Excessive vitamin A (VA) negatively impacts bone. Interactions between VA and vitamin D (VD) in bone health are not well-understood. This study used a traditional two-by-two factorial design. Pigs were weaned and randomized to four treatments (n = 13/group): -A-D, -A+D, +A-D, and +A+D for 3 and 5 wk. Serum, liver, kidney, adrenal glands, spleen, and lung were analyzed by ultra-performance LC. Growth was evaluated by weight measured weekly and BMD by DXA. Weights were higher in -A+D (18.1 ± 1.0 kg) and +A+D (18.2 ± 2.3 kg) at 5 wk than in -A-D (15.5 ± 2.1 kg) and +A-D (15.8 ± 1.5 kg). Serum retinol concentrations were 0.25 ± 0.023, 0.22 ± 0.10, 0.77 ± 0.12, and 0.84 ± 0.28 µmol/L; and liver VA concentrations were 0.016 ± 0.015, 0.0065 ± 0.0035, 2.97 ± 0.43, 3.05 ± 0.68 µmol/g in -A-D, -A+D, +A-D, and +A+D, respectively. Serum 25(OH)D3 concentrations were 1.5 ± 1.11, 1.8 ± 0.43, 27.7 ± 8.91, and 23.9 ± 6.67 ng/mL in -A-D, +A-D, -A+D, +A+D, respectively, indicating a deficiency in -D and adequacy in +D. BMD was highest in +D (p < 0.001). VA and the interaction had no effect on BMD. Dietary VD influenced weight gain, BMD, and health despite VA status.

Background: This study aims to investigate the postoperative improvement of paralysis, fusion rate and risk factors for kyphosis progression in adults affected with spinal caries. Methods: Overall, 134 patients with spinal caries from the thoracic to lumbar spine from 1992 to 2021 were included in this study. Data concerning the affected level (thoracic, thoracolumbar, lumbar, and lumbosacral), bone fusion rate, and progression of the postoperative local kyphosis angle were collected. The risk factors for the progression of local kyphosis angle after anterior spinal fixation (ASF) were determined using linear regression analysis. Results: Preoperatively, the degree of spinal cord paralysis was D and E on Frankel classification. Improvement of paralysis was good with surgery, especially from C, D. The overall bone fusion rate was 83.2%. The only factor influencing the progression of local kyphosis angle after ASF was the level of the affected vertebra. Progression of kyphosis angle after ASF was very advanced in the thoracolumbar transition area. Conclusions: Surgical improvement in paraplegia and the fusion rate of ASF with only grafted bone was good. However, in patients affected in the thoracolumbar spine region, posterior instrumentation is desirable because of local kyphosis progression risk after surgery.

Objectives  Expandable transforaminal interbody fusion (TLIF) devices have been developed to introduce more segmental lordosis through a narrow operative corridor, but there are concerns about the degree of achievable correction with a small graft footprint. In this report, we describe the technical nuances associated with placing bilateral expandable cages for correction of iatrogenic deformity. Materials and Methods  A 60-year-old female with symptomatic global sagittal malalignment and a severe lumbar kyphotic deformity after five prior lumbar surgeries presented to our institution. We performed multilevel posterior column osteotomies, a L3-4 intradiscal osteotomy, and placed bilateral lordotic expandable TLIF cages at the level of maximum segmental kyphosis. Results  We achieve a 21-degree correction of the patient\'s focal kyphotic deformity and restoration of the patient global sagittal alignment. Conclusion  This case demonstrates both the feasibility and utility of placing bilateral expandable TLIF cages at a single disc space in the setting of severe focal sagittal malalignment. This technique expands the implant footprint and, when coupled with an intradiscal osteotomy, allows for a significant restoration of segmental lordosis.

OBJECTIVE: To put forward a new index of cervical curvature evaluation - relative cervical curvature area,and a new classification of cervical spine was proposed according to the relative cervical curvature area.
METHODS: A total of 167 subjects with cervical spondylosis were included in the study. Firstly, 119 subjects were selected to measure C2-C7 lordosis angle by Cobb angle method, Harrison posterior tangent method and Jackson physiological stress line method, and then their relative cervical curvature area, C1-C7 Cobb angle, C7 slope and T1 slope were measured.The correlation between relative cervical curvature area and three measurement methods and common sagittal parameters was analyzed.According to the angle classification method, we calculated the diagnostic boundary value of the relative cervical curvature area classification, and selected 48 subjects to evaluate its diagnostic efficacy.Finally, 119 subjects were re-evaluated according to the diagnostic threshold and the number of intersections to verify the feasibility of the new classification.
RESULTS: The results showed that the relative cervical curvature area index had good intra-observer and inter-observer repeatability. Relative cervical curvature area was correlated with Harrison posterior tangent method ( r = 0.930 ), Cobb angle method ( r = 0.886 ) and Jackson physiological stress line method ( r = 0.920 ), and correlated with C1-C7 Cobb angle, C7 slope and T1 slope.The relative cervical curvature area has a good diagnostic performance for distinguishing patients with lordosis, straightening and kyphosis.According to the new classification of cervical spine, 119 subjects were divided into 57 simple lordosis, 11 simple straightening, 4 simple kyphosis, 26 S-type and 21 RS-type.
CONCLUSIONS: The relative cervical curvature area uses the area parameter instead of the original angle parameter and distance parameter to incorporate the change of segmental curvature, which makes up for the shortcomings of the Cobb angle method that only evaluates the curvature of two vertebrae, and better reflects the cervical curvature.Studies have shown that relative cervical curvature area has good repeatability and diagnostic value, and found that it has a good correlation with common cervical sagittal parameters.The new classification of cervical spine makes up for the disadvantage that the angle classification method cannot distinguish between S-type and RS-type, and initially proposes to use the number of intersections and the relative absolute value area to reflect the severity of S-type.

Complications from medial branch blocks (MBBs) are rare when following proper procedural protocol. Dropped head syndrome (DHS) is characterized by profound muscle weakness in the cervical spine, resulting in a failure to maintain a level horizontal gaze and, in the worst cases, a chin-on-chest deformity. In this case report, we described DHS developing after cervical MBBs using short-acting anesthetic agents and subsequent management. A 69-year-old woman with a previous C6-C7 anterior cervical discectomy and fusion (ACDF) underwent bilateral posterior cervical MBBs targeting the C4-C5 and C5-C6 levels. Immediately following the injection, she reported a sudden inability to lift her head and was subsequently diagnosed with DHS. This condition continued with minimal improvement for over six months. After weighing the risks, the patient elected to avoid surgery, and she was provided a soft cervical collar and prescribed physical therapy. DHS is a debilitating condition more commonly associated with neurodegenerative conditions and inflammatory myopathy, which has received limited attention due to its rarity as a complication of cervical radiofrequency neurotomy. Surgery for this condition, when considered, typically involves long-segment posterior cervical instrumented fusion. Undergoing such a surgery is a complicated discussion that should consider patient clinical factors and preferences. The clinical impact of loss of strength in paraspinal musculature in this patient population is clearly deserving of further study.

OBJECTIVE: To establish a novel classification system for predicting the risk of intraoperative neurophysiological monitoring (IONM) events in surgically-treated patients with kyphotic deformity.
METHODS: Patients with kyphotic deformity who underwent surgical correction of cervicothoracic, thoracic, or thoracolumbar kyphosis in our center from July 2005 to December 2020 were recruited. We proposed a classification system to describe the morphology of the spinal cord on T2-weighted sagittal magnetic resonance imaging: type A, circular/symmetric cord with visible cerebrospinal fluid (CSF) between the cord and vertebral body; type B, circular/oval/symmetric cord with no visible CSF between the cord and vertebral body; type C, spinal cord that is fattened/deformed by the vertebral body, with no visible CSF between the cord and vertebral body. Furthermore, based on type C, the spinal cord compression ratio (CR) < 50% was defined as the subtype C-, while the spinal cord CR ≥ 50% was defined as the subtype C+. IONM event was documented, and a comparative analysis was made to evaluate the prevalence of IONM events among patients with diverse spinal cord types.
RESULTS: A total of 294 patients were reviewed, including 73 in type A; 153 in type B; 53 in subtype C- and 15 in subtype C+. Lower extremity transcranial motor-evoked potentials and/or somatosensory evoked potentials were lost intraoperatively in 41 cases (13.9%), among which 4 patients with type C showed no return of spinal cord monitoring data. The 14 subtype C+ patients (93.3%) had IONM events. Univariate logistic regression analysis showed that patients with a type C spinal cord (subtype C-: odds ratio [OR], 10.390; 95% confidence interval [CI], 2.215-48.735; p = 0.003; subtype C+, OR, 497.000; 95% CI, 42.126- 5,863.611; p < 0.001) are at significantly higher risk of a positive IONM event during deformity correction compared to those with a type A. In further multiple logistic regression analysis, the spinal cord classification (OR, 5.371; 95% CI, 2.966-9.727; p < 0.001) was confirmed as an independent risk factor for IONM events.
CONCLUSIONS: We presented a new spinal cord classification system based on the relative position of the spinal cord and vertebrae to predict the risk of IONM events in patients with kyphotic deformity. In patients with type C spinal cord, especially those in C+ cases, it is essential to be aware of potential IONM events, and adopt standard operating procedures to facilitate neurological recovery.

OBJECTIVE: Few studies have reported radiographic and clinical outcomes of transverse process hook (TPH) placement at the proximal thoracic upper instrumented vertebra (UIV) in adult spinal deformity (ASD) surgery. This study aims to investigate radiographic and clinical outcomes of TPH placement at the UIV for ASD surgery.
METHODS: This is a retrospective cohort of 56 patients with ASD (age, 59 ± 13 years; followup, 44 ± 19 months) from Johns Hopkins Hospital, who underwent long posterior spinal fusion to the proximal thoracic spine (T2-5). Visual analogue scale (VAS) for back pain, Oswestry Disability Index (ODI), 36-item Short Form health survey scores, thoracic kyphosis (TK), lumbar lordosis, sacral slope, pelvic tilt, pelvic incidence, proximal junctional kyphosis (PJK) angle, PJK incidence, pattern of PJK, grades of TPH dislodgement, revision surgery, and factors associated with high-grade TPH dislodgement were analyzed.
RESULTS: VAS for back pain and ODI values improved significantly from preoperatively to final follow-up. Mean change in PJK angle was 12° (range, 0.5°-43°). Twenty patients (36%) developed PJK, of whom 13 had compression fractures at 1 vertebra distal to the UIV (UIV-1). Final TPH position was stable in 42 patients (75%). In most patients (86%), TPH dislodgement did not progress after 6-month postoperative follow-up. Three patients (5.3%) underwent revision surgery to extend the fusion because of symptomatic PJK. Unstable TPH position was associated only with revision surgery and TK.
CONCLUSIONS: TPH placement at the proximal thoracic UIV for long fusion showed favorable clinical and radiographic outcomes in terms of the incidence of PJK and mean PJK angle at mean 44-month follow-up. TPHs placed in the proximal thoracic UIV were in stable position in 75% of patients. Compression fracture at UIV-1 was the most common pattern of PJK. PJK angle progression was greater in revision cases and in patients with greater preoperative thoracic kyphosis.

UNASSIGNED: The methods previously proposed in the literature to assess patients with rotator cuff related shoulder pain, based on special orthopedic tests to precisely identify the structure causing the shoulder symptoms have been recently challenged. This opens the possibility of a different way of physical examination.
UNASSIGNED: To analyze the differences in shoulder range of motion, strength and thoracic kyphosis between rotator cuff related shoulder pain patients and an asymptomatic group.
UNASSIGNED: The protocol of the present research was registered in the International Prospective Register of Systematic Review (PROSPERO) (registration number CRD42021258924). Database search of observational studies was conducted in MEDLINE, EMBASE, WOS and CINHAL until July 2023, which assessed shoulder or neck neuro-musculoskeletal non-invasive physical examination compared to an asymptomatic group. Two investigators assessed eligibility and study quality. The Newcastle Ottawa Scale was used to evaluate the methodology quality.
UNASSIGNED: Eight studies (N = 604) were selected for the quantitative analysis. Meta-analysis showed statistical differences with large effect for shoulder flexion (I2 = 91.7%, p < 0.01, HG = -1.30), external rotation (I2 = 83.2%, p < 0.01, HG = -1.16) and internal rotation range of motion (I2 = 0%, p < 0.01, HG = -1.32). Regarding to shoulder strength; only internal rotation strength showed statistical differences with small effect (I2 = 42.8%, p < 0.05, HG = -0.3).
UNASSIGNED: There is moderate to strong evidence that patients with rotator cuff related shoulder pain present less shoulder flexion, internal and external rotation range of motion and less internal rotation strength than asymptomatic individuals.

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BACKGROUND: Upper Cross Syndrome is a pattern of muscle imbalance and postural dysfunction that can cause discomfort and pain. This study\'s objective was to compare the effects of Pilates exercises, corrective exercises, and Alexander\'s technique on upper cross syndrome in adolescent girls aged 13-16 years: a six-week intervention study.
METHODS: The present study was Quasi-experimental, and its statistical population consisted of 13 to 16-year-old female students. Forty-five students who were diagnosed with upper cross syndrome were purposefully selected as samples and randomly assigned to three groups: Pilates exercises (N = 15), corrective exercises (N = 15), and Alexander\'s technique (N = 15). The participants performed exercises for 60 min per session, three sessions per week, and six weeks. This study\'s objective was to compare the effects of Pilates exercises, corrective exercises, and Alexander\'s technique on upper cross syndrome in adolescent girls aged 13-16 years: a six-week intervention study. This study was retrospectively registered in the Iranian Registry of Clinical Trials (IRCT) on 2023-09-19 to comply with the journal\'s policies. The assigned trial registration number is IRCT20230810059106N1.
RESULTS: The results of the dependent t-test showed significant decreases in forward head angle (p = 0.0001), rounded shoulder (p = 0.001), and kyphosis (p = 0.0001) as a result of corrective exercises. There were also significant decreases in forward head angle (p = 0.0001), rounded shoulder (p = 0.002), and kyphosis (p = 0.001) after six weeks of practising Alexander\'s technique. However, in the case of Pilates exercises, a significant decrease in forward head angle (p = 0.110), rounded shoulder (p = 0.598), and kyphosis (p = 0.371) was not observed. The one-way analysis of variance revealed a significant difference in the forward head angle (p = 0.012), rounded shoulders (p = 0.013), and kyphosis (p = 0.009).
CONCLUSIONS: The effect of Alexander\'s technique and corrective exercises on forward head angle, rounded shoulder, and kyphosis abnormalities was almost similar and more effective than pilates exercises.