Early Experience With Novel Molded Allograft Anchors for the Management of Screw Loosening in Elderly Patients With Reduced Bone Density in Primary and Revision Lumbar Surgery.

BACKGROUND: Various strategies have been used to reduce pedicle screw loosening following lumbar instrumented fusion, but all strategies have limitations. In this prospective multicenter cohort study, outcomes of elderly patients with reduced bone density who underwent primary or revision fusion surgery using a novel technique of pedicle screw augmentation with demineralized bone fiber (DBF) anchors were evaluated. METHODS: This study included elderly patients (aged >65 years) with dual-energy x-ray absorptiometry-confirmed reduced bone density who required lumbar pedicle screw fixation and were treated with supplemental DBF allograft anchors during primary or revision surgery. The need for DBF anchors was determined by evaluating preoperative computed tomography (CT) scans (for revision surgery) and by the surgeons' tactile feedback intraoperatively during pedicle screw insertion and removal. After determining the pedicle screw void diameter with a sizing instrument, DBF anchors and pedicle screws of the same diameter were placed into the void. CT scans were obtained on postoperative day 2 to assess pedicle breach, pedicle fracture, or anchor material extrusion and at 6 and 12 months postoperatively to assess screw loosening. Thereafter, to minimize radiation exposure, CT scans were only performed for recurrence of pain. RESULTS: Twenty-three patients (79% women; mean age, 74 years) received 50 lumbosacral pedicle screws augmented with DBF anchors. Most surgeries (n = 18, 78%) were revisions, and most anchors were inserted into revision pedicle screw trajectories (n = 33, 66%). Day-2 CT scans revealed no pedicle breach/fracture or extrusion of anchor material. During a mean follow-up of 15 months (12-20 months), no screw loosening was detected, and no patient required pedicle screw revision surgery. There were no adverse events attributable to DBF allografts. CONCLUSIONS: DBF allograft anchors appear to be safe and effective for augmenting pedicle screws during revision surgeries in female elderly patients with reduced bone density. CLINICAL RELEVANCE: Clinically, DBF reduced the rate of pedicle screw loosening in patients with reduced bone density. A significant reduction in screw loosening can decrease the need for revision surgeries, which are costly and carry additional risks. Enhanced bone integration from the DBF may promote better healing and long-term stability.

A Test of Reliability: Cranial Rhythmic Impulse for Distant Diagnoses.

Context The osteopathic cranial field suggests that cranial rhythmic impulse (CRI) can be used to examine distal segments. However, there is a lack of research on the reliability of using CRI to diagnose other distal segments. This study aims to evaluate the effectiveness of using the cranial vault hold compared to traditional osteopathic diagnostic techniques to diagnose somatic dysfunctions at the following segments: atlantooccipital joint (OA), atlantoaxial joint (AA), cervical-4 (C4), cervical-7 (C7), thoracic-6 (T6), thoracic-12 (T12), lumbar-3 (L3), sacrum, left innominate, right fibular head, and left radial head. Objective To determine if palpation of CRI can reliably detect somatic dysfunctions in multiple distal segments. Methods The study compared osteopathic physicians' diagnoses of specific segments (OA, AA, C4, C7, T6, T12, L3, sacrum, left innominate, right fibular head, and left radial head) using the cranial vault hold and direct palpation. Two osteopathic neuromusculoskeletal medicine experts (cranial group) diagnosed distal segments via the cranial vault hold, while board-certified osteopathic physicians (confirmatory group) used direct palpation. We recruited 44 second-year osteopathic medical students and osteopathic physicians via a school-wide email. Each participant lay supine on a massage table for diagnosis. A neuromusculoskeletal expert, with a scribe, diagnosed the segments using the cranial vault hold. The process was repeated by a second neuromusculoskeletal expert with another scribe. Two osteopathic physicians then diagnosed the same subjects using direct palpatory techniques. Both osteopathic physicians had to agree on a diagnosis for the segment, or it was excluded from comparison. Cohen's kappa coefficient measured inter-rater reliability between the cranial and confirmatory groups. Results Cranial physician 1 provided all 484 diagnoses, while cranial physician 2 provided 152. Cranial physician 1 showed positive agreement with the confirmatory group (κ>0) in 2/11 (18.2%) segments: T12 and left innominate (κ=0.009 and 0.007). Cranial physician 2 showed positive agreement (κ>0) in 4/11 (36.4%) segments: OA, AA, C4, and left innominate (κ=0.050, 0.031, 0.130, and 0.154). Inter-rater reliability between cranial physicians showed positive agreement in 6/11 (54.5%) segments: OA, AA, C4, sacrum, left innominate, and right fibular head (κ=0.125, 0.022, 0.048, 0.036, 0.154, and 0.0261). Conclusion The positive kappa values, all between 0 and 0.2, indicate the inter-rater reliability for diagnosis with the vault hold is above random chance but has none to slight reliability. The kappa coefficients comparing both cranial physicians indicate positive agreement in six segments, supporting palpation of the same phenomena in six out of 11 (54.5%) segments. However, none of the positive kappa values were statistically significant (p>0.05) and the effect sizes were small, likely due to shared bias among the evaluators. We conclude our experiment suggests palpation of the cranium may not reliably diagnose distal segments. However, our experiment may support a connection between CRI and distal segment somatic dysfunctions. Considering diagnoses of certain segments are above random chance, more research is needed to confirm whether there is a connection between palpation of the CRI and the diagnosis of a distal somatic dysfunction.

Negotiating for new technologies: guidelines for the procurement of assistive technologies in spinal surgery: a narrative review.

Background and Objective: This is a narrative review with the objective to discuss available assistive technologies for spinal surgery. Characteristics, costs, and compatibility of the different systems are summarized and recommendations made regarding acquiring these technologies. The availability of assistive technologies in spine surgery continues to evolve rapidly. The literature is lacking a collective summary of the available technologies and guidelines for acquisition. This is a narrative review which (I) presents an up-to-date summary of the currently available assistive technologies in spinal surgery; (II) makes comment on the utility of imaging, navigation, and robotics; (III) makes recommendations for the utility of the platform based on hospital size and (IV) discuss factors involved in negotiating for the purchase of these new technologies. Methods: We assemble the most up-to-date collection of description, characteristics and pricing of assistive technologies in spinal surgery. We compare and contrast these technologies and make recommendations regarding acquisition. Key Content and Findings: These technologies require a learning-curve for the surgeon and the operating room staff to understand how to use them efficiently. Surgeons need to be involved in the process of purchase decisions. Surgeons occupy a unique position in the health care infrastructure as their approach to care has significant ramifications on both the quality and cost of care. Surgeons should maintain conviction that their training and practice has allowed the use of these technologies to provide safer and more effective care for patients. Conclusions: Assistive technologies and prostheses for spinal fusion are evolving rapidly. This article serves as an encompassing reference to the current technologies. These technologies will play a significant role in the delivery of spinal health care in the future. All stakeholders stand to benefit from the increased value these technologies bring to patient care.

Surface landmarks for anterior lumbar access: is fluoroscopy necessary?

BACKGROUND CONTEXT: Anterior lumbar fusion surgery is increasing by an estimated 24% annually in the United States. There is a paucity of precise anatomic guidelines to help surgeons determine the appropriate anterior access incision site. PURPOSE: The purpose of this study is to compare the available anterior surface landmarks for the L4/L5 and L5/S1 disk levels to the disk levels determined by fluoroscopy, with the goal of creating a guide for surgical incision sites in anterior lumbar access surgery. STUDY DESIGN: A prospective, observational cohort study of consecutive patients undergoing anterior lumbar spinal exposure for anterior lumbar interbody fusion (ALIF), total disk replacement (TDR), or a combination of the two procedures at levels L4/L5 and/or L5/S1. PATIENT SAMPLE: All patients (n=183) undergoing primary ALIF and/or TDR surgery from June 2018 to April 2021 at the study sites were assessed for inclusion, and 18 patients were excluded. The remaining 165 patients were included in the study, and a total of 208 surgical levels were exposed. OUTCOME MEASURES: Mean, standard deviation, and 95% confidence interval (CI) were calculated. At each level, the distance from the symphysis pubis to the target disk level (SD distance) and the distance from the symphysis pubis to the umbilicus (SU distance) were measured, and the SD/SU ratio was calculated. Paired 2-tailed t tests were used to assess significant differences (p<.05). An R2 (coefficient of determination) test was used to assess variability of the SD distance, SU distance, and SD/SU ratio at each level. METHODS: All physiologic and anatomic measures were collected prospectively by the investigators, including intraoperative measurements of SD and SU. Demographic and previous health history data were collected at the time of study enrollment. RESULTS: The mean age of the 165 study participants was 48±14 years (range 18-80 years), and 97 (61%) were male. A total of 208 disk levels were exposed: 140 at L5/S1 and 68 at L4/L5. For the L5/S1, the SD ranged from 0 to 12.5 cm, with a mean of 5.2±1.9 cm (95% CI 4.88-5.52). For the L4/L5 level, the SD ranged from 6 to 15.5 cm, with a mean of 10.7±2.3 cm (95% CI 10.2-11.2). SD/SU ratios at both levels were lower in overweight (body mass index [BMI] 25-29.9) and obese (BMI 30-34.9) groups than in normal body mass index groups. There was no significant difference in SD/SU ratios between females and males at either L5/S1 (p=.39) or L4/L5 (p=.66). CONCLUSION: Clinically important variability in SD distances (≥9.5 cm) was observed for both the L5/S1 and L4/L5 disk levels. SD/SU ratios provided more consistent estimates of disk location than SD distance alone, but they still displayed substantial variability. Thus, intraoperative fluoroscopy remains mandatory to accurately plan the surgical incision for anterior lumbar access surgery.

Accuracy of Canine Scent Detection of Non-Small Cell Lung Cancer in Blood Serum.

CONTEXT: Early detection provides the best opportunity for lung cancer survival; however, lung cancer is difficult to detect early because symptoms do not often appear until later stages. Current screening methods such as x-ray and computed tomographic imaging lack the sensitivity and specificity needed for effective early diagnosis. Dogs have highly developed olfactory systems and may be able to detect cancer in its primary stages. Their scent detection could be used to identify biomarkers associated with various types of lung cancer. OBJECTIVE: To determine the accuracy of trained beagles' ability to use their olfactory system to differentiate the odor of the blood serum of patients with lung cancer from the blood serum of healthy controls. METHODS: Over the course of 8 weeks, operant conditioning via clicker training was used to train dogs to use their olfactory system to distinguish blood serum from patients with malignant lung cancer from blood serum from healthy controls in a double-blind study. After training, non-small cell lung cancer and healthy control blood serum samples were presented to the dogs, and the sensitivity and specificity of each dog were analyzed. RESULTS: Four dogs were trained for the study, but 1 was unmotivated by training and removed from the study. Three dogs were able to correctly identify the cancer samples with a sensitivity of 96.7%, specificity of 97.5%, positive predictive value of 90.6%, and negative predictive value of 99.2%. CONCLUSION: Trained dogs were able to identify non-small cell lung cancer samples from healthy controls. The findings of this study provide a starting point for a larger-scale research project designed to explore the use of canine scent detection as a tool for cancer biomarkers.

Assessment of Pulmonary Function After Osteopathic Manipulative Treatment vs Standard Pulmonary Rehabilitation in a Healthy Population.

CONTEXT: Standard pulmonary rehabilitation (SPR) does not use osteopathic manipulative treatment (OMT), but OMT has potential to improve lung function and patient perception of breathing. OBJECTIVE: To analyze the immediate effects of OMT and SPR techniques on pulmonary function using spirometry and subjective ratings in young, healthy persons. METHODS: Participants were healthy students recruited from the Lake Erie College of Osteopathic Medicine-Bradenton and were randomly assigned to either the OMT or SPR group. During the first 4 weeks, each participant in the OMT group received 1 OMT technique (rib raising, doming of the diaphragm, thoracic lymphatic pump, and thoracic high velocity, low amplitude), and each participant in the SPR group received 1 SPR treatment (tapotement, pursed lip breathing, saline nebulizer, and rest) per week. Treatments were then ranked based on positive change in pulmonary function as measured by forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC). During the fifth week, the OMT group received the 2 highest-ranked OMT techniques, and the SPR group received the 2 highest-ranked SPR treatments. During the sixth week, the OMT group received the highest-ranked OMT and SPR treatment, while the SPR group received the same treatment combination but in the reverse order. Pulmonary function, as measured through FEV1, FVC, and FEV1/FVC, were collected before and after each treatment or treatment combination. Participants subjectively rated change in breathing after each treatment. RESULTS: A total of 53 students participated in the study, with 28 in the OMT group and 25 in the SPR group. In the OMT group, rib raising yielded the highest positive mean (SD) change of 0.001 (0.136) L in FEV1 and 0.052 (0.183) L in FVC, followed by lymphatic pump, with a change of 0.080 (0.169) L in FEV1 and -0.031 (0.229) L in FVC. In the SPR group, pursed lip breathing yielded the highest positive mean (SD) change of 0.101 (0.278) L in FEV1 and 0.031 (0.179) L in FVC, followed by tapotement, with a change of 0.045 (0.229) L in FEV1 and 0.061 (0.239) L in FVC. Saline treatment significantly decreased lung function. All other treatments did not result in any significant changes in lung function. Overall, SPR subjective ratings were significantly lower than ratings for both OMT and combination (OMT+SPR) treatments. CONCLUSIONS: Saline significantly reduced lung function and had low subjective posttreatment ratings in young healthy adults. Additionally, OMT and combination OMT and SPR significantly improved subjective breathing more than SPR alone. Future applications of this study include evaluating OMT and SPR effects on lung function in patients with various pulmonary conditions.

Osteopathic manipulative treatment for self-reported fatigue, stress, and depression in first-year osteopathic medical students.

CONTEXT: During medical education, many students experience psychological distress, including symptoms such as fatigue, stress, and depression. OBJECTIVE: To evaluate the effect of osteopathic manipulative treatment (OMT) on self-perceived fatigue, stress, and depression in first-year osteopathic medical students. METHODS: This randomized controlled pilot study with repeated measures was conducted at the Lake Erie College of Osteopathic Medicine-Bradenton in Florida during the fall 2012 semester. First-year osteopathic medical students voluntarily enrolled in the study and were randomly assigned to directed OMT (D-OMT), nondirected OMT (ND-OMT), or control groups. The D-OMT and ND-OMT groups received treatment by osteopathic physicians weekly for 4 weeks. The control group received no treatment. All groups completed the Epworth Sleepiness Scale (ESS), the Self-Perceived Stress Scale (SPSS), and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire 9 (PHQ-9) depression scale before treatment (pretest), after 2 treatments (midtest), and after 4 treatments (posttest). RESULTS: All participants self-reported as white and single, with both sexes equally represented, and had an mean age of 24 years. Analysis of ESS scores revealed a statistically significant decrease in the D-OMT group from pretest and posttest scores and a statistically significant increase in the ND-OMT group from pretest to midtest but not from pretest to posttest scores. No statistically significant differences were noted in the control group scores on this measure. No statistically significant differences were seen in the SPSS or PHQ-9 scores from pretest to midtest or pretest to posttest in any of the 3 groups. CONCLUSION: The D-OMT regimen used in the current study produced a statistically significant decrease in self-perceived fatigue in first-year osteopathic medical students. Osteopathic manipulative treatment represents a potential modality to reduce self-perceived distress in medical students. Further research is warranted.

Optic neuritis and retinal ganglion cell loss in a chronic murine model of multiple sclerosis.

Multiple sclerosis (MS) and its animal model experimental autoimmune encephalomyelitis (EAE) are neurodegenerative diseases with characteristic inflammatory demyelination in the central nervous system, including the optic nerve. Neuronal and axonal damage is considered to be the main cause of long-term disability in patients with MS. Neuronal loss, including retinal ganglion cell (RGC) apoptosis in eyes with optic neuritis (ON), also occurs in EAE. However, there is significant variability in the clinical course and level of neuronal damage in MS and EAE. The current studies examine the mechanisms and kinetics of RGC loss in C57/BL6 mice immunized with myelin oligodendrocyte glycoprotein to induce a chronic EAE disease. Clinical progression of EAE was scored daily and vision was assessed by optokinetic responses. At various time points, RGCs were counted and optic nerves were examined for inflammatory cell infiltration. Almost all EAE mice develop ON by day 15 post-immunization; however, RGC loss is delayed in these mice. No RGC loss is detected 25 days post-immunization, whereas RGC numbers in EAE mice significantly and progressively decrease compared to controls from 35 to 50 days post-immunization. The delayed time course of RGC loss is in stark contrast to that reported in relapsing EAE, as well as in rats with chronic EAE. Results suggest that different clinical disease courses of optic nerve inflammation may trigger distinct mechanisms of neuronal damage, or RGCs in different rodent strains may have variable resistance to neuronal degeneration.