From Modic to Disc Endplate Bone Marrow Complex - The Natural Course and Clinical Implication of Vertebral Endplate Changes.

STUDY DESIGN: Review article. OBJECTIVES: A review of literature on the epidemiology, natural course, pathobiology and clinical implications of vertebral endplate changes. METHODS: A literature search was performed using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the last 10 years were analysed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "Vertebral endplate changes", "Modic changes", "Disc Endplate Bone Marrow complex". RESULTS: The disc, endplate (EP), and bone marrow region of the spine constitute a unified morphological and functional unit, with isolated degeneration of any one structure being uncommon. Disc degeneration causes endplate defects, which result in direct communication and a constant cross-talk between the disc and the vertebral body. This may result in a persistent inflammatory state of the vertebral bone marrow, serving as a major pain generator. This review article focuses on vertebral endplate changes and how the current understanding has progressed from the Modic classification to the Disc Endplate Bone Marrow complex classification. It provides a clear portrayal of the natural course of these alterations and their clinical implications in low back pain. CONCLUSIONS: In light of the heightened interest and current prominence of vertebral endplate changes within the spine community, we must progress beyond the Modic changes to achieve a comprehensive understanding. The DEBM complex classification will play a major part in disc degeneration research and clinical care, representing a considerable advancement in our understanding of the vertebral endplate changes over the classical Modic changes.

Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish Optimizing Management and Minimizing Risk of Osteoporotic Vertebral Fractures - Perspectives of the AO Spine KF Trauma and Infection Group Key Opinion Leaders.

STUDY DESIGN: Literature review with clinical recommendations. OBJECTIVE: To highlight important studies about osteoporotic spinal fractures (OF) that may be integrated into clinical practice based on the assessment of the AO Spine KF Trauma and Infection group key opinion leaders. METHODS: 4 important studies about OF that may affect current clinical practice of spinal surgeons were selected and reviewed with the aim of providing clinical recommendations to streamline the journey of research into clinical practice. Recommendations were graded as strong or conditional following the GRADE methodology. RESULTS: 4 studies were selected. Article 1: a validation of the Osteoporotic Fracture (OF)-score to treat OF fractures. Conditional recommendation to incorporate the OF score in the management of fractures to improve clinical results. Article 2: a randomized multicenter study comparing romosozumab/alendronate vs alendronate to decrease the incidence of new vertebral fractures. Strong recommendation that the group receiving romosozumab/alendronate had a decreased risk of new OF when compared with the alendronate only group only. Article 3: a systematic literature review of spinal orthoses in the management of. Conditional recommendation to prescribe a spinal orthosis to decrease pain and improve quality of life. Article 4: post-traumatic deformity after OF. A conditional recommendation that middle column injury and pre-injury use of steroids may lead to high risk of post-traumatic deformity after OF. CONCLUSIONS: Management of patients with OF is still complex and challenging. This review provides some recommendations that may help surgeons to better manage these patients and improve their clinical practice.

The incidence and risk factors for unplanned readmission within 90 days after surgical treatment of spinal fractures.

INTRODUCTION: Unplanned readmissions after spine surgery are undesired, and cause significant functional, and financial distress to the patients and healthcare system. Though critical, knowledge about readmissions after surgery for traumatic spinal injuries (TSI) is scarce and under-evaluated. METHODS: Consecutive patients surgically treated for TSI and who had unplanned readmission within 90 days post-discharge were studied. Peri-operative demographic and surgical variables, surgical treatment, level of injury, delay in surgery, ASIA score, other organ injuries, peri-operative complications, smoking, ICU stay, co-morbidity, and the length of hospital stay were studied and correlated with the causes for readmission. RESULTS: Among 884 patients, 4.98% (n = 44) had unplanned readmissions within 90 days of discharge. Notably, 50% (n = 22) patients were readmitted within the first 30 days. The common causes of readmissions were urinary tract related problems (27%, n = 12), pressure ulcers (20.4%, n = 9), respiratory problems (13.6%, n = 6), surgical wound related problems (14%, n = 7,) limb injuries (11.4%, n = 5), and others (11%, n = 5). The total beds lost secondary to readmissions was 314 days, and the mean bed-days lost per patient was 7.2 ± 5.1. Thirteen peri-operative risk factors were associated with unplanned readmissions, among which, smoking (OR 2.2), diabetes (OR 2.4), and pressure sore during index admission (OR 16.7) were strong independent predictors. CONCLUSION: The incidence of unplanned readmissions after TSI was 5%, which was similar to elective spine surgeries but the causes and risk factors are different. Non-surgical complications related to urinary tract, respiratory care and pressure sores were the most common causes. Pre-operative smoking status, diabetes mellitus and pressure sores noted in the index admission were important independent risk factors.

Foot pressure transfers are altered in lumbar radiculopathy but reversible after surgery: a prospective, pedobarography study.

BACKGROUND CONTEXT: Patients with lower lumbar stenosis and disc herniation report disability in standing and ambulation, despite normal neurological examination. The L5 and S1 nerve roots support the entire motor and sensory function of the foot, and their radiculopathy can affect foot loading during standing and walking. This has not been quantified before. PURPOSE: To quantify alterations in static and dynamic foot pressure transfers in patients with lower lumbar nerve root compression, and document any beneficial effects of surgical decompression. STUDY DESIGN: Prospective, case-control study. PATIENT SAMPLE: Cases-Patients with unilateral radiculopathy (L5/S1) with normal neurology (n=50); Controls - Healthy volunteers (n=50). METHODS: The volunteers and patients underwent pedobarographic analysis during standing (static) and walking (dynamic), and fifteen (12 dynamic and three static) parameters were documented. The patient's preoperative values were compared with that of the healthy volunteers. All the 50 patients underwent surgical decompression, and clinical outcome measures (VAS/ODI at 3 months) were documented. Pedobarographic analysis was repeated in the postoperative period (48 hours) and 3-month follow-up and compared with the preoperative scores. RESULTS: In healthy controls, the mean values of all 15 parameters were comparable between the right and the left side (p>.05). When compared to controls, the patients had significantly lower maximum foot loads (p=.01) and average foot loads (p=.05) on the affected side during walking indicating lesser load transmission, in the preoperative period. Within the affected foot, the load transfer was higher on the first metatarsal/ medial arch while significantly less on the lateral metatarsals (p=.04). The percentage load on whole foot and forefoot was significantly less on standing (p=.01). Significant improvements were noted in the postoperative period, especially in the maximum foot surface area (p=.01), maximum and average foot loads, and improved weight transfers on lateral arch and forefoot (p=.02). The load on whole foot increased significantly from 46.1%±5.5% (preoperative) to 48.1%±5.5% (postoperative) and 49.9%±3.3% at follow-up (p=.01). CONCLUSION: This is the first study using pedobarography to document altered foot pressure patterns during ambulation in patients with disc herniation and stenosis. Decreased load transfer, asymmetrical and unphysiological distribution of pressures on the affected foot were observed during weight bearing, which improved after surgical decompression.

Long COVID Characteristics and Experience: A Descriptive Study From the Yale LISTEN Research Cohort.

BACKGROUND: The experience of people with long COVID needs further amplification, especially with a comprehensive focus on symptomatology, treatments, and the impact on daily life and finances. Our intent is to describe the experience of people with long COVID symptomatology and characterize the psychological, social, and financial challenges they experience. METHODS: We collected data from individuals aged 18 and older reporting long COVID as participants in the Yale Listen to Immune, Symptom and Treatment Experiences Now study. The sample population included 441 participants surveyed between May 2022 and July 2023. We evaluated their demographic characteristics, socioeconomic and psychological status, index infection period, health status, quality of life, symptoms, treatments, prepandemic comorbidities, and new-onset conditions. RESULTS: Overall, the median age of the participants with long COVID was 46 years (interquartile range [IQR]: 38-57 years); 74% were women, 86% were non-Hispanic White, and 93% were from the United States. Participants reported a low health status measured by the Euro-QoL visual analog scale, with a median score of 49 (IQR: 32-61). Participants documented a diverse range of symptoms, with all 96 possible symptom choices being reported. Additionally, participants had tried many treatments (median number of treatments: 19, IQR: 12-28). They were also experiencing psychological distress, social isolation, and financial stress. CONCLUSIONS: Despite having tried numerous treatments, participants with long COVID continued to experience an array of health and financial challenges-findings that underscore the failure of the healthcare system to address the medical needs of people with long COVID. These insights highlight the need for crucial medical, mental health, financial, and community support services, as well as further scientific investigation to address the complex impact of long COVID.

Factors Associated with Long COVID Recovery among US Adults.

BACKGROUND: While factors associated with long COVID (LC) continue to be illuminated, little is known about recovery. This study used national survey data to assess factors associated with recovery from LC. METHODS: We used data from the 2022 National Health Interview Survey, a cross-sectional sample of noninstitutionalized US adults. Survey analysis was used to account for oversampling and nonresponse bias and to obtain nationally representative estimates. A multivariable logistic regression model was used to identify potential predictors of LC recovery. RESULTS: Among those reporting ever having COVID-19, 17.7% or an estimated 17.5 million American adults reported ever having LC, and among those with LC, 48.5% or an estimated 8.5 million reported having recovered. Multivariable logistic regression analysis showed that Hispanic adults were significantly more likely than White adults to report recovery from LC. At the same time, those with severe COVID-19 symptoms and those who had more than a high school degree, were aged 40 years or older, or were female were less likely to report recovery. CONCLUSION: Significant variations in LC recovery were noted across age, sex, race and ethnicity, education, and severity of COVID-19 symptoms. Further work is needed to elucidate the causes of these differences and identify strategies to increase recovery rates.

Factors Associated With Long COVID: Insights From Two Nationwide Surveys.

BACKGROUND: Long COVID is a multisystemic condition that affects the lives of millions of people globally, yet factors associated with it are poorly defined. Our purpose in this study was to identify factors associated with long COVID. METHODS: This cross-sectional study used data from the 2022 Behavioral Risk Factor Surveillance System (BRFSS) and the 2022 National Health Interview Survey (NHIS). We restricted the sample to individuals aged 18 and older who reported a positive COVID-19 test or doctor's diagnosis. Individuals who reported symptoms of at least 3 months were assumed to have long COVID. We identified demographic and clinical characteristics associated with long COVID, in unadjusted and adjusted analyses. RESULTS: The study included 124,313 individuals in the BRFSS cohort and 10,131 in the NHIS cohort who reported a COVID-19 infection, with 26,783 (21.5%) and 1797 (17.7%) reporting long COVID, respectively. We found middle age, female sex, lack of a college degree, and severity of acute COVID-19 infection to be associated with long COVID. In contrast, non-Hispanic Asian and Black Americans were less likely to report long COVID compared with non-Hispanic White individuals. These findings were consistent across datasets. CONCLUSIONS: Several demographic features were associated with long COVID, which may be the result of social, clinical, or biological influences.

Understanding Decision Making as It Influences Treatment in Thoracolumbar Burst Fractures Without Neurological Deficit: Conceptual Framework and Methodology.

STUDY DESIGN: This paper presents a description of a conceptual framework and methodology that is applicable to the manuscripts that comprise this focus issue. OBJECTIVES: Our goal is to present a conceptual framework which is relied upon to better understand the processes through which surgeons make therapeutic decisions around how to treat thoracolumbar burst fractures (TL) fractures. METHODS: We will describe the methodology used in the AO Spine TL A3/4 Study prospective observational study and how the radiographs collected for this study were utilized to study the relationships between various variables that factor into surgeon decision making. RESULTS: With 22 expert spine trauma surgeons analyzing the acute CT scans of 183 patients with TL fractures we were able to perform pairwise analyses, look at reliability and correlations between responses and develop frequency tables, and regression models to assess the relationships and interactions between variables. We also used machine learning to develop decision trees. CONCLUSIONS: This paper outlines the overall methodological elements that are common to the subsequent papers in this focus issue.

Using Equipoise to Determine the Radiographic Characteristics Leading to Agreement on Best Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficits.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVES: Our goal was to assess radiographic characteristics associated with agreement and disagreement in treatment recommendation in thoracolumbar (TL) burst fractures. METHODS: A panel of 22 AO Spine Knowledge Forum Trauma experts reviewed 183 cases and were asked to: (1) classify the fracture; (2) assess degree of certainty of PLC disruption; (3) assess degree of comminution; and (4) make a treatment recommendation. Equipoise threshold used was 77% (77:23 distribution of uncertainty or 17 vs 5 experts). Two groups were created: consensus vs equipoise. RESULTS: Of the 183 cases reviewed, the experts reached full consensus in only 8 cases (4.4%). Eighty-one cases (44.3%) were included in the agreement group and 102 cases (55.7%) in the equipoise group. A3/A4 fractures were more common in the equipoise group (92.0% vs 83.7%, P < .001). The agreement group had higher degree of certainty of PLC disruption [35.8% (SD 34.2) vs 27.6 (SD 27.3), P < .001] and more common use of the M1 modifier (44.3% vs 38.3%, P < .001). Overall, the degree of comminution was slightly higher in the equipoise group [47.8 (SD 20.5) vs 45.7 (SD 23.4), P < .001]. CONCLUSIONS: The agreement group had a higher degree of certainty of PLC injury and more common use of M1 modifier (more type B fractures). The equipoise group had more A3/A4 type fractures. Future studies are required to identify the role of comminution in decision making as degree of comminution was slightly higher in the equipoise group.

Predictive Algorithm for Surgery Recommendation in Thoracolumbar Burst Fractures Without Neurological Deficits.

STUDY DESIGN: Predictive algorithm via decision tree. OBJECTIVES: Artificial intelligence (AI) remain an emerging field and have not previously been used to guide therapeutic decision making in thoracolumbar burst fractures. Building such models may reduce the variability in treatment recommendations. The goal of this study was to build a mathematical prediction rule based upon radiographic variables to guide treatment decisions. METHODS: Twenty-two surgeons from the AO Knowledge Forum Trauma reviewed 183 cases from the Spine TL A3/A4 prospective study (classification, degree of certainty of posterior ligamentous complex (PLC) injury, use of M1 modifier, degree of comminution, treatment recommendation). Reviewers' regions were classified as Europe, North/South America and Asia. Classification and regression trees were used to create models that would predict the treatment recommendation based upon radiographic variables. We applied the decision tree model which accounts for the possibility of non-normal distributions of data. Cross-validation technique as used to validate the multivariable analyses. RESULTS: The accuracy of the model was excellent at 82.4%. Variables included in the algorithm were certainty of PLC injury (%), degree of comminution (%), the use of M1 modifier and geographical regions. The algorithm showed that if a patient has a certainty of PLC injury over 57.5%, then there is a 97.0% chance of receiving surgery. If certainty of PLC injury was low and comminution was above 37.5%, a patient had 74.2% chance of receiving surgery in Europe and Asia vs 22.7% chance in North/South America. Throughout the algorithm, the use of the M1 modifier increased the probability of receiving surgery by 21.4% on average. CONCLUSION: This study presents a predictive analytic algorithm to guide decision-making in the treatment of thoracolumbar burst fractures without neurological deficits. PLC injury assessment over 57.5% was highly predictive of receiving surgery (97.0%). A high degree of comminution resulted in a higher chance of receiving surgery in Europe or Asia vs North/South America. Future studies could include clinical and other variables to enhance predictive ability or use machine learning for outcomes prediction in thoracolumbar burst fractures.

Interobserver Reliability in the Classification of Thoracolumbar Fractures Using the AO Spine TL Injury Classification System Among 22 Clinical Experts in Spine Trauma Care.

STUDY DESIGN: Reliability study utilizing 183 injury CT scans by 22 spine trauma experts with assessment of radiographic features, classification of injuries and treatment recommendations. OBJECTIVES: To assess the reliability of the AOSpine TL Injury Classification System (TLICS) including the categories within the classification and the M1 modifier. METHODS: Kappa and Intraclass correlation coefficients were produced. Associations of various imaging characteristics (comminution, PLC status) and treatment recommendations were analyzed through regression analysis. Multivariable logistic regression modeling was used for making predictive algorithms. RESULTS: Reliability of the AO Spine TLICS at differentiating A3 and A4 injuries (N = 71) (K = .466; 95% CI .458 - .474; P < .001) demonstrated moderate agreement. Similarly, the average intraclass correlation coefficient (ICC) amongst A3 and A4 injuries was excellent (ICC = .934; 95% CI .919 - .947; P < .001) and the ICC between individual measures was moderate (ICC = .403; 95% CI .351 - .461; P < .001). The overall agreement on the utilization of the M1 modifier amongst A3 and A4 injuries was fair (K = .161; 95% CI .151 - .171; P < .001). The ICC for PLC status in A3 and A4 injuries averaged across all measures was excellent (ICC = .936; 95% CI .922 - .949; P < .001). The M1 modifier suggests respondents are nearly 40% more confident that the PLC is injured amongst all injuries. The M1 modifier was employed at a higher frequency as injuries were classified higher in the classification system. CONCLUSIONS: The reliability of surgeons differentiating between A3 and A4 injuries in the AOSpine TLICS is substantial and the utilization of the M1 modifier occurs more frequently with higher grades in the system.

Expert Opinion, Real-World Classification, and Decision-Making in Thoracolumbar Burst Fractures Without Neurologic Deficits?

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVES: To compare decision-making between an expert panel and real-world spine surgeons in thoracolumbar burst fractures (TLBFs) without neurological deficits and analyze which factors influence surgical decision-making. METHODS: This study is a sub-analysis of a prospective observational study in TL fractures. Twenty two experts were asked to review 183 CT scans and recommend treatment for each fracture. The expert recommendation was based on radiographic review. RESULTS: Overall agreement between the expert panel and real-world surgeons regarding surgery was 63.2%. In 36.8% of cases, the expert panel recommended surgery that was not performed in real-world scenarios. Conversely, in cases where the expert panel recommended non-surgical treatment, only 38.6% received non-surgical treatment, while 61.4% underwent surgery. A separate analysis of A3 and A4 fractures revealed that expert panel recommended surgery for 30% of A3 injuries and 68% of A4 injuries. However, 61% of patients with both A3 and A4 fractures received surgery in the real world. Multivariate analysis demonstrated that a 1% increase in certainty of PLC injury led to a 4% increase in surgery recommendation among the expert panel, while a .2% increase in the likelihood of receiving surgery in the real world. CONCLUSION: Surgical decision-making varied between the expert panel and real-world treating surgeons. Differences appear to be less evident in A3/A4 burst fractures making this specific group of fractures a real challenge independent of the level of expertise.

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

STUDY DESIGN: A prospective study. OBJECTIVE: to evaluate the impact of vertebral body comminution and Posterior Ligamentous Complex (PLC) integrity on the treatment recommendations of thoracolumbar fractures among an expert panel of 22 spine surgeons. METHODS: A review of 183 prospectively collected thoracolumbar burst fracture computed tomography (CT) scans by an expert panel of 22 trauma spine surgeons to assess vertebral body comminution and PLC integrity. This study is a sub-study of a prospective observational study of thoracolumbar burst fractures (Spine TL A3/A4). Each expert was asked to grade the degree of comminution and certainty about the PLC disruption from 0 to 100, with 0 representing the intact vertebral body or intact PLC and 100 representing complete comminution or complete PLC disruption, respectively. RESULTS: ≥45% comminution had a 74% chance of having surgery recommended, while <25% comminution had an 86.3% chance of non-surgical treatment. A comminution from 25 to 45% had a 57% chance of non-surgical management. ≥55% PLC injury certainity had a 97% chance of having surgery, and ≥45-55% PLC injury certainty had a 65%. <20% PLC injury had a 64% chance of having non-operative treatment. A 20 to 45% PLC injury certainity had a 56% chance of non-surgical management. There was fair inter-rater agreement on the degree of comminution (ICC .57 [95% CI 0.52-.63]) and the PLC integrity (ICC .42 [95% CI 0.37-.48]). CONCLUSION: The study concludes that vetebral comminution and PLC integrity are major dterminant in decision making of thoracolumbar fractures without neurological deficit. However, more objective, reliable, and accurate methods of assessment of these variables are warranted.

The AO Spine Thoracolumbar Injury Classification System and Treatment Algorithm in Decision Making for Thoracolumbar Burst Fractures Without Neurologic Deficit.

STUDY DESIGN: Prospective Observational Study. OBJECTIVE: To determine the alignment of the AO Spine Thoracolumbar Injury Classification system and treatment algorithm with contemporary surgical decision making. METHODS: 183 cases of thoracolumbar burst fractures were reviewed by 22 AO Spine Knowledge Forum Trauma experts. These experienced clinicians classified the fracture morphology, integrity of the posterior ligamentous complex and degree of comminution. Management recommendations were collected. RESULTS: There was a statistically significant stepwise increase in rates of operative management with escalating category of injury (P < .001). An excellent correlation existed between recommended expert management and the actual treatment of each injury category: A0/A1/A2 (OR 1.09, 95% CI 0.70-1.69, P = .71), A3/4 (OR 1.62, 95% CI 0.98-2.66, P = .58) and B1/B2/C (1.00, 95% CI 0.87-1.14, P = .99). Thoracolumbar A4 fractures were more likely to be surgically stabilized than A3 fractures (68.2% vs 30.9%, P < .001). A modifier indicating indeterminate ligamentous injury increased the rate of operative management when comparing type B and C injuries to type A3/A4 injuries (OR 39.19, 95% CI 20.84-73.69, P < .01 vs OR 27.72, 95% CI 14.68-52.33, P < .01). CONCLUSIONS: The AO Spine Thoracolumbar Injury Classification system introduces fracture morphology in a rational and hierarchical manner of escalating severity. Thoracolumbar A4 complete burst fractures were more likely to be operatively managed than A3 fractures. Flexion-distraction type B injuries and translational type C injuries were much more likely to have surgery recommended than type A fractures regardless of the M1 modifier. A suspected posterior ligamentous injury increased the likelihood of surgeons favoring surgical stabilization.

Unusual Mechanism of Injury during a Wedding Tradition Leading to a Metacarpal Shaft Fracture - A Case Report.

Introduction: "Joota Chori" is a traditional Indian wedding ritual which involves playful competition between the bride's and the groom's friends, with the aim of hiding and retrieving the groom's shoes. Case Report: We describe a rare case scenario wherein an orthopedic surgeon sustained a metacarpal shaft fracture while gripping the shoe and engaging in a tussle with the groom's friends. Despite feeling a sudden snap and experiencing pain, the surgeon held onto the shoe. The subsequent diagnosis revealed a 4th metacarpal long oblique shaft fracture. Conclusion: This case highlights the uncommon mechanism of injury involving forceful hyperextension of the MCP joint and the potential risks associated with physically intense wedding rituals. It also emphasizes the importance of adequate first aid resources and medical attention at wedding venues to promptly address musculoskeletal injuries.

Oxidative stress and COVID-19-associated neuronal dysfunction: mechanisms and therapeutic implications.

Severe acute respiratory syndrome (SARS)-CoV-2 virus causes novel coronavirus disease 2019 (COVID-19), and there is a possible role for oxidative stress in the pathophysiology of neurological diseases associated with COVID-19. Excessive oxidative stress could be responsible for the thrombosis and other neuronal dysfunctions observed in COVID-19. This review discusses the role of oxidative stress associated with SARS-CoV-2 and the mechanisms involved. Furthermore, the various therapeutics implicated in treating COVID-19 and the oxidative stress that contributes to the etiology and pathogenesis of COVID-19-induced neuronal dysfunction are discussed. Further mechanistic and clinical research to combat COVID-19 is warranted to understand the exact mechanisms, and its true clinical effects need to be investigated to minimize neurological complications from COVID-19.

The Diagnostic Process of Spinal Post-traumatic Deformity: An Expert Survey of 7 Cases, Consensus on Clinical Relevance Does Exist.

STUDY DESIGN: Survey of cases. OBJECTIVE: To evaluate the opinion of experts in the diagnostic process of clinically relevant Spinal Post-traumatic Deformity (SPTD). SUMMARY OF BACKGROUND DATA: SPTD is a potential complication of spine trauma that can cause decreased function and quality of life impairment. The question of when SPTD becomes clinically relevant is yet to be resolved. METHODS: The survey of 7 cases was sent to 31 experts. The case presentation was medical history, diagnostic assessment, evaluation of diagnostic assessment, diagnosis, and treatment options. Means, ranges, percentages of participants, and descriptive statistics were calculated. RESULTS: Seventeen spinal surgeons reviewed the presented cases. The items' fracture type and complaints were rated by the participants as more important, but no agreement existed on the items of medical history. In patients with possible SPTD in the cervical spine (C) area, participants requested a conventional radiograph (CR) (76%-83%), a flexion/extension CR (61%-71%), a computed tomography (CT)-scan (76%-89%), and a magnetic resonance (MR)-scan (89%-94%). In thoracolumbar spine (ThL) cases, full spine CR (89%-100%), CT scan (72%-94%), and MR scan (65%-94%) were requested most often. There was a consensus on 5 out of 7 cases with clinically relevant SPTD (82%-100%). When consensus existed on the diagnosis of SPTD, there was a consensus on the case being compensated or decompensated and being symptomatic or asymptomatic. CONCLUSIONS: There was strong agreement in 5 out of 7 cases on the presence of the diagnosis of clinically relevant SPTD. Among spine experts, there is a strong consensus to use CT scan and MR scan, a cervical CR for C-cases, and a full spine CR for ThL-cases. The lack of agreement on items of the medical history suggests that a Delphi study can help us reach a consensus on the essential items of clinically relevant SPTD. LEVEL OF EVIDENCE: Level V.

"Satellite pedicle screws" - A novel technique of pedicle screw insertion in obese patients undergoing lumbar fusion.

The presence of thick sub-cutaneous fat and bulky paraspinal musculature mandates extensive surgical dissection in obese patients undergoing open Transforaminal lumbar interbody fusion surgery. Securing a 'converging' pedicle screw trajectory becomes difficult by the counterforces of the erector spinae muscles and thick sub-cutaneous fat in obese patients, especially at the L5-S1 level. We describe the use of a limited standard posterior midline exposure and a separate, far lateral 'satellite' incision to insert pedicle screws in an optimal trajectory in obese patients. Through proper pre-operative planning of the axial and sagittal MRI, the appropriate entry site is determined which is executed intra-operatively to insert pedicle screws freehand. Through a single 1.5 cm incision, both L5-S1 screws were inserted. Fourteen obese patients (mean BMI was 30.5 ± 1.1) received 56 satellite pedicle screws for TLIF at L5-S1 level. The mean age was 48.3 ± 9.7 years. The mean blood loss was 244.8 ± 114 ml and the mean operative time was 126.7 ± 82.8 min. In all patients, the screws were inserted as per pre-operative planning without any difficulties. All wounds healed well without wound complications. There were no screw related complications, and in the antero-posterior and lateral radiographs, there were no screw breaches. Satellite free-hand pedicle screws are safe and easily reproducible. They enable limited dissection of the main surgical wound and well-medialised converging pedicle screws in obese patients.

Preoperative pain sensitivity predicts postoperative pain severity and analgesics requirement in lumbar fusion surgery - a prospective observational study.

BACKGROUND CONTENT: The goal of postoperative pain management is to facilitate the patient's return to normal activity and decrease the detrimental effects of acute postsurgical pain. In order to provide more tailored and successful pain treatment, it is necessary to identify individuals who are at a high risk of experiencing severe postoperative pain. The most precise way to assess pain sensitivity is by determining the pressure pain threshold and heat pain threshold by objective methods using a digital algometer and neurotouch respectively. PURPOSE: The primary aim of the study is to assess the preoperative pain threshold and its influence on postoperative pain severity and analgesics requirements in patients undergoing lumbar fusion surgeries. STUDY DESIGN: Prospective, observational study. PATIENT SAMPLE: Sixty patients requiring a single-level lumbar fusion surgery. OUTCOME MEASURES: Postoperative pain intensity and the amount of postoperative analgesics consumption. METHODS: In our patients, preoperative pain sensitivity was assessed by pressure pain threshold measurements with the help of a digital algometer, and heat pain threshold using a neurotouch instrument. In addition, pain sensitivity questionnaires (PSQ) were used in all our patients to determine pain sensitivity. Preoperative psychosocial and functional assessments were performed by Hospital anxiety-depression scores (HADS), and Oswestry disability index (ODI) respectively. Preoperative visual analog scale (VAS) score was determined at three instances of needle prick (phlebotomy, glucometer blood sugar, and intradermal antibiotic test dose) and during the range of movements of the lumbar spine region. Postoperative VAS score and postoperative breakthrough analgesic requirements were recorded in all of these patients from day 0 to day 3. RESULTS: The average age of the patients was 51.11±13.467 years and 70% were females. Females had lower mean algometry values (72.14±7.56) compared to males (77.34±6.33). Patients with higher HADS (p<.0016), higher PSQ (p<.001), higher ODI scores(p<.001), and female gender significantly correlated with a lower algometer average indicating high pain sensitivity. Patients with lower preoperative VAS scores and with higher neurotouch scores showed lower postoperative VAS scores at different time periods. Preoperative VAS scores, algometer average scores, neurotouch scores, and HADS scores were considered as independent variables (predictors) for postoperative VAS at 6 hours period. By the multivariate analysis, factors like preoperative VAS scores, algometer average scores, and HADS scores were statistically significant (p<.05). There was a significant correlation between algometer average scores (p<.001) with the breakthrough analgesics. CONCLUSION: Preoperative assessment of pain sensitivity can predict postoperative analgesic requirements and aid in recovery. Patients with a lower pain threshold should be counseled preoperatively and also receive a better titration of analgesics perioperatively.