The aim of this study was to systematically compare the safety and accuracy of robot-assisted (RA) technique with conventional freehand with/without fluoroscopy-assisted (CT) pedicle screw insertion for spine disease. A systematic search was performed on PubMed, EMBASE, the Cochrane Library, MEDLINE, China National Knowledge Infrastructure (CNKI), and WANFANG for randomized controlled trials (RCTs) that investigated the safety and accuracy of RA compared with conventional freehand with/without fluoroscopy-assisted pedicle screw insertion for spine disease from 2012 to 2019. This meta-analysis used Mantel-Haenszel or inverse variance method with mixed-effects model for heterogeneity, calculating the odds ratio (OR), mean difference (MD), standardized mean difference (SMD), and 95% confidence intervals (CIs). The results of heterogeneity, subgroup analysis, and risk of bias were analyzed.Aims
Methods
Magnetically controlled growing rods (MCGR) have been gaining popularity in the management of early-onset scoliosis (EOS) over the past decade. We present our experience with the first 44 MCGR consecutive cases treated at our institution. This is a retrospective review of consecutive cases of MCGR performed in our institution between 2012 and 2018. This cohort consisted of 44 children (25 females and 19 males), with a mean age of 7.9 years (3.7 to 13.6). There were 41 primary cases and three revisions from other rod systems. The majority (38 children) had dual rods. The group represents a mixed aetiology including idiopathic (20), neuromuscular (13), syndromic (9), and congenital (2). The mean follow-up was 4.1 years, with a minimum of two years. Nine children graduated to definitive fusion. We evaluated radiological parameters of deformity correction (Cobb angle), and spinal growth (T1-T12 and T1-S1 heights), as well as complications during the course of treatment.Aims
Methods
The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons. An organizational model is presented based on case centralization in hub hospitals and early management of surgical cases to reduce hospital stay. Data from all the patients admitted for emergency spinal surgery from the beginning of the outbreak were prospectively collected and compared to data from patients admitted for the same reason in the same time span in the previous year, and treated by the same integrated team.Aims
Methods
Inflammatory response plays a pivotal role in the pathophysiological process of intervertebral disc degeneration (IDD). A20 (also known as tumour necrosis factor alpha-induced protein 3 (TNFAIP3)) is a ubiquitin-editing enzyme that restricts nuclear factor-kappa B (NF-κB) signalling. A20 prevents the occurrence of multiple inflammatory diseases. However, the role of A20 in the initiation of IDD has not been elucidated. The aim of the study was to investigate the effect of A20 in senescence of TNF alpha (TNF-α)-induced nucleus pulposus cells (NPCs). Immunohistochemical staining was performed to observe the expression of A20 in normal and degenerated human intervertebral discs. The NPCs were dissected from the tail vertebrae of healthy male Sprague-Dawley rats and were cultured in the incubator. In the experiment, TNF-α was used to mimic the inflammatory environment of IDD. The cell viability and senescence were examined to investigate the effect of A20 on TNF-α-treated NPCs. The expression of messenger RNA (mRNA)-encoding proteins related to matrix macromolecules (collagen II, aggrecan) and senescence markers (p53, p16). Additionally, NF-κB/p65 activity of NPCs was detected within different test compounds.Aims
Methods
Severe spinal deformity in growing patients often requires surgical management. We describe the incidence of spinal deformity surgery in a National Health Service. Descriptive study of prospectively collected data. Clinical data of all patients undergoing surgery for spinal deformity between 2005 and 2018 was collected, compared to the demographics of the national population, and analyzed by underlying aetiology.Aims
Methods
Lower back pain is a leading cause of disability and a common condition seen by osteopaths. Evidence and advice for the safest lifting posture vary, as do healthcare practitioners' attitudes towards back pain. The aim of this study was to understand osteopaths' beliefs about safe lifting postures, their attitudes towards back pain, and to compare these findings with published data from physiotherapists and manual handling advisors. A cross-sectional electronic survey was used to invite a sample of UK osteopaths to select images that best represent their perception of safe lifting posture (straight or rounded back), and to complete the Back Pain Attitudes Questionnaire (Back-PAQ, Appendix 1). Data was analysed to assess lifting posture selection and relationship to back pain attitudes. 46 (85.2%) out of 54 osteopaths selected straight back posture as safest, these participants had significantly more negative attitudes to back pain injury (i.e. higher Back-PAQ scores), than the 8 osteopaths who selected a rounded back posture (p = 0.007). Data from 266 physiotherapists and 132 manual handling advisors revealed an overall agreement about straight back lifting posture, however revealed differences in Back-PAQ attitude between the professions.Purpose and background
Methods and results
Non-specific chronic low back pain (NSCLBP) poses a significant disability and economic burden worldwide. Fear avoidance is suggested to contribute to its chronicity and reduced treatment effect. National guidelines recommend exercise as a component of multidisciplinary rehabilitation but its interaction with fear avoidance is ambiguous. This systematic review examined the effect of exercise-based interventions (EBIs) on fear avoidance NSCLBP. RCTs comparing EBIs to usual care in adults with NSCLBP were included. A systematic search of CINAHL, Medline, EMBASE, Web of Science, Scopus and Cochrane Library (up to January 2019) revealed 10 eligible trials. Following risk of bias assessment, 6 studies were included for data extraction and narrative synthesis. EBIs were not found superior to usual care in reducing fear avoidance at any follow-up. There was evidence that reducing fear avoidance is probably not the mechanism through which EBIs affect pain and disability. In adherent patients, EBIs did not result in greater clinically relevant improvements in pain or disability than usual care, in the short- or intermediate-term.Background and Purpose
Methods and Results
The rate of subsidence for lumbar fusion surgery is variable from 7- 89%. Subsidance can affect the outcome of surgery by compramising alignment, foraminal height and stability. Modic changes have been shown to affect the stiffness and strength of the vertebral end plate and shown to affect both fusion rates and clinical outcome. Ongoing laboratory investigations into the material properties of the degenerate lumbar spine show modic changes affect the end plate and trabecular bone mechanics. This study aims to bridge this basic science research into clinical practice. A retrospective analysis of all patients in two tertiary spinal centres who have undergone lumbar interbody fusion with the implantation of a ‘cage’ over the past 6 years were analysed by two independent spinal surgeons. Pre-operative MRI findings were correlated with post-operative interbody cage subsidence after 1 year.Background
Methods
Despite several hundred RCTs of exercise for persistent non-specific low back pain (NSLBP), the treatment targets of exercise are unclear. In a systematic review we observed 30 direct and indirect treatment targets of exercise described across 23 RCTs for persistent NSLBP. Since not all treatment targets and outcomes can be assessed in all RCTs, it is therefore important to prioritise these treatment targets through consensus from key stakeholders. These consensus workshops aimed to agree treatment targets for the use of exercise interventions in randomised controlled trials (RCTs) in persistent NSLBP using nominal group workshop (NGW) methodology. The first UK workshop included people who had experience of exercise to manage their persistent NSLBP, clinicians who prescribe exercise for persistent NSLBP, and researchers who design exercise interventions tested in RCTs. The second workshop included participants attending an international back and neck pain research workshop. Twelve participants took part in the UK NGW and fifteen took part in the final ranking of the exercise treatment targets. In addition to the original list of 30 treatment targets, a further 26 ideas were generated. After grouping and voting, 18 treatment targets were prioritised. The top five ranked targets of exercise interventions for persistent NSLBP were: pain reduction, improvement in function, reduction of fear of movement, encouragement of normal movement and improvement of mobility. The results of the international NGW will also be presented.Background and Aim of Study
Methods and Results
Clinical researchers use Pfirrmann classification for grading intervertebral disc degeneration radiologically. Basic researchers have access to morphology and instead use the Thompson score. The aim of this study was to assess the inter-observer reliability of both classifications, along with their correlation. We obtained T2-weighted MR images of 80 human lumbar intervertebral discs with various stages of degeneration to assess the Pfirrmann-score. Then the discs were dissected midsagittally to obtain the Thompson-score. The observers were typical users of both grading systems: a spine surgeon, radiology resident, orthopaedic resident, and a basic scientist, all experts on intervertebral disc degeneration. Cohen's kappa (CK) was used to determine inter-observer reliability, and intra-class correlation (ICC) as a measure for the variation between the outcomes. For the Thompson score, the average CK was 0.366 and ICC score 0.873. The average inter-observer reliability for the Pfirrmann score was 0.214 (CK) and 0.790 (ICC). Comparing the grading systems, the intra-observer agreement was 0.240 (CK) and 0.685 (ICC).Purpose of study and background
Methods and Results
Injectable hydrogels via minimally invasive surgery offer benefits to the healthcare system, reduced risk of infection, scar formation and the cost of treatment. Development of new treatments with the use of novel biomaterials requires significant pre-clinical testing and must comply with regulations before they can reach the bedside. In the European economic area (EEA) one of the first hurdles of this process is attaining the CE marking which protects the health, safety and environmental aspects of a product. Implanted materials fall under the class III medical device EU745 regulation standards. To attain the CE marking for a product parties must provide evidence of the materials safety with an investigational medicinal product dossier (IMPD). We have been working to develop a new thermoresponsive injectable biomaterial hydrogel (NPgel) for the treatment of intervertebral disc (IVD) disease. A large part of the IMPD requires information on how the hydrogel physical properties change over time in bodily conditions. We have been studying 6 batches of NPgel over 18 months, tracking the materials wet/ dry weight, structure and composition. To date we have found that NPgel in liquids more similar to the body (with protein and salts) appear to be stable and safe, whilst those in distilled water swell and disintegrate over time. Subtle long-term changes to the material composition were found and we are currently investigating its ramifications.Introduction
Methods and Results
We have developed a new synthetic hydrogel that can be injected directly into the intervertebral disc (IVD) without major surgery. Designed to improve fixation of joint prosthesis, support bone healing or improve spinal fusion, the liquid may support the differentiation of native IVD cells towards osteoblast-like cells cultured within the hydrogel. Here we investigate the potential of this gel system (Bgel) to induce bone formation within intervertebral disc tissue. IVD tissue obtained from patients undergoing discectomy, or cadaveric samples, were cultured within a novel explant device. The hydrogel was injected, with and without mesenchymal stem cells (MSCs), and cultured under hypoxia, to mimic the degenerate IVD environment, for 4 weeks. Explants were embedded to wax and native cellular migration into the hydrogel was investigated, together with cellular phenotype and matrix deposition.Introduction
Methods
Modic changes (MC) are a risk factor for development of chronic low back pain (CLBP). There is no agreement about the cause of inflammation in MC, but autoimmunity has been suggested. The aim of the study was to investigate whether treatment with lactic acid bacteria for 100 days was associated with change of disability and pain, via a change in the gut microbiota inducing a change in the immune system, in patients with CLBP and type 1 MC during one year follow-up. Eighty-nine patients with CLBP and type 1 MC were randomized to receive either one capsule Background and purpose
Methods
Intervertebral disc degeneration (IVDD) associated with low back pain is a major contributor to global disability. Current treatments are poorly efficient in the long-term resulting in medical complications. Therefore, minimally invasive injectable therapies are required to repopulate damaged tissues and aid regeneration. Among injectable biomaterials, self-assembling peptide hydrogels (SAPHs) represent potential candidates as 3D cell carriers. Moreover, the advent of graphene-related materials has opened the route for the fabrication of graphene-containing hydrogel nanocomposites to direct cellular fate. Here, we incorporated graphene oxide (GO) within a SAPH to develop a biocompatible and injectable hydrogel to be used as cell carrier to treat IVDD. Hydrogel morphology and mechanical properties have been investigated showing high mechanical properties (G'=12kPa) comparable with human native nucleus pulposus (NP) tissue (G'=10kPa), along with ease of handling and injectability in dry and body fluid conditions. Hydrogel nanocomposites resulted biocompatible for the encapsulation of bovine NP cells, showing higher viability (>80%) and metabolic activity in 3D cell culture over 7 days, compared to GO-free hydrogels. Moreover, GO has demonstrated to bind TGF-β3 biomolecules with high efficiency, suggesting the use of GO as local reservoir of growth factors within the injected hydrogel to promote extracellular matrix deposition and tissue repair.Introduction
Methods and results
The EU-funded Back-UP project aims to develop a cloud computer platform to guide the treatment of low back and neck pain (LBNP) in first contact care and early rehabilitation. In order to identify evidence-based treatment options that can be recommended and are accessible to people with LBNP across Europe, we conducted a systematic review of recently published guidelines. Electronic databases, including Medline, Embase, CINAHL, PsycINFO, HMIC, Epistemonikos, PEDro, TRIP, NICE, SIGN, WHO, Guidelines International Network (G-I-N) and DynaMed Plus were searched. We searched for guidelines published by European health professional or guideline development organisations since 2013, focusing on the primary care management of adult patients presenting with back or neck pain (including whiplash associated symptoms, radicular pain, and pregnancy-related LBP). The AGREE-II tool was used to assess the quality of guideline development and reporting.Background and aims
Methods
Both overall spine shape and the size and shape of individual vertebrae undergo rapid growth and development during early childhood. Motor development milestones such as age of walking influence spine development, with delayed ambulation linked with spinal conditions including spondylolysis. However, it is unclear whether associations between motor development and spine morphology persist into older age. Therefore, these associations were examined using data from the MRC National Survey of Health and Development, a large nationally-representative British cohort, followed up since birth in 1946. Statistical shape modelling was used to characterise spinal shape (L5-T10) and identify modes of variation in shape (SM) from dual energy x-ray absorptiometry images of the spine taken at age 60–64 years (N=1327 individuals; 51.8% female). Associations between walking age in months (reported by mothers at 2 years) and SMs were examined with adjustment for sex, birthweight, socioeconomic position, height, lean mass and fat mass. Later onset of independent walking was weakly associated with greater lordosis (SM1; Purpose and Background
Methods and Results
Trunk muscle activity and thoraco-lumbar kinematics have been shown to discriminate non-specific chronic low back pain (NSCLBP) subgroups from healthy controls. Thoracic spine kinematics and muscle activity whilst intuitively associated with NSCLBP, has received less attention and the possibility of intra-regional interactions remains an area for exploration. Determine relationships between muscle activation and kinematics in active extension pattern (AEP) and flexion pattern (FP) subgroups and no-low back pain controls during a sagittal bending task.Background
Purpose
Mesenchymal stem cells (MSCs) are undergoing evaluation as a potential new therapy for immune and inflammatory-mediated conditions such as IVD degeneration (IDD). Both adipose (ASCs) and bone-marrow (BMSCs) derived MSCs have been widely used in this regard. The optimal tissue source and expansion conditions required to exploit the regenerative capacity of these cells are not yet fully elucidated. In addition the phenotypic response of transplanted cells to the disease environment is not well understood. In this study, ASCs and BMSCs were exposed to a combination of hypoxic conditioning and selected inflammatory mediators, conditions that mimic the microenvironment of the degenerate IVD, in an effort to understand their therapeutic potency for Donor-matched ASCs and MSCs were pre-conditioned with either IL-1β (10ng/ml) or TNFα (10ng/ml) for 48 hours under hypoxic conditions (5% O2). Conditioned media was collected and 45 different immunomodulatory proteins were analysed using human magnetic Luminex® assay. Secreted levels of several key cytokines and chemokines, both pro- and anti-inflammatory, were significantly upregulated in ASCs and BMSCs following the conditioning regime. Under all conditions tested, ASCs expressed significantly higher levels of IL-4, IL-6, IL-10, IL-12, TGF-α, and GCSF compared to BMSCs. Pre-conditioning with TNFα resulted in significantly higher levels of IL-10 while preconditioning with IL-1β resulted in higher levels of IL-6, IL-12 and GCSF.Background
Methods and Results
The intervertebral disc is constantly subjected to forces generated by movement. But degeneration can disrupt normal biomechanics, generating uneven and complex loading patterns. Evidence suggests that these forces are converted into voltages through different mechanisms, such as streaming potentials. This implicates voltage-gated ion channels in the biological remodelling response of the disc to loading. These signalling pathways have not been studied, and this incomplete understanding of disc mechanotransduction may hinder regenerative therapies. The purpose of this study is to identify and determine the role of voltage-gated ion channels in the intervertebral disc and to investigate any changes in degeneration. Primary bovine and human disc cells were cultured in monolayer or alginate beads for experiments. Cells were treated with altered osmolarity alone or in combination with IL-1β. Ion flux was measured through calcium influx and will be further investigated using the xCelligence RTCA CardioECR. Immunohistochemistry was performed on human and bovine discs to evaluate expression levels of ion channels. RNA was extracted from bovine NP cells and will be analysed through PCR/Microarray for gene expression.Purpose and Background
Methods and Results
This report presents independent research commissioned by the National Institute for Health Research (NIHR) (NIHR HTA project number 12/201/09). NEF is a Senior NIHR Investigator and was supported through an NIHR Research Professorship (NIHR-RP-011-015). KK was supported by a HEFCE Senior Clinical Lectureship award. The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, MRC, CCF, NETSCC, the Health Technology Assessment programme or the Department of Health. Stratified care (SC) has previously been found to be a cost-effective approach for primary care LBP patients. The SCOPiC trial compared the clinical and cost-effectiveness of a modified SC model combining prognostic and clinical characteristics to allocate sciatica patients into one of three groups (with matched care pathways) versus non-stratified, usual care (UC).Funding
Background and Purpose
