Musculoskeletal health in the workplace

Musculoskeletal (MSK) problems remain the most frequent reason why individuals are absent from work, including those with work-related musculoskeletal disorders (WRMSDs or MSDs) and those with chronic MSK problems. This paper aims to examine changes in work and the workforce since 2000; how work impacts on chronic MSK conditions and how we can help people with these conditions to stay at work. While our knowledge of the causes of WRMSDs has increased since 2000, there has been limited workplace action in reducing exposure to hazards. A life course approach is needed as individuals of all ages are reporting MSK problems. How people work has also changed and informalisation of work contracts has increased with a perceived concurrent reduction in occupational safety and health (OSH) protection. Retaining people at work with MSK problems requires compliance with relevant safety, health and diversity legislation and a risk management approach. Good and open communication within the workplace and identification of other sources of support is also necessary. Considerations must be made at the individual level (internal motivation), organisational level (a supportive manager) and self-management of symptoms. Simple case examples are provided in the paper of what works in practice as well as a proposed research agenda. Increased awareness at all levels of society of MSK health is essential.     

Risk of vertebral artery injury: comparison between C1–C2 transarticular and C2 pedicle screws

Background contextTo our knowledge, no large series comparing the risk of vertebral artery injury by C1–C2 transarticular screw versus C2 pedicle screw have been published. In addition, no comparative studies have been performed on those with a high-riding vertebral artery and/or a narrow pedicle who are thought to be at higher risk than those with normal anatomy.PurposeTo compare the risk of vertebral artery injury by C1–C2 transarticular screw versus C2 pedicle screw in an overall patient population and subsets of patients with a high-riding vertebral artery and a narrow pedicle using computed tomography (CT) scan images and three-dimensional (3D) screw trajectory software.Study designRadiographic analysis using CT scans.Patient sampleComputed tomography scans of 269 consecutive patients, for a total of 538 potential screw insertion sites for each type of screw.Outcome measuresCortical perforation into the vertebral artery groove of C2 by a screw.MethodsWe simulated the placement of 4.0 mm transarticular and pedicle screws using 1-mm-sliced CT scans and 3D screw trajectory software. We then compared the frequency of C2 vertebral artery groove violation by the two different fixation methods. This was done in the overall patient population, in the subset of those with a high-riding vertebral artery (defined as an isthmus height ≤5 mm or internal height ≤2 mm on sagittal images) and with a narrow pedicle (defined as a pedicle width ≤4 mm on axial images).ResultsThere were 78 high-riding vertebral arteries (14.5%) and 51 narrow pedicles (9.5%). Most (82%) of the narrow pedicles had a concurrent high-riding vertebral artery, whereas only 54% of the high-riding vertebral arteries had a concurrent narrow pedicle. Overall, 9.5% of transarticular and 8.0% of pedicle screws violated the C2 vertebral artery groove without a significant difference between the two types of screws (p=.17). Among those with a high-riding vertebral artery, vertebral artery groove violation was significantly lower (p=.02) with pedicle (49%) than with transarticular (63%) screws. Among those with a narrow pedicle, vertebral artery groove violation was high in both groups (71% with transarticular and 76% with pedicle screws) but without a significant difference between the two groups (p=.55).ConclusionsOverall, neither technique has more inherent anatomic risk of vertebral artery injury. However, in the presence of a high-riding vertebral artery, placement of a pedicle screw is significantly safer than the placement of a transarticular screw. Narrow pedicles, which might be anticipated to lead to higher risk for a pedicle screw than a transarticular screw, did not result in a significant difference because most patients (82%) with narrow pedicles had a concurrent high-riding vertebral artery that also increased the risk with a transarticular screw. Except in case of a high-riding vertebral artery, our results suggest that the surgeon can opt for either technique and expect similar anatomic risks of vertebral artery injury.     

Stair climbing ability in patients with early knee osteoarthritis: Defining the clinical hallmarks of early disease

BackgroundA growing clinical interest has been shown towards identifying knee osteoarthritis (OA) patients at earlier stages. The early detection of knee OA may allow for more effective interventions.Research questionThe aim of this study was to determine the discriminative ability of a stair-climb test (SCT) in identifying patients with early knee OA, and to determine if descending stair time during the SCT is better than ascending stair time for the identification of these patients.MethodsThis study was a secondary, cross-sectional analysis of baseline data from a randomized controlled trial. Adults with moderate to severe knee pain were enrolled (n = 57; mean age 58.9 years; 71.9% women). Each participant performed an 11-step SCT (11-SCT) while wearing shoes with a pressure sensor insole. A receiver operating characteristic analysis was used to examine the discriminative power of 11-SCT for identifying early knee OA (Kellgren and Lawrence grade 1). The discriminative power was also compared between the ascending and descending 11-SCT time as evaluated by the pressure sensor.ResultsThe 11-SCT time in patients with early knee OA was 0.55 s longer than that in those with symptomatic non-radiographic OA. A one-second increase in the 11-SCT time was significantly associated with 1.9-fold increased odds of early knee OA being present. The 11-SCT value with the best balance of sensitivity and specificity for identifying early knee OA was 8.33 s (area under the curve: 0.711). The descending time was not significantly better than the ascending time for identifying early knee OA.SignificanceThis study determined the time values of an 11-SCT that may be useful for identifying early knee OA patients. These preliminary findings may serve as the foundation for future studies investigating the clinical hallmarks associated with early knee OA.     

Ultrasound-based navigated pedicle screw insertion without intraoperative radiation: feasibility study on porcine cadavers

BACKGROUNDNavigation systems for spinal fusion surgery rely on intraoperative computed tomography (CT) or fluoroscopy imaging. Both expose patient, surgeons and operating room staff to significant amounts of radiation. Alternative methods involving intraoperative ultrasound (iUS) imaging have recently shown promise for image-to-patient registration. Yet, the feasibility and safety of iUS navigation in spinal fusion have not been demonstrated.PURPOSETo evaluate the accuracy of pedicle screw insertion in lumbar and thoracolumbar spinal fusion using a fully automated iUS navigation system.STUDY DESIGNProspective porcine cadaver study.METHODSFive porcine cadavers were used to instrument the lumbar and thoracolumbar spine using posterior open surgery. During the procedure, iUS images were acquired and used to establish automatic registration between the anatomy and preoperative CT images. Navigation was performed with the preoperative CT using tracked instruments. The accuracy of the system was measured as the distance of manually collected points to the preoperative CT vertebral surface and compared against fiducial-based registration. A postoperative CT was acquired, and screw placements were manually verified. We report breach rates, as well as axial and sagittal screw deviations.RESULTSA total of 56 screws were inserted (5.50 mm diameter n=50, and 6.50 mm diameter n=6). Fifty-two screws were inserted safely without breach. Four screws (7.14%) presented a medial breach with an average deviation of 1.35±0.37 mm (all <2 mm). Two breaches were caused by 6.50 mm diameter screws, and two by 5.50 mm screws. For vertebrae instrumented with 5.50 mm screws, the average axial diameter of the pedicle was 9.29 mm leaving a 1.89 mm margin in the left and right pedicle. For vertebrae instrumented with 6.50 mm screws, the average axial diameter of the pedicle was 8.99 mm leaving a 1.24 mm error margin in the left and right pedicle. The average distance to the vertebral surface was 0.96 mm using iUS registration and 0.97 mm using fiducial-based registration.CONCLUSIONSWe successfully implanted all pedicle screws in the thoracolumbar spine using the ultrasound-based navigation system. All breaches recorded were minor (<2 mm) and the breach rate (7.14%) was comparable to existing literature. More investigation is needed to evaluate consistency, reproducibility, and performance in surgical context.CLINICAL SIGNIFICANCEIntraoperative US-based navigation is feasible and practical for pedicle screw insertion in a porcine model. It might be used as a low-cost and radiation-free alternative to intraoperative CT and fluoroscopy in the future.     

Effects of general anesthesia with and without thoracic epidural block on length of stay after open spine surgery: a single-blinded randomized controlled trial

BACKGROUND CONTEXTLength of hospital stay (LOS) is an important concern in all types of surgery, and the enhanced recovery after surgery (ERAS) protocol has been developed to improve perioperative management and outcomes, which require multidisciplinary management. In terms of pain control, intraoperative regional anesthesia and postoperative opioid-sparing analgesia are recommended. For open spine surgery, we aimed to combine thoracic epidural analgesia to reduce pain and opioid-related side effects, thereby hastening recovery.PURPOSEThis study aimed to compare the length of hospital stay after open complete laminectomy with fusion between general anesthesia and combined general anesthesia involving a single thoracic epidural injection.DESIGNA randomized single-blinded controlled study.PATIENT SAMPLEThirty-eight patients scheduled for elective open laminectomy with fusion between I and III levels were selected.OUTCOME MEASURESLOS, postoperative pain, patient-controlled morphine consumption at 24 hours, patient satisfaction score, and other opioid-related side effects were recorded.METHODSPatients were randomly selected to receive standard general anesthesia (GA) or GA combined with a single-shot thoracic epidural at T11–T12 or T12–L1, a block with 10 mL of 0.25% bupivacaine, and 4 mg of morphine.RESULTSThere were no significant differences in the demographic variables between groups. LOS was significantly lower in the combined epidural and/or GA than in the control group (3.78±0.81 [mean±standard deviation] and 4.79±1.51 days, respectively; p=.017). Numeric rating score (at rest) at the post-anesthesia care unit, 24 hours postoperative morphine consumption (mg), operating time, and blood loss were significantly lower in the epidural group. Patients who received combined epidural and/or GA were more likely to report higher patient satisfaction (p=.008). However, the incidence of intraoperative hypotension was significantly higher in the epidural group (72.2% vs. 21.1%, p=.003). The incidences of adverse events and surgical field rating scores did not differ between the 2 patient groups.CONCLUSIONSCombined lower thoracic epidural and/or GA in patients undergoing elective lumbar spine surgery was associated with decreased LOS.     

Flexibility does not affect the dorsiflexion of foot and the popliteal angle in young adults

BackgroundThe aim of the study was to assess how flexibility affects the dorsiflexion of foot and the popliteal angle test results in junior high school students.MethodsThe subjects were 142 students from the 2nd, and 3rd year of Poznań junior high schools (age between 13 and 15).Each subject was examined 6 times: there were 3 raters, a specialist in orthopaedics, a resident doctor and a physical therapy student, and each of them performed 2 measurements. Flexibility was also measured using the Beighton scale (score from 0 to 9).ResultsSince the Beighton scale is ordinal in order to evaluate the relationship between flexibility and the range of motion Spearman's rank correlation coefficient was calculated. The statistical analysis showed no correlation between flexibility measured on the Beighton scale and the range of passive foot dorsiflexion and the popliteal angle.ConclusionsThe degree of flexibility does not affect the dorsiflexion of the foot and the popliteal angle in junior high students. At this age the range of dorsiflexion is determined by the length of the triceps surae muscle while the popliteal angle depends on the length of the muscles on the back of the thigh.     

The effect of insulin dependent diabetes on bone metabolism and growth after spinal fusion

STUDY DESIGNExperimental animal model.OBJECTIVEThe purpose of this study was to evaluate the hypothesis that insulin dependent diabetes mellitus (IDDM) will inhibit the formation of a solid bony union after spinal fusion surgery via an alteration of the microenvironment at the fusion site in a rat model.SUMMARY OF BACKGROUND DATAPrevious studies report diabetes mellitus (DM) and specifically IDDM as a risk factor for complications and poor surgical outcomes following spinal fusion.METHODSTwenty control and 22 diabetic rats were obtained at 5 weeks of age. At 20 weeks of age, all animals underwent posterolateral lumbar fusion surgery using a tailbone autograft with diabetic rats receiving an implantable time release insulin pellet. A subset of rats was sacrificed 1-week postsurgery for growth factor (PDGF, IGF-I, TGF-β, and VEGF) and proinflammatory cytokine ELISA analysis. All other rats were sacrificed 3-months postsurgery for fusion evaluation via manual palpation and micro CT. Glycated hemoglobin (HbA1c) was measured at surgery and sacrifice on all animals.RESULTSCompared with healthy rats undergoing spinal fusion, rats with IDDM demonstrated a significant reduction in manual palpation fusion rates (16.7% vs. 43%, p<.05). Average bone mineral density, bone volume, and bone volume fraction were also significantly reduced and negatively correlated to blood glucose levels. IL-1B, IL-5, IL-10, TNF-α, and KC/GRO were significantly elevated in fusion beds of IDDM rats.CONCLUSIONSThis study demonstrates that rats with IDDM demonstrate a reduced rate and quality of spinal fusion with increased local levels of inflammatory cytokines. Targeted modalities are required to improve bone healing in this growing, high-risk population.CLINICAL SIGNIFICANCEThis is the first translational animal model of IDDM to evaluate the rate and quality of spinal fusion while controlling for other surgical and patient-related risk factors. Our findings demonstrate the complex nature by which IDDM impairs bone healing and highlight the need for additional basic science research to further elucidate this mechanism in order to develop more effective therapeutic interventions.