Pain in the sacroiliac joint may be caused by abnormal joint motion. Diagnosis is mainly based on clinical tests. The aims of this study were to examine whether low-dose computed tomography with ...provocation of the hip could detect sacroiliac joint motion, and to study whether provocation of the hip results in greater sacroiliac joint motion in the ipsilateral than in the contralateral sacroiliac joint.
12 patients with sacroiliac joint pain were examined with low-dose computed tomography scans of the sacroiliac joint, one with the hips in the neutral position, and one each in provocation with the left or the right hip in a figure-of-4 position. Accuracy was tested by comparing internal rotation of the sacrum with internal rotation in the sacroiliac joint. Motion in the sacroiliac joint was assessed by comparing the position of each of the ilia with the reference, the sacrum. Data is shown as mean with 95% confidence interval (CI).
We observed greater motion in the sacroiliac joint than internally in the sacrum, i.e., 0.57° (CI 0.43-0.71) vs. 0.20° (CI 0.11-0.28). The motion of the geometric center of the moving object for the sacroiliac joint was larger on the provoked side; mean difference 0.17 mm (CI 0.01-0.33), P = 0.04. Corresponding figures for rotation were mean difference 0.19° (CI 0.10-0.28), P < 0.001. Compared with the sacrum, the largest motion was seen at the anterior superior iliac spine; mean difference 0.38 mm (CI 0.10-0.66), P = 0.001.
Provocation in the figure-of-4 position of the hip results in sacroiliac joint motion measurable with computed tomography motion analysis. Provocation of the hip induces larger motion on the ipsilateral than on the contralateral sacroiliac joint.
Introduction
Idiopathic scoliosis is the most common spinal deformity in children. Treatment strategies aim to halt progression of the curve. Patients are treated mainly with thoracolumbosacral ...orthosis (TLSO) if indicated. This form of brace treatment has been shown to be cumbersome and tough on growing individuals. However, computer aided design and manufactured (CAD/CAM) braces might increase comfortability and ultimately outcome if compliance is improved. In a multicenter, randomized controlled trial, we aim to compare CAD/CAM designed Boston 3D-brace to standard Boston brace.
Methods
Subjects: 170 previously untreated and skeletally immature children diagnosed with idiopathic scoliosis, aged 9–17 years of age (curve magnitude Cobb 25–40 degrees) will be included. Interventions: Both groups will receive a physical activity prescription according to the World Health Organization recommendations. Randomization will be performed 1:1 to a 3D CAD/CAM designed Boston 3D-brace or a standard Boston brace, both with prescribed daily wear time of 20 hours. Outcome: The subjects will participate in the study until curve progression or until skeletal maturity. The primary outcome variable is failure of treatment, defined as progression of the Cobb angle more than 6 degrees compared to the baseline x-ray. The progression is confirmed if seen on two consecutive standing spinal x-rays. Radiographs will be taken at each six-month follow-up. Secondary outcome measures include patient and clinical reported outcomes, including number of individuals requiring surgical intervention.
Discussion
This study will show if efficacy in brace treatment can be improved with new brace designs.
Trial registration
The protocol has been registered on ClinicalTrials.gov, identifier:
NCT04805437
.
Studies suggest increased revision risk of total hip arthroplasty (THA) in individuals with lumbar spinal fusion, but studies including non-fused individuals are lacking. We aimed to investigate ...whether individuals undergoing lumbar spinal stenosis surgery with or without fusion are at an increased risk of reoperation before or after THA.
The Swedish Spine Register and the Swedish arthroplasty register were searched from 2000 through 2021. Chi-square, Kaplan-Meier and binary multivariate logistic regression were used to compare reoperation rates up to 10 years after THA surgery.
7,908 individuals had undergone lumbar spinal stenosis surgery (LSSS) (fusion n = 1,281) and THA. LSSS before THA compared with THA-only controls was associated with a higher risk of THA reoperations: 87 (2%) out of 3,892 vs. 123 (1%) out of 11,662 (P < 0.001). LSSS after THA compared with THA-only controls was not associated with a higher risk of reoperation, confirmed by Kaplan- Meier analyses and binary multivariate logistic regression. Mortality was lower in individuals undergoing both LSSS and THA, regardless of procedure order. There was no difference in THA reoperations in individuals who had undergone LSSS before THA without fusion or with fusion. The individuals who had undergone LSSS after THA with fusion had an increased risk of THA reoperation compared with those without fusion.
LSSS with or without fusion before THA is associated with an increased risk of THA reoperation. Spinal fusion increased the risk of reoperation of THA when performed after THA.
Background and purpose - The sacroiliac joint is increasingly recognized as a cause of pain in 15-30% of patients with low back pain. Nonoperative management is not always successful and surgical ...treatment with fusion of the joint is increasingly recommended. According to the literature, minimally invasive fusion reduces pain and improves function compared with nonoperative treatment. It is, however, unclear to what extent the placebo effect influences these results.
Patients and methods - The trial is designed as a prospective multi-center, double-blind, randomized sham-surgery controlled trial with 2 parallel groups. 60 patients with a suspected diagnosis of sacroiliac joint pain confirmed with sacroiliac joint injection are included according to the trial inclusion criteria. Patients are randomized with a 1:1 allocation into 2 groups of 30 patients each. The primary end-point is group difference in sacroiliac joint pain intensity on the operated side at 6 months postoperatively, measured by the Numeric Rating Scale. The main objective is to examine whether there is a difference in pain reduction between patients treated with a minimally invasive fusion of the sacroiliac joint compared with patients undergoing a sham operation.
Results - Unblinding occurs after the completed 6-month follow-up. The primary analysis will be performed when all patients have completed 6 months' follow-up. Follow-ups are continued to at least 2 years postoperatively. Data from the different groups will be compared based on the "intention to treat" principle.
Background and purpose: There is conflicting evidence regarding treatment outcomes after minimally invasive sacroiliac joint fusion for long-lasting severe sacroiliac joint pain. The primary aim of ...our cohort study was to investigate change in patient-reported outcome measures (PROMs) after minimally invasive sacroiliac joint surgery in daily practice in the Swedish Spine Registry. Secondary aims were to explore the proportion of patients reaching a patient acceptable symptom score (PASS) and the minimal clinically important difference (MCID) for pain scores, physical function, and health-related quality of life outcomes; furthermore, to evaluate self-reported satisfaction, walking distance, and changes in proportions of patients on full sick leave/disability leave and report complications and reoperations.Methods: Data from the Swedish Spine Registry was collected for patients with first-time sacroiliac joint fusion, aged 21 to 70 years, with PROMs available preoperatively, at 1 or 2 years after last surgery. PROMs included Oswestry Disability Index (ODI), Numeric Rating Scale (NRS) for low back pain (LBP) and leg pain, and EQ-VAS, in addition to demographic variables. We calculated mean change from pre- to postoperative and the proportion of patients achieving MCID and PASS.Results: 68 patients had available pre- and postoperative data, with a mean age of 45 years (range 25–70) and 59 (87%) were female. At follow-up the mean reduction was 2.3 NRS points (95% confidence interval CI 1.6–2.9; P < 0.001) for LBP and 14.8 points (CI 10.6–18.9; P < 0.001) for ODI. EQ-VAS improved by 22 points (CI 15.4–30.3, P < 0.001) at follow-up. Approximately half of the patients achieved MCID and PASS for pain (MCID NRS LBP: 38/65 59% and PASS NRS LBP: 32/66 49%) and physical function (MCID ODI: 27/67 40% and PASS ODI: 24/67 36%). The odds for increasing the patient’s walking distance to over 1 km at follow-up were 3.5 (CI 1.8–7.0; P < 0.0001), and of getting off full sick leave or full disability leave was 0.57 (CI 0.4–0.8; P = 0.001). In the first 3 months after surgery 3 complications were reported, and in the follow-up period 2 reoperations.Conclusion: We found moderate treatment outcomes after minimally invasive sacroiliac joint fusion when applied in daily practice with moderate pain relief and small improvements in physical function.
The treatment for patients with thoracolumbar burst fractures without neurological deficit or complete rupture of the posterior ligament complex (PLC) is controversial and includes both surgical and ...non-surgical options. Current evidence on which treatment is optimal remains inconclusive. In this study we compare surgical with non-surgical treatment.
The study is a nationwide, multicenter, register-based randomized controlled trial (R-RCT). Patients with a thoracolumbar burst fracture will be identified by the Swedish Fracture Register. The admitting physician will be notified during the registration process and the patient will be screened for eligibility. Patients, 18 to 66 years old without neurologic deficit to more than a single nerve root and without complete rupture of the PLC, are eligible for the study. 202 patients will be randomized in a 1:1 relation to either surgical or non-surgical treatment. Patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI) and radiological data, will be collected at the time of injury, after 3-4 months, and after 1 year. Additional data from national health registries will be collected after 1 year.
The primary outcome is the ODI 1 year after injury. Secondary outcomes include additional PROMs, adverse events, drug consumption, sick leave, healthcare consumption, and imaging data.
The primary outcome is the ODI 1 year after injury. Secondary outcomes include additional PROMs, adverse events, drug consumption, sick leave, healthcare consumption, and imaging data. Estimated duration - The study started on September 1, 2021 and will continue for approximately 4 years. Trial registration - The trial is registered at www.clinicaltrials.com, NCT05003180.
Adults treated surgically for lumbar disc herniation in adolescence have a higher degree of lumbar disc degeneration than controls. We aimed to establish whether the degree of lumbar degeneration ...differs at diagnosis or at follow-up between surgically and non-surgically treated individuals.
We identified individuals with a lumbar disc herniation in adolescence diagnosed with magnetic resonance imaging (MRI) and contacted them for follow-up MRI. Lumbar degeneration was assessed according to Pfirrmann, Modic, and total end plate score (TEP score). Patient-reported outcome measures at follow-up comprised the Oswestry Disability Index (ODI), EQ-5D-3-level version, 36-Item Short Form Health Survey (SF-36), and Visual Analogue Scale (VAS) for back and leg pain. Fisher's exact test, Mann-Whitney U tests, Wilcoxon tests, and logistic regression were used for statistical analysis.
MRIs were available at diagnosis and after a mean of 11.9 years in 17 surgically treated individuals and 14 non-surgically treated individuals. Lumbar degeneration was similar at diagnosis (P = 0.2) and at follow-up, with the exception of higher TEP scores in surgically treated individuals at levels L4-L5 and L5-S1 at follow-up (P ≤ 0.03), but this difference did not remain after adjustment for age and sex (P ≥ 0.8). There were no significant differences in patient-reported outcome measures between the groups at follow-up (all P ≥ 0.2).
Adolescents with a lumbar disc herniation have, irrespective of treatment, a similar degree of lumbar degeneration at the time of diagnosis, and similar lumbar degeneration and patient-reported outcomes at long-term follow-up.
The Swedish Fracture Register (SFR) is a national quality register for all types of fractures in Sweden. Spine fractures have been included since 2015 and are classified using a modified AOSpine ...classification. The aim of this study was to determine the accuracy of the classification of thoracolumbar burst fractures in the SFR.
Assessments of medical images were conducted in 277 consecutive patients with a thoracolumbar burst fracture (T10-L3) identified in the SFR. Two independent reviewers classified the fractures according to the AOSpine classification, with a third reviewer resolving disagreement. The combined results of the reviewers were considered the gold standard. The intra- and inter-rater reliability of the reviewers was determined with Cohen's kappa and percent agreement. The SFR classification was compared with the gold standard using positive predictive values (PPV), Cohen's kappa and percent agreement.
The reliability between reviewers was high (Cohen's kappa 0.70-0.97). The PPV for correctly classifying burst fractures in the SFR was high irrespective of physician experience (76-89%), treatment (82% non-operative, 95% operative) and hospital type (83% county, 95% university). The inter-rater reliability of B-type injuries and the overall SFR classification compared with the gold standard was low (Cohen's kappa 0.16 and 0.17 respectively).
The SFR demonstrates a high PPV for accurately classifying burst fractures, regardless of physician experience, treatment and hospital type. However, the reliability of B-type injuries and overall classification in the SFR was found to be low. Future studies on burst fractures using SFR data where classification is important should include a review of medical images to verify the diagnosis.
Abstract
Adolescent idiopathic scoliosis (AIS) is the most common musculoskeletal disorder of childhood development. The genetic architecture of AIS is complex, and the great majority of risk factors ...are undiscovered. To identify new AIS susceptibility loci, we conducted the first genome-wide meta-analysis of AIS genome-wide association studies, including 7956 cases and 88 459 controls from 3 ancestral groups. Three novel loci that surpassed genome-wide significance were uncovered in intragenic regions of the CDH13 (P-value_rs4513093 = 1.7E-15), ABO (P-value_ rs687621 = 7.3E-10) and SOX6 (P-value_rs1455114 = 2.98E-08) genes. Restricting the analysis to females improved the associations at multiple loci, most notably with variants within CDH13 despite the reduction in sample size. Genome-wide gene-functional enrichment analysis identified significant perturbation of pathways involving cartilage and connective tissue development. Expression of both SOX6 and CDH13 was detected in cartilage chondrocytes and chromatin immunoprecipitation sequencing experiments in that tissue revealed multiple HeK27ac-positive peaks overlapping associated loci. Our results further define the genetic architecture of AIS and highlight the importance of vertebral cartilage development in its pathogenesis.
Background and purpose - Emerging evidence from sham-controlled trials suggest that surgical treatment entails substantial non-specific treatment effects in addition to specific surgical effects. ...Yet, information on surgeons' actual behaviors and beliefs regarding non-specific treatment and placebo effects is scarce. We determined surgeons' clinical behaviors and attitudes regarding placebo effects.
Methods - A national online survey was developed in collaboration with surgeons and administered via an electronic link.
Results - All surgical clinics in Sweden were approached and 22% of surgeons participated (n = 105). Surgeons believed it was important for them to interact and build rapport with patients before surgery rather than perform surgery on colleagues' patients (90%). They endorsed the importance of non-specific treatment effects in surgery generally (90%) and reported that they actively harness non-specific treatment effects (97%), including conveying confidence and calm (87%), building a positive interaction (75%), and making eye contact (72%). In communication regarding the likely outcomes of surgery, surgeons emphasized accurate scientific information of benefits/risks (90%) and complete honesty (63%). A majority felt that the improvement after some currently performed surgical procedures might be entirely explained by placebo effects (78%). Surgeons saw benefits with sham-controlled surgery trials, nevertheless, they were reluctant to refer patients to sham controlled trials (46%).
Interpretation - Surgeons believe that their words and behaviors are important components of their professional competence. Surgeons saw the patient-physician relationship, transparency, and honesty as critical. Understanding the non-specific components of surgery has the potential to improve the way surgical treatment is delivered and lead to better patient outcomes.
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