Mauricio Campos

The Spine Instability Neoplastic Score: an independent reliability and reproducibility analysis.

BACKGROUND Metastatic vertebral instability has not yet been clearly defined in the literature; there still exists a paucity of reliable criteria to assess the risk of vertebral collapse. PURPOSE We performed an independent interobserver and intraobserver agreement evaluation of the Spine Instability Neoplastic Score (SINS) and correlated the score with selected clinical cases and the treatment they received. STUDY DESIGN Independent reliability study for the newly created SINS. PATIENT SAMPLE Thirty patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected from the orthopedic surgery and radiotherapy departments databases. OUTCOME MEASURES Patients were rated and classified for spinal stability using SINS. Intraclass correlation coefficient (ICC) and Fleisss kappa measures were occupied for reliability analysis. METHODS Patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected and classified for spinal stability using the SINS by orthopedic surgeons and nonorthopedic oncology specialists. ICC and Fleisss kappa were calculated for inter- and intraobserver agreement. A comparative analysis of SINS and the actual management was also conducted. RESULTS Interobserver ICC reliability for the SINS was 0.79; κ values for location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement were 0.81, 0.58, 0.21, 0.45, 0.42, and 0.29 respectively. Intraobserver ICC for the SINS scores was 0.96; ICC values for the same components were 0.98, 0.98, 0.87, 0.88, 0.92, and 0.86, respectively. Potentially unstable lesions (SINS score≥7) were operated on in 62.5%. CONCLUSIONS SINS seem to be a reproducible tool that could be used equally by multiple specialists to estimate metastatic vertebral stability; however, prospective clinical validation is still pending.

An independent interobserver reliability and intraobserver reproducibility evaluation of the new AOSpine Thoracolumbar Spine Injury Classification System.

Study Design. Agreement study. Objective. To perform an independent interobserver and intraobserver agreement evaluation of the new AOSpine Thoracolumbar Spine Injury Classification System. Summary of Background Data. The new AOSpine Thoracolumbar Spine Injury Classification System was recently published. It showed substantial reliability and reproducibility among the surgeons who developed it; however, an independent evaluation has not been performed. Methods. Anteroposterior and lateral radiographs, and computed tomographic scans of 70 patients with acute traumatic thoracolumbar injuries were selected and classified using the morphological grading of the new AOSpine Thoracolumbar Spine Injury Classification System by 6 evaluators (3 spine surgeons and 3 orthopedic surgery residents). After a 6-week interval, the 70 cases were presented in a random sequence to the same evaluators for repeat evaluation. The Kappa coefficient (&kgr;) was used to determine the interobserver and intraobserver agreement. Results. The interobserver reliability was substantial when considering the fracture type (A, B, or C), with a &kgr;= 0.62 (0.57–0.66). The interobserver agreement when considering the subtypes was moderate; &kgr;= 0.55 (0.52–0.57). The intraobserver reproducibility was also substantial, with 85.95% full intraobserver reproducibility considering the fracture type, with &kgr;= 0.77 (0.72–0.83), and was also substantial when considering subtypes with 75.71% full agreement and &kgr;= 0.71 (0.67–0.76). No significant differences were observed between spine surgeons and orthopedic residents in the overall interobserver reliability and intraobserver reproducibility, or in the inter- and intraobserver agreement of specific A, B, or C types of injuries. Conclusion. This classification allows adequate agreement among different observers and by the same observer on separate occasions. Future prospective studies should evaluate whether this classification improves clinical decision making. Level of Evidence: 2

Unanticipated revision surgery in adolescent idiopathic scoliosis.

Study Design. Retrospective case series. Objective. The objective of this study was to share our experience in the surgical treatment of adolescent idiopathic scoliosis (AIS), specifically the rate of revision surgeries and their indications. Summary of Background Data. Minimizing AIS surgical morbidity includes prevention of short- and long-term complications that could require an unanticipated revision. There have been an increasing number of reports about revision rates and their causes in AIS. This study summarizes the experience of a large patient population treated by a single surgeon in a single institution. Methods. All patients who underwent surgical treatment for AIS between 10 and 20 years of age during 1983 to 2005 were reviewed. All revision surgeries performed during the same period were searched. The indications for revision and type of procedure performed were recorded. Results. A total of 502 patients with AIS underwent spinal fusion with instrumentation at an average age of 14.3 years at initial surgery. In 485 patients, the surgery consisted of posterior-only spinal fusion. A total of 24 revision surgeries were performed for 23 patients (4.9%; cumulative probability of revision = 8%). The primary indications for revision were residual rib deformity (n = 8), instrumentation dislodgement (n = 4), compensatory curve progression (n = 3), junctional kyphosis (n = 3), and symptomatic implants (n = 3). One patient had a late infection. There was 1 case of pseudoarthrosis. One patient requested scar revision. There were no cases of neurological deficit. Conclusion. In this single-surgeon series, revision after the index spinal fusion was required for a relatively low proportion of patients. The main indications for revision were residual rib deformity, hook dislodgment, and progression of the unfused compensatory curve.

An independent inter- and intra-observer agreement evaluation of the AOSpine subaxial cervical spine injury classification system.

Study Design. An agreement study. Objective. The aim of this study was to perform an independent interobserver and intraobserver agreement assessment of the AOSpine subaxial cervical spine injury classification system. Summary of Background Data. The AOSpine subaxial cervical spine injury classification system was recently described. It showed substantial inter- and intraobserver agreement in the study describing it; however, an independent evaluation has not been performed. Methods. Anteroposterior and lateral radiographs, computed tomography scans, and magnetic resonance imaging of 65 patients with acute traumatic subaxial cervical spine injuries were selected and classified using the morphologic grading of the subaxial cervical spine injury classification system by 6 evaluators (3 spine surgeons and 3 orthopedic surgery residents). After a 6-week interval, the 65 cases were presented to the same evaluators in a random sequence for repeat evaluation. The kappa coefficient (&kgr;) was used to determine the inter- and intraobserver agreement. Results. The interobserver agreement was substantial when considering the fracture main types (A, B, C, or F), with &kgr; = 0.61 (0.57–0.64), but moderate when considering the subtypes: &kgr; = 0.57 (0.54–0.60). The intraobserver agreement was substantial considering the fracture types, with &kgr; = 0.68 (0.62–0.74) and considering subtypes, &kgr; = 0.62 (0.57–0.66). No significant differences were observed between spine surgeons and orthopedic residents in the overall inter- and intraobserver agreement, or in the inter- and intraobserver agreement of specific A, B, C, or F type of injuries. Conclusion. This classification allows adequate agreement among different observers and by the same observer on separate occasions. Future prospective studies should determine whether this classification allows surgeons to decide the best treatment for patients with subaxial cervical spine injuries. Level of Evidence: 3

Infantile Thoracolumbar Kyphosis Secondary to Lumbar Hypoplasia

BACKGROUND There is a normal transition from the kyphotic alignment that is present in the spine of the newborn to the normal sagittal contours that are present in the adult spine. Although abnormal kyphosis at the thoracolumbar junction in infants is rare, it can result from congenital anomalies and bone dysplasias. We report the cases of seven otherwise normal infants who had thoracolumbar kyphosis due to lumbar hypoplasia, with total spontaneous resolution over time. METHODS The medical records of seven patients who met the inclusion criteria were reviewed. Clinical data and radiographs were analyzed to rule out the presence of congenital anomalies or bone dysplasias. Progression of kyphosis was measured on serial radiographs made with the patient sitting and standing. RESULTS All patients were managed conservatively with observation alone. No patient had a neurologic deficit. The average age at the time of the initial diagnosis was 5.3 months, and the average duration of follow-up was 5.7 years. Three cases of kyphosis were secondary to L1 hypoplasia, and four were secondary to L2 hypoplasia. The average initial kyphosis was 34.2 degrees, which progressed to 0.4 degrees of lordosis at the time of the latest follow-up. CONCLUSIONS Thoracolumbar kyphosis in normal infants secondary to lumbar hypoplasia may resolve spontaneously. After congenital anomalies and bone dysplasias are ruled out, a period of observation is advised.

Actualización en estenorraquis lumbar: diagnóstico, tratamiento y controversias

Spinal lumbar stenosis is a disease that occurs mainly between the 5th and 7th decade of life and can be congenital or acquired. The latter has many etiologies, but a degenerative cause is the most common. Stenosis is a narrowing of the spinal canal diameter caused by many factors such as bulging discs, hypertrophy of flavum ligament, facet capsule thickening and osteophyte formation. The classical symptom of the disease is sciatic pain, that improves with lumbar flexion and worsens with ambulation. Neurological examination is often normal and the most useful imaging test is magnetic resonance imaging (MRI). Conservative management consists in non-steroidal anti-inflammatory drugs, muscle relaxants, physical therapy and epidural - radicular infiltrations. Spinal infiltrations have a proven efficacy for pain management. A good result of this therapy predicts a favorable outcome after surgery. Surgical treatment consists in decompression with or without lumbar fusion. The addition of an arthrodesis is recommended for degenerative spondylolisthesis, correction of deformities, recurrent spinal stenosis with instability, sagittal or coronal imbalance and adjacent segment disease.

Helping Elderly Users Report Pain Levels: A Study of User Experience with Mobile and Wearable Interfaces

Pain is usually measured through patient reports during doctor visits, but it requires regular evaluation under real-life conditions to be resolved effectively. Over half of older adults suffer from pain. Chronic conditions such as this one may be monitored through technology; however, elderly users require technology to be specifically designed for them, because many have cognitive and physical limitations and lack digital skills. The purpose of this article is to study whether mobile or wearable devices are appropriate to self-report pain levels and to find which body position is more appropriate for elderly people to wear a device to self-report pain. We implemented three prototypes and conducted two phases of evaluation. We found that users preferred the wearable device over the mobile application and that a wearable to self-report pain should be designed specifically for this purpose. Regarding the placement of the wearable, we found that there was no preferred position overall, although the neck position received the most positive feedback. We believe that the possibility of creating a wearable device that may be placed in different positions may be the best solution to satisfy users’ individual preferences.

Chronic liver failure and concomitant distant infections are associated with high rates of neurological involvement in pyogenic spinal infections.

Study Design. A retrospective study of a consecutive series of all patients with pyogenic spinal infections treated at a single institution over a 10-year period. Objective. To investigate risk factors for neurologic impairment with pyogenic spinal infections. Summary of Background Data. Pyogenic spinal infections are frequently associated with neurologic deficit at the time of initial diagnosis. Current evidence suggests that advanced age, diabetes mellitus, rheumatoid arthritis, systemic corticosteroid therapy, impaired immune status, infection with Staphylococcus aureus, and more proximal infections are risk factors for neurologic involvement. To the authors’ knowledge, however, the influence of chronic liver failure or concomitant nonspinal infection has not been previously investigated. Methods. A review of all patients discharged with a diagnosis of pyogenic spinal infection was performed. Data were collected, including age, sex, site of infection, degree of neurologic impairment, bacterial organism isolated, and various medical comorbidities such as diabetes mellitus, rheumatoid arthritis, chronic corticosteroid therapy, chronic liver failure, chronic renal failure, smoking, human immunodeficiency virus infection, intravenous drug abuse, cancer, cardiac disease, and the presence of a distant, nonspinal site of infection. Results. Fifty-five consecutive patients with pyogenic spinal infections were identified. Statistical analysis demonstrated that the presence of an epidural abscess, chronic liver failure, or a distant nonspinal infection were the only significant risk factors for neurologic involvement. Conclusion. The current data suggest that chronic liver failure and the presence of a distant nonspinal infection are possible risk factors for neurologic involvement in patients with pyogenic spinal infections. These risk factors have not been previously described. This knowledge warrants closer surveillance for neurologic deficit in patients with these conditions.

Rachipagus Parasite Associated with Myelocystocele and Diastematomyelia

A case of parasitic rachipagus associated with myelocystocele, diastematomyelia and teratoma is presented. The parasite was successfully removed, and the spinal canal was reconstructed using bone harvested from the parasite.

Lumbar paraspinal muscle fat infiltration is independently associated with sex, age, and inter-vertebral disc degeneration in symptomatic patients

PurposeTo determine the association of paraspinal muscles and psoas relative cross-sectional area (RCSA) and fat signal fraction (FSF) with sex, age, and intervertebral disc degeneration (IDD) in symptomatic patients.MethodsWe retrospectively evaluated 80 adult patients with spinal symptoms using T2-weighted magnetic resonance images. We determined RCSA and FSF of the paraspinal muscles (erector spinae and multifidus) and psoas from L1–L2 to L5–S1; we determined IDD using the Pfirrmann classification. We compared differences in muscle RCSA and FSF based on sex and IDD, and we correlated age and IDD with RCSA and FSF. Using multivariate linear regression analyses, we determined the impact of sex, age, and IDD on RCSA and FSF.ResultsMen exhibited larger psoas RCSA but not larger paraspinal muscles RCSA than women. Women had larger FSF in the paraspinal muscles and psoas. Increasing IDD was associated with larger FSF if ≥2 Pfirrmann grades were observed. IDD correlated with FSF of the paraspinal muscles, and age correlated with FSF of the paraspinal muscles and psoas. IDD was less consistently correlated with RCSA, but age correlated negatively with RCSA of all three muscles. Linear regression analyses demonstrated that sex, age, and IDD were each independently associated with FSF of the paraspinal muscles; additionally, sex and age, but not IDD, were associated with psoas FSF. RCSA was less consistently influenced by these three variables.ConclusionsSex, age, and IDD are independently associated with paraspinal muscles FSF; only sex and age influence psoas FSF.