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Radiofrequency ablation of the medial branch is commonly used to treat chronic low back pain involving facet joints, which accounts for 12% to 37% of the total cases of chronic low back pain. An adverse effect of this procedure is the denervation of the multifidus muscle, which may lead to its atrophy which can affect the spine and possibly disc degeneration. This study aims to quantify changes in joint angles and loading caused by multifidus denervation after radiofrequency ablation. AnyBody model of the torso was used to evaluate intervertebral joints in flexion, lateral bending, and torsion. Force-dependent kinematics was used to calculate joint angles and forces. These dependent variables were investigated in intact multifidus, unilateral, and bilateral ablations of L3L4, L4L5, and L5S1 joints. The results showed pronounced angular joint changes, especially in bilateral ablations in flexion, when compared with other cases. The same changes' trend from intact to unilaterally then bilaterally ablated multifidus occurred in joint angles of lateral bending. Meanwhile, joint forces were not adversely affected. These results suggest that multifidus denervation after radiofrequency ablation affects spinal mechanics. Such changes may be associated with abnormal tissue deformations and stresses that can potentially alter their mechanobiology and homeostasis, thereby possibly affecting the health of the spine. [ABSTRACT FROM AUTHOR]

In this review, we elaborate on how musculoskeletal (MSK) modeling combined with dynamic movement simulation is gradually evolving from a research tool to a promising in silico tool to assist medical doctors and physical therapists in decision making by providing parameters relating to dynamic MSK function and loading. This review primarily focuses on our own and related work to illustrate the framework and the interpretation of MSK model-based parameters in patients with 3 different conditions, that is, degenerative joint disease, cerebral palsy, and adult spinal deformities. By selecting these 3 clinical applications, we also aim to demonstrate the differing levels of clinical readiness of the different simulation frameworks introducing in silico model-based biomarkers of motor function to inform MSK rehabilitation and treatment, with the application for adult spinal deformities being the most recent of the 3. Based on these applications, barriers to clinical integration and positioning of these in silico technologies within standard clinical practice are discussed in the light of specific challenges related to model assumptions, required level of complexity and personalization, and clinical implementation. [ABSTRACT FROM AUTHOR]

Background: Spinal arachnoid web (AW) is a very rare entity, with a limited number of cases documented in the literature. Our manuscript represented a comprehensive general review, encompassing various aspects of the subject matter without focusing on any single element. The objective of this systematic review was to describe and analyze reported cases of surgically proven spinal arachnoid webs (AWs) to elucidate their imaging and clinical features, pathophysiology, and optimal management strategies, and to determine the total number of documented cases in the literature. Patterns and commonalities across reported cases were identified to provide a clearer framework for diagnosing and treating this elusive condition. A search of Web of Science, PubMed, and Scopus, respecting PRISMA guidelines, was conducted to include reported cases of surgically proven spinal AW. Our surgically proven case was included as well. The search yielded 196 cases of surgically confirmed spinal AWs in the literature. Adding our case, the total is 197. They are seen commonly in middle-aged patients, slightly more prevalent in males, and often without an evident cause. Sensation disturbances were the most frequently found clinical signs, followed by gait difficulties, weakness, and pain. Symptoms were predominantly located in the lower limbs and trunk. On imaging, an indentation to the rear aspect of the spinal cord was most frequently found at the mid-thorax followed by the upper thorax, often associated with a syrinx or a hyperintense T2 cord signal, usually extending rostrally. Excision was the most efficient treatment. Short conclusion: The assessment found that AW cases are rare in the literature, indicating the disease's scarcity. It manifests insidiously, with the shortest latency reported being 2 weeks. Upper limb symptoms occur in a quarter of cases regardless of the AW's thoracic location, likely due to rostral syrinx and cerebrospinal fluid flow disturbances. Most pathology results revealed fibrous connective tissue, similar to findings in arachnoid cysts, suggesting that AW may result from a ruptured arachnoid cyst or its precursor. Using 3D SPACE STIR and CISS MRI sequences is recommended to visualize the arachnoid band directly. [ABSTRACT FROM AUTHOR]

Degenerative disc disease is the leading cause of lower back and leg pain, considerably impacting daily life and incurring substantial medical expenses for those affected. The development of annulus fibrosus tissue engineering offers hope for treating this condition. However, the current annulus fibrosus tissue engineering scaffolds fail to accurately mimic the natural biological environment of the annulus fibrosus, resulting in limited secretion of extracellular matrix produced by the seeded cells and poor biomechanical properties of the constructed biomimetic annulus fibrosus tissue. This inability to match the biomechanical performance of the natural annulus fibrosus hinders the successful treatment of annulus fibrosus defects. In this study, we fabricated decellularized annulus fibrosus matrix (DAFM)/chitosan hydrogel-1 (DAFM: Chitosan 6:2) and DAFM/chitosan hydrogel-2 (DAFM: Chitosan 4:4) by varying the ratio of DAFM to chitosan. Rat annulus fibrosus (AF)-derived stem cells were cultured on these hydrogel scaffolds, and the cell morphology, AF-related gene expression, and Interleukin-6 (IL-6) levels were investigated. Additionally, magnetic resonance imaging, Hematoxylin and eosin staining, and Safranine and Fast Green staining were performed to evaluate the repair effect of the DAFM/chitosan hydrogels in vivo. The gene expression results showed that the expression of Collagen type I (Col-I), Collagen type I (Col-II), and aggrecan by annulus fibrosus stem cells (AFSCs) cultured on the DAFM/chitosan-1 hydrogel was higher compared with the DAFM/chitosan-2 hydrogel. Conversely, the expression of metalloproteinase-9 (MMP-9) and IL-6 was lower on the DAFM/chitosan-1 hydrogel compared with the DAFM/chitosan-2 hydrogel. In vivo, both the DAFM/chitosan-1 and DAFM/chitosan-2 hydrogels could partially repair large defects of the annulus fibrosus in rat tail vertebrae. In conclusion, the DAFM/chitosan-1 hydrogel could be regarded as a candidate scaffold material for the repair of annulus fibrosus defects, offering the potential for improved treatment outcomes. [ABSTRACT FROM AUTHOR]

The estimation of survival is extremely important for metastatic disease in the spine. The aim of this study was to determine the factors affecting the outcome of patients with spinal metastasis, primarily the character of neurologic deficit and the histopathology of the tumor. A retrospective examination was made of 158 patients with spinal metastasis who were followed up in our clinic between 2010 and 2020 and underwent surgical intervention. The patients were examined in respect of demographic characteristics, the primary tumor, comorbidities, preoperative-postoperative visual aAnalog scale scores, preoperative-postoperative neurologic examinations and neurologic deficit if present and ambulation status, postoperative survival duration, tumor localization, characteristics of the surgeries, complications, the Karnofsky Performance Scale, revised Tokuhashi, and Tomita scores. Spinal metastasis was seen more frequently in males (72.8% male, 27.8% female). Male gender, multiple level involvement, intradural localization, and Karnofsky Performance Scale <70 were seen to cause a shorter survival time. Patients with a primary focus of hematologic malignancy, breast cancer, and lymphoma had a longer survival. The revised Tokuhashi and Tomita scores were observed to be successful in the prediction of survival. A decrease in postoperative visual analog scale score had a positive effect on functional survival. The absence of preoperative neurological deficit and the patient's ability for preoperative and postoperative ambulation affected survival positively. The overall survival period decreased in patients who were mobilized in the early postoperative period but became nonmobile in the late period, and in those who were nonmobile in both the early and late postoperative periods. The neurologic and ambulatory status, the Tomita and Tokuhashi scores, intradural localization, and gender are the factors with a significant effect on prognosis. [ABSTRACT FROM AUTHOR]

A significant dilemma exists for the surgical plan of spinal metastases with a spinal instability neoplastic score (SINS) of 7–12. Our aim is to trim down this range of "potential instability" and find a virtual cut-off value for instrumentation. We performed a retrospective study on 60 patients who underwent surgical intervention for vertebral metastasis. They were segregated into 'instrumented' and "noninstrumented" groups. The primary endpoint of the study was to see whether surgical stabilization was done. Although univariate analysis showed the overall SINS score, involvement of posterior elements, and mechanical pain to be the factors that significantly affected our decision making in favor of stabilization, only the SINS score was found to be statistically significant on multivariate analysis. On plotting the proportion of patients undergoing stabilization at each SINS score we found the curves to crossover between SINS 8 and 9, ran almost parallel to each other at values 9 and 10 and then seemed to diverge from each other significantly at values above 10. Taking SINS 9 as the cut-off value above which instrumentation is advised, the receiver operating characteristic curve had a sensitivity of 67.57% (95% confidence interval 50.21% to 81.99%) and specificity of 73.91% (95% confidence interval 51.59% to 89.77%). The area under the curve was 0.79 (0.67–0.91). SINS 9–10 seems to be the actual ambiguous subset in the wider subgroup of the 'potentially unstable' category SINS 7–12, like a 'Matryoshka doll'. A SINS value of 9 can be seen as a cut-off value for instrumentation. [ABSTRACT FROM AUTHOR]

Background: To compare the clinical and radiological outcomes of modified mini-open transforaminal lumbar interbody fusion (mMO-TLIF) via posterior midline incision for "targeted limited dissection" versus minimal invasive transforaminal lumbar interbody fusion (MIS-TLIF) via Wiltse approach in lumbar degenerative diseases. Methods: A total of 60 consecutive patients in our center from January 2019 to March 2020 were enrolled, including 30 patients who were treated with mMO-TLIF via posterior midline incision and 30 treated with MIS-TLIF through the Wiltse approach. Perioperative parameters were recorded. The questionnaires of Oswestry Disability Index (ODI) and Visual Analogue Score (VAS) were conducted before the operation and after the operation (3 days, 1 week, and 2 years). CT and MRI radiological outcomes were evaluated before the operation and at a 2-year follow-up. Results: There were no significant differences in the general data, gender, age, and BMI between the two groups. All patients were successfully operated without intraoperative complications. There were significant differences between the two groups in the operation time (p < 0.001) and intraoperative bleeding (p < 0.05). There was no difference in ODI and VAS scores between groups pre- and post-operatively, but they were both significantly improved compared to those before the operation (p < 0.01). At a 2-year follow-up, the paraspinal muscle atrophy and fat infiltration were increased comparing to pre-operation, but the difference was also not statistically significant (p > 0.05). In addition, both the two groups' fusion rates were more than 90% at a 2-year follow-up, however, no difference was detected between the two groups. Conclusion: mMO-TLIF via midline incision for "targeted limited dissection" could achieve similar clinical and radiological outcomes as MIS-TLIF for lumbar degenerative disease. [ABSTRACT FROM AUTHOR]

Study Design. Experimental porcine anterior cervical discectomy and fusion (ACDF) model: a proof-of-concept study. Objective. The effect of monetite synthetic bone graft (SBG) containing calcium pyrophosphate and ß-tricalcium phosphate on cervical spinal fusion in a noninstrumented two-level large animal model. Summary of Background Data. ACDF is the gold standard surgical technique for the treatment of degenerative cervical spinal diseases. However, pseudarthrosis associated with increased patient morbidity occurs in ~2.6% of the surgeries. SBG may enhance bony fusion and subsequently decrease the risk of pseudarthrosis. Recent studies on monetite-based SBGs for use in large cranial defects in humans have shown promising bone healing results, necessitating further investigation of their use in cervical spinal fusion. Materials and Methods. Four adult female Danish Göttingen minipigs received partial cervical anterior discectomy and intervertebral defects at an upper and lower level. One defect was filled with SBG, and the other was left empty. Bony fusion was evaluated using computed tomography (CT) at three-month intervals for 12 months. Fifteen months postsurgery, the animals were euthanized for further ex vivo qualitative histopathologic and micro-CT evaluations. Fusion rates were compared using the Fisher exact test at each time point. Results. Increased interbody bony fusion rates were observed at SBG levels (4/4) compared with control levels (0/4) evaluated by CT at 6 and 9 months postsurgery (P=0.029). Fusion was observed at all SBG levels 12 months postsurgery and at only one control level. Histopathologic evaluation confirmed high-quality interbody bony fusion at all SBG levels and fusion by spondylosis at one control level. Conclusion. This proof-of-concept study provides preliminary evidence of a novel, calcium pyrophosphate-containing, and ß-tricalcium phosphate-containing monetite SBG that promotes bony fusion compared with a negative control in a clinically relevant porcine model of ACDF. [ABSTRACT FROM AUTHOR]

Introduction: Primary hydatid cyst of the spinal cord is exceedingly rare. Diagnosis at the early stages is difficult as they may be asymptomatic or have mild vague pain. Patients typically present when there are features of cord/root compression. Magnetic resonance imaging (MRI) stands as the primary investigative modality, but even then, preoperative diagnosis might not always be possible as it may resemble other pathological conditions. Methods: This was a case report of a single case with evidence-based discussion. Informed consent was obtained. Case Report: We present a 62-year-old female patient with progressive paraparesis and numbness of bilateral lower limbs. MRI was suggestive of a tubercular pleurospinal lesion at the D9-D10 level. However, intraoperatively, it was identified to be a rare case of primary pleurospinal (thoracic) hydatid cyst. The patient was managed with complete surgical removal of all the cysts and antihelminthic drug therapy with no evidence of recurrence at the 2-year follow-up. Conclusion: Radiological diagnosis might not be accurate and hydatidosis must be kept in mind to avoid intraoperative confusion. Timely diagnosis, appropriate surgical planning, and comprehensive follow-up are crucial for achieving optimal outcomes. [ABSTRACT FROM AUTHOR]

Background: MR elastography (MRE) may provide quantitative imaging biomarkers of lumbar back muscles (LBMs), complementing MRI in spinal diseases by assessing muscle mechanical properties. However, reproducibility analyses for MRE of LBM are lacking. Purpose: To assess technical failure, within‐day and inter‐day reproducibility, robustness with the excitation source positioning, and inter‐observer agreement of MRE of muscles. Study Type: Prospective. Subjects: Seventeen healthy subjects (mean age 28 ± 4 years; 11 females). Field Strength/Sequence: 1.5 T, gradient‐echo MRE, T1‐weighted turbo spin echo. Assessment: The pneumatic driver was centered at L3 level. Four MRE were performed during two visits, 2–4 weeks apart, each consisting of two MRE with less than 10 minutes inter‐scan interval. At Visit 1, after the first MRE, the coil and driver were removed, then reinstalled. The MRE was repeated. At Visit 2, following the first MRE, only the driver was moved down 5 cm. The MRE was repeated. Two radiologists segmented the multifidus and erector spinae muscles. Statistical Tests: Paired t‐test, analysis of variance, intraclass correlation coefficients (ICCs). P‐values <0.05 were considered statistically significant. Results: Mean stiffness of LBM ranged from 1.44 to 1.60 kPa. Mean technical failure rate was 2.5%. Inter‐observer agreement was excellent (ICC ranging from 0.82 [0.64–0.96] to 0.99 [0.98–0.99] in the multifidus, and from 0.85 [0.69–0.92] to 0.99 [0.97–0.99] in the erector spinae muscles). Within‐day reproducibility was fair in the multifidus (ICC: 0.53 [0.47–0.77]) and good in the erector spinae muscles (ICC: 0.74 [0.48–0.88]). Reproducibility after moving the driver was excellent in both multifidus (ICC: 0.85 [0.69–0.93]) and erector spinae muscles (ICC: 0.84 [0.67–0.92]). Inter‐day reproducibility was excellent in the multifidus (ICC: 0.76 [0.48–0.89]) and poor in the erector spinae muscles (ICC: 0.23 [−0.61 to 0.63]). Data Conclusion: MRE of LBM provides measurements of stiffness with fair to excellent reproducibility and excellent inter‐observer agreement. However, inter‐day reproducibility in the multifidus muscles indicated that the herein used MRE protocol may not be optimal for this muscle. Evidence Level: 2 Technical Efficacy: Stage 1 [ABSTRACT FROM AUTHOR]

Background: Some young patients with preserved functional status suffering from aggressive isolated neoplastic disease of the thoracic spine may be eligible from curative en-bloc vertebrectomy surgical treatment. Method: Long-segment posterior pedicle screw fixation is performed. Complete excision of the posterior arch and of ribs posterior aspect is performed. Finger blunt dissection is performed between vertebral body, pleura, and aorta allowing to place a soft abdominal valve and then Gigli saws surrounding the anterior aspect of the spine, in order to saw the upper and the lower discs. Unilateral temporary rod is placed. The vertebral body is dislodged from posterior ligament and then removed by circling laterally around spinal cord. An expandable vertebral implant is placed. Conclusion: Posterior en-bloc thoracic vertebrectomy is a highly technical yet achievable procedure which carries a curative intent for isolated neoplastic spine lesions. [ABSTRACT FROM AUTHOR]

Background: Non-contiguous two-level Anterior Cervical Discectomy and Fusion (ACDF) may be a viable option for patients with degenerative cervical myelopathy and imaging-evident spine and radicular compression at two non-contiguous cervical levels. The risk of hastening degeneration and triggering Adjacent Segment Disease at the spine levels located between the fused levels is a putative adverse event, which was assessed in a few studies. The aim of this study is to investigate the clinical outcomes of patients undergoing non-contiguous two levels ACDF and to assess biomechanical modifications at non-fused segments. Method: We retrospectively reviewed all patients with noncontiguous two-level spine and radicular compression, who underwent simultaneous noncontiguous two-level ACDF at our center. We analyzed clinical and radiological outcomes and investigated the rate of adjacent segment disease. Radiographic parameters were calculated on pre- and postoperative images. Results: Thirty-two patients underwent simultaneous noncontiguous two-level ACDF for cervical myelo-radiculopathy between 2015 and 2021 and were followed up for a mean period of 43.3 months. For all patients, the mJOA score significantly improved from 14.57 ± 2.3 to 16.5 ± 2.1 (p<0.01) and the NDI score significantly decreased from 21.45 ± 4.3 to 12.8 ± 2.3 (p<0.01) postoperatively. Cervical lordosis increased after surgery (from 9.65° ±9.47 to 15.12° ± 6.09); intermediate disc height decreased (5.68 mm ± 0.57 to 5.27 mm ±0.98); the ROMs of intermediate (from 12.45 ± 2.33 to 14.77 ± 1.98), cranial (from 14.63 ± 1.59 to 15.71 ± 1.02), and caudal (from 11.58 ± 2.32 to 13.33 ± 2.67) segments slightly increased. During follow-up assessment, in one patient the myelopathy worsened due to spine compression at the intermediate level. Conclusions: Simultaneous and non-contiguous two-level ACDF is a safe and effective procedure. The occurrence of postoperative adjacent and intermediate segment disease is rare. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study is to use two-sample Mendelian randomization (MR) to investigate the causal relationship between skin microbiota, especially Propionibacterium acnes, and intervertebral disc degeneration (IVDD), low back pain (LBP) and sciatica. Methods: We conducted a two-sample MR using the aggregated data from the whole genome-wide association studies (GWAS). 150 skin microbiota were derived from the GWAS catalog and IVDD, LBP and sciatica were obtained from the IEU Open GWAS project. Inverse-variance weighted (IVW) was the primary research method, with MR-Egger and Weighted median as supplementary methods. Perform sensitivity analysis and reverse MR analysis on all MR results and use multivariate MR to adjust for confounding factors. Results: MR revealed five skin microbiota associated with IVDD, four associated with LBP, and two with sciatica. Specifically, P.acnes in sebaceous skin environments were associated with reduced risk of IVDD; IVDD was found to increase the abundance of P.acnes in moist skin. Furthermore, ASV010 [Staphylococcus (unc.)] from dry skin was a risk factor for LBP and sciatica; ASV045 [Acinetobacter (unc.)] from dry skin and Genus Rothia from dry skin exhibited potential protective effects against LBP; ASV065 [Finegoldia (unc.)] from dry skin was a protective factor for IVDD and LBP. ASV054 [Enhydrobacter (unc.)] from moist skin, Genus Bacteroides from dry skin and Genus Kocuria from dry skin were identified as being associated with an increased risk of IVDD. Genus Streptococcus from moist skin was considered to be associated with an increased risk of sciatica. Conclusions: This study identified a potential causal relationship between skin microbiota and IVDD, LBP, and sciatica. No evidence suggests skin-derived P.acnes is a risk factor for IVDD, LBP and sciatica. At the same time, IVDD can potentially cause an increase in P.acnes abundance, which supports the contamination theory. [ABSTRACT FROM AUTHOR]

Low back pain is the most common musculoskeletal complaint accounting for over 30 million visits to primary care physicians annually. Serious pathology is found in less than 1% of these visits. Therefore it is often a challenge to distinguish worrisome findings requiring further workup and treatment from common complaints of pain. Gout is an inflammatory arthritis that most commonly affects the appendicular skeleton. It is characterized by the saturation of uric acid and deposition of monosodium urate crystals in joints and tissues. Spinal involvement is rare and is not typically considered on the differential diagnosis for a patient presenting with acute low back pain. We present such a case of a 35-year-old male who presented with intractable back pain, highlighting the need to recognize signs and symptoms that raise suspicion for spinal gout. [ABSTRACT FROM AUTHOR]

Background: Managing medication use in older orthopedic patients is imperative to extend their healthy life expectancy in an aging society. However, the actual situation regarding polypharmacy, the intake of potentially inappropriate medications (PIMs), and fall risk-increasing drugs (FRIDs) among older orthopedic patients is not well characterized. This study aimed to investigate the medication-based profiles of older orthopedic patients to highlight the critical points of concern. Methods: We retrospectively reviewed the clinical data of consecutive patients aged ≥ 65 years who underwent orthopedic surgery at two acute care hospitals between April 2020 and March 2021. The cutoff number of prescribed drugs for polypharmacy was set at 6. According to the specified guidelines, 19 categories of drugs were identified as PIMs, and 10 categories were classified as FRIDs. Results: A total of 995 older patients with orthopedic surgery were assessed, of which 57.4% were diagnosed with polypharmacy, 66.0% were receiving PIMs, and 41.7% were receiving FRIDs. The prevalence of FRID intake did not significantly differ among patients with degenerative spinal disease (n = 316), degenerative disease of extremities (n = 331), and fractures (n = 272). Compared with patients with degenerative disease of the extremities, the multivariable-adjusted prevalence ratios (PRs) of polypharmacy and PIM intake were significantly higher in patients with degenerative spinal disease (1.26 [confidence intervals (CI): 1.11–1.44] and 1.12 [CI: 1.00–1.25]), respectively. Use of antiemetic drugs (adjusted PR, 13.36; 95% CI: 3.14–56.81) and nonsteroidal anti-inflammatory drugs (adjusted PR, 1.37; 95% CI: 1.05–1.78) was significantly higher in patients with degenerative spinal disease. Among patients with degenerative spinal disease, the prevalence of antiemetic drug intake was 8.7% in lumbar spinal patients and 0% in cervical spinal patients. Conclusions: More than half of the orthopedic patients in this study were affected by polypharmacy, and approximately two-thirds were prescribed some form of PIMs. Patients with degenerative spinal disease showed a significantly higher prevalence of polypharmacy and PIM use compared with other orthopedic diseases. Particular attention should be paid to the high frequency of antiemetic drugs and nonsteroidal anti-inflammatory drugs intake among patients with degenerative lumbar spine conditions. [ABSTRACT FROM AUTHOR]

Objective Long-term follow-ups of prehabilitation programs for lumbar spine surgery are lacking, and more comprehensive evaluations are needed. In the current study, we evaluated the long-term effects of a prehabilitation program compared with conventional care in relation to lumbar fusion surgery in patients with degenerative disc disease. Methods Patients (n = 118) receiving lumbar fusion surgery were included in a multicenter randomized controlled trial, involving 1 university hospital and 2 spine clinics. The intervention was a person-centered prehabilitation program based on cognitive-behavioral physical therapy that targeted psychological presurgical risk factors, physical activity, and overall health. The control group received conventional preoperative care. Patient-reported outcome measures (PROMs) included assessments at 8 time-points: low back disability (primary outcome), back pain intensity, leg pain intensity, pain catastrophizing, fear of movement, anxiety and depressive mood, health-related quality of life, and patient-specific functioning. Physical activity and physical capacity were assessed at 5 time points. Linear mixed models were used to analyze the effects of the intervention. Results There were no significant differences between groups at the 12- and 24-month follow-ups for any outcome, except for the One Leg Stand test 1 year following surgery, in favor of the control group. There were significant improvements for both groups, from baseline to the 12- and 24-month follow-ups for all physical capacity test and patient-reported outcome measures, except for leg pain and self-efficacy for exercise. Conclusion No long-term effects were found for the prehabilitation program compared to conventional care. Physical activity did not improve over time, despite significantly improved self-reported functioning and physical capacity measurements. Impact These findings have implications for the current understanding of the long-term effects of prehabilitation and suggest that future research should focus on programs promoting physical activity both before and after lumbar spine surgery to decrease the risk of long-term adverse health outcomes. [ABSTRACT FROM AUTHOR]

Background: Atlantoaxial instability is the most common cervical instability in patients with rheumatoid arthritis (RA). Its course may differ in different patients and may have different degrees of severity and symptoms. Methods: There are a number of studies on systemic factors associated with the development of this instability, but there are few publications in the scientific literature on the influence of biomechanical factors on the development of cervical instability. One of the areas that allows the study of biomechanical factors influencing spine pathologies is the analysis of sagittal balance using radiological parameters. The study of radiological parameters of sagittal balance has contributed to understanding the pathology of selected spine diseases and is currently an indispensable tool in planning surgical treatment. Results: The presented study, conducted on a group of RA patients with cervical instability, was performed to look for a relationship between C1–C2 instability and sagittal balance parameters. Conclusions: Among the examined selected parameters, a statistically relationship between C1–C2 instability and the Cobb angle C1–C7 and OD-HA parameters has been found. This confirms the need for further in-depth research on this areas. [ABSTRACT FROM AUTHOR]

Degenerative diseases of the lumbar spine decrease lumbar lordosis (LL). Anterior lumbar interbody fusion (ALIF) at the L5-S1 disc space improves segmental lordosis, LL, and sagittal balance. This study investigated reciprocal changes in spinopelvic alignment after L5-S1 ALIF. A retrospective chart review identified patients who underwent L5-S1 ALIF with or without posterior fixation at a single institution (November 1, 2016 to October 1, 2021). Changes in pelvic tilt, sacral slope, proximal LL (L1-L4), distal LL (L4-S1), total LL (L1-S1), segmental lordosis, pelvic incidence–LL mismatch, thoracic kyphosis, cervical lordosis, and sagittal vertical axis were measured on preoperative and postoperative radiographs. Forty-eight patients were identified. Immediate postoperative radiographs were obtained at a mean (SD) of 17 (20) days after surgery; delayed radiographs were obtained 184 (82) days after surgery. After surgery, patients had significantly decreased pelvic tilt (15.71° [7.25°] vs. 17.52° [7.67°], P = 0.003) and proximal LL (11.86° [10.67°] vs. 16.03° [10.45°], P < 0.001) and increased sacral slope (39.49° [9.27°] vs. 36.31° [10.39°], P < 0.001), LL (55.35° [13.15°] vs. 51.63° [13.38°], P = 0.001), and distal LL (43.17° [9.33°] vs. 35.80° [8.02°], P < 0.001). Segmental lordosis increased significantly at L5-S1 and decreased significantly at L2-3, L3-4, and L4-5. Lordosis distribution index increased from 72.55 (19.53) to 81.38 (22.83) (P < 0.001). L5-S1 ALIF was associated with increased L5-S1 segmental lordosis accompanied by pelvic anteversion and a reciprocal decrease in proximal LL. These changes may represent a reversal of compensatory mechanisms, suggesting an overall relaxation of spinopelvic alignment after L5-S1 ALIF. [ABSTRACT FROM AUTHOR]

Purpose: To conduct an independent assessment of inter- and intraobserver agreement for the META score as a tool for differentiating osteoporotic vertebral fractures and multiple myeloma vertebral fractures. Methods: This is a retrospective observational study. The magnetic resonance imaging analysis was made by two independent spinal surgeons. We designated a Subjective assessment, in which the surgeon should establish a diagnostic classification for each vertebral fracture based on personal experience: secondary to osteoporosis, categorized as a benign vertebral fracture (BVF), or attributed to multiple myeloma, categorized a malign vertebral fracture (MVF). After a 90-day interval, both surgeons repeated the evaluations. For the next step, the observers should establish a diagnosis between BVF and MVF according to the META score system, and both observers repeated the evaluations after a 90-day interval. The intra and interobserver reliability of the Subjective evaluation was studied using the kappa (κ) test. Then, the META evaluations were paralleled using the intraclass correlation coefficient (ICC). Results: A total of 220 patients who had the potential to participate in the study were initially enrolled, but after applying the exclusion criteria, 44 patients were included. Thirty-three patients had BVF, and 12 patients presented MVF. Interobserver agreement for both Subjective evaluations moments (initial and 90-days interval) found a slight agreement for both moments (0.35 and 0.40 respectively). Kappa test for both META evaluations moments (initial and 90-days interval) found a moderate interobserver agreement for both moments (0.54 and 0.48 respectively). It was observed that the ICC calculated for the Initial evaluation using META score was 0.680 and that in the 90-days interval was 0.726, indicating regular to good agreement. Kappa test for intraobserver agreements for the Subjective evaluation presented moderate agreement for both Surgeons. On the other side, Kappa test for intraobserver agreements for the META evaluation presented substantial agreement for both Surgeons. The Intraclass Correlation Coefficient of the META score found presented an almost perfect agreement for both Surgeons. Conclusion: Intra and interobserver agreement for both surgeons were unsatisfactory. The lack of consistent reproducibility by the same observer discourages and disfavors the routine use of the META score in clinical decision making, when potentially cases of multiple myeloma may be present. [ABSTRACT FROM AUTHOR]

Fusions for lumbar spine diseases are widely performed and have a growing incidence, especially in elderly population. The goal of this study was to assess national trends of lumbar spinal fusions and examine the risk for reoperations after a lumbar fusion with a focus on 'epidemiologic transition' relating to age. The prospectively collected Korean Health Insurance Review and Assessment Service (HIRA) nationwide cohort database was retrospectively reviewed. The total 278,815 patients who underwent lumbar spinal fusions for degenerative spine diseases between 2010 and 2018 were reviewed and used to assess trends in operative incidence. The 37,050 patients who underwent lumbar fusions between 1/2010 and 12/2011 were enrolled to determine 8-year reoperation rates. The overall number of lumbar spinal fusions were analyzed for the national annual trend. Demographic data, reoperation rates, and confounding clinical factors were evaluated. The overall number of lumbar spinal fusions was analyzed to determine the national annual trend of operative incidence. For the reoperation rate analysis, the primary outcome measured was the cumulative incidence of revision operations within a minimum 8-year follow-up period. Additional outcomes included comparative analyses of the reoperation rate with respect to age, sex, or other underlying comorbidities. Over time, elderly patients comprised a larger portion of the cohort (2010:24.2%; 2018:37.6%), while operations in younger patients decreased over time (2010:40.3%; 2018:27.0%). In the cohort of patients with a minimum 8-year follow-up (n=37,050), rates of reoperation peaked in patients aged 60–69 years (17.6 per 1000 person-years [HR 2.20 compared to <40years]) and decreased for more elderly patients (14.3 per 1000 person-years [HR 1.80 compared to <40years]). Age was the most significant risk factor for reoperation. Osteoporosis was also a risk factor for reoperation in postmenopausal females. Increasing incidence of lumbar fusions in elderly patients was seen however the risk of reoperation decreased in patients aged 70 or more. Lumbar fusion for elderly patients should not be hesitated in the decision-making process because of concerns about reoperation. [ABSTRACT FROM AUTHOR]

Purpose: Since an increase in the occurrence of native vertebral osteomyelitis (VO) is expected and reliable projections are missing, it is urgent to provide a reliable forecast model and make it a part of future health care considerations. Methods: Comprehensive nationwide data provided by the Federal Statistical Office of Germany were used to forecast total numbers and incidence rates (IR) of VO as a function of age and gender until 2040. Projections were done using autoregressive integrated moving average model on historical data from 2005 to 2019 in relation to official population projections from 2020 to 2040. Results: The IR of VO is expected to increase from 12.4 in 2019 to 21.5 per 100,000 inhabitants [95% CI 20.9–22.1] in 2040. The highest increase is predicted in patients over 75 years of age for both men and women leading to a steep increase in absolute numbers, which is fourfold higher compared to patients younger than 75 years. While the IR per age group will not increase any further after 2035, the subsequent increase is due to a higher number of individuals aged 75 years or older. Conclusions: Our data suggest that increasing IR of VO will seriously challenge healthcare systems, particularly due to demographic change and increasing proportions of populations turning 75 years and older. With respect to globally fast aging populations, future health care policies need to address this burden by anticipating limitations in financial and human resources and developing high-level evidence-based guidelines for prevention and interdisciplinary treatment. [ABSTRACT FROM AUTHOR]

Primary bone lymphoma of the spine (PBL) is a rare entity that may be misdiagnosed due to its atypical location and clinical and imaging features mimicking certain pathologies as infectious processes, which complicates and delays diagnosis. Our case reports a patient in her sixties who had been suffering from chronic low back pain for a year, and had gradually started to develop cruralgia. She underwent a blood sample, magnetic resonance imaging (MRI), and positron emission tomography (18F-FDG-PET/CT) which revealed inflammatory syndrome, and an image of spondylodiscitis of the lumbar spine associated with a morphological and metabolical widespread invasion posteriorly suggesting epiduritis. No other lesions were found on the rest of the body. Neurosurgical management was performed and a biopsy was made. Histological results showed aggressive and diffuse large B-cell lymphoma, suggesting a diagnosis of PBL. This case highlights the first case of spondylodiscitis mimicking PBL in the lumbar spine, the intricacies of the diagnostic work-up, and the complexity of discriminating with an infectious process in the spine, as both have a similar, non-specific clinical presentation, while morphological and metabolic findings can be alike. [ABSTRACT FROM AUTHOR]

AbstractIntroductionResearch QuestionResultsDiscussion and ConclusionParkinson’s disease is a common neurodegenerative disease. With an aging population, co-existent degenerative diseases of the spine in these patients will become more prevalent.This systematic review and meta-analysis aims to establish the incidence and risk of adverse outcomes following spinal surgery in patients with Parkinson’s disease. Material and Methods A literature review was carried out in order to identify studies assessing the outcomes of adult patients with Parkinson’s disease undergoing spinal surgery for degenerative conditions. Studies with less than ten subjects or those assessing surgery for spinal deformity or trauma were excluded.Of 74 studies identified, seven were included for meta-analysis. In the 689,578 participants, there was a significantly higher incidence, but not higher risk, of complications (0.54 95% CI [0.19–0.85] vs 0.07 95% CI [0.01–0.41]; p = 0.048) and revision surgery (0.6 95% CI [0.25–0.88] vs 0.1 95% CI [0.05–0.19]; p = 0.003) amongst patients with Parkinson’s disease compared to controls. We also demonstrated a significantly lower incidence but not lower risk of clinical improvement (0.27 95% CI [0.16–0.41] vs 0.57 95% CI [0.36–0.76]; p = 0.02) after surgery in patients with Parkinson’s disease. There was no difference in the incidence or risk of death following surgery.Spinal surgery for concomitant degenerative diseases in patients with Parkinson’s disease is associated with a lower incidence of clinical improvement and a higher incidence of complications. Medical management should be optimised before an individually tailored and well-considered surgical intervention is implemented. [ABSTRACT FROM AUTHOR]

Study design: A systematic review and Bayesian network meta-analysis (NMA). Objective: To compare the effectiveness and safety of different posterior decompression techniques for LSS. Summary of background data: Lumbar spinal stenosis (LSS) is one of the most common degenerative spinal diseases that result in claudication, back and leg pain, and disability. Currently, posterior decompression techniques are widely used as an effective treatment for LSS. Methods: An electronic literature search was performed using the EMBASE, Web of Science, PubMed, and Cochrane Library databases. Two authors independently performed data extraction and quality assessment. A Bayesian random effects model was constructed to incorporate the estimates of direct and indirect treatment comparisons and rank the interventions in order. Results: In all, 14 eligible studies comprising 1,260 patients with LSS were included. Five interventions were identified, namely, spinal processes osteotomy (SPO), conventional laminotomy/laminectomy (CL), unilateral laminotomy/laminectomy (UL), bilateral laminotomy/ laminectomy (BL), and spinous process-splitting laminotomy/laminectomy (SPSL). Among these, SPO was the most promising surgical option for decreasing back and leg pain and for lowering the Oswestry Disability Index (ODI). SSPL had the shortest operation time, while SPSL was associated with maximum blood loss. SPO and UL were superior to other posterior decompression techniques concerning lesser blood loss and shorter length of hospital stay, respectively. Patients who underwent BL had the lowest postoperative complication rates. Conclusion: Overall, SPO was found to be a good surgical choice for patients with LSS. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective cohort study. Objective. To evaluate how preoperative Oswestry Disability Index (ODI) thresholds might affect minimal clinically important difference (MCID) achievement following lumbar fusion. Summary of Background Data. As payers invest in alternative payment models, some are suggesting threshold cutoffs of patientreported outcomes (PROMs) in reimbursement approvals for orthopedic procedures. The feasibility of this has not been investigated in spine surgery. Materials/Methods. We included all adult patients undergoing one to three-level primary lumbar fusion at a single urban tertiary academic center from 2014 to 2020. ODI was collected preoperatively and one year postoperatively. We implemented theoretical threshold cutoffs at increments of 10. MCID was set at 14.3. The percent of patients meeting MCID were determined among patients "approved" or "denied" at each threshold. At each threshold, the positive predictive value (PPV) for MCID attainment was calculated. Results. A total 1368 patients were included and 62.4% (N=364) achieved MCID. As the ODI thresholds increased, a greater percent of patients in each group reached the MCID. At the lowest ODI threshold, 6.58% (N= 90) of patients would be denied, rising to 20.2%, 39.5%, 58.4%, 79.9%, and 91.4% at ODI thresholds of 30, 40, 50, 60, and 70, respectively. The PPV increased from 0.072 among patients with ODI>20 to 0.919 at ODI> 70. The number of patients denied a clinical improvement in the denied category per patient achieving the MCID increased at each threshold (ODI > 20: 1.96; ODI> 30: 2.40; ODI >40: 2.75; ODI>50: 3.03; ODI> 60: 3.54; ODI> 70: 3.75). Conclusion. Patients with poorer preoperative ODI are significantly more likely to achieve MCID following lumbar spine fusion at all ODI thresholds. Setting a preoperative ODI threshold for surgical eligibility will restrict access to patients who may benefit from spine fusion despite ODI> 20 demonstrating the lowest predictive value for MCID achievement. [ABSTRACT FROM AUTHOR]

Purpose: Greater trochanter pain syndrome (GTPS) is highly discussed during spine surgeons, accompanies lumbar pain and complicates differential diagnosis. The aim is to raise awareness among physicians and demonstrate the lumbar spine degenerative diseases (LSDD) association with GTPS. Methods: A retro-prospective analysis enrolled 172 patients with LSDD with GTPS signs. Group I – retrospective (n = 112), group II – prospective (n = 60). Patients of group II with the confirmed diagnosis clinically and by the ultrasound recieved a GCS injection (Betamethasone 2 mg\ml + 5 mg\ml — 1.0). Also the VAS, X-ray and SPSS Statistics package were used. Results: 112 patients in group I, 89 (79.5%) had increased pain in the hip early postOp to 7.8 points by VAS. All patients required trigger point injections of GCS and 68 (77%) received a repeat injection. 76 from 112 patients were tracked for long-term results, and recurrence of GTPS was detected in five people who treated conservatively for three months without dynamics. They were identified GTPS by ultrasound. During the injection, 39 from 43 (90%) patients noted pain reduction to 2.1 by VAS, but symptoms of radiculopathy or spinal stenosis persisted. Two patients (5%) did not note any changes. Two patients (5%) noted complete pain regression and refused the surgery. Conclusion: Timely detection of GTPS among spinal surgeons influences tactics and, in some cases, allows one to avoid unnecessary surgical interventions. In turn, ignoring the symptoms of GTPS in the preoperative period can lead to pain intensification in the greater trochanter after surgery for degenerative diseases of the spine. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the quality and reliability of YouTube videos focusing on unilateral biportal endoscopic spine surgery, a novel technique for spinal decompression in degenerative spinal disease. This cross-sectional study, conducted in February 2023, involved an online search on YouTube using the term "unilateral biportal endoscopic spine surgery". Video popularity was assessed using the Video Power Index. Video reliability and quality were measured using the Global Quality Scale, the Journal of the American Medical Association benchmark criteria, and the modified DISCERN instrument. Ninety-three videos were included for evaluation. Uploader profiles were categorized by continent, with 61.3% from Asia, 35.5% from the United States, 2.2% from Africa, and 1.1% from Australia. When comparing 3 groups as South Korea, United States, and other countries, no significant differences were observed in the technical characteristics of the videos. However, the educational quality and reliability of the videos were higher in those uploaded from South Korea (P < 0.001).When the videos were divided into 2 groups according to their educational quality, significant difference were noted in video duration, loading time, video quality, and reliability (P < 0.001). The YouTube videos on unilateral biportal endoscopic spine surgery showed high quality and reliability. However, videos from South Korea were found to have higher educational quality and reliability, while other specifications were similar for all videos. Furthermore, it was determined that videos uploaded more recently and with longer duration were of higher quality. [ABSTRACT FROM AUTHOR]

Summary: Background: Faecal incontinence is a highly prevalent and very distressing condition that occurs throughout the entire paediatric age. Aim: To summarise advances in the understanding of the epidemiology, pathophysiology, evaluation and treatment of children with faecal incontinence due to either disorders of gut–brain interaction or organic diseases. Methods: Literature review on prevalence, impact, diagnosis and treatment options for children with faecal incontinence, interspersed with observations from the author's lifelong career focused on evaluation of children with motility disorders. Results: Faecal incontinence in children is most commonly due to unrecognised or insufficiently treated functional constipation with overflow incontinence. Non‐retentive faecal incontinence (NRFI) is probably more common than previously thought and is particularly challenging to treat. Organic diseases such as anorectal malformations (ARMs), Hirschsprung disease and spinal defects are often associated with faecal incontinence; in these conditions, faecal incontinence has a profound impact on quality of life. Recognition of the different pathophysiologic mechanisms causing the incontinence is essential for a successful treatment plan. A thorough physical examination and history is all that is needed in the diagnosis of the causes of faecal incontinence related to disorders of gut–brain interaction. Colonic transit studies or x‐rays may help to differentiate retentive from NRFI. Manometry tests are helpful in determining the mechanisms underlying the incontinence in children operated on for ARMs or Hirschsprung diseases. Multiple behavioural, medical and surgical interventions are available to lessen the severity of faecal incontinence and its impact on the daily life of affected individuals. Conclusions: Recent advances offer hope for children with faecal incontinence. [ABSTRACT FROM AUTHOR]

Background: Concurrent spinal pathology is frequent in patients undergoing total hip arthroplasty (THA). In this study we examined whether spinopelvic interactions affect THA outcomes at a minimum follow-up of 10 years. Patients and methods: 295 patients with a mean age of 63.3 (range 56‒80) years receiving a THA between 2006 and 2009 were assessed. Of these, 195 had mild lumbar disc degeneration and 100 had advanced lumbar spondylosis. We analysed the changes in the Harris Hip Score (HHS) and the survival rate for postoperative low back pain (LBP) and dislocation. Changes in acetabular component position, sacro-femoral-pubic (SFP) and pelvic obliquity (PO) angles were assessed with radiological images. Results: The mean HHS was lower in female patients (p = 0.009), patients >65 years of age (p < 0.001) and those with advanced lumbar spondylosis (p = 0.002). 52 (71.2%) of the patients reporting preoperative LBP experienced improvement after THA while 47 (21.1%) of those without preoperative LBP postoperatively reported new onset LBP. Female patients (p = 0.025; hazard ratio [HR]: 1.831; 95% CI, 1.081–3.101) and those with preoperative LBP (p = 0.007; HR 2.068; 95% CI, 1.221–3.504) were at a higher risk of developing postoperative LBP at 10 years. 4 out of 9 THA dislocations were late and had shown decreasing SFP angle values over time. Acetabular component inclination and anteversion angles increased over time, whereas the SFP angle was associated with sex and age and the PO angle with age and the severity of any preoperative lumbar degeneration. Conclusions: Concurrent spinal pathology influences THA outcomes at a minimum follow-up of 10 years. Sex, age, and associated lumbar degeneration can affect clinical and radiological changes over time. A decrease in SFP angle values over time was found in patients sustaining late dislocation. [ABSTRACT FROM AUTHOR]

The classification of medical devices by the Food and Drug Administration (FDA) involves rigorous scrutiny from specialized panels that designate devices as Class I, II, or III depending on their levels of relative risk to patient health. Posterior rigid pedicle screw systems were first classified by the FDA in 1984 and have since revolutionized the treatment of many spine pathologies. Despite this early classification by the FDA, posterior cervical pedicle and lateral mass screws were not reclassified from unclassified to Class III and then to Class II until 2019, nearly 35 years after their initial classification. This reclassification process involved a decades-long interplay between the FDA, formal panels, manufacturers, academic leaders, practicing physicians, and patients. It was delayed by lawsuits and a paucity of data demonstrating the ability to improve outcomes for cervical spinal pathologies. The off-label use of thoracolumbar pedicle screw rigid fixation systems by early adopters assisted manufacturers and professional organizations in providing the necessary data for the reclassification process. This case study highlights the collaboration between physicians and professional organizations in facilitating FDA reclassification and underscores changes to the current classification process that could avoid the prolonged dichotomy between common medical practice and FDA guidelines. [ABSTRACT FROM AUTHOR]

Early detection of disc degeneration and categorizing them is very important for the treatment plan and better prognosis. We aimed to assess the efficacy of apparent diffusion coefficient (ADC) mapping and T2 mapping in the early detection and grading of the severity of degenerative disc disease. In this review, the articles published until July 2022, from the PubMed database were used. All articles contained information about the application of ADC and T2 mapping in the detection of disc degeneration. A total of 40 articles were included in this review. We assessed each article for the feasibility of both techniques to categorize the degeneration. ADC values of nucleus pulposus (NP) showed a negative correlation with Pfirrmann grades and age. T2 values of NP and annulus fibrosus (AF) are significantly decreased with an increase in Pfirrmann grades. And also, as age increases, T2 values of NP and posterior AF decreased significantly. ADC and T2 mapping techniques are sensitive in the detection and categorization of disc degeneration. It is highly recommended to include quantitative magnetic resonance imaging techniques in routine spine imaging protocol in a patient with complaints of back pain. [ABSTRACT FROM AUTHOR]

Background: Oral health management has become increasingly important for acute inpatients. Older patients often require extended periods of medical care, and oral health management is necessary in the convalescent period following the acute period. During the convalescent period, oral health management remains unclear as convalescent hospitals have limited dental resources, and effective dental care must be provided if the objective of hospitalization is to improve life functions. This study aimed to clarify the relationship between daily functioning and oral health status at the time of admission to a convalescent hospital to aid in improving daily functioning in the convalescent period. Methods: We included patients admitted to the rehabilitation department of a specific convalescent hospital from January to December 2021. A total of 375 patients were included in the study, with complete data records. At admission, we gathered information from the medical records, including the patient's age, sex, primary disease, Charlson Comorbidity Index, Mini Nutritional Assessment Short-Form (MNA-SF), Functional Oral Intake Scale (FOIS), Functional Independence Measure (FIM), number of teeth, and Oral Health Assessment Tool (OHAT). Statistical analysis was conducted using SPSS Ver. 27, with a significance level of 5%. Results: The mean age of the 375 participants (189 men and 186 women) was 75.0 ± 12.1 years (range, 42–97 years), and over 80% were > 65 years. About 30% of major diseases could be attributed to strokes and fractures, followed by spinal cord and spine diseases. In non-stroke patients, multiple regression analysis using FIM motor, FIM cognitive, and FIM and OHAT total scores as objective variables showed that higher total scores of MNA-SF, FOIS, and lower modified Rankin Scale and OHAT were significantly associated with better FIMs. Lower OHAT scores were significantly associated with lower FOIS and MNA-SF scores, male sex, having fewer teeth, and poor dietary patterns. Conclusions: The convalescent period is an opportune time to provide intensive dental care due to the generally stable condition and extended hospital stay. Our results suggest that oral health management, such as dysphagia rehabilitation and denture treatment, is important for maintaining and improving independence, a key objective of convalescent rehabilitation, and malnutrition improvement. [ABSTRACT FROM AUTHOR]

Objectives: High variation in clinical practice may indicate uncertainty and potentially low-value care. Methods to identify low value care are often not well defined or transparent and can be time intensive. In this paper we explore the usefulness of variation analysis of routinely-collected data about surgical procedures in England to identify potentially low-value surgical care. Methods: This is a national ecological study using Hospital Episode Statistics linked to mid-year population estimates and indices of multiple deprivation in England, 2014/15-2018/19. We identified the top 5% of surgical procedures in terms of growth in standardised procedure rates for 2014/15 to 2018/19 and variation in procedure rates between clinical commissioning groups as measured by the systematic component of variance (SCV). A targeted literature review was conducted to explore the evidence for each of the identified techniques. Procedures without evidence of cost-effectiveness were viewed as of potentially low value. Results: We identified six surgical procedures that had a high growth rate of 37% or more over 5 years, and four with higher geographical variation (SCV >1.6). There was evidence for two of the 10 procedures that surgery was more cost-effective than non-surgical treatment albeit with uncertainty around optimal surgical technique. The evidence base for eight procedures was less clear cut, with uncertainty around clinical- and/or cost-effectiveness. These were: deep brain stimulation; removing the prostate; surgical spine procedures; a procedure to alleviate pain in the spine; surgery for dislocated joints due to trauma and associated surgery for traumatic fractures; hip joint replacement with cemented pelvic component or cemented femoral component; and shoulder joint replacement. Conclusions: This study demonstrates that variation analysis could be regularly used to identify potentially low-value procedures. This can provide important insights into optimising services and the potential de-adoption of costly interventions and treatments that do not benefit patients and the health system more widely. Early identification of potentially low value care can inform prioritisation of clinical trials to generate evidence on effectiveness and cost-effectiveness before treatments become established in clinical practice. [ABSTRACT FROM AUTHOR]

One of the frequent causes of low back pain is intervertebral disc degeneration (IDD), which is followed by discogenic pain. Some significant risk factors that have been linked to the onset and progression of IDD include age, mechanical imbalance, changes in nutrition and inflammation. According to recent studies, five types of animal models are established for producing IDD: the spontaneous models, the puncture models, the biomechanical models, the chemical models and the hybrid models. These models are crucial in studying and understanding IDD's natural history and identifying potential treatment targets for IDD. In our study, we'll talk about the technical aspects of these models, the time between model establishment and the apparition of observable degradation, and their potential in various research. Each animal model should be compared to the human natural IDD pathogenesis to guide future research efforts in this area. By improving knowledge and appropriate application of various animal models, we seek to raise awareness of this illness and further translational research. [ABSTRACT FROM AUTHOR]

Background: Radiography is commonly used in the assessment of spinal disorders, despite a lack of high-quality evidence demonstrating improved clinical outcomes or additional benefit to the patient. There is disagreement amongst chiropractors regarding the appropriate use of radiography for clinical management. This study aims to qualitatively explore chiropractors' perceptions on the use of spinal radiographs in clinical practice with respect to how they determine when to order radiographs; and how they use radiographs to inform clinical management. Methods: Online qualitative semi-structured interviews were conducted with 17 Australian chiropractors who currently manage patients with spinal disorders. Convienence, snowball, and purposive sampling strategies were used to ensure an appropriate breadth and depth of participant characterisitcs and beliefs. Interview data were recorded, transcribed and analysed using framework analysis. Results: Three themes were developed to describe how chiropractors determined when to order radiographs. These themes included specific findings from the clinical encounter that may inform clinical management, their perceptions of radiation risk, and the influence of clinical experience/intuition. Three themes and four subthemes were developed for how chiropractors use radiographs to inform their management. These themes explored the use of radiography for the application of chiropractic technique, as well as the role of radiographs in predicting patient prognosis, and as an educational tool to provide reassurance. Conclusion: Australian chiropractors' decision-making around spinal radiography is diverse and can be influenced by a number of clinical and external factors. Previously unexplored uses of spinal radiography in clinical practice were highlighted. Some chiropractors reported potential benefits of radiography that are currently not supported by research evidence. Future research should address how radiographic findings are reported to patients with spinal disorders and how this could be optimised to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Non-traumatic orthopedic conditions are pathological conditions involving musculoskeletal system that includes muscles, tendons, bone and joints and associated with frequent medical and surgical care and high treatment costs. There is paucity of information on the pattern of non-traumatic orthopedic conditions in low and middle income countries. The purpose of this study was to determine the epidemiology of non-traumatic orthopedic conditions among inpatients at the Kenyatta National Hospital in Kenya. This was a cross-sectional study with a sample of 175 charts reviewed. Approximately, 70.3% of the inpatients were aged between 25 to 64 years of age with the mean age of 39.97 years (STD 18.78). Ever married tended to be older 53.5 (95% CI: 46.8–60.2) years than other marital statuses. Approximately, 60.6% were males, 38.9% had comorbidities and 49.1% were casuals or unemployed. All inpatients were Kenyans with Nairobi County comprising 52.6% of all inpatients. Approximately, 77.7% were self-referrals. The commonest non-trauma orthopaedic conditions were infection and non-union (35.4%) and spinal degenerative diseases (20.60%) and the least was limb deformities (1.70%). Compared to females, males were 3.703 (p<0.001) times more likely to have infection and non-union. Patients with primary, secondary and tertiary education were 88.2% (p<0.001), 75.6% (p<0.001) and 68.1% (p = 0.016) less likely to have infection and non-union compared to those with no or preschool education. Widows were 8.500 (p = 0.028) times more likely to have spinal degenerative disease than married. Males were 70.8% (p = 0.031) less likely to have osteoarthritis than females. Inpatients with secondary education were 5.250 (p = 0.040) times more likely to have osteoarthritis than those with no or preschool education. In conclusion, majority of inpatients were young and middle aged adults. Infection and non-union and spinal degenerative diseases were the most common non-trauma orthopedic conditions. While males and those with low education were more likely to have infection and non-union, married were more likely to have spinal degenerative disease. Osteoarthritis was more likely among female admissions. [ABSTRACT FROM AUTHOR]

Background: Diffusion tensor imaging (DTI) has been increasingly recognized for its capability to study microstructural changes in the neuropathology of brain diseases. However, the optimal DTI metric and its diagnostic utility for a variety of spinal cord diseases are still under investigation. Purpose: To evaluate the diagnostic efficacy of DTI metrics for differentiating between cervical spondylosis, myelitis, and spinal tumors. Methods: This retrospective study analyzed DTI scans from 68 patients (22 with cervical spondylosis, 23 with myelitis, and 23 with spinal tumors). DTI indicators, including fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD) and axial diffusivity (AD), were calculated. The Kruskal–Wallis test was used to compare these indicators, followed by Receiver Operating Characteristic (ROC) curve analysis, to evaluate the diagnostic efficacy of each indicator across disease pairs. Additionally, we explored the correlations of DTI indicators with specific clinical measurements. Results: FA values were significantly lower in tumor patients compared to those with cervical spondylosis (p < 0.0001) and myelitis (p < 0.05). Additionally, tumor patients exhibited significantly elevated MD and RD values relative to the spondylosis and myelitis groups. ROC curve analysis underscored FA's superior discriminative performance, with an area under the curve (AUC) of 0.902 for differentiating tumors from cervical spondylosis, and an AUC of 0.748 for distinguishing cervical myelitis from spondylosis. Furthermore, a significant negative correlation was observed between FA values and Expanded Disability Status Scores (EDSSs) in myelitis patients (r = −0.62, p = 0.002), as well as between FA values and Ki-67 scores in tumor patients (r = −0.71, p = 0.0002). Conclusion: DTI indicators, especially FA, have the potential in distinguishing spondylosis, myelitis, and spinal cord tumors. The significant correlation between FA values and clinical indicators highlights the value of FA in the clinical assessment and prognosis of spinal diseases and may be applied in diagnostic protocols in the future. [ABSTRACT FROM AUTHOR]

Purpose: Facet joint degeneration (FJD) is a major cause of low back pain. Parathyroid hormone (PTH) (1–34) is commonly used to treat osteoporosis. However, little is known about its effects on FJD induced by estrogen deficiency. This study aims to investigate the effects of PTH (1–34) on FJD induced by estrogen deficiency and the underlying pathogenesis of the disease. Methods: Forty 3-month-old female Sprague-Dawley rats were randomly divided into four groups: 30 received bilateral ovariectomy (OVX) followed by 12 weeks of treatment with normal saline, PTH (1–34) or 17β-estradiol (E2), and 10 received sham surgery followed by administration of normal saline. Status and Wnt/β-catenin signaling activity in the cartilage and subchondral bone of the L4–L5 FJs and serum biomarkers were analyzed. Results: Administration of PTH (1–34) and E2 ameliorated cartilage lesions, and significantly decreased MMP-13 and caspase-3 levels and chondrocyte apoptosis. PTH (1–34) but not E2 significantly increased cartilage thickness, number of chondrocytes, and the expression of aggrecan. PTH (1–34) significantly improved microarchitecture parameters of subchondral bone, increased the expression of collagen I and osteocalcin, and decreased RANKL/OPG ratio. E2 treatment significantly increased the OPG level and decreased the RANKL/OPG ratio in the subchondral bone of ovariectomized rats, but it did not significantly improve the microarchitecture parameters of subchondral bone. Wnt3a and β-catenin expression was significantly reduced in the articular cartilage and subchondral bone in OVX rats, but PTH (1–34) could increase the expression of these proteins. E2 significantly increased the activity of Wnt/β-catenin pathway only in cartilage, but not in subchondral bone. The restoration of Wnt/β-catenin signaling had an obvious correlation with the improvement of some parameters associated with the FJs status. Conclusion: Wnt/β-catenin signaling may be a potential therapeutic target for FJD induced by estrogen deficiency. PTH (1–34) is effective in treating this disease with better efficacy than 17β-estradiol, and the efficacy may be attributed to its restoration of Wnt/β-catenin signaling. [ABSTRACT FROM AUTHOR]

Qualitative meta-ethnography. Pre-registered with OSF:10.17605/OSF.IO/UTZE6. To understand the patient experience pre- and/or post-lumbar spine surgery. Literature search: A literature search was conducted in MEDLINE, EMBASE, EmCare and CINAHL from inception to October 17, 2022. Study selection criteria: Peer-reviewed qualitative or mixed-method studies of English text investigating the beliefs, perceptions, or experiences of adults (≥18 years old) pre- and/or post-lumbar spine surgery for degenerative, non-traumatic or non-infectious concerns. Data synthesis: The eMERGE meta-ethnography reporting guidelines were followed to create themes and subthemes from the original themes of the included studies. A quality appraisal was performed using the McMaster Quality Appraisal tool. We included 18 studies and identified five themes that were separated into pre- and post-operative categories. The two pre-operative themes included [1]: the influence of physiotherapy interventions on patients' experiences, and [2] the importance of education/the power of communication, and the three post-operative themes included [1]: psychosocial coping [2], redefining oneself post-operatively, and [3] experience with the healthcare system. These findings emphasize the complexity of the peri-operative experience for individuals undergoing lumbar spine surgery. Future research should focus on addressing psychosocial factors that may optimize patient experiences and recovery following LSS. The results of this study identified potential pre-operative and post-operative factors that may influence whether patients' have positive or negative perioperative experiences with lumbar spine surgery. Health care providers should be encouraged to focus on psychosocial factors that can be implemented in the health care system to improve the perioperative experience of patients undergoing lumbar spine surgery. [ABSTRACT FROM AUTHOR]

Background: Endoscopic spine lumbar interbody fusion (Endo-LIF) is well-regarded within the academic community. However, it presents challenges such as intraoperative disorientation, high rates of nerve damage, a steep learning curve, and prolonged surgical times, often occurring during the creation of the operative channel. Furthermore, the undefined safe operational zones under endoscopy continue to pose risks to surgical safety. We aimed to analyse the anatomical data of Kambin's triangle via CT imaging to define the parameters of the safe operating area for transforaminal posterior lumbar interbody fusion (TPLIF), providing crucial insights for clinical practice. Methods: We selected the L4–L5 intervertebral space. Using three-dimensional (3D), we identified Kambin's triangle and the endocircle within it, and recorded the position of point 'J' on the adjacent facet joint as the centre 'O' of the circle shifts by angle 'β.' The diameter of the inscribed circle 'd,' the abduction angle 'β,' and the distances 'L1' and 'L2' were measured from the trephine's edge to the exiting and traversing nerve roots, respectively. Results: Using a trephine with a diameter of 8 mm in TPLIF has a significant safety distance. The safe operating area under the TPLIF microscope was also clarified. Conclusions: Through CT imaging research, combined with 3D simulation, we identified the anatomical data of the L4–L5 segment Kambin's triangle, to clarify the safe operation area under TPLIF. We propose a simple and easy positioning method and provide a novel surgical technique to establish working channels faster and reduce nerve damage rates. At the same time, according to this method, the Kambin's triangle anatomical data of the patient's lumbar spine diseased segments can be measured through CT 3D reconstruction of the lumbar spine, and individualised preoperative design can be conducted to select the appropriate specifications of visible trephine and supporting tools. This may effectively reduce the learning curve, shorten the time operation time, and improve surgical safety. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to evaluate the potential of zoledronic acid for reducing the incidence of cage subsidence and enhancing interbody fusion rates following oblique lumbar interbody fusion (OLIF) surgery, particularly as the first reported evidence of the role of zoledronic acid combined with OLIF. Methods: A retrospective analysis was conducted on data from 108 elderly patients treated for degenerative lumbar diseases using OLIF combined with bilateral pedicle screw fixation from January 2018 to December 2021. Patients were divided into the zoledronic acid (ZOL) group (43 patients, 67 surgical segments) and the control group (65 patients, 86 surgical segments). A comparative analysis of the radiographic and clinical outcomes between the groups was performed, employing univariate and multivariate regression analyses to explore the relationships between cage subsidence and the independent variables. Results: Radiographic outcomes, including anterior height, posterior height, disc height, coronal disc angle, foraminal height, and lumbar lordosis, were not significantly different between the two groups. Similarly, no statistically significant differences were noted in the back visual analog scale (VAS) scores and Oswestry Disability Index (ODI) scores between the groups. However, at the 1-year follow-up, the leg VAS score was lower in the ZOL group than in the control group (P = 0.028). The ZOL group demonstrated a notably lower cage subsidence rate (20.9%) than did the control group (43.0%) (P < 0.001). There was no significant difference in the interbody fusion rate between the ZOL group (93.0%) and the control group (90.8%). Non-use of zoledronic acid emerged as an independent risk factor for cage subsidence (OR = 6.047, P = 0.003), along with lower bone mineral density, lower postoperative anterior height, and concave endplate morphology. The model exhibited robust discriminative performance, with an area under the curve (AUC) of 0.872. Conclusion: The administration of zoledronic acid mitigates the risk of cage subsidence following OLIF combined with bilateral pedicle screw fixation in elderly patients; however, it does not improve the interbody fusion rate. [ABSTRACT FROM AUTHOR]

Recent research in computational imaging largely focuses on developing machine learning (ML) techniques for image recognition in the medical field, which requires large-scale and high-quality training datasets consisting of raw images and annotated images. However, suitable experimental datasets for cervical spine X-ray are scarce. We fill the gap by providing an open-access Cervical Spine X-ray Atlas (CSXA), which includes 4963 raw PNG images and 4963 annotated images with JSON format (JavaScript Object Notation). Every image in the CSXA is enriched with gender, age, pixel equivalent, asymptomatic and symptomatic classifications, cervical curvature categorization and 118 quantitative parameters. Subsequently, an efficient algorithm has developed to transform 23 keypoints in images into 77 quantitative parameters for cervical spine disease diagnosis and treatment. The algorithm's development is intended to assist future researchers in repurposing annotated images for the advancement of machine learning techniques across various image recognition tasks. The CSXA and algorithm are open-access with the intention of aiding the research communities in experiment replication and advancing the field of medical imaging in cervical spine. [ABSTRACT FROM AUTHOR]

Background data: Lumbar instability is considered an essential aetiology of low back pain (LBP) which is always accompanied by considerable disability. The term ‘instability’ remains poorly defined. But it is most broadly explained by any change of the normal mechanism of spinal motion which leads to pain and/or neurological impairment. It was reported that, ‘Segmental instability can be defined as a pathological reaction to the applied loads, characterized by motion in motion segments more than normal constraints. The dynamic system can stabilize an unstable segment adequately but permits more mobility in the fixed levels than the conventional fixation systems. Study design: prospective, consecutive study Patients and methods: This study was conducted in Mansoura University hospitals over one year (starting from September 2019 till August 2020) Twenty patients who presented with back pain fulfilled our criteria and were included in this study and underwent surgery for lumbar fixation using a hybrid performance system with dynamic coupler. The history of all patients was taken and they were subjected to clinical examination and preoperative full radiological examination. Visual Analogue Scale (VAS) was used to evaluate POP. Regular follow-up visits were arranged for our cases 6 weeks, three months and 6 months postoperative. Results: This study included 20 patients (7 males and 13 females). The ages of the studied patients ranged from 20 to 33 years. 9 patients presented with L4- 5 affection, 8 patients with L3- 4 affection and three patients with L2-3 affection. The mean basal VAS score was 5.45 (range=4-6) while the mean six months VAS score was 0.40 (range=0-1) with a statistically significant difference from the basal VAS score (p ˂ 0.001). Also, the results show that post-operative QoL scale scores was significantly higher (p˂ 0.001) compared with pre-operative QoL scale scores (Physical function (54.30 vs. 67.10), limitations due to physical health (55.55 vs. 67.90)). Conclusion: The current study suggested that Dynamic lumbar fixation provides favourable and stable clinical mid-term results in patients suffering from a degenerative lumbar spinal disease (DLSD) and can be a considerable alternative to fusion surgery in these patients. [ABSTRACT FROM AUTHOR]

Several studies have investigated the mechanical behavior of the thoracolumbar spine. However, finding an accurate reference for the normal functional local alignment and segmental motion (SM) at the thoracolumbar junction (TLJ) is challenging. Therefore, this study aimed to assess age- and sex-related changes and differences in local alignment and SM at the TLJ. The study recruited healthy subjects aged 20 to 79 without complaints of back pain. Healthy subjects (60 males and 60 females) with appropriate imaging results were enrolled in the study. The subjects were divided into age groups (20–29, 30–39, 40–49, 50–59, 60–69, and 70–79 years); each group included 10 subjects of each sex. The SM at the TLJ was small but noticeable, and the motion gradually increased toward the lower level of the TLJ, closer to the lumbar region. No significant differences were observed between male and female subjects in any SM measurements at the TLJ. The SM at the TLJ gradually decreased with age, while local kyphosis of TLJ progressed. The results also showed that the thoracolumbar slope value did not change with age and remained at a mean of −12.8 ± 7.2° (P = 0.893). This study's results provide valuable guidance for appropriate surgical planning and rehabilitation of patients with spinal diseases or trauma. Furthermore, the results can be the basis for categorizing accurate criteria to evaluate the degree of disability after treatment. [ABSTRACT FROM AUTHOR]

Background: In the past decade, Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with a microscopic tubular technique has become a surgical procedure that reduces surgical-related morbidity, shortens hospital stays, and expedites early rehabilitation in the treatment of lumbar degenerative diseases (LDD). Unilateral biportal endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) has emerged as a novel surgical technique. The present study aims to compare the clinical outcomes and postoperative complications of MIS-TLIF and Endo-TLIF for treating LDD. Methods: A retrospective analysis of LLD patients undergoing either Endo-TLIF or MIS-TLIF was performed. Patient demographics, operative data (operation time, estimated blood loss, length of hospitalization), and complications were recorded. The visual analog scale (VAS) score for leg and back pain and the Oswestry Disability Index (ODI) score were used to evaluate the clinical outcomes. Results: This study involved 80 patients, 56 in the MIS-TLIF group and 34 in the Endo-TLIF group. The Endo-TLIF group showed a more substantial improvement in the VAS for back pain at 3 weeks post-surgery compared to the MIS-TLIF group. However, at the 1-year mark after surgery, there were no significant differences between the groups in the mean VAS for back pain and VAS for leg pain. Interestingly, the ODI at one year demonstrated a significant improvement in the Endo-TLIF group compared to the MIS-TLIF group. Additionally, the MIS-TLIF group exhibited a shorter operative time than the Endo-TLIF group, with no notable differences in estimated blood loss, length of hospitalization, and complications between the two groups. Conclusion: Endo-TLIF and MIS-TLIF are both safe and effective for LDD. In surgical decision-making, clinicians may consider nuances revealed in this study, such as lower early postoperative back pain with Endo-TLIF and shorter operative time with MIS-TLIF. [ABSTRACT FROM AUTHOR]

Study design: The GAP score predicted post-operative mechanical complications more effectively whereas SRS-Schwab classification improved evaluation of postoperative PROMs. Objective: The study compared the GAP Score and SRS-Schwab Classification in predicting surgical outcomes for adult spinal deformity (ASD) and elucidated whether both systems should be included in the preoperative planning. Materials and methods: Radiographic measurements and health-related quality of life scores at baseline, 6 weeks after surgery, and the last follow-up were collected from a cohort of 69 ASD patients subjected to long segment spinal fusion surgery after they were grouped by GAP score and SRS-Schwab classification respectively. Fisher's exact test and receiver operator characteristic (ROC) curve analysis was used to compare the incidence of mechanical complications and the discriminant capacity during revision surgery between the two groups. Postoperative patient-reported outcomes measures (PROMs) were compared by one-way ANOVA, and the proportions of MCID achieved for PROMs compared by chi-square test between the two groups. Results: The overall incidence of mechanical complications and revision surgery were 42% and 8.7%. Both GAP score and its categories predicted mechanical complications and revision surgery, but the GAP score system could not predict the improvements of PROMs. The SRS-Schwab classification could predict the occurrence of postoperative mechanical complications and improvements of postoperative PROMs between the aligned, moderately misaligned and severely misaligned groups (P < 0.05). Conclusion: Hence, a comprehensive surgical strategy for postoperative planning may improve patients' quality of life and minimize mechanical complications. [ABSTRACT FROM AUTHOR]

Purpose: Recently, many studies revealed that frailty affects unfavorably on postoperative outcomes in lumbar spinal diseases. This study aimed to investigate the relationship between frailty and clinical outcomes while identifying risk factors associated with worse clinical outcomes following lumbar spinal surgery. Methods: From March 2019 to February 2021, we prospectively enrolled eligible patients with degenerative lumbar spinal diseases requiring surgery. Frailty was assessed preoperatively. To identify the impact of frailty on lumbar spinal diseases, clinical outcomes, which were measured with patient-reported outcomes (PROs) and postoperative complications, were compared according to the frailty. PROs were assessed preoperatively and one year postoperatively. In addition, risk factors for preoperative and postoperative worse clinical outcomes were investigated. Results: PROs were constantly lower in the frail group than in the non-frail group before and after surgery, and the change of PROs between before and after surgery and postoperative complications were not different between the groups. In addition, frailty was a persistent risk factor for postoperative worse clinical outcome before and after surgery in lumbar spinal surgery. Conclusion: Frailty persistently affects the clinical outcome negatively before and after surgery in lumbar spinal surgery. However, as the change of the clinical outcome is not different between the frail group and the non-frail group, it is difficult to interpret whether the frail patients are vulnerable to the surgery. In conclusion, frailty is not an independent risk factor for worse clinical outcome in lumbar spinal surgery. [ABSTRACT FROM AUTHOR]

Accurate and efficient segmenting of vertebral bodies, muscles, and discs is crucial for analyzing various spinal diseases. However, traditional methods are either laborious and time-consuming (manual segmentation) or require extensive training data (fully automatic segmentation). FastCleverSeg, our proposed semi-automatic segmentation approach, addresses those limitations by significantly reducing user interaction while maintaining high accuracy. First, we reduce user interaction by requiring the manual annotation of only two or three slices. Next, we automatically Estimate the Annotation on Intermediary Slices (EANIS) using traditional computer vision/graphics concepts. Finally, our proposed method leverages improved voxel weight balancing to achieve fast and precise volumetric segmentation in the segmentation process. Experimental evaluations on our assembled diverse MRI databases comprising 179 patients (60 male, 119 female), demonstrate a remarkable 25 ms (30 ms standard deviation) processing time and a significant reduction in user interaction compared to existing approaches. Importantly, FastCleverSeg maintains or surpasses the segmentation quality of competing methods, achieving a Dice score of 94%. This invaluable tool empowers physicians to efficiently generate reliable ground truths, expediting the segmentation process and paving the way for future integration with deep learning approaches. In turn, this opens exciting possibilities for future fully automated spine segmentation. [ABSTRACT FROM AUTHOR]

Lumbar back pain is one of the main causes of disability around the world. Most patients will complain of back pain at least once in their lifetime. The degenerative spine is considered the main cause and is extremely common in the elderly population. Consequently, treatment-related costs are a major burden to the healthcare system in developed and undeveloped countries. After the failure of conservative treatments or to avoid daily chronic drug intake, invasive treatments should be suggested. In a world where many patients reject surgery and prefer minimally invasive procedures, interventional radiology is pivotal in pain management and could represent a bridge between medical therapy and surgical treatment. We herein report the different image-guided procedures that can be used to manage degenerative spine-related low back pain. Particularly, we will focus on indications, different techniques, and treatment outcomes reported in the literature. This literature review focuses on the different minimally invasive percutaneous treatments currently available, underlining the central role of radiologists having the capability to use high-end imaging technology for diagnosis and subsequent treatment, allowing a global approach, reducing unnecessary surgeries and prolonged pain-reliever drug intake with their consequent related complications, improving patients' quality of life, and reducing the economic burden. [ABSTRACT FROM AUTHOR]