Purpose of the study. The aim of this work was to study the influence of the slice orientation of T2 axial images in numerical measurements of DSCA and study the effect that this change of slice angle would have on the morphological grading assessment. Methods and Results. TSE T2 three dimensional aquisition MRI studies reconstructed with OsiriX DICOM viewer from 32 patients were used. Patients included were a series of consecutive cases with either suspected spinal stenosis or low back pain. A total of 97 disc levels were studied and axial reconstructions were made at 0°, +10°, +20°, +30° relative to the disc space orientation. For each image, DSCA was digitally measured and a severity grade was assigned by two observers according to the recently-published 4-point (A-D) morphological grading system. Interobserver kappa score was 0.71. Statistical analysis of DSCA measurements was performed using kappa and t-tests. Comparing DCSA between 0° at each level and +10°, +20° and +30° slice orientation, a significant increase in surface area was found in each case (P<0.0001). % change in DSCA combining all disc levels comparing 0° and +10°: range -15.48% to +31.89% (SD 18.40%); 0° and +20°: range -24.00% to +143.82% (SD 20.45%); 0° and +30°: range -29.35% to +231.13% (SD 26.52%). At 13 disc levels, DSCA was <100mm. 2. at 0°, but changed to >100mm. 2. in three cases by a +10° increase, in five cases by a +20° increase and in 10 cases by a +30° increase. In only two out of 97 levels studied did the morphological grading change as the angle increased, one of which was not amongst those above (change in DSCA from <100mm. 2. to >100mm. 2. ). Conclusion. MRI slice angle significantly affects DSCA, and thus potentially the decision taken regarding management whilst morphological grading is little affected by image acquisition technique

Lateral oblique radiographs are considered important for the identification of spondylolytic lesions, but these projections will give a clear view only when the radiological beam is in the plane of the defect. We studied the variation in orientation of spondylolytic lesions on CT scans of 34 patients with 69 defects. There was a wide variation of angle: only 32% of defects were orientated within 15° of the 45° lateral oblique plane. Lateral oblique radiographs should not be considered as the definitive investigation for spondylolysis. We suggest that CT scans with reverse gantry angle are now more appropriate than oblique radiography for the assessment of spondylolysis. Variation in the angle of the defect may also need consideration when direct repair is being planned

Aims. The aim of this study was to determine the differences in spinal imaging characteristics between subjects with or without lumbar developmental spinal stenosis (DSS) in a population-based cohort. Methods. This was a radiological analysis of 2,387 participants who underwent L1-S1 MRI. Means and ranges were calculated for age, sex, BMI, and MRI measurements. Anteroposterior (AP) vertebral canal diameters were used to differentiate those with DSS from controls. Other imaging parameters included vertebral body dimensions, spinal canal dimensions, disc degeneration scores, and facet joint orientation. Mann-Whitney U and chi-squared tests were conducted to search for measurement differences between those with DSS and controls. In order to identify possible associations between DSS and MRI parameters, those who were statistically significant in the univariate binary logistic regression were included in a multivariate stepwise logistic regression after adjusting for demographics. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported where appropriate. Results. Axial AP vertebral canal diameter (p < 0.001), interpedicular distance (p < 0.001), AP dural sac diameter (p < 0.001), lamina angle (p < 0.001), and sagittal mid-vertebral body height (p < 0.001) were significantly different between those identified as having DSS and controls. Narrower interpedicular distance (OR 0.745 (95% CI 0.618 to 0.900); p = 0.002) and AP dural sac diameter (OR 0.506 (95% CI 0.400 to 0.641); p < 0.001) were associated with DSS. Lamina angle (OR 1.127 (95% CI 1.045 to 1.214); p = 0.002) and right facet joint angulation (OR 0.022 (95% CI 0.002 to 0.247); p = 0.002) were also associated with DSS. No association was observed between disc parameters and DSS. Conclusion. From this large-scale cohort, the canal size is found to be independent of body stature. Other than spinal canal dimensions, abnormal orientations of lamina angle and facet joint angulation may also be a result of developmental variations, leading to increased likelihood of DSS. Other skeletal parameters are spared. There was no relationship between DSS and soft tissue changes of the spinal column, which suggests that DSS is a unique result of bony maldevelopment. These findings require validation in other ethnicities and populations. Level of Evidence: I (diagnostic study). Cite this article: Bone Joint J 2021;103-B(4):725–733

Background. An improved understanding of intervertebral disc (IVD) structure and function is required for treatment development. Loading induces micro-fractures at the interface between the nucleus pulposus (NP) and the annulus fibrosus (AF), which is hypothesized to induce a cascade of cellular changes leading to degeneration. However, there is limited understanding of the structural relationship between the NP and AF at this interface and particularly response to load. Here, X-ray scattering is utilised to provide hierarchical morphometric information of collagen structure across the IVD, especially the interface region under load. Methodology. IVDs were imaged using the I22 SAXS/WAXS beamline at Diamond Light Source. Peaks associated with the D-banded structure of collagen fibrils were fitted to quantify their azimuthal distribution, as well the magnitude and direction of internal strains under static and applied strain (0–20%). Results. IVD tissue regions exhibited structural “AF-like” and “NP-like” fingerprints. Demonstrating high internal strains on collagen fibres particularly within the NP region of the disc. AF and NP regions showed distinct collagen orientation and internal strains with an apparent lack of bracing structure seen at the interface between the differential mechanical tissues. X-ray scattering under tensile strain provided structural information at high resolution, with clear differences observed between normal and degenerate discs under load. Conclusion. X ray scattering has been utilised to develop an improved understanding of collagen structure across the intervertebral disc which can be utilised to gain an increased understanding of load induced propagation of micro fissures and disc degeneration. Conflict of Interest: No conflict of interest. Funding: BioPro Network, UCL for funding this study through support from the MRC (MR/R025673/1)

Purpose of the study and background. Healthcare practitioners' (HCPs) attitudes and beliefs about MSK pain influence their practice behaviour. The Pain Attitudes and Beliefs Scale (PABS), developed for use in the context of LBP, consists of two subscales (biomedical and biopsychosocial) is the most widely used measure. However, poor performance of the biopsychosocial orientation scale is attributed, in part, to inadequate conceptualisation of the orientation. Purpose. To develop a new biopsychosocial scale and adapt the PABS to assess HCPs' attitudes and beliefs about common MSK pain. Methods and results. A grounded conceptualisation process was conducted with 40 MSK HCPs and/or researchers using concept mapping methodology. The resultant conceptual framework consisted of six primary domains of biopsychosocial clinical orientation (bio-clinical, therapeutic relationship, individual patient aspects, emotions, social and work) and informed development of new scale items. These items were included with existing PABS items in a national survey of UK-based HCPs, and analysis was conducted on 587 responses. Exploratory and confirmatory factor analyses identified and confirmed a new 10-item biopsychosocial scale (Cronbach's alpha of 0.83). The new biopsychosocial and existing biomedical scales demonstrated good test-retest reliability (ICC(2,1) 0.77 and 0.74 respectively). Standard error of measurement and smallest detectable change were also established. Conclusion. The new generic MSK version of the PABS biopsychosocial scale shows promising structural validity and test-retest reliability. The existing PABS biomedical scale's structure and performance was upheld. The new conceptual framework provides a contemporary, comprehensive understanding of the biopsychosocial clinical approach to common MSK pain, with potential value for the development, delivery and evaluation of biopsychosocial clinical practice. No conflicts of interest. Sources of funding:. Kirsty Duncan was the holder of an ACORN PhD studentship from Keele University. Part of the conceptualisation component of this work was also supported by a Chartered Society of Physiotherapy Charitable Trust International Lecture Fund Award. Annette Bishop and Nadine Foster were supported through an NIHR Research Professorship for Nadine Foster (NIHR-RP-011-015). NEF is an NIHR Senior Investigator. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health

Background. There is an increasing burden of LBP. Clinical guidelines promote physical activity (PA) and self-management strategies and aim to reform unhelpful clinical activity. This study explores osteopaths' beliefs about non-specific low back pain (NSLBP) and the role of activity in the treatment of NSLBP. Methods. Semi-structured interviews were conducted with a purposive sample of twelve qualified osteopaths in the UK. Interviews were transcribed verbatim and constructivist grounded theory was used to conceptualise, collect and analyse data. Results. Four categories; practitioners' beliefs and mode of practice, PA interventions used, challenges and obstacles to promoting activity and strategies used in practice; conceptualised three practitioner styles. Variation was reported in the management of NSLBP, perceptions of successful PA interventions and strategies used in practice. Perceived obstacles to PA were identified. A proposed model highlights how different practitioner styles adopted a biomedical or behavioural orientation towards NSLBP, leading to different approaches to behavioural change strategies and self-management in the treatment of NSLBP. Conclusion. There are opportunities for educational programs to enhance competencies in exercise prescription and activity promotion, and knowledge of behavioural change strategies to promote self-management in NSLBP. Further quantitative research is recommended to measure osteopaths' attitudes and behaviour related to activity promotion and to test clinical effectiveness of related interventions. No conflicts of interest. No funding obtained

Aim of Study and Background. The vertebral endplate (VEP) is characterised as a bilayer of cartilage and bone, acting as a boundary between the disc and the vertebra. The disc being the largest avascular tissue in the body, relies primarily on the nutritional pathways from the vascular network in the adjacent VEP. Disruption of this nutrient supply has been identified as a major contributor to disc degeneration, yet the 3D topology of the network is poorly understood. The aim of this work is the characterisation of this vascular network to further understand the physiology of the vascular network and the correlation between disc degeneration and nutrient supply. Methods and Results. Caudal and cranial VEP sections were sampled from lumbar ovine spines and imaged using high-resolution micro-computed tomography (micro-CT) at 4.92 µm pixel size. The diameter, length, orientation and depth from the VEP surface were measured for individual canals using 3D canal centreline models using ScanIP. The results showed higher concentration of canals in the central regions of the VEP and in caudal VEP to the disc. Large transverse canals were identified running parallel to the VEP surface connected to both the disc and the vertebra, and depth-dependence of the length and diameter of the canals was recorded. Conclusion. This work demonstrates that the micro-CT, coupled with centreline models is an extremely useful tool for the characterisation of the vascular network in the VEP. Further study is required to evaluate the effect of degeneration on the observed patterns and to assess reliability of these results when compared with human VEP. No conflicts of interest. No funding obtained

The objective of this study was to assess the reliability and appropriateness of statistical shape modelling for capturing variation in thoracic vertebral anatomy for future use in assessing scoliotic vertebral morphology. Magnetic resonance (MR) images of the thoracic vertebrae were acquired from 20 healthy adults (12 female, 8 male) using a 1.5 T MR scanner (Intera, Philips). A T1 weighted spin-echo sequence (repetition time = 294 ms, echo time = 8 ms, number of signal averages = 3) was used. A set of slices (number = 27, thickness = 1.9 mm, gap = 1.63 mm, pixel size = 0.5 mm) were acquired for each vertebrae, parallel to the mid-transverse plane of the vertebral body. Repeated imaging, including participant repositioning, was performed for T4, T8 and T12 to assess reliability. Landmark points were placed on the images to define anatomical features consisting of the vertebral body and foramen, pedicles, transverse and spinous processes, inferior and superior facets. A statistical shape model was created using software tools developed in MATLAB (R2013a, The MathWorks Inc.). The model was used to determine the mean vertebral shape and ‘modes of variation’ describing patterns in vertebral shape. Analysis of variance was used to test for differences between vertebral levels and subjects and reliability was assessed by determining the within-subject standard deviation from the repeated measurements. The first three modes of variation, shown below (green = mean, red and blue = ±2 standard deviations about the mean), accounted for 70% of the variation in thoracic vertebral shape (Mode 1 = 44%, Mode 2 = 19%, Mode 3 = 4%). Visual inspection indicated that these modes described variation in anatomical features such as the aspect ratio of the vertebral bodies, width and orientation of the pedicles, and position and orientation of the processes and facet points. Variation in shape along the thoracic spine, characterised by these modes of variation, was consistent with that reported in the literature. Significant differences (p< 0.05) between vertebral levels and between some subjects were found. The reliability of the method was good with low relative error (Mode 1 = 5%, Mode 2 = 8%, Mode 3 = 19%). Statistical shape modelling provides a reliable method for characterizing many anatomical features of the thoracic vertebrae in a compact number of variables. This is useful for robustly assessing morphological differences between scoliotic and non-scoliotic vertebrae and in assessing entry points and trajectories for pedicle screws

Introduction. Spinopelvic parameters describe the orientation, shape, and morphology of the spine and pelvis. These parameters change during the first 10 years of life in children without spinal deformity; however, spinopelvic parameters have yet to be defined in children with significant early-onset scoliosis (EOS). Sagittal plane alignment could affect the natural history and outcome of interventions for EOS. As a result, spinopelvic parameters are being defined for this population. On the basis of the landmarks used for measurement of these parameters, there may be inherent error in performing these measurements on the immature pelvis. The purpose of this study is to define the variability associatedwith the measurement of spinopelvic parameters in children with EOS. Methods. Standing, lateral radiographs of 11 patients with untreated EOS were evaluated. Sagittal spinopelvic parameters (pelvic incidence [PI], pelvic tilt [PT], sacral slope [SS], and modified pelvic radius angle [PR]) were measured. To assess intraobserver reliability, these measurements were repeated 15 days apart. To define interobserver reliability, radiographs were measured by 2 independent observers. Results. Average age was 5·7 years and average Cobb angle was 80·8°. Repeated measurements by one observer showed no significant differences for any of the parameters. Paired samples correlations showed a moderate correlation between measurements of PI (0·564), whereas stronger correlations were demonstrated for measurements of PT (0·816), SS (0·947), and PR (0·789). Interobserver analysis showed a significant difference in measurement of SS (p=0·003), whereasmeasurements of PI, PT, and PR did not differ significantly between independent observers. Conclusions. Intraobserver variabilty yielded acceptable correlations for PT, SS, and PR; however, we noted only a moderate correlation for PI. Interobserver analysis showed a significant difference only in SS. The intraobserver and interobserver variablity of measurements for PT and PR were superior than were those for PI and SS. This finding may be related to difficulties in determining the orientation of the sacral endplate in the immature pelvis when measuring PI and SS

Spinal deformities are a common feature of Marfan’s syndrome and can be a significant cause of morbidity. The morphology of the scoliosis associated with this condition was previously described by Sponseller, but no correlation with the pelvic parameters has been seen. We performed a retrospective radiological study of 58 patients with scoliosis, secondary to Marfan’s syndrome and related the findings in the thoracolumbar spine to the pelvic parameters, including pelvic version (tilt), pelvic incidence and sacral slope. Our results showed marked abnormalities in the pelvic values compared with those found in the unaffected population, with increased retroversion of the pelvis in particular. In addition we found a close correlation between the different patterns of pelvic parameters and scoliosis morphology. We found that pelvic abnormalities may partially dictate the spinal disorders seen in Marfan’s syndrome. Our results supplement the well-established Sponseller classification, as well as stressing the importance of considering the orientation of the pelvis when planning surgery

Aims

The aim of this study is to test the hypothesis that three grades of sagittal compensation for standing posture (normal, compensated, and decompensated) correlate with health-related quality of life measurements (HRQOL).

Purpose. To study the relationship between Zygoapophysial Joint Tropism and pathologic fractures affecting lumbar and thoracic vertebrae in elderly patients. Methods. The sagittal plane orientation of the Zygoapophysial joints (facets or ZAJ) of 324 vertebrae of 63 patients were measured on MRI scans, stratified into lumbar and thoracic, fractured and non-fractured, and then classified according to the presence of tropism. The correlation between tropism and fractures, demographics pertaining to age, spinal level, and morbidity were studied. Results. From the 415 ZAJ pairs studied, 23 were excluded because of insufficient imaging leaving 388 ZAJ pairs. In 155 Thoracic ZAJ pairs, there 92 with a fracture, 39% demonstrating tropism; and there were 63 with no fracture, 43% demonstrating tropism. In 237 Lumbar ZAJ pairs, there were 144 with a fracture, 73% demonstrating tropism; there were 93 with no fracture, 42% demonstrating tropism. Conclusion. Our study suggests a correlation between the emergence of pathological fractures in the spine and tropism which is statistically significant in the lumbar but not in the thoracic. The authors confirm that this abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Aims

The aim of this study was to use diffusion tensor imaging (DTI) to investigate changes in diffusion metrics in patients with cervical spondylotic myelopathy (CSM) up to five years after decompressive surgery. We correlated these changes with clinical outcomes as scored by the Modified Japanese Orthopedic Association (mJOA) method, Neck Disability Index (NDI), and Visual Analogue Scale (VAS).

Aims

Significant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis.

Generally, it is considered to be safe in preventing iatrogenic instability if half of the facet joint is left intact during decompression surgeries. By removing half of the facets can we get adequate decompression of the nerve roots? Is there a difference at different levels in the lower lumbar spine? What is the inclination of the facet joint at each level and how does it affect the stability?. Retrospective study. We analysed 200 consecutive magnetic reasonance imaging (MRI) scans of the lumbosacral spine at L3/4, L4/5, and L5/S1 levels. We measured the difference in the distance from midline to the lateral border of the foramen and from midline to the middle of the facet joint at each level on either sides. The angle of the facet joint was also noted. The distance to the foramen from the level of the middle of the facet joints seem to be between 5-6mm lateral at every level. The angle of the facet joints at L3/4 is 35.9°+/−7.4°, while at L4/5 it is 43.2°+/−8.0°, and at L5/S1 it is 49.4°+/−10.1°. In lumbar spine decompression surgeries, after the midline decompression extending up to half of the facet joints, a further undercutting of the facet joints to 5-6mm is therefore required to completely decompress the nerve root in the foramen. The more coronal orientation of the facet joint at L5/S1 conforms better stability than that at L3/4level. Therefore, stabilisation of the spine should be considered if more than 2cm of the posterior elements are removed from midline at L3/4 level

Background. Several theories have been put forward with respect to the mechanical role of the thoracolumbar fascia (TLF) but none have been substantiated in part due to an inability to explore its function in vivo. This study explored the use of ultrasound to image the layers of the TLF in vivo. Methods. Initially a cadaveric dissection of the fascia was performed to gain an appreciation of the 3-D orientation and representation of the TLF in the lumbar region. A conventional ultrasound system (Diasus, Dynamic Imaging Ltd) was then used to image the 3 layers of the fascia on 40 normal subjects (18 males and 22 females, mean age 27.3±5.8 years) and the reliability of these measures was investigated on a subset of this population. Results. Using ultrasound, the posterior and middle layer of the TLF could be readily identified, however it was not possible to visualise the anterior layer due to the limitations of the scanner used. The thickness of the posterior layer ranged from 1.3 ±0.4 to 1.5±0.4 mm depending on location relative to the spinous process. The middle layer tended to be thinner being 1.0±0.4mm on average. Intra-observer errors were within acceptable ranges, although not ideal. Conclusion. Ultrasound may be an important tool for understanding the mechanical role of fascia, however this would necessitate the use of high resolution scanner to enhance the reliability of images. Further work is required to image changes in the presentation of fascia in different loaded functional positions

The difficulties in the management of chronic lower back pain are recognised by professionals and patients alike but this recognition can stem from very different perspectives. This paper discusses how patients identify ways in which their experience and perception of pain changes over time and how that impacts on their relationship with professionals delivering a treatment regime. It presents the results of secondary analysis of longitudinal patient data collected under a serial qualitative interview methodology in which the analytical focus is on patients' changing expectations and perceptions of pain. This orientation to the data demonstrates not only established notions of ‘acceptance’ within biographical disruption, but also ways in which individuals revise, mediate, negotiate and integrate meanings of pain to gain both short and long-term coherence. By taking a more holistic view of patient narratives that situates treatment prescriptions and related behaviours within the context of individuals' everyday life, the analysis highlights ‘sense-making’ as a dynamic process. In doing so, it shows that patients draw reference points not only from their most immediate experiences of chronic low back pain but also from the (dis)continuities of lifecourse experience prior to the onset of pain and anticipated for the future. The paper therefore seeks to both illuminate the dynamics of the patient perspective and provide indicators of where some differences in patient/professional perceptions may lie. Suggestions for promoting concordance between patients and health care professionals will be discussed

Background. The clinical assessment of Chronic Low Back Pain (CLBP) is usually undertaken at a single time point at clinic rather than through continuous monitoring. To address this, a wearable prototype sensor to monitor motion of the lumbar spine and pelvis has been developed. Sensor Development, Testing and Results. The system devised was based on inertial sensor technology combined with wireless Body Sensor Network (BSN) platform. This was tested on 16 healthy volunteers for ten common movements (including sit to stand, lifting, walking, and stairs) with results validated by optical tracking. Preliminary findings suggest good agreement between the optical tracker and device with mean average orientation error (°) ranging from 0.1 ± 2.3 to 4.2 ± 2.6. The sensor repeatability errors range from 0 to 4° while subject movement variability ranged from 4% to 14%. Parameters of angular motion suggest greater movement of the lumbar spine compared to the pelvis with mean velocities (°/s) for lumbar spine ranging from 15.3 to 74.13 and pelvis ranging from 5.6 to 40.74. Further analysis revealed the extent to which the pelvis was engaged, as a proportion of the total movement. This demonstrated that the pelvis underwent smooth transitions from low (0.02), moderate (0.4) to high (0.99) use during different movement phases. Conclusion. A wearable sensor has been developed to record and quantify lumbar and pelvic movement. This permits an understanding of the lumbo-pelvic relationship to be characterized in an objective way during daily tasks. The next stage of the project will involve testing with CLBP patients

Introduction. Spinopelvic parameters describe the orientation, shape, and morphology of the spine and pelvis. In children without spinal deformity, these parameters change during the first 10 years of life; however, spinopelvic parameters need to be defined in children with significant early-onset scoliosis (EOS). The purpose of this study is to examine the effects of EOS on sagittal spinopelvic alignment. We hypothesise that sagittal spinopelvic parameters for patients with EOS will differ from age-matched children without spinal deformity. These values will act as a baseline for future studies and may predict postoperative complications such as proximal junctional kyphosis and implant failure in children being treated with growing systems. Methods. Standing, lateral radiographs of 82 untreated patients with EOS with Cobb angle greater than 50° were evaluated. Sagittal spine parameters (sagittal balance, thoracic kyphosis [TK], lumbar lordosis [LL]) and sagittal pelvic parameters (pelvic incidence [PI], pelvic tilt [PT], sacral slope [SS], and modified pelvic radius angle [PR]) were measured. These results were compared with those reported by Mac-Thiong and colleagues (Spine, 2004) for a group of similar aged children without spinal deformity. Results. Patients had a mean age of 5·17 years and mean Cobb angle of 73·3° (□}17·3°). Mean sagittal spine parameters were: sagittal balance (+2·4 cm [□}4·03]), TK (38·2° [□}20·8°]), and LL (47·8° [□}17·7°]). These values were similar to those reported for asymptomatic patients (table). Mean sagittal pelvic parameters were: PI (47·1° [□}15·6°]), PT (10·3° [□}10·7°]), SS (35·5° [□}12·2°]), and PR (57·1° [□}21·2°]). Although PI was similar to age-matched controls, PT was significantly higher and there was a trend for lower SS in the study population. Conclusions. Sagittal plane spine parameters in children with EOS were similar to those in children without spinal deformity. Pelvic parameters (PI, SS, PR) were similar between groups; however, children with EOS had signs of pelvic retroversion (increased pelvic tilt)