Modic Change: An Emerging Complication in the Aging Population.

STUDY DESIGN: This was a literature review. OBJECTIVE: The objective of this study was to review the pathogenesis, prevalence, clinical associations, diagnostic modalities, and treatment options for patients with lower back pain (LBP) associated with Modic change (MC). SUMMARY OF BACKGROUND DATA: Vertebral body endplates are located between the intervertebral disk and adjacent vertebral body. Despite their crucial roles in nutrition and biomechanical stability, vertebral endplates are extremely susceptible to mechanical failure. Studies examining the events leading to disk degeneration have shown that failure often begins at the endplates. Endplate degeneration with subchondral bone marrow changes were originally noticed on magnetic resonance imaging. These magnetic resonance imaging signal changes were classified as MC. METHODS: A literature review was conducted on the history, etiology, risk factors, diagnostic modalities, and treatment of LBP with MC. RESULTS: Type 1 MC refers to the presence of increased vascularization and bone marrow edema within the vertebral body. Type 2 MC involves fatty marrow replacement within the vertebral body. Type 3 MC reflects subchondral bone sclerosis. Despite the original classification, research has supported the notion that MCs possess a transitional nature. Furthermore, type 1 MCs have been strongly associated with inflammation and severe LBP, while types 2 and 3 tend to be more stable and demonstrate less refractory pain. With a strong association to LBP, understanding the etiology of MC is crucial to optimal treatment planning. Various etiologic theories have been proposed including autoimmunity, mechanics, infection, and genetic factors. CONCLUSIONS: With the aging nature of the population, MC has emerged as an extremely prevalent issue. Research into the pathogenesis of MC is important for planning preventative and therapeutic strategies. Such strategies may include rehabilitation, surgical fixation, stabilization, steroid or cement injection, or antibiotics. Improved diagnostic methods in clinical practice are thus critical to properly identify patients suffering from MC, plan early intervention, and hasten return to functioning.

Infra-adjacent Segment Disease After Lumbar Fusion: An Analysis of Pelvic Parameters.

STUDY DESIGN: Cross-sectional observational cohort study. OBJECTIVE: The aim of this study was to determine the incidence and risk factors associated with the development of sacroiliac joint (SIJ) dysfunction following lumbosacral fusion. SUMMARY OF BACKGROUND DATA: Adjacent segment degeneration to both proximal and distal areas of spinal fusion is a postoperative complication of lumbar fusion. Various studies examined supra-adjacent degeneration following lumbar fusion, but few focused on infra-adjacent degeneration. In lumbosacral fusion, fusion extends to the sacrum, placing increased stress on the SIJ. METHODS: A total of 2069 sequential patients who underwent lumbosacral fusion surgery from 2008 to 2018 at a single academic medical center were retrospectively reviewed. Patients who subsequently developed SIJ dysfunction were identified. SIJ dysfunction was defined as patients who met the diagnostic criteria with physical examination and received an SIJ injection with clinical evidence of improvement. Controls, without subsequent SIJ dysfunction, were matched with cases based on levels of fusion, age, sex, and body mass index. Pre-and postoperative pelvic parameters were measured, including pelvic incidence, pelvic tilt (PT), sacral slope, lumbar lordosis, lumbosacral angle, L4 incidence and L5 incidence. RESULTS: Of 2069 patients who underwent lumbosacral fusion, 81 patients (3.9%) met criteria for SIJ dysfunction. Measurements were made for 47 of 81 patients who had SIJ dysfunction, that had both pre- and post-operative imaging. Measurements for 44 matched controls were taken. Postoperative PT was significantly lower in SIJ dysfunction patients compared to controls (20.82°â€Š±â€Š2.19° vs. 27.28°â€Š±â€Š2.30°; P < 0.05), as was L5 incidence (28.64°â€Š±â€Š3.38° vs. 37.11°â€Š± 3.50°; P < 0.05). CONCLUSION: Incidence of the SIJ dysfunction after lumbosacral fusion surgery was 3.9% and these patients had a significantly lower PT and L5 incidence compared to the control group. Significantly low PT may be derived from weak hamstring muscles, predisposing a patient to SIJ dysfunction. Therefore, hamstring muscle strengthening exercise for patients with decreased PT after lumbosacral fusion may decrease the incidence of SIJ dysfunction.Level of Evidence: 3.

Overview and Spinal Implications of Leg Length Discrepancy: Narrative Review.

Leg length discrepancy (LLD) is an underrecognized and prevalent condition among the U.S. population, with effects varying depending on the cause and size of the discrepancy. LLD occurs when the paired lower extremities are unequal in length and can be etiologically classified as functional or structural. Length differences are typically less than 10 mm and asymptomatic or easily compensated for by the patient through self-lengthening or shortening of the lower extremities. Literature review of the etiology, diagnostic modalities, clinical complications, and treatment option for patients with LLD. LLD can be assessed directly through tape measurements or indirectly through palpation of bony landmarks. Imaging modalities, specifically radiography, are more precise and help identify coexistent deformity. Once LLD has been diagnosed, evaluation for potential adverse complications is necessary. Discrepancies greater than 20 mm can alter biomechanics and loading patterns with resultant functional limitations and musculoskeletal disorders, such as functional scoliosis. Functional scoliosis is nonprogressive and involves a structurally normal spine with an apparent lateral curvature, which regresses fully or partially when the LLD is corrected. Long-standing LLD and functional scoliosis often result in permanent degenerative changes in the facet joints and intervertebral discs of the spine. Further understanding of the contribution of LLD in the development of scoliosis and degenerative spine disease will allow for more effective preventative treatment strategies and hasten return to function.

Treatment of severe COVID-19 with convalescent plasma in Bronx, NYC.

Convalescent plasma with severe acute respiratory disease coronavirus 2 (SARS-CoV-2) antibodies (CCP) may hold promise as a treatment for coronavirus disease 2019 (COVID-19). We compared the mortality and clinical outcome of patients with COVID-19 who received 200 mL of CCP with a spike protein IgG titer ≥ 1:2430 (median 1:47,385) within 72 hours of admission with propensity score-matched controls cared for at a medical center in the Bronx, between April 13 and May 4, 2020. Matching criteria for controls were age, sex, body mass index, race, ethnicity, comorbidities, week of admission, oxygen requirement, D-dimer, lymphocyte counts, corticosteroid use, and anticoagulation use. There was no difference in mortality or oxygenation between CCP recipients and controls at day 28. When stratified by age, compared with matched controls, CCP recipients less than 65 years had 4-fold lower risk of mortality and 4-fold lower risk of deterioration in oxygenation or mortality at day 28. For CCP recipients, pretransfusion spike protein IgG, IgM, and IgA titers were associated with mortality at day 28 in univariate analyses. No adverse effects of CCP were observed. Our results suggest CCP may be beneficial for hospitalized patients less than 65 years, but data from controlled trials are needed to validate this finding and establish the effect of aging on CCP efficacy.

Establishing the validity of surface topography for assessment of scoliosis: a prospective study.

STUDY DESIGN: Descriptive survey. OBJECTIVES: Compare radiographic parameters measured using surface topography (ST) with those obtained radiographically to determine the validity of ST for scoliotic assessment. METHODS: While anterior-posterior radiography is the gold standard for diagnosing scoliosis, repeated radiographic use is associated with increased carcinogenicity. Studies have thus focused on radiation-free systems, including ST, to calculate the scoliotic angle. Seventeen patients ages 25-76 were included. Each patient received one AP radiograph and three repeated ST measurements over two months. Values were analyzed by two raters to determine comparability between ST and radiographic measurements. Interobserver reliability (ICC) was calculated and statistical significance was determined by the p-value of a paired two-tailed t-test. RESULTS: ICC showed excellent reliability (> 0.90). There was no significant difference (p > 0.40) in apical vertebral deviation/translation between conventional radiography (0.9 ± 0.8) and ST (1.2 ± 1.0). There was no significant difference (p > 0.30) in sagittal balance radiographic (4.0 ± 3.1) and ST (4.4 ± 3.3), and coronal balance radiographic (1.4 ± 1.3) and ST (1.1 ± 1.1) measurements. Significant difference (p < .001) was found between lumbar lordosis radiographic (52.6 ± 18.4) and ST (37.9 ± 16.6), kyphotic angle radiographic (35.1 ± 16.0) and ST (50.0 ± 11.9), and scoliotic angle radiographic (11.3 ± 12.4) and ST (17.7 ± 10.2) measurements. CONCLUSIONS: No significant difference was observed between various ST and radiographic measurements, including apical vertebral deviation, sagittal balance, and coronal balance. While a larger prospective study is needed to further assess the validity of ST, these initial measurements suggest the possibility of an effective and radiation-free adjunctive method of assessing balance in the coronal plane.

Treatment of Severe COVID-19 with Convalescent Plasma in the Bronx, NYC.

Convalescent plasma with severe acute respiratory disease coronavirus 2 (SARS-CoV-2) antibodies (CCP) may hold promise as treatment for Coronavirus Disease 2019 (COVID-19). We compared the mortality and clinical outcome of patients with COVID-19 who received 200mL of CCP with a Spike protein IgG titer ≥1:2,430 (median 1:47,385) within 72 hours of admission to propensity score-matched controls cared for at a medical center in the Bronx, between April 13 to May 4, 2020. Matching criteria for controls were age, sex, body mass index, race, ethnicity, comorbidities, week of admission, oxygen requirement, D-dimer, lymphocyte counts, corticosteroids, and anticoagulation use. There was no difference in mortality or oxygenation between CCP recipients and controls at day 28. When stratified by age, compared to matched controls, CCP recipients <65 years had 4-fold lower mortality and 4-fold lower deterioration in oxygenation or mortality at day 28. For CCP recipients, pre-transfusion Spike protein IgG, IgM and IgA titers were associated with mortality at day 28 in univariate analyses. No adverse effects of CCP were observed. Our results suggest CCP may be beneficial for hospitalized patients <65 years, but data from controlled trials is needed to validate this finding and establish the effect of ageing on CCP efficacy.

Understanding breast asymmetry and its relation to AIS.

STUDY DESIGN: Literature Review. OBJECTIVE: Review the pathophysiology, causes, and treatment of breast asymmetry in patients with adolescent idiopathic scoliosis (AIS), as well as postoperative patient assessment and health-related quality of life. BACKGROUND DATA: Female breast development begins at 35-day gestation and continues 2-4-year post-thelarche to achieve final volume and shape. During the post-pubertal period, errors in growth and development may result in breast asymmetry. Breast asymmetry typically attenuates with time, but can be pronounced in individuals with AIS. During adolescence, there is rapid development and, thus AIS patients are increasingly sensitive, physically and emotionally, to breast changes. While breast asymmetry can be monitored through radiographic measures and surface topography, pre- and postoperative patient assessment is also critical in determination of optimal patient treatment. METHODS: A comprehensive literature review was performed on the pathophysiology, causes, and treatment of breast asymmetry. The advantages and limitations of various treatment options based on patient satisfaction were also investigated. RESULTS: Various treatment options exist for breast asymmetry correction in AIS patients. Surgical correction involves an aesthetic outcome, as well as social, physical, and psychological impact on the patient. Despite the benefit of correction surgery, in terms of function and self-image, patient-reported outcomes still appear lower postoperatively in the domains of pain and mental health. CONCLUSION: Breast asymmetry is very common, especially among AIS patients, and is often corrected with surgical augmentation. AIS correction surgery has been shown to aggravate breast asymmetry and negatively affect patient-reported outcomes. Other treatment modalities should thus be considered when presented with an adolescent patient. Understanding patient concerns and their relation to quality of life will help guide surgical and medical interventions in correction of AIS deformities. Long-term follow-up studies are necessary to determine whether such interventions are successful and if patients remain healthy. LEVEL OF EVIDENCE: N/A.

Evaluating the role of surface topography in the surveillance of scoliosis.

STUDY DESIGN: Literature review. OBJECTIVE: To review the history, modern uses, limitations, and future direction of surface topography (ST) in surveillance of scoliosis. Spinal deformities, including scoliosis, can be characterized using measurements such as the Cobb angle, lateral curvature, and vertebral rotation. The gold standard for diagnosis and surveillance of such deformities utilizes radiographic images. To minimize repeated radiation exposure, many systems have been developed utilizing ST. ST measures local deviations of a surface from a flat plane. Applying this concept to spinal deformities, ST can non-radiographically study the 3-dimensional shape of the back. One ST system, rasterstereography, projects parallel white light lines onto a patient's back and analyzes line distortion with a camera. While radiography has long been considered the primary diagnostic tool for scoliosis, rasterstereography may possess alternative or complementary benefits in monitoring scoliosis and other diseases. METHODS: A comprehensive literature review was performed on the history, development, and validity of ST. The advantages and limitations of this technique were compared to those of radiography. RESULTS: While the initial goal of ST, designing a system to accurately reproduce the Cobb angle, was not successful, research efforts over the last 40 years have attempted to improve this correlation. ST technologies, including rasterstereography and the Formetric ST System, currently play important roles in scoliosis surveillance, research, and minimizing radiation exposure in longitudinal care of patients. Such technologies are also useful as an adjunct to X-rays for monitoring disease progression, especially in Parkinson's disease. CONCLUSION: Despite its limitations, ST has proven useful across multiple fields of medicine. It is a safe and cost-effective tool for long-term surveillance of scoliosis and early detection of progressive disease. With technological improvements, the Formetric System will become a critical alternative in dynamic spinal motion and gait analysis. LEVEL OF EVIDENCE: N/A.