Session 6: Spine

18. November
11:00 - 12:00
Lokale: 202-203
Chairmen: Søren Morgen & Simon Toftgaard Skov

45. Inter-variability in radiographic parameter and general evaluation of a low dose fluoroscopic technique in patients with idiopathic scoliosis.
christian wong, Jens Adriansen, Jytte Jeppsen, Andreas Balslev-Clausen
Department of Orthopedics, University Hospital of Hvidovre Kettegaard Allé 30, 2650 Hvidovre, Denmark;Department of Radiology, University Hospital of Hvidovre Kettegaard Allé 30, 2650 Hvidovre, Denmark;Center for health technology, Region of Copenhagen Kettegaard Allé 30, 2650 Hvidovre, Denmark

Background: Adolescent idiopathic scoliosis (AIS) is a frequent occurring spinal disorder in an adolescent female. Serial radiographs are used to monitor for progression but have a potential radiation-induced oncogenic effect. We examined a low-dose fluoroscopic technique (LFT) to perform radiographs of AIS with an inherently lower risk for malignancy.
Aim: The present study aimed to compare the LFT with traditional radiographs for scoliosis (ORT), to see if LFT is adequate for clinical radiographic evaluation of AIS as well as having a lower radiation dose.
Materials and Methods: Image quality was evaluated using a pediatric trunk phantom for LTF and ORT. We measured primary physical characteristics for image quality evaluation of noise, contrast, spatial resolution, SNR and CNR. Three independent raters evaluated the quality of the image by observer-based methods of ICS and VGAS of 25 phantom images. Radiation doses were evaluated by DAP measurements. Two raters performed measurements of 6 radiographic parameters once and separately for 342 LFT images of 136 patients with AIS.
Results: The average noise and contrast were approximately 15-fold higher for the LFT. The SNR and CNR were similar. Evaluating the 25 images of the phantom, the overall ICS and VGAS were 3-fold higher for ORT compared to LFT for L3 and similar for Th6. For the clinical radiographs, the average measurement of CA was 16.4 degrees (dg) with a standard deviation of 12 dg. The absolute average difference (MAD) was 1.67 dg. The standard error of the mean of CA was 2.72 dg for the ORT and 2.69 dg for the LFT. ICC for CA (0.852) was almost perfect, but for the other radiographic parameters fair or worse. For radiation dose, the average DAP for the LFT was 8-fold lower than for ORT.
Interpretation / Conclusion: In conclusion, the LFT are reliable for CA measurements, thus being useful for follow-up evaluation of scoliosis progression as in a clinical setting. LFT is not adequate for appreciating the pathology of the spinal skeletal structures, thus not useful for the initial evaluation of AIS. Even though the image quality is lower for LFT than ORT, the merits are the marked less radiation and lowered malignancy risk, thus following the principles of ALARA.

46. Are Modic changes associated with health-related quality of life after discectomy - a study on 620 patients with two-year follow-up
Bendix Tom, Ohrt-Nissen Søren , Paulsen Rune , Andreasen Andreas , Støttrup Chrstian, Brorson Stig , Carreon Leah Y. , Andersen Mikkel Østerheden
Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital; Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital; Center for Rheumatology and Spine Diseases, Rigshospitalet / University of Copenhagen; Spine Surgery and Research, Spine Center of Southern Denmark – part of Lillebaelt Hospital; Spine Surgery and Research, Spine Center of Southern Denmark – part of Lillebaelt Hospital; Spine Surgery and Research, Spine Center of Southern Denmark – part of Lillebaelt Hospital; Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital; Spine Surgery and Research, Spine Center of Southern Denmark – part of Lillebaelt Hospital; Spine Surgery and Research, Spine Center of Southern Denmark – part of Lillebaelt Hospital;

Background: Previous studies have failed to show a clinically significant association between Modic changes (MCs) and patient-reported outcomes (PRO’s) after lumbar discectomy
Aim: To assess whether MCs are associated with health- related quality of life, long-term physical disability, back- or leg pain after discectomy
Materials and Methods: Data from the Danish National Spine Registry on patients undergoing first-time lumbar discectomy at a single institution from 2014-17 with an accessible preoperative lumbar MRI, complete pre-operative and two-year follow-up questionnaires were obtained. PRO’s including ODI, EQ-5D, VAS back and leg pain, and patient satisfaction were collected. Patients were stratified based on the presence (+MC) or absence (-MC) of MCs on the preoperative MRI.
Results: Of 620 patients included, MCs were present in 270 patients (47%). Of these, MC type 1 (MC-1) was present in 70 (25%) and MC type 2 (MC-2) in 210 (75%) patients. Preoperative data for ODI, EQ-5D, VAS-BP, and VAS-LP were comparable for the +MC and -MC groups. Both groups had a statistically significant improvement in PRO’s from baseline compared to two-year follow-up (p<0.001). At two- year follow-up, both groups had improved with no significant difference between them in regards to ODI (15.5 vs. 17.2, p=0.208); EQ-5D (0.75 vs.0.72, p=0.167); VAS-BP (27.1 vs. 28.3, p=0.617); VAS-LP (26.8 vs. 25.0, p=0.446) and patient satisfaction (74% vs. 76%, p=0.878).
Interpretation / Conclusion: MCs were not found to be associated with health- related quality of life, disability, back- or leg pain, or patient satisfaction two years after lumbar discectomy.

47. Serum Metal Ion Levels in Adolescent Idiopathic Scoliosis (AIS) Patients 25 years after treated with Harrington Rod Instrumentation or Bracing
Simon Thorbjørn Sørensen, Anne Vibeke Schmedes, Mikkel Østerheden Andersen, Leah Carreon, Ane Simony
Center for Spine Surgery and Research, Rygcenter Syddanmark - Sygehus Lillebælt; Department of Clinical Biochemistry and Immunology, Sygehus Lillebælt; Center for Spine Surgery and Research, Rygcenter Syddanmark - Sygehus Lillebælt; Center for Spine Surgery and Research, Rygcenter Syddanmark - Sygehus Lillebælt; Center for Spine Surgery and Research, Rygcenter Syddanmark - Sygehus Lillebælt

Background: Surgical instrumentation in children with adolescent idiopathic scoliosis (AIS) is performed early in life and the implants are left in situ for the rest of the patient’s life. Concern has been raised regarding persistent elevated levels of serum metal ions, but only a few studies on the topic have been published.
Aim: The aim of this study was to compare the levels of serum metal ions in patients with AIS treated with either Harrington Rod Instrumentation or Bracing.
Materials and Methods: AIS patients treated with Boston brace (BB) or posterior spinal fusion with Harrington rod instrumentation (HR) from 1983 to 1990 were requested to return to clinic. One hundred fifty-nine (73 %) of 219 patients were available for follow-up of whom 115 agreed to have a blood draw.
Results: The proportion of patients who agreed to have a blood draw were similar in the BB (48 of 100, 48 %) and HR (67 of 115, 60 %, p = 0.085) groups. None of the surgical patients had their implants removed. Mean age at follow-up (BB: 43.2 yrs vs HR: 43.5 yrs, p = 0.566) and mean length of follow up (BB: 26.5 yrs vs HR: 24.5 yrs). Mean Chromium serum levels were similar between the BB (2.7 nmol/L) and the HR (2.9 nmol/L, p = 0.827). Mean Cobalt serum levels were also similar between the BB (2.6 nmol/L) and the HR (2.8 nmol/L, p = 0.200).
Interpretation / Conclusion: Serum metal ions were similar in AIS patients treated with bracing or Harrington Rod instrumentation 25 years after initiation of treatment.

48. Interbody fusion does not influence development of lumbar compensatory mechanisms 10 year after lumbar fusion
Kristian Høy, Kamilla Troung, Mads Henriksen, Thomas Andersen
Department of Orthopedics, Aarhus University Hospital, Denmark Department of Neurosurgery, Aarhus University Hospital, Denmark Department of Radiology, Aarhus University Hospital, Denmark Department of Orthopedics, Rigshospitalet University of Copenhagen, Denmark

Background: Restoration of lumbar lordosis in lumbar spine surgery is thought to be associated with better postoperative outcomes. Various inter- body fusion techniques can theoretical help to change and correct sagittal balance. Pelvic plays a central role in sagittal balance. The Three key pelvic parameters are pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). The last 2 can change due to compensatory mechanism. Decrease in SS is posed to increase risk of adjacent segment degeneration (ASD)
Aim: To assess radiographic signs of degenerative changes and compensatory mechanisms after lumbar fusion at 10 year follow-up and their relation to outcome comparing posterolateral instrumented fusion (PLF) to Transforaminal interbody lumbar fusion (TLIF) in a RCT
Materials and Methods: 100 pat. enrolled in a RCT between TLIF and PLF had standing lumbar radiographs analyzed with respect to olisthesis, lordotic angle at adjacent level (AL) and differences in SS. SS was determined by PI = PT + SS. Clinical outcome was measured by Owestry disability index (ODI) and SF-36 Physical Function (PF), Bodily pain (BP) and Physical Component Summary(PCS). Data was analyzed using STATA
Results: There was no difference in development of olisthesis at the (AL) between the two groups at 10 year follow-up (p=0.43). Lordotic angle of the adjacent disc decreased with 5 or more degrees in 6 patients in the TLIF group and 3 in the PLF group. Three pats in the TLIF group and 4 in the PLF group had an increase in lordotic angle at the adjacent disc, the remainders were unchanged (p=0.58). Five pat. in the TLIF group and 7 in the PLF groups had a decrease in SS of 5 degrees or more (p=0.51).There was no difference in ODI score nor PF, BS & PCS at 10 year follow-up between those who developed changes in adjacent disc angle and those who remained unchanged (p=0.49, p=0.20, p=0.94 p=0.65). The same held true for changes in SS (p=0.46, p=0.49, p=0.39, p= 0.58)
Interpretation / Conclusion: No difference between the two fusion methods with respect to degenerative changes visible on radiographs at 10 years follow-up. Signs suggesting development in compensatory mechanisms (SS) was not associated with poorer clinical outcome

49. Clinical and patient-reported outcome after posterolateral - versus transforaminal lumbar interbody fusion - A matched cohort study on 422 patients with two-year follow-up
Søren Ohrt-Nissen, Leah Carreon, Mikkel O Andersen, Peter M Udby
Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Køge; Center for spine surgery and research, Spine Center of Southern Denmark – part of Lillebaelt Hospital, Middelfart

Background: Posterolateral- and transforaminal lumbar interbody fusion (PLIF and TLIF) are well-described techniques for treating lumbar mechanical disc degeneration. TLIF is preferred by some, due to easier foraminal decompression and less retraction of dura and nerve root, reducing the risk of nerve injury and epidural scarring. TLIF preserves the posterior tension band, which may provide better biomechanical stability. Whether these theoretical advantages translate to better clinical outcomes is unknown.
Aim: To compare clinical and patient-reported outcome (PRO) two years after TLIF or PLIF in patients with symptomatic lumbar mechanical disc degeneration.
Materials and Methods: This was a dual-center study over an eight-year period on patients undergoing single level fusion surgery with either TLIF or PLIF. We analyzed prospectively collected pre- and postoperative data from the national Danish surgical spine database (DaneSpine). The primary outcome was Oswestry Disability Index (ODI) score at two-year follow-up. Secondary outcome measures were scores on the European Quality of Life–5 Dimensions (EQ-5D) and visual analog scale (VAS) and the rate of intraoperative complications. To minimize baseline differences between the groups, propensity-score matching was employed in a 1:1 fashion, balancing the groups on preoperative factors including age, sex, back and leg pain, ODI, EQ-5D and previous spine surgery.
Results: The matched cohort included 211 patients in each cohort. There was no significant difference between the groups in the mean score on the ODI at two years (PLIF: 33±20 vs. TLIF: 35±20, p= 0.222). We found no statistically significant differences in EQ-5D score (0.64±0.26 vs. 0.61±0.25, p= 0.201), VAS score for back pain (46±31 vs. 48±29, p= 633)) or leg pain (41±32 vs.41±33, p=0.938) between the PLIF and TLIF groups, respectively. Dural tears occurred in 9.5% in the PLIF group and 1.9% in the TLIF group (p=0.002) corresponding to a relative risk of 5.0 (95%CI 1.7- 14.4).
Interpretation / Conclusion: We found no significant difference in PRO at two-year follow-up between PLIF and TLIF for the treatment of symptomatic lumbar disc degeneration. PLIF is associated with a five-times higher risk of dural tears.

50. Comparison of interventions for lumbar disc herniation: a systematic review with network meta-analysis
Kresten Wendell Rickers, Peter Heide Pedersen, Torben Tvedebrink, Søren Eiskjær
Interdisciplinary Orthopedics, Aalborg University Hospital, Hobrovej 18-22, DK9000 Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Soender Skovvej 15, DK9000 Aalborg, Denmark; Department of Mathematical Sciences, Aalborg University, Skjernvej 4A, DK9220 Aalborg Oe, Denmark

Background: There are a wide variety of surgical methods for treating lumbar disc herniation. Development has previous mainly been on minimal invasive technics. High revision rates due to reherniation has brought focus on technics to avoid reherniation.
Aim: The aim of this systematic review was to compare all current surgical methods for treating lumbar disc herniation, including newer methods with implants for annulus repair and dynamic stabilization.
Materials and Methods: A systematic review of randomized controlled trials comparing surgical treatments. Literature search in PubMed, Embase, and Cochrane library databases identified eligible studies. The investigated outcomes were: changes in pain (VAS score), disability score (Oswestry and Roland Morris) and reoperation rate with a minimum follow-up of one year. A network meta-analysis was performed in order to compare treatments and ranking.
Results: Thirty-two RCT studies, with 4877 participants, and 8 different interventions were identified. A significant difference was seen in change of pain score, as all treatments were superior to conservative treatment and percutaneous discectomy. This difference was only found to be of clinically importance when comparing conservative treatment and dynamic stabilization. There was no significant difference in reoperation rates or change in disability score, regardless of treatment. However, SUCRA plots showed a trend in ranking annulus repair and dynamic stabilization highest. Risk of bias assessment showed that 15 studies had a high overall risk of bias.
Interpretation / Conclusion: With this network meta-analysis, we have aimed to compare all treatments for herniated lumbar disc in one large comprehensive systematic review and network meta-analysis. We have compared across the 3 main outcomes: disability score, pain score and reoperation rate. We were not able to rank one single treatment as the best. Most of the treatments performed at the same level. However percutaneous discectomy and conservative treatment consistently performed worse than the other treatments. In general, the CINeMA evaluation according to the GRADE recommendations gave a high level of confidence for the study comparisons.

51. The clinical significance of the Modic changes grading score
Peter Udby, Signe Elmose, Mikkel Østerheden Andersen, Leah Carreon
Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Roskilde, Denmark; Spine Surgery and Research, Spine Center of Southern Denmark, Lillebaelt Hospital, Middelfart, Denmark

Background: MC is present in up to 50% of all chronic low back pain patients. A grading score for MC has been previously proposed, but the association between the extent of MC involvement in the vertebral body, or MC grade and patient-reported outcomes (PRO) has not been investigated.
Aim: To evaluate the clinical significance and inter- observer reliability of the MC grading score in patients with low back pain and MC
Materials and Methods: MRI-scans from patients who had a discectomy registered in the Danish national spine register, DaneSpine, were reviewed. Based on the MRI findings the patients were divided into two groups: +MC and -MC. The MRI of patients +MC were graded using the MC grading score from A-C. All MRIs were reviewed by two physicians to evaluate the intra- and inter-reliability of the MC grading score. The association between MC grade and disability as measured by ODI and EQ-5D was analyzed by t-test.
Results: In total 300 patients were included, of these 150 had MC- 73 patients with MC-1 and 77 patients with MC-2. Of the +MC group, 34% had Grade A changes, 45% Grade B, and 21% Grade C. A scatter-plot showed that some patients with Grade B had worse PROs than some patients with grade C. Thus, patients were stratified into Grade A vs Grade B-C. A statistically significant higher percentage of patients with MC-1 had grade B-C changes compared to patients with MC-2 (p<0.001). Grade B-C changes were significantly associated with a worse preoperative ODI-score, 44 vs. 52 (p=0.02) and EQ-5D 0.46 vs. 0.26 (p=0.05) compared to Grade A. The intra- and inter-reliability of the MC grading score demonstrated substantial reliability, Intra Kappa=0.73, and Inter Kappa=0.64.
Interpretation / Conclusion: The current study found a significant difference in the vertical extent of MC between MC-1 and MC-2. An increased vertical extent of the intervertebral MC was significantly associated with worse preoperative PROs. The reliability for the grading score was substantial for both intra- and interobserver reliability in a clinically relevant population. We suggest that further studies on degenerative spine changes include a description of the vertebral extent of MC as an MC grading score.