Showing papers in "Spine in 2007"
TL;DR: Meticulous knowledge of potential intraoperative and postoperative ACDF-related complications is of paramount importance so as to avoid them whenever possible, as well as to successfully and safely manage them when they are inevitable.
Abstract: Study design Retrospective review study with literature review. Objective The goal of our current study is to raise awareness on complications associated with anterior cervical discectomy and fusion (ACDF) and their early detection and proper management. Summary of background data It is known that ACDF constitutes one of the most commonly performed spinal procedures. Its outcome is quite satisfactory in the majority of cases. However, occasional complications can become troublesome, and in rare circumstances, catastrophic. Although there are several case reports describing such complications, their rate of occurrence is generally underreported, and data regarding their exact incidence in large clinical series are lacking. Meticulous knowledge of potential intraoperative and postoperative ACDF-related complications is of paramount importance so as to avoid them whenever possible, as well as to successfully and safely manage them when they are inevitable. Methods In a retrospective study, 1015 patients undergoing first-time ACDF for cervical radiculopathy and/or myelopathy due to degenerative disc disease and/or cervical spondylosis were evaluated. A standard Smith-Robinson approach was used in all our patients, while an autologous or allograft was used, with or without a plate. Operative reports, hospital and outpatient clinic charts, and radiographic studies were reviewed for procedure-related complications. Mean follow-up time was 26.4 months. Results The mortality rate in our current series was 0.1% (1 of 1015 patients, death occurred secondary to an esophageal perforation). Our overall morbidity rate was 19.3% (196 of 1015 patients). The most common complication was the development of isolated postoperative dysphagia, which observed in 9.5% of our patients. Postoperative hematoma occurred in 5.6%, but required surgical intervention in only 2.4% of our cases. Symptomatic recurrent laryngeal nerve palsy occurred in 3.1% of our cases. Dural penetration occurred in 0.5%, esophageal perforation in 0.3%, worsening of preexisting myelopathy in 0.2%, Horner's syndrome in 0.1%, instrumentation backout in 0.1%, and superficial wound infection in 0.1% of our cases. Conclusion Meticulous knowledge of the ACDF-associated complications allows for their proper management. Postoperative dysphagia, hematoma, and recurrent laryngeal nerve palsy were the most common complications in our series. Management of complications was successful in the vast majority of our cases.
850 citations
TL;DR: The results indicate the potential of radiosurgery in the treatment of patients with spinal metastases, especially those with solitary sites of spine involvement, to improve long-term palliation.
Abstract: Study design A prospective nonrandomized, longitudinal cohort study. Objective To evaluate the clinical outcomes of single-fraction radiosurgery as part of the management of metastatic spine tumors. Summary of background data The role of stereotactic radiosurgery for the treatment of spinal lesions has previously been limited by the availability of effective target immobilization and target tracking devices. Large clinical experience with spinal radiosurgery to properly assess clinical experience has previously been limited. Methods A cohort of 500 cases of spinal metastases underwent radiosurgery. Ages ranged from 18 to 85 years (mean 56). Lesion location included 73 cervical, 212 thoracic, 112 lumbar, and 103 sacral. Results The maximum intratumoral dose ranged from 12.5 to 25 Gy (mean 20). Tumor volume ranged from 0.20 to 264 mL (mean 46). Long-term pain improvement occurred in 290 of 336 cases (86%). Long-term tumor control was demonstrated in 90% of lesions treated with radiosurgery as a primary treatment modality and in 88% of lesions treated for radiographic tumor progression. Twenty-seven of 32 cases (84%) with a progressive neurologic deficit before treatment experienced at least some clinical improvement. Conclusions The results indicate the potential of radiosurgery in the treatment of patients with spinal metastases, especially those with solitary sites of spine involvement, to improve long-term palliation.
681 citations
TL;DR: In this paper, a meta-analysis of the published literature was conducted specifically looking at accuracy and the postoperative methods used for the assessment of pedicle screw placement in the human spine.
Abstract: Study design A meta-analysis of the published literature was conducted specifically looking at accuracy and the postoperative methods used for the assessment of pedicle screw placement in the human spine. Objectives This study specifically aimed to identify postoperative methods used for pedicle screw placement assessment, including the most common method, and to report cumulative pedicle screw placement study statistics from synthesis of the published literature. Summary of background data Safety concerns have driven specific interests in the accuracy and precision of pedicle screw placement. A large variation in reported accuracy may exist partly due to the lack of a standardized evaluation method and/or the lack of consensus to what, or in which range, is pedicle screw placement accuracy considered satisfactory. Methods A MEDLINE search was executed covering the span from 1966 until 2006, and references from identified papers were reviewed. An extensive database was constructed for synthesis of the identified studies. Subgroups and descriptive statistics were determined based on the type of population, in vivo or cadaveric, and separated based on whether the assistance of navigation was employed. Results In total, we report on 130 studies resulting in 37,337 total pedicle screws implanted, of which 34,107 (91.3%) were identified as accurately placed for the combined in vivo and cadaveric populations. The most common assessment method identified pedicle screw violations simply as either present or absent. Overall, the median placement accuracy for the in vivo assisted navigation subgroup (95.2%) was higher than that of the subgroup without the use of navigation (90.3%). Conclusions Navigation does indeed provide a higher accuracy in the placement of pedicle screws for most of the subgroups presented. However, an exception is found at the thoracic levels for both the in vivo and cadaveric populations, where no advantage in the use of navigation was found.
518 citations
TL;DR: Although patients improved over the 2-year follow-up regardless of initial treatment, those undergoing decompressive surgery reported greater improvement regarding leg pain, back pain, and overall disability.
Abstract: Study design A randomized controlled trial. Objectives To assess the effectiveness of decompressive surgery as compared with nonoperative measures in the treatment of patients with lumbar spinal stenosis. Summary of background data No previous randomized trial has assessed the effectiveness of surgery in comparison with conservative treatment for spinal stenosis. Methods Four university hospitals agreed on the classification of the disease, inclusion and exclusion criteria, radiographic routines, surgical principles, nonoperative treatment options, and follow-up protocols. A total of 94 patients were randomized into a surgical or nonoperative treatment group: 50 and 44 patients, respectively. Surgery comprised undercutting laminectomy of the stenotic segments in 10 patients augmented with transpedicular fusion. The primary outcome was based on assessment of functional disability using the Oswestry Disability Index (scale, 0-100). Data on the intensity of leg and back pain (scales, 0-10), as well as self-reported and measured walking ability were compiled at randomization and at follow-up examinations at 6, 12, and 24 months. Results Both treatment groups showed improvement during follow-up. At 1 year, the mean difference in favor of surgery was 11.3 in disability (95% confidence interval [CI], 4.3-18.4), 1.7 in leg pain (95% CI, 0.4-3.0), and 2.3(95% CI, 1.1-3.6) in back pain. At the 2-year follow-up, the mean differences were slightly less: 7.8 in disability (95% CI, 0.8-14.9) 1.5 in leg pain (95% CI, 0.3-2.8), and 2.1 in back pain (95% CI, 1.0-3.3). Walking ability, either reported or measured, did not differ between the two treatment groups. Conclusions Although patients improved over the 2-year follow-up regardless of initial treatment, those undergoing decompressive surgery reported greater improvement regarding leg pain, back pain, and overall disability. The relative benefit of initial surgical treatment diminished over time, but outcomes of surgery remained favorable at 2 years. Longer follow-up is needed to determine if these differences persist.
502 citations
TL;DR: In this article, the authors evaluated the long-term safety and effectiveness of the ProDisc-L total disc replacement (TDR) as part of an FDA-mandated postmarket approval study.
Abstract: Object. The purpose of this study was to evaluate the long-term safety and effectiveness of the ProDisc-L total disc replacement (TDR) as part of an FDA-mandated postmarket approval study. This report summarizes the clinical findings after 5 years of follow-up. Methods. Two hundred thirty-six patients were treated and followed up for 5 years; 161 TDRs and 75 fusions had been performed in these patients. The primary outcome was a 10-component success end point. Secondary outcome measures included neurological status, secondary surgery, Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36), visual analog scale (VAS) assessing pain and satisfaction, radiographic data, narcotic use, activity, and recreation status. Patients were monitored through their 5-year postoperative visits under the FDA postmarket surveillance provisions in the original investigational device exemption approval. Results. The overall follow-up rate at 5 years was 81.8%. Study success demonstrated that TDR was noninferior to fusion with a 12.5% margin (p = 0.0099). Both TDR and fusion treatment groups maintained significant improvement on the ODI at 5 years compared with baseline (p < 0.0001). Secondary surgeries at the index level were performed in 12% of fusion patients and 8% of TDR patients. Radiographically, none of the TDRs developed spontaneous fusion. The segmental range of motion following TDR remained within normal range, although it decreased by approximately 0.5° in years 3 to 5. The VAS pain scores decreased from preoperative values by 48% in both treatment groups at 5 years. Patient satisfaction remained high in both groups (77%), while the percentage of patients indicating that they would have the surgery again was higher in TDR patients (82.5%) than in fusion patients (68.0%). Conclusions. Patients in both groups maintained significant improvement during the 5-year follow-up. The TDR group had significantly better improvement on some scales. Although TDR patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and TDR are reasonable surgical options in this specific patient population.
451 citations
TL;DR: The prevalence of complications was found to increase with the greater number of levels fused and the presence of a comorbidity had no association with complication rates and neither had an effect on final patient reported outcomes, which showed significant improvement.
Abstract: STUDY DESIGN A retrospective analysis, including prospectively collected patient outcomes data. OBJECTIVE To determine the rate of complications and outcomes in patients >or=60 years of age who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure. SUMMARY OF BACKGROUND DATA As the population ages, an increasing number of older patients are presenting with spinal deformity disorders that may require major reconstructive procedures. Previous studies have reported complication rates as high as 80% in this age group for 1- and 2-level fusion procedures. The prevalence of complications was found to increase with the greater number of levels fused. METHODS Forty-six patients who were 60 years of age or older underwent a thoracic or lumbar arthrodesis procedure consisting of 5 levels or greater. Diagnosis, comorbidities, operative data, hospital data, major and minor complications, and deaths were recorded. Oswestry Disability Index (ODI) Scores were used to evaluate clinical outcomes. RESULTS Thirty-eight females and 8 males with a mean age of 67 years (range, 60-85 years) and a mean follow-up of 4.2 years (range, 2-11 years) had complete records. Thirty-six (78%) patients had at least 1 comorbidity. Twenty-nine (63%) patients had at least 1 prior spinal surgery. A mean of 9 levels (range, 5-16 levels) were fused in each patient. The overall complication rate was 37%. The major complication rate was 20%. ODI improved from 49 to 25 for a mean improvement of 24 (49%) (P < 0.0001). CONCLUSION The overall complication rate was 37% and the major complication rate was 20%. Increasing age was a significant factor (P < 0.05) in predicting the presence of a complication. Patients older than 69 years had more complications. The presence of a comorbidity had no association with complication rates and neither had an effect on final patient reported outcomes, which showed significant improvement (ODI preoperative, 49; postoperative, 25) (P < 0.0001).
435 citations
TL;DR: Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial and, for spondylolisthesis, reoperation is less likely following fusion than following decompression alone.
Abstract: STUDY DESIGN Retrospective cohort study using a hospital discharge registry of all nonfederal acute care hospitals in Washington state. OBJECTIVES To determine the cumulative incidence of reoperation following lumbar surgery for degenerative disease and, for specific diagnoses, to compare the frequency of reoperation following fusion with that following decompression alone. SUMMARY OF BACKGROUND DATA Repeat lumbar spine operations are generally undesirable, implying persistent symptoms, progression of degenerative changes, or treatment complications. Compared to decompression alone, spine fusion is commonly viewed as a stabilizing treatment that may reduce the need for additional surgery. However, indications for fusion surgery in degenerative spine disorders remain controversial, and the effects of fusion on reoperation rates are unclear. METHODS Adults who underwent inpatient lumbar surgery for degenerative spine disorders in 1990-1993 (n = 24,882) were identified from International Classification of Diseases ninth Revision, Clinical Modification codes and then categorized as having either a lumbar decompression surgery or lumbar fusion surgery. We then compared the subsequent incidence of lumbar spine surgery between these groups. RESULTS Patients who had surgery in 1990-93 had a 19% cumulative incidence of reoperation during the subsequent 11 years. Patients with spondylolisthesis had a lower cumulative incidence of reoperation after fusion surgery than after decompression alone (17.1% vs. 28.0%, P = 0.002). For other diagnoses combined, the cumulative incidence of reoperation was higher following fusion than following decompression alone (21.5% vs. 18.8%, P = 0.008). After fusion surgery, 62.5% of reoperations were associated with a diagnosis suggesting device complication or pseudarthrosis. CONCLUSION Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial. For spondylolisthesis, reoperation is less likely following fusion than following decompression alone. For other degenerative spine conditions, the cumulative incidence of reoperation is higher or unimproved after a fusion procedure compared to decompression alone.
433 citations
TL;DR: Age at surgery over 50 years and length of fusion were significant risk factors for the development of ASD in the lumbar spine and Circumferential fusion versus posterior-only fusion was not a significant factor in theDevelopment of ASD.
Abstract: Study design Retrospective radiographic outcomes analysis. Objective We had 3 hypotheses: 1) a longer fusion; 2) a more proximal instrumented vertebra, and 3) circumferential fusion versus posterior-only fusion would increase the likelihood of adjacent segment disease (ASD). Summary of background data The literature analyzing risk factors, prevalence, and presentation of patients with ASD is varied and without clear consensus. Methods A total of 188 patients with minimum 5-year follow-up who had lumbar/thoracolumbar fusion with pedicle screw instrumentation for degenerative disorders were included. Radiographic ASD was defined by: 1) development of spondylolisthesis >4 mm, 2) segmental kyphosis >10 degrees , 3) complete collapse of disc space, or 4) more than 2 grades worsening of Weiner classification. Clinical ASD was defined as 1) symptomatic spinal stenosis, 2) intractable back pain, or 3) subsequent sagittal or coronal imbalance. Results Radiographic ASD occurred in 42.6% (80 of 188) of patients. Patients with radiographic ASD had worse Oswestry scores (20.3 vs. 12.5; P = 0.001) at ultimate follow-up than those without ASD. Clinical ASD developed in 30.3% (57 of 188) of patients. Clinical ASD manifested as spinal stenosis (n = 47), instability-type back pain (n = 5), and sagittal or coronal imbalance (n = 5). Age at surgery over 50 years and length of fusion were significant risk factors for the development of ASD in the lumbar spine. Fusion to L1-L3 proximally increased the risk of ASD when compared with L4 and L5. Circumferential fusion versus posterior fusion was not a significant factor in the development of ASD. Conclusion Patients over the age of 50 were at higher risk of developing clinical ASD than those 50 years old or younger. Length of fusion was a significant risk factor in the development of ASD in the lumbar spine. Fusion up to L1-L3 increased the risk of ASD when compared with L4 and L5. Circumferential fusion, as opposed to posterolateral fusion, was not a statistically significant risk factor for the development of ASD.
411 citations
Thomas Jefferson University1, University of Calgary2, University of Utah3, University of British Columbia4, Walter Reed Army Institute of Research5, University of Wisconsin-Madison6, Utrecht University7, University of Kansas8, University of Toronto9, University of Rochester10, University of Maryland, Baltimore11
TL;DR: The Sub-axial Injury Classification and Severity Scale provides a comprehensive classification system for subaxial cervical trauma and compares favorably to the Harris and Ferguson & Allen systems.
Abstract: Study design The classification system was derived through a literature review and expert opinion of experienced spine surgeons. In addition, a multicenter reliability and validity study of the system was conducted on a collection of trauma cases. Objectives To define a novel classification system for subaxial cervical spine trauma that conveys information about injury pattern, severity, treatment considerations, and prognosis. To evaluate reliability and validity of this system. Summary of background data Classification of subaxial cervical spine injuries remains largely descriptive, lacking standardization and prognostic information. Methods Clinical and radiographic variables encountered in subaxial cervical trauma were identified by a working section of the Spine Trauma Study Group. Significant limitations of existing systems were defined and addressed within the new system. This system, as well as the Harris and Ferguson & Allen systems, was applied by 20 spine surgeons to 11 cervical trauma cases. Six weeks later, the cases were randomly reordered and again scored. Interrater reliability, intrarater reliability, and validity were assessed. Results Each of 3 main categories (injury morphology, disco-ligamentous complex, and neurologic status) identified as integrally important to injury classification was assigned a weighted score; the injury severity score was obtained by summing the scores from each category. Treatment options were assigned based on threshold values of the severity score. Interrater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.49, 0.57, and 0.87, respectively. Intrarater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.66, 0.75, and 0.90, respectively. Raters agreed with treatment recommendations of the algorithm in 93.3% of cases, suggesting high construct validity. The reliability compared favorably to the Harris and Ferguson & Allen systems. Conclusion The Sub-axial Injury Classification and Severity Scale provides a comprehensive classification system for subaxial cervical trauma. Early validity and reliability data are encouraging.
402 citations
TL;DR: It is suggested that risk for minor complications may be a less substantial obstacle than previously assumed for surgical treatment in adult spinal deformity and adversely affected outcome at 1 year after surgery.
Abstract: Study design Retrospective case-control series. Objective The purpose of this study is to determine whether perioperative complications alter subsequent clinical outcome measures in adult spinal deformity surgery. Summary of background data Increasingly, the benefit of surgical intervention is being evaluated based on patient reported outcomes and standardized health related quality of life (HRQOL) measures. As improvement or deterioration in HRQOL scores becomes a standard for clinical evaluation in adult spinal deformity, the correlation between HRQOL outcome scores and historic benchmarks, such as curve correction, sagittal balance, fusion healing, or the occurrence of a complication, must be clarified. Methods This study analyzes a prospective multicenter data base for adult spinal deformity. Patients with major, minor, and no complications were matched using a logistic regression technique producing 46 patients in each group. Standardized outcome measures at baseline and at 1 year postop were compared. Results Forty-seven major complications were reported in 46 patients. Sixty-two minor complications were noted in 46 patients. Comparison between the 3 complication groups revealed that 1-year postoperative outcome measures were not statistically different for the Scoliosis Research Society Outcomes Instrument, Medical Outcomes Short Form-36 (SF-12), Oswestry Disability Index, or Numerical Pain Scales. The only significant interaction was in the rate of change from preop to 1-year postop for the SF-12 general health subscale. For the group with major complications, SF-12 general health deteriorated by 2.1 points from preop to 1-year postop. During the same period, the group with minor complications experienced an improvement of 4.2 points and the group with no complications experienced an improvement of 1.5 points. Conclusion This study suggests that risk for minor complications may be a less substantial obstacle than previously assumed for surgical treatment in adult spinal deformity. In contrast, major complications were reported in approximately 10% of cases and adversely affected outcome as evidenced by the deterioration in SF-12 general health scores at 1 year after surgery.
388 citations
TL;DR: The present study, based on the authors' initial experience with the minimally invasive approach, could confirm favorable results reported by previous uncontrolled cohort studies in the aspects of less blood loss, less transfusion need, less postoperative back pain, quicker recovery, and shorter hospital stay.
Abstract: Study design Prospective cohort study. Objectives To determine the statistical difference between the minimally invasive and traditional open approach for one-level instrumented posterior lumbar interbody fusion by comparing the perioperative data, clinical outcome, and radiographic result. Summary of background data Posterior lumbar fusion performed with mini-incision using tubular retractor has been advocated as a minimally invasive technique. Proponents have claimed that minimally invasive techniques reduce postoperative pain, blood loss, transfusion needs, and the length of hospital stay compared with the traditional open techniques. But there was no well-designed comparison study that supports these claims. Methods We studied a consecutive series of 61 patients who underwent one-level PLIF procedure (32 cases performed with minimally invasive approach and 29 cases with traditional open approach) by one surgeon at one hospital, from October 2003 until October 2004. The following data were compared between the 2 groups with 1-year minimum follow-up: the clinical and radiographic results, surgical time, estimated blood loss, transfusion needs, postoperative back pain by visual analogue scale, time needed before ambulation, length of hospital stay, and complications. Results There was no significant difference between the 2 groups in the aspects of the clinical and radiographic results with 1-year minimum follow-up. The minimally invasive group was found to have a significantly less blood loss, less needs of transfusion, less postoperative back pain, shorter recovery time before ambulation, and shorter length of hospital stay. However, the minimally invasive group needed significantly longer surgical time and showed 2 cases of technical complications. Conclusions The present study, which was based on the authors' initial experience with the minimally invasive approach, could confirm favorable results reported by previous uncontrolled cohort studies in the aspects of less blood loss, less transfusion need, less postoperative back pain, quicker recovery, and shorter hospital stay. It also showed the similar surgical efficacy of the minimally invasive approach with that of the traditional open technique. However, the minimally invasive technique needs longer surgical time and a prudent attention to lower the risk of technical complications. Further long-term, prospective studies involving a larger study group are needed to determine the benefits of this minimally invasive percutaneous procedure.
TL;DR: A population-based cross-sectional multiregion postal survey was used to provide a descriptive epidemiology of the prevalence and severity of back pain in German adults and to analyze sociodemographic correlates for disabling back pain within and across regions.
Abstract: Study design A population-based cross-sectional multiregion postal survey. Objective To provide a descriptive epidemiology of the prevalence and severity of back pain in German adults and to analyze sociodemographic correlates for disabling back pain within and across regions. Summary of background data Back pain is a leading health problem in Germany. However, comprehensive population-based evidence on the severity of back pain is still fragmentary for this country. Despite earlier findings concerning large prevalence differences across regions, systematic explanations remain to be ascertained. Methods Questionnaire data were collected for 9263 subjects in 5 German cities and regions (population-based random samples, postal questionnaire). Point, 1-year, and lifetime prevalence were assessed using direct questions, and graded back pain was determined using the Graded Chronic Pain Scale. Poststratification was applied to adjust for cross-regional sociodemographic differences. Results Point-prevalence was 37.1%, 1-year prevalence 76.0%, and lifetime prevalence 85.5%. A substantial minority had severe (Grade II, 8.0%) or disabling back pain (Grade III-IV, 11.2%). Subjects with a low educational level reported substantially more disabling back pain. This variable was an important predictor for large cross-regional differences in the burden of back pain. Conclusion Back pain is a highly prevalent condition in Germany. Disabling back pain in this country may be regarded as part of a social disadvantage syndrome. Educational level should receive greater attention in future cross-regional comparisons of back pain.
TL;DR: The modified Pfirrmann grading system is useful at discriminating severity of disc degeneration in elderly subjects and can be applied with good intra- and interobserver agreement.
Abstract: Study design A reliability study was conducted. OBJECTIVE.: To modify a grading system for lumbar disc degeneration and to test the reliability of this modified grading system. Summary of background data The 5-level Pfirrmann grading system for disc degeneration did not prove discriminatory when used to assess disc degeneration in the elderly spine. Such discriminatory power is necessary to test the association between other variables and severity of disc degeneration. Methods An 8-level modified grading system for lumbar disc degeneration was developed including a description of the changes expected for each grade and a 24-image reference panel. The reliability of the modified grading system was tested on 260 lumbar intervertebral discs in 52 subjects (26 men, 26 female) with a mean age of 73 years (range, 67-83 years). All examinations were analyzed independently by 3 readers. Intraobserver and interobserver reliabilities were assessed by calculating weighted kappa statistics. Results On average, for all 3 readers, 0.39% of the 260 discs were classified as Grade 2, 22% were classified as Grade 3, 21.5% were classified as Grade 4, 25.3% were classified as Grade 5, 19.1% were classified as Grade 6, 7.1% were classified as Grade 7, and 4.8% were classified as Grade 8. Intraobserver agreement was excellent (weighted kappa range, 0.79-0.91) with substantial interobserver agreement (weighted kappa range, 0.65-0.67). Complete intraobserver agreement was obtained, on average, in 85% of all discs with 84% of disagreement being as a result of a 1 grade difference. Complete interobserver agreement was obtained, on average, in 66% of all discs with 91% of disagreement being as a result of a 1 grade difference. Conclusion The modified Pfirrmann grading system is useful at discriminating severity of disc degeneration in elderly subjects. The system can be applied with good intra- and interobserver agreement.
TL;DR: Although there is wide discrepancy in the manner in which adolescent spinal pain is reported, it is evident that lifetime prevalence rates increase steadily with age and approximate adult levels by around the age of 18 years.
Abstract: Study design Systematic literature review. Objective To explore the available research literature, and provide an up-to-date synthesis of the epidemiology of idiopathic adolescent spinal pain (IASP). Summary of background data IASP and its potential causes have been a concern to researchers for over 2 decades. Because it has been suggested that IASP is related to the incidence of adult spinal pain, it appears important to synthesize what is currently known about IASP. Method A systematic meta-synthesis approach was used to identify secondary review articles and primary epidemiological studies regarding any type of IASP (neck, upper back, or low back). Results A total of 56 primary epidemiological (cross-sectional or longitudinal) studies were identified. Spinal or back pain was the most commonly reported measure, with the lifetime prevalence figures ranging from 4.7% to 74.4%. The lifetime prevalence of low back pain had a similar range, 7% to 72%. The prevalence of pain in other areas of the spine (i.e., thoracic spine and neck) was variably reported, as were incidence rates for all areas of the adolescent spine. IASP is thus a significant problem, and the prevalence figures approach those of adults. There is some evidence that IASP is a risk factor for spinal pain in adulthood. However, there was considerable variation in how back pain was defined, the areas of the spine that were reported on, the manner in which data were collected and reported, thus preventing any significant comparisons of prevalence or incidence rates across studies. Conclusion Although there is wide discrepancy in the manner in which adolescent spinal pain is reported, it is evident that lifetime prevalence rates increase steadily with age and approximate adult levels by around the age of 18 years. There is an opportunity for further longitudinal research, with standardized methodology, to be undertaken that builds on the findings from this large group of studies.
TL;DR: The estimated MCIC should be used as an indication for relevant changes in clinical practice and if there are no objections doing so, the optimal cutoff point of the ROC curve may be a good choice.
Abstract: Study design Prospective, single-cohort study. Objective To assess the minimal clinically important change (MCIC) on the Neck Disability Index (NDI) and the Numerical Rating Scale (NRS) for pain in patients with neck pain. Summary of background data Both measurement instruments are frequently used in research and clinical practice, but which changes are clinically relevant is still unknown. Methods The MCIC was estimated with 2 different methods, both integrating an anchor-based and distribution-based approach: the minimal detectable change (MDC) and the optimal cutoff point of the ROC curve. The study population consisted of 183 patients with nonspecific neck pain. Results The results show an MDC of 10.5 points for the NDI (scale range, 0-50) and 4.3 points for the NRS (scale range, 0-10), and optimal cutoff points of the ROC curve of 3.5 for the NDI and 2.5 for the NRS. Conclusion The estimated MCIC should be used as an indication for relevant changes in clinical practice. Using the optimal cutoff point of the ROC curve, false positives and false negatives are equally weighted; and if there are no objections doing so, the optimal cutoff point of the ROC curve may be a good choice.
TL;DR: Abundant blood loss was a significant risk factor for early perioperative complications and the improvement of Oswestry disability index was less in patients with late complications, and number of levels fused was related to blood loss.
Abstract: Study design Radiographic analysis was performed retrospectively. Outcomes and complications were collected prospectively. Objectives To assess complications after posterior fusion and instrumentation for degenerative lumbar scoliosis, to determine risk factors of complications, and to analyze the clinical outcomes of surgery. Summary of background data The complications after degenerative lumbar scoliosis surgery have reported to be high. Risk factors for developing complications are unknown. Methods Forty-seven patients (average age, 66.6 years; range, 48-83 years) with degenerative lumbar scoliosis undergoing posterior fusion and instrumentation were analyzed. Seven patients had additional posterior lumbar interbody fusion at the lumbosacral junction. The average number of levels fused was 4.7 +/- 2.2 segments. We evaluated the early perioperative ( Results There were 14 early perioperative complications and 18 late complications. There was 1 case of mortality by pulmonary embolism. Early complications included ileus, urinary tract infection, transient delirium, superficial infection, and neurologic deficit. Late complications included adjacent segment diseases, pseudarthrosis, and loosening of screws. Adjacent segment disease developed at the proximal segment in 10 patients and at the distal segment in 5 patients. Pseudarthrosis was noted at the lumbosacral junction in 2 patients. Revision surgery was performed in 7 patients. Older patients (>65 years) had the tendency to increase early complications without statistical difference (P = 0.053). Excessive intraoperative blood loss was the most significant risk factor for the development of early perioperative complications, and number of levels fused was related to blood loss. Operative time and multiple medical comorbidities were not associated with higher complication rate. There were no specific factors related to the development of late complications. Conclusion The complication rate after posterior fusion and instrumentation for degenerative lumbar scoliosis was 68%. Abundant blood loss was a significant risk factor for early perioperative complications. The improvement of Oswestry disability index was less in patients with late complications.
TL;DR: Surgery may be more efficacious than unstructured nonsurgical care for chronic back pain but may not be more efficient than structured cognitive-behavior therapy.
Abstract: Study design Systematic review of randomized trials comparing surgical to nonsurgical treatment of discogenic back pain Objective Compare research methods and results Summary of background data Recent reports have increased debate about the role of surgery in the treatment of chronic back pain associated with lumbar disc degeneration We conducted a systematic review of randomized trials comparing lumbar fusion surgery to nonsurgical treatment of chronic back pain associated with lumbar disc degeneration Methods A literature search identified 5 randomized trials that compared fusion to nonoperative treatment for chronic low back pain Excluding 1 trial for spondylolisthesis, we compared study participants, interventions, analyses, and outcomes in 4 trials that focused on nonspecific chronic back Results All trials enrolled similar subjects One study suggested greater improvement in back-specific disability for fusion compared to unstructured nonoperative care at 2 years, but the trial did not report data according to intent-to-treat principles Three trials suggested no substantial difference in disability scores at 1-year and 2-years when fusion was compared to a 3-week cognitive-behavior treatment addressing fears about back injury However, 2 of these trials were underpowered to identify clinically important differences The third trial had high rates of cross-over (>20% for each treatment) and loss to follow-up (20%); it is unclear how these affected results Conclusions Surgery may be more efficacious than unstructured nonsurgical care for chronic back pain but may not be more efficacious than structured cognitive-behavior therapy Methodological limitations of the randomized trials prevent firm conclusions
TL;DR: Iso-C navigation increases accuracy, and reduces surgical time and radiation in thoracic deformity correction surgeries, according to patients with scoliosis and patients with kyphosis.
Abstract: STUDY DESIGN Randomized clinical trial (level I evidence). OBJECTIVE To compare the accuracy of non-navigation and Iso-C based navigation in pedicle screw fixation in thoracic spine deformities. SUMMARY OF BACKGROUND DATA Thoracic pedicle screw insertion for spinal deformity correction can be associated with increased pedicle breaches. Iso-C based navigation has been reported to improve the accuracy of pedicle screw placement, but its use in the presence of deformity has not been reported. METHODS Twenty-seven patients with scoliosis and 6 patients with kyphosis had a total of 478 thoracic pedicle screws. The average Cobb angle was 58.4 degrees +/- 8 degrees (range 50 degrees -80 degrees), and the mean kyphotic angle was 54.6 degrees +/- 4 degrees (range 51 degrees -76 degrees). By random allocation, 17 patients had screw insertion under navigation (242 screws) and 16 under fluoroscopic control (236 screws). The 2 groups were compared for accuracy of screw placement, time for screw insertion, and the number of times the C-arm had to be brought into the field. Two independent blinded observers determined accuracy using postoperative computed tomography assessments. RESULTS There were 54 (23%) pedicle breaches in the non-navigation group as compared to only 5 (2%) in the navigation group (P < 0.001). Thirty-eight screws (16%) in the non-navigation group had penetrated the anterior or lateral cortex compared to 2 screws (0.8%) in the navigation group. Average screw insertion time in the non-navigation group was 4.61 +/- 1.05 minutes (range 1.8-6.5) compared to 2.37 +/- 0.72 minutes (range 1.16-4.5) in navigation group (P < 0.01). The C-arm had to be moved into the operation field on an average of 1.5 +/- 0.25 times (range 1-3) per screw. With single screening data, an average of 11.4 pedicles (range 9-14) could be visualized without necessity to bring the C-arm into operating field again. CONCLUSIONS Iso-C navigation increases accuracy, and reduces surgical time and radiation in thoracic deformity correction surgeries.
TL;DR: Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear.
Abstract: Study design An updated Cochrane Review. Objectives To assess the effects of surgical interventions for the treatment of lumbar disc prolapse. Summary of background data Disc prolapse accounts for 5% of low back disorders yet is one of the most common reasons for surgery. There is still little scientific evidence supporting some interventions. Methods Use of standard Cochrane review methods to analyze all randomized controlled trials published up to January 1, 2007. Results Forty randomized controlled trials (RCTs) and 2 quasi-RCTs were identified. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Four trials directly compared discectomy with conservative management, and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis, and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an interposition gel covering the dura (5 trials) and of fat (4 trials) show that they can reduce scar formation, although there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy. There are no published RCTs of coblation therapy or transforaminal endoscopic discectomy. Conclusion Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. The evidence for other minimally invasive techniques remains unclear except for chemonucleolysis using chymopapain, which is no longer widely available.
TL;DR: A lack of consensus regarding the indications for ESIs is suggested and are cause for concern given the large expenditures for these procedures, which increased dramatically in the Medicare population from 1994 to 2001.
Abstract: Study design Anecdotal reports and limited data suggest that the use of spinal injections is increasing, despite equivocal evidence about efficacy. Objective We sought to evaluate trends in lumbosacral injection use for low back pain, including the specialties providing the injections and the costs of care. Summary of background data The current literature reports success rates of 18% to 90% for lumbosacral steroid injections, depending on methodology, outcome measures, patient selection, and technique. Preliminary data suggest that spinal injection rates are rising, despite ambiguity in the literature regarding their clinical effectiveness. Methods We used Medicare Physician Part B claims for 1994 through 2001 to examine the use of epidural steroid injections (ESI), facet joint injections, sacroiliac joint injections, and related fluoroscopy. Fee-for-service Medicare enrollees 65 years of age and older were included in this study. We used Current Procedural Technology (CPT) codes to identify the number of procedures performed each year, as well as trends in expenditures, physician specialties involved, and diagnoses assigned. Results Between 1994 and 2001, there was a 271% increase in lumbar ESIs, from 553 of 100,000 to 2055 of 100,000 patients, and a 231% increase in facet injections from 80 of 100,000 to 264 of 100,000 patients. The total inflation-adjusted reimbursed costs (professional fees only) for lumbosacral injections increased from $24 million to over $175 million. Also, costs per injection doubled, from $115 to $227 per injection. Forty percent of all ESIs were associated with diagnosis codes for sciatica, radiculopathy, or herniated disc, whereas axial low back pain diagnoses accounted for 36%, and spinal stenosis for 23%. Conclusion Lumbosacral injections increased dramatically in the Medicare population from 1994 to 2001. Less than half were performed for sciatica or radiculopathy, where the greatest evidence of benefit is available. These findings suggest a lack of consensus regarding the indications for ESIs and are cause for concern given the large expenditures for these procedures.
TL;DR: Pedicle screw augmentation with polymethyl methacrylate improves the initial fixation strength and fatigue strength of instrumentation in osteoporotic vertebrae.
Abstract: STUDY DESIGN: Pedicle screw pullout testing in osteoporotic and control human cadaveric vertebrae, comparing augmented and control vertebrae. OBJECTIVE: To compare the pullout strengths of pedicle screws fixed in osteoporotic vertebrae using polymethyl methacrylate delivered by 2 augmentation techniques, a standard transpedicular approach and kyphoplasty type approach. SUMMARY OF BACKGROUND DATA: Pedicle screw instrumentation of the osteoporotic spine carries an increased risk of screw loosening, pullout, and fixation failure. Osteoporosis is often cited as a contraindication for pedicle screw fixation. Augmentation of the vertebral pedicle and body using polymethyl methacrylate may improve fixation strength and construct survival in the osteoporotic vertebrae. While the utility of polymethyl methacrylate has been demonstrated for salvage of screws that have been pulled out, the effect of the cement technique on pullout strength in osteoporotic vertebrae has not been previously studied. METHODS: Thirteen osteoporotic and 9 healthy human lumbar vertebrae were tested. All specimens were instrumented with pedicle screws using a uniform technique. Osteoporotic pedicles were augmented with polymethyl methacrylate using either a kyphoplasty type technique or a transpedicular augmentation technique. Screws were tested in a paired testing array, randomly assigning the augmentation techniques to opposite sides of each vertebra. Pullout to failure was performed either primarily or after a 5000-cycle tangential fatigue conditioning exposure. After testing, following screw removal, specimens were cut in the axial plane through the center of the vertebral body to inspect the cement distribution. RESULTS: Pedicle screws placed in osteoporotic vertebrae had higher pullout loads when augmented with the kyphoplasty technique compared to transpedicular augmentation (1414 +/- 338 versus 756 +/- 300 N, respectively; P < 0.001). An unpaired t test showed that fatigued pedicle screws in osteoporotic vertebrae augmented by kyphoplasty showed higher pullout resistance than those placed in healthy control vertebrae (P = 0.002). Both kyphoplasty type augmentation (P = 0.007) and transpedicular augmentation (P = 0.02) increased pullout loads compared to pedicle screws placed in nonaugmented osteoporotic vertebrae when tested after fatigue cycling. CONCLUSIONS: Pedicle screw augmentation with polymethyl methacrylate improves the initial fixation strength and fatigue strength of instrumentation in osteoporotic vertebrae. Pedicle screws augmented using the kyphoplasty technique had significantly greater pullout strength than those augmented with transpedicular augmentation technique and those placed in healthy control vertebrae with no augmentation.
TL;DR: This study demonstrates a significant risk of serious neurologic injury after cervical TF-ESIs, whereby inadvertent intra-arterial injection of particulate corticosteroid causes a distal infarct.
Abstract: STUDY DESIGN Survey/case series. OBJECTIVE To survey pain physicians about neurologic infarctions following cervical transforaminal epidural steroid injections (TF-ESIs). SUMMARY OF BACKGROUND DATA Cervical TF-ESIs are commonly performed in patients with cervical radiculopathy, although there are no randomized controlled studies supporting their efficacy. Eight case reports of brain and spinal cord infarction have been published. In addition, one of the investigators (M.S.W.) has reviewed 4 cases of major cerebellum/brainstem infarction following cervical TF-ESIs with methylprednisolone. METHODS To better characterize these complications, anonymous surveys were sent to all U.S. physician members of the American Pain Society. Respondents were asked about awareness of complications, year of occurrence, practice setting and specialty of the treating physician, use of fluoroscopy/contrast/local anesthetic/corticosteroid, doses administered, and CT/MRI/autopsy findings. RESULTS Overall response rate was 21.4% (287 of 1340). In all, 78 complications were reported, including 16 vertebrobasilar brain infarcts, 12 cervical spinal cord infarcts, and 2 combined brain/spinal cord infarcts. Brain infarcts invariably involved the cerebellum, brainstem, or posterior cerebral artery territory. Thirteen cases resulted in a fatal outcome: 5 with brain infarcts, 1 with combined brain/spinal cord infarcts, 1 following high spinal anesthesia, 1 associated with a seizure, and 5 with unspecified etiology. All 4 cases with corticosteroid alone involved methylprednisolone, resulting in 3 cerebellar infarcts and 1 posterior cerebral territory infarct. Of these, 3 had fatal outcomes and 2 autopsies revealed no vertebral artery trauma. CONCLUSIONS This study demonstrates a significant risk of serious neurologic injury after cervical TF-ESIs. A growing body of evidence supports an embolic mechanism, whereby inadvertent intra-arterial injection of particulate corticosteroid causes a distal infarct. Embolism to the distal basilar artery region can cause midbrain, pons, cerebellum, thalamus, temporal and occipital lobe infarctions. Other potential mechanisms of infarction include vertebral artery perforation causing dissection/thrombosis and needle-induced vasospasm.
TL;DR: Pedicle subtraction osteotomy can provide satisfactory clinical and radiographic outcomes for patients with a minimum 5-year follow-up despite needing pseudarthrosis revision and some component of increasingly positive sagittal vertical axis between 2 years and 5 to 8 years of follow- up.
Abstract: STUDY DESIGN Retrospective study. OBJECTIVE To report results at a minimum 5 years after pedicle subtraction osteotomy for fixed sagittal imbalance. SUMMARY OF BACKGROUND DATA No one has reported results of pedicle subtraction osteotomies with a 5- to 8-year follow-up. METHOD Thirty-five consecutive patients with sagittal imbalance (29 females/6 males, average age at surgery, 53.1 years) treated with lumbar pedicle subtraction osteotomies (1 at L1, 13 at L2, 20 at L3, and 1 at L4) at 1 institution were analyzed (average follow-up, 5.8 years; range, 5-7.6 years). Radiographic and clinical outcomes analysis was performed. RESULTS There were no significant regional radiographic changes between 2 years postoperative and the ultimate follow-up (proximal junctional change, P = 0.30; thoracic kyphosis, P = 0.38; and lumbar lordosis, P = 0.84), although many patients did demonstrate an increasingly anterior C7 sagittal plumb with time. Ten pseudarthroses (29%) occurred in 8 patients and were revised between 2 and 5 years postoperative. There were no pseudarthroses at the osteotomy level (9 at the thoracolumbar junction, 1 at the LS junction), but at the levels added to the previous fusions. There was no degradation in Oswestry and Scoliosis Research Society (SRS) outcome scores between 2 years postoperative and ultimate follow-up (P = 0.23 and 0.90, respectively). Patients reported very good satisfaction (87%), good self-image (76%), good function (69%), and fair pain subscales (66%) at ultimate follow-up. Sagittal vertical axis <8 cm at ultimate follow-up was significant for better SRS outcomes scores (P = 0.038). Eight patients with revised pseudarthroses did not demonstrate poorer SRS outcomes scores (P = 0.52). Those 8 patients were queried after their pseudarthrosis revision surgery. CONCLUSION Pedicle subtraction osteotomy can provide satisfactory clinical and radiographic outcomes for patients with a minimum 5-year follow-up despite needing pseudarthrosis revision and some component of increasingly positive sagittal vertical axis between 2 years and 5 to 8 years of follow-up. The level of patient satisfaction and self-image subscales were high after more than 5 years of follow-up. Restoration and maintenance of sagittal vertical axis <8 cm were important to the ultimate sagittal reconstruction.
TL;DR: This paper provides a reference to compare disc geometries of experimental animal models to the human lumbar disc, to aid both in interpretation of and in planning for experimental disc research, and to provide normalized disc geometry parameters for computational models.
Abstract: Study design Measurement and normalization of disc geometry parameters for several animal models used in disc research. Objectives To compare normalized values of disc geometry to the human disc geometry to aid in the selection and interpretation of animal model studies. Summary of background data Animal models are widely used to study intervertebral disc degeneration and to evaluate disc treatment methods because of the availability of the tissue, the decreased variability between subjects compared with humans, and the feasibility to perform in vivo experiments. There is a general lack of comparative data with respect to the human disc analog for animal models. Methods The disc height, lateral width, AP width, area, and the nucleus pulposus lateral width, AP width, area, and centroid offset were all measured and normalized by 2 scaling factors, lateral width and disc area, for comparison to human. Results The species studied were ranked according to the average percent deviation of the normalized disc height, AP width and nucleus pulposus area from human geometry as: mouse lumbar (12%), rat lumbar (15%), mouse tail (18%), baboon (19%), bovine tail (22%), rabbit (26%), sheep (31%), and rat tail (46%). Conclusions This paper provides a reference to compare disc geometries of experimental animal models to the human lumbar disc, to aid both in interpretation of and in planning for experimental disc research, and to provide normalized disc geometry parameters for computational models.
TL;DR: It is suggested that the use of opioids for the management of acute LBP may be counterproductive to recovery, and the associations between early opioids and outcomes were evaluated using multivariate linear and logistic regression models.
Abstract: Study design Retrospective cohort study of workers' compensation (WC) claims with acute disabling low back pain (LBP). Objective To examine the association between early opioid use for acute LBP and outcomes: disability duration, medical costs, "late opioid" use (> or = 5 prescriptions from 30 to 730 days), and surgery in a 2-year period following LBP onset. Summary of background data Opioid analgesics have become more accepted for acute pain management. However, treatment guidelines recommend limited opioid use for acute LBP management. Little is known about the long-term impact on outcomes of opioid use for acute LBP. Methods The sample consisted of 8443 claimants from a large WC database with new-onset, disabling LBP that occurred between January 1, 2002 and December 31, 2003. Based on morphine equivalent amount (MEA) in milligrams received in the first 15 days ("early opioids"), claimants were divided into 5 groups (0, 1-140, 141-225, 226-450, 450+). The associations between early opioids and outcomes were evaluated using multivariate linear and logistic regression models. Covariates included age, gender, job tenure, and low back injury severity. Injury severity was classified using ICD-9 codes. Results Twenty-one percent of claimants received at least 1 early opioid prescription. After controlling for the covariates, mean disability duration, mean medical costs, and risk of surgery and late opioid use increased monotonically with increasing MEA. Those who received more than 450 mg MEA were, on average, disabled 69 days longer than those who received no early opioids (95% confidence interval [CI], 49.2-88.9). Compared with the lowest MEA group (0 mg opioid), the risk for surgery was 3 times greater (95% CI, 2.4-4.0) and the risk of receiving late opioids was 6 times greater (95% CI, 4.9-7.7) in the highest MEA group. Low back injury severity was a strong predictor of all the outcomes. Conclusion Given the negative association between receipt of early opioids for acute LBP and outcomes, it is suggested that the use of opioids for the management of acute LBP may be counterproductive to recovery.
TL;DR: Two-year postoperative PJK prevalence in AIS following 3 different posterior segmental posterior spinal instrumentation and fusion surgeries was 27%, with a larger preoperative thoracic kyphosis angle, greater immediate postoperativeThoracoplasty decrease, and male sex correlated significantly with PJK.
Abstract: Study design Retrospective study. Objective Determine proximal junctional kyphosis (PJK) prevalence and analyze risk factors associated with PJK in adolescent idiopathic scoliosis (AIS) patients following 3 different posterior segmental spinal instrumentation and fusion surgeries. Summary of background data No comparison study exists on proximal junctional AIS changes following 3 different segmental posterior spinal instrumentation and fusion surgeries at 2 years postoperative. Methods A clinical/radiographic assessment was conducted in 410 consecutive AIS patients (average age = 14.7, range = 10.6-20) (men/women = 73/337) treated with instrumented segmental posterior spinal fusion with 2-year follow-up. Revision and anterior cases were not included. Standing long-cassette radiographic measurements were analyzed including various sagittal/coronal parameters for preoperative, early postoperative, and 2-year follow-up. Abnormal PJK was defined by proximal junction sagittal Cobb angles between the lower endplate of the uppermost instrumented vertebra and the upper endplate of 2 supradjacent vertebrae >or=+10 degrees and at least 10 degrees greater than the preoperative measurement at 2 years postoperative. Results PJK prevalence defined at 2 years postoperative was 27% (111 of 410 patients). Statistically significant factors: larger preoperative thoracic kyphosis angle (T5-T12 >40 degrees vs. T5-T12 10 degrees -40 degrees vs. T5-T12 5 degrees vs. 5 degrees decrease-5 degrees increase vs. increase >5 degrees ; P 12 versus 12>or= (P = 0.12), the uppermost instrumented vertebra among T2, T3, T4, T5 (P = 0.75). There were no significant differences in Scoliosis Research Society Patient Questionnaire-24 outcome-scores (PJK total score = 97.0, self-image subscales = 21.3 vs. non-PJK group = 95.3, 21.0) (P = 0.34 total score, P = 0.54 self-image subscale). Conclusion Two-year postoperative PJK prevalence in AIS following 3 different posterior segmental spinal instrumentation and fusion surgeries was 27%. A larger preoperative thoracic kyphosis angle, greater immediate postoperative thoracic kyphosis angle decrease, thoracoplasty, and male sex correlated significantly with PJK. There were no significant differences in Scoliosis Research Society Patient Questionnaire-24 outcome-scores between the PJK and non-PJK group.
TL;DR: The analytical data indicated that the pathologically degenerate human disc contained populations of skeletal progenitor cells, and these findings suggest that these endogenous progenitors may be used to orchestrate the repair of the intervertebral disc.
Abstract: STUDY DESIGN To identify and characterize endogenous progenitor cell population from intervertebral disc. OBJECTIVE To determine if progenitor cells exist in degenerate human discs. SUMMARY OF BACKGROUND DATA Back pain, a significant source of morbidity in our society, is directly linked to the pathology of the intervertebral disc. Because disc disease is accompanied by a loss of cellularity, there is considerable interest in regeneration of cells of both the anulus fibrosus (AF) and nucleus pulposus (NP). METHODS To determine if skeletal progenitor cells are present in the disc, samples were obtained from the degenerate AF and NP of 5 patients (Thompson grade 2 and 3, mean age 34 +/- 7.6 years) undergoing anterior cervical discectomy and fusion procedures as well as adult rat lumbar spine. RESULTS Cells isolated from degenerate human tissues expressed CD105, CD166, CD63, CD49a, CD90, CD73, p75 low affinity nerve growth factor receptor, and CD133/1, proteins that are characteristic of marrow mesenchymal stem cells. In osteogenic media, there was an induction of alkaline phosphatase activity and expression of alkaline phosphatase, osteocalcin, and Runx-2 mRNA. When maintained in adipogenic media, a small percentage of cells displayed evidence of adipogenic differentiation: accumulation of cytosolic lipid droplets and increased expression of peroxisome proliferator-activated receptor-gamma2 and lipoprotein lipase mRNA. AF- and NP-derived cells also evidenced chondrogenic differentiation. CD133 (+) cells in the AF were able to commit to either the chondrogenic or adipogenic lineages. The results of the human disc studies were confirmed using cell derived from the NP and AF tissue of the mature rat disc. CONCLUSION The analytical data indicated that the pathologically degenerate human disc contained populations of skeletal progenitor cells. These findings suggest that these endogenous progenitors may be used to orchestrate the repair of the intervertebral disc.
TL;DR: Complications and mortality were more common in the elderly, and after posterior fusions or surgical procedures associated with a primary diagnosis of cervical spondylosis with myelopathy, and there are significant differences in outcome associated with age, primary diagnosis, and type of surgical procedure.
Abstract: STUDY DESIGN Retrospective cohort. OBJECTIVES To describe the incidence of complications and mortality associated with surgery for degenerative disease of the cervical spine using population-based data. To evaluate the associations between complications and mortality and age, primary diagnosis and type of surgical procedure. SUMMARY OF BACKGROUND DATA Recent studies have shown an increase in the number of cervical spine surgeries performed for degenerative disease in the United States. However, the associations between complications and mortality and age, primary diagnosis and type of surgical procedure are not well described using population-based data. METHODS We created an algorithm defining degenerative cervical spine disease and associated complications using the International Classification of Diseases-ninth revision Clinical Modification codes. Using the Nationwide Inpatient Sample, we determined the primary diagnoses, surgical procedures, and associated in-hospital complications and mortality from 1992 to 2001. RESULTS From 1992 to 2001, the Nationwide Inpatient Sample included an estimated 932,009 (0.3%) hospital discharges associated with cervical spine surgery for degenerative disease. The majority of admissions were for herniated disc (56%) and cervical spondylosis with myelopathy (19%). Complications and mortality were more common in the elderly, and after posterior fusions or surgical procedures associated with a primary diagnosis of cervical spondylosis with myelopathy. CONCLUSIONS There are significant differences in outcome associated with age, primary diagnosis, and type of surgical procedure. Administrative databases may underestimate the incidence of complications, but these population-based studies may provide information for comparison with surgical case series and help evaluate rare or severe complications.
TL;DR: BMI longitudinally and at index evaluations, age, and angle of lordosis were significantly associated with degenerative spondylolisthesis in women, and increased age was associated with increased age in both sexes.
Abstract: STUDY DESIGN: A cross-sectional epidemiological survey of 4151 participants of the Copenhagen Osteoarthritis Study. OBJECTIVE: To identify prevalences and individual risk factors for degenerative lumbar spondylolisthesis. SUMMARY OF BACKGROUND DATA: The Copenhagen Osteoarthritis Study has registered health parameters since 1976. In 1993, standardized, lateral radiographs of the lumbar spine were recorded. There were 1533 men and 2618 women. METHODS: Statistical correlations were made between degenerative spondylolisthesis, and physical, occupational, and general epidemiological data. RESULTS: A total of 254 cases of lumbar slip were found (males 2.7%, females 8.4%). In females, no significant relationship between age at menopause or childbirths and the presence of degenerative spondylolisthesis were found. In women, relationships between body mass index (BMI) in 1976 and L4 olisthesis (P = 0.001), and between BMI in 1993 and both L4 and L5 olisthesis were found (L4: P = 0.003; L5: P = 0.006). Lumbar lordosis was associated with degenerative spondylolisthesis in women. Occupational exposures to daily lifting or smoking were not associated with degenerative spondylolisthesis. Degenerative spondylolisthesis was associated with increased age in both sexes (L4: P < 0.001; L5: P < 0.001). CONCLUSIONS: BMI longitudinally and at index evaluations, age, and angle of lordosis were significantly associated with degenerative spondylolisthesis in women. In men, no individual risk factors for degenerative spondylolisthesis were found, save increased age.
TL;DR: Intraoperative or postoperative neurologic deficits are relatively common following a PSO; however, in a majority of cases, deficits are not likely to be permanent.
Abstract: STUDY DESIGN Clinical, radiographic, and outcomes assessment focusing on neurologic complications in patients undergoing pedicle subtraction osteotomy (PSO). Clinical data were collected prospectively. Radiographic analysis was performed retrospectively. OBJECTIVE To evaluate intraoperative and postoperative neurologic deficits following lumbar PSOs in order to determine risk factors, treatment strategies, and patient outcome. SUMMARY OF BACKGROUND DATA Although technically demanding, PSOs have been increasingly used to restore lumbar lordosis and correct sagittal deformity. Although some reports have commented on various complications of the procedure, to our knowledge, there have been no studies focusing on neurologic complications of the osteotomy. METHODS An analysis of 108 consecutive patients with an average age of 54.8 +/- 14.0 years and treated with a lumbar PSO at 1 institution over a 10-year period (1995-2005) was performed. Medical records, radiographs, and neuromonitoring data were analyzed. Clinical outcome was assessed using the Oswestry Disability Index and the Scoliosis Research Society (SRS)-24 instruments. RESULTS A total of 108 PSOs were performed. Following surgery, lumbar lordosis increased from -17.1 degrees +/- 19.3 degrees to -49.3 degrees +/- 14.7 degrees (P < 0.000), and sagittal balance improved from 131 +/- 73 mm to 23 +/- 48 mm (P < 0.000). Intraoperative and postoperative deficits (defined as motor loss of 2 grades or more or loss of bowel/bladder control) were seen in 12 patients (11.1%) and were permanent in 3 patients (2.8%). With time motor function improved by 1 grade in 2 patients and all 3 were able to ambulate. Intraoperative neuromonitoring did not detect the deficits. In 9 patients, additional surgical intervention consisted of central enlargement and further decompression. Deficits were thought to be due to a combination of subluxation, residual dorsal impingement, and dural buckling. CONCLUSION Intraoperative or postoperative neurologic deficits are relatively common following a PSO; however, in a majority of cases, deficits are not likely to be permanent.