The Hip Center Rule Can be Used to Decide if Measured Pelvic Incidence is Accurate

STUDY DESIGN: Simulation study. OBJECTIVE: Pelvic incidence (PI) should be considered during surgical planning. The ideal patient position with both hip centers perfectly aligned for a lateral radiograph is rarely obtained. It has been suggested that a radiograph with axial and coronal rotation up to 20° is acceptable to obtain a measured PI within 6 degrees of the actual PI. We seek to: (1) evaluate the effect of variations in PI and patient malpositioning on measured vs true PI, and (2) determine whether the presence of one hip center within the bony acetabular rim of the contralateral hip can serve as a simple clinical decision rule on the accuracy of measured PI. METHODS: Published anthropometric three-dimensional pelvic landmark coordinates were used in this study. Radiographic projections were generated using linear algebra for combinations of axial and coronal rotation from -20° to +20°. True and measured PIs were compared. RESULTS: Rotation to 20° cannot be uniformly accepted as decision rule. Pelvises with higher PIs are more sensitive to malpositioning with greater PI deviation with smaller amounts of rotation. Diagnostic performance of the hip center rule demonstrated a sensitivity of 25.58% and a specificity of 100.00%. CONCLUSIONS: Rather than assessing the quality of radiographs for PI measurement by magnitude of malpositioning, we recommend clinicians use the hip center rule. As long as at least one hip center is contained within the bony acetabular rim of the contralateral hip, there is high confidence that measured PI will be within 6° of true PI

Thoracic Epidural Abscesses: A Systematic Review.

Study Design: Systematic review. Objectives: Past research has demonstrated increased speed and severity of progression for spinal epidural abscesses (SEAs) of the thoracic level, specifically, when compared with SEAs of other spinal cord levels. Untreated, this infection can result in permanent neurological sequelae with eventual progression to death if inadequately managed. Despite the seriousness of this disease, no articles have focused on the presentation, diagnosis, and treatment of SEAs of the thoracic level. For this reason, specific focus on SEAs of the thoracic level occurred when researchers designed and implemented the following systematic review. Methods: A query of Ovid-Medline and EMBASE, Cochrane Central, and additional review sources was conducted. Search criteria focused on articles specific to thoracic epidural abscesses. Results: Twenty-five articles met inclusion criteria. The most commonly reported symptoms present on admission included back pain, paraparesis/paraplegia, fever, and loss of bowel/bladder control. Significant risk factors included diabetes, intravenous drug use, and advanced age ( Conclusions: For the first time researchers have focused specifically on SEAs of the thoracic level, as opposed to previously published general analysis of SEAs as a whole. Based on the results, investigators recommend early magnetic resonance imaging of the spine, laboratory workup (sedimentation rate/C-reactive protein, complete blood count), abscess culture followed by empiric antibiotics, and immediate surgical decompression when neurological deficits are present

The Psychometric Properties of a Self-Administered, Open-Source Module for Valuing Metastatic Epidural Spinal Cord Compression Utilities.

INTRODUCTION: Web surveys are often used for utility valuation. Typically, custom utility valuation tools that have not undergone psychometric evaluation are used. OBJECTIVES: This study aimed to determine the psychometric properties of a metastatic epidural spinal cord compression (MESCC) module run on a customizable open-source, internet-based, self-directed utility valuation platform (Self-directed Online Assessment of Preferences [SOAP]). METHODS: Individuals accompanying patients to the emergency department waiting room in Ottawa, Canada, were recruited. Participants made SOAP MESCC health state valuations in the waiting room and 48 h later at home. Validity, agreement reliability, and responsiveness were measured by logical consistency of responses, smallest detectable change, the interclass correlation coefficient, and Guyatt\u27s responsiveness index, respectively. RESULTS: Of 285 participants who completed utility valuations, only 113 (39.6%) completed the re-test. Of these 113 participants, 92 (81.4%) provided valid responses on the first test and 75 (66.4%) provided valid responses on the test and re-test. Agreement for all groups of health states was adequate, since their smallest detectable change was less than the minimal clinically important difference. The mean interclass correlation coefficients for all health states were \u3e 0.8, indicating at least substantial reliability. Guyatt\u27s responsiveness indices all exceeded 0.80, indicating a high level of responsiveness. CONCLUSIONS: To our knowledge, this is the first validated open-source, web-based, self-directed utility valuation module. We have demonstrated the SOAP MESCC module is valid, reproducible, and responsive for obtaining ex ante utilities. Considering the successful psychometric validation of the SOAP MESCC module, other investigators can consider developing modules for other diseases where direct utility valuation is needed

Kyphoplasty vs Vertebroplasty: A Systematic Review of Height Restoration in Osteoporotic Vertebral Compression Fractures

Background: Back pain is a leading cause of morbidity in older US adults, especially those with osteoporosis. Osteoporotic vertebral compression fractures (OVCF) commonly occur in people with osteoporosis. ~1/3 of OVCF are symptomatic with acute or chronic low back pain. Annual US cases of osteoporosis with OVCF are ~700,000/year. OVCF and osteoporosis cause high levels of morbidity, decreased functional independence, and chronic pain. Conservative treatment for OVCF is often insufficient for many patients. Insufficient vertebral height caused by OVCF can lead to spinal deformities, reduced pulmonary function, depression, reduced mobility, and lower quality of life. Surgical correction is a viable option for increasing vertebral height in patients with OVCF. Kyphoplasty and vertebroplasty are vertebral augmentation therapies that can restore bone height for the alleviation of OVCF. Both procedures involve injection of a polymer cement into sites of fracture. Only kyphoplasty involves using an inflatable balloon to first make space for polymer injection. These minimally invasive procedures are recommended for patients who have OVCF but are refractory to conventional therapies. Also, patients with benign bone tumors or traumatic acute vertebral compression fractures with a local kyphotic angle greater than 15 degrees can benefit from these procedures. The aim of our systematic review was to identify the overall effectiveness of kyphoplasty and vertebroplasty. Height restoration after treatment was used as the key indicator of therapeutic success. Restoration of function and pain relief were also assessed. Purpose: To critically investigate whether vertebral body height restoration correlates with pain relief after kyphoplasty and vertebroplasty. Primary Outcome: height restoration. Secondary Outcomes: pain relief, functionality, cement leakage, Cobb’s Angle, wedge angle restoration, kyphosis angle restoration, and Gardner’s angle. We assessed only randomized controlled trials (RCTs) to generate a more robust and clinically applicable. We also provide an update on the literature comparing kyphoplasty versus vertebroplasty for height restoration, pain relief, and function restoration. We searched 6 databases to ensure that the review was comprehensive. Methods: We performed a systematic review per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol. Level II randomized controlled trials assessing kyphoplasty and/or vertebroplasty were included. Study selection inclusion criteria: patients \u3e 18 years, in English, study of OVCF, active comparator vs placebo, outcome measure of height restoration, with pain relief and functionality as secondary outcomes. Of 4147 individual articles, 238 articles were screened, and 33 were analyzed. Of the 33 analyzed studies, 6 compared kyphoplasty to vertebroplasty. Results: Vertebral Height Restoration 7 studies of vertobroplasty 2 showed height loss 1 showed height restoration 2 showed absolute height gain 20 studies of kyphoplasty None showed height loss 8 showed height restoration 8 showed absolute height gain 6 head-to-head comparisons 3 showed correlation of cement injection volume with improved height 5 favored kyphoplasty for height restoration Alleviation of Pain: Assessed by visual analogue scale (VAS)score 6 of 6 vertebroplasty studies showed reduced postop pain 6 of 18 kyphoplasty studies showed sustained reduced pain at 12 months 6 studies compared kyphoplasty & vertebroplasty and none saw a difference between the 2 for reducing postop pain Restoration of Function Assessed by Oswestry disability index (ODI) 3 studies showed improved ODI after vertebroplasty at 18 to 36 months postop 4 studies showed improved ODI at 12 months after kyphoplasty 3 studies compared kyphoplasty & vertebroplasty and all showed lower postop ODI Conclusions: Both kyphoplasty and vertebroplasty are effective treatments for OVCF and are viable options for OVCF patients. Both treatments restored some vertebral body height, reduced kyphosis angle, improved Cobbs angle, and improved wedge angle. Both treatments showed similar benefits of pain reduction and improved functionality. It was unclear whether fracture type or age of fracture influence procedure outcomes. Kyphoplasty has the possibility of cement leakage, which can lead to negative outcomes. It was not possible to conclude whether one approach was superior.https://scholarlycommons.henryford.com/sarcd2021/1006/thumbnail.jp

The psychometric properties of a self-administered, open-source, web-based tool for valuing metastatic spinal cord compression health states

Objectives: Internet market research panels are often used as a substitute for general population samples for ex ante utility valuation. Typically, custom utility valuation tools that have not undergone psychometric evaluation are used. This study aims to determine the psychometric properties of a customizable opensource internet-based self-directed utility valuation tool the (Self-directed Online Assessment of Preferences; SOAP) module for metastatic epidural spinal cord compression health states. Methods: Individuals accompanying patients to the emergency department waiting room were recruited into this study. Participants made SOAP metastatic epidural spinal cord compression health state valuations in the waiting room, and 48 hours later at home. Validity, agreement reliability, and responsiveness were measured by logical consistency of responses, Smallest Detectable Change, the Interclass Correlation Coefficient, and Guyatt\u27s Responsiveness Index respectively. Results: Of 285 participants who completed utility valuations, only 113 (39.6%) completed the re-test. Of these 113 participants, 92 (81.4%) provided valid responses on the first test, and 75 (66.4%) provided valid responses on the test and re-test. Agreement for all groups of health states was adequate since their Smallest Detectable Change was less than the Minimally Clinically Important Difference. The mean Interclass Correlation Coefficient s for all health states were greater than 0.8 indicating at least substantial reliability. Guyatt\u27s Responsiveness Indices all exceeded 0.80, indicating high level of responsiveness. Conclusions: The SOAP metastatic epidural spinal cord compression module is a valid, reproducible and responsive tool for obtaining ex ante utilities. This tool can now be used to obtain general population valuations of metastatic epidural spinal cord compression health states. Additional modules could be developed to facilitate decision making for other diseases

A general population utility valuation study for metastatic spinal cord compression

Objectives: A particularly disabling consequence of cancer is metastatic epidural spinal cord compression (MESCC). Few prospective studies on the treatment of MESCC have collected quality-adjusted-life-year weights (termed “utilities”). Utilities are an important summative measure which distills health outcomes to a single number that can be used by healthcare providers to counsel patients and policy makers to make funding decisions. The primary objective of this study is to obtain utility valuations for the 31 unique MESCC health states from a Canadian general population perspective. The secondary objective of this study is to determine the relative importance of various aspects to quality-of-life in MESCC. Method: We recruited a sample of 822 adult Canadians from a market research company. Quota sampling was used to ensure that the participants were representative of the Canadian population in terms of age, gender, and province of residence. Participants were asked to rate 6 of the 31 MESCC health states using the validated SOAP tool. Results: Sixty-six percent of participants provided logical ratings (for example perfect health was rated higher than non-ambulatory health states). The regression model building exercise revealed that members of the general population value all attributes characterizing MESCC health states equally. Furthermore, dysfunction follows a pattern of diminishing marginal disutility). That is, each additional dysfunction affects a smaller incremental change in utility than the previous dysfunction. These results demonstrate that from the societal perspective, physical function is valued equal to other facets of well-being. Ambulation and continence, which are dysfunctions addressed by surgery, are no more important than other attributes evaluated (pain, other symptoms, and level of independence). Conclusions: We have provided utility estimates for metastatic epidural spinal cord compression health states. The utility values derived from this study can be used to help inform population level healthcare decision making, such as allocation of limited resources for specific treatments. Approximately 63.7% of participants completed, understood and engaged in the task. Thus self-administered utility valuation over the internet is feasible. This approach can serve as a model for deriving utilities for conditions for which quality-oflife data is not available

Rotational Anatomy of the Radius and Ulna: Surgical Implications

© 2020 American Society for Surgery of the Hand Purpose: The rotational anatomy of the forearm bones is not well defined. This study aims to further the understanding of the torsion of the radius and ulna to better guide treatment. Methods: Computed tomography images of 98 cadaveric forearms were obtained and 3-dimensional models of the radius and ulna were generated and analyzed. The rotation of the radius was evaluated by comparing the orientation of the distal radius central axis (DRCA) with the volar cortex of the distal radius (DR) and biceps tuberosity (BT). The rotation of the ulna was evaluated by assessing the orientation of the ulnar head with respect to the proximal ulna. Results: The DR volar cortex pronates from distal to proximal. The BT was 43.8° ± 16.9° supinated from the DRCA (range, 2.7°–86.5°). The mean difference in rotation between contralateral biceps tuberosities was 7.0° ± 7.1°. The volar cortex of the DR was 12.6° ± 5.4° supinated compared with the DRCA. The ulnar head was pronated 8.4° ± 14.9° with respect to the greater sigmoid notch (range, 50.3° pronation–22.0° supination). Conclusions: The BT has a variable orientation relative to the DR, but it is generally located anteromedially in a supinated arm or 136° opposite the radial styloid. Understanding the rotational anatomy of the radius and ulna can play an important role in surgical planning and implant design. The rotational anatomy of the radius and ulna varies significantly between individuals, but is similar in contralateral limbs. Clinical relevance: Distal radius volar cortex rotational anatomy can help guide treatment of DR fractures and malunions as well as assist in positioning of wrist arthroplasty implants, particularly in the presence of bone loss. The side-to-side similarities demonstrated in this study should be helpful in managing patients with segmental bone loss or fracture malunion and those requiring joint reconstruction

Calculating Ex-ante Utilities From the modified Japanese Orthopedic Association Score: A Prerequisite for Quantifying the Value of Care for Cervical Myelopathy

STUDY DESIGN: General population utility valuation study. OBJECTIVE: The aim of this study was to develop a technique for calculating utilities from the modified Japanese Orthopedic Association (mJOA) Score. SUMMARY OF BACKGROUND DATA: The ability to calculate quality-adjusted life-years (QALYs) for degenerative cervical myelopathy (DCM) would enhance treatment decision making and facilitate economic analysis. QALYs are calculated using utilities. METHODS: We recruited a sample of 760 adults from a market research panel. Using an online discrete choice experiment, participants rated eight choice sets based on mJOA health states. A multiattribute utility function was estimated using a mixed multinomial-logit regression model. The sample was partitioned into a training set used for model fitting and validation set used for model evaluation. RESULTS: The regression model demonstrated good predictive performance on the validation set with an area under the curve of 0.81 (95% confidence interval: 0.80-0.82)). The regression model was used to develop a utility scoring rubric for the mJOA. Regression results revealed that participants did not regard all mJOA domains as equally important. The rank order of importance was (in decreasing order): lower extremity motor function, upper extremity motor function, sphincter dysfunction, upper extremity sensation. CONCLUSION: This study provides a simple technique for converting the mJOA score to utilities and quantify the importance of mJOA domains. The ability to evaluate QALYs for DCM will facilitate economic analysis and patient counseling. Clinicians should heed these findings and offer treatments that maximize function in the attributes viewed most important by patients.Level of Evidence: 3

Calculating ex-ante Utilities From the Neck Disability Index Score: Quantifying the Value of Care For Cervical Spine Pathology

STUDY DESIGN: General population utility valuation study. OBJECTIVE: To develop a technique for calculating utilities from the Neck Disability Index (NDI) score. METHODS: We recruited a sample of 1200 adults from a market research panel. Using an online discrete choice experiment (DCE), participants rated 10 choice sets based on NDI health states. A multi-attribute utility function was estimated using a mixed multinomial-logit regression model (MIXL). The sample was partitioned into a training set used for model fitting and validation set used for model evaluation. RESULTS: The regression model demonstrated good predictive performance on the validation set with an AUC of .77 (95% CI: .76-.78). The regression model was used to develop a utility scoring rubric for the NDI. Regression results also revealed that participants did not regard all NDI items as equally important. The rank order of importance was (in decreasing order): pain intensity = work; personal care = headache; concentration = sleeping; driving; recreation; lifting; and lastly reading. CONCLUSIONS: This study provides a simple technique for converting the NDI score to utilities and quantify the relative importance of individual NDI items. The ability to evaluate quality-adjusted life-years using these utilities for cervical spine pain and disability could facilitate economic analysis and aid in allocation of healthcare resources

Back to Bayesian: A strategy to enhance prognostication of metastatic spine disease.

AIMS: Clinicians must consider prognosis when offering treatment to patients with spine metastases. Although several prognostic indices have been developed and validated for this purpose, they may not be applicable in the current era of targeted systemic therapies. Even before the introduction of targeted therapies, these prognostic indices should not have been directly used for individual patient decision making without contextualising with other sources of data. By contextualising, we mean that prognostic estimates should not be based on these scores alone and formally incorporate clinically relevant factors not part of prognostic indices. Contextualisation requires the use of Bayesian statistics which may be unfamiliar to many readers. In this paper we show readers how to correctly apply prognostic scores to individual patients using Bayesian statistics. Through Bayesian analysis, we explore the impact of new targeted therapies on prognostic estimates obtained using the Tokuhashi score. METHODS: We provide a worked calculation for the probability of a patient surviving up to 6 months using dichotomous prognostication. We then demonstrate how to calculate a patient\u27s expected survival using continuous prognostication. Sensitivity of the posterior distribution to prior assumptions is illustrated through effective sample size adjustment. RESULTS: When the predicted prognosis from the Tokuhashi score is contextualised with data on contemporary systemic treatments, patients previously deemed non-surgical candidates may be eligible for surgery. CONCLUSIONS: Bayesian prognostication generates intuitive results and allows multiple data points to be synthesised transparently. These techniques can extend the usefulness of existing prognostic scores in the era of targeted systemic therapies