A relationship has been suggested between lumbar disc herniation (LDH) and chronic bacterial infection frequently involving Propionibacterium acnes, which is known to cause chronic infection through ...the formation of biofilm aggregates. The objective of the study was to assess whether a disc infection involving biofilm formation is present in patients with LDH. A total of 51 LDH patients and 14 controls were included. Bacterial DNA was detected by real‐time polymerase chain reaction (PCR) in 16/51 samples in the LDH group and 7/14 controls (p = 0.215). Sequencing identified bacteria in 9/16 and 6/7 PCR positive samples in the LDH and control groups, respectively. All samples were stained using fluorescence in situ hybridization (FISH) and examined by confocal laser scanning microscopy. Microscopy demonstrated tissue‐embedded bacterial aggregates with host inflammatory cells in 7/51 LDH patients and no controls. The presence of both bacterial aggregates and inflammatory cells suggests a chronic infection in a subset of LDH patients. The finding of bacterial 16S rDNA in both LDH and control disc tissue highlights the importance of microscopic observation to discriminate infection vs contamination. Our findings may have therapeutic implications, as the treatment of biofilm infections is different and more challenging than traditional infections.
Proximal humeral fractures (PHF) can be managed surgically or non-surgically. Locking plates have been the preferred head-preserving surgical technique while hemiarthroplasty (HA) or reverse shoulder ...arthroplasty (RSA) have been used in joint replacement surgery. We describe the epidemiology and trends in management of acute PHF in Denmark with a focus on (i) changes in the incidence of PHF; (ii) changes in the proportion of surgical cases; and (iii) changes in preferred surgical techniques.
Data on diagnoses and interventions was retrieved from the Danish National Patient Register. Patients aged 18 years and above were included. Surgical treatment was defined as the diagnosis of PHF combined with a predefined surgical procedure code within 3 weeks of injury. Data on plate osteosynthesis, HA, RSA, and "other techniques" was retrieved. Non-surgical treatment was defined as no relevant surgical procedure code within 3 weeks.
We identified 137,436 PHF (72% women) in the Danish National Patient Register. The overall mean incidence was 138/100,000/year (500 for women 60 years or above). Non-surgical treatment accounted for 119,966 (87%). The 17,470 surgical procedures included 42% locking plates, 34% arthroplasties, and 25% other techniques. The rate of surgery declined from 17% in 2013 to 11% in 2018.
The overall incidence of PHF remained stable between 1996 and 2018 but the absolute number increased. The approach to PHF remains predominantly non-surgical. The number of surgeries in Denmark have decreased since 2013, especially for locking plates and HA, while RSA is increasingly used.
Hypothesis
Fusing shorter than the last touched vertebra (LTV) is a safe approach in flexible main thoracic (MT) adolescent idiopathic scoliosis (AIS) curves.
Methods
This was a prospective study on ...consecutive AIS patients surgically treated with selective fusion of the MT curve. Fusion-level selection was based on the fulcrum-bending radiograph method. Patients were grouped based on the position of the lowest instrumented vertebra as proximal to the LTV (proxLTV,
n
= 43), at the LTV (atLTV,
n
= 45), and distal to the LTV (distLTV,
n
= 21).
Results
A total of 109 patients were included in the study. Preoperatively, the distLTV group had greater lumbar Cobb angle, lumbar apical translation, and less flexibility in the MT curve. At 2-year follow-up, the groups did not differ in MT curve correction, but the distLTV had larger lumbar Cobb angle, more apical translation, and worse coronal balance. Distal adding-on was observed in 11 patients (26%) in the proxLTV group, four patients (9%) in the atLTV group, and one patient (5%) in the distLTV group (
p
= 0.031). Adding-on was associated with younger patients and lower Risser grade at the time of surgery but not with any other radiographic parameter. No differences in SRS-22r scores were observed between the groups.
Conclusions
Proximal fusion carries the risk of adding-on, but leaving unfused segments in the lower spine increases the potential for compensatory mechanisms to improve spinal and truncal balance. In mature patients with a flexible MT curve, surgeons may consider fusion at or cranial to the LTV.
Retrospective cohort study.
To determine treatment outcome with providence brace (PB) and to assess the ability of pretreatment supine lateral bending radiographs (SLBR) in predicting curve ...progression.
Results from treatment with the PB for adolescent idiopathic ccoliosis (AIS) have been inconsistent and further research is needed. The association between flexibility, as determined by pretreatment SLBR, and curve progression has not previously been examined.
All patients treated with the PB from 2006 to 2011 who met Scoliosis Research Society (SRS) bracing criteria were included. Flexibility of the curve was determined based on SLBR and radiographic variables were registered at beginning of treatment and at skeletal maturity (SM) or before surgery. An increase in standing Cobb angle by more than 5 degrees was considered progression. Follow-up SRS-22 scores were compared with a control group with minor AIS. Analysis included multiple linear and logistic regression.
A total of 63 patients were included. Mean age was 13.3 years (SD: 1.5) and mean standing Cobb angle was 34° (SD: 5°). Radiographic progression was observed in 43% of patients at SM and surgical rate was 27% and 37% at SM and 2-year follow up, respectively. SRS-22 total scores were similar but the mental health score was significantly better in the control group (P = 0.042). Multiple linear regression analysis showed that decreased flexibility adjusted for age, Cobb angle, and menarchal status was significantly associated with curve progression (P < 0.001). Multiple logistic regression analysis showed that a one percent increase in flexibility was associated with a decrease in risk of curve progression ≥6° (odds ratio = 0.95; 95% confidence interval 0.90-0.98; P = 0.013).
Progression was seen in 43% of AIS patients treated with the PB. Increase in flexibility was independently associated with a decreased risk of progression.
3.
Retrospective analysis of prospectively collected data.
To validate the Global Alignment and Proportion (GAP) score in a single-center cohort of adult spinal deformity (ASD) patients.
Surgical ...treatment for ASD is associated with a high risk of mechanical failure and consequent revision surgery. To improve prediction of mechanical complications, the GAP score was developed with promising results. Development was based on the assumption that not all patients would benefit from the same fixed radiographic targets as pelvic incidence is an individual, morphological parameter that greatly influences the sagittal curves of the spine.
In a validation study of the GAP score, patients undergoing ASD surgery with four or more levels of instrumentation were consecutively included at a tertiary spine unit. Patients were followed for a minimum of two years. Pre- and postoperative GAP score and categories were calculated for all patients, and the association with mechanical failure and revision surgery was analyzed.
A total of 149 patients with a mean age of 57.4 years were included. Overall, the rates of mechanical failure and revision surgery were 51% and 35% respectively. The area under the curve (AUC) using receiver operating characteristic was classified as "no or low discriminatory power" for the GAP score in predicting either outcome (AUC = 0.50 and 0.49, respectively). Similarly, there were no significant associations between GAP categories and the occurrence of mechanical failure or revision surgery when using Cochran-Armitage test of trend (p = .28 for mechanical failure and p = .58 for revision surgery).
In a consecutive series of surgically treated ASD patients, we found no significant association between postoperative GAP score and mechanical failure or revision surgery. Despite minor limitations in similarities to the original study cohort, further validation studies or adjustments to the original scoring system are proposed.
Level II.
Purpose
The purpose of the study was to assess the changes in flexibility during night-time bracing in skeletally immature adolescent idiopathic scoliosis (AIS) with curves in the surgical range.
...Materials and methods
We included a consecutive cohort of 89 AIS patients with curves ≥ 45° and an estimated growth potential. All patients were eventually treated with fusion surgery, and all patients had side-bending radiographs prior to both bracing and surgery. Curves were classified as structural or non-structural curves according to Lenke at both timepoints.
Results
The main curve progressed by a mean of 12 ± 10° and the secondary curve by 8 ± 8°. Flexibility of the main curve decreased from 50 ± 19% to 44 ± 19% (
p
= 0.001) and the underlying curve from 85 ± 21% to 77 ± 22% (
p
= 0.005). In 69 patients (79%), the Lenke category did not progress during bracing. In 14 patients (15%), the progression in Lenke type occurred in the thoracic region (i.e., Lenke type 1 to type 2), while six patients (7%) progressed in the lumbar region (i.e., type 1 to type 3).
In the 69 patients that did not progress, we found that the last touched vertebra moved distally by one or two levels in 26 patients.
Conclusions
This is the first study to describe that curve flexibility decreases during bracing in severe AIS. However, this had only a modest impact on the surgical strategy. Bracing as a holding strategy can be applied, but the risk of losing flexibility in the lumbar spine should be outweighed against the risks of premature fusion surgery.
BACKGROUND
The surgical treatment of adolescent idiopathic scoliosis can be associated with substantial blood loss, requiring allogeneic red blood cell (RBC) transfusion. This study describes the use ...of RBC and the effect of a standardized perioperative patient blood management program.
STUDY DESIGN AND METHODS
Patients treated with posterior instrumented fusion were consecutively enrolled over a 6‐year period. Patient blood management strategies were implemented in 2011, including prophylactic tranexamic acid, intraoperative permissive hypotension, restrictive fluid therapy (including avoidance of synthetic colloids), restrictive RBC trigger according to institutional standardized protocol, the use of cell savage, and goal‐directed therapy according to thrombelastography.
RESULTS
In total, 210 patients were included. 64 patients (31%) received RBC transfusions. A decline in the intraoperative rate of RBC transfusion was observed, from 77% in 2011 to 13% in 2016 (p < 0.001). Patients in the transfusion group had a significantly larger major curve, lower preoperative hemoglobin, higher estimated blood loss, and an increased use of crystalloid volume resuscitation. Multiple logistic regression showed that significant predictors for RBC transfusion were preoperative hemoglobin level (odds ratio OR, 0.40; 95% confidence interval CI, 0.27‐0.57), estimated blood loss (OR, 1.26; 95% CI, 1.15‐1.42), and year of surgery (indicating the effect of patient blood management) (OR per year, 0.76; 95% CI, 0.58‐0.99).
CONCLUSION
A perioperative patient blood management program substantially reduced the need for RBC transfusion. A preoperative evaluation of anemia is essential to further minimize transfusion rates.
Purpose
Adolescent idiopathic scoliosis (AIS) is characterized by coronal scoliosis and often a sagittal hypokyphosis. The effect of bracing on the sagittal profile is not well understood. The aim of ...this study is to assess the effect of night-time bracing on the sagittal profile in patients with AIS.
Methods
We retrospectively included AIS patients with a main curve of 25–45° treated with a night-time brace in our institution between 2005 and 2018. Patients with estimated growth potential based on either Risser stage, hand X-rays, or menarchal status were included. Coronal and sagittal radiographic parameters were recorded at both brace- initiation and -termination. Patients were followed until surgery or one year after brace termination. Results were compared to a published cohort of full-time braced patients.
Results
One hundred forty-six patients were included. Maximum thoracic kyphosis (TK) increased 2.5° (± 9.7) (
p
= 0.003), corresponding to a 3.5-fold relative risk increase post bracing in TK compared to a full-time brace cohort. Twenty-seven percent (
n
= 36) of the patients were hypokyphotic (T4/T12 < 20°) at brace initiation compared with 19% (
n
= 26) at brace termination (
p
= 0.134). All other sagittal parameters remained the same at follow-up. We found no association between progression in the coronal plane and change in sagittal parameters.
Conclusion
This is the first study to indicate that night-time bracing of AIS does not induce hypokyphosis. We found a small increase in TK, with a substantially lower risk of developing flat back deformity compared to full-time bracing. The coronal curve progression was not coupled to a change in TK.
Low back pain (LBP) is a common cause of impaired quality of life and disability and studies regarding surgical management of patients with LBP show a high variation in patient-reported success rate.
...To find valuable preoperative clinical risk factors and variables associated with a non-satisfactory patient-reported outcome following surgery.
The Danish surgical spine database (DaneSpine) was used to collect eight years of pre- and postoperative data on patients undergoing single-level fusions with either posterior- (PLIF) or transforaminal lumbar interbody fusions (TLIF). The primary outcome was patient nonsatisfaction. We collected data on European Quality of Life–5 Dimensions (EQ-5D), visual analogue scale (VAS), Oswestry Disability Index (ODI) score, pain intensity, duration of back pain, previous discectomy, and expectations regarding return to work after surgery at 2-year follow-up.
The cohort included 453 patients of which 19% reported treatment nonsatisfaction. The nonsatisfaction group demonstrated higher preoperative VAS scores for back pain (75 ± 19 vs. 68 ± 21, p = 0.006) and leg pain (65 ± 25 vs. 58 ± 28, p = 0.004). The preoperative EQ-5D score was significantly lower in the nonsatisfaction group (0.203 + 0.262 vs. 0.291 ± 0.312, p = 0.016). There was no statistical significance between patient nonsatisfaction and preoperative ODI score, age, body mass index, duration of back pain or expectations regarding return to work after surgery.
Low preoperative EQ-5D scores and high VAS leg and back pain scores were statistically significant with patient nonsatisfaction following surgery and may prove to be valuable tools in the preoperative screening and alignment of patient expectations.
•One of the common causes of impaired health-related quality of life and disability is low back pain (LBP).•Overall, chronic LBP-induced disability has a major impact on millions of patient lives.•The specific surgical technique does not appear to affect the long-term patient-reported outcomes (PROs) but studies on lumbar fusion show a high variation in patient-reported success rate.•Low preoperative EQ-5D scores and high VAS leg and back pain scores were statistically significant with patient nonsatisfaction following surgery.
Purpose
Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of adolescent idiopathic scoliosis (AIS). The Scoliosis Research ...Society recommends bracing for Risser stages 0–2 as Risser stage 3 or above is considered low risk. Very few studies have assessed the risk of progression during bracing in Risser stages 3–4. The objective of the current study is to determine if Risser stages 3–4 provide a meaningful cutoff in terms of progression risk in patients with AIS treated with night-time bracing.
Methods
AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25 and 40 degrees and Risser stages 0–4 were retrospectively included. Curve progression (> 5 degrees increase) was monitored until surgery or SM. Skeletal maturity was defined as either 2 years postmenarchal, no height development or closed ulnar epiphyseal plates on radiographs.
Results
One hundred and thirty-five patients were included (Risser stages 0–2:
n
= 86 and 3–4:
n
= 49). Overall, radiographic curve progression occurred in 52% while progression beyond 45 degrees was seen in 35%. The progression rate in the Risser 0–2 group was 60% and 37% in the Risser 3–4 group (
p
= 0.012). In multivariate logistic regression analysis, adjusted for Risser stages and age, only premenarchal status showed a statistically significant association with progression (OR: 2.68, 95%CI 1.08–6.67).
Conclusion
Risser stage does not provide a clinically meaningful differentiation of progression risk in AIS patients treated with a night-time brace. Risk assessment should include other more reliable measures of skeletal growth potential.
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