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Background In interventional pain medicine, cervical facet joint (CFJ) pain is commonly treated with CFJ denervation techniques, almost automatically assuming degeneration of the CFJs as an important cause of CFJ pain. A standard cervical X‐ray is still commonly used in the clinical evaluation of patients suspected for CFJ degeneration. Although degenerative features can be visualized by different radiological imaging techniques, the relation between radiological degenerative features of the cervical spine and pain remains controversial. Paramount in order to estimate the clinical usefulness of a radiological imaging is to establish the reproducibility of the radiological scoring system. A reproducible and clinically feasible diagnostic scoring system was developed to estimate cervical degeneration on standard cervical X‐rays. Materials and Methods A reproducibility study for the interpretation of degenerative abnormalities on standard cervical X‐rays was performed, using a dichotomous outcome (degenerative abnormalities present Yes/No). The estimation of intervertebral disc height loss on standard cervical X‐rays was validated with computed tomography (CT) scan measurements. Results Five radiological degenerative features on standard cervical X‐rays (disc height loss, anterior vertebral osteophytes, posterior vertebral osteophytes, vertebral end plate sclerosis, and uncovertebral osteoarthritis) showed a substantial to excellent reproducibility (kappa value ≥ 0.60). The qualitative definition of disc height loss used in the reproducibility study showed a substantial agreement with the actual measurements of disc height loss on CT scan (kappa value = 0.69). Conclusion Subjective judgment of a cervical standard X‐ray is a reproducible method to demonstrate degenerative abnormalities of the cervical spine.

The Active-Controlled Fracture Study in Postmenopausal Women With Osteoporosis at High Risk (ARCH) trial (NCT01631214; https://clinicaltrials.gov/ct2/show/NCT01631214) showed that romosozumab for 1 year followed by alendronate led to larger areal bone mineral density (aBMD) gains and superior fracture risk reduction versus alendronate alone. aBMD correlates with bone strength but does not capture all determinants of bone strength that might be differentially affected by various osteoporosis therapeutic agents. We therefore used quantitative computed tomography (QCT) and finite element analysis (FEA) to assess changes in lumbar spine volumetric bone mineral density (vBMD), bone volume, bone mineral content (BMC), and bone strength with romosozumab versus alendronate in a subset of ARCH patients. In ARCH, 4093 postmenopausal women with severe osteoporosis received monthly romosozumab 210 mg sc or weekly oral alendronate 70 mg for 12 months, followed by open-label weekly oral alendronate 70 mg for ≥12 months. Of these, 90 (49 romosozumab, 41 alendronate) enrolled in the QCT/FEA imaging substudy. QCT scans at baseline and at months 6, 12, and 24 were assessed to determine changes in integral (total), cortical, and trabecular lumbar spine vBMD and corresponding bone strength by FEA. Additional outcomes assessed include changes in aBMD, bone volume, and BMC. Romosozumab caused greater gains in lumbar spine integral, cortical, and trabecular vBMD and BMC than alendronate at months 6 and 12, with the greater gains maintained upon transition to alendronate through month 24. These improvements were accompanied by significantly greater increases in FEA bone strength (p

Background Fluoroscopic‐guided lumbar procedures have increased in daily pain practice because the lumbar spine is one of the most common sources of pain. Interventional pain fellows must develop a minimum number of skills during their training in order to achieve the competences without neglecting radiological safety. However, medical training in fluoroscopic‐guided interventions is being affected by the current coronavirus disease 2019 (COVID‐19) situation. Methods The objective of this study was to evaluate the use of a phantom model for lumbar injection as a training strategy during the COVID‐19 pandemic in fellows of interventional pain. The study was divided into theoretical and practical modules. The hands‐on practice was performed in a lumbar model phantom where fellows were evaluated in four fluoroscopically guided approaches: intra‐articular facet block (IAFB), medial branch block (MBB), transforaminal block (TFB), and interlaminar block (ILB) divided in 5 sessions. The aim was to make as many punctures as possible in every session. We measured total procedural performance (TPP), total needle hand time (TNH), and total radiation dose generated by the fluoroscopic machine (TRD) during each procedure. Additionally, a survey was applied to evaluate confidence and satisfaction before and after training. Results A total of 320 lumbar punctures were completed. The results were statistically significant in all approaches attempted (p

The objective of this study is to determine the bone mineral density (BMD) changes in adjacent vertebra following anterior cervical discectomy and fusion (ACDF). Consecutive patients undergoing ACDF with available preoperative and postoperative computed tomography (CT) imaging were included. Quantitative CT measurements of screw-free cervical and first thoracic vertebra were performed. Comparisons between pre- and postoperative BMD in the vertebrae one or two levels above the upper instrumented vertebra (UIV + 1, UIV + 2) and one level below the lowest instrumented vertebra (LIV + 1) were assessed. Seventy-two patients (men, 66.7%) met the inclusion criteria. The patient population was 91.7% Caucasian with a mean age of 55.0 years. The mean interval (±SD) between surgery and secondary CT was 157 ± 23 days. Preoperative BMD (±SD) in UIV + 1 was 300.6 ± 66.2 mg/cm3 . There was a significant BMD loss of 1.5% at UIV + 1 after surgery, resulting in a postoperative BMD of 296.2 ± 64.8 mg/cm3 (p = .029). At UIV + 2 and LIV + 1, no significant differences between pre- and postoperative BMD (304.7 ± 75.7 mg/cm3 vs. 299.8 ± 74.3 mg/cm3 , 197.3 ± 50.4 mg/cm3 vs. 200.8 ± 48.7 mg/cm3 , p = .113 and p = .078, respectively) were observed. Clinical significance Our results demonstrate a small BMD decrease of 1.5% at UIV + 1. This suggests that the effect of ACDF surgery on the adjacent levels might be smaller compared to the previously described lumbar BMD loss of 10%-20% following posterior lumbar fusion procedures.

Importance Childhood and adolescence are critical periods for lifelong bone mineral accrual, but few studies have determined the impact of childhood adiposity on adult bone density. Objective To determine the long‐term impact of childhood adiposity on adult areal bone mineral density (aBMD) and the effect of adult adiposity on this relationship. Methods We conducted a longitudinal study of 1156 adults (56.3% men), for whom skinfold thickness (SFT) had been measured during childhood (6–18 years) and fat mass percentage (FMP) and aBMD were measured during adulthood (29–43 years). Adult aBMD in the lumbar spine (LS), femoral neck (FN), arms, and legs was measured using dual‐energy X‐ray absorptiometry. The direct effect of childhood SFT and its indirect effect through adult FMP on adult aBMD were estimated using general linear regression and a causal steps approach. Results Significant positive associations between childhood SFT and adult aBMD were found in the LS in men (β = 0.089, P = 0.044) and in all the skeletal sites in women. With respect to the adult fat–bone relationship, high adult FMP was associated with low aBMD in most of the sites in men, but with high FN aBMD in women (β = 0.144, P = 0.002). Moreover, suppressive effects of adult FMP on the associations between childhood SFT and adult aBMD in the LS (−34.8%) and legs (−67.1%) of men, and a positive effect on the FN aBMD in women (17.0%) were identified. Interpretation Childhood adiposity appears to have a positive long‐term effect on adult aBMD, which may be reduced by adiposity in adult men but reinforced by adiposity in adult women., This longitudinal study presented sexual discrepancies in fat‐bone relationship from a life course perspective. Childhood adiposity appears to have a positive long‐term effect on adult aBMD, which may be reduced by adiposity in adult men but reinforced by adiposity in adult women.

Low back pain is a very common symptom and the leading cause of disability throughout the world. Several degenerative imaging findings seen on magnetic resonance imaging are associated with low back pain but none of them is specific for presence of low back pain as abnormal findings are prevalent among asymptomatic subjects as well. The purpose of this population-based study was to investigate if more specific magnetic resonance imaging predictors of low back pain could be found via texture analysis and machine learning. We used this methodology to classify T2 -weighted magnetic resonance images from the Northern Finland Birth Cohort 1966 data to symptomatic and asymptomatic groups. Lumbar spine magnetic resonance imaging was performed using a fast spin-echo sequence at 1.5 T. Texture analysis pipeline consisting of textural feature extraction, principal component analysis, and logistic regression classifier was applied to the data to classify them into symptomatic (clinically relevant pain with frequency ≥ 30 days and intensity ≥ 6/10) and asymptomatic (frequency ≤ 7 days, intensity ≤ 3/10, and no previous pain episodes in the follow-up period) groups. Best classification results were observed applying texture analysis to the two lowest intervertebral discs (L4-L5 and L5-S1), with accuracy of 83%, specificity of 83%, sensitivity of 82%, negative predictive value of 94%, precision of 56%, and receiver operating characteristic area-under-curve of 0.91. To conclude, textural features from T2 -weighted magnetic resonance images can be applied in low back pain classification. This article is protected by copyright. All rights reserved.

Magnetic resonance imaging findings often do not distinguish those with and without low back pain. However, there are still a large number of people who undergo magnetic resonance imaging to help determine the aetiology of their back pain. Texture analysis shows promise for classification of tissues that look similar, and machine learning can minimize the number of comparisons. This study aimed to determine if texture features from lumbar spine magnetic resonance imaging differ between people with and without low back pain. Fourteen participants with chronic low back pain were matched for age, weight, and gender with 14 healthy volunteers. A custom texture analysis software was used to construct a grey-level, co-occurrence matrix with one to four pixels offset in 0° direction for the disc, and superior and inferior endplate regions. The Random Forests Algorithm was used to select the most promising classifiers. Linear mixed-effect model analysis was used to compare groups (pain vs pain-free) at each level controlling for age. Random Forest algorithm recommended focusing on intervertebral discs and endplate zones at L4-5 and L5-S1. Differences were observed between groups for L5-S1 superior endplate contrast, homogeneity, energy (p=0.02). Differences were observed for L5-S1 disc contrast and homogeneity (p

Lumbar pigmented villonodular synovitis is rarely localized on the lumbar spine. Awareness of pigmented villonodular synovitis is important despite its rarity because it may mimic several other lesions of this location.

AIM Assess the association and predictive value of geriatric nutritional risk index (GNRI), body composition, and bone mineral density (BMD) in haemodialysis (HD) patients. METHODS Laboratory data, body composition parameters measured via body composition monitor, and radius, lumbar spine, femoral neck BMD measured using dual energy X-ray absorptiometry were assessed in all subjects on HD or online haemodiafiltration (HDF) at baseline. Regression analysis for GNRI, Cox proportional hazard analyses and comparison of multiple receiver operating characteristic (ROC) curves were performed. RESULTS Among all 264 patients, age was 65 ± 12 years and dialysis vintage was 79 (39-144) months. GNRI tertile (T)1, T2, and T3 were 88 (85-91), 94 (93-95), and 98 (97-101), respectively. Patients in GNRI T1 had lower fat tissue index (FTI), lean tissue index, and femoral neck, lumbar spine, and distal mid-third radius BMD, but higher overhydration/extracellular fluid than patients in GNRI T2 or T3 (P

Localized pain in the absence of local lesion may represent referred pain from the spine, in a child, arising from a benign spinal schwannoma. It can be diagnosed by MRI. Surgical excision of the tumor relieves the symptoms.

Body composition is increasingly recognized as an important factor in cancer outcomes. Use of computed tomography (CT) in cancer care provides the opportunity to accurately quantify whole‐body lean and adipose tissues from images at the third lumbar spine. We sought to substantiate the use of routinely captured, single‐slice chest CT images at the thoracic level for evaluation of skeletal muscle, residual lean tissue, and adiposity among pediatric solid tumor patients. We performed a retrospective analysis among children who underwent treatment for a solid tumor at Columbia University Irving Medical Center. Skeletal muscle (SM), residual lean tissue (RLT), and adipose tissue cross‐sectional areas (cm2) were analyzed at diagnosis and at first follow‐up for disease evaluation (6–14 weeks). Imaging analysis was performed utilizing slice‐O‐matic image analysis software. Of the 57 patients identified, 39 had chest CT imaging that included intervertebral level T12‐L1, and 22 also had concurrent imaging at L3. Correlation coefficients between body composition variables at T12‐L1 and L3 were strong (r = 0.93–0.98). Paired t‐test showed a significant decrease in SM (−4.2 ± 8.12, p = 0.003) and RLT (−10.7 ± 28.5, p = 0.025) as well as a trend toward a significant increase in visceral adipose tissue (3.10 ± 9.65, p = 0.052). Univariable analysis demonstrated a significant association between increasing age and increased SM loss (β = −0.496 with SE = 0.194, p = 0.011), and a lack of association between body mass index and body composition changes. We provide the first line of evidence that single‐slice images from routinely obtained chest CT scans provide a simple, readily available mechanism for assessing body composition in pediatric solid tumor patients. Adverse body composition changes were observed, particularly among adolescents and young adults. Precis: Changes in body composition can be detected via routine CT images in pediatric patients undergoing treatment for solid tumors., Body composition is a growing area of interest. Several studies in adults with cancer have found that suboptimal body composition (increased fat, decreased muscle) is strongly associated with the efficacy of treatment, quality of life, and death. However, its use in clinical practice, especially pediatrics, is limited due to the lack of a readily available, sensitive indicator. We sought to substantiate the use of routinely collected CT images to measure body composition. Our results substantiate the use of CT images for the evaluation of body composition thereby creating new clinical and research opportunities in pediatric cancer care.

Objectives A series of constant anatomical structures were used as guide targets for screw placement to improve the accuracy of cortical screw placement and reduce surgical injury and fluoroscopy radiation. The most commonly used angles and distances between the cortical bone screw insertion point and the lateral margins of the isthmus were selected as the contents of the questionnaire. Methods A total of 40 physicians were selected to determine the specific values for each angle and distance. Screw placements were performed on four dry and six wet lumbar spine specimens according to the proposed anatomical target guidance technique. A total of 100 cortical bone trajectories were evaluated using X‐ray and CT scanning of the specimens to verify the practicability, accuracy, and safety of the anatomical target guidance technique in screw placement. Results The average deviation rates for angle and distance determination were 105.5% and 14.33%, respectively, indicating a significant difference between the estimated and actual values from other angles (P, Due to the inaccuracy of the traditional methods in determining the angle of screw insertion, a series of spinal intrinsic anatomical landmarks visually observed were set up as orientation targets to guide cortical bone trajectory (CBT) insertion process through the relationship between the insertion point and landmarks. X‐ray and CT scan results demonstrated that the use of constant anatomical structures as guide targets could assist the placement of CBT and reduce surgical injury and fluoroscopy radiation.

Objective To illustrate the posterior longitudinal ligament is one of the tissue candidates who can contribute to low back pain (LBP). Methods This is a retrospective study. A series of 72 patients who underwent single-level percutaneous endoscopic lumbar discectomy performed for lumbar disc herniation with LBP from June 2014 to June 2016 were examined. There are 42 males and 30 females. The ages of patients were 40 to 57 years, and the mean age was 49.8 years. The symptomatic disc level was at L4-5 in 43 patients and L5 S1 in 29 patients. Thirty-two patients (19 patients in L4-5 disc level, 13 patients in L5 S1 disc level) had LBP (which was limited to the lower back and buttock area) before the operation. All of the operative approaches were performed under local anesthesia. A posterior body diagram (15 cm × 10 cm) was made for this study to record the pain distribution. The centered foci of low back pain were subjectively recorded before, during, and after the operation. The transforaminal endoscopic spine system technology was used in this study. Radiological examinations (X-ray, computed tomography, and magnetic resonance imaging) were performed prior to and after surgery. The Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) scores were taken before and after the surgery to observe the degree of pain. The VSA and ODI score before and after operation were expressed as mean ± SD, and compared by t-test for statistical analysis. Results When inciting the posterior longitudinal ligament during the operation, all 72 patients had provoked low back pain. Forty-three patients with symptomatic discs at L4-5 had pain foci in the lower back and upper gluteal region under the L4 spinous process. Twenty-nine patients with symptomatic discs at L5 S1 had pain foci in the gluteal region under the S1 spinous process. The pain localizations of L4-5 and L5 S1 were different. After the surgery, the provoked low back pain disappeared, and had not returned in any of the patients at the 6-month follow-up. After the operation, one patient suffered from lower limb pain that he did not have before the operation, and the lower limb pain abated a few days later. Three patients had cerebrospinal fluid leakage and were treated with higher pressure applied on the incision and bed rest for 10 days. During the 6-months follow-up period, the mean VAS decreased from 5.97 ± 1.10 to 2.13 ± 0.78. The mean ODI score decreased from 23.14 ± 3.28 to 7.92 ± 1.85. Conclusions The intervertebral posterior longitudinal ligament may be one of the tissues from which low back pain originates.

The spinal epidural and posterior ligamentous complex spaces are important anatomic regions which are the target of various radiologic procedures in the cervical, thoracic and lumbar spine for the purpose of analgesia and anaesthesia. Given the frequency with which procedures are performed in and around the epidural space, a sound understanding of the associated anatomy is paramount to ensure the safety and efficacy of procedural intervention.

Eliglustat is a first‐line oral therapy for adults with Gaucher disease type 1 (GD1) with extensive, intermediate, or poor CYP2D6‐metabolizer phenotypes (90% of patients). We report real‐world outcomes after 2 years of eliglustat therapy in the International Collaborative Gaucher Group Gaucher Registry (NCT00358943). As of January 2019, baseline and 2‐year data (±1 year) were available for 231 eliglustat‐treated GD1 patients: 19 treatment‐naïve (zero splenectomized) and 212 ERT patients who switched to eliglustat (36 splenectomized). Most patients (89%) were from the United States, where eliglustat was first approved. In treatment‐naïve patients, mean hemoglobin increased from 12.4 to 13.4 g/dL (P = .004, n = 18), mean platelet count increased from 113 to 156 × 109/L (P

Lumbar fusion is a procedure associated with several indications, but screw failure remains a major complication, with an incidence ranging 10% to 50%. Several solutions have been proposed, ranging from more efficient screw geometry to enhance bone quality, conversely, drilling instrumentation have not been thoroughly explored. The conventional instrumentation (regular [R]) techniques render the bony spicules excavated impractical, while additive techniques (osseodensification [OD]) compact them against the osteotomy walls and predispose them as nucleating surfaces/sites for new bone. This work presents a case-controlled split model for in vivo/ex vivo comparison of R vs OD osteotomy instrumentation in posterior lumbar fixation in an ovine model to determine feasibility and potential advantages of the OD drilling technique in terms of mechanical and histomorphology outcomes. Eight pedicle screws measuring 4.5 mm × 45 mm were installed in each lumbar spine of eight adult sheep (four per side). The left side underwent R instrumentation, while the right underwent OD drilling. The animals were killed at 6- and 12-week and the vertebrae removed. Pullout strength and non-decalcified histologic analysis were performed. Significant mechanical stability differences were observed between OD and R groups at 6- (387 N vs 292 N) and 12-week (312 N vs 212 N) time points. Morphometric analysis did not detect significant differences in bone area fraction occupancy between R and OD groups, while it is to note that OD showed increased presence of bone spiculae. Mechanical pullout testing demonstrated that OD drilling provided higher degrees of implant anchoring as a function of time, whereas a significant reduction was observed for the R group.

Bone remodeling is reduced in hypoparathyroidism, resulting in increased areal bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) and abnormal skeletal indices by transiliac bone biopsy. We have now studied skeletal microstructure by high-resolution peripheral quantitative computed tomography (HR-pQCT) through 4 years of treatment with recombinant human PTH(1-84) (rhPTH[1-84]) in 33 patients with hypoparathyroidism (19 with postsurgical disease, 14 idiopathic). We calculated Z-scores for our cohort compared with previously published normative values. We report results at baseline and 1, 2, and 4 years of continuous therapy with rhPTH(1-84). The majority of patients (62%) took rhPTH(1-84) 100 μg every other day for the majority of the 4 years. At 48 months, areal bone density increased at the lumbar spine (+4.9% ± 0.9%) and femoral neck (+2.4% ± 0.9%), with declines at the total hip (-2.3% ± 0.8%) and ultradistal radius (-2.1% ± 0.7%) (p < .05 for all). By HR-pQCT, at the radius site, very similar to the ultradistal DXA site, total volumetric BMD declined from baseline but remained above normative values at 48 months (Z-score + 0.56). Cortical volumetric BMD was lower than normative controls at baseline at the radius and tibia (Z-scores -1.28 and - 1.69, respectively) and further declined at 48 months (-2.13 and - 2.56, respectively). Cortical porosity was higher than normative controls at baseline at the tibia (Z-score + 0.72) and increased through 48 months of therapy at both sites (Z-scores +1.80 and + 1.40, respectively). Failure load declined from baseline at both the radius and tibia, although remained higher than normative controls at 48 months (Z-scores +1.71 and + 1.17, respectively). This is the first report of noninvasive high-resolution imaging in a cohort of hypoparathyroid patients treated with any PTH therapy for this length of time. The results give insights into the effects of long-term rhPTH(1-84) in hypoparathyroidism. © 2020 American Society for Bone and Mineral Research.

Introduction In 2018, ARPANSA published updated national DRLs for adult CT, which were first published in 2012, and augmented the national DRL categories. This paper presents the updated national DRLs and describes the process by which they were produced. Methods Examine patient survey data submitted to the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) National Diagnostic Reference Level Service (NDRLS). Determine the quartiles of the distributions of median survey dose metrics with categorisation by procedure type. Engage a liaison panel representing the radiology professions to review procedure categories and recommend revised national DRLs. The revised NDRL procedure categories are: head (non‐contrast brain (trauma/headache)), cervical spine (Non‐contrast (trauma)), soft‐tissue neck (post‐contrast (oncology)), chest (post‐contrast (oncology)), abdomen–pelvis (post‐contrast (oncology)), kidney–ureter–bladder (non‐contrast (suspected renal colic)), chest–abdomen–pelvis (post‐contrast (oncology)) and lumbar spine (non‐contrast (degenerative pain)). Results The existing six procedure categories were revised and refined. Updated Australian national diagnostic reference levels for adult CT were recommended and endorsed for eight procedure categories: head (52 mGy/880 mGycm), cervical spine (23 mGy/470 mGycm),soft‐tissue neck (17 mGy/450 mGycm), chest (10 mGy/390 mGycm), abdomen–pelvis (13 mGy/600 mGycm), kidney–ureter–bladder (13 mGy/600 mGycm), chest–abdomen–pelvis (11 mGy/940 mGycm) and lumbar spine (26 mGy/670 mGycm). The updated national DRLs are between 12 and 26% lower than the previous DRLs for dose‐length product and between 13 and 63% lower for volume computed tomography dose index. Conclusions Australian national DRLs for adult CT have been reviewed and revised. The revised national DRLs are lower, better reflecting current practice among imaging facilities in Australia. The revised Australian national DRLs are similar to those in other developed countries., Australian national DRLs for adult CT have been reviewed and revised. Revised DRLs are set at the 75th percentile of the distribution of facility medians in 2017 data. The revised DRLs better reflect current practice and are similar to those in other developed countries.

BACKGROUND Impaired bone mineral density (BMD) and osteoporosis are commonly found in patients who have undergone heart transplantation (HT), which increases the risk for bone fractures which is associated with increased morbidity and mortality in adults. However, the long-term evolution of BMD after HT in pediatric patients has not been thoroughly investigated. METHOD Bone mineral density up to 10 years after HT was investigated in 30 patients who underwent HT at an age

Percutaneous transforaminal lumbar punctures (TFLPs) offer alternative access routes to the lumbar subarachnoid cistern. Safe fluoroscopic insertion of a needle through a lumbar intervertebral foramen (IVF) should ideally avoid the exiting spinal nerve and surrounding vascular pedicles. A crescentic region in the posterior aspect of IVF is the conventional position for needle placement during TFLP, but the underlying anatomic basis for this has not been evaluated fully. To enhance TFLP safety, we defined the morphometry of normal lumbar IVFs and precise locations of neurovascular structures in the IVF posterior crescent. We retrospectively reviewed high-resolution T2-weighted lumbar spine magnetic resonance images of 40 normal adults to establish normative dimensions of each IVF from L1 to L5 bilaterally. We segmented the IVF posterior crescent into three parts, and within each, measured the areas occupied by neurovascular structures. We statistically correlated the presence or absence of neurovascular structures in each crescent segment using a chi-square test. The mean morphometrics for all 304 IVFs in 10 males and 30 females of similar ages were: area 115.3 ± 29.5 mm2 ; height 18.0 ± 2.4 mm; and width at mid-disc level 5.6 ± 2.1 mm. We found a significant association between crescent segment and presence or absence of neurovascular structures (χ2 = 95.9, p < .001). A post-hoc calculation of adjusted standardized residuals identified a significant association between the middle crescent segment and absence of neurovascular structures. Thus, the middle segment of the IVF posterior crescent is significantly most devoid of neurovascular structures, and more often would be the safest target for needle placement during TFLP.

Gross features of disc degeneration (DD) that are associated with back pain include tears in the anulus fibrosus, structural changes of the endplates, and a collapse of the anulus. The aim of this study is the detailed visualization and microstructural characterization of DD using microcomputed tomography (μCT) and a dedicated image post‐processing pipeline. In detail, we investigate a cadaveric spine that shows both types of DD between L1 and L2 and between L2 and L3, respectively. The lumbar spine was obtained from a male donor aged 74 years. The complete specimen was scanned using μCT with an isometric voxel size of 93 μm. Subsequently, regions of interest (ROI) were prepared featuring each complete intervertebral disc including the adjacent endplates. ROIs were then additionally scanned with a voxel size of 35 μm and by means of magnetic resonance imaging. The collapsed endplate of the superior L2 showed explicit signs of an endplate‐driven degeneration, including bony endplate failures. In contrast, the intervertebral disc between L2 and L3 showed indications of an annulus‐driven DD including severe disc height loss and concentric tears. Using μCT we were able to visualize and quantify bone and cartilage features in DD. We showed that in both cases a suite of structural changes accompanies cartilage degeneration, including microstructural bony adaptions to counteract changes in the biomechanical loading regimen., Using μCT volume data of a cadaveric lumbar spine, we visualized internal defects of two disrupted intervertebral discs and accompanying bone lesions. We showed that disc degeneration is characterized by a complex suite of pathological changes including endplate damage, circumferential tears, and disc height reduction.

The focus of this work is to assess the long-term progression of degeneration in the ovine lumbar spine following a minimally invasive model injury comparable to the damage of an intervertebral disc (IVD) herniation. A partial nucleotomy was performed on 18 sheep via the percutaneous dorsolateral approach. The animals were culled at 6 and 12 months to evaluate the damaged and neighboring functional spine units (FSUs) for degenerative characteristics via μ-CT and histology. Both quantitative μ-CT and histology investigations demonstrated statistically significant differences between the native and damaged FSUs investigated. Qualitative analysis of μ-CT revealed numerous pathological markers consistent with intervertebral disc degeneration (IDD), with differences in frequency and severity between the native and damaged FSUs. The annulus fibrosus reforms a pressure seal within 6 weeks, but the extent of the trauma is significant enough to initiate IVD degeneration, which is already clearly visible at 6 months and especially so 12 months post-op. IDD pathology consistent with signs of a herniation was seen in both the 6- and 12-month groups. This technique provides a useful model injury for the preclinical evaluation of IDD in large animal models, especially in regards to simulating disc herniation as well as for testing the efficacy of associated therapies in the future. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2376-2388, 2019.

The intrauterine environment is known to influence foetal development and future health. Low birthweight has been linked to smaller vertebral canals in children and decreased adulthood spine bone mineral content. Perinatal factors affecting lumbar spine curvature have not yet been considered but could be important for adult spinal health, as lumbar movement during lifting, a risk factor for backpain, is associated with lordosis. To investigate this, lumbar spine magnetic resonance images at age 10 years and perinatal and maternal data (birthweight, placental weight, gestation length, crown‐heel length, maternal age, height, weight and smoking status) from 161 children born in Aberdeen in 1988–1989 were acquired. Statistical shape modelling, using principal component analysis, quantified variations in lumbar spine shape and resulting modes of variation were assessed in combination with perinatal data using correlations and analyses of covariance, adjusted for potential confounders. Spine modes 1–3 (SM1–SM3) captured 75% of the variation in lumbar spine shape. The first and third modes described the total amount (SM1) and evenness of curvature distribution (SM3). SM2 accounted for variations in antero‐posterior vertebral diameter relative to vertebral height, increasing positive scores representing a larger relative diameter. Adjusting for gestation length and sex, SM2 positively correlated with birthweight (r = 0.25, P

Background Cement augmentation is a technique used to increase the stability and purchase of pedicle screws in poor quality bone. Various methods can be applied for cement delivery, such as cement injection before screw placement and the use of fenestrated screws. However, potential problems can arise with the use of cement augmentation. Case presentation A 66-year-old man with a lower trunk deformity, severe kyphosis, and sagittal imbalance following fusion (L2-5 ), with minimal comorbidities, was referred to our unit 9 months after surgery. Pain and progressive kyphosis were investigated clinically and radiographically with computed tomography (CT) scans to assess the status of the hardware and fusion. CT imaging revealed that cement was present only at the distal tip of the fenestrated screws at the L4 vertebral level. A non-union was present along with loosening and a halo around the body of the pedicle screws, and there was evidence of pullout of inferior screws. Conclusion Single-level cement augmentation of pedicle screw in a posterior construct and distal tip cement augmentation of the screw results in a fixed pivot point. Micromotion in cranio-caudal loading during flexion and extension may result in screw toggling with the single-level cement-augmented tip as a fulcrum. This may cause screw loosening, which can lead to pullout and loss of construct stability. The halo around the screw suggests bone loss and/or a fibrous tissue interface, which further complicates revision surgery. Stress shielding and polymethylmethacrylate cement present additional difficulties. The findings of this technical note question the risks and benefits of cement-augmented fenestrated pedicle screw fixation for spinal fusion. Although incidences of such cases are uncommon, surgeons should perform this technique with caution. Accurate restoration of lumbar lordosis during index procedures is important to minimize the risk of construct failure.

Previously we reported the results of a 4-year extension of a 2-year randomized placebo-controlled trial showing that the antiresorptive effects of two annual 4-mg doses of zoledronate in HIV-infected men persisted for at least 5 years after the second dose. We set out to determine whether the effects on BMD and bone turnover persist beyond 10 years. We invited all participants in the original trial known to be alive and living in New Zealand to attend an additional visit approximately 12 years after trial entry and 11 years after their second dose of study medication. The outcome measures were BMD at the lumbar spine, proximal femur, and total body, and markers of bone turnover. Twenty-five of the 43 men originally enrolled in the trial attended the final visit, representing 25 of 31 (81%) participants alive and residing in New Zealand at the time. The average duration of follow-up was 12.4 years. At the final visit, BMD remained higher in the zoledronate group than the placebo group (lumbar spine 3.7%, 95% CI, 0.1 to 7.3; total hip 3.7%, 95% CI, 1.2 to 6.2; femoral neck 5.0%, 95% CI, 2.1 to 7.9; total body 2.4%, 95% CI, 0.7 to 4.0), and the between-group differences in BMD remained stable between 6 and 12 years. Serum CTx remained lower in the zoledronate group than the placebo group between 6 and 12 years and, at the final visit, was 45% lower (95% CI, 25 to 64) than the placebo group. P1NP was 26% (95% CI, 4 to 48) lower in the zoledronate group than the placebo group at the final visit. In summary, two annual 4-mg doses of zoledronate have effects on bone turnover and BMD in men that persist for at least 11 years after the second dose. © 2019 American Society for Bone and Mineral Research.

The aim of the current study was to investigate the multi-dimensional characteristics of lumbar endplate defects in humans in relation to disc degeneration and other MRI phenotypes as well as their role with pain and disability. A total of 108 subjects were recruited and underwent 3T MRI of the lumbar spine. Structural endplate defects were identified and their dimensions were measured in terms of maximum width and depth, and were then standardized to the actual width of the endplate and depth of the vertebral body, respectively. Both width and depth of all endplate defects in each subject were added separately and scores were assigned on the basis of size from 1 to 3. Combining both scores provided "cumulative endplate defect scores." Disc degeneration scores, Modic changes, disc displacement, HIZ, and facet joint changes were assessed. Subject demographics, pain profile, and Oswestry Disability Index (ODI) were also obtained. Endplate defects were observed in 67.5% of the subjects and in 13.5% of the endplates. All dimensions of endplate defects showed significance with disc degenerative scores, Modic changes, and posterior disc displacement (p < 0.05). Maximum width (p = 0.009) and its standardized value (p = 0.02), and cumulative endplate defect scores (p = 0.004) increased with narrow facet joints. Cumulative endplate defect scores showed a strong positive association with ODI (p < 0.05) compared to disc degenerative scores. Large size endplate defects were strongly associated with degenerative spine changes and more back-related disability. Findings from this study stress the need to assess endplate findings from a multi-dimensional perspective, whose role may have clinical utility. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Summary Objective Many women use combined hormonal contraceptives (CHC) during adolescence during which they are accruing peak areal bone mineral density (BMD) that relates to lifetime fracture risk. To build BMD requires formation with which CHC‐related exogenous oestrogen may interfere. We compared peak BMD accrual in adolescents using and not using CHC. Design/Participants We performed literature searches for prospective published peer‐reviewed articles providing 12‐ to 24‐month BMD change in adolescent (12‐ to 19‐year‐old) women using CHC vs CHC‐unexposed control women. Methods Meta‐analyses used random‐effects models to assess BMD change rate at lumbar spine (LS) and other sites in adolescent CHC users vs CHC nonusers. Results Literature searches yielded 84 publications of which nine were eligible. Adolescent‐only data were sought from cohorts with wider age inclusions. The 12‐month LS meta‐analysis with eight paired comparisons in 1535 adolescents showed a weighted mean BMD difference of −0.02 (95% confidence interval [CI]: −0.05 to 0.00) g/cm2 in CHC‐exposed adolescents (P = 0.04). The 24‐month LS meta‐analysis with five paired comparisons in 885 adolescents showed a highly significant weighted mean BMD difference of −0.02 (95% CI: −0.03 to −0.01) g/cm2 in CHC‐exposed adolescents (P = 0.0006). Heterogeneities by I 2 were 96% and 85%, respectively. Insufficient data for other bone sites precluded quantitative analysis. Conclusion Given that adolescent exposure to CHC appears to be increasing, this evidence for potential impairment of peak spinal BMD accrual is of concern and suggests a potential public health problem. Randomized controlled trial data are needed to determine CHC effects on adolescent bone health.

Lumbar spinal fusion may cause adjacent segment degeneration (ASD) in the long term. Recently, inserting an interspinous process device (IPD) proximal to the fusion has been proposed to prevent ASD. The aim of this study was to investigate the biomechanics of lumbar fusion with proximal IPD implantation (LFPI) under both static loads and whole body vibration (WBV). A previously validated finite element (FE) model of the L1-5 lumbar spine was modified to simulate L4-5 fusion. Three different IPDs (Coflex-F, Wallis and DIAM) were inserted at the L3-4 segment of the fusion model to construct the LFPI models. The intact and surgical FE models were analyzed under static loads and WBV, respectively. Under static loading conditions, LFPI decreased range of motion (ROM) and intradiscal pressure (IDP) at the transition segment L3-4 compared with the fusion case. At the segment (L2-3) adjacent to the transition level, LFPI induced higher motion and IDP than rigid fusion. Under WBV, vibration amplitudes of the L3-4 IDP and L4-5 facet joint force (FJF) decreased by more than 54.3% after surgery. The LFPI model with the DIAM system offered the most comparable biomechanics to the intact model under static loads, and decreased the dynamic responses of the L4-5 FJF under WBV. The LFPI model with the Wallis and Coflex-F systems could stabilize the transition segment, and decrease dynamic responses of the L3-4 IDP. The DIAM system may be more suitable in LFPI.