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SummaryThis study evaluated the use of low-dose chest computed tomography (LDCT) for detecting bone fragility. LDCT-measured vertebral bone attenuation by volumetric methods showed good correlation with bone mineral density (BMD) measured by dual-energy x-ray absorptiometry (DXA, and good diagnostic performance for identifying osteoporosis and compression fractures. The results of this study suggest the feasibility of obtaining comprehensive information on bone health in subjects undergoing LDCT.IntroductionOsteoporosis is a prevalent but underdiagnosed disease that increases fracture risk. This study evaluated the utility of vertebral attenuation derived from low-dose chest computed tomography (LDCT) compared to dual-energy x-ray absorptiometry (DXA) for detecting bone fragility.MethodsA total of 232 subjects (78 men and 154 women) aged above 50 years who underwent both LDCT and DXA within 30 days were evaluated. LDCT-measured bone attenuation in Hounsfield units (HU) of four vertebrae (T4, T7, T10, and L1) was evaluated using volumetric methods for correlation with DXA-measured bone mineral density (BMD) and for the diagnosis of compression fractures, osteoporosis, and low BMD (osteoporosis or osteopenia) in men and women, with DXA measurements as the reference standard.ResultsThe average attenuation of the four vertebrae showed strong correlation with DXA-measured BMD of the lumbar spine (r = 0.726, p < 0.05). In receiver-operating characteristic (ROC) analyses, the area under the curve (AUC) across LDCT-measured thresholds of the average attenuation to distinguish compression fractures was 0.827, and a threshold of 129.5 HU yielded 90.9 % sensitivity and 64.4 % specificity. Similarly, average attenuation showed high AUCs and good diagnostic performance for detecting osteoporosis and low BMD in both men and women. Among 44 subjects with compression fractures, the average bone attenuation showed strong negative correlation with both the worst fracture grade (r = −0.525, p < 0.05) and cumulative fracture grade score (r = −0.633, p < 0.05).ConclusionLDCT-measured bone attenuation by volumetric methods showed good correlation with BMD measured by DXA and good diagnostic performance for identifying bone fragility.

Background. For thoracolumbar burst fractures, traditional four-screw (one above and one below) short-segment instrumentation is popular and has a high failure rate. Additional augmentation at the fractured vertebrae is believed to reduce surgical failure. The purpose of this study was to examine the clinical and radiographic results of patients who underwent short-segment posterior instrumentation with augmentation by screws and bone substitutes at the fractured vertebrae and to compare these data to those of patients who underwent long-segment instrumentation for thoracolumbar burst fractures. Methods. The study group had twenty patients who underwent short-segment instrumentation with additional augmentation by two screws and bone substitutes at the fractured vertebrae. The control group contained twenty-two patients who underwent eight-screw long instrumentation without vertebra augmentation. Local kyphosis and the anterior body height of the fractured vertebrae were measured. The severity of the fractured vertebrae was evaluated with the load sharing classification (LSC). Any implant failure or loss of correction >10° at the final follow-up was defined as surgical failure. Results. Both groups had similar distributions in terms of age, sex, the injured level, and the mechanism of injury before operation. During the operation, the study group had significantly less blood loss (136.0 vs. 363.6 ml, p=0.001) and required shorter operating times (146.8 vs. 157.5 minutes, p=0.112) than the control group. Immediately after surgery, the study group had better correction of the local kyphosis angle (13.4° vs. 11.9°, p=0.212) and restoration of the anterior height (34.7% vs. 31.0%, p=0.326) than the control group. At the final follow-up, no patients in the study group and only one patient in the control group experienced surgical failure. Conclusions. Patients with thoracolumbar burst fractures who received six-screw short-segment posterior fixators with augmentation at the level of the fractured vertebrae via injectable artificial bone substitute achieved satisfactory clinical and radiographic results, and this method could replace long-segment instrumentation methods used in unstable thoracolumbar burst fractures.

Background and Study Aim. To evaluate anterior-posterior spine curvatures and incidence of sagittal defects in children and adolescents practicing traditional Karate. Material and Methods. 152 people aged 6-16 yrs, mean age 10.5±3.03. The study group (SG), subjects attending traditional Karate classes for min one year, 60 minutes twice a week (76 people). The control group (CG) randomly selected on 1:1 basis to match SG. The anterior-posterior curvatures were measured with a gravitational inclinometer. Sauder’s norms were used to assess postural defects. Body mass, height, and BMI were measured. Mann-Whitney U-test/Student’s t-test for independent variables, χ2 test, and Cramer V test were used in statistical analysis. Results. Significant differences were observed between the groups in lumbosacral inclination ALPHA1 p<0.001; karateka had significantly lower ALPHA 1 and greater thoracic inclination (GAMMA TH/L) p=0.23. In study group, lumbosacral angle flattening (ALPHA 2) (81.6%) was greater than in CG (56.6%). ALPHA 2 (43.4%) was more frequently within the norm in CG. Increased ALPHA 2 was reported only among SG (2.6%). Differences were statistically significant (χ2 (2) = 15.23 p<0.001) and of moderate power (Cramer V=0.31). Regarding thoracic kyphosis and lumbar lordosis, there were no statistically significant differences between the groups. Conclusions. Traditional Karate affects pelvic tilt leading to posterior tilt; it correlates with somatic parameters: height, mass, and BMI in terms of spine curvatures. The size of the lumbar lordosis and thoracic kyphosis in karatekas is comparable to that of those not practicing sport. Frequent incidence of reduced pelvic tilt in karatekas requires implementing exercises activating anterior tilt during training session.

Normal displacement of the conus medullaris with unilateral and bilateral SLR has been quantified and the \"principle of linear dependence\" has been described. Explore whether previously recorded movements of conus medullaris with SLRs are i) primarily due to transmission of tensile forces transmitted through the neural tissues during SLR or ii) the result of reciprocal movements between vertebrae and nerves. Controlled radiologic study. Ten asymptomatic volunteers were scanned with a 1.5T magnetic resonance (MR) scanner using T2 weighted spc 3D scanning sequences and a device that permits greater ranges of SLR. Displacement of the conus medullaris during the unilateral and sham SLR was quantified reliably with a randomized procedure. Conus displacement in response to unilateral and sham SLRs was quantified and the results compared. The conus displaced caudally in the spinal canal by 3.54±0.87 mm (mean±SD) with unilateral (p≤.001) and proximally by 0.32±1.6 mm with sham SLR (p≤.542). Pearson correlations were higher than 0.99 for both intra- and inter-observer reliability and the observed power was 1 for unilateral SLRs and 0.054 and 0.149 for left and right sham SLR respectively. Four relevant points emerge from the presented data: i) reciprocal movements between the spinal cord and the surrounding vertebrae are likely to occur during SLR in asymptomatic subjects, ii) conus medullaris displacement in the vertebral canal with SLR is primarily due to transmission of tensile forces through the neural tissues, iii) when tensile forces are transmitted through the neural system as in the clinical SLR, the magnitude of conus medullaris displacement prevails over the amount of bone adjustment.

Background Cervicothoracic (CT) junction hypomobility has been proposed as a contributing factor for neck pain. However, there are limited studies that compared the effect of CT junction mobilization against an effective intervention in neck pain. Thoracic spine manipulation is a nonspecific intervention for neck pain where remote spinal segments are treated based on the concept of regional interdependence. The effectiveness of segment-specific spinal mobilization in the cervical spine has been researched in the last few years, and no definite conclusions could be made from the previous studies. The above reasons warrant the investigation of the effects of a specific CT junction mobilization against a nonspecific thoracic manipulation intervention in neck pain. The present study aims to compare the immediate effects of C7-T1 Maitland mobilization with thoracic manipulation in individuals with mechanical neck pain presenting with CT junction dysfunction specifically. Methods A randomized clinical trial is conducted where participants with complaints of mechanical neck pain and CT junction dysfunction randomly assigned to either C7-T1 level Maitland mobilization group or mid-thoracic (T3-T6) manipulation group (active control group). In both the groups, the post graduate student (SJ) pursuing Master’s in orthopedic physiotherapy delivered the intervention. The outcomes of cervical flexion, extension, side flexion & rotation range of motion (ROM) were measured before & after the intervention with a cervical range of motion (CROM) device. Self-reported pain intensity was measured with the numerical pain rating scale (NPRS). The post-intervention between-group comparison was performed using a one-way ANCOVA test. Results Forty-two participants with mean age CT junction group: 35.14 ± 10.13 and Thoracic manipulation group: 38.47 ± 11.47 were recruited for the study. No significant differences in the post-intervention baseline adjusted outcomes of cervical ROM & self-reported pain intensity were identified between the groups after the treatment (p = 0.08, 0.95, 0.01, 0.39, 0.29, 0.27for flexion, extension, bilateral lateral flexion & rotations respectively) & neck pain intensity (p = 0.68). However, within-group, pre, and post comparison showed significant improvements in cervical ROM and pain in both groups. Conclusion This preliminary study identified that CT junction mobilization is not superior to thoracic manipulation on the outcomes of cervical ROM and neck pain when level-specific CT junction mobilization was compared with remote mid-thoracic manipulation in individuals with mechanical neck pain and CT junction dysfunction. Trial registration CTRI: 2018/04/013088, Registered 6 April 2018, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=24418

Background: Thoracic facet joints have been implicated as the source of chronic pain in the mid back or upper back in 34% to 42% of patients when the modified criteria of the International Association for the Study of Pain (IASP) is utilized. Various therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include intraarticular injections, medial branch blocks, and radiofrequency neurotomy of thoracic medial branch nerves. Study Design: A randomized, double-blind, active controlled trial. Setting: A private practice, interventional pain management setting, and a specialty referral center setting in the United States. Objective: To determine the clinical effectiveness of therapeutic local anesthetic medial branch blocks with or without steroid in managing chronic function-limiting mid back or upper back pain of facet joint origin. Methods: The study was performed in an interventional pain management private practice, a tertiary referral center, in the United States. A total of 100 participants were included, with 50 participants in each of the local anesthetic and steroid groups. All of the participants met the diagnostic criteria of thoracic facet joint pain by means of comparative, controlled diagnostic blocks and the inclusion criteria. Group I participants received thoracic medial branch blocks with bupivacaine, whereas Group II participants received thoracic medial branch blocks with bupivacaine and non-particulate betamethasone. Outcomes Assessment: Outcomes measures included numeric rating scores (NRS), Oswestry Disability Index (ODI), opioid intake, and return to work status at baseline, 3 months, 6 months, and 12 months. Significant pain relief was defined as ≥ 50% pain relief and/or a positive change in ODI scores. Results: In Group I and Group II 90% of participants showed significant pain relief and functional improvement at 12 months. The majority of the participants experienced significant pain relief of 47.2 ± 10.1 weeks in Group I and 46.3 ± 8.4 weeks in Group II, requiring approximately 3.5 treatments per year with an average relief of 15.8 ± 10.5 in Group I and 13.6 ± 3.6 weeks in Group II per episode of treatment. Limitations: Study limitations include the lack of a placebo group. Conclusions: Therapeutic thoracic medial branch blocks, with or without steroid, may provide a management option for chronic function-limiting mid back or upper back pain of facet joint origin. Clinical Trial: NCT00355706 Key words: Chronic spinal pain, thoracic pain, thoracic facet or zygapophysial joint pain, facet joint nerve or medial branch blocks, comparative controlled local anesthetic blocks, therapeutic thoracic medial branch blocks.

Single injections in the anterior region of the thoracic paravertebral space (TPVS) have been reported to generate a multisegmental longitudinal spreading pattern more frequently than those in the posterior region of the TPVS. In this trial, we examined the hypothesis that a continuous thoracic paravertebral block (TPVB) administered through a catheter inserted into the anterior region of the TPVS allows a wider sensory block dispersion. Fifty consecutive patients undergoing video-assisted thoracic surgery were enrolled. Before the surgery, an infusion catheter was inserted into the TPVS through a needle placed adjacent to either the parietal pleura (group A) or internal intercostal membrane (group P) using an ultrasound-guided intercostal transverse approach according to a randomized allocation schedule. A chest radiograph was obtained postoperatively after injection of 10 mL of radiopaque dye through the catheter. Thereafter, 20 mL of 0.375% levobupivacaine was injected via the catheter, followed by commencement of continuous TPVB with 0.25% levobupivacaine at 8 mL/h. The primary outcome was the number of blocked dermatomes at 24 h after surgery. The secondary outcomes included radiopaque dye spreading patterns, the number of segments reached by the radiopaque dye, the number of blocked dermatomes at 2 h after surgery, and pain scores. The median (interquartile range [range]) number of blocked dermatomes 24 h after surgery was 3 (2.75–4 [1–6]) in group A (n = 22) and 2 (1.5–3 [0–7]) in group P (n = 25; p = 0.037). No significant differences in the other outcomes were found between the groups. In conclusion, a continuous TPVB administered using a catheter supposedly inserted into the anterior region of the TPVS allows a wider sensory block dispersion than a catheter inserted into the posterior region of the TPVS. This trial is registered with the UMIN Clinical Trials Registry (UMIN000018578).

Background The aim of this randomized clinical trial was to assess the effect of early orthodontic treatment for unilateral posterior cross bite in the late deciduous and early mixed dentition using orthopedic parameters. Methods Early orthodontic treatment was performed by initial maxillary expansion and subsequent activator therapy (Münster treatment concept). The patient sample was initially comprised of 80 patients with unilateral posterior cross bite (mean age 7.3 years, SD 2.1 years). After randomization, 77 children attended the initial examination appointment (therapy = 37, control = 40); 31 children in the therapy group and 35 children in the control group were monitored at the follow-up examination (T2). The mean interval between T1 and T2 was 1.1 years (SD 0.2 years). Rasterstereography was used for back shape analysis at T1 and T2. Using the profile, the kyphotic and lordotic angle, the surface rotation, the lateral deviation, pelvic tilt and pelvic torsion, statistical differences at T1 and T2 between the therapy and control groups were calculated ( t -test). Our working hypothesis was, that early orthodontic treatment can induce negative therapeutic changes in body posture through thoracic and lumbar position changes in preadolescents with uniltaral cross bite. Results No clinically relevant differences between the control and the therapy groups at T1 and T2 were found for the parameters of kyphotic and lordotic angle, the surface rotation, lateral deviation, pelvic tilt, and pelvic torsion. Conclusions Our working hypothesis was tested to be not correct (within the limitations of this study). This randomized clinical trial demonstrates that in a juvenile population with unilateral posterior cross bite the selected early orthodontic treatment protocol does not affect negatively the postural parameters. Trial registration DRKS00003497 on DRKS

We postulated that the lowest instrumented vertebra (LIV) can be determined based on the apical vertebra. Seventy-two Lenke type 1 patients (average age: 13.6 years) receiving posterior spinal fusion were randomised into two groups. In group A, the apical vertebra was used to determine the LIV and in group B the neutral vertebra was used. All patients had Cobb angles <90° and average follow-up was over three years. Posteroanterior and lateral standing radiographs were used to assess flexibility, Cobb angle and distance from the C7 line to the central sacral vertical line. Both methods produced statistically significant changes in Cobb angle, sagittal T5–T12 and plumb line deviation, and there were no significant differences between the two methods. More cases of imbalance occurred in group B (five) than group A (two). We conclude that the apical vertebra can be used to determine the LIV in patients with Lenke type 1 adolescent idiopathic scoliosis.

Objective:Prospective studies have shown that quantitative ultrasound (QUS) techniques predict the risk of fracture of the proximal femur with similar standardised risk ratios to dual-energy x-ray absorptiometry (DXA). Few studies have investigated these devices for the prediction of vertebral fractures. The Basel Osteoporosis Study (BOS) is a population-based prospective study to assess the performance of QUS devices and DXA in predicting incident vertebral fractures.Methods:432 women aged 60–80 years were followed-up for 3 years. Incident vertebral fractures were assessed radiologically. Bone measurements using DXA (spine and hip) and QUS measurements (calcaneus and proximal phalanges) were performed. Measurements were assessed for their value in predicting incident vertebral fractures using logistic regression.Results:QUS measurements at the calcaneus and DXA measurements discriminated between women with and without incident vertebral fracture, (20% height reduction). The relative risks (RRs) for vertebral fracture, adjusted for age, were 2.3 for the Stiffness Index (SI) and 2.8 for the Quantitative Ultrasound Index (QUI) at the calcaneus and 2.0 for bone mineral density at the lumbar spine. The predictive value (AUC (95% CI)) of QUS measurements at the calcaneus remained highly significant (0.70 for SI, 0.72 for the QUI, and 0.67 for DXA at the lumbar spine) even after adjustment for other confounding variables.Conclusions:QUS of the calcaneus and bone mineral density measurements were shown to be significant predictors of incident vertebral fracture. The RRs for QUS measurements at the calcaneus are of similar magnitude as for DXA measurements.