Aims. It has been well documented in the arthroplasty literature that lumbar degenerative disc disease (DDD) contributes to abnormal spinopelvic motion. However, the relationship between the severity or pattern of hip osteoarthritis (OA) as measured on an anteroposterior (AP) pelvic view and spinopelvic biomechanics has not been well investigated. Therefore, the aim of the study is to examine the association between the severity and pattern of hip OA and spinopelvic motion. Methods. A retrospective chart review was conducted to identify patients undergoing primary total hip arthroplasty (THA). Plain AP pelvic radiographs were reviewed to document the morphological characteristic of osteoarthritic hips. Lateral spine-pelvis-hip sitting and standing plain radiographs were used to measure sacral slope (SS) and pelvic femoral angle (PFA) in each position. Lumbar disc spaces were measured to determine the presence of DDD. The difference between sitting and standing SS and PFA were calculated to quantify spinopelvic motion (ΔSS) and hip motion (ΔPFA), respectively. Univariate analysis and Pearson correlation were used to identify morphological hip characteristics associated with changes in spinopelvic motion. Results. In total, 139 patients were included. Increased spinopelvic motion was observed in patients with loss of femoral head contour, cam deformity, and acetabular bone loss (all p < 0.05). Loss of hip motion was observed in patients with loss of femoral head contour, cam deformity, and acetabular bone loss (all p < 0.001). A decreased joint space was associated with a decreased ΔPFA (p = 0.040). The presence of disc space narrowing, disc space narrowing > two levels, and disc narrowing involving the L5–S1 segment were associated with decreased spinopelvic motion (all p < 0.05). Conclusion. Preoperative hip OA as assessed on an AP pelvic radiograph predicts spinopelvic motion. These data suggest that specific hip osteoarthritic morphological characteristics listed above alter spinopelvic motion to a greater extent than others. Cite this article: Bone Joint J 2023;105-B(5):496–503

Background. The majority of adults will experience an episode of low back pain during their life. Patients with non-specific low back pain and lumbar disc degeneration (LDD) may experience spinal pain and morning stiffness because of a comparable inflammatory process as in patients with osteoarthritis of the knee and/or hip. Therefore, this study assessed the association between spinal morning stiffness, LDD and systemic inflammation in middle aged and elderly patients with low back pain. Methods. This cross-sectional study used the baseline data of the BACE study, including patients aged ≥55 years visiting a general practitioner with a new episode of back pain. The association between spinal morning stiffness, the radiographic features of lumbar disc degeneration and systemic inflammation measured with serum C-reactive protein was assessed with multivariable logistic regression models. Results. At baseline, a total of 661 back pain patients were included. Mean age was 66 years (SD 8), 416 (63%) reported spinal morning stiffness and 108 (16%) showed signs of systemic inflammation measured with CRP. Both LDD definitions were significantly associated with spinal morning stiffness (osteophytes OR=1.5 95% CI 1.1–2.1, narrowing OR=1.7 95% CI 1.2–2.4) and spinal morning stiffness >30 minutes (osteophytes OR=1.9 95% CI 1.2–3.0, narrowing OR=3.0 95% CI 1.7–5.2) For severity of disc space narrowing we found a clear dose response relationship with spinal morning stiffness. We found no associations between spinal morning stiffness and the features of LDD with systemic inflammation. Conclusions. This study demonstrated an association between the presence and duration of spinal morning stiffness and radiographic LDD features. No conflicts of interest. No funding obtained

Objectives

Researchers continue to seek easier ways to evaluate the quality of bone and screen for osteoporosis and osteopenia. Until recently, radiographic images of various parts of the body, except the distal femur, have been reappraised in the light of dual-energy X-ray absorptiometry (DXA) findings. The incidence of osteoporotic fractures around the knee joint in the elderly continues to increase. The aim of this study was to propose two new radiographic parameters of the distal femur for the assessment of bone quality.

Aims

The aim of this study was to investigate the clinical and radiographic outcomes of microendoscopic laminotomy in patients with lumbar stenosis and concurrent degenerative spondylolisthesis (DS), and to determine the effect of this procedure on spinal stability.

Objectives

Pedicle-lengthening osteotomy is a novel surgery for lumbar spinal stenosis (LSS), which achieves substantial enlargement of the spinal canal by expansion of the bilateral pedicle osteotomy sites. Few studies have evaluated the impact of this new surgery on spinal canal volume (SCV) and neural foramen dimension (NFD) in three different types of LSS patients.

Aims

A total of 30 patients with thoracolumbar/lumbar adolescent idiopathic scoliosis (AIS) treated between 1989 and 2000 with anterior correction and fusion surgery using dual-rod instrumentation were reviewed.

Aims

The aims of this study were to evaluate the clinical and radiological outcomes of instrumented posterolateral fusion (PLF) performed in patients with rheumatoid arthritis (RA).

The April 2013 Spine Roundup³⁶⁰ looks at: smuggling spinal implants; local bone graft and PLIF; predicting disability with slipped discs; mortality and spinal surgery; spondyloarthropathy; brachytherapy; and fibrin mesh and BMP.

The June 2012 Spine Roundup³⁶⁰ looks at: back pain; spinal fusion for tuberculosis; anatomical course of the recurrent laryngeal nerve; groin pain with normal imaging; the herniated intervertebral disc; obesity’s effect on the spine; the medicolegal risks of cauda equina syndrome; and intravenous lidocaine use and failed back surgery syndrome.

We conducted a prospective follow-up MRI study of originally asymptomatic healthy subjects to clarify the development of Modic changes in the cervical spine over a ten-year period and to identify related factors. Previously, 497 asymptomatic healthy volunteers with no history of cervical trauma or surgery underwent MRI. Of these, 223 underwent a second MRI at a mean follow-up of 11.6 years (10 to 12.7). These 223 subjects comprised 133 men and 100 women with a mean age at second MRI of 50.5 years (23 to 83). Modic changes were classified as not present and types 1 to 3. Changes in Modic types over time and relationships between Modic changes and progression of degeneration of the disc or clinical symptoms were evaluated. A total of 31 subjects (13.9%) showed Modic changes at follow-up: type 1 in nine, type 2 in 18, type 3 in two, and types 1 and 2 in two. Modic changes at follow-up were significantly associated with numbness or pain in the arm, but not with neck pain or shoulder stiffness. Age (≥ 40 years), gender (male), and pre-existing disc degeneration were significantly associated with newly developed Modic changes.

In the cervical spine over a ten-year period, type 2 Modic changes developed most frequently. Newly developed Modic changes were significantly associated with age, gender, and pre-existing disc degeneration.

The Lumbar Spinous Processes (LSP) have an important anatomical and biomechanical function protecting the neural structures in the spinal canal, and as an anchor for the inter and supraspinous ligaments, and the inter-segmental paraspinal muscles. They also influence access to the spinal canal for neural decompressive surgical procedures. More recently the LSPs have attracted increased interest as a site for surgical device attachment in an attempt to both decrease the symptoms of spinal stenosis, and as a site for intersegmental stabilization without formal fusion. There is evidence that various anatomical structures have altered morphology with ageing, and there is anecdotal evidence of changing LSP morphology with age. This study aims to clarify the influence of age on LSP morphology, and on lumbar spine alignment. 200 CT scans of the abdomen were reformatted with bone windows in sagittal and coronal planes allowing precise measurement of LSP dimensions, and Lumbar Lordosis. Observers were blinded to patient demographics. Inter-observer reliability was examined. Data was analysed by an independent statistician. The smallest LSP is at L5. The male LSP is on average 2–3mm higher and 1mm wider than the female LSP. LSP height increases significantly with age at every level in the lumbar spine (p< 10-5 at L2). The LSPs increase in height by 2–5mm between 20–85 years of age (p< 10-6), which was as much as 31% at L5 (p< 10-8). Width increases proportionally more, by 3–4mm or greater than 50% at each lumbar level (p< 10–11). Lumbar lordosis decreases in relation to increasing LSP height (p< 10-4) but is independent of increasing LSP width (p=0.2). This study demonstrates that the dimensions of the LSP change with age. Increases in LSP height occur with age. More impressive increases in LSP width occur with advancing age. This study suggests that loss of lumbar lordosis is correlated with changing LSP morphology. The increased width of the LSP with age influences access to the spinal canal, particularly if midline-preserving approaches are attempted in the ageing population. There is increased bone volume for bone grafting procedures with increasing age. The reduced distance between LSPs with age may influence design of implants that stabilize this region of the spine, and occur not only as a result of disc space narrowing, but also as a consequence of increased LSP dimensions

A number of causes have been advanced to explain the destructive discovertebral (Andersson) lesions that occur in ankylosing spondylitis, and various treatments have been proposed, depending on the presumed cause. The purpose of this study was to identify the causes of these lesions by defining their clinical and radiological characteristics.

We retrospectively reviewed 622 patients with ankylosing spondylitis. In all, 33 patients (5.3%) had these lesions, affecting 100 spinal segments. Inflammatory lesions were found in 91 segments of 24 patients (3.9%) and traumatic lesions in nine segments of nine patients (1.4%). The inflammatory lesions were associated with recent-onset disease; a low modified Stoke ankylosing spondylitis spine score (mSASSS) due to incomplete bony ankylosis between vertebral bodies; multiple lesions; inflammatory changes on MRI; reversal of the inflammatory changes and central bony ankylosis at follow-up; and a good response to anti-inflammatory drugs. Traumatic lesions were associated with prolonged disease duration; a high mSASSS due to complete bony ankylosis between vertebral bodies; a previous history of trauma; single lesions; nonunion of fractures of the posterior column; acute kyphoscoliotic deformity with the lesion at the apex; instability, and the need for operative treatment due to that instability.

It is essential to distinguish between inflammatory and traumatic Andersson lesions, as the former respond to medical treatment whereas the latter require surgery.

In a prospective observational study we compared the two-year outcome of lumbar fusion by a simple technique using translaminar screws (n = 57) with a more extensive method using transforaminal lumbar interbody fusion and pedicular screw fixation (n = 63) in consecutive patients with degenerative disease of the lumbar spine. Outcome was assessed using the validated multidimensional Core Outcome Measures Index. Blood loss and operating time were significantly lower in the translaminar screw group (p < 0.01). The complication rates were similar in each group (2% to 4%). In all, 91% of the patients returned their questionnaire at two-years. The groups did not differ in Core Outcome Measures Index score reduction, 3.6 (sd 2.5) (translaminar screws) vs 4.0 (sd 2.8) (transforaminal lumbar interbody fusion) (p = 0.39); ‘good’ global outcomes, 78% (translaminar screws) vs 78% (transforaminal lumbar interbody fusion) (p = 0.99) or satisfaction with treatment, 82% (translaminar screws) vs 86% (transforaminal lumbar interbody fusion) (p = 0.52).

The two fusion techniques differed markedly in their extent and the cost of the implants, but were associated with almost identical patient-orientated outcomes.

Extensive three-point stabilisation is not always required to achieve satisfactory patient-orientated results at two years.

Purpose: We present the early results of a pilot study of 10 patients evaluating the basic safety and performance of an in situ polymerising protein hydrogel used in discectomy to prevent recurrent nuclear herniation, reduce motion segment instability and preserve disc height. Method: Patients with radicular symptoms due to a MRI scan proven disc herniation, failed at least 3 months of conservative therapy, and had mild to moderate disc space narrowing. A standard open discectomy was performed to create a cavity for the implant, which was injected into the void through the annulotomy. The implant polymerised within 2 minutes. All patients had standard post-operative care for open discectomy. The patients were assessed pre-operatively and post-operatively at 6 weeks, 3, and 6 months using Visual Analogue pain scale (VAS), Oswestry Disability index (ODI), SF-36 Health Survey (SF-36) and positional MRI scan in sitting (flexion, extension and neutral), erect and supine positions. To date, seven patients have a six-month follow up. Results: Six females and 4 males were implanted into either the L4/L5 (5 patients) or L5/S1 (5 patients) level. The mean age of the patients was 40.6 years with a range of 19–57 years. ODI decreased from a mean of 49.2 pre-operatively to a mean of 11 at 6 months, and numerical pain score from of 5.86 to 1.62. Physical Component Score improved from a mean of 28.52 pre-operatively to 48.10 at 6 months. Two patients have suffered recurrent herniation, male (L5/S1) at 10 days, and a female (L5/S1) at 8 months, both requiring surgery. Conclusion: Early clinical results indicate that the material can be used to fill the nuclear void following discectomy. Long-term data will be collected and evaluated to determine its efficacy in reducing spinal segment instability and preserving disc height

A 48-year old man presented with back pain that was resistant to treatment. An MR scan showed spondylolisthesis at L4-5 and narrowing of the exit foraminae. He had a posterior fusion which did not relieve his symptoms. He continued to have back pain and developed subcutaneous nodules in both forearms. Biopsy from the skin revealed cutaneous sarcoidosis, and one from the lumbar spine showed sarcoidosis granuloma between the bone trabeculae. A CT scan of the abdomen and chest revealed axillary lymphadenopathy, mediastinal enlarged nodes, apical nodular nodes and splenomegaly. The patient was started on large doses of methotrexate and steroids. His angiotensin-converting enzyme and calcium levels returned to normal and the back pain resolved.

Introduction: Following surgical discectomy for pro-lapsed lumbar intervertebral disc, a proportion of patients develop leg symptoms on the side contra-lateral to the original surgery. Among other causes, subsequent disc space narrowing together with on-going degenerative changes may cause root entrapment in the lateral recess or in the intervertebral canal at the level of the previous disc prolapse. It has been previously reported that the results of discectomy are less successful in patients with pre-existing spinal stenosis. It may be argued that patients with a narrow spinal canal would be more prone to the development of contra-lateral symptoms. The aim of this study was to determine whether any measurement on the pre-operative CT scan could predict the development of contra-lateral symptoms, or provide an indication for prophylactic decompression of the contra-lateral side at the time of the original surgery. Materials & Methods: In a retrospective cohort of 43 patients following lumbar discectomy, eight subsequently developed symptoms on the contra-lateral side of whom three required subsequent contra-lateral surgery. A relationship was demonstrated between a measurement taken on the pre-operative CT scan (the oblique sub-facet distance) and the occurrence of contra-lateral symptoms following discectomy. Conclusion: An oblique sub-facet distance of 8mm or less predicted the development of contra-lateral symptoms with a sensitivity of 75 % and a specificity of 74%

Lumbar disc replacement with a modern articulating disc prosthesis was first done in 1984, using the Charité SB I prosthesis. Since then other discs, easier to implant, have been developed (Prodisc, Maverick, Centurion). We present short-term (6 to 18 month) clinical results of implantation of 121 Centurion disc prostheses in 93 consecutive patients. This modular three-component titanium/polyethylene disc is inserted as one unit and suitable for minimal interventional approaches. The mean age of the patients was 43 years (23 to 63). The primary diagnosis was degenerative disc disease, with 16 patients having symptoms of spinal stenosis. Forty-four patients underwent single-level disc replacements and 28 double-level disc replacements. Nine patients had a fusion of another level at the time of the index procedure and 12 patients had disc replacement at a junctional level after previous fusion procedures. At 6-month follow-up of 50 patients, clinical outcome was excellent in 27 patients, good in 16, fair in four and poor in three. The Oswestry score improved from 51.2 ±16.0 preoperatively to 13.2 ± 17.8 (p < 0.01) at 6 months. One of the first 29 patients was lost to follow-up. In the other 28 there were 16 excellent, seven good, three fair and two poor outcomes. The Oswestry score improved from 49.7 ± 17.5 preoperatively to 13.0 ± 14.9 (p < 0.01) at 1 year. Good short-term clinical results were achieved in a heterogeneous patient group, largely with advanced disc degeneration and severe disc space narrowing. Using a new insertion mechanism, posterior placement within the disc space and disc space distraction could be reliably achieved even in preoperatively collapsed and immobile disc spaces

Introduction: posterior lumbar interbody fusion can theoretically allow neural decompression directly and by restoration of disc height and appropriate lumbar lordosis. The technique of insertion of a trapezoidal lordotic wedge spacer (ramp) into the disc space before rotating it into position theoretically will obtain both an increase in disc height and allow correction of lordosis. However observations suggest that incongruity between a flat implant and a curved end plate, and possible settling of the implant into the vertebral body may limit the ability of the technique to achieve its full theoretical potential. This paper attempts to establish the capacity of this technique to (1) restore disc height, and (2) alter segmental lordosis. Methods: pre- and post-operative lateral radiographs were obtained from 34 patients who had undergone posterior lumbar interbody fusion using carbon fibre spacers with a lordotic angle of five degrees. Supplemental pedicle screws were used in all cases. The procedure was performed at l2/3 in one case, at l3/4 in two cases, at l4/5 16 cases and l5/1 in 15 cases. Measurements of pre- and post-operative lordosis, anterior and posterior disc height, slip percentage and anterior and posterior positioning of the prosthesis were made. To allow for comparison of length measurements the raw data were normalised by dividing by the inferior end plate length. Results: stepwise multiple linear regression showed the only variable to be related to final post-operative lordosis was pre-operative lordosis (p = 0.026). There was no relationship between final lordosis and implant placement or slip percentage. The regression line suggested that small pre-operative segmental angles (less than 7.5 degrees) were increased post-operatively while large pre-operative angles (greater than 7.5 degrees) were reduced. This suggests that the segment is attempting to accommodate to the five-degree implant. The regression equation only explains 14% of the total variance (r. 2. = 0.144). The mean normalised posterior disc height increased significantly by 55% (0.1195 to 0.1844) (paired t test p < 0.0001) and the mean normalised anterior disc height increased by 18% (0.27151 to 0.32251) (paired t test p < 0.007). Changes in both anterior and posterior disc height were highly correlated with pre-operative disc height (r = −0.6729 p < 0.0001, r = −0.7402 p < 0.0001). Discussion: posterior lumbar interbody fusion using a five degree wedged spacer can lead to significant improvements in anterior and posterior disc height when the disc space is narrowed and maintain disc height when the disc height is normal. The insertion of a wedged implant causes the segment to approximate the lordosis of the implant. The variation is however large. Possible causes for this variation are a mismatch between the flat implant and a curved end plate and end plate subsidence. Having a curved implant end plate and a selection of lordotic angles may possibly reduce the former effect

Cadaveric lumbar spine specimens of "motion segments", each including two vertebrae and the linking disc and facet joints, were compressed. The pressure across the facet joints was measured using interposed pressure-recording paper. This was repeated for 12 pairs of facet joints at four angles of posture and with three different disc heights. The results were that pressure between the facets increased significantly with narrowing of the disc space and with increasing angles of extension. Extra-articular impingement was found to be caused, or worsened, by disc space narrowing. Increased pressure or impingement may be a source of pain in patients with reduced disc spaces