How has genetics altered our understanding of low back pain: implications for its treatment

Concurrent Session 15 - The gene pearl: genetics and your practiceLow back pain is one of the most common disorders seen in general, orthopaedic and rheumatological practice. While there are many causes, one of the most common is degenerative disc disease. This has traditionally been thought of as a degenerative condition with ageing and spinal loading being major aetiological factors. However, recent epidemiological and twins studies would suggest a major genetic component. Over the past 10 years, we have collected the HKU degenerative disc disease cohort, which consists of 3500 population based subjects between 18 and 55, and of Southern Chinese origin. All individuals are characterized clinically and by MRI, and blood samples obtained for DNA isolation. Using this unique database, we have demonstrated a number of novel genetic risk factors that predispose our population to disc degeneration. We were also able to demonstrate a significant relationship between degenerative disc disease and low back pain, as well as some unusual patterns of disc degeneration with relevance on the aetiology of degeneration. The talk will discuss these in detail, and how they have altered our understanding of low back pain, and therefore the ways that we should be treating them, with particular emphasis on novel diagnostic methods and biological therapies.postprintThe 2011 Combined Scientific Meeting of ANZCA / HKCA, Hong Kong, China, 14-17 May 2011

How has genetics altered our understanding of low back pain: implications for its treatment

Concurrent Session 15 - The gene pearl: genetics and your practiceLow back pain is one of the most common disorders seen in general, orthopaedic and rheumatological practice. While there are many causes, one of the most common is degenerative disc disease. This has traditionally been thought of as a degenerative condition with ageing and spinal loading being major aetiological factors. However, recent epidemiological and twins studies would suggest a major genetic component. Over the past 10 years, we have collected the HKU degenerative disc disease cohort, which consists of 3500 population based subjects between 18 and 55, and of Southern Chinese origin. All individuals are characterized clinically and by MRI, and blood samples obtained for DNA isolation. Using this unique database, we have demonstrated a number of novel genetic risk factors that predispose our population to disc degeneration. We were also able to demonstrate a significant relationship between degenerative disc disease and low back pain, as well as some unusual patterns of disc degeneration with relevance on the aetiology of degeneration. The talk will discuss these in detail, and how they have altered our understanding of low back pain, and therefore the ways that we should be treating them, with particular emphasis on novel diagnostic methods and biological therapies.postprintThe 2011 Combined Scientific Meeting of ANZCA / HKCA, Hong Kong, China, 14-17 May 2011

Verification Of Measurements Of Lumbar Spinal Dimensions In T1- And T2-weighted Magnetic Resonance Imaging Sequences

BACKGROUND CONTEXT: Magnetic resonance imaging (MRI) is commonly used to assess patients with lumbar spinal stenosis. No single MRI sequence has been shown to be superior in spinal canal measurements. There are also cost concerns for the increased clinical and research use of MRI. Using only a single sequence may lower the financial burden; however, this requires spinal canal measurements in both T1 and T2 MRI to be reliable. Evidence for this is currently lacking. PURPOSE: The aim of this study was to determine the intra- and inter-reader reliability of MRI measurements of the lumbar spine and the reliability of measurements using T1- and T2-weighted MRI films. STUDY DESIGN/SETTING: Retrospective study. PATIENT SAMPLE: Forty-two randomly selected patients who underwent spinal stenosis surgery. OUTCOME MEASURES: Lumbar spinal canal measurements and reliability analysis between T1- and T2-weighted MRI. METHODS: Qualitative ratings of MRI features were performed according to previously published criteria by 2 independent readers (JP-YC, HS). Measurements in axial scan included midline anteroposterior (AP) vertebral body diameter, midvertebral body width, midline AP spinal canal diameter, midline AP dural sac diameter, spinal canal width/interpedicular distance, pedicle width (right and left), and lamina angle. Measurements in the sagittal scan included midline AP body diameter, midvertebral body height, and AP spinal canal diameter. Cronbach alpha was used to characterize intra- and inter-reader reliability for qualitative rating data. Similarly, T1 and T2 comparison also was performed in the same manner. RESULTS: Good to excellent intra- and interobserver reliability was obtained for all measurements. Reliability analysis of all T1 and T2 measurements was excellent. CONCLUSIONS: Either T1 or T2 images can be used for measurements of spinal canal dimensions. These findings are of importance, as not every patient undergoing preoperative MRI assessment will necessarily have both sequences performed and only a single sequence is required for research studies. Our findings are also of relevance in measurement of lumbar canal diameters.postprin

Progressive shoulder arthropathy

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Decompression without Fusion for Low-Grade Degenerative Spondylolisthesis

STUDY DESIGN: Retrospective series. PURPOSE: Assess results of decompression-only surgery for low-grade degenerative spondylolisthesis with consideration of instability. OVERVIEW OF LITERATURE: There is no consensus on whether fusion or decompression-only surgery leads to better outcomes for patients with low-grade degenerative spondylolisthesis. Current trends support fusion but many studies are flawed due to over-generalization without consideration of radiological instability and their variable presentations and natural history. METHODS: Patients with surgically treated degenerative spondylolisthesis from 1990-2013 were included. Clinical and radiological instability measures were included. Any residual or recurrence of symptoms, revision surgery performed and functional outcome scores including the numerical global rate of change scale, visual analogue scale, and modified Barthel index were measured. Follow-up periods for patients were divided into short-term (10 years). RESULTS: A total of 64 patients were recruited. Mechanical low back pain was noted in 48 patients and most (85.4%) had relief of back pain postoperatively. Radiological instability was noted in 4 subjects by flexion-extension radiographs and 12 subjects with prone traction radiographs by increased disc height and reduction of olisthesis and slip angle. From the results of the short-term, mid-term and long-term follow-up, reoperation only occurred within the first 5-year follow-up period. All functional scores improved from preoperative to postoperative 1-year follow-up. CONCLUSIONS: Decompression-only for low-grade degenerative spondylolisthesis has good long-term results despite instability. Further higher-level studies should be performed on this patient group with radiological instability to suggest the superior surgical option.published_or_final_versio

Surgical treatment of acute TB spondylitis: indications and outcomes

Introduction: Spinal tuberculosis represents a challenging disease to treat, not because of the technical expertise or the time required to cure it, but more so because of the decisions involved to treat it. The Medical Research Council (MRC) Working Party on Tuberculosis of the Spine designed trials to help address several questions. Methods: A comprehensive literature search was performed using PubMed Medline, including English articles from 1934 to 1012, which pertain to spinal tuberculosis, with special effort in tracing the 13 MRC reports. The primary focus was on disease eradication, fusion rate, and a secondary focus on both short and long-term results in terms of disease recurrence and alignment. Additional searches were made on the use of spinal implants for infection cases. Results: After reviewing MRC and non-MRC reports, it was evident that the "Hong Kong operation", which involved radical debridement and strut grafting the lesion, produced better short-, medium- and long-term results in such aspects as fusion rate, spinal deformity and relapse of abscess/sinus. Subsequent work by others demonstrated the importance of prevention of progressive kyphosis, therefore the need to identify risk factors for these and pre-emptive measures such as kyphosis correction, careful graft selection, and instrumentation. Conclusion: Improvement in quality of life is also accompanied by higher patient expectations. Though developing nations may lack the resources now, eventually patients will demand better functional and cosmetic results after being afflicted by this disfiguring and potentially disabling disease, and the "Hong Kong operation" represented the best outcome, provided resources were available. © 2012 The Author(s).published_or_final_versio

A rare postoperative complication of anterior lower thoracic instrumentation: diaphragmatic laceration with hemothorax

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The value of radiographs obtained during forced traction under general anaesthesia in predicting flexibility in idiopathic scoliosis with Cobb angles exceeding 60 degree

Our aim in this prospective radiological study was to determine whether the flexibility rate calculated from radiographs obtained during forced traction under general anaesthesia, was better than that of fulcrum-bending radiographs before corrective surgery in predicting the extent of the available correction in patients with idiopathic scoliosis. We evaluated 33 patients with a Cobb angle > 60 degrees on a standing posteroanterior radiograph, who had been treated by posterior correction. Pre-operative standing fulcrum-bending radiographs and those with forced-traction under general anaesthesia were obtained. Post-operative standing radiographs were taken after surgical correction. The mean forced-traction flexibility rate was 55% (SD 11.3) which was significantly higher than the mean fulcrum-bending flexibility rate of 32% (SD 16.1) (p 60 degrees in the standing position and may identify those patients for whom supplementary anterior surgery can be avoided.published_or_final_versio

Reliability Analysis of the Distal Radius and Ulna Classification for Assessing Skeletal Maturity for Patients with Adolescent Idiopathic Scoliosis

Study Design Prospective radiographic study. Objective To test the reliability of the Distal Radius and Ulna Classification (DRU). Methods This single-center study included prospectively recruited subjects with adolescent idiopathic scoliosis managed with bracing. The left-hand radiographs were measured using the DRU classification by two examiners. Intra- and interobserver reliability analysis were performed using intraclass correlation (ICC) analysis. Results From these clinics, 161 patients (124 females and 37 males) with left-hand radiographs were included in the study. The mean age was 13.3 years (standard deviation: 1.5). There was excellent intra- (ICC: 0.93 to 0.95) and interobserver (ICC: 0.97) reliability. Conclusions The DRU classification scheme has been shown to be accurate in determining the peak growth phase and growth cessation. It has now been confirmed to be a reliable tool. Future prospective studies should be performed to investigate its application in deciding when to apply bracing or operative treatment.published_or_final_versio