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Background Clinical outcomes following lumbar medial branch radiofrequency ablation (RFA) have been inconsistent. One possible reason is less-than-optimal placement of the electrode along the medial branch at the lateral neck of superior articular process (SAP). Needle angles that define optimal placement (i.e. parallel to the medial branch) may be helpful for consistent technical performance of RFA. Despite its importance, there is a lack of anatomical studies that quantify RFA needle placement angles. Objective To quantify and compare needle angles to achieve parallel placement along the medial branch as it courses on the middle two-quarters of the lateral neck of the SAP at the L1–L5 vertebrae. Design Osteological Study. Methods Ten lumbar vertebral columns were used in this study. Needles were placed along the periosteum of the middle two-quarters of the lateral neck of SAP. Mean needle angles for L1–L5 were quantified and compared using posterior (n = 100) and lateral (n = 100) photographs. Results Mean needle angles varied ranging from 29.29 ± 17.82° to 47.22 ± 16.27° lateral to the parasagittal plane (posterior view) and 33.53 ± 10.23° to 49.19 ± 10.69° caudal to the superior vertebral endplate (lateral view). Significant differences in mean angles were found between: L1/L3 (P  = .008), L1/L4 (P  = .003), and L1/L5 (P  = .040) in the posterior view and L1/L3 (P  = .042), L1/L4 (P  < .001), L1/L5 (P  < .001), L2/L4 (P  = .004), and L2/L5 (P  = .004) in lateral view. Conclusions Variability of needle angles suggest a standard "one-size-fits-all" approach may not be the optimal technique. Future research is necessary to determine optimal patient-specific needle angles from a more detailed and granular analysis of fluoroscopic landmarks. [ABSTRACT FROM AUTHOR]

BACKGROUND: For the treatment of single-level lumbar degenerative disc disease (DDD), oblique lateral interbody fusion (OLIF) has clinical advantages. Whether internal fixation needs to be combined for treatment has been the subject of debate. OBJECTIVE: To compare the early clinical effects of standalone oblique lateral interbody fusion (S-OLIF) versus OLIF combined with lateral screw fixation of the vertebral body (F-OLIF) on single-level lumbar DDD. METHODS: A retrospective analysis was performed on the data of 34 patients for whom the OLIF technique was applied to treat single-level lumbar DDD from August 2018 to May 2021. Patients were divided into the S-OLIF (n = 18) and F-OLIF groups (n = 16). Intraoperative blood loss, operative time, and length of hospital stay were recorded. The pain visual analogue scale (VAS) and Oswestry disability index (ODI) before and after the operation were evaluated. The disc height (DH), foraminal height (FH), fused segment lordosis (FSL), lumbar lordosis (LL), cage subsidence, and fusion by CT examination were measured before and after the operation. RESULTS: The S-OLIF group experienced a shorter operative time and less intraoperative blood loss than the F-OLIF group, and the differences were statistically significant (p < 0.05), but the difference in the length of hospital stay was not statistically significant. The postoperative VAS score and ODI of the two groups were significantly lower than those before the operation, but the postoperative differences between the two groups were not statistically significant. Differences were not statistically significant in postoperative FH, DH, FSL and LL of the two groups. Both groups were followed up for no less than 12 months. In the two groups, fusion was achieved at the last follow-up visit. CONCLUSION: According to short-term follow-up results, both S-OLIF and F-OLIF can achieve reliable and stable fusion and good clinical effect in the treatment of single-level lumbar DDD. [ABSTRACT FROM AUTHOR]

There are often misconceptions associated with early mobilization in postoperative spine surgery patients related to initiating mobility and staff responsibilities. Nursing staff and nursing certified technicians are responsible for ambulating patients after lumbar laminectomy surgery, resulting in improvement in clinical outcomes (Rupich et al., 2018). Lack of early mobilization in postoperative lumbar laminectomy patients may result in complications such as hospital-acquired weakness, infection, and increased length of hospital stay (Fiasconaro et al., 2020). The purpose of this quality improvement (QI) project was to increase mobilization at 24 and 48 hours in postoperative lumbar laminectomy patients as evidenced by improved electronic medical record (EMR) documentation. The Plan-Do-Check-Act (PDCA) model was used to frame the project, which took place on a neurological focused care unit in a Midwest tertiary care center. A retrospective chart audit indicated that documentation of mobility in the postoperative lumbar laminectomy patients was lacking. Staff education, using a self-paced module, was initiated related to the benefits of mobility in postoperative lumbar laminectomy patients and the importance of documentation in the EMR. The use of the John Hopkins Highest Level of Mobility scale and 6-clicks scale was discussed. A secondary chart review over 4 weeks posteducation showed results of improved documentation of early mobilized patients. This QI project demonstrated the impact of staff education on promoting mobility and appropriate documentation in the postoperative laminectomy patient. Future retrospective chart reviews will be undertaken to determine the effectiveness of a one-time education workshop on the impact of early ambulation over time. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to investigate whether the prone position could affect near-infrared spectroscopy (NIRS) values in patients with a high body mass index (BMI). Methods: A total of 40 patients with the American Society of Anesthesiology physical status I-III who underwent lumbar disc hernia repair for one or two levels were included in this prospective study. NIRS monitorization was performed on all patients after routine monitoring. The patients were allocated equally to two groups according to BMI: Group I (BMI =30 kg/m2) and Group II (BMI <30 kg/m2). Results: The mean intra-abdominal pressure (IAP) measured at the prone position was higher in Group I (p=0.005). There was a statistically significant positive correlation between BMI and IAP values at the prone position (r=0.471, p =0.002). A total of 8 patients suffered a =20% decrease in regional cerebral oxygen saturation, with 6 in Group I and 2 in Group II. Discussion and Conclusion: Intragroup IAP values increased over time and were significantly higher in obese patients. Regional cerebral oxygen saturation dropped in both groups until the 20th minute of the prone positioning and then was stabilized. These findings might be used for anesthetic management of patients undergoing lumbar surgeries within the first 20 min. [ABSTRACT FROM AUTHOR]

Background: The intent of this meta-analysis was to examine the efficacy of thoracolumbar interfascial plane block (TLIP) for pain control after lumbar spinal surgery. Methods: Randomized controlled trials (RCTs) published on PubMed, CENTRAL, Scopus, Embase, and Web of Science databases up to February 10, 2023, comparing TLIP with no or sham block or wound infiltration for lumbar spinal surgeries were included. Pain scores, total analgesic consumption, and postoperative nausea and vomiting (PONV) were analyzed. Results: Seventeen RCTs were eligible. Comparing TLIP with no block or sham block, the meta-analysis showed a significant decrease of pain scores at rest and movement at 2 h, 8 h, 12 h, and 24 h. Pooled analysis of four studies showed a significant difference in pain scores at rest between TLIP and wound infiltration group at 8 h but not at 2 h, 12 h, and 24 h. Total analgesic consumption was significantly reduced with TLIP block as compared to no block/sham block and wound infiltration. TLIP block also significantly reduced PONV. GRADE assessment of the evidence was moderate. Conclusion: Moderate quality evidence indicates that TLIP blocks are effective in pain control after lumbar spinal surgeries. TLIP reduces pain scores at rest and movement for up to 24 h, reduces total analgesic consumption, and the incidence of PONV. However, evidence of its efficacy as compared to wound infiltration of local anesthetics is scarce. Results should be interpreted with caution owing low to moderate quality of the primary studies and marked heterogeneity. [ABSTRACT FROM AUTHOR]

Objective: To analyze the association between different postoperative hemoglobin (Hb) levels and postoperative outcomes in patients who have undergone primary lumbar interbody fusion, and to investigate the risk factors and establish a predictive nomogram mode for postoperative Hb < 80 g/L. Methods: We retrospectively analyzed 726 cases who underwent primary lumbar interbody fusion surgery between January 2018 and December 2021in our hospital. All patients were divided into three groups according to the postoperative Hb levels (< 70 g/L, 70–79 g/L, ≥ 80 g/L). The postoperative outcomes among the three groups were compared, and the risk factors for postoperative Hb < 80 g/L were identified by univariate and multivariable logistic regression analysis. Based on these independent predictors, a nomogram model was developed. Predictive discriminative and accuracy ability of the predicting model was assessed using the concordance index (C-index) and calibration plot. Clinical application was validated using decision curve analysis. Internal validation was performed using the bootstrapping validation. Results: Patients with postoperative Hb < 80 g/L had higher rates of postoperative blood transfusion, a greater length of stay, higher rates of wound complications, and higher hospitalization costs than those with postoperative Hb ≥ 80 g/L. Preoperative Hb, preoperative platelets, fusion segments, body mass index, operation time, and intraoperative blood loss independently were associated with postoperative Hb < 80 g/L. Intraoperative blood salvage was found to be a negative predictor for postoperative Hb < 80 g/L (OR, 0.21 [95% CI 0.09–0.50]). The area under the curve of the nomogram model was 0.950. After internal validations, the C-index of the model was 0.939. The DCA and calibration curve suggested that the nomogram model had a good consistency and clinical utility. Conclusions: Postoperative Hb < 80 g/L in patients following primary lumbar interbody fusion surgery increased blood transfusions requirement and was independently associated with poor outcomes. A novel nomogram model was established and could conveniently predict the risk of postoperative Hb < 80 g/L in patients after this type of surgery. [ABSTRACT FROM AUTHOR]

Background: Degenerative lumbar spinal stenosis (DLSS) is a complex clinical syndrome that leads to spinal compression. Decompression with fusion has been the most commonly used surgical procedure for treating DLSS symptoms for many years. However, the exact role of fusion and its effectiveness in DLSS therapy has recently been debated. Objective: The main purpose of this study was to compare the efficacy and safety of decompression alone and decompression plus fusion in the treatment of DLSS with or without spondylolisthesis. Study Design: A systematic review and meta‐analysis of the therapeutic effects of decompression for DLSS with or without the combination of fusion. Methods: A literature search in five relevant databases, including Web of Science, PubMed, Embase, Medline, and Cochrane Library was performed from the inception of the database to March 2022. Only randomized controlled trials (RCTs) assessing the comparison between decompression and decompression plus fusion for DLSS were included. Results: A total of seven studies, 894 patients were analyzed in this meta‐analysis. Among these, 443 patients were included in the decompression plus fusion group while 451 patients were included in the decompression alone group. Pooled analysis showed that the combination of decompression with fusion had no superior benefits to decompression alone in terms of Oswestry Disability Index (ODI) score in the first 2 years and long‐term follow‐up after surgery, also no significant difference in the improvement of back and leg pain was found between two groups. Adding fusion to decompression was associated with a longer operation time, higher complication rate, more blood loss, and extended hospital stay. Furthermore, there was no difference in reoperation rates and patients' satisfaction between the two groups at the last follow‐up. Conclusion: Decompression plus fusion may not be associated with a better clinical outcome in ODI scores and back or leg pain improvement but with a longer duration of operation time, extended hospital stay, and more blood loss. [ABSTRACT FROM AUTHOR]

Percutaneous intradiscal drainage had little established evidence to date. We assessed the outcomes of C-arm cone-beam CT-guided (CBCT-guided) procedures for spondylodiscitis and compare procedures with and without intradiscal drainage. A retrospective review was conducted on patients who underwent CBCT-guided procedures for spondylodiscitis with fluid collection in the intradiscal space between January 2010 and September 2021. Included patients were divided into two groups: with and without 'intradiscal drainage' (ID and non-ID, respectively). A total of 87 patients with thoracolumbar discitis (mean age 73.4 ± 12.3 years, 35 females) were included. There was no significant difference in clinical outcomes between groups. Although insignificant, a subgroup analysis of patients with discitis and psoas abscess showed a higher infection control success rate (81% (17/21) vs 58% (7/12), p =.23) and faster median C-reactive protein improvement (CRP <3 mg/dL: 12 vs 42 days, p =.11, CRP <1 mg/dL: 27 vs 45 days, p =.097) of ID than of non-ID. Findings did not clarify the role of intradiscal drainage when it was indicated in all cases of spondylodiscitis with fluid collection. Future studies with larger sample sizes of selected discitis cases are expected to demonstrate the superiority of intradiscal drainage. [ABSTRACT FROM AUTHOR]

Objective: To compare the clinical and radiological outcomes between an anterior to psoas (ATP) approach combined with cortical bone trajectory (CBT) fixation (ATP group) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) combined with CBT fixation (MI-TLIF group) for treating patients with lumbar degenerative disc disease and instability. Methods: This retrospective study included patients who underwent interbody fusion and internal fixation between May 1, 2019, and September 30, 2020, using the ATP or MI-TLIF approach to treat degenerative lumbar disc disease and instability. The visual analog scale (VAS) score, Oswestry Disability Index (ODI) results, blood loss, operation time, complications, and bony fusion were analyzed and compared to understand clinical outcomes. Clinical and radiologic follow-up for all patients was at least 12 months. Results: The ATP approach combined with CBT fixation resulted in less blood loss, earlier reduced VAS scores, better ODI scores, but longer operation time. At 12 months, the fusion rates in the ATP and MITLIF groups were 90% (18/20) and 72% (13/18), respectively. Conclusion: Our results show that the ATP approach combined with CBT fixation had the advantage of less blood loss, earlier recovery in VAS scores, and better ODI than in MI-TLIF. Indirect and direct decompression could be successfully integrated by the ATP approach combined with CBT fixation and laminectomy. [ABSTRACT FROM AUTHOR]

Introduction: Retrolaminar block (RLB) is a novel thoracic truncal block for analgesia for the thoracic and abdominal walls. However, the analgesic efficacy of RLB in patients undergoing selective lumbar herniectomy is not well known. The aim of this study is to determine the analgesic efficacy of RLB by measuring the pain intensity of patients with the Numeric Pain Rating Scale and evaluating the non-steroid anti-inflammatory drugs and opioid consumption after the surgery. Methods: Thirty patients with the American Society of Anesthesiologists physical status 1, 2, and 3 undergoing lumbar herniectomy of less than three levels between June 2019 and December 2019 were included in the study. The patients were evaluated in two groups: the RLB group (group R, n=15) and the intravenous (IV) analgesics group (group C, n=15). 10 mL 0.25% bupivacaine was applied bilaterally at the RLB. Tenoxicam, tramadol, and aldolan were administered as post-operative IV analgesic treatment. Numeric Rating Scale scores were evaluated at 2, 8, 12, 24, and 48 h after the surgery. Ketorolac and opioid consumption were evaluated at 24th and 48th h. Results: Compared with group C, group R exhibited lower pain scores at 2, 8, 12, and 24 h postoperatively (p<0.05 for each). Tenoxicam and tramadol doses at 24 and 48 h were lower in group R than the group C (p<0.05 for each). Discussion and Conclusion: The retrolaminar block is an effective technique for post-operative analgesia in patients undergoing selective lumbar herniectomy within the first 24 h without significant complication. [ABSTRACT FROM AUTHOR]

Surgical site infection (SSI) is a common and serious complication of transforaminal lumbar interbody fusion (TLIF), and the occurrence of SSI usually leads to prolonged hospitalisation, increased medical costs, poor prognosis, and even death. The objectives of this study were to compare the incidence of SSI in patients with type 2 diabetes, investigate the correlation between perioperative glycemic variability and postoperative SSI, and develop a nomogram model to predict the risk of SSI. This study retrospectively analysed 339 patients with type 2 diabetes who underwent TLIF in the spinal surgery department of the Affiliated Zhongda Hospital of Southeast University from January 2018 to September 2021. The medical records of all patients were collected, and postoperative infection cases were determined according to the diagnostic criteria of surgical site infection. The risk factors for postoperative SSI were analysed by univariate and multivariate logistic regression. And Nomogram prediction model was established and validated. The nomogram incorporated seven independent predictors. Preoperative FPG‐CV was the most important independent risk predictor of SSI, followed by preoperative MFBG, duration of drain placement, postoperative FPG‐CV, preoperative blood glucose control scheme, duration of diabetes >5 years, and the number of fused vertebrae ≥2. The nomogram showed good diagnostic accuracy for the SS of both the training cohort and the validation cohort (AUC = 0.915 and AUC = 0.890). The calibration curves for the two cohorts both showed optimal agreement between nomogram prediction and actual observation. In conclusion, preoperative and postoperative glycemic variability is closely related to the occurrence of SSI. We developed and validated a nomogram to accurately predict the risk of SSI after TLIF surgery. It's helpful for spinal surgeons to formulate reasonable treatment plans and prevention strategies for type 2 diabetes patients. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort. Objectives: Allocating cost is challenging with traditional hospital accounting. Time-driven activity-based costing (TDABC) is an efficient method to accurately assign cost. We sought to characterize the variation in direct total hospital cost (THC) among both lumbar fusion approaches and surgeons. Methods: Patients were treated with single-level anterior interbody (ALIF), lateral interbody (LLIF), transforaminal interbody (TLIF), instrumented posterolateral (PLF) or in-situ fusion (ISF) for degenerative disease. Process maps were developed for preoperative, intraoperative and postoperative care. THC was composed of implant, medication, other supply, and personnel costs. Linear regression and descriptive statistics were used to analyze THC variation. Results: A total of 696 patients underwent surgery by 8 surgeons. Approximately 50% of THC variation was associated with procedure choice while patient characteristics explained 10%. Implants (including biologics) accounted for 45% of cost. With reference to PLF, THC ranged from 0.6x (ISF) to 1.7x (LLIF). Implant cost ranged from 2.5x reference (LLIF) to 0.1x (ISF). There was a 1.7x difference between the highest THC surgeon and the lowest. The fusion type with the highest THC variation was TLIF. The surgeon with the highest TLIF THC was 1.5x more expensive than the surgeon with the lowest. Conclusions: Surgeon-based choices have the greatest effect on THC variation and represent the largest opportunities for cost savings. Primary single-level lumbar fusion THC is driven primarily by fusion type. Implants, including biologics, account for nearly half this cost. Future work should incorporate outcomes data to characterize the differential value conferred by higher THC fusions. [ABSTRACT FROM AUTHOR]

Background: Current evidence suggests that the magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score is a good parameter for evaluating bone quality. We aimed to assess whether the VBQ score can predict the occurrence of postoperative cage subsidence after oblique lumbar interbody fusion (OLIF) surgery. Methods: Patients (n = 102) who had undergone single-level OLIF with a minimal follow-up for 1 year were reviewed in this study. Demographic and radiographic data of these patients were collected. Cage subsidence was defined as ≥ 2 mm of cage migration into the inferior endplate, superior endplate, or both. Further, the MRI-based VBQ score was measured on T1-weighted images. Moreover, univariable and multivariable binary logistic regression analyses were performed. Meanwhile, Pearson analysis was used to evaluate the correlation among the VBQ score, average lumbar dual-energy X-ray absorptiometry (DEXA) T-score, and degree of cage subsidence. Furthermore, ad-hoc analysis was used along with receiver operating characteristic curve analysis to assess the predictive ability of the VBQ score and average lumbar DEXA T-score. Results: Of 102 participants, cage subsidence was observed in 39 (38.24%) patients. According to the univariable analysis, patients with subsidence had older age, higher antiosteoporotic drug use, larger disk height change, a more concave morphology of inferior and superior endplates, higher VBQ score, and lower average lumbar DEXA T-score compared to patients without subsidence. In the multivariable logistic regression analysis, a higher VBQ score was significantly associated with an increased risk of subsidence (OR = 23.158 ± 0.849, 95% CI 4.381–122.399, p < 0.001), and it was the only significant and independent predictor of subsidence after OLIF. Moreover, the VBQ score was moderately correlated with the average lumbar DEXA T-score (r = − 0.576, p < 0.001) and the amount of cage subsidence (r = 0.649, p < 0.001). Furthermore, this score significantly predicted cage subsidence with an accuracy of 83.9%. Conclusions: The VBQ score can independently predict postoperative cage subsidence in patients undergoing OLIF surgery. [ABSTRACT FROM AUTHOR]

Background: To investigate the clinical safety and efficacy of ViBone® Viable Bone Matrix (VBM), a next generation cellular bone matrix allograft that comprises all three essential bone-forming components: osteogenic, osteoinductive, and osteoconductive factors, and is optimized to enhance cell viability and bone formation. Methods: This was a multi-center, prospective, post-market study evaluating the safety and efficacy of ViBone VBM in patients undergoing 1–3 level anterior cervical discectomy and fusion or lumbar interbody fusion surgery. Patients were evaluated at baseline, 6-month, and 12-month follow-up clinically and radiographically. Clinical assessment included Visual Analog Scale for pain (VAS-pain), the Neck Disability Index (NDI) for patients with cervical pathologies, and the Oswestry Disability Index (ODI) for patients with lumbar pathologies. Fusion success defined by an independent radiologist was determined radiographically by plain films. Results: Clinical outcomes evaluated with VAS-pain, NDI, and ODI scales were improved significantly at 6 and 12 months compared to baseline. All patients reached clinically significant improvements at 12 months. There were no adverse events or infections attributed to ViBone VBM. At 12 months, the fusion rate per patient was 88.1% in cervical and 97.6% in lumbar patients, while per-level fusion was 98.5% for cervical and 100% for lumbar segments. Conclusions: Patients undergoing cervical and lumbar spinal fusion implanted with ViBone VBM demonstrated favorable outcomes at 6 months and 12 months as measured by subjective clinical measures and radiographic fusion rates. Trial registration This study was registered as NCT03425682 on 1/29/2018. [ABSTRACT FROM AUTHOR]

Background: The treatment of patients with Lenke 5 adolescent idiopathic scoliosis (AIS) is closely related to the pelvic because the spine–pelvis is an interacting whole. Besides, the choice of fusion segment is a significant issue; with the optimal choice, there will be fewer complications and restoring the pelvic morphology to some extent. This study aims to analyze the impact of changes in sagittal parameters and selection of the lowest instrumented vertebra (LIV) on spine and pelvic morphology for better surgical strategy. Method: Ninety-four patients with Lenke 5 AIS who underwent selective posterior thoracolumbar/lumbar (TL/L) curve fusion were included in the study and grouped according to pelvic morphology and position of LIV. Spinopelvic parameters were measured preoperatively, postoperatively, and at the latest follow-up. The patient's preoperative and last follow-up quality of life was assessed with the MOS item short-form health survey (SF-36) and scoliosis research society 22-item (SRS-22). Result: Patients being posterior pelvic tilt had the oldest mean age (P = 0.010), the smallest lumbar lordosis (LL) (P = 0.036), the smallest thoracic kyphosis (TK) (P = 0.399) as well as the smallest proximal junctional angle (PJA) while those being anterior pelvic tilt had the largest PJA. The follow-up TK significantly increased in both groups of anterior and normal pelvic tilt (P < 0.039, P < 0.006) while no significant changes were observed in the posterior pelvic tilt group. When LIV is above L4, the follow-up PJA was larger than other groups (P = 0.049, P = 0.006). When LIV is below L4, the follow-up TK and PT were larger and LL was smaller than other groups(P < 0.05). The SF-36 and SRS-22 scores were better in the LIV = L4 group than in other groups at the last follow-up (P < 0.05). Conclusion: The correction of TK and LL after surgery can improve pelvic morphology. Besides, LIV is best set at L4, which will facilitate the recovery of TK, the improvement of symptoms, and the prevention of complications and pelvic deformities. Level of evidence Level III. [ABSTRACT FROM AUTHOR]

Study design: Retrospective cohort study. Objective: The purpose of this study was to evaluate the reliability of modified classification system of migrated nucleus pulposus and its clinical application value. Methods: We retrieved 1000 lumbar MRI of different patients in Hangzhou Hospital of Traditional Chinese Medicine from January 2016 to December 2019 for interpretation, and screened 105 migrated lumbar MRI for inclusion in the study. Three spinal surgeons made classification according to the modified classification method. Two weeks later, the sorting data of the patients were shuffled and the classification was judged by three doctors again. The consistency and repeatability of the improved classification were evaluated by Kappa coefficient. The general data of the included patients were collected. The patients were followed up for 2 years, and the risk factors of surgical treatment of patients with migrated lumbar disc herniation were analyzed. The treatment plan, surgical approach, operation time, VAS score, ODI score and other relevant data of the included patients were collected to evaluate the guiding effect of the classification system on clinical practice. Results: In this study, the incidence of migrated lumbar disc herniation was about 10.5%, and most of the patients were male. Patients with higher BMI are more likely to develop this disease. Our study confirmed that the modified classification has moderate to high confidence. During the 2-year follow-up period, 66 patients (62.9%) were treated conservatively, and the patients with conservative treatment were mainly A2 and B2 type (59.1%). Thirty-nine patients (37.1%) underwent surgical treatment. The patients recovered well after operation, and the low back pain and ODI index were significantly improved at 1 year after operation (P < 0.05). We suggest that type A1 and B1 migrated nucleus pulposus can be removed by posterior approach. For type A2, B2, C1, C2, the lateral approach is recommended to remove the nucleus pulposus directly. Logistic regression and ROC analysis showed that disease duration (≥ 1 year) and BMI (≥ 24) maybe were risk factors for surgical treatment of patients with migrated lumbar disc herniation. Conclusion: The modified classification has good reliability. In the current study, the experience level of spine surgeons does not affect the reliability of the classification system. Our study confirmed that this classification has a good reference value for guiding the treatment plan and the choice of surgical approach. [ABSTRACT FROM AUTHOR]

Background: This review aimed to identify variables influencing clinicians' application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners. Methods: Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval. Results: 71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97–84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17–327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results. Conclusions: Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2. Systematic review registration PROSPERO (CRD42021250039). [ABSTRACT FROM AUTHOR]

Lumbar fusion is one of the most commonly used surgical procedures to improve the pain and instability of the spinal vertebrae. After surgery, patients experience varying degrees of pain. The aim of this study was to determine the effect of tizanidine for the management of postoperative pain after lumbar spinal fusion surgery. This randomized clinical trial study was performed on 50 patients who were selected for spinal fusion surgery. Patients were randomly divided into two groups of 25 patients. Patients in the tizanidine and placebo groups received 4 mg oral tizanidine and placebo one hour before surgery and 24 hours after that. Severity of pain, presence of nausea, vomiting, pruritus, headache, vertigo, xerostomia, somnolence, bradycardia and excess opiate in the two groups were evaluated and recorded prior to exit from recovery and 2, 4, 6, 12, 24 and 48 hours after surgery. Data were analyzed by SPSS software version 24. There was a significant difference in pain score in tizanidine group at 24 and 48 hours after surgery compared with placebo (P <0.005). In the control group, the use of morphine sulfate was more than the tizanidine group. There was no significant difference in the incidence of side effects in the two groups (P> 0.05). Low dose tizanidine in postoperative pain management is effective without significant side effects. Due to its simpler administration, it is recommended to use for postoperative pain control after lumbar fusion surgery. [ABSTRACT FROM AUTHOR]

Objective: The lumbar fusion is an important surgery for the orthopedic diseases. The rehabilitation might improve the outcome of patients with lumbar fusion surgery. The rehabilitation-related effects can be revealed by a systemic review and meta-analysis of randomized clinical trials (RCTs). The purpose of this study is to clarify the rehabilitation effects in the patients with lumbar fusion surgery. Methods: We performed a systematic search and a meta-analysis for the RCT of rehabilitation treatment on the patients with lumbar fusion surgery. The comparison between rehabilitation treatment (including psychological rehabilitation, exercise, and multimodal rehabilitation) and typical treatment was performed to find if the rehabilitation treatment can improve the outcome after the lumbar fusion surgery. Fifteen studies of lumbar fusion patients under rehabilitation treatment and typical treatment were enrolled in a variety of rehabilitation modalities. The focused outcome was the rehabilitation-related effects on the fear, disability, and pain of patients after the lumbar fusion surgery. Results: Five hundred twenty-eight rehabilitation subjects and 498 controls were enrolled. The psychological-related rehabilitation showed a significant decrease in pain-related fear when compared to usual treatment. The multimodal rehabilitation can improve the disability outcome to a greater extent when compared to usual treatment. The multimodal rehabilitation seemed to have a more significantly positive effect to decrease disability after lumbar fusion surgery. In addition, the exercise and multimodal rehabilitation can relieve the pain after lumbar fusion surgery. The exercise rehabilitation seemed to have a more significantly positive effect to relieve pain after lumbar fusion surgery. Conclusion: The rehabilitation might relieve the pain-related fear, disability, and pain after lumbar fusion surgery. [ABSTRACT FROM AUTHOR]

Objective: The endoscopic spine surgery (ESS) approach is associated with high levels of patient satisfaction, shorter recovery time, and reduced complications. The present study reports multicenter, international data, comparing ESS and non-ESS approaches for singlelevel lumbar decompression, and proposes a frailty-driven predictive model for nonhome discharge (NHD) disposition. Methods: Cases of ESS and non-ESS lumbar spine decompression were queried from the American College of Surgeons National Surgical Quality Improvement Program database (2017-2020). Propensity score matching was performed on baseline characteristics frailty score (measured by risk analysis index [RAI] and modified frailty index-5 [mFI-5]). The primary outcome of interest was NHD disposition. A predictive model was built using logistic regression with RAI as the primary driver. Results: Single-level nonfusion spine lumbar decompression surgery was performed in 38,686 patients. Frailty, as measured by RAI, was a reliable predictor of NHD with excellent discriminatory accuracy in receiver operating characteristic (ROC) curve analysis: C-statistic: 0.80 (95% confidence interval [CI], 0.65-0.94) in ESS cohort, C-statistic: 0.75 (95% CI, 0.73-0.76) overall cohort. After propensity score matching, there was a reduction in total operative time (89 minutes vs. 103 minutes, p = 0.049) and hospital length of stay (LOS) (0.82 days vs. 1.37 days, p < 0.001) in patients treated endoscopically. In ROC curve analysis, the frailty-driven predictive model performed with excellent diagnostic accuracy for the primary outcome of NHD (C-statistic: 0.87; 95% CI, 0.85-0.88). Conclusion: After frailty-based propensity matching, ESS is associated with reduced operative time, shorter hospital LOS, and decreased NHD. The RAI frailty-driven model predicts NHD with excellent diagnostic accuracy and may be applied to preoperative decisionmaking with a user-friendly calculator: nsgyfrailtyoutcomeslab.shinyapps.io/lumbar_decompression_ dischargedispo. [ABSTRACT FROM AUTHOR]

Objective: Expandable cage technology has emerged for lumbar interbody fusion to restore intervertebral disc space height and alignment through a narrow surgical corridor. The purpose of this study is to present the technique of biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using dual direction expandable cage and provide early clinical results. Methods: We performed the biportal endoscopic TLIF using a dual direction expandable titanium cage for height restoration and a larger footprint in 10 patients. Clinical parameters including Oswestry Disability Index (ODI), visual analogue scale (VAS), and complications were retrospectively analyzed. Also, we investigated radiologic parameters using preoperative and postoperative x-ray images. Results: We successfully inserted dual direction expandable cages during biportal endoscopic TLIF. There was no significant subsidence or collapse of the expandable cages during the 6-month follow-up period. Lumbar lordosis and disc height were significantly increased after surgery. ODI and VAS scores were significantly improved at 6 months after surgery. Conclusion: In this report, we describe the first use of a dual direction expandable interbody TLIF cage that expands in both width and height in biportal endoscopic TLIF surgery. Early clinical and radiographic outcomes of this TLIF technique may be favorable in early 6-month follow-up. [ABSTRACT FROM AUTHOR]

To determine the feasibility, safety and preliminary effectiveness of preoperative functional high-intensity interval training (f-HIIT) for high-risk patients undergoing LSF. High-risk patients eligible for elective 1–3 level LSF were included. Feasibility and safety of the preoperative f-HIIT program was determined by measuring participation and attrition rates, training adherence, adverse events, reached training intensity and preoperative progression in physical fitness. Preliminary effect of the preoperative f-HIIT program was estimated on time to postoperative functional recovery and length of hospital stay (LoS) between high-risk patients who did and did not participate in the prehabilitation program. Eleven out of 23 high-risk patients opted to participate in the f-HIIT program, which was safe and feasible, as no adverse events occurred and only one out of 74 sessions was missed (1.4%). Trained high-risk patients improved their physical fitness with 21.2% on average and obtained faster time to functional recovery compared to matched untrained patients (median 4.5 vs 7.5 days; p = 0.013). No effect was seen on LoS (median 7 vs 8 days (p = 0.58)). The preoperative f-HIIT program is feasible, safe and shortened time to postoperative functional recovery in patients who underwent LSF. Preoperative high-intensity interval training is safe and feasible for high-risk patients opting for lumbar spinal fusion. In a relatively small sample the study shows preoperative high-intensity interval training could reduce time to functional recovery in high-risk patients opting for lumbar spinal fusion. [ABSTRACT FROM AUTHOR]

Objective High-impact chronic pain (HICP) is a term that characterizes the presence of a severe and troubling pain-related condition. To date, the prevalence of HICP in lumbar spine surgery recipients and their HICP transitions from before to after surgery are unexplored. The purpose was to define HICP prevalence, transition types, and outcomes in lumbar spine surgery recipients and to identify predictors of HICP outcomes. Methods In total, 43,536 lumbar surgery recipients were evaluated for HICP transition. Lumbar spine surgery recipients were categorized as having HICP preoperatively and at 3 months after surgery if they exhibited chronic and severe pain and at least one major activity limitation. Four HICP transition groups (Stable Low Pain, Transition from HICP, Transition to HICP, and Stable High Pain) were categorized and evaluated for outcomes. Multivariate multinomial modeling was used to predict HICP transition categorization. Results In this sample, 15.1% of individuals exhibited HICP preoperatively; this value declined to 5.1% at 3 months after surgery. Those with HICP at baseline and 3 months had more comorbidities and worse overall outcomes. Biological, psychological, and social factors predicted HICP transition or Stable High Pain; some of the strongest involved social factors of 2 or more to transition to HICP (OR = 1.43; 95% CI = 1.21–1.68), and baseline report of pain/disability (OR = 3.84; 95% CI = 3.20–4.61) and psychological comorbidity (OR = 1.78; 95% CI = 1.48–2.12) to Stable Stable High Pain. Conclusion The percentage of individuals with HICP preoperatively (15.1%) was low, which further diminished over a 3-month period (5.1%). Postoperative HICP groups had higher levels of comorbidities and worse baseline outcomes scores. Transition to and maintenance of HICP status was predicted by biological, psychological, and social factors. [ABSTRACT FROM AUTHOR]

Objectives: The erector spinae plane (ESP) block is a newly defined regional anesthesia technique first described in 2016. The aim of this meta-analysis is to assess the efficacy of ESP block in improving analgesia following lumbar surgery. Methods: PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials (RCTs) that compared the analgesic efficacy of the ESP block with non-block care for lumbar surgery from inception 3 August 2021. The primary outcomes were postoperative opioid consumption and pain scores during the first 24 h. Postoperative pain was measured as pain at rest and on movement at postoperative 0, 4, 8, 12, and 24 h expressed on a visual analog scale (VAS), where 0 = no pain and 10 = the most severe pain. Results: 11 studies involving 775 patients were included in our analysis. The use of ESP block significantly decreased 24-h opioid consumption (WMD, -8.70; 95% CI, -10.48 to -6.93; I2 = 97.5%; P < 0.001) compared with the non-block. Moreover, ESP block reduced pain scores at postoperative time-points up to 24 h. ESP block also prolonged the time to first analgesic request (WMD = 6.93; 95% CI: 3.44 to 10.43, I2 = 99.8%; P < 0.001). There was less PONV with ESP block versus non-block group (RR, 0.354; 95% CI, 0.23 to 0.56; I2 = 25.2%; P < 0.001), but no difference in pruritus. Conclusions: ESP block provides less opioid consumption and PONV, lower pain scores, and longer time to first analgesic request in patients undergoing lumbar surgery compared to general anesthesia alone. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to determine the proportion of hidden blood loss (HBL) in patients treated with minimally invasive surgery, and to compare the HBL between patients treated with percutaneous pedicle screw fixation (PPSF) and the mini-open Wiltse approach with pedicle screw fixation (MWPSF). Methods: From January 2017 to January 2019, a total of 119 patients with thoracolumbar fractures were included in the analysis, of which 58 cases received PPSF and 61 cases received MWPSF. The clinical information and demographic results were collected and compared. And the HBL of the patients is calculated by the combination formulas of Nadler, Gross and Sehat. Results: Compared with the PPSF group, operation time of MWPSF is shorter. The fluoroscopy times are 13.6 ± 3.0 in PPSF group and 5.6 ± 1.6 in MWPSF group (p < 0.001). As shown in Table 3, the intraoperative blood loss in PPSF group is 31.9 ± 9.6 ml, which is significantly less than that in the MWPSF group (44.0 ± 14.9 ml). The HBL (445.7 ± 228.9 ml), and HBL% (91.2 ± 7.7%) of the PPSF group are significantly higher than that in the MWPSF group (P < 0.05). And the total blood loss (TBL) of the PPSF group (477.6 ± 228.8 ml) is also more than that in the MWPSF group (401.0 ± 171.3 ml). Conclusions: Our results suggest that in the minimally invasive surgical treatment of thoracolumbar fractures, the perioperative HBL is much higher than visible blood loss (VBL). Although PPSF has less intraoperative blood loss, it has higher TBL and HBL than those of MWPSF. Compared with MWPSF, we should pay more attention to the postoperative anemia status of patients with thoracolumbar fractures undergoing PPSF surgery. [ABSTRACT FROM AUTHOR]

Background: Lumbar interbody fusion techniques treat degenerative lumbar diseases effectively. Minimally invasive lateral lumbar interbody fusion (LLIF) decreases soft tissue disruption and accelerates recovery better than standard open posterior lumbar interbody fusion (PLIF). However, the material cost of LLIF is high, especially in Thailand. The cost-effectiveness of LLIF and PLIF in developing countries is unclear. This study compared the cost-utility and clinical outcomes of LLIF and PLIF in Thailand. Methods: Data from patients with lumbar spondylosis who underwent single-level LLIF and PLIF between 2014 and 2020 were retrospectively reviewed. Preoperative and 1-year follow-up EuroQol-5D-5L and healthcare costs were collected. A cost-utility analysis with a lifetime time horizon was performed using a societal perspective. Outcomes are reported as the incremental cost-effectiveness ratio (ICER) and quality-adjusted life-year (QALY) gained. A Thai willingness-to-pay threshold of 5003 US dollars (USD) per QALY gained was used. Results: The 136 enrolled patients had a mean age of 62.26 ± 11.66 years. Fifty-nine patients underwent LLIF, while 77 underwent PLIF. The PLIF group experienced greater estimated blood loss (458.96 vs 167.03 ml; P < 0.001), but the LLIF group had a longer operative time (222.80 vs 194.62 min; P = 0.007). One year postoperatively, the groups' Oswestry Disability Index and EuroQol-Visual Analog Scale scores were improved without statistical significance. The PLIF group had a significantly better utility score than the LLIF group (0.89 vs 0.84; P = 0.023). LLIF's total lifetime cost was less than that of PLIF (30,124 and 33,003 USD). Relative to PLIF, LLIF was not cost-effective according to the Thai willingness-to-pay threshold, with an ICER of 19,359 USD per QALY gained. Conclusions: LLIF demonstrated lower total lifetime cost from a societal perspective. Regard to our data, at the 1-year follow-up, the improvement in patient quality of life was less with LLIF than with PLIF. Additionally, economic evaluation modeling based on the context of Thailand showed that LLIF was not cost-effective compared with PLIF. A strategy that facilitates the selection of patients for LLIF is required to optimize patient benefits. [ABSTRACT FROM AUTHOR]

Study design: Retrospective single center cohort study. Purpose: Spinal instrumentation in combination with antibiotic therapy is a treatment option for acute or chronic pyogenic spondylodiscitis (PSD). This study compares the early fusion outcome for multi-level and single-level PSD after urgent surgical treatment with interbody fusion in combination with fixation. Methods: This is a retrospective cohort study. Over a 10 year period at a single institution, all surgically treated patients received surgical debridement, fusion und fixation of the spine to treat PSD. Multi-level cases were either adjacent to each other on the spine or distant. Fusion rates were assessed at 3 and 12 months after surgery. We analyzed demographic data, ASA status, duration of surgery, location and length of spine affected, Charlson comorbidity index (CCI), and early complications. Results: A total of 172 patients were included. Of these, 114 patients suffered from single-level and 58 from multi-level PSD. The most frequent location was the lumbar spine (54.0%) followed by the thoracic spine (18.0%). The PSD was adjacent in 19.0% and distant in 81.0% of multi-level cases. Fusion rates at the 3 month follow-up did not differ among the multi-level group (p = 0.27 for both adjacent and distant sites). In the single-level group, sufficient fusion was achieved in 70.2% of cases. Pathogen identification was possible 58.5% of the time. Conclusions: Surgical treatment of multi-level PSD is a safe option. Our study demonstrates that there was no significant difference in early fusion outcomes between single-level and multi-level PSD, whether adjacent or distant. [ABSTRACT FROM AUTHOR]

Objective: Surgical site infection (SSI), a common serious complication within 1 month after transforaminal lumbar interbody fusion (TLIF), usually leads to poor prognosis and even death. The objective of this study is to investigate the factors related to SSI within 1 month after TLIF. We have developed a dynamic nomogram to change treatment or prevent infection based on accurate predictions. Materials and methods: We retrospectively analyzed 383 patients who received TLIF at our institution from January 1, 2019, to June 30, 2022. The outcome variable in the current study was the occurrence of SSI within 1 month after surgery. Univariate logistic regression analysis was first performed to assess risk factors for SSI within 1 month after surgery, followed by inclusion of significant variables at P < 0.05 in multivariate logistic regression analysis. The independent risk variables were subsequently utilized to build a nomogram model. The consistency index (C-index), calibration curve and receiver operating characteristic curve were used to evaluate the performance of the model. And the decision curve analysis (DCA) was used to analyze the clinical value of the nomogram. Results: The multivariate logistic regression models further screened for three independent influences on the occurrence of SSI after TLIF, including lumbar paraspinal (multifidus and erector spinae) muscles (LPM) fat infiltration, diabetes and surgery duration. Based on the three independent factors, a nomogram prediction model was built. The area under the curve for the nomogram including these predictors was 0.929 in both the training and validation samples. Both the training and validation samples had high levels of agreement on the calibration curves, and the nomograms C-index was 0.929 and 0.955, respectively. DCA showed that if the threshold probability was less than 0.74, it was beneficial to use this nomograph to predict the risk of SSI after TLIF. In addition, the nomogram was converted to a web-based calculator that provides a graphical representation of the probability of SSI occurring within 1 month after TLIF. Conclusion: A nomogram including LPM fat infiltration, surgery duration and diabetes is a promising model for predicting the risk of SSI within 1 month after TLIF. This nomogram assists clinicians in stratifying patients, hence boosting decision-making based on evidence and personalizing the best appropriate treatment. [ABSTRACT FROM AUTHOR]

Introduction: This article introduced the management of a case with severe left lower extremity pain and forced hip flexion after posterior lumbar interbody fusion and a final diagnosis of left psoas hematoma. Materials and methods: Here we reported a case of a 65-year-old female received posterior lumbar interbody fusion (PLIF) for L4-L5 spondylolisthesis and L4 instability. On the postoperative day one, the hemoglobin level decreased from 108 g/L to 78 g/L. Meanwhile, the patient presented low back pain and inner thigh radiating pain (VAS pain scale = 8). The pain was so severe that it could be barely relieved by keeping left hip in flexion position. On the postoperative day 6, the pain was still severe even after taking mecobalamin, ankylosaurus, dehydrant agents and central pain relievers(VAS pain scale = 9). Computed Tomography indicated a left intramuscular hematoma image extending down to the left iliac fossa. Active hemorrhage of lumbar segmental arterial was detected by B-ultrasound. The patient then received vascular embolization under angiography on the postoperative day 7. Results: The pain in the low back and inner thigh were significantly relieved after the procedure (VAS3-4). On the postoperative day nineteen, the left hip can be fully extended, but the patient was still not able to stand on left leg without a walking stick. On the postoperative day 27, she was able to walk independently. Discussion: The main reason for the complication was the second conical dilation channel slipped and entered the lateral side of the vertebral body along the transverse process. After timely embolization, pain was significantly relieved and muscle strength was improved. Conclusions: Angiographic embolization is an effective treatment for psoas hematoma after posterior lumbar interbody fusion. [ABSTRACT FROM AUTHOR]

Instrumented lumbar spinal fusion is common and results in biomechanical changes at adjacent spinal segments that increase facet load bearing. This can cause facet-mediated pain at levels adjacent to the surgical construct. Medial branch nerve radiofrequency ablation (RFA) exists as a treatment for some cases. It is important to acknowledge that the approach and instrumentation used during some specific lumbar fusion approaches will disrupt the medial branch nerve(s). Thus, the proceduralist must consider the fusion approach when determining which medial branch nerves are necessary to anesthetize for diagnosis and then to potentially target with RFA. This article discusses the relevant technical considerations for preparing for RFA to denervate lumbosacral facet joints adjacent to fusion constructs. [ABSTRACT FROM AUTHOR]

Due to the increase in life expectancy, lumbar spinal canal stenosis has now become one of the most common spinal surgical diagnoses. The main symptom is the claudication spinalis, i.e. the shortening of the walking distance. In addition to clinical diagnostics, magnetic resonance imaging is the gold standard. Conservative therapy should always come first. This can be necessary in an outpatient setting or as an inpatient, multimodal pain therapy. If imaging and symptoms correlate and if conservative therapy is unsuccessful and severe pain with pronounced spinal claudication symptoms persist, then surgery is indicated. The aim of all surgical procedures used is decompression of the spinal canal, and in the case of instability of the motion segment, additional fusion. In this overview article, the diagnosis „lumbar spinal canal stenosis" is examined and possible therapy options are shown. [ABSTRACT FROM AUTHOR]

As a result of solicited muscles, strong friction, and tensile force on cutaneous tissue, the difference in closure procedure and management strategies and complications of surgical incision healing is a real challenge in lumbar spine surgery. We performed a retrospective study to compare different types of wound closure in lumbar spine surgery. 4383 patients were included in this study. Wound dehiscence was more common in the intracutaneous suture group than in the far‐ near‐near‐far suture group. Delayed wound healing occurred more in the far‐near near‐far suture group than intracutaneous suture group. Also, the far‐near near‐far interrupted point suture group showed a higher ratio of delayed wound healing compared with crossover suture. The superficial wound infection rate was roughly the same in all types of sutures with an average value of 0.79% with 0.81% SD. This is a preliminary study to compare different types of operative wounds showing the pros and cons related to each option. [ABSTRACT FROM AUTHOR]

Objective. Pedicle screw loosening is one of the main complications after pedicle screw fixation. However, there are few reliable measures for prediction of screw loosening. The current study was carried out to find an effective method to use preoperative CT scanning as a predictor of screw loosening in the elderly patients and provide guidance for preoperative surgical planning. Methods. Patients who were treated with lumbar pedicle screw fixation procedure in our department for degenerative lumbar disorders between January 2015 and January 2021 were retrospectively included in the current study. CT scan attenuation of each vertebra was measured with Hounsfield units (HU). Screw loosening was determined in postoperatively X-ray tests. One-way analysis of variance (ANOVA) and receiver operating characteristic (ROC) curve analysis were carried out with IBMSPSS 24.00 software. Results. Screw loosening was observed in 44 of 215 patients (124 male, 91 female, average age 58.4 ± 7.6 years) during a mean follow-up time of 19.0 ± 11.2 months (range 12-32 months). No significant differences were found among the patients concerning patient gender, BMI, habit of smoking, and whether or not the patient had diabetes or suffered from spondylolisthesis (P > 0.05). The average HU value of lumbar vertebra was 122.4 ± 32.8 HU in the screw loosening group and 142.4 ± 38.2 HU in the control group, and the difference was significant (P < 0.01). ROC curve analysis revealed that the average HU value of L1-L5 has a relatively larger area under the curve (AUC) of 0.689 (95% CI: 0.605-0.773). With the sensitivity of 68% and specificity of 57%, a HU cut-off value of ≤124 HU is a plausible cut-off point to predict screw loosening. Conclusions. A prospective CT scan HU value-based prediction can be used to decide whether or not to use screw augmentation methods. A cut-off L1-L5 average HU value of 124 HU can be used as an independent risk factor for screw loosening in instrumented lumbar vertebra. More predictive indexes should be involved to achieve higher sensitivity and specificity in future clinical practice. [ABSTRACT FROM AUTHOR]

Introduction: The role of patient-reported outcomes in preoperative assessment is not well studied. There is recent interest in studying whether Patient-reported outcomes scores can be used either independently, or in conjunction with clinical findings, in the assessment of patients for surgery. Aims: To investigate if improvement in clinically significant scores correlate with post-operative patient satisfaction in 1-2 level transforaminal lumbar interbody fusion (TLIF) surgery. We also aim to define a threshold Oswestry Disability Index (ODI) which correlate with achieving post-operative MCID and patient satisfaction. Methods: 1001 patients who underwent single or double level TLIF (Minimally invasive and Open) in our institution with at least 2 years follow up were included in this study. We studied self-reported measures including patient satisfaction and ODI score. Results: At 2-year follow-up, the overall mean ODI score improved from 49.7 ± 18.3 to 13.9 ± 15.2 (P < 0.001) with 74.6% of patients meeting the MCID. Patient satisfaction was achieved in 95.3% of all patients. In the MIS group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.72 (95% CI 0.65-0.86). In the open group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.70 (95% CI 0.62-0.77). Using the preoperative cut-offs found, there was no significant difference in patient satisfaction in both MIS and open groups. Conclusions: Overall, our patients undergoing TLIF had good 2-year ODI score improvement and patient satisfaction after surgery. While meeting the MCID for ODI score correlates with patients' satisfaction postoperatively, 75% of patients not meeting the MCID for ODI score remained satisfied with the surgery. We are unable to define a threshold pre-operative ODI which correlates with achieving post-operative MCID and patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: Percutaneous kyphoplasty (PKP) has been demonstrated to be effective in the treatment of osteoporotic vertebral compression fractures (OVCF). However, bilateral puncture techniques take more time to accept more X-ray radiation; some spinal surgeons apply unilateral puncture PKP, but the cement cannot be symmetrically distributed in the vertebral body, so we apply a directional bone cement delivery device that undergoes PKP through the unilateral pedicle puncture. This research aims to compare the clinical and radiological results of PKP via unilateral pedicle approach using a traditional bone cement delivery device and a directional bone cement delivery device and determine the value of a directional delivery device for the therapy of thoracolumbar compression fracture in the elderly. Methods: We undertook a retrospective analysis of patients with single-level OVCF treated with unilateral pedicle puncture PKP from Jan 2018 to Jan 2020. Operation time, radiation exposure, bone cement injection volume, and the incidence of bone cement leakage were recorded for presentation, and the cement leakage and bone cement distribution were measured by X-ray and computed tomography scan. The patients were followed up postoperatively and were assessed mainly with regard to clinical and radiological outcomes. Results: There was no significant difference in the operation time, radiation exposure time, and incidence of bone cement leakage between the two groups. A significant difference was observed in the volume of bone cement injection between the two groups. All patients in both groups had significantly less pain after the procedures, compared with their preoperative period pain. There were no significant differences in Visual Analogue Scale, the relative height of the vertebral body, Cobb angle, and Quality of Life Questionnaire of the European Foundation for Osteoporosis between the two groups at 1 week after PKP, significant difference was observed only 12 months after operation. Conclusion: Application of directional bone cement delivery device is safe and feasible, compared with the application of traditional bone cement delivery device, without prolonging the operative time, radiation exposure time, and the incidence of bone cement leakage. It has the advantages of good short- and medium-term effect, excellent bone cement distribution, and low incidence of kyphosis recurrence. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy and safety of tranexamic acid (TXA) in hemostasis in patients undergoing posterior lumbar interbody fusion (PLIF) by meta-analysis. Methods: This study was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42022354812). The databases PubMed, Cochrane Library, Web of Science, and Embase were searched for randomized controlled trial (RCT) papers on the use of TXA in patients with PLIF from database establishment to August 2022. Two researchers screened the literature, extracted data, evaluated the risk of bias of the included studies, recorded the authors, sample size, type of study design, and TXA dose of each study, and extracted the intraoperative blood loss, number of blood transfusions, total blood loss, drainage volume, operation time, and incidence of deep venous thrombosis in each study. Meta-analysis was performed using RevMan 5.4 software provided by Cochrane Library. Results: A total of 14 RCTs with a total of 1681 patients were included in this study, including 836 patients in the TXA group and 845 patients in the control group. The intraoperative blood loss [mean difference (MD) = − 125.97, 95% confidence interval (CI) (− 138.56, − 113.37), P < 0.0001] and less total blood loss [MD = − 204.28, 95% CI (− 227.38, − 181.18), P < 0.00001] in TXA group were lower than the control group. Statistical significance was also observed in postoperative drainage volume [MD = − 115.03, 95% CI (− 123.89, − 106.17), P < 0.00001], operation time [MD = − 8.10, 95% CI (− 14.49, − 1.71), P = 0.01], and blood transfusion rate [odds ratio (OR) = 0.30, 95% CI (0.23, 0.39), P < 0.00001]. However, there was no statistical difference observed in the incidence of deep venous thrombosis [OR = 0.83, 95% CI (0.56, 1.21), P = 0.33]. Conclusion: The application of TXA in PLIF can reduce intraoperative blood loss, total blood loss, drainage volume, the incidence of transfusion events, and operation time without increasing the risk of deep venous thrombosis. [ABSTRACT FROM AUTHOR]

Study Design: Finite element models of the L3-S1 vertebrae were reconstructed using computed tomography scans. Objective: We compared the biomechanical performances of an oblique lateral interbody fusion (OLIF) cage in different bone density mode. Summary of Background Data: Low bone density is an els.key factor limiting the use of stand-alone OLIF cage. Methods: Four models—intact (M0), normal bone density with OLIF (M1), bone mass loss with OLIF (M2), and osteoporotic with OLIF (M3)—were created based on 3-dimensional scans. Flexion, extension, and lateral bending movements (each lasting 10 N·m) were performed on the superior surface of the L3 vertebra with a compressive preload of 500 N. Range of motion (ROM), peak stresses in the L4-5 cortical endplates, cage stress, and adjacent intervertebral disk stress were evaluated. Results: ROMs during different physiological movements were similar to those reported by previous researchers. Compared with that in M0, L4-5 ROMs of all movements decreased in M1, M2 and M3, most evidently in M3. Stress distribution in the cortical endplates rose to 7.8% in M1 and M2, even 16.2% in M3. Cage stress increased by less than 8.1% in M1 and M2, but by 25.3% in M3, especially in the movements of extension and right rotation. Compared with that in M0, L3-4 and L5-S1 intervertebral disk stress increased with bone density in all the other models, by up to 69.8% and 98.3%, respectively. As osteoporosis worsened, stress in the adjacent intervertebral disk also increased. Conclusion: Stand-alone OLIF in M3 is not recommended because of the risk of cage subsidence. OLIF in M1 and M2 achieved similar results in various lumbar spine movements. In M1 and M2 model (T > − 2.5), the L4–L5 showed reduced mobility in all directions, increased rigidity, limited cage displacement, lessened deformation, and better stability. [ABSTRACT FROM AUTHOR]

Background and purpose -- Studies investigating the effect of spinal surgery on both physical capability (PC) and subjective well-being (SW) are scarce. We aimed to investigate self-reported PC and SW up to 20 years after lumbar spine surgery. Patients and methods -- 6,612 postmenopausal Finnish women (47-56 years at baseline [BL]), from the Osteoporosis Risk Factor and Prevention (OSTPRE) study, were followed-up (FU) for 20 years. The Finnish Care Register for Healthcare (CRFH) provided data on surgery in the OSTPRE population on lumbar spinal stenosis (LSS) and lumbar disc herniation (LDH). PC and SW of women with lumbar surgery was compared with that of women without lumbar surgery. A chi-square analysis was conducted to analyze the statistical differences in the distribution of PC and SW. A propensity score-matched control analysis was also performed in addition to analysis of the total population-based control group. Results -- In women without lumbar surgery 94% reported good PC at BL, which decreased to 79% at the 20-year FU. For those with LSS/LDH surgery, 84%/(37/50) reported good PC at BL and 80%/(33/50) at 20-year FU, respectively. Good SW was reported by 48% of the control group at BL, 50% at 10-year FU, and 42% at 20-year FU. Women with LSS/LDH surgery before the 10-year FU reported good SW as follows: (6/50)/38% at BL, (12/48)/39% at 10-year FU, and (9/50)/37% at 20-year FU. Conclusion -- Patients with LSS and LDH report lower PC and SW. Lumbar spinal surgery improves PC and SW in the short term, with early LDH surgery showing the greatest benefits whereas late surgery did not. Overall, PC and SW are lower both initially and during the 20-year FU when compared with the age-matched controls except for early LDH surgery. [ABSTRACT FROM AUTHOR]

BACKGROUND: Andersson lesion (AL) is a rare complication of ankylosing spondylitis (AS). Its clinical outcome of surgical treatment needs further exploration. OBJECTIVE: To evaluate the clinical and radiological outcomes of transforaminal thoracolumbar intervertebral fusion (TTIF) in the treatment of AS patients with thoracolumbar AL. METHODS: Fourteen patients with thoracolumbar AL who suffered from back pain, spinal instability or kyphotic deformity were retrospectively recruited. The clinical outcomes were evaluated with Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Radiological outcomes were measured with local kyphotic (LK) angle and general kyphotic (GK) angle. RESULTS: Before surgical treatment for the AL patients, their VAS score and ODI score was 8.0 ± 0.2 and 64.0 ± 6.9, respectively. After TTIF surgery, VAS score of the patients was improved to 2.4 ± 0.5 (p < 0.01) and ODI score was decreased to 17.0 ± 3.7 (p < 0.01). One patient with neurological deficit showed an improvement in the Frankel grade from C to D and all others were grated E-level before and after surgery. For radiological outcomes, patients' LK angle was reduced from 18.5 ± 7.2 to 11.0 ± 6.4 (p < 0.01) and GK angle was reduced to 38.6 ± 8.8 from 42.8 ± 10.4 (p < 0.01) at the 1-year follow-up. CONCLUSION: For AS patients with thoracolumbar AL, we propose that TTIF is an effective and safe operative treatment, which can achieve good fusion, satisfactory radiological and clinical outcomes. [ABSTRACT FROM AUTHOR]

Background and objective: Anterior lumbar interbody fusion (ALIF) and oblique lumbar interbody fusion (OLIF) have shown a great surgical potential, while it has always been controversial which surgical approach and which type of fixation system should be selected. This study investigated the biomechanical response of ALIF and OLIF with various supplementary fixation systems using the finite element method. Materials and methods: Lumbar L4–L5 ALIF and OLIF models stabilized by different supplementary fixation systems (stand-alone cage, integrated stand-alone cage, anterior plate, and bilateral pedicle screw) were developed to assess the segmental range of motion (ROM), endplate stress (EPS), and screw-bone interface stress (SBIS). Experimental results: ALIF showed lower ROM and EPS than OLIF in all motion planes and less SBIS in the most of motion planes compared with OLIF when the anterior plate or pedicle screw was used. ALIF induced higher ROM, while lower EPS and SBIS than OLIF in the majority of motion planes when integrated stand-alone cage was utilized. Using a stand-alone cage in ALIF and OLIF led to cage migration. Integrated stand-alone cage prevented the cage migration, whereas caused significantly larger ROM, EPS, and SBIS than other fixation systems except for the rotation plane. In the most of motion planes, the pedicle screw had the lowest ROM, EPS, and SBIS. The anterior plate induced a slightly larger ROM, EPS, and SBIS than the pedicle screw, while the differences were not significant. Conclusion: ALIF exhibited a better performance in postoperative segmental stability, endplate stress, and screw-bone interface stress than OLIF when the anterior plate or the pedicle screw was used. The pedicle screw could provide the greatest postoperative segmental stability, less cage subsidence incidence, and lower risk of fixation system loosening in ALIF and OLIF. The anterior plate could also contribute to the stability required and fewer complications, while not as effectively as the pedicle screw. Extreme caution should be regarded when the stand-alone cage is used due to the risk of cage migration. The integrated stand-alone cage may be an alternative method; however, further optimization is needed to reduce complications and improve postoperative segmental stability. [ABSTRACT FROM AUTHOR]

Background: Most traumatic vertebral fractures occur in the thoracolumbar junction, lumbar spine, less frequently in the middle thoracic and upper thoracic spine. The aim of this study was to evaluate the retrospective multifactorial evaluation of cases who underwent vertebral stabilization after acute traumatic thoracolumbar fractures. Materials and Methods: Between 2020-2022, 60 patients who underwent vertebral stabilization after acute traumatic thoracolumbar fractures were evaluated postoperatively. Each patient Clinical data, type and location of fracture, presence of neurological damage, pre- and postoperative radiological measurements, post-operative complications, reoperation, Arbeitsgemeinschaft für Osteosynthesefragen Spine and American Spinal Injury Association classification data were evaluated. Results: The mean age of the patients was 33.5+16.2. When the trauma etiology of the patients was examined, falling was the most common with 68.3%, car traffic accident and suicide were the second most common with 13.3%, and non-vehicle traffic accident was observed with 3.3%. Considering the localization, trauma L1 fracture was observed in 20 patients. Type B fractures were seen in 28 patients. While no complications were observed in 53 patients, revision surgery was performed in 5 patients. It was observed that the postoperative neurological examination of the patient with preoperative American Spinal Injury Association A did not change. Conclusions: Thoracolonbar fractures usually occur after high-energy trauma. It is frequently seen in the thoracolumbar junction and causes neurological deficits. Neurological recovery is limited in patients with complete deficits. However, neurological improvement can be observed in incomplete fractures. Treatment of patients should be started immediately and they should be allowed to return to their routine life. [ABSTRACT FROM AUTHOR]

Introduction: Thoracolumbar spine fracture is one of the commonest spinal fractures. The treatment of choice of surgery is still controversial. This is a retrospective analysis of clinical and radiological outcomes of long and short segment stabilization for patients admitted with thoracolumbar fracture in our hospitals. Material and Method: Inclusion criteria included a single level of thoracolumbar fracture, excluding pre-existing deformity or spinal surgery, osteoporosis, and pathological fracture. Clinical parameters included visual analogue scale (VAS), operative time, intraoperative blood loss, and postoperative length of stay. Radiological parameters included wedge angle and anterior and posterior vertebral height ratio. Results: From June 2007 to May 2020, 56 patients (male=31, female=25) were recruited. There were 25 patients in the short segment group (open= 11, minimal invasive surgery (MIS)=14) and 31 patients in the long segment group. Clinically, significantly better VAS at 6 months (1 vs. 1.96; p=0.041), shorter post-op length of stay (16 days vs. 25 days; p=0.01), and less blood loss (178 ml vs. 824 ml; p< 0.01) were found in the short segment group. Radiologically, the short segment group showed significantly better wedge angle at immediate (5° vs. 9.23°; p=0.002) and long-term follow-up (7.41° vs. 11.43°; p=0.01). Moreover, the short segment group has significantly better post-op anterior and posterior vertebral height ratios. Within the short segment group, the MIS group showed significantly less blood loss (82 ml vs. 303 ml; p <0.01). However radiological parameters favour the open group. Discussion and Conclusion: For single-level thoracolumbar fracture, both long and short stabilizations were effective in reducing and stabilizing the fracture. However, the short segment group showed significantly superior results. Moreover, a minimally invasive technique in short segment stabilization showed even less blood loss but less optimal radiological results. Therefore, short segment stabilization could be the treatment of choice for traumatic thoracolumbar spine fractures. [ABSTRACT FROM AUTHOR]

Copyright of Karya Journal of Health Science is the property of Karya Journal of Health Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The most common predisposing factor for low back pain is a prolapsed lumber intervertebral disc. It is the most prevalent symptom in the modern population, albeit it was formerly the ancient curse of society, and it affects 80% of the population at some time in their lives. The goal of this study was to assess the efficacy of physiotherapy versus surgery for patients with prolapsed intervertebral disc. A thorough search of Medline, Embase, CINAHL, CENTRAL, and PEDro was done. Randomized control trial and prospective cohort study relevant to physiotherapy versus surgery, physiotherapy management alone, surgery among the lumbar disc herniation patients were included. Studies that were written in English and came out between 2006 and 2018 were enlisted using inclusion criteria. For screening, identified similar types of articles, avoid duplicate articles, and finally compare and contrast 5 articles. In the short-term, according to the majority of the articles, surgery was more beneficial than conservative treatment. However, there was no discernible difference between physiotherapy and surgery after a long period of observation, and the re-operation rate after surgery was 3%-20% within the first 1-2 years. Physiotherapy intervention had no adverse effects, whereas surgery had some adverse effects. In all circumstances, physiotherapy intervention is more effective than surgery. Physiotherapy interventions should be prescribed in a structured way. [ABSTRACT FROM AUTHOR]

Identification of novel markers would contribute to the individualised risk assessment and development of a risk prediction model. This study aimed to investigate the role of the C‐reactive protein to albumin ratio (CAR) in predicting surgical site infection (SSI) following instrumented posterior lumbar interbody fusion (PLIF) of lumbar degenerative diseases. This study enrolled patients who underwent PLIF and instrumentation for treatment of lumbar degenerative diseases between 2015 and 2020. Electronic medical records were inquired for data collection, with follow‐up register for identifying SSI cases. The optimal cut‐off for CAR was determined by constructing the receiver operator characteristic (ROC) curve. Patients with high‐ or low‐CAR value were compared using the univariate analyses, and the association between CAR and the risk of SSI was investigated using multivariate logistics regression analysis. A total of 905 patients were enrolled, twenty‐nine (3.2%) had developed an SSI with 72.4% occurring during index hospitalisation, and 11 (1.2%) had deep and 18 (2.0%) superficial SSIs. An SSI was associated with additional 10.7 days of index total hospital stay (P =.001). The CAR was 0–5.43 (median, 0.05), and the optimal cut‐off was 0.09 and area under the curve was 0.720 (P <.001). 336 (37.1%) patients had a CAR ≥0.09 and 22 (6.5%) developed an SSI, with a crude risk of 5.6 relative to those with a low CAR. The multivariate analyses showed CAR ≥0.09 was associated with 8.06‐fold increased risk of SSI, together with diabetes (P =.018), while hypertension was identified as a protective factor (OR, 0.34; 95%CI, 0.11–1.00, P =.049). High CAR is found to significantly predict the incident SSI following instrumented PLIF of lumbar degenerative diseases, and can be considered as a useful index in practice only after it is verified by future high‐level evidences. [ABSTRACT FROM AUTHOR]

Introduction: This article introduced the management of a case with severe left lower extremity pain and forced hip flexion after posterior lumbar interbody fusion and a final diagnosis of left psoas hematoma. Materials and methods: Here we reported a case of a 65-year-old female received posterior lumbar interbody fusion (PLIF) for L4-L5 spondylolisthesis and L4 instability. On the postoperative day one, the hemoglobin level decreased from 108 g/L to 78 g/L. Meanwhile, the patient presented low back pain and inner thigh radiating pain (VAS pain scale = 8). The pain was so severe that it could be barely relieved by keeping left hip in flexion position. On the postoperative day 6, the pain was still severe even after taking mecobalamin, ankylosaurus, dehydrant agents and central pain relievers(VAS pain scale = 9). Computed Tomography indicated a left intramuscular hematoma image extending down to the left iliac fossa. Active hemorrhage of lumbar segmental arterial was detected by B-ultrasound. The patient then received vascular embolization under angiography on the postoperative day 7. Results: The pain in the low back and inner thigh were significantly relieved after the procedure (VAS3-4). On the postoperative day nineteen, the left hip can be fully extended, but the patient was still not able to stand on left leg without a walking stick. On the postoperative day 27, she was able to walk independently. Discussion: The main reason for the complication was the second conical dilation channel slipped and entered the lateral side of the vertebral body along the transverse process. After timely embolization, pain was significantly relieved and muscle strength was improved. Conclusions: Angiographic embolization is an effective treatment for psoas hematoma after posterior lumbar interbody fusion. [ABSTRACT FROM AUTHOR]

Introduction: The role of patient-reported outcomes in preoperative assessment is not well studied. There is recent interest in studying whether Patient-reported outcomes scores can be used either independently, or in conjunction with clinical findings, in the assessment of patients for surgery. Aims: To investigate if improvement in clinically significant scores correlate with post-operative patient satisfaction in 1-2 level transforaminal lumbar interbody fusion (TLIF) surgery. We also aim to define a threshold Oswestry Disability Index (ODI) which correlate with achieving postoperative MCID and patient satisfaction. Methods: 1001 patients who underwent single or double level TLIF (Minimally invasive and Open) in our institution with at least 2 years follow up were included in this study. We studied self-reported measures including patient satisfaction and ODI score. Results: At 2-year follow-up, the overall mean ODI score improved from 49.7 ± 18.3 to 13.9 ± 15.2 (P < 0.001) with 74.6% of patients meeting the MCID. Patient satisfaction was achieved in 95.3% of all patients. In the MIS group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.72 (95% CI 0.65-0.86). In the open group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.70 (95% CI 0.62-0.77). Using the preoperative cut-offs found, there was no significant difference in patient satisfaction in both MIS and open groups. Conclusions: Overall, our patients undergoing TLIF had good 2-year ODI score improvement and patient satisfaction after surgery. While meeting the MCID for ODI score correlates with patients' satisfaction postoperatively, 75% of patients not meeting the MCID for ODI score remained satisfied with the surgery. We are unable to define a threshold pre-operative ODI which correlates with achieving post-operative MCID and patient satisfaction. [ABSTRACT FROM AUTHOR]

Copyright of Ahi Evran Medical Journal is the property of Ahi Evran University and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

BACKGROUND: herniated disc usually presents pain accompanied with paresthesia and loss of muscle strength, causing limitations in the activities of daily life. Among the therapeutic strategies aimed at obtaining an improvement in the symptomatology, highlights the Osteopathic manipulation. Methods: 11 computerized databases were consulted. Regarding the eligibility criteria, only articles of the randomized controlled clinical trial type were included. The tool for assessing the risk of bias was the one proposed by Cochrane. Results: A total of 3 randomized controlled clinical trials were selected and considered low risk of bias. The results showed an improvement in all the variables measured in the experimental group of osteopathic manipulation. However, the improvement was greater in the study group that was underwent surgery. CONCLUSIONS: lumbar manipulation spinal is an effective technique to improve the symptomatology of pain originating from a herniated lumbar disc. None of the participants had adverse reactions and their outcome improved significantly in the short and long term. Nevertheless, the studies obtained were limited in number. [ABSTRACT FROM AUTHOR]

Copyright of Physiotherapy Canada is the property of University of Toronto Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)