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Purpose: In the treatment of patients with adult spinal deformity, analysis of spinopelvic balance is essential in clinical assessment and surgical planning. There is currently no gold standard for measurement, whether done by hand or with digital software. New semi-automated software exists that purports to increase efficiency, but its reliability is unknown in the literature. Methods: Full spine X-rays were retrospectively reviewed from 25 adult patients seen between 2014 and 2017. Patients were included if they had > 5 cm of sagittal imbalance and radiographs of sufficient quality to perform balance measurements, without prior surgical spinal fusion and/or instrumentation. Spinopelvic parameters were measured in two radiographic programs: one with basic, non-spine-specific measurement tools (eUnity, Client Outlook, Waterloo, Canada); and a second with spine-specific semi-automated measurement tools (Sectra, Sectra AB, Linköping, Sweden). Balance parameters included SVA, PI, PT, and LL. Data were compared by examining inter-rater and inter-program reliability using interclass correlation coefficient (ICC). Results: The subjects’ mean age was 67.9 ± 13.8 years old, and 32% were male. The inter-program reliability was strong, with ICC values greater than 0.91 for each parameter. Similarly, there was strong inter-observer reliability with ICC values greater than 0.88. These results persisted on delayed repeat measurement (p< 0.001 for all measurements). Conclusion: There is excellent inter-observer and inter-program reliability between the basic PACS and semi-automated programs. These data demonstrate that the purported efficiency of semi-automated measurement programs does not come at the cost of measurement reliability.

Study Design: Retrospective cohort study. Objectives: Assess differences between staged (=3 days) and same-day surgery in perioperative factors, radiographic measures, and complications. Summary of Background Data: Surgical adult spinal deformity correction may require combined anterior and posterior approaches. To modulate risk, some surgeons perform surgery that is expected to be longer and/or more complex in two stages. Prior studies comparing staged (=7 days) and same-day surgery demonstrated mixed results and none have examined results with shorter staging intervals. Methods: Retrospective review of adults undergoing combined anterior/posterior approaches for spinal deformity over a 3-year period at a single institution (n=92). Univariate differences between staged and same-day surgery were assessed with chi-squared, Fisher exact, and Mann-Whitney Utests. Generalized estimating equations assessed whether differences in perioperative outcomes between groups remained after adjusting for differences in demographic and surgical characteristics. Results: In univariate analyses, staged surgery was associated with a length of stay (LOS) 3 days longer than same-day surgery (9.2 vs. 6.3 days, p< .001), and greater operative time, blood loss, transfusion requirement, and days in intensive care unit (p< .001 for each). Staged surgery had a higher rate of thrombotic events (p= .011) but did not differ in readmission rates or other complications. Radiographically, improvements in Cobb angle (average 13° vs. 17°, p= .028), lumbar lordosis (average 14° vs. 23°, p= .019), and PI-LL mismatch (average 10° vs. 2° p= .018) were greater for staged surgery, likely related to more extensive use of osteotomies in the staged group. Conclusions: Although univariate analysis of our results were in accordance with previously published works, multivariate analysis allowing individual case risk adjustment revealed that LOS was not significantly increased in the staged group as reported in previous studies. There was no difference in infection rates as previously described but an increase in thrombotic events was observed. Level of Evidence: Level III.

We asked the following questions: 1. Does the use of an structured review instrument (SRI) at journal club increase presentation quality, as measured objectively by a standardized evaluation rubric? 2. Does SRI use increase the time required to prepare for journal club? 3. Does SRI use positively impact presenter perceptions about confidence while presenting, satisfaction, and journal club effectiveness, as measured by postparticipation surveys?

To explore changes in the phenotypic features of Sjögren's syndrome (SS), and in SSstatus among participants in the Sjögren's International Collaborative Clinical Alliance (SICCA) registry over a 2–3‐year interval. All participants in the SICCAregistry who were found to have any objective measures of salivary hypofunction, dry eye, focal lymphocytic sialadenitis in minor salivary gland biopsy, or anti‐SSA/SSBantibodies were recalled over a window of 2 to 3 years after their baseline examinations to repeat all clinical examinations and specimen collections to determine whether there was any change in phenotypic features and in SSstatus. As of September 15, 2013, a total of 3,514 participants had enrolled in SICCA, and among 3,310 eligible, 771 presented for a followup visit. Among participants found to have SSusing the 2012 American College of Rheumatology (ACR) classification criteria, 93% again met the criteria after 2 to 3 years, and this proportion was 89% when using the 2016 ACR/European League Against Rheumatism (EULAR) criteria. Among those who did not meet ACRor ACR/EULARcriteria at baseline, 9% and 8%, respectively, had progressed and met them at followup. Those with hypergammaglobulinemia and hypocomplementemia at study entry were, respectively, 4 and 6 times more likely to progress to SSby ACRcriteria than those without these characteristics (95% confidence interval 1.5–10.1 and 1.8–20.4, respectively). While there was stability over a 2–3‐year period of both individual phenotypic features of SSand of SSstatus, hypergammaglobulinemia and hypocomplementemia at study entry were predictive of progression to SS.

Overgrowth of epidural fat, known as spinal epidural lipomatosis (SEL), can cause symptomatic compression of the spinal cord, conus medullaris, or cauda equina. Suggested predisposing factors such as obesity, steroid use, and diabetes mellitus have been based on a few reported cases, many of which were not surgically confirmed. There is a paucity of epidemiological data in surgically confirmed cases for this disorder. The purpose of this independently reviewed, retrospective, matched cohort analysis was to compare the demographics and incidence of comorbidities of patients who underwent lumbar decompression for SEL vs degenerative stenosis without SEL. Two surgeons' databases were reviewed to identify patients older than 18 years who underwent decompression surgery for magnetic resonance imaging–verified, symptomatic lumbar SEL. A matched control group comprised an equal number of patients with degenerative stenosis (n=14). Demographic data, body mass index, symptom type/duration, comorbidities, complications, treatment history, and associated pathology were collected from medical records. Previously suggested risk factors, such as obesity, endocrinopathy, and epidural steroid injections, were not significantly different between the SEL and control groups. Furthermore, there were no differences in operative times, complications, or blood loss. The only noted difference between the 2 groups was the preoperative duration of symptoms, on average double in patients with SEL. This series represents the largest of its kind reported to date. Because symptom duration was the only difference noted, it is postulated to be the result of lack of awareness of SEL. Future prospective study in a larger group of patients is warranted. [Overgrowth of epidural fat, known as spinal epidural lipomatosis (SEL), can cause symptomatic compression of the spinal cord, conus medullaris, or cauda equina. Suggested predisposing factors such as obesity, steroid use, and diabetes mellitus have been based on a few reported cases, many of which were not surgically confirmed. There is a paucity of epidemiological data in surgically confirmed cases for this disorder. The purpose of this independently reviewed, retrospective, matched cohort analysis was to compare the demographics and incidence of comorbidities of patients who underwent lumbar decompression for SEL vs degenerative stenosis without SEL. Two surgeons' databases were reviewed to identify patients older than 18 years who underwent decompression surgery for magnetic resonance imaging–verified, symptomatic lumbar SEL. A matched control group comprised an equal number of patients with degenerative stenosis (n=14). Demographic data, body mass index, symptom type/duration, comorbidities, complications, treatment history, and associated pathology were collected from medical records. Previously suggested risk factors, such as obesity, endocrinopathy, and epidural steroid injections, were not significantly different between the SEL and control groups. Furthermore, there were no differences in operative times, complications, or blood loss. The only noted difference between the 2 groups was the preoperative duration of symptoms, on average double in patients with SEL. This series represents the largest of its kind reported to date. Because symptom duration was the only difference noted, it is postulated to be the result of lack of awareness of SEL. Future prospective study in a larger group of patients is warranted. [Orthopedics.2016; 39(3):163–168.]

Retrospective radiographic study.

There is little consensus regarding the surgical management of adult spine deformity (ASD) because of its variable presentation and lack of accepted standardized surgical indications and classifications. The objective of this study was to evaluate factors influencing surgeons' decision making regarding ASD based on patient clinical and radiographic data.

Introduction: There is little consensus regarding the surgical management of adult spine deformity (ASD) because of its variable presentation and lack of accepted standardized surgical indications and classifications. The objective of this study was to evaluate factors influencing surgeons’ decision making regarding ASD based on patient clinical and radiographic data. Methods: A total of 28 international adult deformity surgeons were asked to complete an online survey of 10 spinal deformity cases. Case presentation included a clinical vignette with photographs, Oswestry Disability Index, and visual analog scores and imaging with 3-feet biplanar spinal radiographs with radiographic measurements. For each case, surgeons were asked whether surgical management would be beneficial, and to grade the factors influencing their decision according to a Likert scale. Descriptive statistics were used to evaluate surgeon demographics, surgical decision, and factors influencing it. Intra-observer and inter-observer reliability were studied using kappa statistics for the appropriateness of surgery and intra-class correlation coefficient statistics for factors influencing surgical decision. Results: The intra-rater and inter-rater reliability in surgeons’ decision-making process were evaluated to kappa values of 0.48 and 0.17, respectively, representing moderate and no agreement. The highest recommendation among surgeons (84.14%) regarding the beneficial effect of surgery was found for cases with severe deformities and cases with neurology. In severe deformity cases, balance was the most important factor in decision making, whereas in deformity cases with neurologic manifestations, neurology was the most important factor. In general, balance and functional status were the most important factors. Inter- and intra-rater agreement on factors importance was good (0.65 and 0.72, respectively). Conclusions: Agreement between surgeons about the factors influencing surgical decision was good, and about the need for surgery was poor. Yet, each surgeon seemed relatively consistent about the consideration given to factors leading to a surgical decision for a given ASD patient.

Rotatory olisthesis is a common finding of adult degenerative scoliosis. An in vitro model of rotatory olisthesis of the lumbar spine and its correlation with the center of rotation (COR) and lumbosacral lordosis (L3–S1) are presented.

Introduction: Rotatory olisthesis is a common finding of adult degenerative scoliosis. An in vitro model of rotatory olisthesis of the lumbar spine and its correlation with the center of rotation (COR) and lumbosacral lordosis (L3–S1) are presented. Methods: Different centers of rotation and various angles of lumbosacral lordosis were tested for the production of rotatory olisthesis. The radiological finding of rotatory scoliosis was excacerbated with the center of rotation lying in the posterior column and with a normo-lordotic or hyperlordotic lumbosacral spine. Twenty-one synthetic models of L3—sacrum with simulation of certain anatomic restraints (ligaments and capsules) and disc disruption at L4–L5 were used. The COR was reproduced at the anterior, middle, or posterior column. A combination of a constant axial load at the lateral side of the upper vertebra and a similar size contralateral-side horizontal axial rotation force at the level of L4 vertebral body were applied to produce a rotatory olisthesis. The loaded specimens were immobilized at the end of the dynamic procedure and were imaged in two planes by fluoroscopy. The lateral and anteroposterior olisthesis at L4–L5 levels as well as L3–L5 scoliotic, L3–S1 lordotic Cobb angles and L4–L5 intervertebral rotation were measured. Results: The radiologic finding of rotatory olisthesis (translation = 1mm with rotation) appeared in the spinal units with the COR in the posterior column, although olisthesis was less than 1mm in specimens with the COR in the anterior or middle column. With COR in the posterior column and 40° to 60° of L3–SI lordosis, rotatory olisthesis at the L4–L5 level was produced with anteroposterior olisthesis as the main component (p <.05). In specimens with 20° to 40° lordosis, lateral olisthesis was the main component of rotatory olisthesis (p <.05), and in less than 20° lordosis, rotatory olisthesis was minimum (translation less than 1 mm). Conclusion: During an in vitro study for the appearance of rotatory olisthesis in the lumbar spine, the COR has been identified to lie in the posterior elements. The main component of rotatory olisthesis is anteroposterior olisthesis and lateral olisthesis in normolordotic and hypolordotic lumbosacral spine, respectively. The described model of rotatory olisthesis in the lumbar spine may serve as a guide for the formation of this deformity and can be the base for future research in the treatment of rotatory olisthesis in degenerative lumbar scoliosis.

Controlled experimental study.

Multinational survey of spine trauma surgeons.

A prospective study was performed in 8 patients with severe ankylosing spondylitis.

A biomechanical comparison of fixation constructs in an experimental fracture model.

Bioresorbable plates have recently been used with anterior cervical discectomy and fusion (ACDF). Compared with metallic plates, bioresorbable plates provide segmental stabilization with minimal imaging artifact, eventual resorption, and increased load sharing. The objectives of the present study were to determine whether a bioresorbable plate can withstand simulated physiologic static and cyclic loading, to compare the reduction in flexibility provided by bioresorbable and titanium plates, and to quantify load sharing between the plate and spine with graft. Sixteen human cervical motion segments were tested to ±2.5 Nm in flexion-extension, lateral bending, and axial rotation. Range of motion (ROM) was measured (1) in the intact state, (2) with ACDF without plating, (3) after addition of either a bioresorbable or titanium plate, and (4) after 500 cycles of combined flexion-extension and axial torsion. Load sharing was evaluated by applying the same fixed rotation both without and with the plate, and was calculated as the moment resisted by the uninstrumented ACDF expressed as a percentage of the plated ACDF state. No plate failures or graft migration occurred during testing. Compared with the uninstrumented ACDF, bioresorbable plates reduced mean ROM by 49 in flexion-extension and 25 in lateral bending, with very little change in torsion. Titanium plates reduced uninstrumented ACDF ROM by 69 in flexion-extension, 45 in lateral bending, and 27 in torsion. Differences between bioresorbable and titanium plates were significant in flexion-extension and lateral bending. Cyclic loading did not significantly change ROM for either plate. More moment was shared in lateral bending by the spinegraft with bioresorbable plates (78) compared with titanium plating (63). Bioresorbable plates contained an intervertebral graft, provided some stabilization, remained intact throughout the simulated immediate postoperative loading, and shared more load with the graft and osteoligamentous spine than titanium plates.

Objective. To assess the efficacy and safety of the fully human recombinant monoclonal anti-TNF antibody adalimumab in routine clinical practice, including comparison of patients with and without previous anti-TNF exposure.Methods. We prospectively studied the outcome of 70 rheumatoid arthritis patients treated with adalimumab in normal clinical practice. The primary outcome measures were Disease Activity Score 28 (DAS28), EULAR (European League Against Rheumatism) response and Health Assessment Questionaire (HAQ).Results. Seventy-seven per cent achieved a EULAR response (26% good, 51% moderate) and 19% were in remission. The mean decrease in DAS28 was 2.1 (6.3–4.2; P<0.001). The mean decrease in HAQ score was 0.34 (2.07–1.73; P<0.001), 66% achieving a clinically significant decrease of greater than 0.22. Twenty-three per cent stopped treatment because of side-effects (7%) or failure to respond (16%). Of the 26 patients who had previously tried 29 biologicals, 65% responded to adalimumab. There was no significant difference in the change in mean DAS (P = 0.69) or HAQ (P = 0.88) between groups with and without previous anti-TNF exposure. Of the 13 patients with previous secondary failure to infliximab, 77% responded to adalimumab. Patients with previous secondary failure had significantly better improvement in DAS (P = 0.023) than patients with previous primary failure.Conclusion. Our clinical experience confirms that adalimumab is effective and safe in the treatment of RA. It also shows adalimumab is effective in patients with previous biological failures, particularly patients with secondary failure to infliximab.

Objectives. To determine, by consensus, the optimal use of leflunomide in rheumatoid arthritis (RA), using a multidisciplinary panel of experts and performing meta-analyses of available dataMethods. A multidisciplinary panel of experts in RA was convened. Important questions, pertinent to the use of leflunomide in the treatment of RA, were defined by consensus at an initial meeting. Each question was allocated to subgroups of two or three members, who worked separately to prepare a balanced opinion, based on published literature, data from individual patients taking part in phase II and phase III clinical trials provided by Aventis, and data from a USA-based medical claims database (AETNA). The full group then reconvened to agree on an overall consensus statement. Recommendations concerning efficacy and tolerability versus comparator drugs and placebo were derived from two new meta-analyses.Results. Leflunomide was at least as effective as sulphasalazine and methotrexate, and equally well tolerated on meta-analysis of trial data. Overall withdrawal rates for all adverse events were similar for all three drugs. Avoidance of the loading dose reduces ‘nuisance’ side-effects (e.g. nausea), but probably delays the onset of action. Adverse events could usually be managed by dose reduction and/or symptomatic therapy.Conclusions. On the basis of efficacy, safety and cost, leflunomide should be considered in patients with RA who have failed first-line DMARD drug therapy. In refractory cases, leflunomide may be used in combination with, for example, methotrexate before biological agents. Therapy should be initiated by a specialist, but repeat prescribing in general practice on a shared care basis is acceptable using agreed protocols. Clear mechanisms are required to monitor toxicity, with good communication between the patient and rheumatologist to manage nuisance side-effects and avoid unnecessary discontinuation of leflunomide.

Superior mesenteric artery (SMA) syndrome is well described in the pediatric literature; however, to date, it has not been described in an adult individual undergoing correction of thoracic kyphosis. Medical history, physical findings, and the results of imaging studies were analyzed to describe the patient’s onset of gastrointestinal obstruction following surgical correction of thoracic kyphosis. The postoperative course was marked by the onset of nausea and vomiting on postoperative day 24. The patient was admitted to the hospital, and the small bowel follow-through study showed blockage of the third portion of the duodenum at the level of the SMA. Oral intake was restricted, and total parenteral nutrition was instituted with complete resolution of her symptoms. At 1 year postoperatively, the patient was symptom-free. Although vascular compression of the duodenum with subsequent nausea and vomiting and electrolyte imbalance, caused by the relative lengthening of the spine, is most commonly associated with surgical correction of coronal plane deformities (ie, scoliosis), it may occur in patients undergoing correction of thoracic kyphosis as well. SMA syndrome is a well known potential complication in adolescents, and it should also be taken into consideration in adults undergoing deformity correction. Early institution of general medical measures of nasogastric suction, oral intake restriction, and intravenous alimentation can be successful.

Few data exist comparing the surgical and nonsurgical treatment of coccygodynia. We sought to retrospectively review our experience with coccygectomy compared with injections for the relief of coccygodynia to determine rates of success and patient satisfaction and identify complications.

Little is known about the natural history of spinal alignment as it ages into the eighth and ninth decades. Fifty asymptomatic volunteers 70–85 years of age (mean 76 years) without any history of spine pain, trauma, or deformity were radiographed in the standing lateral position, from C7 to the pelvis including the hips. Measurements included segmental angulations, kyphosis, lordosis, and C7 plumb line balance. In addition, measurements of sagittal pelvic balance were made (pelvic incidence, tilting, sacral slope, and S1 overhang). Average kyphosis was 52° (range 29° to 79°); the average lordosis was −57° (range −96° to −20°). The C7 plumb line on average fell 40 mm anterior to the posterosuperior corner of S1. The anterior positioning of C7 was also positively correlated with age and decreasing lordosis. This provides further data into the natural history of the aging spine.

Retrospective study of patients after extension of previous scoliosis fusions to the pelvis.

A biomechanical study of the rigidity of various scoliosis constructs instrumented with and without caudal pedicle screw anchors and with none, one, or two cross-link devices.

The authors studied the rotational effect of sublaminar wiring on the spinal pelvic axis on 20 patients who were being treated for adolescent idiopathic scoliosis.

Magnetic resonance imaging was used to determine the natural history of asymptomatic thoracic disc herniations.

The postoperative course of patients who developed a pulmonary embolus after thoracolumbar or lumbar spinal fusion treated with heparin was studied to quantify the morbidity risk of anticoagulation.

An experimental animal study using an established technique for measuring in vivomotion in canines was designed to improve measurement techniques and to eliminate the effects of the instrument mounting technique on the tissue and subsequently on the motion being measured.

Eighteen patients with adolescent idiopathic scoliosis treated with ISOLA instrumentation and 13 treated with CotrelDubousset instrumentation were studied before and after surgery with computed tomography scans.

A retrospective review of late pelvic ring fractures after long spine fusions to the lumbosacral spine.

A retrospective review of 15 patients with Down syndrome who had undergone arthrodesis of the upper cervical spine for instability.

This study is a biomechanical study on human cadaver pelves using strain gauges to measure strains at different locations in response to different load states.

Following gastric resection a slightly reduced haemoglobin is common. The use of erythrocyte morphology as a screening test for deficient absorption of haematinics is unsatisfactory; false positive (42.8%) and false negative (41.6%) results are encountered too frequently to recommend its use. The elderly postgastrectomy patient with mild anaemia may have biochemical evidence of iron, folic acid, or vitamin B12 deficiency with normal erythrocyte morphology.

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Retrospective cohort study.