Clinical Outcomes of Robotic Versus Freehand Pedicle Screw Placement After One-to Three-Level Lumbar Fusion

Study Design Retrospective cohort study Objectives The purpose of this study is to compare patient-reported outcome measures (PROMs) for patients undergoing one-to three-level lumbar fusion using robotically assisted vs freehand pedicle screw placement. Methods Patients who underwent either robotically assisted or freehand pedicle screw placement for one-to three-level lumbar fusion surgery from January 1, 2014 to August 31, 2020 at a single academic institution were identified. Propensity score matching was performed based on demographic variables. Clinical and surgical outcomes were compared between groups. Recovery Ratios (RR) and the proportion of patients achieving the minimally clinically important difference (%MCID) were calculated for Oswestry Disability Index, PCS-12, MCS-12, VAS Back, and VAS Leg at 1 year. Surgical outcomes included complication and revision rates. Results A total of 262 patients were included in the study (85 robotic and 177 freehand). No significant differences were found in ΔPROM scores, RR, or MCID between patients who underwent robotically assisted vs freehand screw placement. The rates of revision (1.70% freehand vs 1.18% robotic, P = 1.000) and complications (.57% freehand vs 1.18% robotic, P = .546) were not found to be statically different between the 2 groups. Controlling for demographic factors, procedure type (robotic vs freehand) did not emerge as a significant predictor of ΔPROM scores on multivariate linear regression analysis. Conclusions Robotically assisted pedicle screw placement did not result in significantly improved clinical or surgical outcomes compared to conventional freehand screw placement for patients undergoing one-to three-level lumbar fusion.

Lateral Thoracolumbar Listhesis as an Independent Predictor of Disability in Adult Scoliosis Patients: Multivariable Assessment Before and After Surgical Realignment

BACKGROUND Lateral (ie, coronal) vertebral listhesis may contribute to disability in adult scoliosis patients. OBJECTIVE To assess for a correlation between lateral listhesis and disability among patients with adult scoliosis. METHODS This was a retrospective multi-center analysis of prospectively collected data. Patients eligible for a minimum of 2-yr follow-up and with coronal plane deformity (defined as maximum Cobb angle ≥20º) were included (n = 724). Outcome measures were Oswestry Disability Index (ODI) and leg pain numeric scale rating. Lateral thoracolumbar listhesis was measured as the maximum vertebral listhesis as a percent of the superior endplate across T1-L5 levels. Linear and logistic regression was utilized, as appropriate. Multivariable analyses adjusted for demographics, comorbidities, surgical invasiveness, maximum Cobb angle, and T1-PA. Minimally clinically important difference (MCID) in ODI was defined as 12.8. RESULTS In total, 724 adult patients were assessed. The mean baseline maximum lateral thoracolumbar listhesis was 18.3% (standard deviation 9.7%). The optimal statistical grouping for lateral listhesis was empirically determined to be none/mild (<6.7%), moderate (6.7-15.4%), and severe (≥15.4%). In multivariable analysis, listhesis of moderate and severe vs none/mild was associated with worse baseline ODI (none/mild = 33.7; moderate = 41.6; severe = 43.9; P < .001 for both comparisons) and leg pain NSR (none/mild = 2.9, moderate = 4.0, severe = 5.1, P < .05). Resolution of severe lateral listhesis to none/mild was independently associated with increased likelihood of reaching MCID in ODI at 2 yr postoperatively (odds ratio 2.1 95% confidence interval 1.2–3.7, P = .0097). CONCLUSION Lateral thoracolumbar listhesis is associated with worse baseline disability among adult scoliosis patients. Resolution of severe lateral listhesis following deformity correction was independently associated with increased likelihood of reaching MCID in ODI at 2-yr follow-up.

EFEKTIVITAS BALANCE EXERCISE DAN GAIT TRAINING DALAM MENINGKATKAN KESEIMBANGAN DAN KECEPATAN BERJALAN PADA KASUS STROKE ISKEMIK

Stroke merupakan hilangnya fungsi otak secara mendadak dan memicu kelumpuhan unilateral yang dapat mengurangi kontrol postur dan keseimbangan sehingga pasien kesulitan untuk berjalan. Tujuan studi kasus ini adalah mengetahui efektivitas balance exercise dan gait training terhadap peningkatan keseimbangan dan kecepatan berjalan pada pasien stroke menggunakan parameter Timed Up and Go Test (TUGT) dan 10 Meter Walk Test (10MWT). Metode yang digunakan adalah evidence-based case report dengan pertanyaan klinis, “Bagaimana efektivitas balance exercise dan gait training terhadap peningkatan keseimbangan dan kecepatan berjalan pada kasus stroke iskemik?” dengan penelusuran bukti pada 3 database, yaitu Pubmed, science direct, dan scopus. Setelah dilakukan 6 kali evaluasi terdapat peningkatan keseimbangan dan kecepatan dimana pada evaluasi pertama didapatkan hasil pengukuran TUGT sebesar 14,14 detik, self selected velocity 0,63m/s dan fast velocity 0,66m/s. Pada evaluasi keenam didapatkan hasil sebesar 09,50 detik, self selected velocity 1,34m/s dan fast velocity 1,40m/s sehingga dapat disimpulkan bahwa balance exercise dan gait training efektif dalam meningkatkan keseimbangan dan kecepatan berjalan pada pasien stroke dengan nilai minimal detectable change (MDC) TUGT sebesar 2,9 detik dan 10MWT pada self selected velocity sebesar 0,18m/s dan fast velocity sebesar 0,13m/s serta nilai minimally clinically important difference (MCID) TUGT sebesar 3,4 detik dan 10MWT sebesar 0,16m/s.

Reliability of the Clinical Outcome Variables Scale for children with cerebral palsy

Background/aims It can be difficult for rehabilitation professionals to use lengthy scales and different outcome measures for diverse clinical conditions in busy outpatient settings. The Clinical Outcome Variables Scale is a functional mobility measure that is applied to various neurological conditions. Determining the inter- and intra-rater reliability of clinical outcome variable scale for children with cerebral palsy will further enhance its utility. Methods A total of 30 children aged between 3 and 16 years with cerebral palsy, who could obey single-step commands, were recruited for the study. Two independent assessors scored the children using the Clinical Outcome Variable Scale to determine inter-rater reliability. A repeat assessment was done by the principal assessor after 24 hours to establish intra-rater reliability. Reliability was estimated using intra-class correlation coefficient values. Results The Clinical Outcome Variables Scale had high Inter- and intra-rater reliability for the composite score (intraclass correlation coefficient=1), the general mobility subscale (intraclass correlation coefficient=0.99), and the ambulation subscale (intraclass correlation coefficient=0.99). The intraclass correlation coefficient for the individual test items were also showed a high correlation, with the variance between the tests and physiotherapists ranging from 0.95 to 1. Conclusions The Clinical Outcome Variables Scale demonstrated high inter- and intra-rater reliability when assessing functional mobility in children with cerebral palsy. Further studies should establish criterion validity and minimally clinically important difference values to maximise the use of the scale.

Glucocorticoid toxicity reduction with Mepolizumab using the glucocorticoid toxicity index

Reduction in glucocorticoid exposure is the primary benefit of new biologic treatments in severe asthma, but there is currently no evidence that reduction in glucocorticoid exposure corresponds to a proportionate reduction in associated toxicity.ObjectivesTo use the validated Glucocorticoid Toxicity Index (GTI) to assess change in glucocorticoid toxicity after 12 months treatment with mepolizumab, and compare toxicity change to glucocorticoid reduction and change in patient reported outcome measures (PROMs).MethodsA longitudinal, real world prospective cohort of 101 consecutive patients with severe asthma commenced on mepolizumab in a Specialist UK Regional Severe Asthma clinic. GTI toxicity assessment, cumulative glucocorticoid exposure and PROMs were recorded on commencing mepolizumab (V1), and after 12 months treatment (V2).ResultsThere was significant reduction in oral glucocorticoid exposure (V1 4280 mg prednisolone/year [interquartile range (IQR) 3083, 5475] versus V2 2450 mg prednisolone/year [1243, 3360], p<0.001). Substantial improvements in individual toxicities were observed but did not correlate with oral glucocorticoid reduction. Mean GTI Aggregate Improvement Score (AIS) was −35.7 (sd 57.8) with a wide range in toxicity change at individual patient level (AIS range −165 to +130); 70% (71/101) had a reduction in toxicity (AIS <0), 3% (3/101) had no change (AIS=0) and 27% (27/101) an increase in overall toxicity. Sixty-two (62/101) patients met the AIS minimally clinically important difference of ≤−10, but AIS did not correlate with glucocorticoid reduction or change in PROMs.ConclusionMepolizumab resulted in substantial oral glucocorticoid reduction but this did not correlate with reduction in oral glucocorticoid toxicity, which varies widely at the individual patient level. Oral glucocorticoid reduction is not a comprehensive measure of response to mepolizumab.

COVID-19 and Cognitive Impairment: Severity, Evolution, and Functional Impact during Inpatient Rehabilitation

Objective: To determine the frequency, magnitude, and change in cognitive impairment in patients with COVID-19 undergoing acute inpatient rehabilitation. We secondarily evaluated correlates of cognitive impairment and the relationship between cognition and functional gain. Design: Cross-sectional observational study with assessments at admission and discharge Setting: Acute inpatient rehabilitation unit within a large, urban academic medical center Participants: 77 patients hospitalized for COVID-19 and subsequently admitted to an inpatient rehabilitation unit between March-August 2020, 45 of whom were re-assessed at discharge. Interventions: N/A Main Outcome Measures: Montreal Cognitive Assessment (MoCA) scores on admission and discharge (when available) and Quality Indicator for Self-Care (QI-SC) scores on admission and discharge. Results: 62/77 (80.5%) of patients demonstrated cognitive deficits on the MoCA at admission: 39/77 (50.6%) were mildly impaired, 20/77 (26%) moderately impaired, and 3/77 (3.9%) severely impaired. Cognitive impairment was associated with a prior history of delirium, but not age or length of acute care hospitalization. 32/45 (71.1%) patients with discharge scores improved and met the MoCA minimally clinically important difference (MCID); however, 35/45 (77.8%) continued to score in the impaired range. Patients who met the MoCA MCID demonstrated significantly greater QI-SC score gains than those that did not meet the MCID (p=.02). Conclusion: Cognitive impairment is common among hospitalized COVID-19 patients requiring acute inpatient rehabilitation. Cognitive impairment improves over the course of inpatient rehabilitation, and is associated with functional gain. Nonetheless, cognitive deficits frequently remain present at discharge, indicating the need for systematic assessment and follow-up, especially given the association with functional outcome.

The resting coronal and sagittal stance position of the torso in adolescents with and without spinal deformity

The purpose of this work is to identify the resting stance of the torso, defined as the position of the C7 vertebral body relative to the sacrum in a ‘birds eye view’, as the coronal and sagittal offset, in those without spinal deformity, those with pre and post-operative AIS, and those with Scheuermann's kyphosis (SK). Using ISIS2 surface topography, the coronal and sagittal offset were measured in a prospective manner in all groups. With bivariate ellipses, a mean and 95% confidence ellipse of the data was developed. Statistical analyses was performed to examine the distribution of the data from the groups. A graphical representation of the data was developed. There were 829 without spinal deformity, 289 in both the pre and post-operative with AIS and 59 with SK. The results showed that the mean coronal offset for all groups was between 2 and 6 mm and the sagittal offset was 12 and 26 mm. Statistically significance was seen for both measures between the non-scoliotic and both AIS groups, along with the pre-operative AIS coronal offset and post-operative AIS sagittal offset and the SK measures. However, all mean values were within the 95% confidence ellipse for all of the groups. Regardless of the size or type of spinal deformity, the position of the C7 vertebral body and sacrum remain within the 95% confidence ellipse of that seen in those without spinal deformity. This work defines the Minimally Clinically Important Difference for all of the groups.

Intra-Operative Soft Tissue Targets For Improved Outcomes In Total Knee Arthroplasty

A poorly balanced, unstable or stiff joint is a leading cause of dissatisfaction and revision after surgery. The quantitative definition of a well-balanced joint, however, remains a source of controversy. This study investigates joint gaps measured by a digitally-controlled ligament tensioning device throughout flexion and its effect on post- operative outcome.Surgeries were performed using the OMNIBotics robot-assisted TKA platform and BalanceBot device. Joint gaps were recorded by the BalanceBot throughout flexion during trialing. Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected at 1-year post-op. Correlations between joint gaps and KOOS outcome were investigated.Knees that reported: a medial gap ≤ lateral gap in extension (p = 0.007, median ∆ = 8.3); an average joint gap of between 1 mm tighter and 1 mm looser than the final insert thickness in midflexion (p = 0.006, median ∆ = 5.5); and an imbalance of less than 1.5 mm in flexion (p = 0.012, median ∆ = 2.8) reported significantly improved pain scores. Patients which satisfied both extension and flexion criteria, or midflexion and flexion criteria reported improved outcomes compared to those which satisfied only one or neither criterion (p = 0.0002, median ∆ = 9.7, p = 0.0019, median ∆ = 8.4 respectively).KOOS Pain scores correlated with joint gap measurements across all flexion angles investigated. Combining joint gap windows, subgroups of patients were found that reported a change in the median KOOS Pain outcome beyond the minimally clinically important difference.