Aims. The aim of this study was to assess the ability of morphological spinal parameters to predict the outcome of bracing in patients with adolescent idiopathic scoliosis (AIS) and to establish a novel supine correction index (SCI) for guiding bracing treatment. Methods. Patients with AIS to be treated by bracing were prospectively recruited between December 2016 and 2018, and were followed until brace removal. In all, 207 patients with a mean age at recruitment of 12.8 years (SD 1.2) were enrolled. Cobb angles, supine flexibility, and the rate of in-brace correction were measured and used to predict curve progression at the end of follow-up. The SCI was defined as the ratio between correction rate and flexibility. Receiver operating characteristic (ROC) curve analysis was carried out to assess the optimal thresholds for flexibility, correction rate, and SCI in predicting a higher risk of progression, defined by a change in Cobb angle of ≥ 5° or the need for surgery. Results. The baseline Cobb angles were similar (p = 0.374) in patients whose curves progressed (32.7° (SD 10.7)) and in those whose curves remained stable (31.4° (SD 6.1)). High supine flexibility (odds ratio (OR) 0.947 (95% CI 0.910 to 0.984); p = 0.006) and correction rate (OR 0.926 (95% CI 0.890 to 0.964); p < 0.001) predicted a lower incidence of progression after adjusting for Cobb angle, Risser sign, curve type, menarche status, distal radius and ulna grading, and brace compliance. ROC curve analysis identified a cut-off of 18.1% for flexibility (sensitivity 0.682, specificity 0.704) and a cut-off of 28.8% for correction rate (sensitivity 0.773, specificity 0.691) in predicting a lower risk of curve progression. A SCI of greater than 1.21 predicted a lower risk of progression (OR 0.4 (95% CI 0.251 to 0.955); sensitivity 0.583, specificity 0.591; p = 0.036). Conclusion. A higher supine flexibility (18.1%) and correction rate (28.8%), and a SCI of greater than 1.21 predicted a lower risk of progression. These novel parameters can be used as a guide to optimize the outcome of bracing. Cite this article: Bone Joint J 2022;104-B(4):495–503

Background. Low back pain can lead to neuroplastic changes in the central nervous system, known as nociplastic pain. As nociplastic pain may be provoked by premorbid sensory profiles, such profiles may be prognostic in the development of nociplastic pain over time. Objectives. To investigate whether four sensory profiles are prognostic in the development of symptoms of nociplastic pain in people with acute low back pain. Methods. A longitudinal type 2 prognostic factor research study was performed in accordance with the PROGRESS framework, using a baseline and a follow-up after 12 weeks, between the Adolescent/Adult Sensory Profile and the Central Sensitisation Inventory. Study participants were consecutively included from primary care physiotherapy practices randomly spread throughout the Netherlands. A multivariable regression analysis was performed to adjust sensory profiles by the level of pain, disability, age, and duration of low back pain. Results. After adjustment Low Registration B=0.41, 95%CI (0.37, 0.99), Sensory Seeking B=0.37, 95%CI (0.24, 0.73), Sensory Sensitive B=0.51, 95%CI (0.50, 1.06), Sensation Avoiding B=0.46, 95%CI (0.43, 0.99) were significantly associated with the development of nociplastic pain symptoms. Conclusion. Sensory profiles in people with acute low back pain predict symptoms of nociplastic pain after 12 weeks. Conflict of interest: No conflict of interest. Sources of funding: No funding obtained

Objective. Low back pain (LBP) is a common debilitating condition with great socioeconomic impact. Identifying individuals at risk of LBP is challenging. We have shown IgG N-glycans are associated with LBP. Herewith, we used polygenic risk scores (PRS) from IgG-glycome to test predictability for LBP. Methods. Clusters of IgG-glycans were identified using weighted correlation network approach in TwinsUK (n = 4246). Genome-wide association studies were carried out for the clusters and top associated SNPs (p<5e-8) were extracted. Weighted PRS was calculated as the sum of the number of copies of effect allele from GWAS multiplied by their effect size using the UK Biobank data (n = 350000). The predictive capacity of the PRS for back pain in UK Biobank was estimated using logistic regression. Results. Multiple SNPs were found to be associated with the glycan clusters near genes known to be involved in glycosylation and the inflammatory response (e.g. ST6GAL1, B4GALT1, FUT8). A total of 175 SNPs was used to calculate weighted PRS. In UK Biobank the PRS was a statically significant, but poor, predictor of the risk of back pain (β = 0.126±0.050, p = 0.015, R. 2. = 2.6e-5). The SNPs on chromosome 14 in regulatory regions of FUT8 gene, one of the key governors of core fucosylation, were found to be significantly associated with back pain in UK Biobank (FDR-adjusted p-value < 0.05). Conclusions. These pilot data suggest that genetic component of glycosylation may be associated with the risk of LBP; however, its predictive ability is poor. Conflict of Interest: YSA is a co-owner of Maatschap PolyOmica. GL is a founder and CEO of Genos Glycoscience Research Laboratory. MBF and FMKW declare no conflict of interests. Sources of Funding: The research has been supported by the EC FP7 project PainOmics (grant agreement #602736) and conducted using the UK Biobank Resource (project # 18219)

Introduction. Pain is an expected and appropriate experience following traumatic musculoskeletal injury. By contrast, chronic pain and disability are unhelpful yet common sequelae of trauma-related injuries. Presently, the mechanisms that underlie the transition from acute to chronic disabling post-traumatic pain are not fully understood. The aim of this study is to identify prognostic factors for risk of developing chronic pain and disability following acute musculoskeletal trauma. Methods. A prospective observational study will recruit two temporally staggered cohorts (n=250 each cohort; 10 cases per candidate predictor) of consecutive acute musculoskeletal trauma patients aged ≥16 years, who are emergency admissions into a Major Trauma Centre in the United Kingdom, with an episode inception defined as the traumatic event. The first cohort will identify prognostic factors to develop a screening tool to predict development of chronic and disabling pain, and the second will allow evaluation of the predictive performance of the tool (validation). The outcome being predicted is an individual's absolute risk of poor outcome measured at 6-months follow-up using the Chronic Pain Grade Scale (poor outcome ≥Grade II). Candidate predictors encompass the four primary mechanisms of pain: nociceptive (e.g. injury characteristics), neuropathic (e.g. painDETECT), inflammatory (biomarkers), and central hypersensitivity (e.g. quantitative sensory testing). Concurrently, patient-reported outcome measures will assess general health and psychosocial factors. Risk of poor outcome will be calculated using multiple variable regression analysis. Conclusion. A prognostic screening tool for post-trauma pain will inform precision rehabilitation, targeting interventions to individual patients to improve clinical and cost effectiveness. Conflicts of interest: None. Sources of funding: NIHR Surgical Reconstruction and Microbiology Research Centre

Aims

The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults.

Introduction. Dual energy X-ray absorptiometry (DEXA) is the gold standard for assessing bone mineral density (BMD) and fracture risk in vivo. However, it has limitations in the spine because vertebrae show marked regional variations in BMD that are difficult to detect clinically. This study investigated whether micro-CT can provide improved estimates of BMD that better predict vertebral strength. Methods. Ten cadaveric vertebral bodies (mean age: 83.7 +/− 10.8 yrs) were scanned using lateral-projection DEXA and Micro-CT. Standardised protocols were used to determine BMD of the whole vertebral body and of anterior/posterior and superior/inferior regions. Vertebral body volume was assessed by water displacement after which specimens were compressed to failure to determine their compressive strength. Specimens were then ashed to determine their bone mineral content (BMC). Parameters were compared using ANOVA and linear regression. Results. Measures of volumetric BMD obtained from Micro-CT were significantly higher than those obtained by DEXA (P<0.001), and estimates using the two techniques were not significantly correlated. DEXA measurements were strongly predictive of compressive strength, with areal BMD of the anterior vertebral body being the best predictor (R. 2. = 0.722, P = 0.002). Micro-CT measurements did not predict strength. Vertebral body BMD (derived from ash weight) correlated more highly with volumetric BMD values obtained from DEXA (R = 0.88) than those obtained from micro-CT (R = 0.72). Conclusion. BMD assessed by lateral DEXA predicted strength and BMC of osteoporotic vertebrae more accurately than micro-CT measures. Poor correlation between BMD measurements from DEXA and micro-CT suggests that ‘phantoms’ used in Micro-CT may require fine-tuning in order to better represent osteoporotic vertebrae

The purpose of this study was to investigate the clinical predictors of surgical outcome in patients with cervical spondylotic myelopathy (CSM). We reviewed a consecutive series of 248 patients (71 women and 177 men) with CSM who had undergone surgery at our institution between January 2000 and October 2010. Their mean age was 59.0 years (16 to 86). Medical records, office notes, and operative reports were reviewed for data collection. Special attention was focused on pre-operative duration and severity as well as post-operative persistence of myelopathic symptoms. Disease severity was graded according to the Nurick classification. Our multivariate logistic regression model indicated that Nurick grade 2 CSM patients have the highest chance of complete symptom resolution (p < 0.001) and improvement to normal gait (p = 0.004) following surgery. Patients who did not improve after surgery had longer duration of myelopathic symptoms than those who did improve post-operatively (17.85 months (1 to 101) vs 11.21 months (1 to 69); p = 0.002). More advanced Nurick grades were not associated with a longer duration of symptoms (p = 0.906). Our data suggest that patients with Nurick grade 2 CSM are most likely to improve from surgery. The duration of myelopathic symptoms does not have an association with disease severity but is an independent prognostic indicator of surgical outcome. Cite this article: Bone Joint J 2013;95-B:966–71

Our aim in this prospective radiological study was to determine whether the flexibility rate calculated from radiographs obtained during forced traction under general anaesthesia, was better than that of fulcrum-bending radiographs before corrective surgery in predicting the extent of the available correction in patients with idiopathic scoliosis. We evaluated 33 patients with a Cobb angle > 60° on a standing posteroanterior radiograph, who had been treated by posterior correction. Pre-operative standing fulcrum-bending radiographs and those with forced-traction under general anaesthesia were obtained. Post-operative standing radiographs were taken after surgical correction. The mean forced-traction flexibility rate was 55% (. sd. 11.3) which was significantly higher than the mean fulcrum-bending flexibility rate of 32% (. sd. 16.1) (p < 0.001). We found no correlation between either the forced-traction or fulcrum-bending flexibility rates and the correction rate post-operatively (p = 0.24 and p = 0.44, respectively). Radiographs obtained during forced traction under general anaesthesia were better at predicting the flexibility of the curve than fulcrum-bending radiographs in curves with a Cobb angle > 60° in the standing position and may identify those patients for whom supplementary anterior surgery can be avoided

We have assessed the influence of somatisation on the outcome of treatment in 81 patients with chronic low back pain. All, irrespective of whether treatment was surgical or conservative, had a significantly better (p < 0.001) health-related quality of life at follow-up on all but one scale of the SF-36. Lower health-related quality of life at follow-up correlated significantly with a higher tendency to somatise before treatment and at follow-up. A logistic regression analysis yielded two factors which predicted the outcome; somatisation (p < 0.001) and ‘doctor shopping’ (the number of physicians consulted before the present inpatient treatment, p < 0.001). These factors accurately distinguished between patients with good and those with poor outcomes in 82%. Patients with somatisation and ‘doctor shopping’ were at a higher risk for a poor outcome. The results show the relevance of somatisation in the outcome of treatment in patients with low back pain

Aims

Patients seeking cervical spine surgery are thought to be increasing in age, comorbidities and functional debilitation. The changing demographics of this population may significantly impact the outcomes of their care, specifically with regards to complications. In this study, our goals were to determine the rates of functionally dependent patients undergoing elective cervical spine procedures and to assess the effect of functional dependence on 30-day morbidity and mortality using a large, validated national cohort.

Aims. This systematic review aims to identify 3D predictors derived from biplanar reconstruction, and to describe current methods for improving curve prediction in patients with mild adolescent idiopathic scoliosis. Methods. A comprehensive search was conducted by three independent investigators on MEDLINE, PubMed, Web of Science, and Cochrane Library. Search terms included “adolescent idiopathic scoliosis”,“3D”, and “progression”. The inclusion and exclusion criteria were carefully defined to include clinical studies. Risk of bias was assessed with the Quality in Prognostic Studies tool (QUIPS) and Appraisal tool for Cross-Sectional Studies (AXIS), and level of evidence for each predictor was rated with the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. In all, 915 publications were identified, with 377 articles subjected to full-text screening; overall, 31 articles were included. Results. Torsion index (TI) and apical vertebral rotation (AVR) were identified as accurate predictors of curve progression in early visits. Initial TI > 3.7° and AVR > 5.8° were predictive of curve progression. Thoracic hypokyphosis was inconsistently observed in progressive curves with weak evidence. While sagittal wedging was observed in mild curves, there is insufficient evidence for its correlation with curve progression. In curves with initial Cobb angle < 25°, Cobb angle was a poor predictor for future curve progression. Prediction accuracy was improved by incorporating serial reconstructions in stepwise layers. However, a lack of post-hoc analysis was identified in studies involving geometrical models. Conclusion. For patients with mild curves, TI and AVR were identified as predictors of curve progression, with TI > 3.7° and AVR > 5.8° found to be important thresholds. Cobb angle acts as a poor predictor in mild curves, and more investigations are required to assess thoracic kyphosis and wedging as predictors. Cumulative reconstruction of radiographs improves prediction accuracy. Comprehensive analysis between progressive and non-progressive curves is recommended to extract meaningful thresholds for clinical prognostication. Cite this article: Bone Jt Open 2024;5(3):243–251

Aims. Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with posterior spinal fusion (PSF). Methods. We retrospectively reviewed all AIS patients who had undergone PSF between January 2018 and January 2020 in a specialist tertiary spinal referral centre. All patients were assessed preoperatively in an anaesthetic clinic. Postoperative care was defined as ward-based (WB) or critical care (CC), based on the preoperative FEV1, FVC, major curve Cobb angle, and the planned number of instrumented levels. Results. Overall, 105 patients were enrolled. Their mean age was 15.5 years (11 to 25) with a mean weight of 55 kg (35 to 103). The mean Cobb angle was 68° (38° to 122°). Of these, 38 patients were preoperatively scored to receive postoperative CC. However, only 19% of the cohort (20/105) actually needed CC-level support. Based on these figures, and an average paediatric intensive care unit stay of one day before stepdown to ward-based care, the potential cost-saving on the first postoperative night for this cohort was over £20,000. There was no statistically significant difference between the Total Pathway Score (TPS), the numerical representation of the four factors being assessed, and the actual level of care received (p = 0.052) or the American Society of Anesthesiologists grade (p = 0.187). Binary logistic regression analysis of the TPS variables showed that the preoperative Cobb angle was the only variable which significantly predicted the need for critical care. Conclusion. Most patients undergoing posterior fusion surgery for AIS do not need critical care. Of the readily available preoperative measures, the Cobb angle is the only predictor of the need for higher levels of care, and has a threshold value of 74.5°. Cite this article: Bone Joint J 2024;106-B(7):713–719

Aims. To systematically evaluate whether bracing can effectively achieve curve regression in patients with adolescent idiopathic scoliosis (AIS), and to identify any predictors of curve regression after bracing. Methods. Two independent reviewers performed a comprehensive literature search in PubMed, Ovid, Web of Science, Scopus, and Cochrane Library to obtain all published information about the effectiveness of bracing in achieving curve regression in AIS patients. Search terms included “brace treatment” or “bracing,” “idiopathic scoliosis,” and “curve regression” or “curve reduction.” Inclusion criteria were studies recruiting patients with AIS undergoing brace treatment and one of the study outcomes must be curve regression or reduction, defined as > 5° reduction in coronal Cobb angle of a major curve upon bracing completion. Exclusion criteria were studies including non-AIS patients, studies not reporting p-value or confidence interval, animal studies, case reports, case series, and systematic reviews. The GRADE approach to assessing quality of evidence was used to evaluate each publication. Results. After abstract and full-text screening, 205 out of 216 articles were excluded. The 11 included studies all reported occurrence of curve regression among AIS patients who were braced. Regression rate ranged from 16.7% to 100%. We found evidence that bracing is effective in achieving curve regression among compliant AIS patients eligible for bracing, i.e. curves of 25° to 40°. A similar effect was also found in patients with major curve sizes ranging from 40° to 60° when combined with scoliosis-specific exercises. There was also evidence showing that a low apical vertebral body height ratio, in-brace correction, smaller pre-brace Cobb angle, and daily pattern of brace-wear compliance predict curve regression after bracing. Conclusion. Bracing provides a corrective effect on scoliotic curves of AIS patients to achieve curve regression, given there is high compliance rate and the incorporation of exercises. Cite this article: Bone Joint J 2024;106-B(3):286–292

Background. Guidelines recommend epidural steroid injections (ESI) for treating severe disc-related sciatica based on trial data showing modest reductions in leg pain, disability and surgery avoidance. Despite their widespread use, there is no clear evidence about which patients are more likely to benefit from ESI. The aim of this study was to generate consensus on potential predictors of outcome following ESI for disc-related sciatica to include in data collection in a future cohort study. Methods. A list of potential predictors of outcome following ESI was generated from existing literature and a consensus meeting with seven experts. Items were subsequently presented in a two-round on-line modified Delphi study to generate consensus among experts on which items are agreed as potential predictors of outcome from ESI (consensus defined as 70% agreement with ranking of remaining items). Results. An initial list of 53 items was generated and 90 experts were invited from seven countries to participate in the on-line Delphi study. Response rates were 48% (n=44) and 73% (n=33) for round 1 and 2 respectively. Twenty-eight additional items suggested by participants in round 1 were included in round 2. Of the 81 items, 14 reached consensus; across domains of medication use, previous surgery, pain intensity, psychosocial factors, imaging findings and type of injection. Highest ranked of remaining items included work-related and clinical assessment items. Conclusion. Based on expert consensus, items that can be routinely collected in clinical practice were identified as potential predictors of outcomes following ESI. These will be tested in a future multicentre cohort study. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Background. Serious traumatic injury is a leading cause of death and disability globally, with the majority of survivors developing chronic pain. Methods. The aims of this study were to describe early predictors of poor long-term outcome for post-trauma pain. We conducted a prospective observational study, recruiting patients admitted to a Major Trauma Centre hospital in England within 14 days of their injuries, and followed them for 12 months. We defined a poor outcome as Chronic Pain Grade ≥ II and measured this at both 6-months and 12-months. A broad range of candidate predictors were used, including surrogates for pain mechanisms, quantitative sensory testing, and psychosocial factors. Univariate models were used to identify the strongest predictors of poor outcome, which were entered into multivariate models. Results. 124 eligible participants were recruited. At 6-months, 19 (23.2%) of 82 respondents reported a good outcome, whereas at 12-months 27 (61.4%) of 44 respondents reported a good outcome. The multivariate model for 6-months produced odds ratios for a unit increase in: number of fractures, 3.179 (0.52 to 19.61); average pain intensity, 1.611 (0.96 to 2.7); pain extent, 1.138 (0.92 to 1.41) and post-traumatic stress symptoms, 1.044 (0.10 to 1.10). At 12-months, equivalent values were: number of fractures, 1.653 (0.77 to 3.55); average pain intensity, 0.967 (0.67 to 1.40); pain extent, 1.062 (0.92 to 1.23) and post-traumatic stress symptoms, 1.025 (0.99 to 1.07). Conclusion. A poor long-term pain outcome from musculoskeletal traumatic injuries can be predicted by measures recorded within days of injury. Conflicts of interest: No conflicts of interest. Sources of funding: This study was funded by the National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC)

Purpose of study and background. Spinal muscle area (SMA) is often employed to assess muscle functionality and is important for understanding the risk individuals may have of developing back pain or the risk of postural instability and falls.. However, handgrip strength (HGS) has also been utilized as a measure of general muscle capacity. This study aimed to examine the relationship between SMA and HGS to assess whether the latter could be used as an accurate indicator of the former. Methods. 150 participants (75 males and 75 females, aged 47–70 years) were selected from the UK Biobank dataset. Handgrip strength values were extracted and averaged over left and right values. Abdominal MRI images were examined and cross-sectional area of the erector spinae and multifidus determined at the L3/4 level and summed to provide a total muscle area. Results. HGS and SMA (mean±sd) were 39.6 ± 7.4 kg and 4664 ± 868 mm. 2. for males and 24.7 ± 5.9 kg, and 3822 ± 579 mm. 2. for females. Pearson correlation between HGS and SMA was r = 0.41 for males (p = <0.001), r = 0.40 for females (p = <0.001), and r = 0.61 for the combined groups (p<0.001). Conclusion. Significant correlations were found between HGS and SMA for individual sexes and combined groups. However, although HGS may be a useful measure for predicting modifications in group responses in spinal muscle function, for example, following an intervention, it does not have the power to confidently predict muscle values at an individual participant level. Conflicts of interest: No conflicts of interest. Sources of funding: Prince Sattam University, KSA, provided a PhD scholarship for Salman Alharthi

Aims. Degenerative cervical spondylosis (DCS) is a common musculoskeletal disease that encompasses a wide range of progressive degenerative changes and affects all components of the cervical spine. DCS imposes very large social and economic burdens. However, its genetic basis remains elusive. Methods. Predicted whole-blood and skeletal muscle gene expression and genome-wide association study (GWAS) data from a DCS database were integrated, and functional summary-based imputation (FUSION) software was used on the integrated data. A transcriptome-wide association study (TWAS) was conducted using FUSION software to assess the association between predicted gene expression and DCS risk. The TWAS-identified genes were verified via comparison with differentially expressed genes (DEGs) in DCS RNA expression profiles in the Gene Expression Omnibus (GEO) (Accession Number: GSE153761). The Functional Mapping and Annotation (FUMA) tool for genome-wide association studies and Meta tools were used for gene functional enrichment and annotation analysis. Results. The TWAS detected 420 DCS genes with p < 0.05 in skeletal muscle, such as ribosomal protein S15A (RPS15A) (PTWAS = 0.001), and 110 genes in whole blood, such as selectin L (SELL) (PTWAS = 0.001). Comparison with the DCS RNA expression profile identified 12 common genes, including Apelin Receptor (APLNR) (PTWAS = 0.001, PDEG = 0.025). In total, 148 DCS-enriched Gene Ontology (GO) terms were identified, such as mast cell degranulation (GO:0043303); 15 DCS-enriched Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were identified, such as the sphingolipid signalling pathway (ko04071). Nine terms, such as degradation of the extracellular matrix (R-HSA-1474228), were common to the TWAS enrichment results and the RNA expression profile. Conclusion. Our results identify putative susceptibility genes; these findings provide new ideas for exploration of the genetic mechanism of DCS development and new targets for preclinical intervention and clinical treatment. Cite this article: Bone Joint Res 2023;12(1):80–90

Aims. To develop and internally validate a preoperative clinical prediction model for acute adjacent vertebral fracture (AVF) after vertebral augmentation to support preoperative decision-making, named the after vertebral augmentation (AVA) score. Methods. In this prognostic study, a multicentre, retrospective single-level vertebral augmentation cohort of 377 patients from six Japanese hospitals was used to derive an AVF prediction model. Backward stepwise selection (p < 0.05) was used to select preoperative clinical and imaging predictors for acute AVF after vertebral augmentation for up to one month, from 14 predictors. We assigned a score to each selected variable based on the regression coefficient and developed the AVA scoring system. We evaluated sensitivity and specificity for each cut-off, area under the curve (AUC), and calibration as diagnostic performance. Internal validation was conducted using bootstrapping to correct the optimism. Results. Of the 377 patients used for model derivation, 58 (15%) had an acute AVF postoperatively. The following preoperative measures on multivariable analysis were summarized in the five-point AVA score: intravertebral instability (≥ 5 mm), focal kyphosis (≥ 10°), duration of symptoms (≥ 30 days), intravertebral cleft, and previous history of vertebral fracture. Internal validation showed a mean optimism of 0.019 with a corrected AUC of 0.77. A cut-off of ≤ one point was chosen to classify a low risk of AVF, for which only four of 137 patients (3%) had AVF with 92.5% sensitivity and 45.6% specificity. A cut-off of ≥ four points was chosen to classify a high risk of AVF, for which 22 of 38 (58%) had AVF with 41.5% sensitivity and 94.5% specificity. Conclusion. In this study, the AVA score was found to be a simple preoperative method for the identification of patients at low and high risk of postoperative acute AVF. This model could be applied to individual patients and could aid in the decision-making before vertebral augmentation. Cite this article: Bone Joint J 2022;104-B(1):97–102

Aims. Developmental cervical spinal stenosis (DcSS) is a well-known predisposing factor for degenerative cervical myelopathy (DCM) but there is a lack of consensus on its definition. This study aims to define DcSS based on MRI, and its multilevel characteristics, to assess the prevalence of DcSS in the general population, and to evaluate the presence of DcSS in the prediction of developing DCM. Methods. This cross-sectional study analyzed MRI spine morphological parameters at C3 to C7 (including anteroposterior (AP) diameter of spinal canal, spinal cord, and vertebral body) from DCM patients (n = 95) and individuals recruited from the general population (n = 2,019). Level-specific median AP spinal canal diameter from DCM patients was used to screen for stenotic levels in the population-based cohort. An individual with multilevel (≥ 3 vertebral levels) AP canal diameter smaller than the DCM median values was considered as having DcSS. The most optimal cut-off canal diameter per level for DcSS was determined by receiver operating characteristic analyses, and multivariable logistic regression was performed for the prediction of developing DCM that required surgery. Results. A total of 2,114 individuals aged 64.6 years (SD 11.9) who underwent surgery from March 2009 to December 2016 were studied. The most optimal cut-off canal diameters for DcSS are: C3 < 12.9 mm, C4 < 11.8 mm, C5 < 11.9 mm, C6 < 12.3 mm, and C7 < 13.3 mm. Overall, 13.0% (262 of 2,019) of the population-based cohort had multilevel DcSS. Multilevel DcSS (odds ratio (OR) 6.12 (95% CI 3.97 to 9.42); p < 0.001) and male sex (OR 4.06 (95% CI 2.55 to 6.45); p < 0.001) were predictors of developing DCM. Conclusion. This is the first MRI-based study for defining DcSS with multilevel canal narrowing. Level-specific cut-off canal diameters for DcSS can be used for early identification of individuals at risk of developing DCM. Individuals with DcSS at ≥ three levels and male sex are recommended for close monitoring or early intervention to avoid traumatic spinal cord injuries from stenosis. Cite this article: Bone Joint J 2024;106-B(11):1333–1341

Aims. To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation. Methods. A retrospective study was conducted using prospectively collected data and patient-reported outcome measures, including the Oswestry Disability Index (ODI), between 2008 and 2019. Postoperative sRDH was identified from clinical notes and the centre’s MRI database, with all imaging providers in the region checked for missing events. The Kaplan-Meier method was used to calculate five-year sRDH incidence. Cox proportional hazards model was used to identify independent variables predictive of sRDH, with any variable not significant at the p < 0.1 level removed. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Results. Complete baseline data capture was available for 733 of 754 (97.2%) consecutive patients. Median follow-up time for censored patients was 2.2 years (interquartile range (IQR) 1.0 to 5.0). sRDH occurred in 63 patients at a median 0.8 years (IQR 0.5 to 1.7) after surgery. The five-year Kaplan-Meier estimate for sRDH was 12.1% (95% CI 9.5 to 15.4), sRDH reoperation was 7.5% (95% CI 5.5 to 10.2), and any-procedure reoperation was 14.1% (95% CI 11.1 to 17.5). Current smoker (HR 2.12 (95% CI 1.26 to 3.56)) and higher preoperative ODI (HR 1.02 (95% CI 1.00 to 1.03)) were independent risk factors associated with sRDH. Current smoker (HR 2.15 (95% CI 1.12 to 4.09)) was an independent risk factor for sRDH reoperation. Conclusion. This is one of the largest series to date which has identified current smoker and higher preoperative disability as independent risk factors for sRDH. Current smoker was an independent risk factor for sRDH reoperation. These findings are important for spinal surgeons and rehabilitation specialists in risk assessment, consenting patients, and perioperative management. Cite this article: Bone Joint J 2023;105-B(3):315–322