Sacroiliac joint (SIJ) dysfunction is an underrecognized yet frequent cause of low back pain, often misdiagnosed due to symptom overlap with other spinal disorders and the absence of clear anatomical abnormalities. This article outlines the diagnostic challenges, clinical presentation, and treatment options for SIJ dysfunction. Risk groups include postpartum women and patients with connective tissue disorders. Diagnosis relies on clinical history, provocation tests, and diagnostic SIJ infiltration with local anesthetics. Initial treatment is conservative, focusing on physical therapy and rehabilitation. For refractory cases, minimally invasive SIJ fusion may be considered, although evidence remains limited. A multidisciplinary approach involving care providers, general practitioners, medical specialists, and paramedical professionals is essential for timely diagnosis and effective care. Increased awareness and structured protocols can reduce unnecessary diagnostics and improve outcomes for patients with persistent low back pain due to SIJ dysfunction.

PURPOSE:The aim of the study was to examine whether there is an incidence difference on surgical site infections between surgeons using different surgical attire during intramedullary fixation for proximal femoral fractures. METHODS:1,431 patients were included and divided into two groups; surgeons wearing balaclava- or skull caps (490 vs 941). The occurrence of surgical site infection was retrospectively assessed and divided into superficial- and deep wound infections. RESULTS:The occurrence of superficial wound infections did not differ significantly between the two groups, with three patients in the balaclava and six in the skull cap group (0.6% vs 0.6%, p = 1.00). Similarly, there was no significant difference in the occurrence of deep wound infections between the groups, with one case in the balaclava and eight in the skull cap group (0.2% vs 0.9%, p = 0.18). CONCLUSION:This study found no statistically significant difference in the incidence of surgical site infections (including both superficial and deep wound infections) between balaclava caps and skull caps. These results suggest that the type of surgical attire does not have a significant impact on the occurrence of surgical site infections in intramedullary nailing for proximal femoral fractures. Therefore, factors such as cost, and sustainability should be considered when selecting surgical attire. In this context, the skull cap would be the preferred option.

The relationship between apoptosis inhibition and cell proliferation was studied during the maturation stages of erythropoiesis, granulopoiesis, and monopoiesis in patients with myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). The anti-apoptotic and proliferative cell fractions were determined in bone marrow aspirates derived from 25 MDS patients and 25 AML patients and compared to 50 nonmalignant cases, using antibodies to Bcl-2 and Ki-67, respectively. These were applied along with ten-color flow cytometry of maturation markers for the three hematopoietic cell lineages. Next, the Bcl-2:Ki-67 ratio was determined as the ratio between the Bcl-2+ and Ki-67+ cell fractions of the specific hematopoietic cell lineages, both in total and during the different stages of maturation. Bone marrow samples from MDS and AML patients showed a significant increase in the anti-apoptotic cell fraction and a reduced proliferative cell compartment compared to non-malignant cases. Overall, the anti-apoptotic cell fraction was particularly increased in the more mature stages, while the proliferative cell fractions were decreased more frequently in the immature stages. These changes varied among different hematopoietic cell lineages. The erythropoietic maturation process showed the most significant differences in both Ki-67+ and Bcl-2+ cell fractions when comparing MDS and AML to non-malignant cases. This difference was restricted to that of the Bcl-2+ cell fractions in the granulopoiesis and that of the Ki-67+ cell fraction of the monopoiesis. All three hematopoietic cell lineages encompass a small fraction of cells (up to 10%) that concurrently exhibit anti-apoptotic and proliferative marker expression. Although MDS and AML patients displayed considerable variability in their anti-apoptotic and proliferation index, the Bcl-2:Ki-67 ratio resulted in a clear separation between the malignant and non-malignant cases. Incorporating this combination of the Bcl-2 and Ki-67 markers into the study of MDS and AML and in future diagnostic workups may provide important insights into the biological behavior of these blood-borne neoplasms and facilitate personalized therapy decisions for patients.

Background and Objectives: All intervertebral discs (IVDs) degenerate with the progression of age. Currently we are unable to differentiate physiological lumbar intervertebral disc degeneration (LIDD) from pathophysiological using imaging. The first step in differentiating physiological from pathophysiological degeneration is to determine physiological LIDD. Biochemical and histological analysis are not viable tools to look at the IVD in patients or healthy subjects due to their invasive character. For this reason, a non-invasive MRI could be the solution to study the lumbar IVD and LIDD. Therefore, the purpose of this systematic literature review is to identify the physiological aging process of the lumbar IVD based on MRI studies in patients of all ages without a history of spine pathology or surgery. Materials and Methods: After searching four databases (PubMed, Embase, Web of Science, and Cochrane), titles and abstracts of the identified studies were screened using inclusion and exclusion criteria. Eligible articles were subjected to a full-text review. Quality assessment was performed using ROBINS-I for risk of bias and Oxford level of evidence. Results: In total, 38 articles were included in this review. Most studies were non-consecutive studies (n = 36). Two studies were exploratory cohort studies. Twenty-two studies were prospective studies and sixteen were retrospective. Level of evidence ranged from 2b–3b. After analysis, we could construct a timeline of physiological degeneration from the age of 20 until 50. A shift in biochemical composition of the IVD and small structural changes can be detected in this timeline. The loss and breakdown of proteoglycan (PG) appears to have a primary role in this initial stadium of LIDD. After the age of 50, degeneration accelerates, resulting in more ultrastructural changes of the IVD as well as loss of height, volume, and disc convexity. No significant difference in degree of LIDD was found between men and women. Finally, the lower lumbar levels L4/5 and L5/S1 had a significantly higher degree of LIDD than upper lumbar levels (L1/2, L2/3, and L3/4). Conclusions: This systematic literature review conceptualizes the theory of physiological ageing in the lumbar IVD based on MRI. Initially, there is change in biochemical composition of the IVD, which eventually results in ultrastructural changes. Future research should aim to validate this theory, preferably in a prospective cohort study.

Background: Clinically meaningful thresholds for patient-reported outcomes are relevant to define and predict success of total hip arthroplasties (THAs). Defining and offering thresholds must consider preoperative symptom severity. Methods: In this retrospective study of 40,213 primary total hip replacements registered in the Dutch Arthroplasty Register (2016-2018), receiver operating curve analysis was used to define minimal clinically important changes and patient-acceptable symptom states with the anchor transition in function. Subgroups were identified for which independent thresholds should be defined. Patient-reported outcome measures were symptoms (pain, Oxford Hip Score [OHS], Hip disability and Osteoarthritis Outcome Score) and quality of life (European Quality of Life 5 Dimensions 3L questionnaire). Results: 94.6% completed the anchor questions, of whom 80.1% reporting “much improved function” 1 year after surgery. Discriminative abilities of thresholds were not good (area under the curve < 0.8). Tercile-specific determination of thresholds improved discrimination and reliability (+10%). Minimal clinically important change values were higher for all outcomes (eg, change in OHS ≥ 24.5 vs ≥ 10.5) in patients with more severe preoperative symptoms. Patient-acceptable symptom state scores for European Quality of Life 5 Dimensions index (≥ 0.809) and OHS (≥ 40.5) showed good discrimination (area under the curve > 0.8). Patients with less symptoms required lower postoperative scores for reporting “much improved function” (postoperative OHS ≥ 38.5 vs 42.5). Tercile-specific thresholds did not improve accuracy of thresholds (Cohens kappa 42%). Conclusions: The present study demonstrates that patients with more severe preoperative symptoms require greater change scores to achieve clinically relevant improvements than patients with less severe preoperative symptoms. This study suggests that current one-size-fits-all thresholds for success of THA should be replaced with more nuanced thresholds. Level of evidence: Level III, Therapeutic Study.

During the first postoperative days following minimally invasive sacroiliac joint fusion (MISJF), patients often report serious pain, which contributes to high utilization of painkillers and prevention of early mobilization. This prospective, double-blind randomized controlled trial investigates the effectiveness of intraoperative SIJ infiltration with bupivacaine 0.50% versus placebo (NaCl 0.9%) in 42 patients in reducing postoperative pain after MISJF. The primary outcome was difference in pain between bupivacaine and placebo groups, assessed as fixed factor in a linear mixed model. Secondary outcomes were opioid consumption, patient satisfaction, adverse events, and length of hospital stay. We found that SIJ infiltration with bupivacaine did not affect postoperative pain scores in comparison with placebo, neither as group-effect (p = 0.68), nor dependent on time (group*time: p = 0.87). None of the secondary outcome parameters were affected in the postoperative period in comparison with placebo, including opioid consumption (p = 0.81). To conclude, intra-articular infiltration of the SIJ with bupivacaine at the end of MISJF surgery is not effective in reducing postoperative pain. Hence, we do not recommend routine use of intraoperative SIJ infiltration with analgesia in MISJF.

Background The effectiveness of transforaminal lumbar interbody fusion (TLIF) compared to posterior lumbar interbody fusion (PLIF) in patients with single-level spondylolisthesis has not been substantiated. To address the evidence gap, a well-powered randomized controlled non-inferiority trial comparing the effectiveness of TLIF with PLIF, entitled the Lumbar Interbody Fusion Trial (LIFT), was conducted. Methods In a multicenter randomized controlled non-inferiority trial among five Dutch hospitals, 161 patients were randomly allocated to either TLIF or PLIF (1:1), stratified according to study site. Patients and statisticians were blinded for group assignment. All patients were over 18 years old with symptomatic single-level degenerative, isthmic or iatrogenic lumbar spondylolisthesis, and eligible for lumbar interbody fusion surgery through a posterior approach. The primary outcome was change in disability measured with the Oswestry Disability Index (ODI) from preoperative to one year postoperative. The non-inferiority limit was set to 7.0 points based on the MCID of ODI. Secondary outcomes were change in quality-adjusted life years (QALY) assessed with EuroQol 5 Dimensions, 5 Levels (EQ-5D-5L) and Short Form Health Survey (SF-36), as well as back and leg pain (Numerical rating scale, NRS), anxiety and depression (Hospital Anxiety Depression Scale; HADS), perioperative blood loss, duration of surgery, duration of hospitalization, and complications. Trial registration: Netherlands Trial Registry, number 5722 (registration date March 30, 2016), Lumbar Interbody Fusion Trial (LIFT): A randomized controlled multicenter trial for surgical treatment of lumbar spondylolisthesis. Findings Patients were included between August 2017 and November 2020. The total study population was 161 patients. Total loss-to-follow-up after one year was 16 patients. Per-protocol analysis included 66 patients in each group. In the TLIF group (mean age 61.6, 36 females), ODI improved from 46.7 to 20.7, whereas in the PLIF group (mean age 61.9, 41 females), it improved from 46.0 to 24.9. This difference (-4.9, 90% CI -12.2 to +2.4) did not reach the non-inferiority limit of 7.0 points in ODI. A significant difference in the secondary outcome measurement, QALY (SF-36), was observed in favor of TLIF (P < 0.05). However, this was not clinically relevant. No difference was found for all other secondary outcome measurements; PROMs (EQ-5D, NRS leg/back, HADS), perioperative blood loss, duration of surgery, duration of hospitalization, and perioperative and postoperative complications. Interpretation For patients with single-level spondylolisthesis, TLIF is non-inferior to PLIF in terms of clinical effectiveness. Disability (measured with ODI) did not differ over time between groups.

This study investigates the intertwined processes of (anti-)apoptosis and cell proliferation in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Utilizing antibodies to Bcl-2 and Ki-67, the CD34-positive blast cell compartments in bone marrow aspirates from 50 non-malignant cases, 25 MDS patients, and 25 AML patients were analyzed for their anti-apoptotic and proliferative cell fractions through ten-color flow cytometry. MDS patients exhibited a significantly increased anti-apoptotic (p=0.0014) and reduced proliferative cell fraction (p=0.0030) in their blast cell population as compared to non-malignant cases. AML patients showed an even more exacerbated trend than MDS patients. The resulting Bcl-2:Ki-67 cell fraction ratios in MDS and AML were significantly increased as compared to the non-malignant cases (p=0.0004 and p<0.0001, respectively). AML patients displayed, however, a high degree of variability in their anti-apoptotic and proliferation index, attributed to heterogeneity in maturation stage and severity of the disease at diagnosis. Using double-labeling for Bcl-2 and Ki-67 it could be shown that besides blast cells with a mutually exclusive Ki-67 and Bcl-2 expression, also blast cells concurrently exhibiting anti-apoptotic and proliferative marker expression were found.Integrating these two dynamic markers into MDS and AML diagnostic workups may enable informed conclusions about their biological behavior, facilitating individualized therapy decisions for patients.

STUDY DESIGN:Prospective, double-blind randomized controlled trial. OBJECTIVE:If an intraoperative single bolus of epidural bupivacaine can result in less postoperative pain following lumbar spinal decompression surgery. SUMMARY OF BACKGROUND DATA:Adequate postoperative pain management following lumbar spinal decompression surgery is important, as it will lead to early mobilization, less complications, and a shorter hospital stay. Opioid consumption should be limited due to their frequently accompanied side effects and their addictive nature. During the final phase of lumbar decompression surgery, the epidural space becomes easily accessible. This might be an ideal moment for surgeons to administer an epidural bolus of analgesia as a safe and effective method for postoperative pain relief. MATERIALS AND METHODS:In this trial, we compared a single intraoperative bolus of epidural analgesia using bupivacaine 0.25% to placebo (NaCl 0.9%) and its effect on postoperative pain following lumbar spinal decompression surgery. The primary outcome was the difference in Numeric (Pain) Rating Scale between the intervention and placebo groups during the first 48 hours after surgery. RESULTS:Both the intervention group and the placebo group consisted of 20 randomized patients (N=40). Statistically significant lower mean Numeric (Pain) Rating Scale pain scores were observed in the intervention group in comparison with the control group (main effect group: -2.35±0.77, P =0.004). The average pain score was lower in the intervention group at all postoperative time points. No study-related complications occurred. CONCLUSION:This randomized controlled trial shows that administrating a bolus of intraoperative epidural bupivacaine is a safe and effective method for reducing early postoperative pain following lumbar decompression surgery.

Patients with low back pain caused by sacroiliac joint (SIJ) dysfunction have an impaired quality of life, due to reported pain, disability and activity limitations. There is increasing evidence that minimally invasive sacroiliac joint fusion (MISJF) results in improvement in pain, disability and quality of life in these patients. Some studies have reported improvements in daily physical activity following MISJF but based on bias-prone self-reports. Our aim was to provide objective data on daily physical activity in patients with SIJ dysfunction. Daily physical activity in daily life of participants was measured using a triaxial accelerometer for seven consecutive days, before surgery and 3 months after surgery. Recorded daily activities were the daily number of events and total time spent sitting or lying, standing, walking, cycling, high-activity and number of steps and sit-to-stand transfers. The quality of life was assessed by the validated Dutch EQ-5D-5 L-questionnaire. No statistical differences were observed between daily physical activity in patients with SIJ dysfunction before and 3 months after MISJF. As compared to matched controls, high-intensity physical activity was lower in both the pre- and postoperative period (p = 0.007) for patients with SIJ dysfunction. The quality of life improved significantly in patients after MSIJF, from 0.418 to 0.797 (p = 0.021) but did not reach the level of controls (1.000). Daily physical activity in patients with postpartum SIJ dysfunction does not improve 3 months following MISJF, while quality of life does improve significantly. The discrepancy between these two observations is food for new research.

ABSTRACT Introduction Adequate postoperative pain management following lumbar spinal decompression surgery is important as it will lead to early mobilization, less complications and shorter hospital stay. Opioid consumption should be limited due to their frequently accompanied side effects and their addictive nature. During the final phase of lumbar decompression surgery, the epidural space becomes easily accessible. This might be an ideal moment for surgeons to administer an epidural bolus of analgesia, as a safe and effective method for post-operative pain relief. Methods This is a double blind randomized controlled trial comparing a single intraoperative bolus of epidural analgesia using bupivacaine 0.25% to placebo (NaCl 0,9%) and its effect on postoperative pain following lumbar spinal decompression surgery. The primary outcome was the difference in NRS pain between the intervention and placebo groups during the first 48h after surgery. It was hypothesized that the intervention group will have lower postoperative NRS pain scores. Results Both the intervention group and the placebo group consisted of 20 randomized patients (N=40). We observed statistically significant lower NRS pain scores in the intervention group in comparison with the control group, with a difference of −1.9 (±1.1). The average pain score was lower in the intervention group at all postoperative time-points. Opioid consumption, quality of life and satisfaction were similar between study groups. No study related complications occurred, and complications rate did not differ between study groups. Conclusion This randomized controlled trial shows that administrating a bolus of intraoperative epidural bupivacaine is a safe and effective method in reducing early postoperative pain following lumbar decompression surgery.

Introduction: The Sacroiliac Joint (SIJ) can be an important and significant cause of low back pain. A dysfunctional SIJ is initially treated with conservative treatment options, although known to have limited effectiveness and durability. Therefore, surgical approaches such as minimally invasive sacroiliac joint fusion (MISJF) have emerged and outcomes appear to be promising in terms of pain reduction and improvement of self-reported mobility. To date, little is known about the effects of MISJF on balance and motion patterns reflective of daily life activities. Methods: A prospective, longitudinal study was conducted to analyze motion patterns in patients with postpartum SIJ dysfunction before and three months after MISJF, and compare these data with age-, BMI- and postpartum-matched controls. Motion was analyzed throughout the execution of three tasks; (1) normal gait, (2) alternated single leg stance (SLS), and (3) sit-to-stance (STS). Spatiotemporal parameters, center of pressure and mass, pelvic angles and other joint angels were measured using a twelvecamera, three-dimensional motion capture system and ground reaction force platforms. Results: Gait analysis revealed no improvement in any of the measured parameters when comparing pre- and postoperative. Patients had a shorter step and stride length and a slower walking speed compared to matched controls. During SLS, improvements in balance were observed after surgery in the patient group, reaching comparable values to the matched control group. Total execution time of an STS improved in patients following MISJF and was comparable to that of matched controls. Conclusion: This study suggests that motion patterns seem to improve after MISJF in patients with postpartum SIJ dysfunction. Most notable differences were an improved balance during SLS and a faster STS performance. Additional studies with longer follow-up and larger sample sizes should provide more detailed insights on motion analysis in patients with postpartum SIJ dysfunction following MISJF.

Background Context: Fluoroscopic devices can be used to visualize subcutaneous and osseous tissue, a useful feature during pedicle screw insertion in lumbar fusion surgery. It is important that both patient and surgeon are exposed as little as possible, since these devices use potential harmful ionizing radiation. Purpose: This study aims to compare radiation exposure of different image-guided techniques in lumbar fusion surgery with pedicle screw insertion. Study Design: Systematic review Methods: Cochrane, Embase, PubMed and Web of Science databases were used to acquire relevant studies. Eligibility criteria were lumbar and/or sacral spine, pedicle screw, mGray and/or Sievert and/or mrem, radiation dose and/or radiation exposure. Image-guided techniques were divided in five groups: conventional C-arm, Carm navigation, C-arm robotic, O-arm navigation and O-arm robotic. Comparisons were made based on effective dose for patients and surgeons, absorbed dose for patients and surgeons and exposure. Risk of bias was assessed using the 2017 Cochrane Risk of Bias tool on RCTs and the Cochrane ROBINS-I tool on NRCTs. Level of evidence was assessed using the guidelines of Oxford Centre for Evidence-based Medicine 2011. Results: A total of 1423 studies were identified of which 38 were included in the analysis and assigned to one of the five groups. Results of radiation dose per procedure and per pedicle screw were described in dose ranges. Conventional C-arm appeared to result in higher effective dose for surgeons, higher absorbed dose for patients and higher exposure, compared to C-arm navigation/robotic and O-arm navigation/robotic. Level of evidence was 3 to 4 in 29 studies. Risk of bias of RCTs was intermediate, mostly due to inadequate blinding. Overall risk of bias score in NRCTs was determined as 'serious'. Conclusions: Ranges of radiation doses using different modalities during pedicle screw insertion in lumbar fusion surgery are wide. Based on the highest numbers in the ranges, conventional C-arm tends to lead to a higher effective dose for surgeons, higher absorbed dose for patients and higher exposure, compared to C-arm-, and Oarm navigation/robotic. The level of evidence is low and risk of bias is fairly high. In future studies, heterogeneity should be limited by standardizing measurement methods and thoroughly describing the image-guided technique settings.

This Data in Brief article displays a flow cytometric assay that was used for the acquisition and analyses of proliferative and anti-apoptotic activity in hematopoietic cells. This dataset includes analyses of the Ki-67 positive fraction (Ki-67 proliferation index) and Bcl-2 positive fraction (Bcl-2 anti-apoptotic index) of the different myeloid bone marrow (BM) cell populations in non-malignant BM, and in BM disorders, i.e. myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). The present dataset comprises 1) the percentage of the CD34 positive blast cells, erythroid cells, myeloid cells and monocytic cells, and 2) the determined Ki-67 positive fraction and Bcl-2 positive fraction of these cell populations in tabular form. This allows the comparison and reproduction of the data when these analyses are repeated in a different setting. Because gating the Ki-67 positive and Bcl-2 positive cells is a critical step in this assay, different gating approaches were compared to determine the most sensitive and specific approach. BM cells from aspirates of 50 non-malignant, 25 MDS and 27 AML cases were stained with 7 different antibody panels and subjected to flow cytometry for determination of the Ki-67 positive cells and Bcl-2 positive cells of the different myeloid cell populations. The Ki-67 or Bcl-2 positive cells were then divided by the total number of cells of the respective cell population to generate the Ki-67 positive fraction (Ki-67 proliferation index) or the Bcl-2 positive fraction (Bcl-2 anti-apoptotic index). The presented data may facilitate the establishment and standardization of flow cytometric analyses of the Ki-67 proliferation index and Bcl-2 anti-apoptotic index of the different myeloid cell populations in non-malignant BM as well as MDS and AML patients in other laboratories. Directions for proper gating of the Ki-67 positive and Bcl-2 positive fraction are crucial for achieving standardization among different laboratories. In addition, the data and the presented assay allows application of Ki-67 and Bcl-2 in a research and clinical setting and this approach can serve as the basis for optimization of the gating strategy and subsequent investigation of other cell biological processes besides proliferation and anti-apoptosis. These data can also promote future research into the role of these parameters in diagnosis of myeloid malignancies, prognosis of myeloid malignancies and therapeutic resistance against anti-cancer therapies in these malignancies. As specific populations were identified based on cell biological characteristics, these data can be useful for evaluating gating algorithms in flow cytometry in general by confirming the outcome (e.g. MDS or AML diagnosis) with the respective proliferation and anti-apoptotic profile of these malignancies. The Ki-67 proliferation index and Bcl-2 anti-apoptotic index may potentially be used for classification of MDS and AML based on supervised machine learning algorithms, while unsupervised machine learning can be deployed at the level of single cells to potentially distinguish non-malignant from malignant cells in the identification of minimal residual disease. Therefore, the present dataset may be of interest for internist-hematologists, immunologists with affinity for hemato-oncology, clinical chemists with sub-specialization of hematology and researchers in the field of hemato-oncology.

OBJECTIVES:Despite the availability of general and national guidelines for the conduct and reporting of economic evaluations, there is heterogeneity in economic evolutions concerning spine surgery. This is partly the result of differing levels of adherence to the existing guidelines and the lack of disease-specific recommendations for economic evaluations. The extensive heterogeneity in study design, follow-up duration and outcome measurements limit the comparability of economic evaluations in spine surgery. This study has three objectives: (1) to create disease-specific recommendations for the design and conduct of trial-based economic evaluations in spine surgery, (2) to define recommendations for reporting economic evaluations in spine surgery as a complement to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist and (3) to discuss methodological challenges and defining the need for future research.DESIGN:A modified Delphi method according to the RAND/UCLA Appropriateness Method.SETTING:A four-step process was followed to create and validate disease-specific statements and recommendations for the conduct and reporting of trial-based economic evaluations in spine surgery. Consensus was defined as >75% agreement.PARTICIPANTS:A total of 20 experts were included in the expert group. Validation of the final recommendations was obtained in a Delphi panel, which consisted of 40 researchers in the field who were not included in the expert group.PRIMARY AND SECONDARY OUTCOME MEASURES:The primary outcome measure is a set of recommendations for the conduct and reporting, as a complement to the CHEERS 2022 checklist, of economic evaluations in spine surgery.RESULTS:A total of 31 recommendations are made. The Delphi panel confirmed consensus on all of the recommendations in the proposed guideline.CONCLUSION:This study provides an accessible and practical guideline for the conduct of trial-based economic evaluations in spine surgery. This disease-specific guideline is a complement to existing guidelines, and should aid in reaching uniformity and comparability.

Background: Total hip arthroplasty is a reliable option to treat osteoarthritis. It reduces pain, increases quality of life, and restores function. The direct anterior approach (DAA), posterior approach (PA), and straight lateral approach (SLA) are mostly used. This systematic review evaluates current literature about costs and cost-effectiveness of DAA, PA, and SLA. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic search, registered in the PROSPERO database (registration number: CRD42021237427), was conducted of databases PubMed, CINAHL, EMBASE, Cochrane, Clinical Trials, Current Controlled Trials, ClinicalTrials.gov, NHS Centre for Review and Dissemination, Econlit, and Web of Science. Eligible studies were randomized controlled trials (RCTs) or comparative cohort studies reporting or comparing costs or cost-effectiveness of either approach as the primary outcome. The risk of bias (RoB) was assessed. For comparison, all costs were converted to American Dollars (reference year 2016). Results: Six systematic review studies were included. RoB ranged from low to high, the level of evidence ranged from 2 to 4, and methodological quality was moderate. Costs ranged from $5313.85 to $15 859.00 (direct) and $1921.00 to $6364.30 (indirect) in DAA. From $5158.46 to $12 344.47 (direct) to $2265.70 to $5566.01 (indirect) for PA and from $3265.62 to $8501.81 (direct) and $2280.16 (indirect) for SLA. Due to heterogeneity of included costs, they were not directly comparable. Solid data about cost-effectiveness cannot be presented. Conclusions: Due to limited and heterogenous evidence about costs and cost-effectiveness, the effect of these in surgical approach is unknown. Further well-powered research to make undisputed conclusions is needed.

BACKGROUND:Physiological motion of the lumbar spine is a topic of interest for musculoskeletal health care professionals since abnormal motion is believed to be related to lumbar complaints. Many researchers have described ranges of motion for the lumbar spine, but only few have mentioned specific motion patterns of each individual segment during flexion and extension, mostly comprising the sequence of segmental initiation in sagittal rotation. However, an adequate definition of physiological motion is still lacking. For the lower cervical spine, a consistent pattern of segmental contributions in a flexion-extension movement in young healthy individuals was described, resulting in a definition of physiological motion of the cervical spine.OBJECTIVE:This study aimed to define the lumbar spines' physiological motion pattern by determining the sequence of segmental contribution in sagittal rotation of each vertebra during maximum flexion and extension in healthy male participants.METHODS:Cinematographic recordings were performed twice in 11 healthy male participants, aged 18-25 years, without a history of spine problems, with a 2-week interval (time point T1 and T2). Image recognition software was used to identify specific patterns in the sequence of segmental contributions per individual by plotting segmental rotation of each individual segment against the cumulative rotation of segments L1 to S1. Intraindividual variability was determined by testing T1 against T2. Intraclass correlation coefficients were tested by reevaluation of 30 intervertebral sequences by a second researcher.RESULTS:No consistent pattern was found when studying the graphs of the cinematographic recordings during flexion. A much more consistent pattern was found during extension, especially in the last phase. It consisted of a peak in rotation in L3L4, followed by a peak in L2L3, and finally, in L1L2. This pattern was present in 71% (15/21) of all recordings; 64% (7/11) of the participants had a consistent pattern at both time points. Sequence of segmental contribution was less consistent in the lumbar spine than the cervical spine, possibly caused by differences in facet orientation, intervertebral discs, overprojection of the pelvis, and muscle recruitment.CONCLUSIONS:In 64% (7/11) of the recordings, a consistent motion pattern was found in the upper lumbar spine during the last phase of extension in asymptomatic young male participants. Physiological motion of the lumbar spine is a broad concept, influenced by multiple factors, which cannot be captured in a firm definition yet.TRIAL REGISTRATION:ClinicalTrials.gov NCT03737227; https://clinicaltrials.gov/ct2/show/NCT03737227.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):RR2-10.2196/14741.

Objectives The present study is a systematic review conducted as part of a methodological approach to develop evidence-based recommendations for economic evaluations in spine surgery. The aim of this systematic review is to evaluate the methodology and quality of currently available clinical cost-effectiveness studies in spine surgery.Study design Systematic literature review.Data sources PubMed, Web of Science, Embase, Cochrane, Cumulative Index to Nursing and Allied Health Literature, EconLit and The National Institute for Health Research Economic Evaluation Database were searched through 8 December 2022.Eligibility criteria for selecting studies Studies were included if they met all of the following eligibility criteria: (1) spine surgery, (2) the study cost-effectiveness and (3) clinical study. Model-based studies were excluded.Data extraction and synthesis The following data items were extracted and evaluated: pathology, number of participants, intervention(s), year, country, study design, time horizon, comparator(s), utility measurement, effectivity measurement, costs measured, perspective, main result and study quality.Results 130 economic evaluations were included. Seventy-four of these studies were retrospective studies. The majority of the studies had a time horizon shorter than 2 years. Utility measures varied between the EuroQol 5 dimensions and variations of the Short-Form Health Survey. Effect measures varied widely between Visual Analogue Scale for pain, Neck Disability Index, Oswestry Disability Index, reoperation rates and adverse events. All studies included direct costs from a healthcare perspective. Indirect costs were included in 47 studies. Total Consensus Health Economic Criteria scores ranged from 2 to 18, with a mean score of 12.0 over all 130 studies.Conclusions The comparability of economic evaluations in spine surgery is extremely low due to different study designs, follow-up duration and outcome measurements such as utility, effectiveness and costs. This illustrates the need for uniformity in conducting and reporting economic evaluations in spine surgery.

Introduction: Spinal disorders are amongst the conditions with the highest burden of disease. To limit the increase of healthcare-related costs in the ageing population, the selection of different types of care for patients with spinal disorders should be optimized. The first step is to investigate the characteristics of these patients and the relationship with treatment. Research Question: The primary aim of this study was to provide insights in the characteristics, symptoms, diagnosis and treatment of patients referred to a specialized spinal health care centre. The secondary aim was to perform an in-depth analysis of resource utilization for a representative subgroup of patients. Methods: This study describes the characteristics of 4855 patients referred to a secondary spine centre. Moreover, an extensive analysis of a representative subgroup of patients (~20%) is performed. Results: The mean age was 58.1, 56% of patients were female, and the mean BMI was 28. In addition, 28% of patients used opioids. Mean self-reported health status was 53.3 (EuroQol 5D Visual Analogue Scale), and pain ranged from 5.8 to 6.7 (Visual Analogue Scale neck/back/arm/leg). Additional imaging was received by 67.7% of patients. Surgical treatment was indicated for 4.9% of patients. The majority (83%) of non-surgically treated patients received out-of-hospital treatment; 25% of patients received no additional imaging or in-hospital treatment. Conclusion: The vast majority of patients received non-surgical treatments. We observed that ~10% of patients did not receive in-hospital imaging or treatment and had acceptable or good questionnaire scores at the time of referral. These findings suggest that there is potential for improvement in efficacy of referral, diagnosis, and treatment. Future studies should aim to develop an evidence base for improved patient selection for clinical pathways. The efficacy of chosen treatments requires investigation of large cohorts.