Converting to reverse shoulder arthroplasty from primary anatomic shoulder arthroplasty and fracture hemiarthroplasty: a radiographic and clinical outcome analysis at 8-years.

INTRODUCTION: Revision shoulder arthroplasty can be challenging. One of the main considerations for surgeons is the type of implant that was placed in the initial surgery. Anatomic shoulder arthroplasty (ASA) is used for cases of osteoarthritis as well as for fractures of the humeral head. Hemiarthroplasty can be used for complex proximal humerus fractures. The purpose of this study is to determine whether there is a difference in clinical and radiographic outcomes between patients that failed primary fracture hemiarthroplasty (FHA), or ASA for osteoarthritis and then required reoperation with a conversion to reverse shoulder arthroplasty (RSA). METHODS: Patients with failed anatomic shoulder replacement, who had undergone conversion to RSA, were enrolled after a mean follow-up of 107 (85-157) months. Two different groups, one with failed ASA implanted for osteoarthritis and one with failed FHA, were created. At follow-up patients were assessed with standard radiographs and clinical outcome scores. RESULTS: Twenty-nine patients (f = 17, m = 12; 51%) suffered from a failed ASA (Group A), while the remaining 28 patients (f = 21, m = 74; 49%) had been revised due to a failed FHA (Group B). Patients of Group B had a poorer Constant score (Group A: 60 vs. Group B: 46; p = 0.02). Abduction (Group A: 115° vs. Group B: 89°; p = 0.02) was worse after conversion of a failed FHA to RSA in comparison to conversions of failed ASA. The mean bone loss of the lateral metaphysis was higher in patients with failed FHA (Group A: 5 mm vs. Group B: 20 mm; p = 0.0). CONCLUSION: The initial indication for anatomic shoulder arthroplasty influences the clinical and radiological outcome after conversion to RSA. Conversion of failed FHA to RSA is related to an increased metaphyseal bone loss, decreased range of motion and poorer clinical outcomes when compared to conversions of failed ASA implanted for osteoarthritis. LEVEL OF EVIDENCE: III Retrospective Cohort Comparison Study.

Postoperative Epidural Fibrosis: Challenges and Opportunities - A Review.

Postoperative epidural fibrosis (EF) is still a major limitation to the success of spine surgery. Fibrotic adhesions in the epidural space, initiated via local trauma and inflammation, can induce difficult-to-treat pain and constitute the main cause of failed back surgery syndrome, which not uncommonly requires operative revision. Manifold agents and methods have been tested for EF relief in order to mitigate this longstanding health burden and its socioeconomic consequences. Although several promising strategies could be identified, few have thus far overcome the high translational hurdle, and there has been little change in standard clinical practice. Nonetheless, notable research progress in the field has put new exciting avenues on the horizon. In this review, we outline the etiology and pathogenesis of EF, portray its clinical and surgical presentation, and critically appraise current efforts and novel approaches toward enhanced prevention and treatment.

Evidence- and data-driven classification of low back pain via artificial intelligence: Protocol of the PREDICT-LBP study.

In patients presenting with low back pain (LBP), once specific causes are excluded (fracture, infection, inflammatory arthritis, cancer, cauda equina and radiculopathy) many clinicians pose a diagnosis of non-specific LBP. Accordingly, current management of non-specific LBP is generic. There is a need for a classification of non-specific LBP that is both data- and evidence-based assessing multi-dimensional pain-related factors in a large sample size. The "PRedictive Evidence Driven Intelligent Classification Tool for Low Back Pain" (PREDICT-LBP) project is a prospective cross-sectional study which will compare 300 women and men with non-specific LBP (aged 18-55 years) with 100 matched referents without a history of LBP. Participants will be recruited from the general public and local medical facilities. Data will be collected on spinal tissue (intervertebral disc composition and morphology, vertebral fat fraction and paraspinal muscle size and composition via magnetic resonance imaging [MRI]), central nervous system adaptation (pain thresholds, temporal summation of pain, brain resting state functional connectivity, structural connectivity and regional volumes via MRI), psychosocial factors (e.g. depression, anxiety) and other musculoskeletal pain symptoms. Dimensionality reduction, cluster validation and fuzzy c-means clustering methods, classification models, and relevant sensitivity analyses, will classify non-specific LBP patients into sub-groups. This project represents a first personalised diagnostic approach to non-specific LBP, with potential for widespread uptake in clinical practice. This project will provide evidence to support clinical trials assessing specific treatments approaches for potential subgroups of patients with non-specific LBP. The classification tool may lead to better patient outcomes and reduction in economic costs.

Diagnosis behind the mask: A rare case of infected Charcot's spine.

Charcot's spine is a very uncommon long-term complication of spinal cord injury. Infection of the spine is a common pathology, but infection of a Charcot's spine is rare and is challenging to diagnose, especially in differentiating between the Charcot defect and the osteomyelitis defect. Surgical reconstruction has to be extremely individualized. A 65-year-old man with a history of thoracic spinal cord injury with paraplegia 49 years ago was admitted to our hospital with high fever and aphasia. After a thorough diagnostic process, destructive Charcot's spine and secondary infection were diagnosed. This report additionally reviews the surgical management of secondary infected destructive lumbar Charcot's spine and follows the patient's recovery and postoperative quality of life.

Single-Portal Proximal Biceps Tenodesis Using an All-Suture Anchor.

The long head of the biceps is an important pain generator of the shoulder joint. Pathologies of the long head of the biceps involve superior labrum anterior to posterior lesions, pulley lesions, partial tears of the biceps tendon, biceps tendonitis, and medial biceps subluxation caused by full-thickness subscapularis tendon tears. Treatment of an inflamed or injured long head of the biceps by either tenotomy or tenodesis is often mandatory during shoulder arthroscopy to avoid persisting pain and possible revision procedures. In comparison with a tenotomy of the biceps tendon, a biceps tenodesis preserves the tension, anatomy, and cosmesis of the biceps muscle. The presented technique demonstrates a single portal technique for a proximal biceps tenodesis in the bicipital groove using an all-suture anchor.

Treatment of proximal humerus fractures using reverse shoulder arthroplasty: do the inclination of the humeral component and the lateral offset of the glenosphere influence the clinical outcome and tuberosity healing?

INTRODUCTION: The employment of reverse shoulder arthroplasty for dislocated proximal humerus fractures of elderly patients becomes increasingly relevant. The standard inclination angle of the humeral component was 155°. Lately, there is a trend towards smaller inclination angles of 145° or 135°. Additionally, there has been an increased focus on the lateralization of the glenosphere. This retrospective comparative study evaluates clinical and radiological results of patients treated for proximal humerus fractures by reverse shoulder arthroplasty with different inclination angles of the humeral component, which was either 135° or 155°. Additionally, a different lateral offset of the glenosphere, which was either 0 mm or 4 mm, was used. METHODS: For this retrospective comparative analysis, 58 out of 66 patients treated by reverse total shoulder arthroplasty for proximal humerus fractures were included. The minimum follow-up was 24 months. Thirty (m = 3, f = 27; mean age 78 years; mean FU 35 months, range 24-58 months) were treated with a standard 155° humeral component and a glenosphere without lateral offset (group A), while 28 patients (m = 2, f = 26; mean age 79 years; mean FU 30 months, range 24-46 months) were treated with a 135° humeral component and a glenosphere with a 4 mm lateral offset (group B). We determined range of motion, Constant score, and the American Shoulder and Elbow Surgeons Shoulder score as clinical outcomes and evaluated tuberosity healing as well as scapula notching. RESULTS: Neither forward flexion (A = 128°, B = 121°; p = 0.710) nor abduction (A = 111°, B = 106°; p = 0.327) revealed differences between the groups. The mean Constant Score rated 63 in group A, while it was 61 in group B (p = 0.350). There were no differences of the ASES Score between the groups (A = 74, B = 72; p = 0.270). There was an increased risk for scapula notching in group A (47%) in comparison to group B (4%, p = 0.001). Healing of the greater tuberosity was achieved in 57% of group A and in 75% of group B (p = 0.142). The healing rate of the lesser tuberosity measured 33% in group A and 71% in group B (p = 0.004). CONCLUSIONS: Both inclination angles of the humeral component are feasible options for the treatment of proximal humerus fractures in elderly patients. Neither the inclination angle nor the lateral offset of the glenosphere seem to have a relevant influence on the clinical outcome. The healing rate of the lesser tuberosity was higher in implants with a decreased neck-shaft angle. There is an increased risk for scapula notching, if a higher inclination angle of the humeral component is chosen. LEVEL OF EVIDENCE: III. Retrospective comparative study.

Treating cuff tear arthropathy by reverse total shoulder arthroplasty: do the inclination of the humeral component and the lateral offset of the glenosphere influence the clinical and the radiological outcome?

PURPOSE: Reverse total shoulder arthroplasty is widely used for the treatment of cuff tear arthropathy. Standard implants consist of a humeral component with an inclination angle of 155° and a glenosphere without lateral offset. Recently, lower inclination angles of the humeral component as well as lateralized glenospheres are implanted to provide better rotation of the arm and to decrease the rate of scapular notching. This study investigates the clinical and radiological results of a standard reverse total shoulder in comparison with an implant with an inclination angle of 135° in combination with a 4 mm lateralized glenosphere in context of cuff tear arthropathy. MATERIAL AND METHODS: For this retrospective comparative analysis 42 patients treated by reverse total shoulder arthroplasty for cuff tear arthropathy were included. Twenty-one patients (m = 11, f = 10; mean age 76 years; mean follow-up 42 months) were treated with a standard 155° humeral component and a standard glenosphere with caudal eccentricity (group A), while twenty-one patients (m = 5, f = 16; mean age 72 years; mean follow-up 34 months) were treated with a 135° humeral component and 4 mm lateral offset of the glenosphere (group B). At follow-up patients of both groups were assessed with plain X-rays (a.p. and axial view), Constant Score, adjusted Constant Score, the subjective shoulder value and the range of motion. RESULTS: The clinical results were similar in both groups concerning the Constant Score (group A = 56.3 vs. group B = 56.1; p = 0.733), the adjusted CS (group A = 70.4% vs. group B = 68.3%; p = 0.589) and the SSV (group A = 72.0% vs. group B = 75.2%; p = 0.947). The range of motion of the operated shoulders did not differ significantly between group A and group B: Abduction = 98° versus 97.9°, p = 0.655; external rotation with the arm at side = 17.9° versus 18.7°, p = 0.703; external rotation with the arm positioned in 90° of abduction = 22.3° versus 24.7°, p = 0.524; forward flexion = 116.1° versus 116.7°, p = 0.760. The rate of scapular notching was higher (p = 0.013) in group A (overall: 66%, grade 1: 29%, grade 2: 29%, grade 3: 10%, grade 4: 0%) in comparison to group B (overall: 33%, grade 1: 33%, grade 2: 0%, grade 3: 0%, grade 4: 0%). Radiolucency around the humeral component was detected in two patients of group B. Stress shielding at the proximal humerus was observed in six patients of Group A (29%; cortical thinning and osteopenia in zone M1 and L1) and two patients of group B (10%; cortical thinning and osteopenia in zone M1 and L1). Calcifications of the triceps origin were observed in both groups (group A = 48% vs. group B = 38%). CONCLUSION: Theoretically, a lower inclination angle of the humeral component and an increased lateral offset of the glenosphere lead to improved impingement-free range of motion and a decreased rate of scapular notching, when compared to a standard reverse total shoulder implant. This study compared two different designs of numerous options concerning the humeral component and the glenosphere. In comparison to a standard-fashioned implant with a humeral inclination of 155° and a standard glenosphere, implants with a humeral inclination angle of 135° and a 4 mm lateralized glenosphere lead to comparable clinical results and rotatory function, while the rate of scapular notching is decreased by almost 50%. While the different implant designs did not affect the clinical outcome, our results indicate that a combination of a lower inclination angle of the humeral component and lateralized glenosphere should be favored to reduce scapular notching. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effectiveness of Radial Extracorporeal Shockwave Therapy in Patients with Acute Low Back Pain-Randomized Controlled Trial.

The aim of this study was to investigate the effect of radial extracorporeal shockwave therapy (rESWT) primarily on acute lumbar back pain (aLBP), and secondarily on physical function and quality of life. This randomized, placebo-controlled, single-blinded trial with 12-week follow-up (FU) randomized 63 patients with aLBP 1:1 into two groups receiving either rESWT (intervention) or sham rESWT (placebo) with a manipulated shockwave head not delivering any shockwaves. Both, rESWT and sham procedure were carried out eight times for four weeks. Both groups received additional analgesics and physiotherapy twice a week. Primary patient-reported outcome measure (PROM) was the visual analogue scale for aLBP (VAS-LBP). Secondary PROMs included the Oswestry disability index (ODI), Roland and Morris Disability Questionnaire (RDQ), EuroQol EQ-5D-3L, and the Beck Depression Index (BDI-II). Primary endpoint was a between-arm comparison of mean changes in VAS-LBP from baseline to final FU. At randomization, there were no differences between the two groups in relation to age and PROMs. Both groups showed significant improvement in all PROMs at final FU. VAS-LBP declined by 60.7% (p < 0.001) in the intervention and by 86.4% (p < 0.001) in the sham group. The intervention group showed significantly less pain relief after 4 and 12 weeks. The EQ-5D submodality pain showed significantly inferior results for the intervention (1.5 (0.58)) compared to the sham group (1.1 (0.33)) (p < 0.014) after eight weeks. No significant intergroup differences were observed for RDQ, ODI or BDI-II. Additional rESWT alongside conventional guideline therapy in aLBP does not have any significant effects on pain intensity, physical function, or quality of life. To the best of our knowledge, this is the first study with a high level of evidence reporting the efficacy of rESWT in aLBP treatment and will be a future basis for decision-making.

Impact of COVID-19 on Continuing Medical Education-Results of an Online Survey Among Users of a Non-profit Multi-Specialty Live Online Education Platform.

Background: The Coronavirus Disease-2019 (COVID-19) pandemic accelerated digitalization in medical education. Continuing medical education (CME) as a substantial component of this system was relevantly affected. Here, we present the results of an online survey highlighting the impact on and the role of online CME. Methods: An online survey of 44 questions was completed by users of a German online CME platform receiving an invitation via newsletter. CME habits, requirements, personal perception, and impact of the pandemic were inquired. Standard statistical methods were applied. Results: A total of 2,961 responders took the survey with 2,949 completed surveys included in the final analysis. Most contributions originated from Germany, Austria, and Switzerland. Physicians accounted for 78.3% (57.5% hospital doctors) of responses followed by midwives (7.3%) and paramedics (5.7%). Participating physicians were mainly board-certified specialists (69%; 55.75% hospital specialists, 13.25% specialists in private practice). Frequent online lectures at regular intervals (77.8%) and combined face-to-face and online CME (55.9%) were favored. A duration of 1-2 h was found ideal (57.5%). Technical issues were less a major concern since the pandemic. Conclusion: A shift from face-to-face toward online CME events was expectedly detected since the outbreak. Online CME was accelerated and promoted by the pandemic. According to the perception of users, the CME system appears to have reacted adequately to meet their demand but does not replace human interaction.

Planning Results for High Tibial Osteotomies in Degenerative Varus Osteoarthritis Using Standing and Supine Whole Leg Radiographs.

OBJECTIVE: In this study, we hypothesized that standing and supine X-rays lead to different preoperative planning results. METHODS: The present study included 168 pictures from 81 patients who were treated surgically with high tibial osteotomy (HTO) for varus deformity between January 2017 and February 2018. Each patient underwent whole leg X-ray examinations in both standing and supine position. On both images, the following parameters were measured: degree of axis deviation (DAD), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), width of medial (MJS) and lateral joint space (LJS), and the correction angle (CA). The results were correlated with the patients' age and body mass index (BMI). To analyze intra-observer reliability, the same researcher, blinded to the previous measurements, remeasured all X-rays from 10 patients 8 weeks after the initial measurements were carried out. RESULTS: While mLDFA (P = 0.075), mMPTA (P = 0.435), and MJS (P = 0.119) did not show any differences between the two modalities, LJS (P = 0.016) and DAD (P < 0.001) differed significantly, leading to different correction angles (P < 0.001). The mean difference of the CA was 1.7° ± 2.2° (range, -2.6° to-15.4°). In 14 legs (17%), the standing X-ray led to a correction angle that was at least 3° larger than the calculation revealed in the supine X-ray; in 4 legs (5%), it was at least 5° larger. Increased BMI (r = 0.191, P = 0.088) and older age (r = 0.057 , P = 0.605) did not show relevant correlation with DAD differences. However, more severe varus malalignment in the supine radiograph did correlate moderately with differences of correction angles between supine and weight-bearing radiographs (r = 0.414, P < 0.001). The analysis of the intra-rater reliability revealed mediocre to excellent intercorrelation coefficients between the measurements of the observer. CONCLUSION: The use of supine and standing X-ray images leads to different planning results when performing high tibial osteotomies for varus gonarthrosis. To avoid potential overcorrection, surgeons might consider increased lateral joint spaces on standing radiographs in osteoarthritic knees with varus deviation.

Complications in TLIF spondylodesis-do they influence the outcome for patients? A prospective two-center study.

PURPOSE: Transforaminal lumbar interbody fusion (TLIF) is a widely accepted surgical procedure for degenerative disk disease. While numerous studies have analyzed complication rates and risk factors this study investigates the extent to which complications after TLIF spondylodesis alter the clinical outcome regarding pain and physical function. METHODS: A prospective clinical two-center study was conducted, including 157 patients undergoing TLIF spondylodesis with 12-month follow-up (FU). Our study classified complications into three subgroups: none (I), minor (IIa), and major complications (IIb). Complications were considered "major" if revision surgery was required or new permanent physical impairment ensued. Clinical outcome was assessed using visual analog scales for back (VAS-B) and leg pain (VAS-L), and Oswestry Disability Index (ODI). RESULTS: Thirty-nine of 157 patients (24.8%) had at least one complication during follow-up. At FU, significant improvement was seen for group I (n = 118) in VAS-B (-50%), VAS-L (-54%), and ODI (-48%) and for group IIa (n = 27) in VAS-B (-40%), VAS-L (-64%), and ODI (-47%). In group IIb (n = 12), VAS-B (-22%, P = 0.089) and ODI (-33%, P = 0.056) improved not significantly, while VAS-L dropped significantly less (-32%, P = 0.013) compared to both other groups. CONCLUSION: Our results suggest that major complications with need of revision surgery after TLIF spondylodesis lead to a significantly worse clinical outcome (VAS-B, VAS-L, and ODI) compared to no or minor complications. It is therefore vitally important to raise the surgeon´s awareness of consequences of major complications, and the topic should be given high priority in clinical work.

Magnetically Controlled Growing Rods in Treatment of Early-Onset Scoliosis: A Single Center Study With a Minimum of 2-Year-Follow up and Preliminary Results After Converting Surgery.

STUDY DESIGN: Case series. OBJECTIVE: To evaluate complications and radiographic parameters after magnetically controlled growing rod (MCGR) index surgery (IS), during lengthening and following converting surgery (CS) with a minimum of 2-year follow up (FU). SUMMARY OF BACKGROUND DATA: MCGR are maintaining skeletal growth in treatment of early onset scoliosis (EOS). There is no data regarding correction potential after CS available. METHODS: Twenty-four cases were included. Two patients with rib and pelvic hook fixation instead of pedicle screws and three patients with previous spinal surgery were excluded from radiographic analysis. RESULTS: Twenty-one patients received grade 3 or 4 in Classification of Early-Onset-Scoliosis (C-EOS) for main curve severity. The kyphotic modifiers (-) were given to seven and (+) to seven patients. Mean age at IS was 10.5 ±â€Š2.4 years with a mean FU time of 42.3 ±â€Š11.3 months. Deformity correction was only achieved during IS (46%) and CS (36%). During MCGR treatment a 5° loss of correction seen, while 25 mm of T1-S1 length was gained during the lengthening period. An overall average lengthening of 1.6 mm per lengthening procedure was achieved. Possibility to gain length during distractions decreases over time. No major failure of the distraction mechanism was observed, only 16 lengthening procedures failed within a total of 264 lengthening procedures. A total of 19 revision surgeries in 10 patients were observed. Four patients received more than one revision surgery. CONCLUSION: Applying MCGR results in a revision rate of 0.23 per patient and per one FU year, while making further lengthening procedures obsolete compared with conventional growing rod techniques. Correction of major curve is possible during IS und CS. The law of diminishing returns applies during the period of lengthening. LEVEL OF EVIDENCE: 4.

Reliability and validity of the Spinal Appearance Questionnaire (SAQ) and the Trunk Appearance Perception Scale (TAPS).

BACKGROUND: The Spinal Appearance Questionnaire (SAQ) and the Trunk Appearance Perception Scale (TAPS) are questionnaires that mostly rely on drawings to assess scoliosis patients' subjective viewpoints on their trunk deformity. Our aim was to perform an in-depth assessment of the psychometric quality of both measures, the SAQ (version 1.1) and TAPS, and compare them to provide practical recommendations. METHODS: Web-based survey study with 255 patients suffering from idiopathic scoliosis (age 30.0 ± 16.7 years, Cobb angle 43.5 ± 20.9°) and 189 matched healthy control individuals. Participants answered a broad set of validated questionnaires including SRS 22-r, PHQ-9, PANAS, FKS, WHO-5, BFI-S, and PTQ. We calculated reliability (Cronbach's α, test-retest correlations) as well as factorial, convergent, divergent, concurrent, and discriminant validity. RESULTS: Reliability was high (Cronbach's α ≥ .86; test-retest r ≥ .80), except for test-retest correlation of the SAQ Expectations scale (r = 0.67). Both the SAQ and TAPS measures showed clear factor solutions, indicating factorial validity. High correlations with theoretically related measures (e.g., SRS 22-r, overall stress, Cobb angle) indicated convergent validity. Moderate correlations occurred with concurrent criteria such as mood, depression, body dysmorphic disorder, and well-being. The matched-pair analysis revealed strong evidence for discriminant validity (Cohen's d > 2 for SAQ total score and TAPS). Subgroup analyses showed that patients with more severe Cobb angles (≥ 40°) and those ≥ 46 years of age had significantly worse SAQ and TAPS scores. CONCLUSION: We recommend using the TAPS for future clinical workups and research, as it is much shorter and revealed slightly higher psychometric quality in comparison to the SAQ.

Rasterstereography versus radiography for assessing shoulder balance in idiopathic scoliosis: A validation study relative to patients' self-image.

BACKGROUND: Shoulder imbalance is a problem for scoliosis patients. Rasterstereography uses radiation-free surface topography to follow up these patients. Its use for assessing shoulder level has not been investigated earlier. OBJECTIVE: This study aimed to determine the accuracy of shoulder assessment using rasterstereography (versus radiography) and to analyze its relationship with patients' self-image. METHODS: In a cross-sectional setting, the reliability and validity of five rasterstereographic shoulder variables were measured in comparison with six radiographic shoulder parameters, using correlation analysis. The patients' self-perception was documented using the Scoliosis Research Society-22 (SRS-22) questionnaire and Trunk Appearance Perception Scale (TAPS). RESULTS: Forty patients were included in the study. The test-retest reliability of all rasterstereographic shoulder parameters was excellent (ICC > 0.95). The validity was moderate in comparison with six radiographic parameters (highest coefficient: 0.582). The radiographic and rasterstereographic shoulder levels correlated with the results in the SRS-22 questionnaire (highest coefficient: -0.463) and TAPS (highest coefficient: 0.413). CONCLUSIONS: Rasterstereography is a reliable and valid method for assessing shoulder level in idiopathic scoliosis. The parameters can be recommended as a complement to radiography and clinical evaluation for follow-up purposes. Radiographic and rasterstereographic shoulder parameters are significantly related to patients' self-perception. Shoulder variables thus need to be considered in scoliosis patients.

Effects of multilevel posterior ligament dissection after spinal instrumentation on adjacent segment biomechanics as a potential risk factor for proximal junctional kyphosis: a biomechanical study.

BACKGROUND: Spinous processes and posterior ligaments, such as inter- and supraspinous ligaments are often sacrificed either deliberately to harvest osseous material for final spondylodesis e.g. in deformity corrective surgery or accidentally after posterior spinal instrumentation. This biomechanical study evaluates the potential destabilizing effect of a progressive dissection of the posterior ligaments (PL) after instrumented spinal fusion as a potential risk factor for proximal junctional kyphosis (PJK). METHODS: Twelve calf lumbar spines were instrumented from L3 to L6 (L3 = upper instrumented vertebra, UIV) and randomly assigned to one of the two study groups (dissection vs. control group). The specimens in the dissection group underwent progressive PL dissection, followed by cyclic flexion motion (250 cycles, moment: + 2.5 to + 20.0 Nm) to simulate physical activity and range of motion (ROM) testing of each segment with pure moments of ±15.0 Nm after each dissection step. The segmental ROM in flexion and extension was measured. The control group underwent the same loading and ROM testing protocol, but without PL dissection. RESULTS: In the treatment group, the normalized mean ROM at L2-L3 (direct adjacent segment of interest, UIV/UIV + 1, PJK-level) increased to 104.7%, 107.3%, and 119.4% after dissection of the PL L4-L6, L3-L6, and L2-L6, respectively. In the control group the mean ROM increased only to 103.2%, 106.7%, and 108.7%. The ROM difference at L2-L3 with regard to the last dissection of the PL was statistically significant (P = 0.017) and a PL dissection in the instrumented segments showed a positive trend towards an increased ROM at UIV/UIV + 1. CONCLUSIONS: A dissection of the PL at UIV/UIV + 1 leads to a significant increase in ROM at this level which can be considered to be a risk factor for PJK and should be definitely avoided during surgery. However, a dissection of the posterior ligaments within the instrumented segments while preserving the ligaments at UIV/UIV + 1 leads to a slight but not significant increase in ROM in the adjacent cranial segment UIV/UIV + 1 in the used experimental setup. Using this experimental setup we could not confirm our initial hypothesis that the posterior ligaments within a long posterior instrumentation should be preserved.

Influence of Age, BMI, Gender and Lumbar Level on T1ρ Magnetic Resonance Imaging of Lumbar Discs in Healthy Asymptomatic Adults.

PURPOSE: To assess the T1ρ range of lumbar intervertebral discs in healthy asymptomatic individuals at 1.5 T and to investigate the influence of age, body mass index (BMI), gender, and lumbar level on T1ρ relaxation. MATERIALS AND METHODS: In a prospective study, a total of 81 volunteers aged 20 - 80 years were included in this study and divided into three age groups (A: 20 - 39y; B: 40 - 59y; C: 60 - 80y). All of the volunteers underwent magnetic resonance imaging (MRI) at 1.5 T with acquisition of sagittal T1ρ images. The calculated T1ρ relaxation times were correlated with age, BMI, gender, and lumbar level relative to the total disc, the annulus fibrosus, and the nucleus pulposus. RESULTS: Age had a significant influence on T1ρ relaxation times at all lumbar levels, with increasing age being associated with reduced relaxation times. There was also a significant difference between age groups A vs. C and B vs. C (P = 0.0008 and P = 0.0149, respectively). No significant differences in T1ρ relaxation time were observed between men and women (P > 0.05). BMI showed a significant negative correlation with T1ρ relaxation times (P < 0.0001). Analysis of the lumbar level revealed a significant decrease in relaxation times from L1/2 to L5 / S1 (P = 0.0013). CONCLUSION: Increasing age correlated significantly with advanced lumbar disc degeneration in asymptomatic individuals, particularly in those aged 60 or older. Increasing BMI correlated significantly with increasing degeneration. The lower discs showed more degeneration than the upper ones. KEY POINTS: · Increasing age significantly reduces the T1ρ relaxation time in the intervertebral discs (P < 0.05). · Gender does not significantly influence T1ρ relaxation times (P > 0.05). · BMI shows a significant negative correlation with T1ρ relaxation times (P < 0.01). · Significantly shorter relaxation times in lower lumbar spine vs. upper lumbar spine (P < 0.01). CITATION FORMAT: · Gübitz R, Lange T, Gosheger G et al. Influence of Age, BMI, Gender and Lumbar Level on T1ρ Magnetic Resonance Imaging of Lumbar Discs in Healthy Asymptomatic Adults. Fortschr Röntgenstr 2018; 190: 144 - 151.

Predictors of shoulder level after spinal fusion in adolescent idiopathic scoliosis.

BACKGROUND: For patients with adolescent idiopathic scoliosis, shoulder balance influences their treatment satisfaction and psychological well-being. Several parameters are known to affect postoperative shoulder balance, but few prognostic models are as yet available. PURPOSE: This study aimed to identify independent predictive factors that can be used to assess preoperatively which patients are at risk of postoperative shoulder elevation, and to build a linear prediction model. METHODS: N = 102 patients with all Lenke types were reviewed radiographically before surgery and 1 year afterward. The outcome measures were coracoid height difference (CHD), clavicular angle (CA), and clavicle-first rib intersection difference (CiRID). Predictive factors commonly used in the literature were investigated using correlation analysis and statistical testing. Significant contributing factors were included in three multiple linear regression models (for CHD, CA, and CiRID). RESULTS: The mean shoulder level (CHD) significantly changed from a lower left shoulder value of -8.5 mm before surgery to 3.3 mm at the follow-up examination. A high preoperative left shoulder level by CiRID, a large amount of Cobb angle correction of the distal thoracic curve, a low preoperative Cobb angle in the lumbar curve, and a structural proximal thoracic curve proved to be determinants and thus risk factors for left-sided shoulder elevation after surgery. The three models predicting CHD, CA, and CiRID at the follow-up examination included these four risk factors and were significant. CONCLUSIONS: Preoperative variables have the strongest influence on shoulder level after spinal instrumentation. Additionally, extensive correction of the distal thoracic curve can cause elevation of the left shoulder.

German validation of the quality of life profile for spinal disorders (QLPSD).

BACKGROUND: The Quality of Life Profile for Spine Deformities (QLPSD) is a self-reporting questionnaire designed for studying patients with spinal deformities. PURPOSE: The aim of the present study was to systematically translate the QLPSD into German (G-QLPSD) and to test its reliability and validity. Special emphasis was intended to be given to patients with different Cobb angles and ages. METHODS: The QLPSD was systematically translated into German and was responded to in a web-based online survey by patients with idiopathic scoliosis and by healthy control individuals to carry out a matched-pair analysis. Participants aged 14 years and older were included. All participants answered a battery of validated questionnaires (SRS 22-r, PHQ-9, PANAS, FKS, WHO-5, BFI-S, PTQ). Reliability testing included Cronbach's alpha and test-retest reliability (retest 8 weeks after initial testing). Factorial, convergent, divergent, concurrent, and discriminant validity were calculated. RESULTS: A total of 255 scoliosis patients (age 30.0 ± 16.7 years, Cobb angle 43.5° ± 20.9°) and 189 matched healthy control individuals were finally included. Cronbach's alpha for the G-QLPSD total score was 0.93 and the test-retest reliability was 0.84. The G-QLPSD total score correlated with the SRS 22-r total score (r = -0.86). All concurrently applied scores showed strong correlations with the G-QLPSD (e.g., depression score PHQ-9: r = 0.70). The matched-pair analysis of 189 pairs showed strong discriminant validity (Cohen's d = 0.78). Patients with more severe Cobb angles (≥40°) and those ≥18 years of age had significantly poorer results than patients with minor curves and younger patients. CONCLUSION: The G-QLPSD proved to be a highly reliable and valid instrument that can be recommended for clinical use in scoliosis patients.