Intrinsic variables associated with low back pain and lumbar spine injury in fast bowlers in cricket: a systematic review.

BACKGROUND: Lumbar spine injuries in fast bowlers account for the greatest missed playing time in cricket. A range of extrinsic and intrinsic variables are hypothesised to be associated with low back pain and lumbar spine injury in fast bowlers, and an improved understanding of intrinsic variables is necessary as these may alter load tolerance and injury risk associated with fast bowling. This review critically evaluated studies reporting intrinsic variables associated with low back pain and lumbar spine injury in fast bowlers and identified areas for future investigation. METHODS: OVID Medline, EMBASE, SPORTDiscus, CINAHL, Web of Science and SCOPUS databases were last searched on 3 June 2022 to identify studies investigating intrinsic variables associated with low back pain and lumbar spine injury in cricket fast bowlers. Terms relevant to cricket fast bowling, and intrinsic variables associated with lumbar spine injury and low back pain in fast bowlers were searched. 1,503 abstracts were screened, and 118 full-text articles were appraised to determine whether they met inclusion criteria. Two authors independently screened search results and assessed risk of bias using a modified version of the Quality in Prognostic Studies tool. RESULTS: Twenty-five studies met the inclusion criteria. Overall, no included studies demonstrated a low risk of bias, two studies were identified as moderate risk, and twenty-three studies were identified as high risk. Conflicting results were reported amongst studies investigating associations of fast bowling kinematics and kinetics, trunk and lumbar anatomical features, anthropometric traits, age, and neuromuscular characteristics with low back pain and lumbar spine injury. CONCLUSION: Inconsistencies in results may be related to differences in study design, injury definitions, participant characteristics, measurement parameters, and statistical analyses. Low back pain and lumbar spine injury occurrence in fast bowlers remain high, and this may be due to an absence of low bias studies that have informed recommendations for their prevention. Future research should employ clearly defined injury outcomes, analyse continuous datasets, utilise models that better represent lumbar kinematics and kinetics during fast bowling, and better quantify previous injury, lumbar anatomical features and lumbar maturation. TRIAL REGISTRATION: Open Science Framework https://doi.org/10.17605/OSF.IO/ERKZ2 .

A biomechanical comparison of posterior fixation approaches in lumbar fusion using computed tomography based lumbosacral spine modelling.

Extreme lateral interbody fusion (XLIF) may be performed with a standalone interbody cage, or with the addition of unilateral or bilateral pedicle screws; however, decisions regarding supplemental fixation are predominantly based on clinical indicators. This study examines the impact of posterior supplemental fixation on facet micromotions, cage loads and load-patterns at adjacent levels in a L4-L5 XLIF at early and late fusion stages. CT data from an asymptomatic subject were segmented into anatomical regions and digitally stitched into a surface mesh of the lumbosacral spine (L1-S1). The interbody cage and posterior instrumentation (unilateral and bilateral) were inserted at L4-L5. The volumetric mesh was imported into finite element software for pre-processing, running nonlinear static solves and post-processing. Loads and micromotions at the index-level facets reduced commensurately with the extent of posterior fixation accompanying the XLIF, while load-pattern changes observed at adjacent facets may be anatomically dependent. In flexion at partial fusion, compressive stress on the cage reduced by 54% and 72% in unilateral and bilateral models respectively; in extension the reductions were 58% and 75% compared to standalone XLIF. A similar pattern was observed at full fusion. Unilateral fixation provided similar stability compared to bilateral, however there was a reduction in cage stress-risers with the bilateral instrumentation. No changes were found at adjacent discs. Posterior supplemental fixation alters biomechanics at the index and adjacent levels in a manner that warrants consideration alongside clinical information. Unilateral instrumentation is a more efficient option where the stability requirements and subsidence risk are not excessive.

Measuring compressive loads on a 'smart' lumbar interbody fusion cage: Proof of concept.

There are several complications associated with lumbar interbody fusion surgery however, pseudarthrosis (non-union) presents a multifaceted challenge in the postoperative management of the patient. Rates of pseudarthrosis range from 3 to 20 % in patients with healthy bone and 20 to 30 % in patients with osteoporosis. The current methods in post-operative follow-up - radiographs and CT, have high false positive rates and poor agreement between them. The aim of this study was to develop and test a proof-of-concept load-sensing interbody cage that may be used to monitor fusion progression. Piezoresistive pressure sensors were calibrated and embedded within a polyether ether ketone (PEEK) interbody cage. Silicone and poly (methyl methacrylate) (PMMA) were inserted in the graft regions to simulate early and solid fusion. The load-sensing cage was subjected to distributed and eccentric compressive loads up to 900 N between synthetic lumbar vertebral bodies. Under maximum load, the anterior sensors recorded a 56-58 % reduction in pressure in the full fusion state compared to early fusion. Lateral regions measured a 36-37 % stress reduction while the central location reduced by 45 %. The two graft states were distinguishable by sensor-recorded pressure at lower loads. The sensors more effectively detected left and right eccentric loads compared to anterior and posterior. Further, the load-sensing cage was able to detect changes in endplate stiffness. The proof-of-concept 'smart' cage could detect differences in fusion state, endplate stiffness, and loading conditions in this in vitro experimental setup.

Clinicians' perceptions around discectomy surgery for lumbar disc herniation: a survey of orthopaedic and neuro-surgeons in Australia and New Zealand.

INTRODUCTION: Understanding practice-based differences in treatment of lumbar disc herniations (LDHs) is vital for reducing unwarranted variation in the delivery of spine surgical health care. Identifying factors that influence surgeons' decision-making will offer useful insights for developing the most cost-effective and safest surgical strategy as well as developing surgeon education materials for common lumbar pathologies. This study was to capture any variation in techniques used by surgeons in Australia and New Zealand (ANZ) region, and perceived complications of different surgical procedures for primary and recurrent LDH (rLDH). MATERIALS AND METHODS: Web-based survey study was emailed to orthopaedic and neurosurgeons who routinely performed spinal surgery in ANZ from Decmber 20, 2018 to February 20, 2020. The response data were analyzed to assess for differences based on geography, practice setting, speciality, practice experience, practice length, and operative volume. RESULTS: Invitations were sent to 150 surgeons; 96 (64%) responded. Most surgeons reported microdiscectomy as their surgical technique of choice for primary LDH (73%) and the first rLDH (72%). For the second rLDH, the preferred choice for most surgeons was fusion surgery (82%). A surgeon's practice setting (academic/private/hybrid) was a statistically significant factor in what surgical procedure was chosen for the first rLDH (P = 0.014). When stratifying based on surgeon experience, there were statisfically significant differences based on the annual volume of spine surgeries performed (perceived reherniation rates following primary discectomy, P = 0.013; perceived reherniation rates following revision surgeries, P = 0.017; perceived intraoperative complications rates following revision surgeries, P = 0.016) and based on the annual volume of lumbar discectomies performed (perceived reherniation rates following revision surgeries, P = 0.022; perceived intraoperative complications rates following revision surgeries, P = 0.036; perceived durotomy rates following primary discectomy, P = 0.023). CONCLUSIONS: Surgeons' annual practice volume and practice setting have significant influences in the selection of surgical procedures and the perception of surgical complications when treating LDHs.

Finite element modeling of temporal bone graft changes in XLIF: Quantifying biomechanical effects at adjacent levels.

Extreme lateral interbody fusion allows for the insertion of a large-footprint interbody cage while maintaining the presence of natural stabilizing ligaments and the facets. It is unclear how the load-distribution mechanisms through these structures alter with temporal changes in the bone graft. The aim of this study was to examine the effects of temporal bone graft changes on load distribution among the cage, graft, and surrounding spinal structures using finite element analysis. Thoracolumbosacral spine computed tomography data from an asymptomatic male subject were segmented into anatomical regions of interest and digitally stitched to generate a surface mesh of the lumbar spine (L1-S1). The interbody cage was inserted into the L4-L5 region during surface meshing. A volumetric mesh was generated and imported into finite element software for pre-processing, running nonlinear static solves, and post-processing. Temporal stiffening was simulated in the graft region with unbonded (Soft Callus, Temporal Stages 1-3, Solid Graft) and bonded (Partial Fusion, Full Fusion) contact. In flexion and extension, cage stress reduced by 20% from the soft callus to solid graft state. Force on the graft was directly related to its stiffness, and load-share between the cage and graft improved with increasing graft stiffness, regardless of whether contact was fused with the endplates. Fused contact between the cage-graft complex and the adjacent endplates shifted load-distribution pathways from the ligaments and facets to the implant, however, these changes did not extend to adjacent levels. These results suggest that once complete fusion is achieved, the existing load paths are seemingly diminished.

Bony Stress and Its Association With Intervertebral Disc Degeneration in the Lumbar Spine: A Systematic Review of Clinical and Basic Science Studies.

STUDY DESIGN: Translational review encompassing basic science and clinical evidence. OBJECTIVES: Multiple components of the lumbar spine interact during its normal and pathological function. Bony stress in the lumbar spine is recognized as a factor in the development of pars interarticularis defect and stress fractures, but its relationship with intervertebral disc (IVD) degeneration is not well understood. Therefore, we conducted a systematic review to examine the relationship between bony stress and IVD degeneration. METHODS: Online databases Scopus, PubMed and MEDLINE via OVID were searched for relevant studies published between January 1980-February 2020, using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Two authors independently analyzed the data, noting characteristics and biases in various studies. RESULTS: Thirty-two articles were included in the review: 8 clinical studies, 9 finite element modeling studies, 3 in-vivo biomechanical testing studies, and 12 in-vitro biomechanical testing studies. Of the 32 articles, 19 supported, 4 rejected and 9 made no conclusion on the hypothesis that there is a positive associative relationship between IVD degeneration and bony stress. However, sufficient evidence was not available to confirm or reject a causal relationship. CONCLUSIONS: Most studies suggest that the prevalence of IVD degeneration increases in the presence of bony stress; whether a causal relationship exists is unclear. The literature recommends early diagnosis and clinical suspicion of IVD degeneration and bony stress. Longitudinal studies are required to explore causal relationships between IVD degeneration and bony stress.

Usefulness of computed tomography based three-dimensional reconstructions to assess the critical shoulder angle.

BACKGROUND: The critical shoulder angle (CSA) is a radiographic measurement that provides an assessment of both glenoid inclination and acromial length. Higher values may correlate with the presence of rotator cuff tears. However, it is difficult to obtain a high-quality true anteroposterior (AP) radiograph of the shoulder, with any excess scapular version or flexion/extension resulting in deviation from the true CSA value. Three-dimensional (3D) bony reconstructions of computed tomography (CT) shoulder scans may be able to be rotated to obtain a similar view to that of true AP radiographs. AIM: To compare CSA measurements performed on 3D bony CT reconstructions, with those on corresponding true AP radiographs. METHODS: CT shoulder scans were matched with true AP radiographs that were classified as either Suter-Henninger type A or C quality. 3D bony reconstructions were segmented from the CT scans, and rotated to replicate an ideal true AP view. Two observers performed CSA measurements using both CT and radiographic images. Measurements were repeated after a one week interval. Reliability was assessed using intraclass correlation coefficients (ICCs) and Bland-Altman plots [bias, limits of agreement (LOA)]. RESULTS: Twenty CT shoulder scans were matched. The mean CSA values were 32.55° (± 4.26°) with radiographs and 29.82° (± 3.49°) with the CT-based method [mean difference 2.73° (± 2.86°); P < 0.001; bias +2.73°; LOA -2.17° to +7.63°]. There was a strong correlation between the two methods (r = 0.748; P < 0.001). Intra-observer reliability was similar, but the best intra-observer values were achieved by the most experienced observer using the CT-based method [ICC: 0.983 (0.958-0.993); bias +0.03°, LOA -1.28° to +1.34°]. Inter-observer reliability was better with the CT-based method [ICC: 0.897 (0.758-0.958), bias +0.24°, LOA -2.93° to +3.41°]. CONCLUSION: The described CT-based method may be a suitable alternative for critical shoulder angle measurement, as it overcomes the difficulty in obtaining a true AP radiographic view.

Ultrasound volume projection image quality selection by ranking from convolutional RankNet.

Periodic inspection and assessment are important for scoliosis patients. 3D ultrasound imaging has become an important means of scoliosis assessment as it is a real-time, cost-effective and radiation-free imaging technique. With the generation of a 3D ultrasound volume projection spine image using our Scolioscan system, a series of 2D coronal ultrasound images are produced at different depths with different qualities. Selecting a high quality image from these 2D images is the crucial task for further scoliosis measurement. However, adjacent images are similar and difficult to distinguish. To learn the nuances between these images, we propose selecting the best image automatically, based on their quality rankings. Here, the ranking algorithm we use is a pairwise learning-to-ranking network, RankNet. Then, to extract more efficient features of input images and to improve the discriminative ability of the model, we adopt the convolutional neural network as the backbone due to its high power of image exploration. Finally, by inputting the images in pairs into the proposed convolutional RankNet, we can select the best images from each case based on the output ranking orders. The experimental result shows that convolutional RankNet achieves better than 95.5% top-3 accuracy, and we prove that this performance is beyond the experience of a human expert.

Complication rates of different discectomy techniques for symptomatic lumbar disc herniation: a systematic review and meta-analysis.

PURPOSE: This meta-analysis aims to compare the complication rates of discectomy/microdiscectomy (OD/MD), microendoscopic discectomy (MED), percutaneous endoscopic lumbar discectomy (PELD), percutaneous laser disc decompression (PLDD), and tubular discectomy for symptomatic lumbar disc herniation (LDH) using general classification and modified Clavien-Dindo classification (MCDC) schemes. METHODS: We searched three online databases for randomized controlled trials (RCTs) and cohort studies. Overall complication rates and complication rates per the above-mentioned classification schemes were considered as primary outcomes. Risk ratio (RR) and their 95% confidence intervals (CI) were evaluated. RESULTS: Seventeen RCTs and 20 cohort studies met the eligibility criteria. RCTs reporting OD/MD, MED, PELD, PLDD, and tubular discectomies had overall complication rates of 16.8% and 16.1%, 21.2%, 5.8%, 8.4%, and 25.8%, respectively. Compared with the OD/MD, there was moderate-quality evidence suggesting that PELD had a lower risk of overall complications (RR = 0.52, 95% CI 0.29-0.91) and high-quality evidence suggesting a lower risk of Type I complications per MCDC (RR = 0.37, 95% CI 0.16-0.81). Compared with the OD/MD data from cohort studies, there was low-quality evidence suggesting a higher risk of Type III complications per MCDC (RR = 10.83, 95% CI 1.29-91.18) for MED, higher risk of reherniations (RR = 1.67,95% CI 1.05-2.64) and reoperations (RR = 1.75, 95% CI 1.20-2.55) for PELD, lower risk of overall complication rates (RR = 0.42, 95% CI 0.25-0.70), post-operative complication rates (RR = 0.42, 95% CI 0.25-0.70), Type III complications per MCDC (RR = 0.39, 95% CI 0.22-0.69), reherniations (RR = 0.56, 95% CI 0.33-0.97) and reoperations (RR = 0.39, 95% CI 0.22-0.69) for PLDD. CONCLUSIONS: Compared with the OD/MD, results of this meta-analysis suggest that PELD has a lower risk of overall complications and a lower risk of complications necessitating conservative treatment. These slides can be retrieved under Electronic Supplementary Material.

Smart orthopaedic implants: A targeted approach for continuous postoperative evaluation in the spine.

Real-time health monitoring systems are emerging in diverse medical fields, tracking biological and physiological signals for direct feedback to the user. Orthopaedics is yet to adapt to innovative trends in health monitoring. Despite an evident entry point during orthopaedic surgeries, clinicians remain unable to objectively examine the structural integrity and biomechanics in the operated region through implantable sensors. As such, postoperative advice can be non-specific and poorly guided. This perspective discusses the clinical need for load-sensing implants that address biomechanical postoperative monitoring, taking the example of spinal interbody cages. Research has attempted to establish sensing approaches in different orthopaedic settings; however, they fail to meet mechanical sensing requirements or lack in vivo translatability, especially in the spine. Polymeric flexible sensors and Microelectromechanical Systems (MEMS) have favourable attributes aligned to the required features for in vivo load-sensing, although these approaches are yet to be tested extensively in orthopaedics. While inductive powering is promising, wireless energy transfer and telemetry are areas of ongoing research. This perspective proposes a thorough understanding of the relevant biomechanics to identify the pertinent sensing parameters, concurrent treatment of sensing and powering aspects, and utilisation of energy harvesting for sensing and data transmission. While sensing advancements have contributed to the rise of real-time health monitoring in other fields of medicine, orthopaedics has so far been overlooked. It is the application of these innovations that will lead to the development of a new generation of 'smart' implants for continuous postoperative evaluation.

Morphological characteristics of the kangaroo lumbar intervertebral discs and comparison with other animal models used in spine research.

PURPOSE: Animal models are frequently used to elucidate pathomechanism and pathophysiology of various disorders of the human intervertebral disc (IVD) and also to develop therapeutic approaches. Here we report morphological characteristics of the kangaroo lumbar IVDs and compare them with other animal models used in spine research. METHODS: Twenty-five fresh-frozen cadaveric lumbar spines (T12-S1) derived from kangaroo carcases (Macropus giganteus) of undetermined age were first scanned in a C-Arm X-ray machine. A photograph of the axial section of the disc including a calibrated metric scale was also acquired. The digital radiographs and photographs were processed in ImageJ to determine the axial and sagittal plane dimensions for the whole disc (WD) and the nucleus pulposus (NP) and the mid-sagittal disc height for all the lumbar levels. RESULTS: Our results suggest that the L6-S1 IVD in kangaroos is distinctly large compared with the upper lumbar IVDs. Based on previously published data, human lumbar IVDs are the largest of all the animal IVDs used in spine research, with camelid cervical IVDs being the closest relative in absolute dimensions (llamas: 78% in disc height, 40% in WD volume, and 38% in NP volume). Kangaroo L6-S1 IVD was approximately 51% in height, 20% in WD volume, and 20% in NP volume of the human lumbar IVD. CONCLUSIONS: We conclude that morphological similarities exist between a kangaroo and human lumbar IVD, especially with the lima bean shape in the axial plane, wedge shape in the sagittal plane, convexity at the cephalad endplates, and percentage volume occupied by the NP in the IVD. These slides can be retrieved under Electronic Supplementary Material.

Assessment of degenerative cervical stenosis on T2-weighted MR imaging: sensitivity to change and reliability of mid-sagittal and axial plane metrics.

STUDY DESIGN: A retrospective cross-sectional study. OBJECTIVE: To assess the sensitivity to change and reliability of various mid-sagittal and axial plane metrics in the assessment of patients with single-level degenerative cervical stenosis on T2-weighted MR imaging. SETTING: A diagnostic MR imaging facility in Sydney (Australia). METHODS: We retrospectively reviewed T2-weighted MR images of 85 consecutive patients (48 M and 37 F) with single-level degenerative cervical stenosis. Canal compromise and cord compression were evaluated using three mid-sagittal plane metrics (M1, M2, and M3) and two axial plane metrics (M4 and M5), at the level of stenosis and nonstenotic cephalad and caudal levels (controls). Sensitivity to change (SC) for each metric was evaluated as the percentage deviation of the measured value from the estimated normal value based on cephalad and caudal controls. Reliability for each metric was evaluated using intraclass correlation coefficients. RESULTS: Degenerative cervical stenosis showed a bimodal distribution peaking at C5-6 (n = 32) and C3-4 (n = 29) levels. The changes in the canal and cord geometry along the rostrocaudal axis were inconsistent. Across all individual subjects (reflecting a range of stenosis severity), M3 (-32.87% ± 10.60%) was more sensitive to change compared with M1 (16.64% ± 16.48%) and M2 (-23.95% ± 11.12%). Similarly, M4 (-24.62% ± 12.17%) was more sensitive to change compared with M5 (-6.71% ± 11.08%). The level of reliability was "moderate" to "excellent" for mid-sagittal plane measurements, and "poor" to "excellent" for axial plane measurements. CONCLUSION: Changes in canal dimensions in the mid-sagittal plane and cord shape in the axial plane are sensitive indicators of degenerative cervical stenosis on T2-weighted MR images.

A novel magnetic resonance imaging postprocessing technique for the assessment of intervertebral disc degeneration-Correlation with histological grading in a rabbit disc degeneration model.

INTRODUCTION: Estimation of intervertebral disc degeneration on magnetic resonance imaging (MRI) is challenging. Qualitative schemes used in clinical practice correlate poorly with pain and quantitative techniques have not entered widespread clinical use. METHODS: As part of a prior study, 25 New Zealand white rabbits underwent annular puncture to induce disc degeneration in 50 noncontiguous lumbar discs. At 16 weeks, the animals underwent multi-echo T2 MRI scanning and were euthanized. The discs were stained and examined histologically. Quantitative T2 relaxation maps were prepared using the nonlinear least squares method. Decay Variance maps were created using a novel technique of aggregating the deviation in the intensity of each echo signal from the expected intensity based on the previous rate of decay. RESULTS: Decay Variance maps showed a clear and well demarcated nucleus pulposus with a consistent rate of decay (low Decay Variance) in healthy discs that showed progressively more variable decay (higher Decay Variance) with increasing degeneration. Decay Variance maps required significantly less time to generate (1.0 ± 0.0 second) compared with traditional T2 relaxometry maps (5 (±0.9) to 1788.9 (±116) seconds). Histology scores correlated strongly with Decay Variance scores (r = 0.82, P < .01) and weakly with T2 signal intensity (r = 0.32, P < .01) and quantitative T2 relaxometry (r = 0.39, P < .01). Decay Variance had superior sensitivity and specificity for the detection of degenerate discs when compared to T2 signal intensity or Quantitative T2 mapping. CONCLUSION: Our results show that using a multi-echo T2 MRI sequence, Decay Variance can quantitatively assess disc degeneration more accurately and with less image-processing time than quantitative T2 relaxometry in a rabbit disc puncture model. The technique is a viable candidate for quantitative assessment of disc degeneration on MRI scans. Further validation on human subjects is needed.

Bony stress in the lumbar spine is associated with intervertebral disc degeneration and low back pain: a retrospective case-control MRI study of patients under 25 years of age.

PURPOSE: Abnormal stress in the lumbar vertebra, also known as bony stress, can be a precursor to degenerative changes which may manifest as low back pain (LBP). However, the prevalence of bony stress in the lumbar spine and its relationship with degenerative changes and LBP is unclear. The purpose of this study was to evaluate the prevalence of bony stress in the lumbar spine and its relationship with intervertebral disc (IVD) degeneration, facet osteoarthritis and LBP in patients under 25 years of age. METHODS: A retrospective case-control study of 130 patients under 25 years of age was conducted from a population of 493 patients who had lumbar MRI across three imaging centres over three years. A cohort of 55 consecutive patients with bony stress was identified. A control group of consecutive patients (n = 75) without bony stress was also selected from the population. RESULTS: Bony stress was prevalent in 11% (95% CI [8.4-14.5%]) of patients and was not diagnosed in 36% (95% CI [22-55%]) of these cases. Patients with bony stress had over twofold (OR 2.3, 95% CI [1.1-4.8]) and fivefold (OR 5.3, 95% CI [2.11-13.3]) higher likelihood of having IVD degeneration and LBP, respectively, when compared with the control group. Bony stress was not found to be associated with facet osteoarthritis. CONCLUSION: Bony stress in the lumbar spine was prevalent in 11% of patients under 25 years of age. It was commonly undiagnosed in radiology reports (not reported in 36% of the cases). Being significantly associated and with an increased likelihood of IVD degeneration and LBP, we posit that bony stress is likely a symptomatic and clinically meaningful diagnostic entity in the assessment of LBP. These slides can be retrieved under Electronic Supplementary Material.

Complication rates of different discectomy techniques for the treatment of lumbar disc herniation: a network meta-analysis.

PURPOSE: The aim of this network meta-analysis (NMA) was to compare the complication rates of discectomy/microdiscectomy, percutaneous laser disc decompression (PLDD), percutaneous endoscopic lumbar discectomy (PELD), microendoscopic discectomy (MED), and tubular discectomy for symptomatic lumbar disc herniation (LDH). METHODS: We searched three online databases for randomized controlled trials (RCTs). Overall complication rates, complication rates per general and modified Clavien-Dindo classification schemes, and reoperation rates were considered as primary outcomes. Odds ratio with 95% confidence intervals for direct comparisons and 95% credible intervals for NMA results were reported. Surface under cumulative ranking curve (SUCRA) was used to estimate ranks for each discectomy technique based on the complication rates. RESULTS: In total, 18 RCTs with 2273 patients were included in this study. Our results showed that there was no significant difference in any of the pairwise comparisons. PELD (SUCRA: 0.856) ranked the lowest for overall complication rates. Discectomy/microdiscectomy (SUCRA: 0.599) and PELD (SUCRA: 0.939) ranked the lowest for intraoperative and post-operative complication rates, respectively. Concerning modified Clavien-Dindo classification scheme, PELD (SUCRA: 0.803), MED (SUCRA: 0.730), and PLDD (SUCRA: 0.605) ranked the lowest for the occurrence of type I, II, and III complications, respectively. Tubular discectomy (SUCRA: 0.699) ranked the lowest for reoperation rates. CONCLUSIONS: The results of this NMA suggest that discectomy/microdiscectomy and PELD are the safest procedures for LDH with minimal intraoperative and post-operative complications, respectively. PELD, MED, and PLDD are the safest procedures for LDH in terms of minimal rates for complications necessitating conservative, pharmacological, and surgical treatment, respectively. These slides can be retrieved under Electronic Supplementary Material.

In Vivo 3D MRI Measurement of Tumour Volume in an Orthotopic Mouse Model of Prostate Cancer.

Prostate cancer (CaP) is the most commonly diagnosed cancer in males in western countries. Orthotopic implantation is considered as an ideal xenograft model for CaP study, and noninvasive measurement of tumor volume changes is important for monitoring responses to anticancer therapies. In this study, the T2-weighted fast spin echo sequence magnetic resonance imaging (MRI) was performed on a CaP orthotopic non-obese diabetic/severe combined immunodeficiency (NOD/SCID) mouse model weekly for 6 weeks post PC-3 CaP cell inoculation, and the fat signal was suppressed using a chemical shift-selective pulse. Subsequently, the MRI data were imported into the image processing software Avizo Standard and stacked into three-dimensional (3D) volumes. Our results demonstrate that MRI, combined with 3D reconstruction, is a feasible and sensitive method to assess tumor growth in a PC-3 orthotopic CaP mouse model and this established monitoring approach is promising for longitudinal observation of CaP xenograft development after anticancer therapy in vivo. Further investigation is needed to validate this protocol in a larger cohort of mice to generate enough statistical power.

The Role of Sacral Slope in the Progression of a Bilateral Spondylolytic Defect at L5 to Spondylolisthesis: A Biomechanical Investigation Using Finite Element Analysis.

STUDY DESIGN: A biomechanical study using finite element analysis. OBJECTIVES: The main objective of this study was to investigate the role of sacral slope in the progression of a L5 bilateral spondylolytic defect to spondylolisthesis. METHODS: A 3-dimensional model of lumbosacral spine was built using computed tomography (CT) data procured from an anonymized healthy male subject. The segmented CT data was manipulated to generate 3 more models representing L5 bilateral spondylolytic defect with normal sacral slope (SS), sacral slope increased by 10° (SS+10), and sacral slope decreased by 10° (SS-10). The 3D models were imported into finite element modelling software Strand7 for preprocessing, running nonlinear static solves, and postprocessing of the results. RESULTS: Directional biomechanical instabilities were induced in the lumbosacral spine as a result of changes in the L5-S1 disc shape secondary to the changes in sacral slope. Compared with the normal L5 lytic model, wedging of the L5-S1 disc (SS+10) resulted in a significantly greater range of motion in flexion (18% ↑) but extension motion characteristics were similar. Conversely, flattening of the L5-S1 disc (SS-10) resulted in a significantly greater range of motion in extension (16% ↑) but flexion motion characteristics were similar to that of the normal L5 lytic model. CONCLUSIONS: Variations in sacral slope while preserving the L5-S1 mid-disc height and orientation of the L5 vertebra resulted in variations in the L5-S1 disc shape. The results suggest that for such extremities in the L5-S1 disc shape different pathomechanisms exist for the progression of the L5 lytic defect to spondylolisthesis.

Mild (not severe) disc degeneration is implicated in the progression of bilateral L5 spondylolysis to spondylolisthesis.

BACKGROUND: Spondylolytic (or lytic) spondylolisthesis is often associated with disc degeneration at the index-level; however, it is not clear if disc degeneration is the cause or the consequence of lytic spondylolisthesis. The main objective of this computed tomography based finite element modelling study was to examine the role of different grades of disc degeneration in the progression of a bilateral L5-lytic defect to spondylolisthesis. METHODS: High-resolution computed tomography data of the lumbosacral spine from an anonymised healthy male subject (26 years old) were segmented to build a 3D-computational model of an INTACT L1-S1 spine. The INTACT model was manipulated to generate four more models representing a bilateral L5-lytic defect and the following states of the L5-S1 disc: nil degeneration (NOR LYTIC), mild degeneration (M-DEG LYTIC), mild degeneration with 50% disc height collapse (M-DEG-COL LYTIC), and severe degeneration with 50% disc height collapse(S-COL LYTIC). The models were imported into a finite element modelling software for pre-processing, running nonlinear-static solves, and post-processing of the results. RESULTS: Compared with the baseline INTACT model, M-DEG LYTIC model experienced the greatest increase in kinematics (Fx range of motion: 73% ↑, Fx intervertebral translation: 53%↑), shear stresses in the annulus (Fx anteroposterior: 163%↑, Fx posteroanterior: 31%↑), and strain in the iliolumbar ligament (Fx: 90%↑). The S-COL LYTIC model experienced a decrease in mobility (Fx range of motion: 48%↓, Fx intervertebral translation: 69%↓) and an increase in normal stresses in the annulus (Fx Tensile: 170%↑; Fx Compressive: 397%↑). No significant difference in results was noted between M-DEG-COL LYTIC and S-COL LYTIC models. CONCLUSIONS: In the presence of a bilateral L5 spondylolytic defect, a mildly degenerate index-level disc experienced greater intervertebral motions and shear stresses compared with a severely degenerate index-level disc in flexion and extension bending motions. Disc height collapse, with or without degenerative changes in the stiffness properties of the disc, is one of the plausible re-stabilisation mechanisms available to the L5-S1 motion segment to mitigate increased intervertebral motions and shear stresses due to a bilateral L5 lytic defect.

Is L5-S1 motion segment different from the rest? A radiographic kinematic assessment of 72 patients with chronic low back pain.

PURPOSE: The relationship between biomechanical instability and degenerative changes in the lumbar spine in chronic low back pain (CLBP) patients remains controversial. The main objective of this retrospective radiographical study was to evaluate changes in kinematics at different lumbar levels (in particular the L5-S1 level) with progressive grades of disc degeneration and facet joint osteoarthritis in CLBP patients. METHODS: Using standing neutral and dynamic flexion/extension (Fx/Ex) radiographs of the lumbar spine, in vivo segmental kinematics at L1-L2 through L5-S1 were evaluated in 72 consecutive CLBP patients. Disc degeneration was quantified using changes in signal intensity and central disc height on mid-sagittal T2-weighted magnetic resonance (MR) scans. Additionally, the presence or absence of facet joint osteoarthritis was noted on T2-weighted axial MR scans. RESULTS: Disc degeneration and facet joint osteoarthritis occurred independent of each other at the L5-S1 level (p = 0.188), but an association was observed between the two at L4-L5 (p < 0.001) and L3-L4 (p < 0.05) levels. In the absence of facet joint osteoarthritis, the L5-S1 segment showed a greater range of motion (ROM) in Ex (3.3° ± 3.6°) and a smaller ROM in Fx (0.6° ± 4.2°) compared with the upper lumbar levels (p < 0.05), but the differences diminished in the presence of it. In the absence of facet joint osteoarthritis, no change in L5-S1 kinematics was observed with progressive disc degeneration, but in its presence, restabilisation of the L5-S1 segment was observed between mild and severe disc degeneration states. CONCLUSION: The L5-S1 motion segment exhibited unique degenerative and kinematic characteristics compared with the upper lumbar motion segments. Disc degeneration and facet joint osteoarthritis occurred independent of each other at the L5-S1 level, but not at the other lumbar levels. Severe disc degeneration in the presence of facet joint osteoarthritis biomechanically restabilised the L5-S1 motion segment.