those that progressed (P>0.05). CONCLUSIONS: A curve >40 degrees at SS7 is at high risk for progressing to a curve measuring >50 degrees or requiring surgery. Those with curves below this threshold still have potential to make clinically significant progression after skeletal maturity. Follow-up of patients beyond SS7 is essential for curves measuring >40 degrees. Reaching SS7 with a curve <50 degrees may not be the endpoint for curve progression, even if predictive of the end of spinal growth. LEVEL OF EVIDENCE: Level III-retrospective research study.

Is Anterior Release Obsolete or Does It Play a Role in Contemporary Adolescent Idiopathic Scoliosis Surgery? A Matched Pair Analysis.

STUDY DESIGN: A retrospective analysis of a prospectively collected database was performed. OBJECTIVE: The purpose of this study is to compare 3-dimensional correction associated with the anterior release (AR) and contemporary posterior instrumentation versus posterior-only surgery. SUMMARY OF BACKGROUND DATA: The role of AR as a tool in the treatment of adolescent idiopathic scoliosis (AIS) has seen a decline with the popularization of thoracic pedicle screw instrumentation. METHODS: Five surgeons were queried for all surgical thoracic AIS cases from 2003 to 2010 treated with thoracoscopic AR/fusion and contemporary posterior instrumentation and fusion and thoracic pedicle screw instrumentation (>80% screws) with 2-year follow-up. These cases were then matched with posterior spinal fusion only cases from a multicenter prospective database. The 2 groups were matched on the basis of major curve magnitude within 5 degrees, T5-T12 kyphosis within 9 degrees, and angle of trunk rotation within 9 degrees. Radiographic and clinical parameters were compared for the 2 groups. Continuous variables were analyzed with analysis of variance and categorical dependent variables with the χ test. RESULTS: A total of 47 cases of AR were matched to 47 (1:1 match) posterior spinal fusion cases. Preoperative parameters were similar between groups (P>0.05). Postoperatively, AR cases had a lower major curve (20 vs. 25 degrees, P=0.034; 72% vs. 66% correction, P=0.037). T5-T12 kyphosis was greater in the AR cases (26 vs. 20 degrees; P=0.005). The angle of trunk rotation was similar for the groups. Anchor density was lower in the AR group (1.6 vs. 1.9; P<0.0001). There were 3 complications associated with the AR: 1 pneumothorax and 2 conversions to minithoracotomies for failure to maintain single lung ventilation. CONCLUSIONS: AR improves coronal and sagittal plane correction in contemporary AIS surgery with a satisfactory complication profile with less pedicle screw density required for clinically similar corrections. A further prospective study on the benefits of AR may help define specific indications.

Measurement of Lumbar Lordosis: A Comparison of 2 Alternatives to the Cobb Angle.

OBJECTIVE: The purpose of this study was to compare 2 alternative methods, the radiologic Harrison Posterior Tangent Method (HPTM) and the nonradiologic Spinal Mouse (SM), to the Cobb angle for measuring lumbar lordosis. METHODS: Sixteen participants with previously existing lateral lumbopelvic radiographs underwent nonradiographic lordosis assessment with a Spinal Mouse. Then 2 investigators analyzed each radiograph twice using the Harrison Posterior Tangent Method and Cobb angle. Correlations were analyzed between HPTM, the Cobb angle, and SM using the Spearman rank correlation coefficient; intraexaminer and interexaminer agreement were analyzed for HPTM and the Cobb angle using intraclass correlation coefficients. RESULTS: The HPTM correlated highly with the Cobb angle (Spearman ρ = 0.936, P < .001); SM had moderate to strong correlations with the Cobb angle (ρ = 0.737, P = .002) and HPTM (ρ = 0.707, P = .003). Intraexaminer and interexaminer agreement for the Cobb angle and HPTM were excellent (all intraclass correlation coefficients > 0.90). One participant had slight kyphosis according to HPTM and SM analyses (which consider the entire lumbar region), whereas the Cobb angle, based only on L1 and L5, reported mild lordosis for that participant. CONCLUSION: In this sample, HPTM measurements showed high correlation with the commonly used Cobb angle, but this method requires more time and effort, and normal values have not been established. The SM may be an alternative when radiographs are inappropriate, but it measures soft tissue contours rather than lordosis itself.

What constitutes the fat signal detected by MRI in the spine of patients with ankylosing spondylitis? A prospective study based on biopsies obtained during planned spinal osteotomy to correct hyperkyphosis or spinal stenosis.

OBJECTIVE: Study the MRI signal of fatty lesions (FL) by immunohistological analysis of vertebral body biopsies of patients with ankylosing spondylitis (AS) compared with degenerative disc disease (DDD). METHODS: Biopsies obtained during planned surgery from vertebral edges where MRI signals of FL was detected were stained with H&E. Immunofluorescence (IF) staining was performed to quantify osteoblasts and osteoclasts. Bone marrow (BM) composition, grade of cellularity and quantification of cells were analysed on six randomly chosen high-power fields (HPF; 0.125 mm2) at 200-fold magnification per patient by two experienced researchers in a blinded manner. RESULTS: Biopsies of 21 patients with AS and 18 with DDD were analysed. Adipocytes were found in the BM of 19 patients with AS (90.5%) versus 5 with DDD (27.8%) (p<0.001), while inflammatory infiltrates were found in in the BM of 8 patients with AS (38.1%) versus 14 with DDD (77.8%) (p=0.035) and fibrosis in 6 patients with AS (28.6%) versus 4 with DDD (22.2%) (p=n .s.). The most frequently detected cells were adipocytes in AS (43.3%) versus DDD (16.1%, p=0.002) and inflammatory mononuclear cells in DDD (55%) versus AS (11.0%, p=0.001). Using IF staining, there was more osteoblastic than osteoclastic activity (6.9 vs 0.17 cells/HPF) in FL as compared with inflammatory BM (1.3 vs 7.4 cells/HPF), respectively. CONCLUSION: MRI FL correspond to presence of adipocytes, resulting to change of cellular homeostasis towards diminution of osteoclasts in the BM of patients with AS. The cross-talk between the different cell types and osteitis, fat and new bone formation needs further study.

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.

Distal Junctional Failure Following Pediatric Spinal Fusion.

BACKGROUND: Adjacent segment pathology is a known complication after spinal fusion, but little has been reported on junctional failure. A series of adolescent patients presented with acute distal junctional failure (DJF). We sought to determine any common features of these patients to develop a prevention strategy. METHODS: A retrospective review was conducted of pediatric patients who developed DJF after instrumented spinal fusion performed at 2 institutions from 1999 to 2013. Patients with proximal junctional failure or junctional kyphosis without failure were excluded. RESULTS: Fifteen subjects were identified with mean follow-up of 38 months. Distal failure occurred a mean of 60 days after index surgery, with history of minor trauma in 4 patients. Failures included 3-column Chance fracture (11) or instrumentation failure (4). Thirteen patients presented with back pain and/or acute kyphosis, whereas 2 asymptomatic patients presented with healed fractures. Two patients also developed new onset of severe lower extremity neurological deficit after fracture, which improved but never resolved after revision. A total of 13/15 subjects required revision surgery, typically within 1 week. Complications associated with revision surgery were encountered in 8 patients (62%). Major complications that required return to the operating room included 2 deep infections, 2 instrumentation failures, and dense lower extremity paralysis that improved after medial screw revision and decompression. At final follow-up, 10 patients are asymptomatic, 2 have persistent neurological deficit, 2 have chronic pain, and 1 has altered gait with gait aid requirement. CONCLUSIONS: This study analyzes a heterogenous cohort of spinal fusion patients who developed DJF from 3-column Chance fracture or instrumentation failure. Revision surgery is typically required, but has a high complication rate and can result in severe neurological deficit, highlighting the morbidity of this complication. It is unclear whether level of the lowest instrumented vertebra contributes to DJF. Increased awareness of junctional failure in children may prompt additional studies to further characterize risk factors and preventative strategies. LEVEL OF EVIDENCE: Level IV-study-type case series.

Kyphosis and incident falls among community-dwelling older adults.

Hyperkyphosis commonly affects older persons and is associated with morbidity and mortality. Many have hypothesized that hyperkyphosis increases fall risk. Within this prospective study of older adults, kyphosis was significantly associated with incident falls over 1 year. Measures of hyperkyphosis could enhance falls risk assessments during primary care office visits. INTRODUCTION: To determine the association between four measures of kyphosis and incident and injurious falls in older persons. METHODS: Community-dwelling adults aged 65 and older (n = 72) residing in southern California were invited to participate in a prospective cohort study. Participants had kyphosis assessed four ways. Two standing measures included a flexicurve ruler placed against the back to derive a kyphotic index and the Debrunner kyphometer, a protractor used to measure the kyphotic angle in degrees. Two lying measures included the blocks method (number of 1.7 cm blocks needed to achieve a neutral head position while lying supine) and traditional Cobb angle calculation derived from DXA based lateral vertebral assessment. Baseline demographic, clinical, and other health information (including a timed up and go (TUG) test) were assessed at a clinic visit. Participants were followed monthly through email or postcard for 1 year, with falls outcomes confirmed through telephone interview. RESULTS: Mean age was 77.8 (± 7.1) among the 52 women and 20 men. Over 12 months, 64% of participants experienced at least one incident fall and 35% experienced an injurious fall. Each standard deviation increase in kyphosis resulted in more than doubling the adjusted odds of an incident fall, even after adjusting for TUG. Odds of injurious falls were less consistent across measures; after adjusting for TUG, only the blocks method was associated with injurious falls. CONCLUSIONS: Each kyphosis measure was independently associated with incident falls. Findings were inconsistent for injurious falls; the blocks measure suggested the strongest association. If these findings are replicated, the blocks measure could be incorporated into office visits as a quick and efficient tool to identify patients at increased fall risk.

Systemic AAV-Mediated ß-Sarcoglycan Delivery Targeting Cardiac and Skeletal Muscle Ameliorates Histological and Functional Deficits in LGMD2E Mice.

Limb-girdle muscular dystrophy type 2E (LGMD2E), resulting from mutations in ß-sarcoglycan (SGCB), is a progressive dystrophy with deteriorating muscle function, respiratory failure, and cardiomyopathy in 50% or more of LGMD2E patients. SGCB knockout mice share many of the phenotypic deficiencies of LGMD2E patients. To investigate systemic SGCB gene transfer to treat skeletal and cardiac muscle deficits, we designed a self-complementary AAVrh74 vector containing a codon-optimized human SGCB transgene driven by a muscle-specific promoter. We delivered scAAV.MHCK7.hSGCB through the tail vein of SGCB-/- mice to provide a rationale for a clinical trial that would lead to clinically meaningful results. This led to 98.1% transgene expression across all muscles that was accompanied by improvements in histopathology. Serum creatine kinase (CK) levels were reduced following treatment by 85.5%. Diaphragm force production increased by 94.4%, kyphoscoliosis of the spine was significantly reduced by 48.1%, overall ambulation increased by 57%, and vertical rearing increased dramatically by 132% following treatment. Importantly, no adverse effects were seen in muscle of wild-type mice injected systemically with scAAV.hSGCB. In this well-defined model of LGMD2E, we have demonstrated the efficacy and safety of systemic scAAV.hSGCB delivery, and these findings have established a path for clinically beneficial AAV-mediated gene therapy for LGMD2E.

Utility of the clivo-axial angle in assessing brainstem deformity: pilot study and literature review.

There is growing recognition of the kyphotic clivo-axial angle (CXA) as an index of risk of brainstem deformity and craniocervical instability. This review of literature and prospective pilot study is the first to address the potential correlation between correction of the pathological CXA and postoperative clinical outcome. The CXA is a useful sentinel to alert the radiologist and surgeon to the possibility of brainstem deformity or instability. Ten adult subjects with ventral brainstem compression, radiographically manifest as a kyphotic CXA, underwent correction of deformity (normalization of the CXA) prior to fusion and occipito-cervical stabilization. The subjects were assessed preoperatively and at one, three, six, and twelve months after surgery, using established clinical metrics: the visual analog pain scale (VAS), American Spinal InjuryAssociation Impairment Scale (ASIA), Oswestry Neck Disability Index, SF 36, and Karnofsky Index. Parametric and non-parametric statistical tests were performed to correlate clinical outcome with CXA. No major complications were observed. Two patients showed pedicle screws adjacent to but not deforming the vertebral artery on post-operative CT scan. All clinical metrics showed statistically significant improvement. Mean CXA was normalized from 135.8° to 163.7°. Correction of abnormal CXA correlated with statistically significant clinical improvement in this cohort of patients. The study supports the thesis that the CXA maybe an important metric for predicting the risk of brainstem and upper spinal cord deformation. Further study is feasible and warranted.

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.

[Evaluation of the impact of sagittal spinal curvatures on musculoskeletal disorders in young people]. / Ocena wplywu krzywizn kregoslupa w plaszczyznie strzalkowej na dolegliwosci miesniowo-szkieletowe u mlodych osób.

BACKGROUND: In Poland, about 85% of the population report low back pain (LBP) symptoms overall. Moreover, 70-80% of people aged below 20 have already experienced back pain. The primary cause of LBP is the loss of spinal lordosis, which initiates changes in geometry of the spine and has impact on limb arrangement. The aim of the study was to attempt to verify the relationship between the 2 main curvatures of the spine and its relation to symptoms in different parts of the musculoskeletal system, in a group of adults. It was assumed that hyperlordosis of the lumbar spine and misbalance of the thoraco-lumbar junction are risk factors for LBP. MATERIAL AND METHODS: The study coverd 231 first-year students, (aged 19-21) of the University of Economics in Katowice. There were 103 men aged 19.5±0.8 years and 128 women aged 19.6±0.8 years. The students completed the Nordic Musculoskeletal Questionnaire (NMQ): 7 days (NMQ7) and 6 months (NMQ6). A Rippstein's plurimeter, was used to measure the angles of thoracic kyphosis (KTH) and lumbar lordosis (KLL). Cut of points was set at 30±5. RESULTS: The results indicate strong and very strong correlation (r = 0.6 and r = 0.8, p < 0.05) between the concave of the back and LBP, which may suggest the relationship between these symptoms and the increased lordosis. CONCLUSIONS: Postural defects in the sagittal plane may predict the occurrence of pain. The results of the study indicate a higher frequency of pain in people with a higher angle of lumbar lordosis. Med Pr 2018;69(1):29-36.

Association Between Myxomatous Mitral Valve Disease and Skeletal Back Abnormalities.

BACKGROUND: Myxomatous mitral valve disease (MMVD) is one of the most prevalent valvular heart diseases, while back pain, neck pain and upper-extremity numbness are some of the most common complaints in outpatient settings. Decreased thoracic kyphosis (straight back) is a known cause of hastening back or neck problems, radiculopathy, or even myelopathy. The study aim was to examine the relationship between MMVD, straight back, and the need for cervical fusion. METHODS: In this single-center retrospective study, patients who underwent mitral valve repair or replacement due to MMVD (cases) based on age, gender and body mass index (BMI), were matched with patients who underwent coronary artery bypass grafting (CABG) surgery and had no history of mitral valve disease (controls). The number of patients in each group who required cervical fusion was also noted. Patients included were aged <65 years at the time of surgery, which was performed between January 2014 and December 2015. Thoracic kyphosis curvature was measured from the length of a perpendicular line drawn from the middle of the anterior border of T8 vertebral body to a vertical line connecting anterior superior T4 and anterior inferior T12 on a lateral chest radiograph (AP distance). An AP distance <12 mm was defined as straight back. A Wilcoxon rank-sum test was used to compare the AP distance between cases and controls, and a chi-square test was used to compare the prevalence of straight back in the two groups. RESULTS: The study cohort included 75 patients in the MMVD group and 225 patients in the CABG group. Straight back was present in 27% of the MMVD group versus only 6.7% of the CABG group (p <0.0001) (Odds ratio 5.1; 95% CI 2.4-10.6). The mean AP distance in the MMVD group was 19.8 ± 8 mm, compared to 22.4 ± 6 mm for CABG cohort (p = 0.017). Of those patients with MMVD who had straight back, 10% required cervical fusion, compared to none in the CABG group. CONCLUSIONS: MMVD is associated with straight back and a relatively high requirement for cervical fusion. Patients with MMVD should be screened for straight back and, if the condition is identified, should consider preventive measures to obviate the need for cervical fusion.

Posterior elements disruption with hybrid constructs in AIS patients: is there an impact on proximal junctional kyphosis?

PURPOSE: Proximal junctional kyphosis (PJK) is a frequent proximal adjacent segment disease following spinal fusion in adolescent idiopathic scoliosis (AIS) and its rate has been estimated to 28% in the literature. The etiology is multifactorial, and risk factors associated with PJK are controversial. The aim of this study was to demonstrate that the disruption of muscular and bony tissue above the upper instrumented vertebra (UIV) during surgery does not increase the rate of PJK in patients undergoing posterior fusion for adolescent idiopathic scoliosis. MATERIAL AND METHOD: 50 patients with AIS operated between June 2014 and January 2016 were included. Every patient underwent a long posterior spine arthrodesis with a hybrid construct (proximal lamino-laminar claw, thoracic sublaminar bands and lumbar screws). The dissection of posterior elements above the UIV was necessary for the placement of proximal anchors. Radiographic analysis including proximal junctional angle, spino-pelvic parameters (cervical lordosis, thoracic kyphosis TK, lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope) and sagittal vertical axis were collected preoperatively and postoperatively at the last control. The numbers of fused levels, locations of upper instrumented vertebra, locations of lower instrumented vertebra, length of fusion segments were also recorded. Multiple odd ratios and other statistical analysis were performed to evaluate the relation between PJK and the potential risk factors. RESULTS: There were 43 females and 7 males with a mean age of 14.8 years at surgery. PJK occurred in 5 out of 50 cases with an incidence of 10%. The mean follow-up was 18 months. There was no significant difference in gender (OR 1.36, p = 0.8), decrease of TK (OR 1.63, p = 0 0.69), location of UIV (OR 2.25, p = 0.4), LIV (OR 2, p = 0.55), and SVA change (OR 1.63, p = 0.46). CONCLUSIONS: The disruption of ligamentous and bony tissue proximal to the UIV during the surgery does not increase the rate of PJK. Level of evidence IV.