Citations

OBJECTIVE The evidence on ankylosing spinal disorders (ASDs), including ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), in the context of spinal fracture stems from studies with relatively small sample sizes. There are no studies addressing the patient-reported outcome measures (PROMs) and health-related quality of life (HRQOL) outcomes associated with spinal fracture in this population. The aim of this study was to investigate differences in complications, mortality, PROMs, and HRQOL in patients with and without ASD who had been treated for spinal fracture. METHODS This is a nationwide multicenter retrospective study of prospectively collected data from the Swedish Fracture Register. All patients with fractures of the cervical, thoracic, or lumbar spine treated surgically and conservatively between January 2015 and December 2021 were eligible for inclusion. Two groups of patients were formed based on the presence or absence of concomitant ASD. Primary outcomes of interest included death and PROMs. For surgically treated patients, data on complications and reoperation rates were retrieved. Propensity score matching with a ratio of 1:1 was used to balance the groups prior to intergroup comparison. Variables included in the matching process were age, sex, mechanism of injury, neurological function on admission (Frankel grade), injury type (high vs low energy), fracture type, injured spinal level, time to treatment, and type of treatment (surgical vs conservative). Kaplan-Meier analyses were used to study overall survival following injury. RESULTS A total of 14,604 patients without ASD and 1368 patients with ASD were included in this study. High-energy injuries were less frequent in patients with ASD (13% vs 24%, p < 0.001). Moreover, patients with ASD were less likely to be neurologically intact on admission (90% vs 94%, p < 0.001). There were 1707 surgically treated patients without ASD and 559 with the disorder. After matching, a higher overall risk of reoperation was found among patients with ASD (9.1% vs 3.4%, p = 0.007). Surgical site infections requiring reoperation (p = 0.012), but not construct failure or CSF leakage requiring reoperation (p ≥ 0.05), were more common among the patients with ASD. Postmatching, there were no differences in overall survival between ASD and non-ASD cases (p > 0.05). Moreover, patients with and without ASD had similar PROMs, as indicated by the EQ-5D-3L index at 1 year after injury (p = 0.59). CONCLUSIONS Self-reported recovery 1 year after spinal fracture occurred to a similar extent in patients with and without ASD. Moreover, ASD alone was not a significant risk factor for death. Finally, surgically treated patients with ASD experienced higher rates of postoperative complications and reoperations following surgery.

OBJECTIVE Proximal junctional kyphosis (PJK) affects 5%–61% of patients following thoracolumbar fusion. Many patients are asymptomatic, but a plurality require surgical revision at a cost of $75,000 per case. This analysis sought to analyze the degree to which bone quality and paraspinal muscle sarcopenia influence PJK failure mode. METHODS Patients undergoing thoracolumbar instrumented fusion with an upper instrumented vertebra (UIV) at the thoracolumbar junction (T10–L2) were identified and data were gathered on surgery, bone quality, pre- and postoperative sagittal alignment, and paraspinal muscle cross-sectional area (CSA). PJK was defined as a ≥ 10° increase in proximal junctional angle from the first postoperative radiograph. PJK was classified as discoligamentous failure (type 1), bone failure (type 2), or screw-bone interface failure (type 3) according to the Yagi-Boachie system. Bone quality was assessed by Hounsfield units (HUs) and the vertebral bone quality (VBQ) score at the UIV. RESULTS One hundred fifty patients were identified (median age 67 years, 53.3% female), 46 of whom experienced PJK (22 type 1, 13 type 2, 11 type 3). The median time to onset was most rapid for type 2 events (2.6 months). There were no differences between patients experiencing PJK versus controls regarding bone quality (HUs or VBQ score) or paraspinal muscle CSA on univariate comparison. However, subdivision by PJK type showed patients experiencing bone failure (type 2) PJK had significantly lower HUs at the UIV and UIV+1 relative to those experiencing type 1 PJK or no PJK (all p < 0.05). The VBQ score trended toward being significant, with a higher VBQ score (worse bone quality) in those suffering type 2 PJK, but did not reach statistical significance (p = 0.07). Patients experiencing discoligamentous failure PJK (type 1) had small multifidus CSA (390 mm 2 ) relative to patients experiencing type 2 (516 mm 2 ) or type 3 (440 mm 2 ) PJK and patients who did not experience PJK (481 mm 2 ), although the difference did not reach statistical significance. On time-to-event analysis, low HUs of the UIV/UIV+1 predicted type 2 (hazard ratio [HR] 0.81, 95% CI 0.70–0.93; p = 0.002) and type 2/3 PJK (HR 0.87, 95% CI 0.78–0.96; p = 0.006) but not type 1 PJK. Low UIV multifidus CSA trended toward being a significant predictor of type 1 PJK (HR 0.85, 95% CI 0.69–1.05; p < 0.10). CONCLUSIONS The combination of underlying bone quality and paraspinal musculature CSA at the UIV appeared to influence failure mode among patients who underwent lumbosacral instrumented fusion terminating at the thoracolumbar junction.

OBJECTIVE The landscape of healthcare policies has undergone significant reforms, with a notable shift toward a patient-centered basis. This change has prioritized the use of metrics reflecting subjective patient-reported outcome measures (PROMs). However, these metrics are often limited, especially in terms of determining clinically relevant changes over time. The concept of the minimal clinically important difference (MCID) has been introduced to address this limitation. In this study, the authors aimed to assess the predictive capability of relative change and its corresponding threshold value, the minimal clinically important relative change (MCIRC), as an alternative to the absolute difference and MCID. METHODS Prospectively collected data from 2006 to 2021 were obtained from the Swedish Spine Registry (Swespine). PROMs included the numeric rating scale (NRS) neck and arm pain scores, the EQ-5D index and EQ visual analog scale (VAS), and the Neck Disability Index (NDI). Anchor-based methods were used to determine MCID and MCIRC. Absolute differences and relative changes were compared in terms of predictive power using the area under the receiver operating characteristic curve (AUC). RESULTS A total of 5323 patients were included. The chosen MCID values were −3 for NRS neck pain, −3 for NRS arm pain, 0.08 for EQ-5D index, 13 for EQ VAS, and −30 for NDI scores. The chosen MCIRC values were −40% for NRS neck pain, −50% for arm pain, 323% for EQ-5D index, 55% for EQ VAS, and −33% for NDI scores. Relative change was superior for NRS neck and arm pain scores and NDI, while absolute difference was superior for EQ-5D and EQ VAS scores. CONCLUSIONS Relative change and its corresponding MCIRC were found to be more appropriate as a surrogate of subjective satisfaction when studying the NRS and NDI scores, whereas absolute difference and MCID was more appropriate when addressing EQ-5D index and EQ VAS scores.

OBJECTIVE Artificial intelligence (AI) is increasingly capable of academic writing, with large language models such as ChatGPT showing potential to assist or even generate scientific manuscripts. However, concerns remain regarding the quality, reliability, and interpretive capabilities of AI-generated content. The authors’ study aimed to compare the quality of a human-written versus an AI-generated scientific manuscript to evaluate the strengths and limitations of AI in the context of academic publishing. METHODS Two manuscripts were developed using identical titles, abstracts, and tables of a simulated analysis: one authored by a physician with multiple publications, and the other generated by ChatGPT-4o. Three independent and blinded reviewers—two human and one AI—assessed each manuscript across five domains: clarity and readability, coherence and flow, technical accuracy, depth, and conciseness and precision. Each category was scored on a 10-point scale, and qualitative feedback was collected to highlight specific strengths and weaknesses. Additionally, all reviewers were asked to deduce authorship of the manuscripts. RESULTS The AI-generated manuscript scored higher in clarity and readability (mean 9.0 vs 7.2), but lower in technical accuracy (mean 6.3 vs 9.3) and depth (mean 5.5 vs 7.5). However, reviewers noted that the AI version lacked depth, critical analysis, and contextual interpretation. All reviewers accurately identified the authorship of each manuscript and tended to rate the version more favorably when it aligned with their own origin (human or AI); i.e., human reviewers assigned higher scores to the human-written manuscript, while the AI reviewer scored the AI-generated manuscript higher. CONCLUSIONS Although AI models can improve some aspects of scientific writing, particularly clarity and readability, they fall short in critical reasoning and contextual understanding. This reinforces the importance of human authorship and oversight in maintaining the critical analysis and scientific accuracy essential for academic publishing. AI may be used as a complementary tool to support, rather than replace, human-led scientific writing.

OBJECTIVE Degenerative lumbar spondylolisthesis is a common cause of back and leg pain influenced by factors like instability, disc degeneration, facet arthropathy, and psychosocial phenotype. Patients’ experience of high-severity pain is complex, with significant implications for surgical planning. The goal of this study was to assess the impact of back pain catastrophizing on long-term outcomes following lumbar spondylolisthesis surgery. METHODS This study uses the Quality Outcomes Database (QOD) lumbar spondylolisthesis dataset and includes prospectively collected data from the 12 highest-enrolling clinical sites participating in the QOD lumbar module. The authors reviewed patients undergoing single-segment surgery for grade 1 degenerative lumbar spondylolisthesis. Severe baseline numeric rating scale for back pain (NRS-BP) scores (≥ 8) were classified as "catastrophizing," and mild to moderate pain scores (< 8) were classified as "non-catastrophizing." Patient-reported outcomes (PROs) were compared for catastrophizing versus non-catastrophizing patients at 60 months. Univariate and multivariate analyses were conducted to assess the impact of catastrophizing on PROs, with multivariate analysis controlling for variables initially reaching a p value < 0.10. RESULTS Of the 608 patients in this analysis, 260 (42.8%) experienced catastrophizing while 348 (57.2%) did not. Catastrophizing patients were significantly younger (59.9 ± 12.2 years vs 63.9 ± 11.7 years, p < 0.001), less often had ≥ 4 years of college education (31.2% vs 42.5%, p = 0.004), and more often used private insurance (58.8% vs 47.7%, p = 0.01). The catastrophizing cohort also had higher rates of depression (24.6% vs 17.0%, p = 0.02) and back pain predominance (45.4% vs 32.2%, p < 0.001). Surgical and perioperative characteristics did not significantly differ between cohorts. Although catastrophizing patients typically reported worse PRO scores at both baseline and 60 months, they demonstrated significantly greater improvement and minimal clinically important difference (MCID) achievement across almost all PROs at 60 months (p < 0.05). However, North American Spine Society (NASS) satisfaction scores at 60 months did not differ significantly between cohorts. Multivariate analysis found that catastrophizing significantly predicted 60-month NRS-BP change (β −1.45, 95% CI −1.81 to −1.09; p < 0.001) and MCID achievement (OR 1.98, 95% CI 1.52–2.58; p < 0.001) but not mean NRS-BP score or other metrics, including NASS satisfaction. CONCLUSIONS Despite presenting with worse baseline symptoms, patients with pain catastrophizing experienced substantial and clinically meaningful improvement following surgery for degenerative lumbar spondylolisthesis. Patient satisfaction was comparable between cohorts, reflecting a nuanced balance between greater absolute improvement and persistence of residual symptoms. These findings underscore that catastrophizing should not be viewed as a barrier to surgical success, while pointing to the need for proactive expectation setting and shared decision-making.

OBJECTIVE The present investigation aimed to 1) develop a new CT-based assessment of endplate bone density (endplate Hounsfield unit [EP-HU]) and 2) analyze if EP-HU was a better predictor than vertebral Hounsfield unit (HU) for subsidence after anterior cervical discectomy and fusion (ACDF). METHODS All adult patients who underwent one- to three-level ACDF with a titanium interbody for radiculopathy and/or myelopathy at an academic center between 2018 and 2020 were retrospectively identified. Based on preoperative sagittal CT scans (left, right, and middle cuts), 2-mm superior and inferior endplate regions were circumscribed with the free draw tool to account for endplate surface undulations. The average of the superior and inferior EP-HUs on all CT cuts was used to calculate EP-HU. Cervical vertebral HUs were determined from the average of axial CT cranial, middle, and caudal cuts circumscribing only trabecular bone. The interbody subsidence of the cranial and caudal endplates of each ACDF level was directly measured on the endplate-facing surface of both coronal and sagittal cuts of postoperative CT scans (at 1 year) to determine the maximum subsidence (subsidence defined as ≥ 2 mm). Univariate and stepwise logistic regression analyses were used to compare subsidence based on CT bone metrics. Receiver operating characteristic (ROC) curve analyses were used to determine the probability of subsidence based on EP-HUs and vertebral HUs. RESULTS A total of 35 patients were included. Subsidence occurred at 32 of 67 unique fusion levels. Subsidence was associated with older age (p = 0.008), diabetes diagnosis (p = 0.015), and decreased interbody length (p = 0.019). EP-HUs exhibited moderate correlation with cervical vertebral HUs (Pearson’s ρ = 0.63). Subsidence was significantly associated with decreased total EP-HUs (subsidence: 475 HU, no subsidence: 543 HU; p = 0.019) and decreased lumbar vertebral HUs (subsidence: 296 HU, no subsidence: 341 HU; p = 0.011). ROC curve analysis identified an optimal EP-HU cutoff of 512.30 (area under the curve [AUC] = 0.701) to predict subsidence. The AUC of the vertebral HUs with respect to subsidence was 0.662. EP-HUs < 512.30 predicted subsidence (OR 6.67, p = 0.001) independent of significant demographic and surgical factors. CONCLUSIONS CT cervical EP-HUs rather than vertebral cervical trabecular HUs may be more efficacious in predicting subsidence after ACDF.

Abstract Background Genital lichen sclerosus (LS) is a chronic inflammatory skin disease that affects men, women and children. It is most common in female patients, with an estimated 1–3% of women affected across their lifetimes. Vulvar LS can cause significant symptoms and affect a person’s quality of life (QoL). To enhance the quality of clinical research and practice, core outcome domains have been identified, including QoL, clinical signs and symptoms, by the Core Outcome Set for Research in Lichen Sclerosus (CORALS) initiative. Objectives To identify key symptoms for the core outcome symptom domain for research in LS. Methods An international multidisciplinary steering committee of experts in vulvar, penile and paediatric LS was convened to define and discuss LS symptoms. A modified eDelphi process was conducted among experts to reach consensus on priority symptoms. An online patient survey was distributed to patient advocacy groups to rank symptoms. A scoping review was performed to identify commonly measured symptoms in LS studies in men, women and children. Results from all three sources were analysed and symptoms selected. Results The patient survey (n = 863) ranked itch, burning, pain, and cuts or tears in the skin as the most important symptoms, with pain with sex being most important to some and least important to others. Ninety-nine per cent of respondents to the survey identified as adult women, limiting generalizability to other populations with LS. Expert consensus identified five key symptoms: itch; pain with vaginal penetration; cuts and tears in the skin; pain; and irritation. The scoping review of 92 manuscripts showed itch, pain with penetration and burning/burning pain as the most frequently measured symptoms. Itch emerged as the most important symptom across all three data sources, with pain also consistently prioritized. Conclusions This study identified five key symptoms for evaluating vulvar LS. Although designed to capture symptoms from all patients with LS, the survey and scoping review both included small populations of male and paediatric participants, highlighting the need for further research in these populations. Based on the results, we suggest measurement of itch, pain, skin cuts and tears, burning and (when relevant) pain with sex within the symptoms core outcome domain for vulvar LS. These findings will be used to inform content validity studies when evaluating potential measurement instruments for the Core Outcome Set.

This study used semi-structured interviews with 11 key opinion leaders to explore why dermatologist involvement in innovation remains limited despite growing investment in the field. It found that barriers such as limited early exposure to industry, time constraints and goal misalignment hinder engagement, but also highlighted solutions like integrating industry exposure into training and fostering new funding models. These findings suggest actionable strategies to bridge gaps between clinicians and industry and promote dermatological innovation.

Abstract Context Patients with mild autonomous cortisol secretion (MACS) can develop adrenal insufficiency after unilateral adrenalectomy. Objective This work aimed to determine the prevalence, duration, and predictors of adrenal insufficiency, and compare postoperative basal cortisol and cosyntropin stimulation test (CST). Methods In this multicenter retrospective study of patients with MACS, adrenal insufficiency was diagnosed when postoperative basal cortisol was less than 10 µg/dL and/or CST &lt; 18 µg/dL. The results were concordant when both tests met cutoffs. Biochemical (BSS) and clinical severity scores (CSS) were calculated. Results Among 281 patients with MACS (80% women), postoperative adrenal insufficiency was diagnosed in 153 (54.5%) patients. Adrenal insufficiency inversely correlated with age (odds ratio [OR] 0.67 per 10 years; 95% CI, 0.53-0.84). Low basal cortisol and CST were associated with younger age (OR 0.64 per 10 years for both) and higher BSS (OR 1.17 and 1.22, respectively). Basal cortisol and CST were discordant in 22% of patients, and the discordance rate was more common in patients with bilateral nodules (32% vs 19%; P &lt; .001). The median time to adrenal insufficiency recovery was 3.9 months (IQR, 3-5.9 months), with longer duration associated with higher BSS and CSS: 3 months for mild, 4 to 5 months for moderate, and 12 to 14 months for severe BSS and CSS. Conclusion Approximately half of patients with MACS developed postoperative adrenal insufficiency, with 50% recovering by 3.9 months after surgery. BSS correlated with basal cortisol, CST, and duration of adrenal insufficiency. As discordant results were noted in 22%, performing both basal cortisol and CST postoperatively should be considered.

Abstract Objective To create a short-term medical service trip (MST) focused, standardized, evidence-based, cost-effective, locally appropriate formulary. Methods Documents from the World Health Organization (WHO), related entities, and primary literature were reviewed to determine best practices. Specific diagnosis and treatment formularies (DTFs) for MST use in the WHO Regions of Africa and the Americas were created. Key findings The DTF guiding principles were being WHO-region specific, addressing primary health needs, including essential medications based on disease prevalence, local availability and affordability, and optimizing patient labeling. Conclusions A thoughtfully crafted DTF for MSTs is one way to advance equitable and safe health care.