Do Current Recommendations for Upper Instrumented Vertebra Predict Shoulder Imbalance? An Attempted Validation of Level Selection for Adolescent Idiopathic Scoliosis

Background

Shoulder balance for adolescent idiopathic scoliosis (AIS) patients is associated with patient satisfaction and self-image. However, few validated systems exist for selecting the upper instrumented vertebra (UIV) post-surgical shoulder balance.

Questions/Purposes

The purpose is to examine the existing UIV selection criteria and correlate with post-surgical shoulder balance in AIS patients.

Methods

Patients who underwent spinal fusion at age 10–18 years for AIS over a 6-year period were reviewed. All patients with a minimum of 1-year radiographic follow-up were included. Imbalance was determined to be radiographic shoulder height |RSH| ≥ 15 mm at latest follow-up. Three UIV selection methods were considered: Lenke, Ilharreborde, and Trobisch. A recommended UIV was determined using each method from pre-surgical radiographs. The recommended UIV for each method was compared to the actual UIV instrumented for all three methods; concordance between these levels was defined as “Correct” UIV selection, and discordance was defined as “Incorrect” selection.

Results

One hundred seventy-one patients were included with 2.3 ± 1.1 year follow-up. For all methods, “Correct” UIV selection resulted in more shoulder imbalance than “Incorrect” UIV selection. Overall shoulder imbalance incidence was improved from 31.0% (53/171) to 15.2% (26/171). New shoulder imbalance incidence for patients with previously level shoulders was 8.8%.

Conclusions

We could not identify a set of UIV selection criteria that accurately predicted post-surgical shoulder balance. Further validated measures are needed in this area. The complexity of proximal thoracic curve correction is underscored in a case example, where shoulder imbalance occurred despite “Correct” UIV selection by all methods.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9451-y) contains supplementary material, which is available to authorized users.     

Static Versus Expandable Devices Provide Similar Clinical Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

HSS Journal ® - Few studies have analyzed differences in radiographic parameters and patient-reported outcomes (PROs) between expandable and static interbody devices in patients undergoing...     

New Strategies in Enhancing Spinal Fusion

HSS Journal ® - The biologic steps involved in creating a bony fusion between adjacent segments of the spine are a complex and highly coordinated series of events. There have been significant...     

Targeting TGFbeta signaling for cancer therapy

Transforming growth factor (TGF) betas are multifunctional polypeptides that regulate several cellular functions, including cell growth and differentiation, extra cellular matrix production, motility and immunosuppression. The growth-inhibiting properties of TGFbeta have gained much attention into its role as a tumor suppressor. There is, however, now increasing evidence that TGFbeta switches roles, from tumor suppressor to tumor promoter, as the tumor progresses. Given the integral role of TGFbeta in the tumor progression, it follows that TGFbeta signaling offers an attractive target for cancer therapy. Several strategies including the use of antisense oligonucleotides for TGFbeta, TGFbeta antibodies, dominant negative TGFbeta receptor II, and small drug-molecules to inhibit TGFbeta receptor I kinase have shown great promise in the preclinical studies. These new findings, coupled with progressing clinical trials indicate that inhibition of TGFbeta signaling may, indeed, be a viable option to cancer therapy. This review summarizes the TGFbeta signaling, the dual role of TGFbeta--as a tumor suppressor and tumor promoter, and various strategies targeted against TGFbeta signaling for cancer therapy. The next few years promise to better our understanding of approaching cancer therapy with an eye to the inhibition of TGFbeta signaling.     

Cervical radiculopathy

Cervical radiculopathy is a common clinical scenario. Patients with radiculopathy typically present with neck pain, arm pain, or both. We review the epidemiology of cervical radiculopathy and discuss the diagnosis of this condition. This includes an overview of the pertinent findings on the patient history and physical examination. We also discuss relevant clinical syndromes that must be considered in the differential diagnosis including peripheral nerve entrapment syndromes and shoulder pathology. The natural history of cervical radiculopathy is reviewed and options for management are discussed. These options include conservative management, non-operative modalities such as physical therapy, steroid injections, and operative intervention. While the exact indications for surgical intervention have not yet been elucidated, we provide an overview of the available literature regarding indications and discuss the timing of intervention. The surgical outcomes of anterior cervical decompression and fusion (ACDF), cervical disc arthroplasty (CDA), and posterior cervical foraminotomy (PCF) are discussed.     

Postoperative pain following posterior iliac crest bone graft harvesting in spine surgery: a prospective,randomized trial

Background Context

Postoperative pain at the site of bone graft harvest for posterior spine fusion is reported to occur in 6%–39% of cases. However, the area around the posterior, superior iliac spine is a frequent site of referred pain for many structures. Therefore, many postoperative spine patients may have pain in the vicinity of the posterior iliac crest that may not in fact be caused by bone graft harvesting. The literature may then overestimate the true incidence of postoperative iliac crest pain.

The Efficacy of Telehealth for the Treatment of Spinal Disorders: Patient-Reported Experiences During the COVID-19 Pandemic

Background

The use of telehealth saw a rapid surge during the early months of the COVID-19 pandemic. There remains little data on how effectively telehealth replicates traditional office visits in the treatment of spinal disorders and how telehealth is perceived by patients with spinal disorders.

Questions/Purposes

We sought to evaluate patient satisfaction with telehealth visits as a platform for delivering care for the treatment of spinal pathology.

Methods

Patients undergoing a telehealth visit with providers specializing in the treatment of spinal disorders (one surgeon and two physiatrists) were provided with an anonymous, online survey. Data on patient satisfaction, effectiveness of the telehealth visit (in comparison with in-person visits), and clarity of communication were collected through 5-point Likert scales; visit characteristics and free-text responses were also collected.

Results

Eighty-four patients responded to the survey. Their attitudes were largely positive, with an overall mean patient satisfaction score of 4.79. Patients gave high scores for clarity of communication during the visit, and for satisfaction with the formulation of treatment plans and their ability to ask questions, they gave the lowest scores to the effectiveness of telemedicine in replacing an in-person visit and ease of interface navigation.

Conclusions

The high overall patient satisfaction reported by our patients seeking care for a spinal pathology supports the growing body of evidence promoting the use of telehealth for orthopedic care. Further research is needed in a standardized telehealth examination of patients with spinal disorders.

     

A biomechanical model for estimating loads on thoracic and lumbar vertebrae

Background

Biomechanical models are commonly used to estimate loads on the spine. Current models have focused on understanding the etiology of low back pain and have not included thoracic vertebral levels. Using experimental data on the stiffness of the thoracic spine, ribcage, and sternum, we developed a new quasi-static stiffness-based biomechanical model to calculate loads on the thoracic and lumbar spine during bending or lifting tasks.

Methods

To assess the sensitivity of the model to our key assumptions, we determined the effect of varying ribcage and sternal stiffness, maximum muscle stress, and objective function on predicted spinal loads. We compared estimates of spinal loading obtained with our model to previously reported in vivo intradiscal pressures and muscle activation patterns.

Findings

Inclusion of the ribs and sternum caused an average decrease in vertebral compressive force of 33% for forward flexion and 18% in a lateral moment task. The impact of maximum muscle stress on vertebral force was limited to a narrow range of values. Compressive forces predicted by our model were strongly correlated to in vivo intradiscal pressure measurements in the thoracic (r = 0.95) and lumbar (r = 1) spine. Predicted trunk muscle activity was also strongly correlated (r = 0.95) with previously published EMG data from the lumbar spine.

Interpretation

The consistency and accuracy of the model predictions appear to be sufficient to justify the use of this model for investigating the relationships between applied loads and injury to the thoracic spine during quasi-static loading activities.