Relationship Between Paraspinal Muscle Morphology, Function, and Physical Status in Common Spinal Disorders

The deep paraspinal muscles are essential for providing physical support and stability to the spinal column. They play a vital role in maintaining fine postural control of the spine and are responsible for controlling all movements of the vertebral column. These muscles work in coordination to ensure proper alignment and movement of the spine, thereby contributing to overall spinal health and function. Dysfunction or weakness in paraspinal muscles can lead to instability, poor posture, and increased risk of spinal pain disorders. Therefore, understanding the role of deep paraspinal muscles is crucial in maintaining spinal health and preventing musculoskeletal disorders. This summary highlights the significance of assessing both morphology and function of paraspinal muscles in common spinal disorders including chronic low back pain (LBP) and degenerative cervical myelopathy (DCM). While previous studies have focused on either morphology or functional deficits separately, this dissertation aims to comprehensively investigate the structure-function relationship using advanced imaging techniques like magnetic resonance imaging (MRI) and ultrasound. Specifically, chapter three focuses on understanding the relationship between lumbar multifidus muscle (MF) muscle morphology and function in chronic LBP patients, utilizing measures such as fatty infiltration, contraction, stiffness, and elasticity. Similarly, chapter four and five aim to assess cervical muscle morphology as predictors of prognosis and functional recovery in patients with DCM, both pre- and post-operatively. Such comprehensive evaluations are crucial for improving diagnosis, intervention, and therapeutic strategies in spinal disorders, ultimately enhancing patients’ clinical outcomes and quality of life. Finally, chapter six discusses the findings from chapters three, four and five and offers a general conclusion and recommendations for future research

Hypermobility syndromes in paediatrics: progressions in assessment and management

Joint Hypermobility Syndrome (JHS) and Ehlers Danlos Syndrome-Hypermobility Type (EDS-HM) referred to collectively as Hypermobility Syndromes (HMS), are heritable disorders of connective tissue comprising symptomatic joint hypermobility predisposing to arthralgia, soft-tissue injury and joint instability which if not managed effectively result in ongoing cycles of disability. How HMS affects paediatric patients and how physiotherapists approach the condition in this population is unclear. The aim of this thesis was to address gaps in knowledge and practice and advance strategies in assessment and management of symptoms. Study 1 involved an original online survey of paediatric physiotherapists, gauging understanding of HMS in children, and investigating current trends in clinical practice regarding diagnosis, treatment and management, in a UK context. Findings highlighted the prevalence of musculoskeletal pain and injury in children, the unsuitability of current diagnostic tools for assessing children, the lack of a standardised approach to diagnosis in addition to preferences for exercise interventions. This needs analysis informed Study 2 which involved the design and implementation of a novel Physical Assessment Battery for Paediatric Hypermobility merging 4 existing tests: the Nine-Point Beighton Score, Revised Brighton Criteria, Paediatric Balance Scale and Paediatric Pain Questionnaire, to capture a more complete profile of symptoms in the functional and clinical assessment of children. Children with diagnoses of HMS were assigned to a clinical group (n=29), and age and gender matched children recruited as a control group (n=25) were tested. Distinct differences were revealed between groups in terms of functional balance, pain intensity and location and trends in physical activity, exercise and sport, in addition to significant correlations observed between hypermobility and both balance and pain intensity scores. Findings from Study 1 and Study 2 twinned with supplementary qualitative data, collectively confirm the need to validate a paediatric specific assessment tool, and design blended treatment and management strategies for children experiencing symptoms to increase quality of life and reduce disability

The safety and efficacy of mesenchymal stem cells for prevention or regeneration of intervertebral disc degeneration: a systematic review

General Posters: abstract no. GP86INTRODUCTION: Mesenchymal stem cells (MSCs) have been used to halt the progression or regenerate the disc with hopes to prevent or treat discogenic back pain. However, the safety and efficacy of the use of MSCs for such treatment in animal and human models at short and long term assessment (i.e. greater than 48 weeks) have not been systematically addressed. This study addressed a systematic review of comparative controlled studies addressing the use of MSCs to that of no treatment/saline for the treatment of disc degeneration. METHODS: Online databases were extensively searched. Controlled trials in animal models and humans were eligible for inclusion. Trial design, MSC characteristics, injection method, disc assessment, outcome intervals, and complication events were assessed. Validity of each study was assessed addressing trial design. Two individuals independently addressed the aforementioned. RESULTS: Twenty-two animal studies were included. No human comparative controlled trials were reported. All three types of MSCs (i.e. derived from bone marrow, synovial and adipose tissue) showed successful inhibition of disc degeneration progression. From three included studies, bone marrow derived MSC showed superior quality of disc repair when compared to other treatments, including TGF-β1, NP bilaminar co-culture and axial distraction regimen. However, osteophyte development was reported in two studies as potential complication of MSC transplantation. CONCLUSIONS: Based on animal models, the current evidence suggests that in the short-term MSC transplantation is safe and effective in halting disc degeneration; however, additional and larger studies are needed to assess the long-term regenerative effects and potential complications. Inconsistency in methodological design and outcome parameters prevent any robust conclusions. In addition, randomized controlled trials in humans are needed to assess the safety and efficacy of such therapy.published_or_final_versio

Anterior Lumbar Interbody Fusion (ALIF): a 360 degrees analysis

Lower back pain is a major cause of morbidity and disability in the western world. Lumbar fusion surgery is indicated in a minority of these patients and ALIF is one of the well-accepted techniques. This thesis represents the body of work, which addresses several aspects of ALIF surgery – a 360-degree overview. Initially we review the role of infection as a cause for degeneration of intervertebral disc, which is the commonest etiology for ALIF surgery. A systematic review demonstrated a high rate of bacterial growth in symptomatic disc degeneration but also raised the concern for the role of contamination and lack of adequate power. A pilot clinical study was undertaken which revealed a similar degree of bacterial infection. This was followed by a multicenter prospective case cohort study (DISC) to compare infection rates, evaluate contamination rate and review histopathological support for inflammation. At interim analysis, we found no difference in true infection rates between cases and controls, high rate of contamination in paraspinal tissue and no correlation between histopathological signs of inflammation and growth of organism. Indications for ALIF surgery and outcomes were evaluated, and ALIF had excellent clinical and radiological outcomes in degenerative disc disease, scoliosis and spondylolisthesis. Adjacent segment disease and failed posterior fusion had small sample size and were not as successful compared to other indications. We perform a clinical study to evaluate objective measurement of physical activity by accelerometers in spine surgery, demonstrating good patient compliance and no correlation between accelerometer measured physical activity and subjective outcome scores. Several radiological outcomes were also investigated. Utilizing a new standardization technique to measure foraminal area, we found ALIF significantly improved all the foraminal parameters, and that posterior disc height correlated with foraminal height restoration. A clinical study on i-factor as a bone graft substitute revealed a high rate of radiological fusion. We also found a reasonable sustained indirect reduction of spondylolisthesis by ALIF. Finally, we evaluated the complications of ALIF surgery particularly the vascular complications. The advantages of the team approach and lessons learnt to minimize complications are discussed

Acupuncture in Modern Medicine

This book contains four integrated sections: 1) Acupuncture Research; 2) New Developments in Acupuncture; 3) Acupuncture Therapy for Clinical Conditions and 4) Assessment and Accessibility in Acupuncture Therapy. Section 1 provides updates on acupuncture research. From acupuncture effects in modulation of immune system to the role of nitric oxide in acupuncture mechanisms, chapters in this section offer readers the newest trends in acupuncture research. Section 2 summarizes new developments in acupuncture. The included chapters discuss new tools and methods in acupuncture such as laser acupuncture, sham needles, and new technologies. Section 3 discusses acupuncture therapy for clinical conditions. The chapters in this section provide comprehensive and critical views of acupuncture therapy and its application in common clinical practice. Section 4 takes a new look at the issues related to assessment and accessibility in acupuncture therapy. These issues are central to developing new standards for outcome assessment and policies that will increase the accessibility to acupuncture therapy

A personalised approach to spine surgery

Background: Anterior lumbar interbody fusion (ALIF) remains one of the mainstay surgical approaches in treating painful degenerative disc disease with or without segmental instability in the lower spine. The risk factors and complication profile for ALIF differs significantly from other established fusion techniques. Objectives: The goal of the first part of this thesis is to establish the factors associated with long-term clinical outcome (Chapter 2) and short-term perioperative outcomes (Chapter 3) following ALIF. Chapter 4 focuses on the long-term radiographic evidence for biomaterial alternatives for ALIF implants, namely titanium (Ti)-coated PEEK integrated cages. Methods and Results: From a prospective cohort analysis of 147 patients undergoing ALIF, elderly age (≥64 years old) was associated with an increased rate of subsidence but does not affect clinical outcomes. Obesity was not associated with postoperative complications or follow-up patient-reported outcomes. Failed fusion was significantly higher for smokers, and they were significantly more likely than non-smokers to experience postoperative complications such as pseudoarthrosis. To assess risk factors for perioperative complications and readmissions after ALIF, the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analysed. ALIF was associated with prolonged length of stay and higher rate of return to operating theatre compared to posterior lumbar fusion. Obesity and alcohol intake increased the risk of 30-day readmissions. Discharge to non-home destination following ALIF was independently associated with wound complications and venous thromboembolism. Finally, a prospective follow-up study was performed to determine the long-term radiographic outcome following ALIF using Ti-coated PEEK cages with allograft and INFUSE. Effective fusion was achieved at up to 24-month follow-up for various indications including degenerative spine/disc disease, low grade lumbar isthmic spondylolisthesis, spondylotic radiculopathy and discogenic low back pain. Conclusions: Collectively, this thesis highlights the importance of personalising the care of an ALIF surgery patient, through identification and optimization of individual risk factors for short-term and long-term outcomes, as well as through choice of implant biomaterial and design

Diseases of the Brain, Head and Neck, Spine 2020–2023

This open access book offers an essential overview of brain, head and neck, and spine imaging. Over the last few years, there have been considerable advances in this area, driven by both clinical and technological developments. Written by leading international experts and teachers, the chapters are disease-oriented and cover all relevant imaging modalities, with a focus on magnetic resonance imaging and computed tomography. The book also includes a synopsis of pediatric imaging. IDKD books are rewritten (not merely updated) every four years, which means they offer a comprehensive review of the state-of-the-art in imaging. The book is clearly structured and features learning objectives, abstracts, subheadings, tables and take-home points, supported by design elements to help readers navigate the text. It will particularly appeal to general radiologists, radiology residents, and interventional radiologists who want to update their diagnostic expertise, as well as clinicians from other specialties who are interested in imaging for their patient care

IN VITRO AND IN VIVO BIOMECHANICAL INVESTIGATION OF THE CLINICAL PRACTICE OF DISC PROLAPSE PREVENTION AND REHABILITATION

Underlying this thesis is the McKenzie school of thought, a physiotherapy approach that teaches clinicians to recommend particular exercises to their clients in an attempt to accelerate recovery/ prevent recurrence of disc prolapse. The recommendations are based on an untested clinical theory that movements opposite to those that cause disc prolapse can achieve reversal of disc prolapse. Little consideration has been given scientifically to the reversal of the failure process of the lumbar discs. Three in vitro and one in vivo study were designed to attain a greater understanding of both disc failure and the mechanics of its clinical treatment responses and thereby provide a foundation for evidence-based practice. The first in vitro study in this thesis compared in vitro and in vivo herniated discs in an attempt to link the two and provide a more thorough understanding of the in vitro model proposed to test the mechanical theory underlying the McKenzie derangement approach. Ten C3/4 osteoligamentus porcine specimens were repeatedly flexed or flexed and side bent to result in posterior migration of the nucleus. Three of the 10 specimens had posterior migration of the nucleus. Statistically significant (p 33%) disc height loss occurred in all 10 specimens. The results provide a sub-classification of in vitro herniated discs that is similar to the spectrum of herniated discs that occurs in vivo. Continuing from the disc height loss sub-classification of post-herniated in vitro discs, the second in vitro study in this thesis pursues alternate methods of creating herniation with the goal of creating herniation without causing more than thirty three percent disc height loss of the specimens. Repeated flexion of porcine cervical specimens under a lower compression level (1kN) resulted in disc herniation but with loss of 50% of the pre-test disc height (p < 0.001). Re-hydrating specimens by injecting the disc after a period of failure testing with a barium sulphate nucleus mix (n = 5) or by placing the specimen in a saline bath for an extended period of time (n = 4) resulted in a significant increase of the disc height of the specimens. Further flexion testing of the specimens significantly reduced the disc height again. Intermittent saline injection of specimens (n = 3) during the failure procedure did not prevent or reduce the disc height loss that occurred in the absence of saline injections. Using higher compression levels (2 and 2.596kN, n = 4), failure testing under torque control (n = 3), non-physiologically starting the annular rupture (n = 5) and using hypolordotic thoracic porcine spines (n = 9) instead of porcine cervical spines were unsuccessful attempts at creating herniations. This study indicated that the in vitro model used in the first in vitro study displayed features from one end of the spectrum of damage seen clinically but was then the best-available. Combined these two studies provide a framework for interpretation of the results of the subsequent and third in vitro study in this thesis. The focus of the third study is the mechanical investigation of the McKenzie clinical theory of the treatment response seen in vivo in prolapsed discs, which is that movements or positioning can alter the location of a displaced portion of nucleus in a prolapsed disc. This study is a proof of the principle on which this aspect of the McKenzie approach is based and provides, to the author’s knowledge, the first scientific evidence supporting the theory that repeating movements opposite to those that caused posterior migration of the nucleus can centralize the prolapsed material. The results indicate that the McKenzie approach works on some prolapsed discs and not on others. Consideration of the changes in disc height of the specimens during the testing procedures offers some understanding of the varied success of this approach and exposes a vast area of future research that will refine the clinical approach and mechanical understanding of this specific disc pathology. The fourth study, an in vivo study, provides a first look at the kinematics and kinetics of the current in vivo application of this approach. Twenty asymptomatic subjects volunteered to participate in this study and performed frequently prescribed McKenzie exercises and a selection of activities of daily living during which a 3-SPACE Isotrak system measured their three dimensional lumbar kinemetics. One subject underwent a series of McKenzie exercises while electromyography and three-dimensional lumbar motion were measured. Mean peak extension of extension in standing and extension in lying exercises were within 3% (SD 22.33%) of each other. An additional 6.75% (SD 11.18%) of extension occurred when the extension in lying exercise was combined with a Grade 3 Maitland extension mobilization to L3, a passive physiotherapy technique that involves the therapist applying intermittent low amplitude oscillations to, in this case, the posterior aspect of the spinous process with the goal of subsequently increasing the range of active motion in the direction of the mobilization. The peak extension during the extension in lying exercise was increased after the mobilization relative to the pre-mobilization range. The mean peak right side bend in the right side glide exercise, normalized to the full right side bend range, was 61% (SD 17.4%). The L4-5 forces at the position of peak extension in extension in lying and extension in standing were 828.97N and 1368.86N respectively. The peak flexion ranges of the activities of daily living investigated match those previously used to create disc prolapse when applied at high repetitions and under moderate axial compression. The lumbar spine ranges achieved in commonly prescribed McKenzie rehabilitative and preventative exercises and those that occur in seemingly non-problematic activities of daily living were quantified. The results of this study will enhance clinical practice by providing quantitative evidence of the relative peak motion of the McKenzie exercises as well as highlighting seemingly benign activities of daily living that involve levels of flexion, side bend and rotation sufficient to cause disc damage and even prolapse. The macroscopic goal of this thesis was to attain a greater understanding of the mechanics of both disc failure and its clinical treatment responses and thereby provide a foundation for evidence-based practice, a goal that was successfully achieved. This thesis ultimately challenged and increased our understanding of pathological discs while simultaneously adding information to assist clinical decision making. Several new contributions to the existing knowledge of lumbar spine biomechanics and clinical concepts of treating disc prolapse have been made