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We aimed to investigate the relationship between superoxide dismutase 2‐related oxidative stress in the paraspinal muscles and spinal alignment, clinical skeletal muscle parameters, and mitochondrial function. Multifidus muscle samples from patients who underwent posterior lumbar surgery were analyzed. Patients with diseases affecting oxidative stress and spinal alignment were excluded. The superoxide dismutase 2 redox index was defined as the ratio of reactive oxygen species (superoxide) to antioxidant enzymes (superoxide dismutase 2) and was used as an index of oxidative stress. Patients were divided into two groups based on the superoxide dismutase 2 redox index. Spinal alignment, clinical skeletal muscle parameters, and succinic dehydrogenase (SDH) mean grayscale value were compared between the groups, with analyzes for both sexes. Multiple regression analyzes were used to adjust for the confounding effect of age on variables showing a significant difference between the two groups. Thirty‐five patients with lumbar degenerative diseases were included. No significant differences were observed between the two groups for any of the parameters in males; however, females with a higher superoxide dismutase 2 redox index had greater lumbar lordosis, lower grip strength, and higher SDH mean grayscale value than those with a lower index. Multiple regression analyzes revealed that the superoxide dismutase 2 redox index was an independent explanatory variable for lumbar lordosis, grip strength, and SDH mean grayscale value in female patients. In conclusion, superoxide dismutase 2‐related oxidative stress in the paraspinal muscles was associated with mitochondrial dysfunction and decreased grip strength in female lumbar degenerative disease patients. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to clarify the relation between global spinal alignment and the necessity of walking aid use in patients with adult spinal deformity (ASD) and to investigate the impact of spinal fixation on mobility status after surgery. Methods: In total, 456 older patients with ASD who had multi-segment spinal fixation surgery and were registered in a multi-center database were investigated. Patients under 60 years of age and those unable to walk preoperatively were excluded. Patients were classified by their mobility status into the independent, cane, and walker groups. Comparison analysis was conducted using radiographic spinopelvic parameters and the previously reported global spine balance (GSB) classification. In addition, preoperative and 2 years postoperative mobility statuses were investigated. Results: Of 261 patients analyzed, 66 used walking aids (canes, 46; walkers, 20). Analysis of preoperative radiographical parameters showed increased pelvic incidence and pelvic incidence-lumbar lordosis mismatch in the walker group and increased sagittal vertebral axis in the cane and walker groups versus the independent group. Analysis of GSB classification showed a higher percentage of walker use in those with severe imbalance (grade 3) in the sagittal classification but not in the coronal classification. While postoperative radiographical improvements were noted, there was no significant difference in the use of walking aids before and 2 years after surgery (P = 0.085). Conclusion: A significant correlation was found between "sagittal" spinal imbalance and increased reliance on walking aids, particularly walkers. However, the limitation of improvement in postoperative mobility status suggested that multiple factors influence the mobility ability of elderly patients with ASD. [ABSTRACT FROM AUTHOR]

Purpose: Recent studies have proposed optimizing the position of the acetabular component based on spinal deformity and stiffness classification to avoid mechanical complication after total hip arthroplasty (THA). The aim of this study was to characterize the dynamic changes in cup alignment post-THA based on the spinopelvic classification and to evaluate the efficacy of cup placement of preventing dislocation. Methods: This prospective study included a total of 169 consecutive patients awaiting THA who were classified into four groups based on spinal deformity (pelvic incidence minus lumbar lordosis) and spinal stiffness (change in sacral slope from the standing to seated positions). The cups were aligned based on the group with fluoroscopy. Additionally, postoperative radiographic inclination (RI), radiographic anteversion (RA) in standard anteroposterior radiograph, and lateral anteinclination (AI) in sitting and standing positions were measured. The cumulative incidence of dislocation was evaluated at a follow-up two years post-THA. Result: RA was significantly greater in the group with normal spine alignment and stiff spine than in other groups (P = 0.0006), and AI in the sitting position was lower than in other groups (P = 0.012). Standing AI did not significantly differ between the groups. One posterior dislocation occurred during the study period (0.6%). Conclusion: AI in the sitting position was lower in patients with normal spinal alignment and stiff spine despite larger RA in the standard anteroposterior radiographs. Consequently, with more anteversion in the normal spinal alignment and stiff spine group, spinopelvic parameters can help guide cup placement to prevent short-term dislocation post-THA. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective review of a prospectively collected multisurgeon registry. Objective. To evaluate the outcomes of minimally invasive (MI) decompression in patients with severe degenerative scoliosis (DS) and identify factors associated with poorer outcomes. Summary of Background Context. MI decompression has gained widespread acceptance as a treatment option for patients with lumbar canal stenosis and DS. However, there is a lack of research regarding the clinical outcomes and the impact of MI decompression location in patients with severe DS exhibiting a Cobb angle exceeding 20°. Materials and Methods. Patients who underwent MI decompression alone were included and categorized into the DS or control groups based on Cobb angle (>20°). Decompression location was labeled as "scoliosis-related" when the decompression levels were across or between end vertebrae and "outside" when the operative levels did not include the end vertebrae. The outcomes, including the Oswestry Disability Index (ODI), were compared between the propensity score-matched groups for improvement and minimal clinical importance difference (MCID) achievement at =1 year postoperatively. Multivariable regression analysis was conducted to identify factors contributing to the nonachievement of MCID in ODI of the DS group at the =1-year time point. Results. A total of 253 patients (41 DS) were included in the study. Following matching for age, sex, osteoporosis status, psoas muscle area, and preoperative ODI, the DS groups exhibited a significantly lower rate of MCID achievement in ODI (DS: 45.5% vs. control 69.0%, P=0.047). The "scoliosis-related" decompression (odds ratio: 9.9, P=0.028) was an independent factor of nonachievement of MCID in ODI within the DS group. Conclusions. In patients with a Cobb angle >20°, lumbar decompression surgery, even in the MI approach, may result in limited improvement of disability and physical function. Caution should be exercised when determining a surgical plan, especially when decompression involves the level between or across the end vertebrae. [ABSTRACT FROM AUTHOR]

Case: A 28-year old male patient was involved in a RTA and sustained a highly comminuted L4 burst fracture with more than 90% canal compromise. Considering the complete loss of power in the respective myotomes but the preservation of sacral sparing there were controversially different surgical options. We successfully performed a posterior only surgical procedure, which applied a modified transpedicle access technique to decompress the spinal canal and to restore the anterior column, achieving full neurological recovery at the final follow-up. Conclusion: A well-planned and executed posterior surgery alone can achieve excellent clinical and radiological result in the treatment of severely comminuted lumbar fractures. [ABSTRACT FROM AUTHOR]

Pelvic incidence (PI)–lumbar lordosis (LL) mismatch has a significant destabilizing effect on the center of gravity sway in the static standing position. However, the association between spinopelvic alignment and balance during gait in healthy volunteers is poorly understood. The degree of PI–LL mismatch and trunk anterior tilt in the static standing posture influences dynamic balance during gait. In this study, 131 healthy volunteers were divided into two groups: harmonious group (PI − LL ≤ 10°; n = 91) and unharmonious group (PI − LL > 10°; n = 40). A two-point accelerometer system was used for gait analysis; accelerometers were attached to the pelvis and upper trunk to measure acceleration in the forward–backward, right–left, and vertical directions so that sagittal (front–back) deviation width, coronal (right–left) width, and vertical width and their ratios were calculated. Measurements were compared between the two groups, and correlations between alignment and accelerometer data were examined. The harmonious group showed a negative correlation between pelvic sagittal width and PI – LL, pelvic tilt (PT), and sagittal vertical axis (SVA) (correlation coefficient ρ = −0.42, −0.38, and −0.4, respectively), and a positive correlation between sagittal ratio and PI − LL (ρ = 0.35). The unharmonious group showed a positive correlation between pelvic sagittal width and PI and PT (ρ = 0.43 and 0.33, respectively) and between sagittal ratio and SVA (ρ = 0.32). The unharmonious group showed a positive correlation between upper trunk sagittal width and PI − LL and PT (ρ = 0.38 and 0.36, respectively). The association between spinal alignment and gait parameters differs depending on the presence or absence of PI–LL mismatch. The degree of pelvic compensation and trunk anterior tilt during static standing were associated with unstable gait balance. • Subjects without PI–LL mismatch reduces pelvic movement during gait with compensation. • Poor compensated subjects with PI–LL mismatch increased upper trunk sway during gait. • Static standing spinal alignment associated with trunk sway during gait. [ABSTRACT FROM AUTHOR]

ABSTRACT: Background: The aging spine often presents multifaceted surgical challenges for the surgeon because it can directly and indirectly impact a patient’s spinal alignment and quality of life. Elderly and osteoporotic patients are predisposed to progressive spinal deformities and potential neurologic compromise and surgical management can be difficult because these patients often present with greater frailty. Methods: This was a literature review of spinal alignment changes, preoperative considerations, and spinal alignment considerations for surgical strategies. Results: Many factors impact spinal alignment as we age including lumbar lordosis flexibility, hip flexion, deformity, and osteoporosis. Preoperative considerations are required to assess the patient’s overall health, bone mineral density, and osteoporosis medications. Careful radiographic assessment of the spinopelvic parameters using various classification/scoring systems provide the surgeon with goals for surgical treatment. An individualized surgical strategy can be planned for the patient including extent of surgery, surgical approach, extent of the constructs, fixation techniques, vertebral augmentation, ligamentous augmentation, and staging surgery. Conclusions: Surgical treatment should only be considered after a thorough assessment of the patient's health, deformity, bone quality and corresponding age matched alignment goals. An individualized treatment approach is often required to tackle the deformity and minimize the risk of hardware related complications and pseudarthrosis. Anabolic agents offer a promising benefit in this patient population by directly addressing and improving their bone quality and mineral density preoperatively and postoperatively.

ABSTRACT: Spinal alignment analysis play an important role in evaluating patients and planning surgical corrections for adult spinal deformity. The history of these parameters is relatively short with the first parameter, the Cobb angle, introduced in 1948 as part of an effort to improve scoliosis evaluation. New developments in the field were limited for nearly 30 years before better imaging technology encouraged new theories and later data about spinal alignment and the relationship between the spine and pelvis. These efforts would ultimately contribute to the creation of foundational spinal alignment parameters, including pelvic incidence, pelvic tilt, and sacral slope. By the 1990s, spinal alignment had become a sustained area of investigation for spinal surgeons and researchers. Novel alignment parameters have since been introduced as our knowledge has evolved and has allowed for valuable research that demonstrates the clinical and surgical value of alignment measurement. This manuscript will explore the history of spinal alignment analysis over the decades.

ObjectiveProximal junctional failure (PJF) is a severe form of proximal junctional kyphosis. Previous reports on PJF have been limited by heterogeneous cohorts and relatively short follow-ups. The authors' objectives herein were to identify risk factors for PJF and to assess its long-term incidence and revision rates in a homogeneous cohort.MethodsThe authors reviewed data from the Adult Symptomatic Lumbar Scoliosis 1 trial (ASLS-1), a National Institutes of Health-sponsored prospective multicenter study. Inclusion criteria were an age ≥ 40 years, ASLS (Cobb angle ≥ 30° and Oswestry Disability Index [ODI] ≥ 20 or Scoliosis Research Society revised 22-item questionnaire [SRS-22r] score ≤ 4.0 in pain, function, or self-image domains), and primary thoracolumbar fusion/fixation to the sacrum/pelvis of ≥ 7 levels. PJF was defined as a postoperative proximal junctional angle (PJA) change > 20°, fracture of the uppermost instrumented vertebra (UIV) or UIV+1 with > 20% vertebral height loss, spondylolisthesis of UIV/UIV+1 > 3 mm, or UIV screw dislodgment.ResultsOne hundred sixty patients (141 women) were included in this analysis and had a median age of 62 years and a mean follow-up of 4.3 years (range 0.1-6.1 years). Forty-six patients (28.8%) had PJF at a median of 0.92 years (IQR 0.14, 1.23 years) following surgery. Based on Kaplan-Meier analyses, PJF rates at 1, 2, 3, and 4 years were 14.4%, 21.9%, 25.9%, and 27.4%, respectively. On univariate analysis, PJF was associated with greater age (p = 0.0316), greater body mass index (BMI; p = 0.0319), worse baseline patient-reported outcome measures (PROMs; ODI, SRS-22r, and SF-12 Physical Component Summary [PCS]; all p < 0.04), the use of posterior column osteotomies (PCOs; p = 0.0039), and greater postoperative thoracic kyphosis (TK; p = 0.0031) and PJA (p < 0.001). The use of UIV hooks was protective against PJF (p = 0.0340). On regression analysis (without postoperative measures), PJF was associated with greater BMI (HR 1.077, 95% CI 1.007-1.153, p = 0.0317), lower preoperative PJA (HR 0.607, 95% CI 0.407-0.906, p = 0.0146), and greater preoperative TK (HR 1.362, 95% CI 1.082-1.715, p = 0.0085). Patients with PJF had worse PROMs at the last follow-up (ODI, SRS-22r subscore and self-image, and SF-12 PCS; p < 0.04). Sixteen PJF patients (34.8%) underwent revision, and PJF recurred in 3 (18.8%).ConclusionsAmong 160 primary ASLS patients with a median age of 62 years and predominant coronal deformity, the PJF rate was 28.8% at a mean 4.3-year follow-up, with a revision rate of 34.8%. On univariate analysis, PJF was associated with a greater age and BMI, worse baseline PROMs, the use of PCOs, and greater postoperative TK and PJA. The use of UIV hooks was protective against PJF. On multivariate analysis (without postoperative measures), a higher risk of PJF was associated with greater BMI and preoperative TK and lower preoperative PJA.

Study designBiomechanical Study.ObjectiveThe search for optimal spinal alignment has led to the development of sophisticated formulas and software for preoperative planning. However, preoperative plans are not always appropriately executed since rod contouring during surgery is often subjective and estimated by the surgeon. We aimed to assess whether rods contoured to specific angles with a French rod bender using a template guide will be more accurate than rods contoured without a template.MethodsTen experienced spine surgeons were requested to contour two 125 × 5.5 mm Ti64 rods to 40°, 60° and 80° without templates and then 2 more rods using 2D metallic templates with the same angles. Rod angles were then measured for accuracy and compared.ResultsAverage angles for rods bent without a template to 40°, 60° and 80° were 60.2°, 78.9° and 97.5°, respectively. Without a template, rods were overbent by a mean of 18.9°. When using templates of 40°, 60° and 80°, mean bend angles were 41.5°, 59.1° and 78.7°, respectively, with an average underbend of 0.2°. Differences between the template and non-template groups for each target angle were all significant (p < 0.001).ConclusionsWithout the template, surgeons tend to overbend rods compared to the desired angle, while surgeons improved markedly with a template guide. This tendency to overbend could have significant impact on patient outcomes and risk of proximal junctional failure and warrants further research to better enable surgeons to more accurately execute preoperative alignment plans.

Abstract Background Aging is associated with muscle atrophy, as typified by sarcopenia. Loss of abdominal muscle strength can cause abdominal wall laxity. The purpose of this study was to investigate the relationship between the sacral vertebra–abdominal wall distance (SAD) and movement performance using a simple lateral spine X-ray image for measuring the SAD. Methods In this retrospective study, we included women aged ≥ 65 years who were attending the outpatient clinic for osteoporosis at our hospital. A total of 287 patients (mean age ± SD, 76.8 ± 7.1 years) with measured SAD were included in the analysis. Patients were divided into two groups based on SAD cutoff (160 mm) and age (75 years), respectively. The patients were examined using the two-foot 20 cm rise test, 3 m Timed Up and Go (TUG) test, two-step test, open-eyed one-leg standing time, and spinal alignment. Normally distributed data are expressed as means (standard deviations) and non-normally distributed data as medians (interquartile range), depending on the results of the Kolmogorov–Smirnov test. Student’s t-test and χ2 test were used for between-group comparisons. Regression analysis was performed with SAD as the objective variable. A two-sided p

Background: With an aging population, degenerative spinal diseases are contributing significantly to the healthcare's burden. Spinal alignment in the context of adult spinal deformities has become an important domain of research. Methods: We conducted a narrative review of the latest considerations in spinal alignment within the context of degenerative spinal conditions, discussed current strategies for morphological assessment and finally identified potential areas for future research. Results: This review reported that degenerative spinal conditions lead to a complex disruption of spinal alignment. It also highlighted the importance of spino-pelvic alignment with specific attention to compensatory mechanisms that occur in response to spinal deformities. Emerging technologies including Artificial Intelligence and epigenetics are showing promises in terms of patient care. Conclusions: Understanding spinal alignment in degenerative conditions underscores the importance of dynamic and individualized assessments. Future research should integrate emerging technologies along with traditional clinical practices in order to optimize patient outcomes and minimize complications for patients suffering from degenerative spinal diseases.

ObjectivePrevious reports of rod fracture (RF) in adult spinal deformity are limited by heterogeneous cohorts, low follow-up rates, and relatively short follow-up durations. Since the majority of RFs present > 2 years after surgery, true occurrence and revision rates remain unclear. The objectives of this study were to better understand the risk factors for RF and assess its occurrence and revision rates following primary thoracolumbar fusions to the sacrum/pelvis for adult symptomatic lumbar scoliosis (ASLS) in a prospective series with long-term follow-up.MethodsPatient records were obtained from the Adult Symptomatic Lumbar Scoliosis-1 (ASLS-1) database, an NIH-sponsored multicenter, prospective study. Inclusion criteria were as follows: patients aged 40-80 years undergoing primary surgeries for ASLS (Cobb angle ≥ 30° and Oswestry Disability Index ≥ 20 or Scoliosis Research Society-22r ≤ 4.0 in pain, function, and/or self-image) with instrumented fusion of ≥ 7 levels that included the sacrum/pelvis. Patients with and without RF were compared to assess risk factors for RF and revision surgery.ResultsInclusion criteria were met by 160 patients (median age 62 years, IQR 55.7-67.9 years). At a median follow-up of 5.1 years (IQR 3.8-6.6 years), there were 92 RFs in 62 patients (38.8%). The median time to RF was 3.0 years (IQR 1.9-4.54 years), and 73% occurred > 2 years following surgery. Based on Kaplan-Meier analyses, estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Baseline radiographic, clinical, and demographic characteristics were similar between patients with and without RF. In Cox regression models, greater postoperative pelvic tilt (HR 1.895, 95% CI 1.196-3.002, p = 0.0065) and greater estimated blood loss (HR 1.02, 95% CI 1.005-1.036, p = 0.0088) were associated with increased risk of RF. Thirty-eight patients (61% of all RFs) underwent revision surgery. Bilateral RF was predictive of revision surgery (HR 3.52, 95% CI 1.8-6.9, p = 0.0002), while patients with unilateral nondisplaced RFs were less likely to require revision (HR 0.39, 95% CI 0.18-0.84, p = 0.016).ConclusionsThis study provides what is to the authors' knowledge the highest-quality data to date on RF rates following ASLS surgery. At a median follow-up of 5.1 years, 38.8% of patients had at least one RF. Estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Greater estimated blood loss and postoperative pelvic tilt were significant risk factors for RF. These findings emphasize the importance of long-term follow-up to realize the true prevalence and cumulative incidence of RF.

Spinal alignment intricately influences functional independence, particularly in older women with osteopenia experiencing mild neck and back pain. This study elucidates the interplay between spinal alignment, bone mineral density (BMD), and muscle strength in elderly women presenting with mild neck and back pain. Focusing on a cohort of 189 older women, we examined the associations among global tilt (GT), coronal and sagittal alignment, BMD, grip strength, and functional independence as gauged by the Barthel index. Our findings indicate significant associations between functional capacity and grip strength, bone density, GT, and pelvic tilt (PT). Elderly women with a Barthel Index above 80 demonstrated higher grip strength and better bone quality, reflected by less negative average T scores. These individuals also exhibited lower values of GT and PT, suggesting a better sagittal alignment compared to those with a Barthel index of 80 or below. The results highlight that deviations in GT and PT are significantly associated with decreased functional independence. These insights emphasize the importance of maintaining optimal spinal alignment and muscle strength to support functional independence in elderly women. This study underscores the potential for targeted interventions that improve postural stability and manage pain effectively in this vulnerable population. [ABSTRACT FROM AUTHOR]

Background: Aging is associated with muscle atrophy, as typified by sarcopenia. Loss of abdominal muscle strength can cause abdominal wall laxity. The purpose of this study was to investigate the relationship between the sacral vertebra–abdominal wall distance (SAD) and movement performance using a simple lateral spine X-ray image for measuring the SAD. Methods: In this retrospective study, we included women aged ≥ 65 years who were attending the outpatient clinic for osteoporosis at our hospital. A total of 287 patients (mean age ± SD, 76.8 ± 7.1 years) with measured SAD were included in the analysis. Patients were divided into two groups based on SAD cutoff (160 mm) and age (75 years), respectively. The patients were examined using the two-foot 20 cm rise test, 3 m Timed Up and Go (TUG) test, two-step test, open-eyed one-leg standing time, and spinal alignment. Normally distributed data are expressed as means (standard deviations) and non-normally distributed data as medians (interquartile range), depending on the results of the Kolmogorov–Smirnov test. Student's t-test and χ2 test were used for between-group comparisons. Regression analysis was performed with SAD as the objective variable. A two-sided p < 0.05 was considered statistically significant. Results: The shorter SAD group performed better in the two-step test, TUG test, and open-eyed one-leg standing time (p < 0.001) as well as in the two-foot 20 cm rise test (p < 0.01) compared to the longer SAD group. Spinal alignment was better in the shorter SAD group than in the longer SAD group, with a shorter sagittal vertical axis (p < 0.001), smaller pelvic tilt (p < 0.001), and greater sacral slope (p < 0.05). Conclusion: SAD was associated with posterior pelvic tilt and movement performance parameters. In addition to testing for osteoporosis, movement performance parameters should be evaluated in women with osteoporosis who are aged ≥ 65 and have greater SAD (≥ 160 mm in this study). The SAD is a new assessment method, and further research is required to verify its validity and reproducibility. This is the first attempt to determine how age and SAD affect movement performance in older adults. [ABSTRACT FROM AUTHOR]

Study Design: A prospective study of healthy volunteers Objectives: The influence of the sagittal alignment of the spine and its influence on the extension reserve have been reported in the literature. However, specific analysis of the intrinsic coxofemoral and extrinsic pelvic component in subjects without any spinal or hip pathologies remains poorly reported. The aim of this study was to categorize the hip extension capacity, or extension reserve (ER), in relation to spinal sagittal alignment whilst standing, in a young healthy population. We hypothesized that the global extension reserve (GER) of the hip joint was influenced by the sagittal spinopelvic alignment. Methods: We evaluated the ER of 120 healthy Caucasian volunteers (56 females (46.7%), 74 males (53.3%); mean age 25.6 years), using low dose radiographs from an EOS® X-ray imaging system in 2 functional positions; neutral standing position and in a forward lunge position. The GER is defined as the sum of the intrinsic (hip) extension reserve (IER) and the extrinsic (pelvic) extension reserve (EER). Cases were grouped into 4 sagittal alignment subtypes according to the Roussouly classification, and analyzed. Results: Global extension reserve values were not significantly different between the 4 Roussouly subtypes (P =.094), nor between patients with a sacral slope (SS) <35° (types 1/2) and ≥ 35° (type 3/4) (P =.837). Statistically significant differences were seen between IER in each subtype (P =.015), and EER (P =.006). No difference in ER was seen between subtypes regarding pelvic incidence (PI). Conclusion: An inverse relationship was found between IER and EER among Roussouly subtypes. The range of motion of the pelvis and the hip joint was higher in patients with a greater sacral slope. [ABSTRACT FROM AUTHOR]

Context: Baseball pitching is a coordinated movement involving the spine. A previous study indicated that increased thoracic kyphosis angle in a standing position was a risk factor for medial elbow injuries in youth baseball players. However, spinal alignments in single-leg standing and their relationships with medial elbow injuries, scapular alignment, or hip joint range of motion are unclear. Objective: To examine the difference in spinal alignment between standing and single-leg standing positions in youth baseball players and analyze their relationship with elbow injuries, scapular alignment, or hip joint range of motion. Design: Cross-sectional study. Setting: University laboratory. Participants: There were 51 youth baseball players with medial epicondylar fragmentation (medial elbow injury group) and 102 healthy youth baseball players (control group). Main Outcome Measures: Thoracic kyphosis, lumbar lordosis, and trunk inclination angles during standing and single-leg standing, forward scapular posture, and hip joint range of motion. Results: In the single-leg standing position, the thoracic kyphosis and backward trunk inclination angles were significantly higher in the medial elbow injury group than in the control group (P =.016 and P =.046, respectively). In the standing position, no significant difference was observed between both groups. The thoracic kyphosis angle in single-leg standing was positively correlated with the bilateral forward scapular posture in the medial elbow injury (P =.008 and P <.001 on the throwing and nonthrowing sides, respectively) and control (P =.010 and P =.032 on the throwing and nonthrowing sides, respectively) groups. Conclusions: High thoracic kyphosis and backward trunk inclination angles are characteristics during single-leg standing in youth baseball players with medial elbow injuries. Spinal alignment measurement in single-leg standing may be useful for identifying youth baseball players who are at risk for sustaining medial elbow injury. [ABSTRACT FROM AUTHOR]

Introduction: Predicting the pre-morbid sagittal profile of the spine or segmental angles could enhance the process of planning the extent of fracture reduction. There is evidence that spinopelvic parameters may be suitable for this purpose. Research question: Is it possible to determine the inflection point and the mono- and bi-segmental endplate angles (EPA) in the thoracolumbar transition (from Th9 to L2) based on age, gender, spinopelvic parameters, and the adjacent EPA in the supine position? Material and methods: Based on Polytrauma CT scans in the supine position, the following spinopelvic parameters were measured using non-fractured spines: pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), and the apex of the LL. Results: In this study, a total of 287 patients with a mean age of 42±16 years were included. Age-related changes were observed, where LL, thoracic kyphosis (TK), and PI increase with age. Gender-related comparisons showed that females had a more pronounced LL and reduced TK. Significant correlations between IP and spinopelvic parameters, with the apex of LL providing the best prediction, were found. However, the overall model quality remained low. Predicting mEPA and bEPA showed positive correlations. The prediction for mEPA L2/3 demonstrated the highest correlation. For bisegmental angles, the most caudal bEPA (L2) exhibited the highest correlation, albeit with some notable absolute differences in the values between measured and predicted values. Discussion and conclusion: While this study highlights the complexity of the relationship between the pelvis and thoracolumbar parameters, finding a predictive tool for thoracolumbar reduction and stabilization was not possible.

Abstract Background Osteoarthritis (OA) and lower back pain (LBP) are most common health problems which lead to pain and disability. This study aimed to systematically review the evidence to find any relationship between knee osteoarthritis (KOA) and LBP or any potential causation. Methods The databases of Scopus, MEDLINE, and Embase were searched from inception to 01 October 2022. Any study published in English assessing live humans over 18 years with KOA and LBP was eligible to be included. Studies were independently screened by two researchers. Data of the included studies were extracted based on the participants, outcomes related to knee and lumbar spine, reported association or causation between LBP and KOA, and study design. Data were narratively analyzed and presented as graphs and table. Methodology quality was assessed. Results Of 9953 titles and abstracts, duplicates were removed, and 7552 were screened. Altogether, 88 full texts were screened, and 13 were eligible for the final inclusion. There were some biomechanical and clinical causations were observed for the concurrent presence of LBP and KOA. Biomechanically, high pelvic incidence is a risk factor for development of spondylolisthesis and KOA. Clinically, knee pain intensity was higher in KOA when presents with LBP. Less than 20% of studies have justified their sample size during the quality assessment. Discussion Development and progression of KOA in patients with degenerative spondylolisthesis may be induced by significantly greater mismatches of lumbo-pelvic sagittal alignment. Elderly patients with degenerative lumbar spondylolisthesis and severe KOA reported a different pelvic morphology, increased sagittal malalignment with a lack of lumbar lordosis due to double-level listhesis, and greater knee flexion contracture than in patients with no to mild and moderate KOA. People with concurrent LBP and KOA have reported poor function with more disability. Both LBP and lumbar kyphosis indicate functional disability and knee symptoms in patients with KOA. Conclusions Different biomechanical and clinical causations were revealed for the concurrent existence of KOA and LBP. Therefore, careful assessment of both back and knee joints should be considered when treating KOA and vice versa. Systematic review registration PROSPERO CRD42022238571

Abstract Background Spinal alignment evaluation is commonly performed in the clinical setting during rehabilitation. However, there is no simple method for its quantitative measurement. Recently, the depth cameras in Kinect sensors have been employed in various commercial and research projects in the healthcare field. We hypothesized that the time-of-flight technology of the Kinect sensor could be applied to quantitatively evaluate spinal alignment. The purpose of this study was to develop a simple and noninvasive evaluation for spinal alignment using the Kinect sensor and to investigate its validity. Methods Twenty-four healthy men participated in the study. Measurement outcomes were the thoracic kyphosis and lumbar lordosis angles in the standing position, using a Spinal Mouse, the validity of which has been previously reported, and the Kinect sensor. In the measurement by the Kinect sensor, a program was created to obtain the three-dimensional coordinates of each point within an area marked on the monitor, and the sums of the angles at each vertebral level were calculated for the thoracic and lumbar areas. Pearson's correlation coefficient was used to analyze the relationship between the Kinect sensor and Spinal Mouse measurements of thoracic kyphosis and lumbar lordosis angles. Results There was a significant positive and moderate correlation between the thoracic kyphosis measurements taken by each device. Contrarily, there was no significant correlation in the lordosis angle between measurements using the Kinect sensor and Spinal Mouse. Conclusions Our results demonstrated the validity of measuring the thoracic kyphosis angle using the Kinect sensor. This indicates that the depth camera in the Kinect sensor is able to perform accurate thoracic alignment measurements quickly and noninvasively.

Spinal alignment intricately influences functional independence, particularly in older women with osteopenia experiencing mild neck and back pain. This study elucidates the interplay between spinal alignment, bone mineral density (BMD), and muscle strength in elderly women presenting with mild neck and back pain. Focusing on a cohort of 189 older women, we examined the associations among global tilt (GT), coronal and sagittal alignment, BMD, grip strength, and functional independence as gauged by the Barthel index. Our findings indicate significant associations between functional capacity and grip strength, bone density, GT, and pelvic tilt (PT). Elderly women with a Barthel Index above 80 demonstrated higher grip strength and better bone quality, reflected by less negative average T scores. These individuals also exhibited lower values of GT and PT, suggesting a better sagittal alignment compared to those with a Barthel index of 80 or below. The results highlight that deviations in GT and PT are significantly associated with decreased functional independence. These insights emphasize the importance of maintaining optimal spinal alignment and muscle strength to support functional independence in elderly women. This study underscores the potential for targeted interventions that improve postural stability and manage pain effectively in this vulnerable population.

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Purpose: Frailty is caused by age-related decline in physical function, which may contribute to worsening spinal alignment. Cardiovascular Health Study (CHS)-criteria for assessing physical function seem more appropriate than frailty index which evaluate comorbiduty. However, there have been no reports investigating the relationship between frailty and spinal alignment using the CHS criteria. This study aimed to examine spinal radiographic parameters using the CHS criteria in volunteers participating in a health screening study. Methods: The subjects were 211 volunteers (71 males and 140 females) aged 60–89 years old who participated in the TOEI study in 2018 and 2020. They were divided into three groups (R: robust, PF: pre-frailty, and F: frailty) according to the score of the Japanese version of the CHS (J-CHS) criteria in 2018. The radiographic parameters were evaluated using a whole-spine standing X-ray. Results: There were 67 volunteers in group R, 124 volunteers in group PF, and 20 volunteers in group F. Of the five items in the J-CHS criteria, low activity was the most common in the PF group (64%). Low activity was also the most common in the F group (100%). Regarding spinal alignment, significant differences were found in C7SVA in 2020 (R:PF:F = 26:31:62 mm, P = 0.047), C2SVA in 2018 (20:34:63 mm, P = 0.019), and C2SVA in 2020 (37:47:78 mm, P = 0.041). Conclusion: Frailty was associated with a worsening in global alignment along the 2- year follow up. The frailty may begin with a decrease in activity and progression of exhaustion; preventing this progression is important through motivation to exercise. Level of evidence: II [ABSTRACT FROM AUTHOR]

Adult spinal deformity (ASD) patients often complain of walking discomfort. However, dynamic balance evaluation methods of gait in ASD have not been well established. Case series study. Characterize the gait of ASD patients using a novel two-point trunk motion measuring device. Sixteen ASD patients scheduled for surgery and 16 healthy control subjects. Trunk swing width and track length of the upper back and sacrum. Gait analysis was performed using a two-point trunk motion measuring device on 16 ASD patients and 16 healthy control subjects. Three measurements were taken for each subject, and the coefficient of variation was determined to compare measurement accuracy between the ASD and control groups. Trunk swing width and track length were measured in three dimensions for comparisons between the groups. The relationship among output indices, sagittal spinal alignment parameters, and quality of life (QOL) questionnaire scores was examined as well. No significant difference was found for the precision of the device between the ASD and control groups. Compared with controls, the walking style of ASD patients tended to have larger right-left swing of the trunk (+14.0 cm and +23.3 cm at the sacrum and upper back, respectively), larger horizontal plane movement of the upper body (+36.4 cm), less vertical movement (-5.9 cm and -8.2 cm up-down swing at the sacrum and upper back, respectively), and longer gait cycle (+0.13 sec). Regarding QOL in ASD patients, greater right-left/front-back swing of the trunk, greater movement in the horizontal plane, and longer gait cycle were associated with lower QOL scores. Conversely, greater vertical movement was associated with higher QOL. ASD patients had unique gait characteristics, the intensity of which were associated with diminished QOL. The two-point trunk motion measuring device may be reliable and useful for the clinical assessment of balance during gait in ASD patients. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study. Objectives: The interactions between hip osteoarthritis (OA) and spinal malalignment are poorly understood. The purpose of this study was to assess the influence of total hip arthroplasty (THA) on standing spinopelvic alignment. Methods: In this retrospective cohort study, patients undergoing THA for OA with pre-and postoperative full-body radiographs were included. Standing spinopelvic parameters were measured. Contralateral hip was graded on the Kellgren-Lawrence scale. Pre-and postoperative alignment parameters were compared by paired t-test. The severity of preoperative thoracolumbar deformity was measured using TPA. Linear regression was performed to assess the impact of preoperative TPA and changes in spinal alignment. Patients were separated into low and high TPA (<20 or >/=20 deg) and change in parameters were compared between groups by t-test. Similarly, the influence of K-L grade, age, and PI were also tested. Results: 95 patients were included (mean age 58.6 yrs, BMI 28.7 kg/m2, 48.2% F). Follow-up radiographs were performed at mean 220 days. Overall, the following significant changes were found from pre-to postoperative: SPT (14.2 vs. 16.1, P = 0.021), CL (−8.9 vs. −5.3, P =.001), TS-CL (18.2 vs. 20.5, P =.037) and SVA (42.6 vs. 32.1, P =.004). Preoperative TPA was significantly associated with the change in PI-LL, SVA, and TPA. High TPA patients significantly decreased SVA more than low TPA patients. There was no significant impact of contralateral hip OA, PI, or age on change in alignment parameters. Conclusion: Spinopelvic alignment changes after THA, evident by a reduction in SVA. Preoperative spinal sagittal deformity impacts this change. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Introduction: Malnutrition could lead to additional medical complications, and the prognostic nutrition index (PNI) is evaluated to assess the nutritional status of patients. However, the midterm postoperative outcomes of malnutrition in patients with adult spinal deformity (ASD) are unclear. This study aims to investigate postoperative midterm spinal alignment and patients' reported outcome measures (PROMs) in malnourished patients with ASD. Methods: This study recruited 303 ASD patients who underwent surgery. Adult patients 50 years old were categorized into the PNI

Excess visceral fat can accumulate owing to lack of exercise. The relationship between metabolic syndrome (MetS) and spinal range of motion (ROM) is not clear. The purpose of this study was to investigate the relationship between MetS and spinal alignment and ROM. Orthopedic evaluation was prospectively performed in 544 participants. The participants were classified into two groups on the basis of the Japanese-specific MetS criteria proposed by the Japanese Committee of the Criteria for MetS (JCCMS). Lower back pain (LBP), knee joint pain with the visual analog scale (VAS), Kellgren–Lawrence (K–L) grade for knee osteoarthritis, body mass index (BMI), and spinal alignment and ROM were evaluated. Forty-four (8.1%) were diagnosed as having MetS. The prevalence rate of K–L grade 4 in the MetS group was significantly higher than that in the non-MetS group (p < 0.05). When sex, age, and BMI were evaluated as covariates, there were significant differences in the VAS score for knee pain (non-MetS group vs MetS group: 13.7 vs 23.3, p < 0.05), L1–S1 flexion spinal ROM (44.1° vs 38.1°, p < 0.001), flexion spinal inclination angle (SIA) ROM (107.6° vs 99.3°, p < 0.01), and SIA ROM (135.4° vs 124.0°, p < 0.05). Knee pain increased and flexion spinal ROM decreased significantly in the MetS group as compared with non-MetS group. Systemic factors associated with MetS may have a specific impact on spinal ROM while promoting knee osteoarthrosis and increased knee pain. [ABSTRACT FROM AUTHOR]

Background: Spinal alignment evaluation is commonly performed in the clinical setting during rehabilitation. However, there is no simple method for its quantitative measurement. Recently, the depth cameras in Kinect sensors have been employed in various commercial and research projects in the healthcare field. We hypothesized that the time-of-flight technology of the Kinect sensor could be applied to quantitatively evaluate spinal alignment. The purpose of this study was to develop a simple and noninvasive evaluation for spinal alignment using the Kinect sensor and to investigate its validity. Methods: Twenty-four healthy men participated in the study. Measurement outcomes were the thoracic kyphosis and lumbar lordosis angles in the standing position, using a Spinal Mouse, the validity of which has been previously reported, and the Kinect sensor. In the measurement by the Kinect sensor, a program was created to obtain the three-dimensional coordinates of each point within an area marked on the monitor, and the sums of the angles at each vertebral level were calculated for the thoracic and lumbar areas. Pearson's correlation coefficient was used to analyze the relationship between the Kinect sensor and Spinal Mouse measurements of thoracic kyphosis and lumbar lordosis angles. Results: There was a significant positive and moderate correlation between the thoracic kyphosis measurements taken by each device. Contrarily, there was no significant correlation in the lordosis angle between measurements using the Kinect sensor and Spinal Mouse. Conclusions: Our results demonstrated the validity of measuring the thoracic kyphosis angle using the Kinect sensor. This indicates that the depth camera in the Kinect sensor is able to perform accurate thoracic alignment measurements quickly and noninvasively. [ABSTRACT FROM AUTHOR]

Background: Osteoarthritis (OA) and lower back pain (LBP) are most common health problems which lead to pain and disability. This study aimed to systematically review the evidence to find any relationship between knee osteoarthritis (KOA) and LBP or any potential causation. Methods: The databases of Scopus, MEDLINE, and Embase were searched from inception to 01 October 2022. Any study published in English assessing live humans over 18 years with KOA and LBP was eligible to be included. Studies were independently screened by two researchers. Data of the included studies were extracted based on the participants, outcomes related to knee and lumbar spine, reported association or causation between LBP and KOA, and study design. Data were narratively analyzed and presented as graphs and table. Methodology quality was assessed. Results: Of 9953 titles and abstracts, duplicates were removed, and 7552 were screened. Altogether, 88 full texts were screened, and 13 were eligible for the final inclusion. There were some biomechanical and clinical causations were observed for the concurrent presence of LBP and KOA. Biomechanically, high pelvic incidence is a risk factor for development of spondylolisthesis and KOA. Clinically, knee pain intensity was higher in KOA when presents with LBP. Less than 20% of studies have justified their sample size during the quality assessment. Discussion: Development and progression of KOA in patients with degenerative spondylolisthesis may be induced by significantly greater mismatches of lumbo-pelvic sagittal alignment. Elderly patients with degenerative lumbar spondylolisthesis and severe KOA reported a different pelvic morphology, increased sagittal malalignment with a lack of lumbar lordosis due to double-level listhesis, and greater knee flexion contracture than in patients with no to mild and moderate KOA. People with concurrent LBP and KOA have reported poor function with more disability. Both LBP and lumbar kyphosis indicate functional disability and knee symptoms in patients with KOA. Conclusions: Different biomechanical and clinical causations were revealed for the concurrent existence of KOA and LBP. Therefore, careful assessment of both back and knee joints should be considered when treating KOA and vice versa. Systematic review registration: PROSPERO CRD42022238571 [ABSTRACT FROM AUTHOR]

Numerical models of the musculoskeletal system as investigative tools are an integral part of biomechanical and clinical research. While finite element modeling is primarily suitable for the examination of deformation states and internal stresses in flexible bodies, multibody modeling is based on the assumption of rigid bodies, that are connected via joints and flexible elements. This simplification allows the consideration of biomechanical systems from a holistic perspective and thus takes into account multiple influencing factors of mechanical loads. Being the source of major health issues worldwide, the human spine is subject to a variety of studies using these models to investigate and understand healthy and pathological biomechanics of the upper body. In this review, we summarize the current state-of-the-art literature on multibody models of the thoracolumbar spine and identify limitations and challenges related to current modeling approaches. [ABSTRACT FROM AUTHOR]

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Introduction: Hip–spine syndrome, wherein flexion deformity of the hip might exaggerate normal lumbar lordosis (LL), was first described in 1983. It could result in subluxation of the posterior facets and cause low back pain (LBP). However, the clinical outcomes of total hip arthroplasty (THA) and spinal alignment changes in patients with lumbar hyperlordosis (hyper LL) remain unknown. We aimed to clarify the proportion of patients with hyper LL before THA and compare pre- and post-operative sagittal spinal alignment, LBP, and clinical outcomes between patients with hyper LL and those with normal LL. Materials and methods: We investigated 278 patients who underwent primary THA between December 2015 and December 2019. Spine radiographs in the standing position were examined preoperatively and 1 year postoperatively. Patients with hyper LL were defined as having a pelvic incidence (PI) minus LL of < − 9° preoperatively. The control group included age- and sex-matched patients with normal LL, defined by a PI minus LL of − 9° to 9°. Clinical outcomes were evaluated using the visual analogue scale (VAS) for LBP, Harris hip score (HHS), Oxford hip score (OHS), and University of California, Los Angeles (UCLA) activity score. Results: Thirty-eight patients (13.7%) had hyper LL, and they exhibited a lower pelvic tilt, lower sagittal vertical axis, and greater sigmoid curvature than did the controls. Evaluation of changes in the spinal alignment after surgery showed that the pelvis tilted more posteriorly, and LL decreased more in the hyper LL group than in the control group. Pre- and post-operative VAS for LBP, HHS, OHS, and UCLA activity scores were not significantly different between the two groups. Conclusion: Hyper LL in patients with hip osteoarthritis had no adverse effects on LBP and the clinical outcomes of THA. Hyper LL may partially result from a flexible and adaptable lumbo-pelvic structure. [ABSTRACT FROM AUTHOR]

Background: The correction of malposition according to vertebral fractures is difficult because the alignment at the time before the fracture is unclear. Therefore, we investigate whether the spinal alignment can be determined by the spino-pelvic parameters. Methods: Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), adjacent endplate angles (EPA), age, sex, body weight, body size, BMI, and age were used to predict mono- and bisegmental EPA (mEPA, bEPA) in the supine position using linear regression models. This study was approved by the Ethics Committee of the Medical Association of Saxony-Anhalt Germany on 20 August 2020, under number 46/20. Results: Using data from 287 patients, the prediction showed R2 from 0.092 up to 0.972. The adjacent cranial and caudal EPA showed by far the most frequently significance in the prediction of all parameters used. Anthropometric and spino-pelvic parameters showed sparse impact, which was frequently in the lower lumbar regions. On average, a very good prediction was found. For two mEPA (L3/4 R2 = 0.914, L4/5 R2 = 0.953) and two bEPA (L3 R2 = 0.899, L4 R2 = 0.972), the R2 was >0.8. However, the predicted EPA differed for individual patients, even in these very effective prediction models—roughly around ±10° as compared to the measured EPA. Conclusions: In general, the prediction showed good to perfect results. In the supine position, the spinopelvic and anthropometric parameters show sparse impact on the prediction of mEPA or bEPA. [ABSTRACT FROM AUTHOR]

Poor posture (thoracic hyperkyphosis) in children is reportedly caused by changes in their living environment. A previous study (conducted 30 years ago) reported that the position of the center of pressure (COP) in a child with an upright posture was approximately 40% from the heel. The present study aimed to determine the position and characteristics of the COP while standing in children aged 6–12 years. This study enrolled 83 elementary school students. A Win-Pod (Medicapteurs) platform was used to measure the COP. The COP position was expressed as a percentage from the heel as a relative ratio with a foot length of 100%. Spinal Mouse® was used to measure thoracic kyphosis, lumbar lordosis, sacral anteversion, and trunk inclination angles in the standing position. The COP position was 30.3±8.9% from the heel. We found positive correlations between the COP position, height, and weight. Further, the COP position was significantly more anterior in 28 upper elementary grade children (35.1 ± 9.2%) than in 25 middle (29.5 ± 8.6%) and 30 lower grade children (26.5 ± 6.7%). Regarding sex differences, the COP position was significantly more anterior in 46 boys (32.3 ± 9.8%) than in 37 girls (27.9 ± 6.9%). There was a weak positive correlation between the COP position and trunk inclination angle (r=0.251, p<0.05). Thus, we found that the COP position in modern children aged 6–12 years while standing was 30.3 ± 8.9% from the heel, indicating a shift toward the heel (backward) compared to that reported in previous studies. [ABSTRACT FROM AUTHOR]

Background: Spinal alignment can have a significant impact on a patient's overall quality of life. Predicting the ideal sagittal spinal alignment of a specific individual is still a difficult task. The Multi-Ethnic Alignment Normative Study (MEANS) investigated skeletal alignment, including the spine and lower extremities, of the largest multi-ethnic cohort of asymptomatic adult volunteers. In this analysis, the authors aim to assess normative values of spinopelvic parameters and the regional cervical, thoracic, and lumbar spinal alignment in asymptomatic volunteers stratified by age and sex.Materials and Methods: Asymptomatic volunteers between ages 18 and 80 years were enrolled prospectively from centers in France, Japan, Singapore, Tunisia, and the United States. Volunteers included reported no significant neck or back pain (Visual Analog Scale ≤2), nor any known spinal disorder(s). All volunteers underwent a standing full-body or full-spine low-dose stereoradiograph.Results: MEANS consisted of 468 volunteers with a mean age of 40.4±14.8 years. Mean cervical lordosis from C2 to C7 was -0.4±12.7°. The T1-slope averaged 23.0±7.9° and showed strong correlation ( r =0.87) with the C7-slope mean of 19.8±8.6°. Thoracic kyphosis (TK) from T4 to T12 showed a mean of 37.4±10.9°. Average L1-S1 lumbar lordosis (LL) was -57.4±11.3°. The mean pelvic incidence (PI) measured 52.0±10.7° and pelvic tilt was 12.5±7.3°. Sacral slope averaged 39.5±8.2°. The average PI-LL was -5.4±10.7°. Approximately 60% of volunteers met the PI-LL criteria within ±10°, 8.3% were ≥10°, while 32.1% were ≤-10°. LL showed moderate correlation with PI ( r =0.53) and TK ( r =0.50), while there was no correlation between TK and PI. Multiple linear regression including PI, TK, and age resulted in the following equation LL=14.6+0.57 (PI)+0.57 (TK)-0.2 (age) ( r =0.75).Conclusions: LL did not change with increasing age in asymptomatic volunteers. However, TK did increase with age leading to an increase in T1-slope and a compensatory increase in cervical lordosis. TK did not correlate with PI and was an independent variable in the prediction of LL.Level Of Evidence: Level II-prospective cohort study. [ABSTRACT FROM AUTHOR]

Background: Although lumbar spinal stenosis (LSS) often coexists with other degenerative conditions, few studies have fully assessed possible contributing factors for low back pain (LBP) in patients with LSS. The purpose of this study was to identify factors associated with the severity of LBP in patients with LSS.Methods: The patients with neurogenic claudication caused by LSS, which was confirmed by magnetic resonance imaging (MRI) were included in this cross-sectional study. Data included ratings of LBP, buttock and leg pain, and numbness on a numerical rating scale (NRS), 36-item Short-Form Survey (SF-36) scores, muscle mass measured by bioelectrical impedance analysis, and radiographic measurements including lumbopelvic alignment and slippage. The severity of LSS, endplate defects, Modic endplate changes, intervertebral disc degeneration, and facet joint osteoarthritis were evaluated on MRI. Spearman correlation and multivariate linear regression analyses were used to examine the factors associated with the severity of LBP (NRS score).Results: A total of 293 patients (135 male and 158 female, average age 72.6 years) were analyzed. LBP was moderately correlated with buttock and leg pain, and buttock and leg numbness. Significant but weak correlations were observed between LBP and body mass index, appendicular and trunk muscle mass, all domains of SF-36, pelvic tilt, total number of endplate defects and Modic endplate changes, and summary score of disc degeneration grading, but not severity or number of spinal stenoses. In the multivariate regression analysis, age, female sex, trunk muscle mass, diabetes, NRS buttock and leg pain, NRS buttock and leg numbness, SF-36 vitality, pelvic tilt, and total number of endplate defects were associated with the severity of LBP.Conclusions: Trunk muscle mass, lumbopelvic alignment, and endplate defects, but not severity of stenosis are partly associated with severity of LBP, but buttock and leg pain and buttock and leg numbness have strongest relationships with LBP in patients with LSS. [ABSTRACT FROM AUTHOR]

Purpose: To clarify the impact of restriction of hip extension on radiographic whole-body sagittal alignment with using postoperative changes of radiographical parameters for hip osteoarthritis. Methods: We prospectively enrolled 68 patients with hip osteoarthritis scheduled for arthroplasty. Variables included manual examination of hip range of motion (H-ROM) and radiographic whole-body sagittal alignment parameters including sagittal vertical axis (SVA), center of acoustic meatus and femoral head offset (CAM-HA), thoracic kyphosis (TK), lumbar lordosis, sacral slope (SS), and knee flexion angle (KF). We divided patients with preoperative hip extension angle < 0 into the extension restriction (ER) + group and ≥ 0 into the ER− group. Differences in H-ROM, radiographic parameters between groups and postoperative changes were comparatively analyzed. Results: Fifty-seven patients (The ER + group included 28 patients and the ER− group included 29 patients.) were available for the analysis. Pre-/postoperative H-ROM were 99.7 ± 24.9/118.1 ± 16.0 degrees (p <.01). Greater increases in SVA (5.4 ± 3.4 vs 3.4 ± 2.8 cm, p =.02) and in CAM-HA (3.9 ± 3.9 vs 2.8 ± 3.4 cm, p = 013) were found in the ER + group versus ER− group. Postoperatively, the ER + group showed an increase in TK (pre-/postoperative: 35.2 ± 9.7/37.4 ± 8.8 degrees, p =.04) and decreases in SS (36.5 ± 9.6/33.7 ± 9.9 degrees, p <.01) and KF (9.5 ± 7.0/6.9 ± 6.0 degrees, p =.02). Postoperative changes in radiographic parameters in the ER− group were not significant. Conclusion: Patients with restriction of hip extension showed global spine imbalance, and significant changes in TK, SS, and KF were observed after arthroplasty. The presence of hip joint disorder and H-ROM restriction must be considered when evaluating spinopelvic alignment and whole-body sagittal alignment. [ABSTRACT FROM AUTHOR]

Previous studies have reported that poor posture can induce various musculoskeletal disorders. Recently, poor posture in children has become a problem. This study aimed to determine the characteristics of sagittal spinal alignment in standing and sitting positions in elementary school students and how spinal alignment changes from standing to sitting position. Moreover, it clarifies how poor posture (hyperkyphosis) in the standing position affects sitting posture. This study was conducted among 83 elementary school students. The Spinal-Mouse® System was used to measure the thoracic kyphosis angle (TKA), upper thoracic angle (UTA), lower thoracic angle (LTA), lumbar lordosis angle (LLA), and sacral anteversion angle (SAA) in the standing and sitting positions. Hyperkyphosis was defined as a thoracic kyphosis angle of >40°. Participants were assigned to two groups: hyperkyphosis and non-hyperkyphosis. Significant differences were noted in all spinal alignment characteristics in both the positions. When spinal alignment was changed from standing to sitting, ΔUTA and ΔLTA correlated with ΔLLA and ΔSAA, respectively. A strong negative correlation was noted between ΔLLA and ΔSAA. In the sitting position, TKA, UTA, and LLA were significantly higher in the hyperkyphosis group than in the non-hyperkyphosis group. ΔUTA was significantly higher in the hyperkyphosis group than in the non-hyperkyphosis group when spinal alignment was changed from standing to sitting. The characteristics of sagittal spinal alignment in the sitting position were significantly different from those in the standing position. The study findings suggest that poor posture (hyperkyphosis) in the standing position affects the sitting posture. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the association between gait profile and spinal alignment in adolescent idiopathic scoliosis (AIS). The study group consisted of 80 AIS and 80 healthy controls. All participants underwent radiographic imaging and measured gait analysis. The gait profile included gait speed, step length, stance phase, cadence, single leg support, double legs support, gait asymmetry (GA), and phase coordination index (PCI). The spinal alignment parameters included pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), and coronal balance (CB). The mean age of the AIS group was 15.1 years, while the control group was 14.6 years. Significant differences were observed between the AIS patients and controls in gait speed, step length, stance phase, cadence, single leg support, double legs support, GA, PT, TK, SVA, and CB. However, no significant differences were found in PCI, SS, PI, and LL (p > 0.05). Additionally, correlation analysis revealed a close relationship between gait profile and spinal alignment parameters. Step length was significantly related to PT, SS, and LL, while GA was correlated with TK in AIS patients. Multiple regression analysis for predictors of step length found that PT and SS accurately predicted step length. First, the AIS group showed significant differences in gait kinematics and spinal alignment compared to the control group. Second, statistically significant correlations were found between gait profile and spinal alignment parameters. Specifically, PT and SS accurately predicted step length, and TK was correlated with GA in AIS patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Study Design: Retrospective cohort study., Objectives: To identify imaging predictors on pre- and perioperative imaging that are associated with a future revision surgery for adjacent segment disease (ASD) following lumbar fusion., Methods: Patients undergoing open posterior lumbar fusion between 2014-2022 were followed-up for >2-year. The initial MRI was evaluated for disc degeneration by Pfirrmann (grade 1-5); Modic changes (0-3); as well as fatty infiltration and functional cross-sectional area (fCSA) of the multifidus, erector spinae, and psoas. Spinopelvic alignment was measured pre- and postoperatively., Results: Of 216 patients, 14.8% (n = 32) required revision surgery for ASD in the further course. There were no significant differences in Modic changes or Pfirrmann grades between the ASD group and controls. Fatty infiltration was significantly higher in the ASD group for both the erector spinae (40.5% vs 36.9%, P = 0.043) and multifidus muscles (61.0% vs 53.9%, P = 0.003). Additionally, the multifidus fCSA was smaller in patients who developed ASD (5.7 cm 2 vs 6.7 cm 2 ). Pre- and postoperative spinopelvic parameters were not significantly different between groups, and no other MRI measurements showed a significant difference. In a multivariable logistic regression model adjusting for age and sex, multifidus fatty infiltration emerged as the only significant predictor of ASD revision surgery ( P = 0.004). Patients with more than 58% multifidus fatty infiltration had over double the risk of developing ASD (OR 2.7, 95% CI: 1.1-6.5, P = 0.032)., Conclusions: Multifidus fatty infiltration is the key imaging predictor for the development of ASD requiring surgical revision. Disc degeneration and spinopelvic alignment appear to have less impact., Competing Interests: Declaration of Conflicting InterestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: AAS reports royalties from Ortho Development, Corp. DePuy Spine Products/Medical Device Business Services, Clariance, Inc.; private investments for Vestia Ventures MiRUS Investment, LLC, ISPH II, LLC, ISPH 3, LLC, and Centinel Spine (Vbros Venture Partners V); consulting fees from DePuy Spine Products/Medical Device Business Services, Clariance, Inc., Kuros Biosciences AG; speaking and/or teaching arrangements for DePuy Spine Products/Medical Device Business Services; membership of scientific advisory board of DePuy Spine Products/Medical Device Business Services, Kuros Biosciences AG, Clariance, Inc., and research support from Spinal Kinetics, Inc./Orthofix, Inc., outside the submitted work. FPC reports royalties from Accelus; ownership interest for 4WEB Medical/4WEB, Inc.; Healthpoint Capital Partners, LP; ISPH II, LLC; ISPH 3 Holdings, LLC; Ivy Health care Capital Partners, LLC; Medical Device Partners II, LLC; Medical Device Partners III, LLC; Orthobond Corporation; Spine Biopharma, LLC; Tissue Differentiation Intelligence, LLC; Tissue Connect Systems, Inc.; VBVP VI, LLC; VBVP X, LLC; Woven Orthopedics Technologies; consulting fees from Spine Biopharma, LLC, and Accelus; membership of scientific advisory board/other office of Healthpoint Capital Partners, Medical Device Partners II, LLC, Orthobond Corporation, Spine Biopharma, LLC, and Woven Orthopedic Technologies; and research support from 4WEB Medical/4WEB, Inc., Camber Spine, Choice Spine, DePuy Synthes, Centinel Spine, and Royal Biologics outside the submitted work. FPG reports royalties from Lanx, Inc. And Ortho Development Corp.; ownership interest in Centinel Spine, BICMD; consulting fees from Lanx, Inc, Ortho Development Corp, and Sea Spine;and stock ownership in Centinel Spine, Healthpoint Capital Partners, LP; membership of scientific advisory board/other office of Healthpoint Capital Partners, outside the submitted work. APH reports research support from Kuros Biosciences AG and Expanding Innovations, Inc.; private investments in Tissue Connect Systems, Inc.; and fellowship support from NuVasive, Inc., Globus Medical North America, Inc., and Alphatec Spine, Inc., outside the submitted work.

Background: With an aging population, degenerative spinal diseases are contributing significantly to the healthcare's burden. Spinal alignment in the context of adult spinal deformities has become an important domain of research., Methods: We conducted a narrative review of the latest considerations in spinal alignment within the context of degenerative spinal conditions, discussed current strategies for morphological assessment and finally identified potential areas for future research., Results: This review reported that degenerative spinal conditions lead to a complex disruption of spinal alignment. It also highlighted the importance of spino-pelvic alignment with specific attention to compensatory mechanisms that occur in response to spinal deformities. Emerging technologies including Artificial Intelligence and epigenetics are showing promises in terms of patient care., Conclusions: Understanding spinal alignment in degenerative conditions underscores the importance of dynamic and individualized assessments. Future research should integrate emerging technologies along with traditional clinical practices in order to optimize patient outcomes and minimize complications for patients suffering from degenerative spinal diseases., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Background Context: Concurrent degeneration of the lumbar spine, hip, and knee can cause significant disability and lower quality of life. Osteoarthritis in the lower extremities can lead to movement limitations, possibly requiring total knee arthroplasty (TKA) or total hip arthroplasty (THA). These procedures often impact spinal posture, causing alterations in spinopelvic alignment and lumbar spine degeneration. It is unclear if patients with a history of prior total joint arthroplasty (TJA) have different spinopelvic alignment compared to patients without., Purpose: To assess the relationship between a history of previous THA or TKA, as well as combined THA and TKA, and the spinopelvic alignment in patients undergoing elective lumbar surgery for degenerative conditions., Study Design: A retrospective analysis was conducted on patients who underwent lumbar surgery for degenerative conditions. The patients were stratified based on a history of TKA, THA, or both TKA and THA., Patient Sample: A total of 632 patients (63% female) with an average age of 64±11 years and an average BMI of 30±6 kg/m 2 were included., Outcome Measures: Patients were stratified based on a history of THA, TKA, or combined THA and TKA. Spinopelvic parameters (lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI)) were assessed. The relationship between spinopelvic alignment and prior TKA, THA or TKA and THA was analyzed METHODS: The data was tested for normal distribution using the Shapiro-Wilk test. We analyzed the relationship between the spinopelvic parameters and the different arthroplasty groups. Differences in scores between groups were examined using ANOVA. Tukey's Honestly Significant Difference test was used for pairwise comparison for significant ANOVA test results. Multivariable linear regression was applied, adjusted for age, sex and BMI., Results: A total of 632 patients (63% female) were included in the study. Of these patients, 74 (12%) had a history of isolated TKA, 40 (6%) had prior isolated THA, and 15 (2%) had TKA and THA prior to lumbar surgery. Patients with prior arthroplasty were predominantly female (59%) and significantly older (68±7 years vs. 63±12 years, p<.001) with a significantly higher BMI (31±6 kg/m 2 vs. 29±6 kg/m 2 , p<.001). The LL was significantly lower (45.0°±13 vs. 50.9°±14 p=.011) in the arthroplasty group compared to the nonarthroplasty group. A history of isolated TKA was significantly associated with lower LL (Est=-3.8, 95% CI -7.3 to -0.3, p=.031) and SS (Est=-2.6, 95% CI -5.0 to -0.2, p=.012) compared to patients without TJA. Prior combined THA and TKA was found to be significantly associated with a higher PT compared to the nonarthroplasty group (Est=5.1, 95% CI 0.4-9.8, p=.034)., Conclusion: The spinopelvic alignment differs between patients with and without prior TJA who undergo elective lumbar surgery. The study shows that a history of TKA is significantly associated with a lower LL and SS. The combination of THA and TKA was associated with a significantly higher PT. These findings highlight the complex relationship between the hip, spine, and knee. Moreover, the results could aid in enhancing preoperative planning of lumbar surgery in patients with known TJA., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Correction of mild flexible cervical deformity (CD) via the posterior approach has been described with and without the use of posterior osteotomies (POs), despite a lack of clarity regarding their necessity or risks. The purpose of this study was to determine whether the use of POs when correcting mild flexible CD leads to improved clinical or radiographic outcomes, as well as defining the relative risks in utilizing them., Methods: A prospective multicenter registry of operative CD patients was analyzed. Inclusion criteria were cervical kyphosis > 10°, cervical scoliosis > 10°, cervical sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical angle > 25°. Mild deformity was defined by a cSVA of 3-5 cm and/or kyphosis < 15°. Flexibility was defined by a C2-7 angular change > 5° on preoperative flexion/extension radiographs. Patients who received a posterior column osteotomy (PCO) (Ames grades 1 and 2) were compared with patients who did not undergo a PCO (noPCO) as well as those who underwent a three-column osteotomy (3CO) (Ames grades 3-6)., Results: Ninety-five patients (33 PCO, 49 noPCO, 13 3CO) met the inclusion criteria. Both the number of levels fused (9.2 vs 7.7, p = 0.001) and the estimated blood loss (EBL) (1027 vs 486 mL, p = 0.012) were higher in the PCO cohort. Patients in the noPCO group were more likely to have a cervical apex of kyphosis (71.1%, p = 0.046), while those undergoing 3COs were more likely to have a thoracic apex (58.3%, p = 0.005). Preoperative cSVA (PCO vs noPCO: 45.4 vs 37.9 cm, p = 0.084), T1 slope (32.5° vs 29.6°, p = 0.376), C2-7 lordosis (-8.9° vs -9.2°, p = 0.942), and modified Japanese Orthopaedic Association (mJOA) score (13.4 vs 13.5, p = 0.854) were similar; however, both Neck Disability Index (NDI) (55.6 vs 42, p = 0.002) and numeric rating scale (NRS) neck (7.2 vs 5.8, p = 0.028) scores were higher in the PCO group before surgery. When adjusting for the use of an anterior approach, there was no significant difference in 1-year postoperative cSVA (35.7 and 35.6 cm, respectively; p = 0.969), C2-7 lordosis (13.7° and 10.1°, respectively; p = 0.393), and patient-reported outcome measures (NRS, NDI, and mJOA) between the PCO and noPCO groups. Two-year radiographic outcomes were largely similar, except for C2 slope, which was higher in the PCO group (29.1° vs 18°, p = 0.026). The overall complication rates progressively increased with more complex osteotomy use (noPCO 68.8% vs PCO 71.9% vs 3CO 75%) but did not reach significance (p = 0.063)., Conclusions: The use of POs for mild flexible adult CD may not be necessary to achieve desirable radiographic correction. They are associated with greater EBL and fusion burden. Further studies are needed to fully delineate the risks of adverse events for various types of osteotomies.

Study Design: A monocentric, retrospective radiographic study with 99 asymptomatic volunteers.Objective: The authors performed the postural analysis commonly scheduled when evaluating sagittal balance in a vertebra-by-vertebra manner by enrolling an asymptomatic population. They measured the position and angulation of each vertebra to reveal those for which the spatial positioning could be relevant during spinal surgeries.Summary Of Background Data: Several recent publications detailed the sagittal alignment parameters and focus on global analysis parameters. Some patients with identical commonly evaluated spinal parameters have exhibited very different profiles, with notable differences in vertebral positions and orientations. Therefore, a fine segmental analysis of position of each vertebra could be interest to gain understanding of spine alignment.Materials and Methods: The authors obtained full-spine EOS x-rays of 99 volunteers in the standard free-standing position. We used a validated three-dimensional reconstruction technique to extract current spinal parameters and the positions and angulations of all vertebrae and lumbar discs. Particular attention was paid to the positions and angulations of the apical and transitional vertebrae in the general population and in subgroups according to pelvic incidence (PI).Results: T1 was the most common transitional cervicothoracic vertebra (in 89.9% of subjects) and was oriented downwards by an average of 22.0° (SD=7.3°, minimum=2.3°, maximum=40.1°). The thoracic apex trio of T5 (22.2%), T6 (28.3%), and T7 (36.4%) were equally found. The transitional thoracolumbar vertebrae were L1 (39.4%) and T12 (33.3%). The lumbar apex was usually the L3-L4 disc (36.4%). T1 seemed to be the transitional vertebra (90%) irrespective of the PI. For the other relevant vertebrae, the greater the PI, the more cranial the vertebra.Conclusions: We performed a detailed three-dimensional assessment of overall spinal balance using positional and rotational parameters. The positions and orientations of all vertebrae were specified, particularly the apical and transitional vertebrae.Level Of Evidence: Level 3. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine the discriminatory ability of age-adjusted alignment offset and the global alignment and proportion (GAP) score parameters to predict postoperative mechanical complications. Methods: Surgical patients from the Adult Symptomatic Lumbar Scoliosis cohort were reviewed at 2 year follow up. Age-adjusted alignment offsets and GAP parameters were calculated for each patient. A series of nonlinear logistic regression models were fit, and the odds of mechanical complications were calculated. The discriminatory ability of the GAP score, GAP score parameters, and age-adjusted alignment offsets were determined plotting receiver operative characteristic (ROC) with the C statistic (AUC). Results: A total of 165 patients were included. A total of 49 mechanical complications occurred in 41 patients (21 proximal junctional kyphosis and 28 pseudoarthrosis). The GAP score had no discriminatory ability in this cohort. Relative lumbar lordosis 15 degrees greater than ideal lumbar lordosis was associated with greater mechanical complications. A lumbar distribution index of 90% was associated with fewer mechanical complications compared to a lumbar distribution index of 65%. Age-adjusted offset alignment targets had no discriminatory ability to predict mechanical complications. Conclusion: Radiographic alignment targets using either age-adjusted alignment target offset or GAP score parameters had minimal ability to predict mechanical complications in isolation. Mechanical complications following adult spinal deformity surgery are complex, and patient factors play a critical role. Clinical trial registeration This study was registered at ClinicalTrials.gov (number NCT00854828) in March 2009. [ABSTRACT FROM AUTHOR]

Background Context: Intraoperative stitched O-arm images are commonplace during spinal deformity correction surgeries; however, the accuracy of stitched images for measuring angular measures is unknown.Purpose: To examine the effect of radiographic parallax effect of stitched O-arm images by assessing the regional curve agreement with measurements from computed tomography (CT).Study Design/setting: Experimental radiographic study.Patient Sample: Four whole body cadavers (age: 81±14, sex: 2M/2F) and two fabricated spine model phantoms from surgical cases, one with extreme scoliosis and one normal spine, were utilized.Outcome Measures: The limits of agreement for angular measures between CT (gold-standard) and intraoperative stitched fluoroscopic images were calculated. Further, intra- and inter-rater reliability was measured.Methods: A series of adjacent anterior-posterior and lateral images were acquired cranial to caudal using an O-arm in three table configurations (standard position, off-axis in the coronal plane, and reverse Trendelenburg) and stitched manually. Regional angular measures were extracted, and the limits of agreement were calculated between each table position and CT using a Bland-Altman approach.Results: The observers displayed excellent inter-rater reliability across table positions (range: 0.944-0.989) and intra-rater reliability (0.979-0.995). The limits of agreement results showed a similar and better agreement was observed for the Standard and Reverse Trendelenburg than the Off-Axis position.Conclusions: This work shows reliable regional curvature measurements can be calculated with good agreement with CT in common table positions, but care should be taken to ensure the patient is perpendicular to the X-rays, particularly in the lateral view. [ABSTRACT FROM AUTHOR]