The Positive Side Effect of Anterior Cervical Decompression and Fusion on Axial Neck Pain

STUDY DESIGN

Observational Cohort Study.

OBJECTIVES

This study aims to comprehensively assess the outcomes of anterior cervical spine surgery in patients who have undergone surgical intervention for radiculopathy or myelopathy, with a specific focus on the surgery's impact on axial neck pain.

METHODS

Data from an institutional spine surgery registry were analyzed for patients who underwent anterior cervical spine surgery between January 2016 and March 2022. Patient demographics, clinical variables, and outcome measures, including the Neck Disability Index (NDI), numeric rating scales for neck and arm pain (NRS-Neck and NRS-Arm), and 36-Item Short Form Health Survey (SF-36) scores, were collected. Statistical analysis included paired t-tests, chi-squared tests, and multivariate linear regression.

RESULTS

Of 257 patients, 156 met the inclusion criteria. Patients showed significant improvement in NDI, NRS-Neck, NRS-Arm, SF-36 (Physical and Mental components), and all changes exceeded the minimum clinically important difference. Multivariate regression revealed that lower preoperative physical and mental component scores and higher preoperative NRS-Neck predicted worse NDI scores at follow-up.

CONCLUSIONS

This study underscores that anterior cervical fusion not only effectively alleviates arm pain and disability but also has a positive impact on axial neck pain, which may not be the primary target of surgery. Our findings emphasize the potential benefits of surgical intervention when neck pain coexists with neurologic compression. This contribution adds to the growing body of evidence emphasizing the importance of precise diagnosis and patient selection. Future research, ideally focusing on patients with isolated neck pain, should further explore alternative surgical approaches to enhance treatment options.

Complications in endoscopic spine surgery: a systematic review

PURPOSE

This systematic review aims to investigate the complication rate of endoscopic spine surgeries, stratifying them by technique, district and kind of procedure performed.

METHODS

This study was conducted according to the PRISMA statement. The literature search was conducted in MEDLINE, CINAHL, EMBASE, Cochrane Register, OTseeker and ScienceDirect database. Types of studies included were observational studies (cohort studies, case-control studies and case series) and randomised or quasi-randomised clinical with human subjects. No restrictions on publication year were applied. Repeated articles, reviews, expert's comments, congress abstracts, technical notes and articles not in English were excluded. Several data were extracted from the articles. In particular, data of perioperative (≤ 3 months) and late (> 3 months) complications were collected and grouped according to: (1) surgical technique [uniportal full-endoscopic spine surgery (UESS) or unilateral biportal endoscopic spine surgery (UBESS)]; (2) spinal district treated [cervical, thoracic or lumbar] and (3) type of procedure [discectomy/decompression or fusion]. Complication analysis was performed in subgroups with at least 100 patients to have clinically meaningful statistical validity.

RESULTS

A total of 117 full-text articles were assessed for eligibility. Of the 117 records included, 95 focused their research on UESS (14 LOE V, 33 LOE IV, 43 LOE III and five LOE II) and 23 on UBESS (three LOE V, eight LOE IV, 10 LOE III and two LOE II). A total of 20,020 patients were extracted to investigate the incidence of different perioperative and late complications, 10,405 for UESS and 9615 for UBESS.

CONCLUSION

The present study summarises the complications reported in the literature for spinal endoscopic procedures. On the one hand, the most relevant described were perioperative complications (transient neurological deficit, dural tear and dysesthesia) that are especially meaningful for endoscopic discectomy and decompression. On the other hand, late complications, such as mechanical implant failure, are more common in endoscopic interbody fusion.

LEVEL OF EVIDENCE

I.

Why Treat Patients with a Major Orthopaedic Surgery Only to Send Them Back to the Vulnerable Conditions That Made Them Sick in the First Place? A Conceptual Scenario to Improve Patient's Journey

Individuals with severe cartilage degeneration of the hip or knee or collapsed vertebrae that cause spine deformities can suffer from joint and neuropathic pain in the back, disuse of the affected limb, and restriction of movements. Surgical intervention is the most widespread and successful solution to date. There is a general belief that eating healthy and staying physically and mentally active might have a preventive role against musculoskeletal disease occurrence, while instead, we are more certain of the benefits deriving from a healthy diet and exercise therapy after major orthopaedic procedures. These aspects are in fact vital components in enhanced recovery after surgery programmes. However, they are applied in hospital settings, are often centre-dependent, and lack primary and tertiary preventive efficacy since end once the patient is discharged. There is the lack of initiatives at the territorial level that ensure a continuum in the patient's journey towards orthopaedic surgery, home transition, and a healthy and long-lasting life. The expert panel advocates the integration of an intermediate lifestyle clinic that promotes healthy eating, physical activity, and sleep hygiene. In this facility directed by professionals in enhancing recovery after surgery, patients can be referred after the surgical indication and before home discharge. Surgery is in fact a moment when individuals are more curious to do their best to heal and stay healthy, representing a timepoint and opportunity for educating patients on how lifestyle changes may optimise not only their surgical recovery but also long-term future health state.

The influence of peri-operative depressive symptoms on medium-term spine surgery outcome: a prospective study

PURPOSE

To investigate the role of depressive symptoms on clinical outcomes in patients undergoing spinal surgery up to 2-year follow-up.

METHODS

The study used data from an institutional spine surgery registry (January 2016, through March 2022) to identify patients (> 18 years) undergoing spine surgery. Patients with Oswestry Disability Index (ODI) < 20/100 at baseline or undergoing surgery on the cervical spine or for idiopathic spinal deformity and trauma patients were excluded. The patients were divided into two groups based on the pre-operative Mental Component Summary (MCS) score of the SF-36: depression group (MCS ≤ 35) or non-depression group (MCS > 35). The ODI and MCS scores trajectory were wined over the 24-month post-surgery between groups. Additionally, a secondary subgroup analysis was conducted comparing outcomes between those with depressive symptoms (persistent-depression subgroup) and those without depressive symptoms (never-depression subgroup) at 3 months after surgery.

RESULTS

A total of 2164 patients who underwent spine surgery were included. The pre-operative depression group reported higher ODI total scores and lower MCS than the pre-operative non-depression group at all time points (P < 0.001). The persistent-depression subgroup reported higher ODI total scores and lower MCS than the never-depression subgroup at all follow-ups (P < 0.001).

CONCLUSION

Functional disability and mental health status improve in patients with depression symptoms undergoing spinal surgery. Despite this improvement, they do not reach the values of non-depressed subjects. Over the 2-year follow-up time, patients with depression show a different trajectory of ODI and MCS. Caregivers should be aware of these results to counsel patients with depression symptoms.

National spine surgery registries' characteristics and aims: globally accepted standards have yet to be met. Results of a scoping review and a complementary survey

BACKGROUND

Surgery involving implantable devices is widely used to solve several health issues. National registries are essential tools for implantable device surveillance and vigilance. In 2017, the European Union encouraged Member States to establish "registries and databanks for specific types of devices" to evaluate device safety and performance and ensure their traceability. Spine-implantable devices significantly impact patient safety and public health; spine registries might help improve surgical outcomes. This study aimed to map existing national spine surgery registries and highlight their features and organisational standards to provide an essential reference for establishing other national registries.

METHODS

A scoping search was performed using the Embase, PubMed/Medline, Scopus, and Web of Science databases for the terms "registry", "register", "implantable", and all terms and synonyms related to spinal diseases and national registries in publications from January 2000 to December 2020. This search was later updated and finalised through a web search and an ad hoc survey to collect further detailed information.

RESULTS

Sixty-two peer-reviewed articles were included, which were related to seven national spine registries, six of which were currently active. Three additional active national registries were found through the web search. The nine selected national registries were set up between 1998 and 2021. They collect data on the procedure and use patient-reported outcome measures (PROMs) for the follow-up.

CONCLUSION

Our study identified nine currently active national spine surgery registries. However, globally accepted standards for developing a national registry of spine surgery are yet to be established. Therefore, an international effort to increase result comparability across registries is highly advisable. We hope the recent initiative from the Orthopaedic Data Evaluation Panel (ODEP) to establish an international collaboration will meet these needs.

Diagnostic Approach and Differences between Spinal Infections and Tumors

STUDY DESIGN

A systematic review of the literature about differential diagnosis between spine infection and bone tumors of the spine.

BACKGROUND AND PURPOSE

The differential diagnosis between spine infection and bone tumors of the spine can be misled by the prevalence of one of the conditions over the other in different areas of the world. A review of the existing literature on suggestive or even pathognomonic imaging aspects of both can be very useful for correctly orientating the diagnosis and deciding the most appropriate area for biopsy. The purpose of our study is to identify which imaging technique is the most reliable to suggest the diagnosis between spine infection and spine bone tumor.

METHODS

A primary search on Medline through PubMed distribution was made. We identified five main groups: tuberculous, atypical spinal tuberculosis, pyogenic spondylitis, and neoplastic (primitive and metastatic). For each group, we evaluated the commonest localization, characteristics at CT, CT perfusion, MRI, MRI with Gadolinium, MRI diffusion (DWI) and, in the end, the main features for each group.

RESULTS

A total of 602 studies were identified through the database search and a screening by titles and abstracts was performed. After applying inclusion and exclusion criteria, 34 articles were excluded and a total of 22 full-text articles were assessed for eligibility. For each article, the role of CT-scan, CT-perfusion, MRI, MRI with Gadolinium and MRI diffusion (DWI) in distinguishing the most reliable features to suggest the diagnosis of spine infection versus bone tumor/metastasis was collected.

CONCLUSION

Definitive differential diagnosis between infection and tumor requires biopsy and culture. The sensitivity and specificity of percutaneous biopsy are 72% and 94%, respectively. Imaging studies can be added to address the diagnosis, but a multidisciplinary discussion with radiologists and nuclear medicine specialists is mandatory.

Quality Control for Spine Registries: Development and Application of a New Protocol

Registries are gaining importance both in clinical practice and for research purposes. However, quality control is paramount to ensure that data are consistent and reliable. Quality control protocols have been proposed for arthroplasty registries, but these are not directly applicable to the spine setting. This study aims to develop a new quality control protocol for spine registries. Based on the available protocols for arthroplasty registries, a new protocol for spine registries was developed. The items included in the protocol were completeness (yearly enrollment rate and rate of assessment completion), consistency, and internal validity (coherence between registry data and medical records for blood loss, body mass index, and treated levels). All aspects were then applied to the spine registry of the Institution to verify its quality for each of the 5 years in which the registry has been used (2016-2020). Regarding completeness, the yearly enrollment rate ranged from 78 to 86%; the completion of preoperative assessment from 79% to 100%. The yearly consistency rate varied from 83% to 86%. Considering internal validity, the interclass correlation coefficient ranged from 0.1 to 0.8 for blood loss and from 0.3 to 0.9 for body mass index. The coherency for treated levels ranged from 25% to 82%. Overall, all 3 items showed an improvement over time. All 3 analyzed domains showed good to excellent results. The overall quality of the registered data improved over time.

En-bloc resection of a chordoma in L3 by a combined open posterior and less invasive retroperitoneal approach: technical description and case report

INTRODUCTION

To fulfill oncological criteria, extensive open anterior and posterior approaches are usually performed in the lumbar spine to obtain an appropriate en-bloc spondylectomy. It is commonly accepted that the price of a tumor-free margin includes such extensive incisions and soft-tissue damage, with consequent relevant blood loss and possible postoperative complications as delayed wound healing. In this article, a case of chordoma in L3 is presented, submitted to an oncologically appropriate en-bloc resection performed by an open posterior approach combined with a mini-retroperitoneal approach. The successful oncologic procedure was combined with a short and uneventful postoperative course.

MATERIALS AND METHODS

The authors present the surgical technique and the possible challenges of minimally invasive anterior oncologic surgery as a contribution to a limited literature.

RESULTS

Up to date, palliative care of single metastases has been the main setting in which anterior, minimally invasive surgery has been performed in the lumbar spine. The authors explained how, in selected cases, this approach can be performed in combination with an open posterior access for an oncologically appropriate treatment of a primary malignant tumor.

CONCLUSION

Anterior, minimally invasive surgery can have a role in selected patients with primary malignant tumors of the lumbar spine. The surgical team should have extensive training both in oncologic and minimally invasive surgery.

Long spine fusions to the sacrum-pelvis are associated with greater post-operative proximal junctional kyphosis angle in sitting position

STUDY DESIGN

A single-centre retrospective study.

BACKGROUND AND PURPOSE

Although adult patients spend most of their time in sitting positions, the assessment of spinopelvic parameters in adult deformity surgery is commonly performed in standing X-rays. Our study compares the standing and sitting sagittal alignment parameters in subjects who underwent thoracolumbar fusion.

METHODS

Patients who underwent corrective surgery for adult scoliosis with at least five instrumented vertebra were stratified according to the upper instrumented vertebra (UIV) and pelvic fixation. Group A:UIV proximal to T6 with pelvis fixation. B:UIV lower than T6 and pelvic fixation. Group C: thoracolumbar fusion without pelvic fixation. Post-operative spinopelvic sagittal parameters were measured in both standing and sitting X-rays.

RESULTS

A total of 51 patients were enrolled in the study (11:Males and 40:Females). The mean age was 52.3 ± 21.7y/o. The comparison of post-operative standing and sitting X-ray within the group A and B showed that a significant change was observed in terms of JA-Junctional Angle-(Group A 6.3 ± 4.3 vs. 8.1 ± 3.3, p value = 0.03) (Group B 8.5 ± 6.4 vs. 10.9 ± 6.4, p value = 0.02). Group C showed statistically significant difference in terms of PT (15.6 ± 11.2 vs. 19.3 ± 9.2, p value = 0.04), AVA-Acetabular Version Angle-(41.1 ± 5.9 vs. 48.3 ± 6.6, p value < 0.01) and LL (- 51.3 ± 16.0 vs. - 42.6 ± 10.7, p value < 0.01).

CONCLUSION

In our series, the post-operative sagittal alignment showed peculiar behaviours and adaptations in sitting position, depending on the length and the site of the instrumented area. If the pelvis is included, the JA tends to significantly increase in sitting position. These findings can improve the knowledge of pathologies as proximal junctional kyphosis or specific cases of anterior hip impingement.

LEVEL OF EVIDENCE

IV.

Need of vascular surgeon and comparison of value for anterior lumbar interbody fusion (ALIF) in lateral decubitus: Delphi consensus

BACKGROUND AND PURPOSE

Anterior lumbar approaches are recommended for clinical conditions that require interbody stability, spinal deformity corrections or a large fusion area. Anterior lumbar interbody fusion in lateral decubitus position (LatALIF) has gained progressive interest in the last years. The study aims to describe the current habit, the perception of safety and the perceptions of need of vascular surgeons according to experienced spine surgeons by comparing LatALIF to the standard L5-S1 supine ALIF (SupALIF).

METHODS

A two-round Delphi method study was conducted to assess the consensus, within expert spine surgeons, regarding the perception of safety, the preoperative planning, the complications management and the need for vascular surgeons by performing anterior approaches (SupALIF vs LatALIF).

RESULTS

A total of 14 experts voluntary were involved in the survey. From 82 sentences voted in the first round, a consensus was reached for 38 items. This included the feasibility of safe LatALIF without systematic involvement of vascular surgeon for routine cases (while for revision cases the involvement of the vascular surgeon is an appropriate option) and the appropriateness of standard MRI to evaluate the accessibility of the vascular window. Thirteen sentences reached the final consensus in the second round, whereas no consensus was reached for the remaining 20 statements.

CONCLUSIONS

The Delphi study collected the consensus on several points, such as the consolidated required experience on anterior approaches, the accurate study of vascular anatomy with MRI, the management of complications and the significant reduction of the surgical times of the LatALIF if compared to SupALIF in combined procedures. Furthermore, the study group agrees that LatALIF can be performed without the need for a vascular surgeon in routine cases.

Prediction of Long-Term Recovery From Disability Using Hemoglobin-Based Models: Results From a Cohort of 1,392 Patients Undergoing Spine Surgery

Hemoglobin and its associated blood values are important laboratory biomarkers that mirror the strength of constitution of patients undergoing spine surgery. Along with the clinical determinants available during the preadmission visit, it is important to explore their potential for predicting clinical success from the patient's perspective in order to make the pre-admission visit more patient-centered. We analyzed data from 1,392 patients with spine deformity, disc disease, or spondylolisthesis enrolled between 2016 and 2019 in our institutional Spine Registry. Patient-reported outcome measure at 17 months after surgery was referred to the Oswestry disability index. High preoperative hemoglobin was found to be the strongest biochemical determinant of clinical success along with high red blood cells count, while low baseline disability, prolonged hospitalization, and long surgical times were associated with poor recovery. The neural network model of these predictors showed a fair diagnostic performance, having an area under the curve of 0.726 and a sensitivity of 86.79%. However, the specificity of the model was 15.15%, thus providing to be unreliable in forecasting poor patient-reported outcomes. In conclusion, preoperative hemoglobin may be one of the key biomarkers on which to build appropriate predictive models of long-term recovery after spine surgery, but it is necessary to include multidimensional variables in the models to increase the reliability at the patient's level.

Perioperative Anesthesia and Acute Smell Alterations in Spine Surgery: A “Sniffing Impairment” Influencing Refeeding?

Medications for general anesthesia can cause smell alterations after surgery, with inhalation anesthetics being the most acknowledged drugs. However, spine patients have been poorly studied in past investigations and whether these alterations could influence the refeeding remains unclear. This research aims to observe detectable dysosmias after spine surgery, to explore any amplified affection of halogenates (DESflurane and SEVoflurane) against total intravenous anesthesia (TIVA), and to spot potential repercussions on the refeeding. Fifty patients between 50 and 85 years old were recruited before elective spine procedure and tested for odor acuity and discrimination using the Sniffin' Sticks test. The odor abilities were re-assessed within the first 15 h after surgery together with the monitoring of food intakes. The threshold reduced from 4.92 ± 1.61 to 4.81 ± 1.64 (p = 0.237) and the discrimination ability reduced from 10.50 ± 1.83 to 9.52 ± 1.98 (p = 0.0005). Anesthetic-specific analysis showed a significant reduction of both threshold (p = 0.004) and discrimination (p = 0.004) in the SEV group, and a significant reduction of discrimination abilities (p = 0.016) in the DES group. No dysosmias were observed in TIVA patients after surgery. Food intakes were lower in the TIVA group compared to both DES (p = 0.026) and SEV (p = 0.017). The food consumed was not associated with the sniffing impairment but appeared to be inversely associated with the surgical time. These results confirmed the evidence on inhalation anesthetics to cause smell alterations in spine patients. Furthermore, the poor early oral intake after complex procedures suggests that spinal deformity surgery could be a practical challenge to early oral nutrition.

Development of the Prevent for Work Questionnaire (P4Wq) for the assessment of musculoskeletal risk factors in the workplace: part 2-pilot study for questionnaire development and validation

OBJECTIVE

The aim of this study was to develop a multifactorial, self-report questionnaire: Prevent for Work Questionnaire (P4Wq). The questionnaire is intended for screening for risk factors in work-related musculoskeletal disorders (WMSDs).

DESIGN

Data were collected from otherwise healthy workers employed in three service areas at a specialist hospital in Italy: healthcare, administration and ancillary services.

SETTING AND PARTICIPANTS

In all, 115 participants were enrolled (67% women; average age 41.5±9.94 years). The content of the tool for WMSDs was derived from three participation rounds of analysis involving a select group of experts who identified the questionnaire domains and items. Participants responded to 89 items in addition to the EuroQol 5 Dimensions Questionnaire (EQ-5D-5L), Fear-Avoidance Beliefs Questionnaire (FABq) and Oswestry Disability Index (ODI). The proportion of missing data and the distribution of responses were analysed for each item. Items with a discrimination index >0.40 and an interitem correlation <0.80 were retained. Factor analysis was performed using the VARIMAX rotation method, factor extraction, and identification, assignment of items to subscales, and assignment of scores to items. Internal consistency, reliability, construct validity and face validity were also assessed.

RESULTS

A total of 52 items were included in the factor analysis and four subscales identified: Physical Stress Subscore (six items); Mental Stress Subscore (six items); Job Satisfaction Subscore (four items) and Kinesiophobia/Catastrophizing Subscore (four items). The items in the final questionnaire version had a factor loading >0.7. The questionnaire consisted of 20 items with good internal consistency (Cronbach's alpha 0.81-0.91), reliability (weighted kappa coefficient 0.617-1.00), good construct validity (EQ-5D-5L, r=-0.549, p<0.001; ODI, r=0.549, p<0.001; FABq work, r=0.688, p<0.001) and satisfactory face validity (universal validity index 96.04%).

CONCLUSION

The P4Wq is a 20-item, multifactorial self-report risk assessment questionnaire. It may provide a useful tool for screening for WMSDs by specifically addressing back disorders. It investigates risks for individual workers and may inform educational programmes and preventive strategies tailored to a worker's needs.

TRIAL REGISTRATION NUMBER

NCT04192604.

Clinical and radiographic performance of indirect foraminal decompression with anterior retroperitoneal lumbar approach for interbody fusion (ALIF)

STUDY DESIGN

Retrospective study BACKGROUND: Indirect decompression with ALIF allows the restoration of the disk and foraminal height with limited soft tissue damage. However, it does not offer a direct view of the neural structure and a direct intraoperative assessment of the results of the decompression is not possible. For this reason, ALIF is often accompanied by posterior, direct decompression. So far, there is no consensus on the effects of indirect decompression alone for L5-S1 foraminal stenosis.

OBJECTIVE

Evaluation of the clinical and mechanical performance of indirect decompression with anterior lumbar interbody fusion (ALIF) in L5-S1 foraminal stenosis.

METHODS

All patients who underwent ALIF at our institution and had a minimum follow-up of six months were assessed for inclusion. Radiographic parameters (anterior and posterior disc height, foraminal height and surface, L5-S1 angle, pelvic incidence, pelvic tilt and lumbar lordosis) and clinical data (Oswestry Disability Index - ODI and Numeric Rating Scale - NRS) before ALIF and at the last follow-up were compared. A regression analysis was performed to investigate the correlation between radiographic and clinical outcomes.

RESULTS

Thirty-four patients were available for the study (55.9% female, mean age 53.4±11.5 years), mean follow-up was 26.4±11.1 months. At the last follow-up, a significant increase in foraminal height (14.6±4.0 vs. 17.9±3.9 mm, p<0.001), posterior disc height (6.5±2 vs. 9.1±2 mm, p<0.001) was observed. ODI and NRS back and leg improved significantly. The NRS leg correlated with foraminal height (r=-0.45), foraminal surface (r=-0.36) and anterior (r=-0.41) and posterior disc height (r=-0.43).

CONCLUSION

ALIF provided significant indirect foraminal decompression and improvement of radicular pain. The increase of foraminal height, surface, and posterior disc height is directly associated with radicular pain improvement.

LEVEL OF EVIDENCE

IV AVAILABILITY OF DATA AND MATERIAL: The datasets used and/or analyzed in the present study are available from the corresponding author on reasonable request.

Osteochondral allograft transplantation for complex distal humeral fractures assisted by 3D computer planning and printing technology: technical note

PURPOSE

The surgical treatment of comminuted distal humeral articular fractures (DHF) is challenging and is jeopardized by the high rate of complications. The study aims to describe the application of osteochondral allograft (OCA) transplantation for the treatment of complex DHF assisted with a 3D printed specific instrumentation.

METHODS

Retrospective study. Inclusion criteria were the presence of an articular multi-fragmented DHF treated with frozen OCA. Clinical, self-reported and radiographic outcomes were collected every 6 months. CT were performed at 2 years FU.

RESULTS

Four patients were included. At a mean follow-up of 37.3 months (24-49) MEPS, DASH and VAS were 90 (80-100), 11.8 (0-25) and 1 (0-3) points, respectively. Not significant complication or reoperation was recorded. Graft healing was observed in 3 cases. In all cases, we observed arthritic progression after 2 years of follow-up.

CONCLUSION

OCA transplantation can be considered a reliable and safe procedure in patients affected by a complex DHF.

LEVEL OF EVIDENCE

Level V. Technical Notes.

European knowledge alliance for innovative measures in prevention of work-related musculoskeletal pain disorders (Prevent4Work Project): protocol for an international mixed-methods longitudinal study

INTRODUCTION

Work-related musculoskeletal (MSK) pain is a highly prevalent condition and one of the main contributors to disability and loss of work capacity. Current approaches to the management and prevention of work-related MSK pain do not consistently integrate current evidence-based knowledge and seem to be outdated. The Prevent4Work (P4W) Project aims to collect and spread evidence-based information to improve the management and prevention of work-related MSK pain. P4W will longitudinally investigate (1) risk factors associated with the prevalence of work-related MSK pain, (2) predictive factors for new events of work-related MSK pain in the short term and (3) the modification of pain beliefs after participating in evidence-based e-learning courses.

METHODS AND ANALYSIS

This project employs a mixed-methods design with international cohorts of workers from Spain, Italy and Denmark. All participants will be assessed using self-reported variables at baseline (ie, cross-sectional design) with follow-up after 3 and 6 months (ie, prospective-predictive design). Throughout the first phase (0-3 months), all participants will be offered to self-enrol in e-learning courses on work-related MSK pain. Changes in pain beliefs (if any) will be assessed. The dataset will include sociodemographic characteristics, physical and psychological job demands, lifestyle-related factors, MSK pain history and pain beliefs. At baseline, all participants will additionally complete the P4W questionnaire developed to detect populations at high risk of suffering work-related MSK pain.Descriptive statistics, binary logistic regression, and analysis of variance will be used to identify the significant factors that influence the history of work-related MSK pain, evaluate the short-term prediction capacity of the P4W questionnaire, and investigate whether workers' participation in e-learning courses will modify their pain beliefs.

ETHICS AND DISSEMINATION

The study received ethical approval from the Ethical Committee of San Jorge University (USJ011-19/20). The results will be made available via peer-reviewed publications, international conferences and P4W official channels.

Peri-Surgical Inflammatory Profile Associated with Mini-Invasive or Standard Open Lumbar Interbody Fusion Approaches

BACKGROUND

Different surgical approaches are available for lumbar interbody fusion (LIF) to treat disc degeneration. However, a quantification of their invasiveness is lacking, and the definition of minimally invasive surgery (MIS) has not been biochemically detailed. We aimed at characterizing the inflammatory, hematological, and clinical peri-surgical responses to different LIF techniques.

METHODS

68 healthy subjects affected by single-level discopathy (L3 to S1) were addressed to MIS, anterior (ALIF, n = 21) or lateral (LLIF, n = 23), and conventional approaches, transforaminal (TLIF, n = 24), based on the preoperative clinical assessment. Venous blood samples were taken 24 h before the surgery and 24 and 72 h after surgery to assess a wide panel of inflammatory and hematological markers.

RESULTS

martial (serum iron and transferrin) and pro-angiogenic profiles (MMP-2, TWEAK) were improved in ALIF and LLIF compared to TLIF, while the acute phase response (C-reactive protein, sCD163) was enhanced in LLIF.

CONCLUSIONS

MIS procedures (ALIF and LLIF) associated with a reduced incidence of post-operative anemic status, faster recovery, and enhanced pro-angiogenic stimuli compared with TLIF. LLIF associated with an earlier activation of innate immune mechanisms than ALIF and TLIF. The trend of the inflammation markers confirms that the theoretically defined mini-invasive procedures behave as such.

Development of the Prevent for Work questionnaire (P4Wq) for assessment of musculoskeletal risk in the workplace: part 1-literature review and domains selection

OBJECTIVE

This study aims to define appropriate domains and items for the development of a self-administered questionnaire to assess the risk of developing work-related musculoskeletal disorder (WMSD) and the risk of its progression to chronicity.

DESIGN

Literature review and survey study.

SETTING AND PARTICIPANTS

A literature review and a two-round interview with 15 experts in musculoskeletal pain were performed to identify the available domains for WMSD assessment.

INTERVENTIONS AND OUTCOME

To ensure quality, only validated questionnaires were included for the Delphi process. A three-round Delphi method, with three round steps, was used to select the most pertinent and relevant domains and items.

RESULTS

Nine questionnaires were identified through the expert discussion and literature review, comprising 38 candidate domains and 504 items. In the first round of the Delphi group, 17 domains reached more than 70% agreement and were selected. In the second round, 10 domains were rejected, while 11 were selected to complete the pool of domains. In the third and final round, 89 items belonging to 28 domains were defined as significant to develop a WMSDs risk assessment questionnaire.

CONCLUSIONS

No specific risk assessment questionnaires for WMSDs were identified from the literature. WMSD risk of presence and chronicity can be defined by an assessment tool based on the biopsychosocial model and the fear-avoidance components of chronic pain. The present study provides the formulation and operationalisation of the constructs in domains and items needed for developing and validating the questionnaire.

Assessment and prediction of spine surgery invasiveness with machine learning techniques

BACKGROUND

The interest in Minimally Invasive Surgery (MIS) techniques has greatly increased in the recent years due to their significant advantages, both in terms of outcome improvement and cost reduction. Also in spine surgery, MIS is now applicable to several conditions and, above all, in low back pain (LBP) treatment. However, reliable and objective measures of invasiveness, necessary to compare different procedures, are still lacking.

METHODS

In this article we study the application of Machine Learning (ML) techniques to define an invasiveness score for LBP procedures based on biological markers and inflammatory profiles. In so doing, we can assess the invasiveness of surgical procedures. We also propose a predictive model for treatment planning based on the evaluation of invasiveness of surgical alternatives for specific patients, using their pre-surgery biomarkers. The data used in study was characterized by low sample size and high-dimensionality, thus we adopted a combination of feature selection, careful selection of ML models and conservative model selection choices in order to address these concerns. We also performed an external validation based on a statistically significantly different datasets in order to confirm the relevance of the findings.

RESULTS

We report the results of an experimental study on real-world data, for which we obtained promising results for both considered applications: we report an AUC of 0.87 for the task of invasiveness score definition, and an AUC of 0.76 for the invasiveness prediction task. The results obtained on the external validation were in agreement with the obtained results. Further, in both cases the performances were considered as excellent by the involved clinicians and the selected predictive features were biologically relevant and associated with invasiveness and biological impact in the relevant literature.

CONCLUSION

Our results show that ML techniques could be effectively employed not only for diagnosis or prognosis, but also for treatment planning, a task of fundamental importance toward personalized and value-based healthcare. These results also show that ML approaches could be effectively used even in scenarios (e.g. pilot studies) where only small samples are available.

Functional outcomes of percutaneous correction of hallux valgus in not symptomatic flatfoot: a case series study

Hallux valgus (HV) and Pes Planus (PP) are two common conditions characterized by aesthetic dissatisfaction with or without pain. The aim of the study was to assess clinical and functional outcomes at two years follow-up of percutaneous surgery in patients with HV and concomitant not-symptomatic PP. From January 2014 to May 2015 a total of 12 females and 2 males (14 feet) were enrolled in the study (mean age 41.9±13.28). The inclusion criteria were patients with HV surgically treated with the percutaneous approach, mild or moderate not symptomatic PP at 24 months follow-up. Percutaneous distal metatarsal osteotomy and exostectomy is performed for all patients and followed by a weekly bandage. American Orthopaedic Foot and Ankle Society (AOFAS) score for HV (AOFAS-HV), patient satisfaction, and preoperative and postoperative X-ray at 6 weeks follow-up were evaluated. Numerical data are reported as the mean± SD and 95% confidence intervals. The pre-operative hallux valgus angle (HVA) was 30.14°±11.26°, the post-operative HVA was 18.36°±10.13 with a mean correction of 11.79°±2.67° with p<0.0001. Mean AOFAS-HV increased from 42.07±10.82 pre-operatively to 83±8.96 post-operatively with p<0.0001. One out of 14 patients had recurrence of HV without needing revision surgery at the last follow-up. All patients were satisfied with the clinical outcomes. Our results suggested that percutaneous osteotomy with the mini-burr is an effective treatment for patients with HV despite PP presence, even if the mean functional score was slightly worse when compared with the literature.

Education as a strategy for managing occupational-related musculoskeletal pain: a scoping review

BACKGROUND

Musculoskeletal (MSK) pain is the primary contributor to disability worldwide. There is a growing consensus that MSK pain is a recurrent multifactorial condition underpinned by health and lifestyle factors. Studies suggest that education on work-related pain and individualised advice could be essential and effective for managing persistent MSK pain.

OBJECTIVE

The objective of this scoping review was to map the existing educational resources for work-related MSK (WRMSK) pain, and the effects of implementing educational strategies in the workplace on managing WRMSK pain.

METHODS

This scoping review assessed original studies that implemented and assessed education as a strategy to manage WMSK pain. Literature search strategies were developed using thesaurus headings (ie, MeSH and CINAHL headings) and free-text search including words related to MSK in an occupational setting. The search was carried out in PubMed, CINAHL, Cochrane Library and Web of Science in the period 12-14 February 2019.

RESULTS

A total of 19 peer-reviewed articles were included and the study design, aim and outcomes were summarised. Of the 19 peer-reviewed articles, 10 randomised controlled trial (RCT) studies assessed the influence of education on work-related MSK pain. Many studies provided a limited description of the education material and assessed/used different methods of delivery. A majority of studies concluded education positively influences work-related MSK pain. Further, some studies reported additive effects of physical activity or ergonomic adjustments.

CONCLUSIONS

There is a gap in knowledge regarding the best content and delivery of education of material in the workplace. Although beneficial outcomes were reported, more RCT studies are required to determine the effects of education material as compared with other interventions, such as exercise or behavioural therapy.

Revision strategies for failed adult spinal deformity surgery

PURPOSE

The aim of this study is to analyse the results of revision surgery for failed adult spinal deformity patients and to describe the surgical strategy selection process, based on the identification of the main clinical diagnosis responsible for failure.

METHODS

We retrospectively reviewed the clinical and radiological data of 77 consecutive patients treated in a 3-year time (2016-2019) for surgical revision of long fusion (more than five levels fused) for adult spinal deformity in a high-volume spine centre, divided into four groups based on the diagnosis: rod breakage (RB) group, proximal junctional failure (PJF) group, distal junctional failure (DJF) group and loss of correction (LOC) group with symptomatic sagittal or coronal malalignment (including iatrogenic flatback).

RESULTS

Seventy-seven patients met our inclusion criteria, with a female prevalence (66 F vs. 11 M). The mean age at revision surgery was 63. Fused levels before surgery were averagely 12, and revision added averagely two levels to the preexisting fusion area. Clinical status was apparently improved in ODI scores and VAS scores, while it was slightly worsened in SF36 scores. Different diagnosis groups have been addressed with different surgical strategies, according to the different surgical goals: interbody cages and multi-rod construct to improve stiffness and favour bony fusion, "kickstand" rod and "tie" rod to correct coronal and sagittal malalignment, specific rod contouring and proximal hooks in "claw" configuration to reduce mechanical stress at the proximal junctional area. Intraoperative complications occurred in 18% of patients and perioperative complications in 39%.

CONCLUSION

Revision surgery in long fusions for adult spinal deformity is a challenging field. Surgical strategy should always be planned carefully. A successful treatment is a direct consequence of a correct preoperative diagnosis, and surgery should address the primary cause of failure. All the above-mentioned surgical techniques and clinical skills should be part of surgeon's expertise when managing these patients. These slides can be retrieved under Electronic Supplementary Material.

Useful and innovative methods for the treatment of postoperative coronal malalignment in adult scoliosis: the "kickstand rod" and "tie rod" procedures

STUDY DESIGN

Surgical technique description and case series.

OBJECTIVE

To describe the use of two techniques for the correction of postoperative coronal imbalance after surgical treatment for adult spine deformity (ASD). Sagittal and coronal spinal malalignments are often present in patients with ASD or in patients who have undergone spine surgery. Surgical correction of coronal imbalance is insufficiently investigated, and the literature provides a limited spectrum of surgical options when compared to sagittal imbalance. Nevertheless, this deformity can compromise the surgical outcome and can increase the risk of hardware failure.

METHODS

The kickstand (KR) and tie rod (TR) techniques utilize an accessory rod, linking the previous instrumentation to an independent iliac screw. After a proper release of the lumbar spine with anterior release or posterior osteotomies, the KR technique pushes with distraction on the concave side, whereas the TR technique pulls with compression on the convex side. Four patients (mean age, 64 years; SD 5.7) affected by severe postoperative coronal imbalance were treated. C7-PL ranges from 39 to 76 mm. The mean preoperative ODI was 70/100 (range from 55 to 82). All patients had previous spinopelvic fixation as a consequence of corrective surgery for adult spine deformity. The patients were surgically treated with the addition of supplementary rods connected to the ilium. The rods were used in the concavity or convexity of the deformity functioning as "kickstand" or "tie" or a combination of both.

RESULTS

The mean surgical correction of C7-PL was 35 mm (range from 20 to 52 mm). In particular, the mean correction for kickstand rod technique was 26 mm and for tie rod technique was 43 mm. All of the patients improved their preoperative disability, and mean ODI was 30/100 (range from 10 to 60) at median 19-month follow-up. All postoperative imaging showed implants were in proper position without hardware failure. All of the patients treated demonstrated an immediate postoperative improvement in terms of coronal displacement of the spine. No complications were observed. At 1-year follow-up, all of the patients remained satisfactory in terms of clinical outcomes.

CONCLUSION

The kickstand and tie rod techniques are effective in the treatment of postoperative coronal malalignment. Further studies are needed to confirm these findings.

LEVEL OF EVIDENCE

V: Case report. These slides can be retrieved under Electronic Supplementary Material.

Stentoplasty of calcaneal fractures: Surgical technique and early outcomes

Calcaneus is the most common site of hindfoot fracture, frequently caused by fall from height or high energy trauma. The therapeutic strategy ranged from non-operative to ORIF (Open Reduction Internal Fixation). Indications for percutaneous fixation include soft tissue damage or relative contraindications to open surgery. Minimally invasive percutaneous calcaneoplasty should be an alternative to ORIF aiming to reach a stable reduction, early functional recovery and short hospital stay. The aim of our study was to evaluate the clinical and radiographic outcomes of calcaneus fractures treated with balloon calcaneoplasty (BCP) by using a new generation vertebral augmentation system, VBS™-Vertebral Body Stent-DePuy Synthes. A total of 10 patients treated with VBS™ system were recruited for the study. Nine fractures were caused by a fall from height and one case by traffic accident. The mean follow-up was 8.9 months (range 2.6-23.1). The fractures were categorized according to Sanders and Essex-Lopresti classifications (5: type II, 3: type III and 2: type IV; 9: "joint depression" type and 1 case "tongue" type). Radiographic measurement (Böhler's and Gissane's angles) were evaluated at both pre-operative and immediate postoperative time. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score as well as a subjective evaluation (Visual Analog Scale, VAS) were used for the clinical assessment at the last follow-up. Mean preoperative Böhler's angle was 12.3 ± 8.41° (95% CI 6.3-18.3°), whereas mean preoperative Gissane's angle was 123.66 ± 20.47° (95% CI 109.0-138.3°). At postoperative follow-up mean Böhler's angle increased to 21.51 ± 4.17° (95% CI 18.5-24.5°; p < 0.01), and mean postoperative Gissane's angle was 121.74°±6.82° (95% CI 116.8°-126.6°). Mean AOFAS at the last follow-up was 70.4 ± 17.44 (95% CI 57.9-82.8). Our study demonstrates that percutaneous calcaneoplasty using VBS™ is an effective treatment for calcaneus fracture and capable to implement correction manoeuvre with clinical and radiographic outcomes comparable with other percutaneous stentoplasty.

Correction to: Spinal deformity and malocclusion association is not supported by high-quality studies: results from a systematic review of the literature

Unfortunately, first name and family name in the author group were incorrectly swapped and published. The complete correct names of the author group are given below.

Anatomical Modifications during the Lateral Transpsoas Approach to the Lumbar Spine. The Impact of Vertebral Rotation

Background

We investigated impact of vertebral axial rotation on neurovascular anatomy in adult spinal deformity (ASD) patients and provided recommendations on the approach based on degree of axial rotation. In order to isolate vertebral rotation (VR) impact from the superimposed degenerative cascade observed in adulthood, adolescent idiopathic scoliosis (AIS) patients were analyzed.

Methods

Magnetic resonance imaging (MRI) scans (L1-S1) from 50 right-convex thoracic (left-convex lumbar) AIS patients were analyzed. At each intervertebral level, VR, lumbar plexus depth (LPD), and vascular structure depth (VSD) were evaluated. Paired t test analyses were used to describe anatomic differences between the concave and convex aspect of our patients' curves. Correlation analysis was used to investigate relationships with soft tissue modifications and VR.

Results

Fifty AIS patients (17M, 33F) with mean thoracic Cobb of 50.6° ± 17.0° and mean lumbar Cobb of 41.9° ± 13.0° were included. Mean VR at each level was L1-2 = -6.6°, L2-3 = -7.7°, L3-4 = -6.5°, L4-5 = -4.7°, L5-S1 = -2.6° (negative value denotes clockwise rotation). We found significant differences (P < .05) between concave-convex (right-left) LPD at each level (L1-2 = 3.7 mm, L2-3 = 5.1 mm, L3-4 = 4.2 mm, L4-5 = 2.2 mm, L5-S1 = 2.2 mm). Vascular structure depth was significantly different at L1-L2 (3.2 mm) and L5-S1 (3 mm). Significant correlation was found between increasing VR and concave-convex LPD difference (r = 0.68, P < .001).

Conclusions

This study demonstrates that displacement of the lumbar plexus is tied to the magnitude of VR in patients with AIS. When approaching the lumbar spine, this displacement widens the safe surgical corridor on the convex side and narrows the corridor on the concave side.

Level of Evidence

IV.

Clinical Relevance

Preoperative review of MRI scans should occur to assess the patient's safe surgical corridor for lateral lumbar interbody fusion (LLIF). Adult spinal deformity surgeons who approach a degenerated spine in patients with progressive AIS in adulthood must carefully plan for patient positioning, neurovascular anatomy, and realignment objectives prior to the day of surgical intervention.

Real-time sonoelastography: principles and clinical applications in tendon disorders. A systematic review

Background

Sonoelastography (SE) is a new ultrasound-based method adopted in an increased number of scientific reports to analyse normal and pathological tendons. The aim of this study is to provide a systematic overview of clinical applications of SE in normal and pathological tendons.

Methods

A systematic research of PubMed, Ovid, and Cochrane Library electronic databases was performed according to PRISMA guideline. Two Authors searched and evaluated the articles independently; a third Author was involved to solve any disagreement. The Oxford Level of Evidence (LoE) was used to assess each article.

Results

There is an increasing interest in the application of SE in the evaluation of healthy and diseased tendons. Many different tendons are amenable for SE evaluation, such as the Achilles and patellar tendons, rotator cuff, common extensor tendons, quadriceps tendon, and the plantar fascia.

Conclusion

SE appears to be a very useful diagnostic tool, in particular in tendon pathology. This is a dynamic examination, provides an immediate evaluation of the tissue elasticity, and may be useful in recognizing tendon abnormalities and in implementing the information available with conventional US.

Level of evidence

IV.

Mini-Invasive Treatment for Brachymetatarsia of the Fourth Ray in Females: Percutaneous Osteotomy With Mini-Burr and External Fixation-A Case Series

Brachymetatarsia is a rare disease defined by metatarsal shortening and characterized by aesthetic dissatisfaction with or without pain. The aim of our study was to evaluate the outcomes of fourth ray brachymetatarsia treated with percutaneous osteotomy using a mini-burr and gradual lengthening with external fixation. A total of 7 females were recruited for the study; 6 (85.71%) of whom had a bilateral deformity, for a total of 13 feet affected by fourth ray brachymetatarsia. Percutaneous diaphysis osteotomy with a mini-burr followed by metatarsal elongation was performed. Metatarsal lengthening was measured as the difference between the preoperative and postoperative length at external fixator removal. The American Orthopaedic Foot and Ankle Society lesser toe metatarsophalangeal-interphalangeal score, patient satisfaction, restoration of Leliévre parabola, and treatment time were evaluated. Numerical data are reported as the mean ± standard deviation and 95% confidence intervals. The Mann-Whitney U test was used to compare the changes in the AOFAS score with a level of significance of p < .05. The mean metatarsal lengthening was 17.46 ± 4.89 (95% confidence interval [CI] 14.8 to 20.12) mm and the mean treatment time was 99.23 ± 8.53 (95% CI 94.59 to 103.87) days. The mean American Orthopaedic Foot and Ankle Society lesser toe metatarsophalangeal-interphalangeal score improved significantly from 76.38 ± 2.66 (95% CI 74.77 to 78.03) preoperatively to 86.46 ± 1.45 (95% CI 84.85 to 88.07) postoperatively (p < .01). In 12 of 13 feet (92.31%), the Leliévre parabola was restored, and the patients were satisfied with the clinical outcomes. The results of our study demonstrate that percutaneous osteotomy with the mini-burr and external fixation is an effective treatment for lengthening of fourth ray brachymetatarsia. Furthermore, we found good clinical and functional outcomes, high patient satisfaction, and a similar duration of treatment compared with other gradual lengthening procedures.

Reliability of the xipho-pubic angle in patients with sagittal imbalance of the spine

BACKGROUND

Proximal junctional kyphosis (PJK) is a frequent complication that compromises the outcomes of spinal surgery, especially for adult deformity. To the date no single risk factor or cause has been identified that explains its occurrence. The purpose of this study was to investigate the test-retest reliability of the radiologic measurements using xipho-pubic angle (XPA) for subjects undergoing surgery for sagittal misalignment of the spine.

METHODS

Retrospective observational cross-sectional study of prospectively collected data. Full-spine standing lateral radiographs of 50 patients who underwent surgery for fixed sagittal imbalance (preoperative and postoperative) were evaluated. Internal consistency, reproducibility, concurrent validity, and discriminative ability of the XPA. Two physicians measured XPA on the 100 randomly sorted and anonymized radiographs on two occasions, one week apart (test and retest conditions), were calculated for inter and intraobserver agreement.

RESULTS

Test-retest reliability of XPA measurement was excellent for pre- (ICC=0.98; P=0.001) and post-surgical (ICC=0.86; P=0.001) radiographs of subjects with sagittal imbalance of the spine. XPA was able to discriminate between preoperative and postoperative radiographs F=17.924, P<0.001) in patients undergoing surgery for fixed sagittal imbalance for both raters. There were significant differences between pre- vs. postoperative XPA, pelvic tilt, lumbar lordosis and sagittal vertical axis values (all P<0.001).

CONCLUSIONS

Xipho-pubic angle had fair to excellent test-retest reliability, and it did possess validity to discriminate between preoperative and postoperative radiographs in patients undergoing surgery for fixed sagittal imbalance.

Maximal access surgery for posterior lumbar interbody fusion with divergent, cortical bone trajectory pedicle screws: a good option to minimize spine access and maximize the field for nerve decompression

BACKGROUND

First advocated by Santoni et al. in 2009, the cortical bone trajectory pedicle screw technique is an alternative to the traditional, convergent technique that shows comparable biomechanical features and potentially requires less aggressive tissue retraction. Aim of this therapy note is to describe this new technique focusing on main advantages and limitations.

METHODS

The authors provide a detailed description of the surgically relevant anatomy focusing on the positioning of the cortical trajectory screws. The surgical technique is then described in a precise step-by-step manner, stressing complication avoidance.

RESULTS

The maximal access surgery posterior lumbar interbody fusion approach is a safe, reproducible procedure allowing for a traditional lumbar spine approach with the benefits of minimal facet joint manipulation and potentially preserving part of their neural innervation and a large part of the paraspinous musculature.

CONCLUSIONS

A dedicated self-retaining retractor and directional neuromonitoring may guide surgeons during the procedure. Nevertheless, the surgeon's knowledge of anatomical landmarks, response to visual and tactile cues and intraoperative decision-making skills remain of paramount importance.

Variations of cervical lordosis and head alignment after pedicle subtraction osteotomy surgery for sagittal imbalance

INTRODUCTION

The variations of the cervical lordosis after correction of sagittal imbalance have been poorly studied. The aim of our study is to verify whether the cervical lordosis changes after surgery for sagittal imbalance.

MATERIALS AND METHODS

Thirty-nine patients were included in the study. Cervical, thoracic and lumbar spine, pelvic and lower-limb sagittal parameters were recorded. The cranial alignment was measured by the newly described Cranial Slope.

RESULTS

The global cervical kyphosis (preop -43°, postop -31.5°) and the upper (preop -24.1°, postop -20.2°) and lower cervical kyphosis (preop -18.1°, postop -9.2°) were significantly reduced after surgical realignment of the trunk. A positive linear correlation was observed between the changes in T1 slope and the lower cervical lordosis, and between T1 slope and the global cervical alignment.

CONCLUSIONS

The cervical lordosis is reduced by surgical correction of malalignment of the trunk, suggesting an adaptive role to maintain the head's neutral position.