The importance of inflammatory biomarkers in non-specific acute and chronic low back pain: a systematic review.

OBJECTIVE: The purpose of this study was to systematically review the evidence on inflammatory biomarkers as analytic predictors of non-specific low back pain (NsLBP). Low back pain (LBP) is the number one cause of disability globally, posing a major health problem that causes an enormous social and economic burden, and there is an increasing interest on the importance of biomarkers in quantifying and even emerge as potential therapeutic tools to LBP. METHODS: A systematic search was conducted on July 2022 in Cochrane Library, MEDLINE and Web of Science for all the available literature. Cross-sectional, longitudinal cohort or case-control studies that evaluated the relationship between inflammatory biomarkers collected from blood samples and low back pain in humans were considered eligible for inclusion, as well as prospective and retrospective studies. RESULTS: The systematic database search resulted in a total of 4016 records, of which 15 articles were included for synthesis. Sample size comprised a total of 14,555 patients with LBP (acute LBP (n = 2073); chronic LBP (n = 12482)) and 494 controls. Most studies found a positive correlation between classic pro-inflammatory biomarkers and NsLBP, namely C-reactive protein (CRP), interleukin 1 (IL-1) and IL-1ß, interleukin 6 (IL-6) and tumour necrosis factor α (TNF-α). On the other hand, anti-inflammatory biomarker interleukin 10 (IL-10) demonstrated a negative association with NsLBP. Four studies have made direct comparisons between ALBP and CLBP groups regarding their inflammatory biomarkers profile. CONCLUSIONS: This systematic review found evidence of increased levels of pro-inflammatory biomarkers CRP, IL-6 and TNF-α and decreased levels of anti-inflammatory biomarker IL-10 in patients with LBP. Hs-CRP was not correlated with LBP. There is insufficient evidence to associate these findings with the degree of pain severity or the activity status of the lumbar pain over time.

Multiple contiguous spinous process fractures, a case report and literature review.

Contiguous spinous process fractures are an extremely rare event with only a few cases described in the literature. They are usually stable lesions treated with analgesic medication, immobilization, physical activity restriction for 4 to 6 weeks and close surveillance. These fractures appear to have a significant risk of nonunion, despite the good reported results. We report a case of a 61 years-old male patient who suffered eight contiguous spinous process fractures following a tractor accident.

Efficacy of Hounsfield Units Measured by Lumbar Computer Tomography on Bone Density Assessment: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: This work aimed to compare the Hounsfield units (HU) value obtained from computed tomography and the t score of dual-energy x-ray absorptiometry (DXA) in the prediction of the lumbar spine bone mineral density (BMD). SUMMARY OF BACKGROUND DATA: Several reports have found a correlation between HU and BMD values based on DXA. Using HUs to infer bone quality has a thorough clinical relevance as it could triage patients at risk for osteoporotic and fragility fractures or modify surgical indications. METHODS: A systematic review in Cochrane Library, Medline, Scopus and Web of Science was performed, using the following query: "hounsfield units" AND ("osteoporosis" OR "spine" OR "bone mineral density" OR "dual x-ray absorptiometry"). We included 18 cohort studies that compared HU value obtained from computed tomography and t score of DXA for predicting regional BMD. RESULTS: A total of 18 studies were included, enrolling 5307 patients. The HU measurement was most frequently made at L1 (N = 3; 18.8%). The mean HU values differentiated based on BMD measured through DXA were reported in seven studies, with values from 54.7 to 130 for osteoporotic, 78.8 to 146 for osteopenic, and from 120.8 to 230 in normal patients. Eight studies identified thresholds for diagnosing osteoporosis through receiver-operating characteristic (ROC) curves, with values ranging from 0.66 to 0.96. Medium HU values reported as diagnostic of osteoporosis ranged between 110 and 150, after exclusion of the two papers presenting outlier values. We infer an HU interval value of 90.9 to 138.7 (95% CI, P  < 0.001) for the diagnosis osteoporosis. CONCLUSIONS: Present data evidence favorable results regarding the possibility of establishing a threshold value for osteoporosis diagnosis from CT measurements of HU. Prospective large-scale studies are needed to more robustly infer the possibility of quantifying BMD based on CT as a screening test and infer a prognostic value of the CT-based evaluation.Level of Evidence: 2.

Surgical risk factors associated with the development of adjacent segment pathology in the lumbar spine.

Adjacent segment pathology (ASP) is a major cause of disability, and the recognition of the surgical risk factors associated with the development of this condition is essential for its prevention.Different surgical approaches, from decompression without fusion to non-instrumented and instrumented fusion, have distinct contributions to the development of ASP.Although motion-preservation procedures could reduce the prevalence of ASP, these are also associated with a higher percentage of complications.Several risk factors associated with previous surgery, namely the chosen surgical approach and anatomical dissection, the choice of interbody fusion, the increment and length of the fusion, and the restoration of sagittal alignment, may influence the development of ASP. Cite this article: EFORT Open Rev 2021;6:966-972. DOI: 10.1302/2058-5241.6.210050.

Patient-Related Risk Factors for the Development of Lumbar Spine Adjacent Segment Pathology.

OBJECTIVES: Individual risk factors for the development of adjacent segment pathology (ASP) need to be investigated and identified to address possible modifiable factors in advance and improve outcomes and reduce medical costs. This study aimed to review the literature regarding patient-related risk factors and sagittal alignment parameters associated with ASP development. METHODS: The authors performed an extensive review of the literature addressing the objectives mentioned earlier. RESULTS: Certain patient factors such as age, gender, obesity, preexisting degeneration, osteoporosis, postmenopausal state, rheumatoid arthritis, and facet tropism may contribute to adjacent segment degeneration. Genetic influences, such as polymorphisms of the vitamin D receptor and collagen IX genes, can also be a potential cause for disc degeneration with consequent deterioration of the motion segment.The influence of sagittal imbalances, particularly after lumbar fusion, is a significant parameter to be taken into account as an independent risk factor for ASP development. CONCLUSIONS: Patient-specific risk factors, such as age, gender, obesity, preexisting degeneration, and genetic features increase the likelihood of developing ASP. On the other hand, sagittal alignment plays a significant role in the development of this condition.

Degenerative cervical myelopathy: a review of current concepts / Mielopatia cervical degenerativa: revisão dos conceitos atuais / Mielopatía cervical degenerativa: revisión de los conceptos actuales

ABSTRACT Herbert von Luschka, a German anatomist, was the first to describe the developmental changes in the anatomical structures of the cervical spine. Degenerative cervical myelopathy (DCM) represents a collection of pathological entities that cause compression of the cervical spinal cord, resulting in a clinical syndrome typified by spasticity, hyperreflexia, pathologic reflexes, finger/hand clumsiness, gait disturbance and sphincter dysfunction. In the cervical spine, certain patients are more likely to have myelopathy due to a congenitally narrowed cervical spine canal. Degenerative changes are more common at C5 and C6 or C6 and C7 due to the increased motion at these levels. Additional contributors to canal narrowing are infolding of the ligamentum flavum, olisthesis, osteophytes, and facet hypertrophy. Myelopathy will develop in approximately 100% of patients with canal stenosis greater than 60% (less than 6 mm sagittal disc cord space). Classically it has an insidious onset, progressing in a stepwise manner with functional decline. Without treatment, patients may progress toward significant paralysis and loss of function. Treatment requires surgery with either anterior or posterior decompression of the area of narrowing, and probable fusion. Factors of a poor prognosis include symptoms lasting for more than 18 months, increased range of motion in the cervical spine, and female gender. In this study, we give an overview of the state-of-the-art in DCM, with a focus on the pathophysiology, clinical presentation, differential diagnosis, imaging evaluation, natural history, treatment options and complications. Level of evidence III; Review article.

RESUMO Herbert von Luschka, anatomista alemão, foi o primeiro a descrever as mudanças no desenvolvimento das estruturas anatômicas da coluna cervical. A mielopatia cervical degenerativa (MCD) representa um conjunto de entidades patológicas que causam compressão da medula espinhal cervical, resultando em uma síndrome clínica caracterizada por espasticidade, hiperreflexia, reflexos patológicos, perda de destreza manual, distúrbios de marcha e disfunção de esfíncteres. Certos pacientes têm maior probabilidade de desenvolver mielopatia na coluna cervical em decorrência de estenose congênita do canal cervical. As alterações degenerativas são mais comuns em C5 e C6 ou C6 e C7 devido ao aumento da mobilidade nesses níveis. Outros fatores que contribuem para a estenose do canal medular são hipertrofia do ligamento amarelo, listese, osteofitose e hipertrofia de facetas. A mielopatia cervical ocorre em aproximadamente 100% dos pacientes com estenose do canal superior a 60%, isto é, espaço da medula discal sagital menor que 6 mm. Em geral, tem início insidioso, progredindo gradualmente com declínio funcional. Sem tratamento, os pacientes podem progredir para paralisia significativa e perda de função. O tratamento requer cirurgia de descompressão anterior ou posterior da área estenosada e provável fusão. Os fatores de mau prognóstico prevalecem no sexo feminino e incluem sintomatologia com duração superior a 18 meses e aumento da amplitude de movimento da coluna cervical. Neste estudo, apresentamos uma visão geral do estado da arte em MCD, com ênfase de fisiopatologia, apresentação clínica, diagnóstico diferencial, avaliação por imagem, história natural, opções de tratamento e complicações. Nível de evidência III; Artigo de revisão.

RESUMEN Herbert von Luschka, anatomista alemán, fue el primero en describir los cambios en el desarrollo de las estructuras anatómicas de la columna cervical. La mielopatía cervical degenerativa (MCD) representa un conjunto de entidades patológicas que causan compresión de la médula espinal cervical, resultando en un síndrome clínico caracterizado por espasticidad, hiperreflexia, reflejos patológicos, pérdida de destreza manual, disturbios de marcha y disfunción de esfínteres. Ciertos pacientes tienen mayor probabilidad de desarrollar mielopatía en la columna cervical como consecuencia de estenosis congénita del canal cervical. Las alteraciones degenerativas son más comunes en C5 y C6 o C6 y C7, debido al aumento de la movilidad en esos niveles. Otros factores que contribuyen para la estenosis del canal medular son la hipertrofia del ligamento amarillo, listesis, osteofitosis e hipertrofia de facetas. La mielopatía cervical ocurre en aproximadamente 100% de los pacientes con estenosis del canal superior a 60%, esto es, espacio de la médula discal sagital menor que 6mm). En general, tiene inicio insidioso, progresando gradualmente con disminución funcional. Sin tratamiento, los pacientes pueden progresar para parálisis significativa y pérdida de función. El tratamiento requiere cirugía de descompresión anterior o posterior del área estenosada y probable fusión. Los factores de mal pronóstico prevalecen en el sexo femenino e incluyen sintomatología con duración superior a 18 meses y aumento de la amplitud de movimiento de la columna cervical. En este estudio, presentamos una visión general del estado del arte en MCD, con énfasis de fisiopatología, presentación clínica, diagnóstico diferencial, evaluación por imagen, historia natural, opciones de tratamiento y complicaciones. Nivel de evidencia III; Artículo de revisión.

Leg length discrepancy in adolescent idiopathic scoliosis / Dismetria dos membros inferiores na escoliose idiopática do adolescente / Discrepancia de la longitud de las piernas en la escoliosis idiopática del adolescente

ABSTRACT Objective The objective of this study is to evaluate leg length discrepancy in adolescent idiopathic scoliosis. Methods A retrospective study of 80 subjects with adolescent idiopathic scoliosis (AIS) was conducted. The inclusion criteria were patients aged 10 to 18 years old with posteroanterior (PA) and lateral full-length radiographs. The exclusion criteria were patients subjected to surgery or orthotic treatment, those with other spinal disease, and those with poor quality x-rays. The parameters evaluated were: age, sex, Risser stage (RS), triradiate cartilage (TC), scoliotic curvatures, differentiated according to Lenke classification, sagittal (SB) and coronal balance (CB), and leg length discrepancy, which was assessed through the difference between the femoral heads (LLD) and through the assessment of pelvic obliquity (PO). Results The majority of patients with AIS demonstrated a mild LLD (<1 cm). The mean LLD was significantly different (p<0.01) between the scoliotic population with a main thoracolumbar curvature and those with a main lumbar curvature. When there was an LLD, it was the left limb that was shortened in most cases. The side of the longer lower limb had a direct influence on the CB (p=0.052). Conclusions This study demonstrates that in an AIS population with small LLD values, the extent of the shortening has a stronger impact on coronal balance and location than on the dimension of the main scoliotic curvature. These results demonstrate the importance of a more in-depth study on the effects of LLD <1 cm in the development of AIS and coronal imbalance. Level of evidence IV; Case Series.

RESUMO Objetivo O objetivo deste estudo é avaliar a discrepância no comprimento dos membros inferiores numa população com escoliose idiopática do adolescente. Métodos Foi realizado um estudo retrospetivo de 80 indivíduos com escoliose idiopática do adolescente (AIS). Os critérios de inclusão foram pacientes de 10 a 18 anos com radiografias coronais e sagitais extralongas, excluindo-se aqueles submetidos à cirurgia ou tratamento com coletes Milwaukee ou Boston, com outras doenças da coluna vertebral ou com exames que não cumpriam a qualidade radiográfica protocolada pelo Centro Hospitalar. Os parâmetros avaliados foram: idade, sexo, estadio de Risser (RS), cartilagem trirradiada (TC), curvaturas escolióticas diferenciadas segundo a classificação de Lenke, balanço sagital (SB), coronal (CB) e discrepância no comprimento dos membros inferiores, avaliado pelo desnível entre as cabeças femorais (LLD) e através da avaliação da obliquidade pélvica (PO). Resultados A maioria dos pacientes com AIS demonstrou LLD ligeira (<1 cm). A média de discrepância no comprimento dos membros inferiores foi significativamente diferente (p<0,01) entre a população escoliótica com uma curvatura toracolombar principal em relação àquela com uma curvatura lombar principal. Quando existe LLD, o membro esquerdo encontra-se encurtado na maioria dos casos e a discrepância dos membros inferiores influencia diretamente no balanço coronal (p=0,052). Conclusão A partir deste estudo, verificamos que, na população com AIS com pequenos valores de LLD, a magnitude do encurtamento tem um impacto de maior relevo no equilíbrio coronal e na localização do que na dimensão da curvatura escoliótica principal. Estes resultados levantam a importância de um estudo mais aprofundado sobre a importância da LLD <1 cm no desenvolvimento de AIS e no desequilíbrio coronal. Nível de evidência IV; Série de Casos.

RESUMEN Objetivos El objetivo de este estudio es evaluar la diferencia de la longitud de los miembros inferiores en la escoliosis idiopática del adolescente. Métodos Se realizó un estudio retrospectivo de 80 pacientes con escoliosis idiopática de adolescente (EIA). Los criterios de inclusión fueron los pacientes de 10 a 18 años con radiografías posteroanteriores (PA) y laterales de longitud completa. Los criterios de exclusión fueron los pacientes sometidos a cirugía o tratamiento ortopédico, aquellos con otra enfermedad de la columna y aquellos con radiografías de mala calidad. Los parámetros evaluados fueron: edad, sexo, estadio Risser (RS), cartílago trirradiado (CT), curvaturas escolióticas, diferenciadas según la clasificación de Lenke, balance sagital (BS) y coronal (BC) y discrepancia en la longitud de la pierna (DLP), que se evaluó a través de la diferencia entre las cabezas femorales y mediante la evaluación de la oblicuidad pélvica (OP). Resultados La mayoría de los pacientes con EIA demostró DLP leve (< 1 cm). La media de la DLP fue significativamente distinta (p < 0,01) entre la población escoliótica con una curvatura toracolumbar principal y los pacientes con curvatura lumbar principal. Cuando había DLP, la extremidad izquierda se acortaba en la mayoría de los casos. El lado de la extremidad más larga tuvo influencia directa en el BC (p = 0,052). Conclusiones Este estudio demuestra que en una población con EIA y bajos valores de DLP, la extensión del acortamiento tiene impacto mayor en el balance y la ubicación coronal que en la dimensión de la curvatura escoliótica principal. Estos resultados muestran la importancia de un estudio más profundo sobre los efectos de DLP < 1 cm en el desarrollo de EIA y el desequilibrio coronal. Nivel de evidencia - IV; Serie de Casos.

Sagittal balance in adolescent idiopathic scoliosis / Balanço sagital na escoliose idiopática do adolescente / Balance sagital en la escoliosis idiopática adolescente

ABSTRACT Objective The objective of this study is to achieve a better understanding of the parameters that influence sagittal balance in a population with adolescent idiopathic scoliosis (AIS). Methods A retrospective study of 80 patients with adolescent idiopathic scoliosis (AIS) was conducted. The parameters evaluated were: age, sex, pelvic incidence (PI), sacral slop (SS), pelvic tilt (PT), sagittal balance (SB), coronal balance (CB), lumbar lordosis (LL), thoracic kyphosis (TK) divided into upper (between T1 and T5) and lower (between T5 and T12), cervical spine alignment (CSA), and Cobb's coronal angle (CCA) of primary scoliotic curvature. Results Regarding the sagittal balance, this study demonstrated a significant statistical positive correlation with cervical shape (p<0.01) and upper thoracic kyphosis (from T1 to T5) (p<0.05), but not with the other variables. LL had a strong influence on lower thoracic curvature (from T5 to T12) and was strongly influenced by the PI and SS. Conclusions Sagittal balance is a parameter that is influenced by multiple factors. In fact, it is closely related to cervical shape and the upper thoracic curvature (from T1 to T5), which in turn, is closely linked to the severity of the scoliotic kyphosis. The Cobb angle of the lower thoracic spine (from T5 to T12) is more closely correlated with the angle of lumbar lordosis than with the upper thoracic kyphosis (from T1 to T5). Level of evidence IV; Case Series.

RESUMO Objetivo O objetivo deste estudo é obter uma melhor compreensão dos parâmetros que influenciam o equilíbrio sagital em uma população com escoliose idiopática do adolescente (AIS). Métodos Foi realizado um estudo retrospectivo de 80 pacientes com escoliose idiopática do adolescente (AIS). Os parâmetros avaliados foram: idade, sexo, incidência pélvica (PI), sacral slope (SS), pelvic tilt (PT), equilíbrio sagital (SB), balanço coronal (CB), lordose lombar (LL), cifose torácica (TK) dividida em alta (entre T1 e T5) e baixa (entre T5 e T12), alinhamento da coluna cervical (CSA) e ângulo de Cobb coronal de curvatura escoliótica principal (CCA). Resultados Em relação ao equilíbrio sagital, demonstrou-se uma correlação positiva significativamente estatística com o formato da coluna cervical (p <0,01) e com o ângulo de cifose da porção superior da coluna torácica (de T1 para T5) (p <0,05), mas não com as demais variáveis. A LL exerce uma forte influência sobre a porção inferior da curvatura torácica (de T5 a T12) e é fortemente influenciada pela PI e SS. Conclusões O equilíbrio sagital é um parâmetro influenciado por múltiplos fatores. De fato, está extremamente relacionado com o formato da coluna cervical e com a coluna torácica superior (de T1 a T5) que, por sua vez, apresenta uma simbiose com a gravidade da curvatura escoliótica. O ângulo de Cobb da porção inferior da coluna torácica (de T5 a T12) apresenta uma relação maior com o ângulo da lordose lombar do que com a curvatura torácica superior (de T1 a T5). Nível de evidência IV; Série de Casos.

RESUMEN Objetivo El objetivo de este estudio es lograr una mejor comprensión de los parámetros que influyen en el equilibrio sagital en una población con escoliosis idiopática del adolescente (EIA). Métodos Se realizó un estudio retrospectivo de 80 pacientes con escoliosis idiopática del adolescente (EIA). Los parámetros evaluados fueron: edad, sexo, incidencia pélvica (IP), inclinación sacra (IS), inclinación pélvica (InP), balance sagital (BS), balance coronal (BC), lordosis lumbar (LL), cifosis torácica (CT) divididos en alta (entre T1 y T5) y baja (entre T5 y T12), alineación de la columna cervical (AC) y ángulo coronal de Cobb (ACC) de curvatura escoliótica primaria. Resultados Con respecto al balance sagital, este estudio demostró una correlación positiva estadísticamente significativa con la forma cervical (p < 0,01) y cifosis de la porción superior de la columna (de T1 a T5) (p < 0,05), pero no con las otras variables. LL tuvo una fuerte influencia en la parte inferior de la curvatura torácica (de T5 a T12) y fue fuertemente influenciada por la IP y la IS. Conclusiones El balance sagital es un parámetro influenciado por múltiples factores. De hecho, está estrechamente relacionado con la forma cervical y la curvatura torácica superior (de T1 a T5), que a su vez, está estrechamente relacionada con la gravedad de la cifosis escoliótica. El ángulo de Cobb de la porción inferior de la columna torácica (de T5 a T12) presenta mayor relación con el ángulo de lordosis lumbar que con la cifosis torácica superior (de T1 a T5). Nivel de evidencia IV; Serie de Casos.