The relationship between radiological paraspinal lumbar measures and clinical measures of sarcopenia in older patients with chronic lower back pain.

Objectives: Sarcopenia is postulated to be an influential factor in chronic low back pain. The aim of this study is to evaluate the relationship between traditional clinical measures of sarcopenia and novel radiographic methods which evaluate overall muscle status, such as adjusted psoas cross-sectional area (APCSA) and degree of fat infiltration (%FI) in paraspinal muscles, in patients with chronic low back pain. Methods: Prospective study performed at our institution from 01/01/19-01/04/19. Inclusion criteria were patients ≥65 years old not requiring surgical intervention presenting to a low back pain assessment clinic. Results: 25 patients were identified (mean age: 73 years, 62% male). On spearman's analyses, %FI shared a significant relationship with hand grip strength (r = -0.37; p=0.03), chair rise (r=0.38; p=0.03), SC (r=0.64; p<0.01), and visual analogue scale scores (r=-0.14; p=0.02). Comparably, a statistically significant correlation was evident between APCSA and %FI (r=-0.40; p=0.02) on analysis. Conclusion: The results of our study demonstrate a statistically significant relationship between APCSA and %FI in the multifidus and erector spinae muscles. Further significant associations of relatability were depicted with traditional clinical measures of sarcopenia. Thus, %FI may be a supplemental indicator of the sarcopenic status of patients presenting with chronic low back pain.

Changing Demographic Trends in spine trauma: The presentation and outcome of Major Spine Trauma in the elderly.

INTRODUCTION: Major trauma has seen a demographic shift in recent years and it is expected that the elderly population will comprise a greater burden on the major trauma service in the near future. However, whether a similar trend exists in those undergoing operative intervention for spinal trauma remains to be elucidated. AIMS: To compare the presentation and outcomes of patients ≥65 years of age sustaining spine trauma to those <65 years at a national tertiary referral spine centre. METHODS: The local Trauma Audit Research Network (TARN) database was analysed to identify spinal patients referred to our institution, a national tertiary referral centre, between 01/2016 and 05/2019. Patients were divided into a young cohort (16-64 years old) and an elderly cohort (> 64 years old). No explicit distinction was made between major and minor spine trauma cases. Variables analysed included patient demographics, injury severity, mortality, interventions, mechanism of injury and length of hospital stay. RESULTS: A total of 669 patients were admitted of which 480 patients underwent operative intervention for spinal trauma. Within the elderly cohort, this represented 75.3% of cases. Among the younger population, road traffic collisions were the most common mechanism of injury (37.1%), while low falls (<2 m) (57.4%) were the most common mechanism among the older population. Patients ≥65 years old had significantly longer length of stay (21 days [1-194] v 14 days [1-183]) and suffered higher 30-day mortality rates (4.6% [0-12] v 0.97% [0-4]). CONCLUSION: Orthopaedic spinal trauma in older people is associated with a significantly higher mortality rate as well as a longer duration of hospitalization. Even though severity of injury is similar for both young and old patients, the mechanism of injury for the older population is of typically much lower energy compared to the high energy trauma affecting younger patients.

Impact of Sarcopenia on Degenerative Lumbar Spondylosis.

Sarcopenia is characterized by progressive age-related and systematic loss of skeletal muscle mass, strength, and function. It was classified as an independent disease in 2016; thus, there is a sparsity of research on the association of sarcopenia with lower back pain and spinal diseases. Its prevalence is around 10% worldwide and it has been shown to be detrimental to quality of life in the elderly. Sarcopenia can be clinically identified by assessing muscle mass and physical performance measurements to show reduced strength (eg, grip strength chair rise and knee extensions) or function (eg, walking speed or distance). Radiographic imaging techniques such as computed tomography, ultrasound, or magnetic resonance imaging help diagnose sarcopenia in the lumbar spine by measuring either the cross-sectional area or the fatty infiltrate of the lumbar musculature. The presence of sarcopenia in patients preoperatively may lead to worse postoperative outcomes. Research in the treatment options for sarcopenia presurgery is still in its infancy but exercise (both aerobic and resistance exercise have been found to slow down the rate of decline in muscle mass and strength with aging) and nutrition have been utilized to varying success and show great promise in the future.

Advantages and Design of PROMIS Questionnaires.

The Patient-Reported Outcomes Measurement Information System (PROMIS) is a National Institute of Health initiative to improve the measurement of clinically important symptoms and outcomes. Patient-Reported Outcomes capture health outcomes that are relevant to the daily functioning of the patient and include the monitoring of physical, mental, and social health. PROMIS offers a standardized tool to measure Patient-Reported Outcomes for use in both the clinical and research setting. It is a flexible and dynamic tool for both patient and clinician, and its use is continuing to grow internationally. This article discusses the rationale and design of this tool, as well as its advantages to both research and clinical practice.

What Is Finite Element Analysis?

Finite element analysis is a computational technique to predict how different materials will react when a range of forces are applied. In the field of orthopedics, this technique has predominantly been used for implant design and testing. As the technology improves, increasing clinical applications are being developed, offering promise in the areas of surgical planning and the opportunity to tailor implants to individual patient characteristics. This article introduces the various preclinical mechanical tests available, as well as providing a brief overview of the finite element analysis technology.

Surgeon proficiency in robot-assisted spine surgery.

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal. There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced. Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described. The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery. Cite this article: Bone Joint J 2020;102-B(5):568-572.

A systematic review of the presentation of scan-negative suspected cauda equina syndrome.

BACKGROUND: A significant proportion of patients presenting with suspected cauda equina syndrome (CES) do not have associated radiological evidence to support the diagnosis, often termed 'scan-negative'. Due to the limited number of studies regarding the matter, there is no clear understanding for this presentation. As a result, no treatment protocol exists for the scan-negative group. The purpose of this review is to assess the potential contributing factors leading to the presentation of suspected CES with normal imaging. METHODS: A systematic review was conducted on PubMed and Cochrane databases. Bibliographies of key articles and Google Scholar were searched for additional results. The search strategy provided 204 results. Of those, 8 had no identifiable causation for suspected CES and were included for systematic review. RESULTS: 6 of 8 studies investigated for a difference in clinical presentation between cohorts that may indicate a normal scan. Studies were either inconclusive and contradictory. Two studies suggest a functional somatic disorder as reasoning for negative MRI, with positive provisional findings. CONCLUSION: A psychogenic hypothesis is plausible and warrants further investigation. The need for additional studies is essential to scheming a potential treatment protocol for the scan-negative population, which currently does not exist.

Image-guidance, Robotics, and the Future of Spine Surgery.

Spine surgery has seen considerable advancements over the last 2 decades, particularly in the fields of image-guidance and robotics. These technologies offer the potential to overcome the various technical challenges in spinal surgery, such as physical and mental fatigue, hand tremor, difficulties with manual dexterity, and surgical precision. This review provides an overview of the image-guidance and robotics systems currently available. It will also provide an insight into the emerging technologies in development in the field of spine surgery. Image-guided and robotic-assisted surgical systems have been demonstrated to be safe, accurate, and time-efficient. Future advancements in the field include "augmented reality" systems, which build on these navigation platforms, but are yet to come to market. These developing technologies have considerable potential to improve the field of spine surgery. Further research is required in this area to determine superiority of these developing technologies over conventional techniques before widespread use should be adapted.

Management of Herniated Lumbar Disk Disease and Cauda Equina Syndrome in Pregnancy.

Lower back pain is a commonly reported symptom during pregnancy. However, herniated lumbar disk disease is an uncommon cause for such pain. Cauda equina syndrome (CES) during pregnancy is a rare clinical scenario. This review highlights the epidemiology, diagnostic and treatment strategies, and challenges encountered when managing herniated lumbar disk disease and CES in pregnancy. Magnetic resonance imaging is the diagnostic modality of choice. Nonoperative treatment strategies are successful in the vast majority of cases in patients with a herniated disk in the absence of CES. CES and progressive neurological deficits remain absolute indications for surgical intervention regardless of gestational age. For such patients or those with debilitating symptoms refractory to nonoperative treatment strategies, surgery has been demonstrated to be safe in the pregnant patient population. However, surgery should be performed with obstetric and midwifery support should complications occur to the fetus.

Familial chronic megacolon presenting in childhood or adulthood: Seeking the presumed gene association.

OBJECTIVE: We identified a pedigree over five generations with 49 members, some of whom had chronic megacolon presenting in adolescence or adulthood. We aimed to assess the genetic cause of chronic megacolon through clinical and DNA studies. DESIGN: After ethical approval and informed consent, family members provided answers to standard bowel disease questionnaires, radiological or surgical records, and DNA (buccal mucosal scraping). Exome DNA sequencing of colon tissue or blood DNA from seven family members with colon or duodenal dilatation, or no megacolon (n = 1) was carried out. Sanger sequencing was performed in 22 additional family members to further evaluate candidate variants. The study focused on genes of potential relevance to enteric nerve (ENS) maturation and Hirschsprung's disease or megacolon, based on the literature (GFRA1, NKX2-1, KIF26A, TPM3, ACTG2, SCN10A, and C17orf107 [CHRNE]) and other genetic variants that co-segregated with megacolon in the six affected family members. RESULTS: Information was available in all except five members alive at time of study; among 30 members who provided DNA, six had definite megacolon, one megaduodenum, seven significant constipation without bowel dilatation, and 16 normal bowel function by questionnaire. Among genes studied, SEMA3F (g.3:50225360A>G; c1873A>G) was found in 6/6 family members with megacolon. The SEMA3F gene variant was assessed as potentially pathogenic, based on M-CAP in silico prediction. SEMA3F function is associated with genes (KIT and PDGFRB) that impact intestinal pacemaker function. CONCLUSION: Familial chronic megacolon appears to be associated with SEMA3F, which is associated with genes impacting enteric nerve or pacemaker function.

Characteristics of chronic megacolon among patients diagnosed with multiple endocrine neoplasia type 2B.

BACKGROUND: Gastrointestinal symptoms are frequent in multiple endocrine neoplasia (MEN) 2B and may be related to megacolon. OBJECTIVE: The objective of this article is to review the clinical features of patients with MEN 2B, particularly megacolon. METHODS: We used natural language processing of electronic medical records of Mayo Clinic patients over 20 years: Eight patients with definite MEN 2B were identified; of these, four had megacolon. From these patients' records, three others with paper medical records were identified through familial association. We used a standard data sheet to identify features of the disease with particular emphasis on megacolon. RESULTS: Of the 11 patients identified with MEN 2B, seven (63%) had megacolon, typically presenting with constipation in infancy or megacolon in childhood. In addition, three patients had esophageal manifestations (two achalasia and one Zenker's diverticulum). Megacolon often required surgical intervention for intractable constipation, abdominal distension and discomfort. Histopathological features of resected colon revealed enteric and extrinsic nerve hyperplasia and ganglioneuromas of the submucosal and myenteric plexuses. CONCLUSIONS: Among patients with MEN 2B, 63% had megacolon. Significant esophageal motor disorders in MEN 2B may affect ∼25% of patients. Any presentation with megacolon should trigger a search for MEN 2B in order to identify the potentially fatal endocrine tumors.