Critical shoulder angle and failure of conservative treatment in patients with atraumatic full thickness rotator cuff tears.

BACKGROUND: Atraumatic full thickness rotator cuff tears (AFTRCT) are common lesions whose incidence increases with age. Physical therapy is an effective conservative treatment in these patients with a reported success rate near 85% within 12 weeks of treatment. The critical shoulder angle (CSA) is a radiographic metric that relates the glenoid inclination with the lateral extension of the acromion in the coronal plane. A larger CSA has been associated with higher incidence of AFTRCT and a higher re-tear rate after surgical treatment. However, no study has yet described an association between a larger CSA and failure of conservatory treatment in ARCT. The main objective of this study is to determine whether there is an association between CSA and failure of physical therapy in patients with AFTRCT. METHODS: We reviewed the imaging and clinical records of 48 patients (53 shoulders), 60% female, with a mean age of 63.2 years (95% CI ± 10.4 years); treated for AFTRCT who also underwent a true anteroposterior radiograph of the shoulder within a year of diagnosis of the tear. We recorded demographic (age, sex, type of work), clinical (comorbidities), and imaging data (CSA, size and location of the tear). We divided the patients into two groups according to success or failure of conservative treatment (indication for surgery), so 21 shoulders (39.6%) required surgery and were classified as failure of conservative treatment. Univariate and multivariate analysis was performed to detect predictors of failure of conservative treatment. RESULTS: The median CSA was 35.5º with no differences between those with failure (median 35.5º, range 29º to 48.2º) and success of conservative treatment (median 35.45º, range 30.2º to 40.3º), p = 0.978. The multivariate analysis showed a younger age in patients with failure of conservative treatment (56.14 ± 9.2 vs 67.8 ± 8.4, p < 0.001) and that male gender was also associated with failure of conservative treatment (57% of men required surgery vs 28% of women, p = 0.035). CONCLUSIONS: It is still unclear if CSA does predict failure of conservative treatment. A lower age and male gender both could predicted failure of conservative treatment in AFTRCT. Further research is needed to better address this subject.

Inter- and intra-observer agreement using the new AOSpine sacral fracture classification, with a comparison between spine and pelvic trauma surgeons.

BACKGROUND: Sacral fractures treatment frequently involves both spine and pelvic trauma surgeons; therefore, a consistent communication among surgical specialists is required. We independently assessed the new AOSpine sacral fracture classification's agreement from the perspective of spine and pelvic trauma surgeons. METHODS: Complete computerized tomography (CT) scans of 80 patients with sacral fractures were selected and classified using the new AOSpine sacral classification system by six spine surgeons and three pelvic trauma surgeons. After four weeks, the 80 cases were presented and reassessed by the same raters in a new random sequence. The Kappa coefficient (κ) was used to measure the inter-and intra-observer agreement. RESULTS: The inter-observer agreement considering the fracture severity types (A, B, or C) was substantial for spine surgeons (κ= 0.68 [0.63 - 0.72]) and pelvic trauma surgeons (κ= 0.74 (0.64 - 0.84). Regarding the subtypes, both groups achieved moderate agreement with κ= 0.52 (0.49 - 0.54) for spine surgeons and κ= 0.51 (0.45 - 0.57) for pelvic trauma surgeons. The intra-observer agreement considering the fracture types was substantial for spine surgeons (κ= 0.74 [0.63 - 0.75]) and almost perfect for pelvic trauma surgeons (κ= 0.84 [0.74 - 0.93]). Concerning the subtypes, both groups achieved substantial agreement with, κ= 0.61 (0.56 - 0.67) for spine surgeons and κ= 0.68 (0.62 - 0.74) for pelvic trauma surgeons. CONCLUSION: This classification allows an adequate communication for spine surgeons and pelvic trauma surgeons at the fracture severity type, but the agreement is only moderate at the subtype level. Future prospective studies are required to evaluate whether this classification allows for treatment recommendations and establishing prognosis in patients with sacral fractures.

Mid and lower thoracic kyphosis changes during adulthood: the influence of age, sex and thoracic coronal curvature.

INTRODUCTION: There is conflicting data on how thoracic kyphosis changes throughout adulthood. We evaluated mid and lower thoracic kyphosis (MTK) in various age groups and the influence of age, sex and coronal curve (CC) on MTK. MATERIAL AND METHODS: We studied 1323 patients 15-80 years-old (54.4% females) previously evaluated with chest radiographs. We established three groups: patients 15-40 (group 1); 41-60 (group 2) and 61-80 years old (group 3). MTK (T5-T12) and CC were measured using Cobb's method. We established differences in MTK between groups using ANOVA with Bonferroni correction. We performed a correlation analysis of MTK with age and CC, and a linear regression analysis to determine if age, sex and CC independently predicted MTK. RESULTS: MTK increased with older age: mean MTK group 1 = 23.4°; group 2 = 27.9° and group 3 = 34.4°, p < 0.01. The increase in MTK was observed in both genders. Scoliosis was more common in females (15.4%) than in males (6.7%), p < 0.01. MTK was correlated with age (r = 0.4; p < 0.01) and slightly correlated with CC (r = 0.07, p < 0.01). MTK was larger in females than in males (29.1° vs. 27.6°, p < 0.01). Age (ß-coefficient = 0.26) and CC (ß-coefficient = 0.14), but not sex, independently influenced MTK in the regression analysis. CONCLUSION: MTK increases with advancing age during adulthood in both genders; CC, but not sex, was an independent predictor of MTK.

An independent inter- and intraobserver agreement assessment of the AOSpine sacral fracture classification system.

BACKGROUND CONTEXT: The AOSpine sacral classification scheme was recently described. It demonstrated substantial interobserver and excellent intraobserver agreement in the study describing it; however, an independent assessment has not been performed. PURPOSE: To perform an independent inter- and intraobserver agreement evaluation of the AOSpine sacral fracture classification system. STUDY DESIGN: Agreement study. METHODS: Complete computerized tomography (CT) scans, including axial images, with coronal and sagittal reconstructions of 80 patients with sacral fractures were selected and classified using the morphologic grading of the AOSpine sacral classification system by six evaluators (from three different countries). Neurological modifiers and case-specific modifiers were not assessed. After a four-week interval, the 80 cases were presented to the same raters in a random sequence for repeat assessment. We used the Kappa coefficient (κ) to establish the inter- and intraobserver agreement. RESULTS: The interobserver agreement was substantial when considering the fracture severity types (A, B, or C), with κ=0.68 (0.63-0.72), but moderate when considering the subtypes: κ=0.52 (0.49-0.54). The intraobserver agreement was substantial considering the fracture types, with κ=0.69 (0.63-0.75), and considering subtypes, κ=0.61 (0.56-0.67). CONCLUSION: The sacral classification system allows adequate interobserver agreement at the type level, but only moderate at the subtypes level. Future prospective studies should evaluate whether this classification system allows surgeons to decide the best treatment and to establish prognosis in patients with sacral fractures.

Management of patients with low back pain in the emergency department: Is it feasible to follow evidence-based recommendations?

OBJECTIVE: Low back pain is frequently seen in patients visiting the ED, but many patients receive medical care with no demonstrable benefits. We studied the clinical characteristics of patients visiting two EDs in Santiago, Chile, and their management to evaluate how it adheres to evidence-based recommendations. METHODS: We studied 519 patients and retrieved their demographic and clinical data, imaging testing and treatments. We determined the effect of sex, age, time from initial symptoms, pain measured with the visual analogue scale, presence of nerve radiation and the presence of red flags and neurological impairment on image testing and the management received. RESULTS: Mean age was 43.8 years; 57.8% were females. Females presented more often red flags (7.3 vs 3%, P = 0.04) and worse pain (visual analogue scale = 7 vs 6, P = 0.04) than males. Imagings were performed in 18.9% of patients; they were more frequently performed in patients with neurological impairment (P = 0.03) and red flags (P = 0.01). Intravenous non-opioids were administered in 25.6%; opioids were administered in 40.1%. Median time in the ED was 91 min (range 18-591); 16 (3.08%) patients were admitted. Age (odds ratio [OR] 1.04 [1.03-1.05], P < 0.01) and red flags (OR 4.9 [1.60-20.08], P < 0.01) influenced imaging testing; pain intensity influenced opioid use (OR 1.6 [1.29-1.95], P < 0.01), hospital admissions (1.95 [1.14-3.33], P < 0.01) and time in the ED (ß = 0.5, P < 0.01). CONCLUSION: Older age, the presence of red flags and pain intensity influenced the management of patients with low back pain in the ED. Future strategies should emphasise avoiding costly and ineffective management in these patients.

An Independent Validation of the Brighton Spondylodiscitis Score and a Proposal to Modify the Score.

INTRODUCTION: The Brighton Spondylodiscitis Score (BSS) aims to identify patients with pyogenic spinal infections (PSIs) requiring surgery; an independent assessment of the BSS is required. METHODS: We evaluated 60 patients with PSIs. Using the BSS, we determined whether patients with low, moderate, and high risk (LMHR) had different rates of surgery. We proposed a modified score (MS) using a logistic regression (LOGR). Applying the MS, we determined whether patients with LMHR exhibited different rates of surgery. Another LOGR determined the association of the BSS and the MS with surgery. A C-statistic using the BSS and the MS was generated. RESULTS: We studied 60 patients (mean age = 63 years); 37 (62%) were men; 30 (50%) required surgery. Using the BSS, patients with LMHR had similar rates of surgery (P = 0.53). LOGR showed that cervical PSIs had a larger chance of surgery (odds ratio [OR] = 7.3 [1.1 to 51.3]) than other locations. Using the MS, patients with moderate- and high-risk were operated more frequently than low-risk patients (P = 0.04). The BSS did not predict surgery (OR = 1.07; P = 0.31), but the MS did (OR = 1.16; P = 0.02). The C-statistic using the BSS (0.59) improved using the MS (0.69), P = 0.03. DISCUSSION: The discriminatory capacity to predict surgery of the BSS augmented using the MS. LEVEL OF EVIDENCE: II (Diagnostic study: Transverse study).

Do Patients Older Than 60 Years With Inflammatory Bowel Disease Have More Vertebral Fractures Than Age-matched Controls? A Study Using Abdominal and Pelvic CT Scans With Sagittal Reformatting as Screening Tool.

INTRODUCTION: It is undetermined whether patients with inflammatory bowel diseases (IBDs) have increased prevalence of vertebral compression fractures (VCFs) since many VCFs are asymptomatic and radiographs may overlook them. We compared the prevalence of VCFs in patients older than 60 years with and without IBDs. METHODS: We studied 55 patients with IBDs and 165 controls who underwent CT scans for nonspinal conditions. We evaluated the presence of VCFs, fracture severity using the Genant score, and we determined whether age, sex, diagnosis of IBD, treatment, and time since diagnosis were associated with VCFs. Using logistic regression analysis, we assessed the independent effect of each variable. RESULTS: Mean age was 72.7 years; 165 patients (75%) were women. Thirty-five patients (16%) had at least one VCF (16.4% IBD; 15.8% controls, P = 0.92); both groups exhibited similar fracture severity. Patients with VCFs were older than patients without VCFs (79.8 versus 70.2, P < 0.01 IBD; 76.4 versus 72.4, P = 0.02 controls). No other clinical variables were different in patients with and without VCFs in either cohort. Only age was independently associated with VCFs in both cohorts. DISCUSSION: VCFs were not more frequent or severe in patients older than 60 years with IBD presented than in age-matched controls.

Scheuermann's disease in patients 15-40 years old: A study to determine its prevalence and its relationship with age and sex using chest radiographs as screening tool.

BACKGROUND: There is insufficient knowledge of the epidemiology of Scheuermann's disease. The data available comes from estimations from young adults with obvious deformity, from studies evaluating children who may not have developed the deformity yet, or from older populations who can develop vertebral wedging secondary to other causes. We aimed to determine the prevalence of Scheuermann's disease in patients 15-40 years old using plain chest radiographs as a screening tool. METHODS: We evaluated 454 patients aged 15-40 years old studied using standing plain chest radiographs. We measured thoracic kyphosis from T5 to T12; using the intraclass correlation coefficient (ICC), we determined inter- and intra-observer agreement. To determine the prevalence of Scheuermann's disease we used the Sorensen criteria. We performed a correlation analysis of thoracic kyphosis and age, and a linear regression to determine the impact of age and sex on the kyphosis angle. RESULTS: The prevalence of Scheuermann's disease was 2.2% (0.9-3.5%). The prevalence was not different in females (1.4%) and males (2.8%), p = 0.36. Inter-and intra-observer agreements were excellent: ICC = 0.93 (0.84-0.97) and 0.97 (0.95-0.98). There was a small positive correlation of kyphosis angle with age (r = 0.110; p = 0.019). Linear regression revealed that age (ß = 0.138; p = 0.019) was an independent predictor of kyphosis angle, but sex was not (ß-coefficient = 0.007; p = 0.994). CONCLUSION: We found a prevalence of Scheuermann's disease of 2.2%, without significant differences between males and females. Age independently influenced the kyphosis angle; sex did not. This study allows a better understanding of the epidemiology of Scheuermann's disease.

Does adding interbody fusion to posterolateral fusion increase success in the surgical management of degenerative lumbar spondylolisthesis? / ¿Es útil agregar una artrodesis intersomática a una artrodesis posterolateral en el tratamiento quirúrgico de la espondilolistesis lumbar degenerativa?

INTRODUCTION: Surgical treatment of lumbar degenerative spondylolisthesis usually involves an interbody fusion in addition to a posterolateral fusion. However, the value of this procedure has not been established. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified four systematic reviews, including nine primary studies; none of them randomized. We concluded performing interbody fusion in addition to posterolateral fusion during the surgical treatment of lumbar degenerative spondylolisthesis might decrease vertebral body slippage and lead to a slight improvement in quality of life. However, it is associated with higher costs.

INTRODUCCIÓN: Frecuentemente se agrega una artrodesis intersomática a la artrodesis posterolateral en el tratamiento quirúrgico de la espondilolistesis degenerativa. Sin embargo, la real utilidad de esta medida no está clara. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cuatro revisiones sistemáticas que en conjunto incluyen nueve estudios primarios, de los cuales ninguno corresponde a un ensayo aleatorizado. Concluimos que agregar una artrodesis intersomática a una artrodesis posterolateral en el tratamiento quirúrgico de la espondilolistesis degenerativa podría asociarse a una disminución en el deslizamiento del cuerpo vertebral y a una leve mejoría de la calidad de vida de los pacientes, pero asociado también a un mayor costo.

¿Es útil agregar una artrodesis intersomática a una artrodesis posterolateral en el tratamiento quirúrgico de la espondilolistesis lumbar degenerativa? / Does adding interbody fusion to posterolateral fusion increase success in the surgical management of degenerative lumbar spondylolisthesis?

INTRODUCCIÓN: Frecuentemente se agrega una artrodesis intersomática a la artrodesis posterolateral en el tratamiento quirúrgico de la espondilolistesis degenerativa. Sin embargo, la real utilidad de esta medida no está clara. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cuatro revisiones sistemáticas que en conjunto incluyen nueve estudios primarios, de los cuales ninguno corresponde a un ensayo aleatorizado. Concluimos que agregar una artrodesis intersomática a una artrodesis posterolateral en el tratamiento quirúrgico de la espondilolistesis degenerativa podría asociarse a una disminución en el deslizamiento del cuerpo vertebral y a una leve mejoría de la calidad de vida de los pacientes, pero asociado también a un mayor costo.

INTRODUCTION: Surgical treatment of lumbar degenerative spondylolisthesis usually involves an interbody fusion in addition to a posterolateral fusion. However, the value of this procedure has not been established. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified four systematic reviews, including nine primary studies; none of them randomized. We concluded performing interbody fusion in addition to posterolateral fusion during the surgical treatment of lumbar degenerative spondylolisthesis might decrease vertebral body slippage and lead to a slight improvement in quality of life. However, it is associated with higher costs.