Correlation between Preoperative MRI Parameters and Oswestry Disability Index in Patients with Lumbar Spinal Stenosis: A Retrospective Study.

Background and Objectives: Lumbar spinal stenosis (LSS) is a degenerative condition posing significant challenges in clinical management. Despite the use of radiological parameters and patient-reported outcome measures like the Oswestry Disability Index (ODI) for evaluation, there is limited understanding of their interrelationship. This study aimed to investigate the correlation between preoperative MRI parameters and ODI scores in patients with LSS undergoing surgical treatment. Materials and Methods: A retrospective analysis was conducted on 86 patients diagnosed with LSS over a 5-year period. Preoperative MRI measurements, including the cross-sectional area of the psoas muscle, lumbar canal stenosis, neural foramina area, and facet joint osteoarthritis, were assessed. ODI scores were collected preoperatively and at a 1-year follow-up. Statistical analyses were performed using IBM SPSS Statistics software (version 26). Results: Weak to moderate correlations were observed between certain MRI parameters and ODI scores. The initial ODI score had a weak positive correlation with the severity of lumbar canal stenosis according to Schizas criteria (rho = 0.327, p = 0.010) and a moderate negative correlation with the relative cross-sectional area of the psoas muscle (rho = -0.498, p = 0.000). At 1-year follow-up, the ODI had a weak negative correlation with the relative cross-sectional area of the psoas muscle (rho = -0.284, p = 0.026). Conclusions: While the severity of LSS showed a weak correlation with initial ODI, it was not a predictor of 1-year postoperative ODI. Furthermore, although the cross-sectional area of the thecal sac, the sagittal area of the neural foramen, and the grade of facet joint osteoarthritis influence the imagistic severity, none of them correlate with ODI. These findings underscore the need for a comprehensive model that integrates multiple imaging and clinical parameters for a holistic understanding of LSS and its functional outcomes.

Cohort study on the relationship between morphologic parameters of paravertebral muscles, BMI and lumbar lordosis on the severity of lumbar stenosis.

INTRODUCTION: There is a growing body of literature separately linking lumbar spinal stenosis (LSS) with various factors such as paravertebral muscle (PVM) impaired function/morphology, lordosis or BMI. However, their interplay is yet to be known. The present study aims to investigate the relationship between PVM morphology, BMI and lumbar lordosis in a population with a surgical indication for LSS. MATERIALS AND METHODS: A cross-sectional retrospective study was conducted on a group of 122 patients diagnosed with LSS in a hospital setting and scheduled for spine surgery. Epidemiological data and body mass index (BMI) were gathered. The cross-sectional area of the psoas muscle (rCSA) at the L4-L5 disc level on preoperative axial T2 MRI was measured. Fat infiltration of the anterior (APVM) and posterior paravertebral muscles (PPVM) was evaluated according to Goutallier classification while the severity of lumbar stenosis was staged according to Schizas criteria. Lumbar lordosis was measured on sagittal MRI using Cobb's angle method. The presence of the "rising psoas" sign was also noted. Statistical analysis of the data was performed using Pearson and Spearman correlations. RESULTS: Statistical analysis revealed a moderate correlation between the severity of LSS and BMI (p = 0.001), and fatty infiltration of paravertebral muscles (p = 0.000, p = 0.000). Adjusting for age, gender, and BMI resulted in a low correlation (p = 0.003, p = 0.045), rCSA correlated negatively with age, gender, and lordosis. BMI had a low positive correlation with lumbar lordosis (p = 0.006), severity (p = 0.001), number of levels (p = 0.005) and PPVM (p = 0.031). CONCLUSIONS: This study highlighted the relationship between PVM morphology and the severity of radiological signs in patients with LSS undergoing spine surgery and found a correlation independent of age, gender, and BMI. BMI was also shown to correlate with the severity after controlling for age and gender. rCSA has limited use in evaluating the severity of LSS.

Reduction of spondylolisthesis and sagittal balance correction by anterior lumbar interbody fusion (ALIF).

PURPOSE: Long time recognized as a cause of lumbar stenosis, degenerative spondylolisthesis has an evolution in interrelation with sagittal balance. This study aimed to assess the role of ALIF in correcting the sagittal balance in patients with degenerative spondylolisthesis. MATERIAL AND METHODS: Twenty patients aged between 47 and 70 years were operated between July 2011 and September 2014 for degenerative spondylolisthesis by ALIF. The pre-operative and post-operative valid standing full spine radiographs were reviewed retrospectively. Clinical and radiological evaluations were conducted pre-operatively and postoperatively at one year and five years. RESULTS: Lumbar lordosis (LL) was measured to 41.16 ± 14.25° pre-operatively and 47.27 ± 11.25° post-operatively (p > 0.05). At one year was 49.76 ± 13.31° and at five years 46.93 ± 9.26° (p > 0.05). Mean gain of lordosis after ALIF at index level was calculated to 8 ± 1.6° [4-12°]. CONCLUSIONS: ALIF offers a good reduction of the slipped vertebra providing good conditions for fusion and is an efficient surgical technique to recreate the sagittal spine balance.

The beginnings of orthopaedics in Romania.

AIM OF THE STUDY: To offer a glimpse into the orthopaedic practice in Romania during the nineteenth century and the first decades of the twentieth century, corresponding to a period when this surgical specialty was defining itself. INTRODUCTION: As in other parts of the world, in Romania, the orthopaedics and traumatology specialty derived from the main general surgery core. At the turn of the nineteenth and twentieth centuries, Romanian doctors were eager to improve and to further develop the medical practice in their home country and, thus, the development of the orthopaedics and traumatology also benefited from this enthusiasm. METHOD: A review of the literature was performed and both the online and offline libraries were searched for specific terms. The resulted data was structured and edited into separate subchapters for each doctor. RESULTS: Summarized biographic information are presented, covering the most distinguished figures that have helped develop orthopedic surgical branch in Romania. Great doctors such as Carol Davila (1828-1884), Constantin Dumitrescu Severeanu (1840-1930), Ernest Juvara (1870-1933), Ioan (Ion) Ghiulamila (1872-1936), Ion (Iancu) Jianu (1880-1972), and Alexandru D. Radulescu (1886-1979) are some of the most renowned for laying the foundation and for developing modern orthopaedics and traumatology in Romania. DISCUSSION: Although up until the late 1860s all doctors practicing in Romania graduated from widely recognized European medical schools, after this period, great surgeons graduated from its own Romanian National Medical School. This led to a blooming development in the surgical and medical field as physicians were competing with each other to bring the best treatments and techniques in medical practice. CONCLUSION: Although orthopaedic practice in the early nineteenth century was poorly represented, after sustained reforms and great visionary surgeons, it had rapidly developed into a separate and well-defined surgical specialty by the early twentieth century.

Case series of patients with pathological dyaphiseal fractures from metastatic bone disease.

INTRODUCTION: Fractures on pathologic bone have major impact on life quality. The appropriate treatment is not standardized, but the current literature delineates that surgery must provide adequate stabilization for the life expectancy. We aimed to review the epidemiology, treatment outcomes and survival in our department. MATERIAL AND METHODS: The electronic database from a major referral centre was searched for patients treated for tumours and fractures by the corresponding ICM-10 codes over five years. Eighty-nine patients were identified. Eleven females and nine males, with an average age of 64 years underwent 23 operations during the selected timeframe. Six fractures were subtrochanteric, five at the femoral neck and five at the femoral diaphysis. Seventeen cases were metastatic carcinomas, out of which five mammary, three pulmonary and seven carcinomas of undetermined origin without immunohistochemistry. RESULTS: Fourteen types of surgical intervention were osteosynthesis with intramedullary nails and six were partial hip replacements of which one had proximal femur resection and revision stem hemiarthroplasty. Four patients had single metastatic lesions which underwent resection and defect filling using PMMA cement (polymethylmethacrylate). The follow-up period ranged between two and seven years or until death. Only five patients (25%) were alive at the last follow-up. Local recurrence appeared in one patient. There was one immediate post-operative complication (dehiscent wound) and one implant failure after five years and was replaced with a larger diameter (exchange nailing). CONCLUSION: Both hip arthroplasty and femoral nailing are safe and routine procedures that are performed with relatively technical ease and low surgical stress and few peri-operative complications for the patient. They allow for immediate mobilization and weight-bearing with moderate and rapidly decreasing pain and discomfort.

The variability of vertebral body volume and pain associated with osteoporotic vertebral fractures: conservative treatment versus percutaneous transpedicular vertebroplasty.

INTRODUCTION: Osteoporotic vertebral fractures (OVF) can lead to late collapse which often causes kyphotic spinal deformity, persistent back pain, decreased lung capacity, increased fracture risk and increased mortality. The purpose of our study is to compare the efficacy and safety of vertebroplasty against conservative management of osteoporotic vertebral fractures without neurologic symptoms. MATERIAL AND METHODS: A total of 66 patients with recent OVF on MRI examination were included in the study. All patients were admitted from September 2009 to September 2012. The cohort was divided into two groups. The first study group consisted of 33 prospectively followed consecutive patients who suffered 40 vertebral osteoporotic fractures treated by percutaneous vertebroplasty (group 1), and the control group consisted of 33 patients who suffered 41 vertebral osteoporotic fractures treated conservatively because they refused vertebroplasty (group 2). The data collection has been conducted in a prospective registration manner. The inclusion criteria consisted of painful OVF matched with imagistic findings. We assessed the results of pain relief and minimal sagittal area of the vertebral body on the axial CT scan at presentation, after the intervention, at six and 12 months after initial presentation. RESULTS: Vertebroplasty with poly(methyl methacrylate) (PMMA) was performed in 30 patients on 39 VBs, including four thoracic vertebras, 27 vertebras of the thoracolumbar jonction and eight lumbar vertebras. Group 2 included 30 patients with 39 OVFs (four thoracic vertebras, 23 vertebras of the thoracolumbar junction and 11 lumbar vertebras). There was no significant difference in VAS scores before treatment (p = 0.229). The mean VAS was 5.90 in Group 1 and 6.28 in Group 2 before the treatment. Mean VAS after vertebroplasty was 0.85 in Group 1. The mean VAS at six months was 0.92 in Group 1 and 3.00 in Group 2 (p < 0.05). The mean VAS at 12 months was 0.92 in Group 1 and 2.36 in Group 2. The mean improvement rate in VAS scores was 84.40% and 62.42%, respectively (p < 0.05). For Group 1, mean area of the VBs measured on sagital CT images was 8.288 at the initial presentation, 8.554 postoperatively, 8.541 at five months and 8.508 at 12 months, respectively, and 8.388 at the initial presentation, 7.976 at six months and 7.585 at 12 months for Group 2 (Fig. 4). DISCUSSIONS: Although conservative treatment is fundamental and achieves good symptom control, in patients who suffer osteoporotic compression fractures (OCF), the incidence of late collapse is high and the prognosis is poor. In order to relieve the pain and avoid VB collapse, vertebroplasty is the recommended treatment in OCFs. Considering the above findings, the dilemma is whether vertebroplasty can change the natural history (pain and deformity) of OCFs. CONCLUSION: In our study on OVF, vertebroplasty delivered superior clinical and radiological outcomes over the first year from intervention when compared to conservative treatment of patients with osteoporotic compression fractures without neurological deficit. We believe that the possibility of evolution towards progressive kyphosis is sufficient to justify prophylactic and therapeutic intervention such as vertebroplasty, a minor gesture compared with extensive correction surgery and stabilization.

Sagittal balance parameters correlate with spinal conformational type and MRI changes in lumbar degenerative disc disease: results of a retrospective study.

PURPOSE: Spinopelvic parameters can be useful in identifying risk factors for lumbar degenerative disc disease, but few studies assess patients with single-level disc herniation and most do not evaluate symptoms. This comparative retrospective study was aimed to analyse spinopelvic parameters, symptoms and MRI changes in patients with single-level lumbar disc herniation undergoing conservative or surgical treatment. METHODS: Patients with clinical and radiological assessment (Japanese Orthopaedic Association Score) and an MRI evaluation of the lumbar spine were identified and divided into two groups: surgically treated (group A) and not requiring surgery (group B). Spinopelvic parameters were determined on standing profile radiographs of the lumbar spine and pelvis, and mean values were compared to those reported in the literature for normal subjects. MRI findings were graded according to the system described by Pfirrmann et al. RESULTS: The study included 71 patients with single-level lumbar disc herniation: 26 in group A (39.4 ± 12.1 years) and 45 in group B (51.4 ± 17.2 years). The notable differences in spinopelvic parameter means between the two groups did not reach statistical significance. A positive correlations of age with pelvic tilt and Pfirrmann changes with pelvic incidence was only found in group A, while both groups showed highly significant positive correlations of pelvic incidence with the spine's conformational type (p = 0.001). CONCLUSIONS: Characteristic changes in spinopelvic parameters identified in patients with lumbar degenerative disc disease were a reduction in pelvic incidence, sacral slope and lumbar lordosis, with an increased pelvic tilt. These were found to correlate with MRI changes in surgically treated patients.

Utility of the pedicle subtraction osteotomy for the correction of sagittal spine imbalance.

INTRODUCTION: Pedicle substraction osteotomy (PSO) in the lumbar spine is indicated in the treatment of large sagittal deformities of the lumbar spine. Substantial complications associated with PSOs include pseudarthrosis and mechanical failure. The purpose of the present study was to assess the complications of this procedure and the causes of mechanical complications. MATERIAL AND METHODS: Fifteen patients aged between 38 and 79 years (mean age 63.8±12.82) were operated on between June 2011 and September 2014 for sagittal imbalance by means of one-level PSO. Pre-operative and post-operative values of radiological spino-pelvic sagittal parameters were measured. Clinical and radiological evaluations were conducted pre-operatively and post-operatively at six months and one year. Clinical evaluation included intra- and post-operative complications. RESULTS: Mean pelvic incidence was 54.86 ± 11.82°. Lumbar lordosis (LL) was measured to be 12.26 ± 18.48° pre-operatively and increased to 42.73 ± 14.05° post-operatively (p< 0.05). Mean gain of lordosis after PSO at index level was calculated to be 28 ± 11° (range, 14-41). SVA decreased post-operatively from 93.46 ± 36.69 mm to 61.73 ±38.68 mm (p< 0.05). Several complications (n = 8), including two minor (one dural tear with no clinical consequences and one transient radicular deficit) and six major with re-intervention, were observed in our series. DISCUSSIONS: Optimal post-operative correction in the sagittal plane: SVA <50 mm, LL= -(PI+10°) is an important parameter to reduce the risk of developing sagittal decompensation which is a common condition after PSO. Rate of complications after PSO is not negligible in the literature up to 45%. CONCLUSIONS: The main cause of mechanical complications was insufficient sagittal correction. To limit the risk of mechanical complications and to achieve a good sagittal balance, PSO must be associated with additional SPOs or a second corrective surgery to obtain a solid anterior fusion.

Microscopic assessment of degenerated intervertebral disc: clinical implications and possible therapeutic challenge.

AIM: To investigate a possible correlation between the histological and morphometric properties of herniated intervertebral disc, clinical and magnetic resonance imaging (MRI) characteristics of patients with lumbar disc degeneration (LDD). MATERIALS AND METHODS: Thirty six patients with LDD were clinically evaluated using Japanese Orthopaedic Association Score (JOAS), visual analogue scale (VAS) for pain in the lower back or in the pelvic limb; MRI-based classification according to Pfirrmann and Modic criteria. All patients underwent decompressive surgery and herniated intervertebral disc samples were histologically and morphometrically analyzed. Data obtained were statistically analyzed for bivariate and partial correlations. RESULTS: The mean area size of chondron clusters correlated with age, JOAS (r=-0.385, p=0.032, tau=-0.279, rho=-0.380), Pfirrmann (r=0.505, p=0.002, tau=0.289, rho=0.365) and Modic (r=0.500, p=0.002, tau=0.331, rho=0.419) grading. There was a strong correlation between maximum area size of chondrons and JOAS (r=-0.427, p=0.009, tau=-0.299, rho=-0.430), Pfirrmann changes (r=0.432, p=0.008, tau=0.309, rho=0.388) and Modic endplate changes (r=0.444, p=0.007, tau=0.343, rho=0.434). JOAS correlated with both MRI classifications used for LDD. CONCLUSION: The intervertebral disc cells tend to aggregate in clusters and the size of the chondrons from LDD correlated with JOAS, Pfirrmann and Modic. JOAS correlates with the imagistic evaluation systems Pfirrmann and Modic.

Intraoperative conjoined lumbosacral nerve roots associated with spondylolisthesis.

Lumbosacral nerve roots anomalies may produce low back pain. These anomalies are reported to be a cause for failed back surgery. They are usually left undiagnosed, especially in endoscopic discectomy techniques. Any surgery for entrapment disorders, performed on a patient with undiagnosed lumbosacral nerve roots anomaly, may lead to serious neural injuries because of an improper surgical technique or decompression. In this report, we describe our experience with a case of L5-S1 spondylolisthesis and associated congenital lumbosacral nerve root anomalies discovered during the surgical intervention, and the difficulties raised by such a discovery. Careful examination of coronal and axial views obtained through high-quality Magnetic Resonance Imaging may lead to a proper diagnosis of this condition leading to an adequate surgical planning, minimizing the intraoperatory complications.

The neurological characteristic of patients with fractures of thoracolumbar junction presenting in Timisoara County Clinical Emergency Hospital's Emergency Unit.

OBJECTIVE: The current study aims to find the neurological characteristic of thoracolumbar junction fractures as well as the impact of a proper initial neurological assessment onto the treatment management of patients admitted into Timisoara County Clinical Emergency Hospital's Emergency Unit. MATERIALS AND METHODS: This is a retrospective study based on patients with thoracolumbar fractures between 2004 and 2009. Age, sex, cause and level of injury, fracture pattern and distribution, and neurological presentation of patients were studied. RESULTS: There were 605 patients with predominance of men (59.17 %); the mean age was 32.4 years old. The main cause of the fractures was represented by car accidents (56.2 %), and associated trauma was found in 38.51 % of the patients. The majority of the patients presented with incomplete neurological deficit (45.62 %), whilst 20.66 % suffered from complete neurological deficit. CONCLUSION: We found a correlation between the fracture level and the neurological deficit, the grade of neurological motor deficit and anal sphincter disorder and stenosis grade in relation to neurological lesions.