Purpose:
To assess the natural history of ossification of yellow ligament (OYL) in the thoracic spine and determine risk factors for progression based on a longitudinal population-based cohort.
...Methods:
A prospective, longitudinal cohort study was performed on a population-based cohort of Southern Chinese volunteers. T2-weighted magnetic resonance imaging (MRI) was used at baseline to identify any OYL and was verified with computed tomography. Follow-up MRI was performed 5 years later. Parameters under study included the size of OYL, levels of involvement, morphology (round, triangular, beak), whether it crossed the midline and any disc degeneration.
Results:
A total of 114 (6.1%) individuals were identified to have OYL at baseline out of the 1864 individuals. Size progression occurred predominantly at the lower thoracic region. Majority of the new OYL were also in the lower thoracic spine and was associated with higher body mass index (BMI). Smokers were associated with OYL size progression while patients with higher BMI tended to develop new OYL at follow-up. Progression commonly occurred at the lower thoracic levels and regression occurred mostly at the upper thoracic levels.
Conclusions:
This is the first population-based series addressing the natural history of OYL. Better understanding of the natural history of OYL may provide incentive to introduce preventive measures such as weight reduction and close monitoring for myelopathy development in those at-risk groups for progression. This is especially important for patients with lower thoracic OYL and who are smokers with higher BMI.
Level of Evidence:
1 (prognostic study).
Purpose
To utilize a global survey to elucidate spine surgeons’ perspectives towards research and resident education within telemedicine.
Methods
A cross-sectional, anonymous email survey was ...circulated to the members of AO Spine, an international organization consisting of spine surgeons from around the world. Questions were selected and revised using a Delphi approach. A major portion of the final survey queried participants on experiences with telemedicine in training, the utility of telemedicine for research, and the efficacy of telemedicine as a teaching tool. Responses were compared by region.
Results
A total of 485 surgeons completed the survey between May 15, 2020 and May 31, 2020. Though most work regularly with trainees (83.3%) and 81.8% agreed that telemedicine should be incorporated into clinical education, 61.7% of respondents stated that trainees are not present during telemedicine visits. With regards to the types of clinical education that telemedicine could provide, only 33.9% of respondents agreed that interpretation of physical exam maneuvers can be taught (mean score = − 0.28, SD = ± 1.13). The most frequent research tasks performed over telehealth were follow-up of imaging (28.7%) and study group meetings (26.6%). Of all survey responses provided by members, there were no regional differences (
p
> 0.05 for all comparisons).
Conclusions
Our study of spine surgeons worldwide noted high agreement among specialists for the implantation of telemedicine in trainee curricula, underscoring the global acceptance of this medium for patient management going forward. A greater emphasis towards trainee participation as well as establishing best practices in telemedicine are essential to equip future spine specialists with the necessary skills for navigating this emerging platform.
Purpose
Spine surgeons around the world have been universally impacted by COVID-19. The current study addressed whether prior experience with disease epidemics among the spine surgeon community had ...an impact on preparedness and response toward COVID-19.
Methods
A 73-item survey was distributed to spine surgeons worldwide via AO Spine. Questions focused on: demographics, COVID-19 preparedness, response, and impact. Respondents with and without prior epidemic experience (e.g., SARS, H1NI, MERS) were assessed on preparedness and response via univariate and multivariate modeling. Results of the survey were compared against the Global Health Security Index.
Results
Totally, 902 surgeons from 7 global regions completed the survey. 24.2% of respondents had prior experience with global health crises. Only 49.6% reported adequate access to personal protective equipment. There were no differences in preparedness reported by respondents with prior epidemic exposure. Government and hospital responses were fairly consistent around the world. Prior epidemic experience did not impact the presence of preparedness guidelines. There were subtle differences in sources of stress, coping strategies, performance of elective surgeries, and impact on income driven by prior epidemic exposure. 94.7% expressed a need for formal, international guidelines to help mitigate the impact of the current and future pandemics.
Conclusions
This is the first study to note that prior experience with infectious disease crises did not appear to help spine surgeons prepare for the current COVID-19 pandemic. Based on survey results, the GHSI was not an effective measure of COVID-19 preparedness. Formal international guidelines for crisis preparedness are needed to mitigate future pandemics.
Background
Histopathological analysis of intervertebral disc (IVD) tissues is a critical domain of back pain research. Identification, description, and classification of attributes that distinguish ...abnormal tissues form a basis for probing disease mechanisms and conceiving novel therapies. Unfortunately, lack of standardized methods and nomenclature can limit comparisons of results across studies and prevent organizing information into a clear representation of the hierarchical, spatial, and temporal patterns of IVD degeneration. Thus, the following Orthopaedic Research Society (ORS) Spine Section Initiative aimed to develop a standardized histopathology scoring scheme for human IVD degeneration.
Methods
Guided by a working group of experts, this prospective process entailed a series of stages that consisted of reviewing and assessing past grading schemes, surveying IVD researchers globally on current practice and recommendations for a new grading system, utilizing expert opinion a taxonomy of histological grading was developed, and validation performed.
Results
A standardized taxonomy was developed, which showed excellent intra‐rater reliability for scoring nucleus pulposus (NP), annulus fibrosus (AF), and cartilaginous end plate (CEP) regions (interclass correlation ICC > .89). The ability to reliably detect subtle changes varied by IVD region, being poorest in the NP (ICC: .89‐.95) where changes at the cellular level were important, vs the AF (ICC: .93‐.98), CEP (ICC: .97‐.98), and boney end plate (ICC: .96‐.99) where matrix and structural changes varied more dramatically with degeneration.
Conclusions
The proposed grading system incorporates more comprehensive descriptions of degenerative features for all the IVD sub‐tissues than prior criteria. While there was excellent reliability, our results reinforce the need for improved training, particularly for novice raters. Future evaluation of the proposed system in real‐world settings (eg, at the microscope) will be needed to further refine criteria and more fully evaluate utility. This improved taxonomy could aid in the understanding of IVD degeneration phenotypes and their association with back pain.
Development of a standardized histopathology scoring scheme for human IVD degeneration.
Study Design:
Cross-sectional, international survey.
Objectives:
The current study addressed the multi-dimensional impact of COVID-19 upon healthcare professionals, particularly spine surgeons, ...worldwide. Secondly, it aimed to identify geographical variations and similarities.
Methods:
A multi-dimensional survey was distributed to surgeons worldwide. Questions were categorized into domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions.
Results:
902 spine surgeons representing 7 global regions completed the survey. 36.8% reported co-morbidities. Of those that underwent viral testing, 15.8% tested positive for COVID-19, and testing likelihood was region-dependent; however, 7.2% would not disclose their infection to their patients. Family health concerns were greatest stressor globally (76.0%), with anxiety levels moderately high. Loss of income, clinical practice and current surgical management were region-dependent, whereby 50.4% indicated personal-protective-equipment were not adequate. 82.3% envisioned a change in their clinical practice as a result of COVID-19. More than 33% of clinical practice was via telemedicine. Research output and teaching/training impact was similar globally. 96.9% were interested in online medical education. 94.7% expressed a need for formal, international guidelines to manage COVID-19 patients.
Conclusions:
In this first, international study to assess the impact of COVID-19 on surgeons worldwide, we identified overall/regional variations and infection rate. The study raises awareness of the needs and challenges of surgeons that will serve as the foundation to establish interventions and guidelines to face future public health crises.
Magnetic resonance imaging (MRI) of the lumbar spine is commonly used to identify the source of low back pain (LBP); however, its use has been questionable. Throughout the years, numerous lumbar ...phenotypes (e.g., endplate abnormalities, Modic changes, black disc) have been studied as possible pain generators. High-intensity zones (HIZs) are of particular interest as they may represent annular tears. However, for over three decades, there has been heated debate as to whether these imaging biomarkers are synonymous with LBP. Therefore, the following study addressed a systematic review of the reported literature addressing the relationship of HIZs and LBP.
A systematic review was conducted via MEDLINE, SCOPUS, Cochrane, PubMed, PubMed Central, EMBASE via Ovid, and Web of Science with the following search terms: "HIZ," "high intensity zone," or "high intensity zones" and "low back pain," "pain," "lumbago," and/or "sciatica." Specific exclusion criteria were also maintained. Two independent reviewers searched the literature, selected the studies, and extracted the data.
We identified six studies from our search strategy that met the inclusion criteria from a total of 756 possible studies. One cross-sectional population-based study and five comparison studies were identified, which provided information regarding the prevalence of HIZs. The prevalence of HIZs was 3 to 61% in subjects with LBP and 2 to 3% in subjects without LBP. Only three studies suggested a significant association between the presence of HIZ and LBP with or without sciatica.
Our systematic review has found evidence that HIZs may be a possible risk factor for LBP; however, a mismatch of the clinical relevance of HIZs between studies still remains. The available evidence is limited by small sample size, heterogeneous study populations, and lack of standardized imaging methods for phenotyping. HIZs may be important lumbar biomarkers that demand further investigation and should be considered in the global imaging assessment of the spine, which may have immense clinical utility. Further large-scale studies with standardized imaging and classification techniques as well as the assessment of patterns of HIZs are necessary to better understand their role with LBP development.
Study Design:
Cross-sectional, anonymous, international survey.
Objectives:
The COVID-19 pandemic has resulted in the rapid adoption of telemedicine in spine surgery. This study sought to determine ...the extent of adoption and global perspectives on telemedicine in spine surgery.
Methods:
All members of AO Spine International were emailed an anonymous survey covering the participant’s experiences with and perceptions of telemedicine. Descriptive statistics were used to depict responses. Responses were compared among regions.
Results:
485 spine surgeons participated in the survey. Telemedicine usage rose from <10.0% to >39.0% of all visits. A majority of providers (60.5%) performed at least one telemedicine visit. The format of “telemedicine” varied widely by region: European (50.0%) and African (45.2%) surgeons were more likely to use phone calls, whereas North (66.7%) and South American (77.0%) surgeons more commonly used video (P < 0.001). North American providers used telemedicine the most during COVID-19 (>60.0% of all visits). 81.9% of all providers “agreed/strongly agreed” telemedicine was easy to use. Respondents tended to “agree” that imaging review, the initial appointment, and postoperative care could be performed using telemedicine. Almost all (95.4%) surgeons preferred at least one in-person visit prior to the day of surgery.
Conclusion:
Our study noted significant geographical differences in the rate of telemedicine adoption and the platform of telemedicine utilized. The results suggest a significant increase in telemedicine utilization, particularly in North America. Spine surgeons found telemedicine feasible for imaging review, initial visits, and follow-up visits although the vast majority still preferred at least one in-person preoperative visit.
A cross-sectional population-based magnetic resonance imaging study of Schmorl nodes (SN) in the lumbar spine.
To determine the prevalence and potential determinants of SN, and their association with ...intervertebral disc degeneration.
SN represent intravertebral disc herniation and are commonly seen in the spine. Their reported prevalence and determinants vary, and their association with disc degeneration remains uncertain. Data based on this large scale population-based study of intervertebral disc degeneration would provide important information for understanding SN and their pathomechanism.
Sagittal T2-weighted magnetic resonance imagings of the lumbar spine were analyzed in 2449 volunteers. Two independent observers assessed the images for the presence of SN, and scored for additional radiologic features (e.g., severity of degeneration, presence of disc bulge/extrusion). Subject demographics were assessed by standardized questionnaire.
SN were found in 16.4% (n = 401; 219 males, 182 females; mean age = 42.3) of our study population (981 males, 1468 females; mean age = 40.4), being most common at L1/2 and L2/3 (54.1%). Multivariate logistic regression revealed that males, taller and heavier individuals had an increased likelihood of SN (P < 0.005), but association between SN and age were not discerned. Overall presence of SN was associated with disc degeneration (P < 0.001), and linearly correlated (R = 0.97) with increase in severity of degeneration. SN were particularly associated with severe disc degeneration at L1/2 and L2/3 with 22- to 15-fold increased odds, respectively (P < 0.0001), but less than 5-fold increased odds (P < 0.001) were noted in the lower lumbar spine.
In a population-based cohort, 16.4% of Southern Chinese subjects had SN at 1 or more lumbar levels. Males, taller and heavier individuals had increased likelihood of SN. Interestingly, SN were highly associated with severity of disc degeneration.
Study Design:
Cross-sectional study.
Objective:
Recently, there has been a rise in children and adolescents developing low back pain and/or sciatica. Degenerative lumbar spine MRI phenotypes can ...occur in this population but reports have been sporadic and the true incidence of such spine changes remains debatable. As such, the study aimed to address the epidemiology of MRI phenotypes of the lumbar spine in this young population.
Methods:
597 children and adolescents with lumbar MRIs were included in the study. T1- and T2-weighted lumbar images from L1/2 to L5/S1 were analyzed in axial and sagittal planes. Global phenotype assessment was performed of each level and based on established nomenclature protocols.
Results:
The cohort consisted of 57.3% (342) boys and 42.7% (255) girls, with a mean age of 10.75 ± 5.25 years (range: 0 to 18 years). The prevalence of imaging findings of lumbar disc degeneration (LDD) and lumbar disc herniation (LDH) were 2.2% (95% CI: 0.93–3.43) and 5.8% (95%CI: 2.58-8.99), respectively. There was significant difference between each disc segment from L1/2 to L5/S1 for both LDD and LDH. Schmorl’s nodes were noted in 16 cases (2.7%, youngest case as 15 years), with 11 boys (68.8%) and most frequent segment as L3/4. Modic changes and high-intensity zones were absent in this cohort.
Conclusions:
LDD can emerge as early as the first decade of life with Schmorl’s nodes, without additional specific phenotypes, including Modic changes and high-intensity zones. The study provides valuable information of a unique age group that is often under-represented but equally important as adults.
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