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ABSTRACT: BACKGROUND CONTEXT: Predictors of complications and mortality after spine trauma are underexplored. At present, no study exists capable of predicting the impact of demographic factors, injury-specific predictors, race, ethnicity, and insurance status on morbidity and mortality after spine trauma. PURPOSE: This study endeavored to describe the impact of patient demographics, comorbidities, injury-specific factors, race/ethnicity, and insurance status on outcomes after spinal trauma using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB). STUDY DESIGN: The weighted sample of 75,351 incidents of spine trauma in the NTDB was used to develop a predictive model for important factors associated with mortality, postinjury complications, length of hospital stay, intensive care unit (ICU) days, and time on a ventilator. PATIENT SAMPLE: A weighted sample of 75,351 incidents of spine trauma as contained in the NTDB. OUTCOME MEASURES: Mortality, postinjury complications, length of hospital stay, ICU days, and time on a ventilator as reported in the NTDB. METHODS: The 2008 NSP of the NTDB was queried to identify patients sustaining spine trauma. Patient demographics, race/ethnicity, insurance status, comorbidities, injury-specific factors, and outcomes were recorded, and a national estimate model was derived. Unadjusted differences in baseline characteristics between racial/ethnic groups and insurance status were evaluated using the t test for continuous variables and Wald chi-square analysis for categorical variables with Bonferroni correction for multiple comparisons. Weighted logistic regression was performed for categorical variables (mortality and risk of one or more complications), and weighted multiple linear regression analysis was used for continuous variables (length of hospital stay, ICU days, and ventilator time). Initial determinations were checked against a sensitivity analysis using imputed data. RESULTS: The weighted sample contained 75,351 incidents of spine trauma. The average age was 45.8 years. Sixty-four percent of the population was male, 9% was black/African American, 38% possessed private/commercial insurance, and 12.5% lacked insurance. The mortality rate was 6% and 16% sustained complications. Increased age, male gender, Injury Severity Score (ISS), and blood pressure at presentation were significant predictors of mortality, whereas age, male gender, other mechanism of injury, ISS, and blood pressure at presentation influenced the risk of one or more complications. Nonwhite and black/African American race increased risk of mortality, and lack of insurance increased mortality and decreased the number of hospital days, ICU days, and ventilator time. CONCLUSIONS: This is the first study to postulate predictors of morbidity and mortality after spinal trauma in a national model. Race/ethnicity and insurance status appear to be associated with greater risk of mortality after spine trauma.
The spine journal: official journal of the North American Spine Society 04/2013; · 2.90 Impact Factor
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ABSTRACT: Study Design: Retrospective Analysis of Prospective Registry DataObjective: To determine the patient characteristics and fracture patterns associated with vertebral artery injury (VAI) in patients with blunt cervical spine injury.Summary of Background Data: VAI associated with cervical spine trauma has the potential for catastrophic clinical sequelae. The patterns of cervical spine injury and patient characteristics associated with VAI remain to be determined.Methods: A retrospective review of prospectively collected data from the American College of Surgeons (ACS) trauma registries at three level 1 trauma centers identified all patients with a cervical spine injury on multidetector computed tomography (MDCT) scan over a 3-year period (Jan 1, 2007 to Jan 1, 2010). Fracture pattern and patient characteristics were recorded. Logistic multivariate regression analysis of independent predictors for VAI and subgroup analysis of neurologic events related to VAI was performed.Results: Twenty-one percent of 1,204 patients with cervical injuries (n = 253) underwent screening for VAI by MDCT angiogram (MDCTA). VAI was diagnosed in 17% (42/253): unilateral in 15% (38/253) and bilateral in 1.6% (4/253) and was associated with a lower GCS(p<.001), a higher ISS(p<.01), and mortality(p<.001). VAI was associated with AS/DISH (cOR = 8.04, 95%C.I.[1.30-49.68];p = .034), and occipitocervical dissociation (p<.001) by univariate analysis and fracture displacement into the transverse foramen ≥ 1mm (aOR = 3.29, 95% C.I.[1.15-9.41]; p = .026), and basilar skull fracture (aOR = 4.25, 95% C.I.[1.25-14.47];p = .021), by multivariate regression model. Subgroup analysis of neurologic events secondary to VAI occurred in 14% (6/42) and the stroke-related mortality rate was 4.8% (2/42). Neurological events were associated with male gender (p = .024), facet subluxation/dislocation (cOR = 9.00, 95% C.I.[1.51-53.74];p = .004) and the diagnosis of AS/DISH (OR = 40.67, 95% C.I.[5.27 - 313.96];p<.001).Conclusions: VAI associated with blunt cervical spine injury is a marker for more severely injured patients. High-risk patients with basilar skull fractures, occipitocervical dissociation, fracture displacement into the transverse foramen>1mm, AS/DISH, and facet subluxation/dislocation deserve focused consideration for VAI screening.
Spine 04/2013; · 2.08 Impact Factor
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ABSTRACT: BACKGROUND CONTEXT: The impact of patient factors and medical comorbidities on the risk of mortality and complications after spinal arthrodesis has not been well described. Prior works have been limited by small sample size, single center data, or the inability to be broadly generalized. PURPOSE: To determine if there is an association between the patient demographic factors, comorbidities, nutritional status, and surgical characteristics and the occurrence of mortality and complications after spinal arthrodesis. STUDY DESIGN: Retrospective review of prospectively collected data in the National Surgical Quality Improvement Program (NSQIP). PATIENT SAMPLE: Patients who underwent spinal arthrodesis and had data registered with the NSQIP between 2005 and 2010. OUTCOME MEASURES: Primary outcomes were death or any complication after spinal arthrodesis. Secondary measures were the development of a specific complication, including wound infection, thromboembolic disease, or cardiac arrest/myocardial infarction. METHODS: The data set of the NSQIP from 2005 to 2010 was queried to identify all patients who underwent spinal arthrodesis. Demographic information, body mass index (BMI), medical comorbidities, arthrodesis procedure, operative time, American Society of Anesthesiologists (ASA) classification, and preoperative albumin were recorded for all patients identified. Mortality, the development of postoperative complications, and the presence of specific complications were also abstracted. Risk factors for mortality and complications were initially evaluated using chi-square and univariate logistic regression analyses. The risk factors that maintained p values less than .2 in univariate analysis were then combined in a multivariate fashion that identified significant, independent, predictors of mortality and complications while controlling for other factors present in the model. Sensitivity analysis was also performed, discriminating between the impact of risk factors on major and minor complications and the relative contribution to overall risk of morbidity. Multivariate analysis resulted in odds ratios (ORs) with 95% confidence intervals (CIs) for each risk factor. Only those predictors with ORs and 95% CI exclusive of 1.0 and p values less than .05 were considered statistically significant. RESULTS: In all, 5,887 patients who underwent spinal arthrodesis were identified. The average age of patients was 55.9 (±14.5) years. Twenty-five (0.42%) patients died after surgery, whereas 608 (10%) sustained a complication. Wound infection was the most common specific complication occurring in 2% of the cohort. Age (p=.03) and pulmonary conditions (p=.002) were found to have a significant association with the risk of mortality. Age exceeding 80 years was found to carry the highest risk of mortality. Age, pulmonary conditions, BMI, history of infection, ASA classification more than 2, neurologic conditions, resident (i.e., trainee) involvement, and procedural times exceeding 309 minutes increased the risk of complications. Body mass index, ASA classification more than 2, resident involvement, and procedural times exceeding 309 minutes were associated with the risk of infection. Although limited to univariate analysis, serum albumin 3.5 g/dL or less increased the risk of mortality, complications, wound infection, and thromboembolic disease. The OR for postoperative mortality among patients with albumin 3.5 g/dL or less was 13.8 (95% CI, 4.6-41.6; p<.001). CONCLUSIONS: Several factors, including patients' age, BMI, ASA classification more than 2, pulmonary conditions, procedural times, and nutritional status likely influence the risk of postoperative morbidity to varying degrees. The risk factors identified here may be more generalizable to the American population as a whole because of the design and methodology of the NSQIP in comparison with previously published studies.
The spine journal: official journal of the North American Spine Society 04/2013; · 2.90 Impact Factor
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ABSTRACT: Little information is available regarding patient-based factors that may influence results following transforaminal lumbar interbody fusion (TLIF) in younger, high-demand individuals. A query of all TLIF procedures performed on active duty military personnel at our institution was conducted for the time period 2005 to 2008. Data was abstracted, including age, gender, military rank, preoperative diagnosis, complications, and ability to remain in the military. Favorable outcome was defined as the ability of the patient receiving TLIF to remain on active duty, without medical separation (Medical Evaluation Board [MEB]), at a minimum of 1 year postsurgery. Univariate analysis was conducted to identify potential risk factors for MEB. Factors with a univariate p value <0.2 were included in multivariate analysis and sensitivity testing to identify independent predictors of outcome. The cohort included 143 patients with an average age of 36.3 years and mean follow-up of 34.9 months. Younger age (odds ratio 0.93 per year increase in age; 95% confidence interval 0.87, 0.98) and Junior Enlisted rank (odds ratio 6.42; 95% confidence interval 2.20, 18.74) were found to increase the risk of MEB, and these relationships were maintained in the sensitivity analyses. These findings highlight the potential role of activity level and sociodemographic status in outcomes after TLIF in a military population.
Military medicine 02/2013; 178(2):228-33. · 0.92 Impact Factor
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ABSTRACT: BACKGROUND CONTEXT: Patients with spinal tumors are often referred for preoperative angiography and embolization before surgical resection to minimize intraoperative bleeding. PURPOSE: The purpose of the present study was to investigate the angiographic appearance of a variety of spinal tumors, assess the safety and efficacy of preoperative embolization in relation to the amount of intraoperative blood loss, and correlate intraoperative tumor histology with the degree of gadolinium enhancement on spinal magnetic resonance imaging (MRI) and tumor vascularity visualized during angiography. STUDY DESIGN/SETTING: Retrospective and single-institution cohort study. PATIENT SAMPLE: One hundred four patients with spinal tumors referred for preoperative embolization. OUTCOME MEASURES: Effectiveness of preoperative embolization in relation to intraoperative blood loss and number of transfused packed red blood cell units in perioperative period (72 hours). METHODS: From 2000 to 2009, 104 patients with spinal tumors underwent 114 spinal angiographies with the intent to embolize feeder vessels before surgery. The effectiveness of embolization was compared with the documented intraoperative blood loss. Angiographic tumor vascularity was graded from 0 (avascular) to 3 (highly vascular). Ninety-four patients had a pre- and post-gadolinium-enhanced MRI of the spine before transarterial embolization. Magnetic resonance imaging vascular enhancement was classified as Grade 3 (avid contrast enhancement), Grade 2 (moderate), or Grade 1 (mild). RESULTS: Transarterial tumor embolization was angiographically complete in 63 (66%) and partial in 33 procedures (34%). In 18 cases, the target was not deemed suitable for embolization. A limited statistical analysis did not reveal a statistical difference in documented intraoperative blood loss between patients with complete versus partial embolization for the entire cohort or when stratified into renal cell carcinoma (RCC; p=.64), multiple myeloma (p=.28), malignant (p=.17) and benign tumor groups (p=.26). There were no clinical complications associated with embolization. There was poor correlation between MRI enhancement and angiographic vascularity. CONCLUSIONS: Preoperative embolization was angiographically effective in most cases. Avid gadolinium enhancement (Grade 3) on MRI was not predictive of hypervascularity on angiography. Furthermore, hypervascularity was not restricted to classically vascular tumors, such as RCC, as it was noted in some patients with breast and prostate cancer. However, with the available numbers, the quality of preoperative embolization did not significantly affect intraoperative blood loss. A future prospective randomized controlled study may be warranted to better characterize the benefits of preoperative embolization for spinal tumors.
The spine journal: official journal of the North American Spine Society 12/2012; · 2.90 Impact Factor
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ABSTRACT: Study Design. Cross-sectional study with prospective recruitmentObjective. To determine the relationship of pain intensity (back and leg) on patients' acceptance of surgical complication risks when deciding whether or not to undergo lumbar spinal fusion.Summary of Background Data. To formulate informed decisions regarding lumbar fusion surgery, preoperative discussions should include a review of the risk of complications balanced with the likelihood of symptom relief. Pain intensity has the potential to influence a patient's decision to consent to lumbar fusion. We hypothesized that pain intensity is associated with a patient's acceptance of surgical complication risks.Methods. Patients being seen for the first time by a spine surgeon for treatment of a non-traumatic or non-neoplastic spinal disorder completed a structured questionnaire. It posed 24 scenarios, each presenting a combination of risks of 3 complications (nerve damage, wound infection, nonunion) and probabilities of symptom relief. For each scenario, the patient indicated whether he/she would/would not consent to a fusion for low back pain (LBP). The sum of the scenarios in which the patient responded that he or she would elect surgery was calculated to represent acceptance of surgical complication risks. A variety of other data were also recorded, including age, gender, education level, race, history of non-spinal surgery, duration of pain, and history of spinal injections. Data were analyzed using bivariate analyses and multivariate regression analyses.Results. The mean number of scenarios accepted by 118 enrolled subjects was 10.2 (median 8, standard deviation 8.5, range 0 to 24, or 42.5% of scenarios). In general, subjects were more likely to accept scenarios with lower risks and higher efficacy. Spearman's rank correlation estimates demonstrated a moderate association between the LBP intensity and acceptance of surgical complication risks (r = 0.37, p = 0.0001) while leg pain intensity had a weak but positive correlation (r = 0.19, p = 0.04). In bivariate analyses history of prior spinal injections was strongly associated with patients' acceptance of surgical complication risks and willingness to proceed with surgery (54.5% of scenarios accepted for those who had injections versus 27.6% for those with no prior spinal injections, p = 0.0001). White patients were more willing to accept surgery (45.9% of scenarios) than non-whites (28.4%, p = 0.03). With the available numbers, age, gender, history of previous non-spinal surgery, education, and the duration of pain demonstrated no clear association with acceptance of surgical complication risks. While education overall was not influential, more educated men had greater risk tolerance than less educated men while more educated women had less risk tolerance than less educated women (p = .023). In multivariate analysis, LBP intensity remained a highly statistically significant correlate (p = 0.001) of the proportion of scenarios accepted, as did a history of prior spinal injections (p = 0.001) and white race (0.03).Conclusion. The current investigation indicates that the intensity of LBP is the most influential factor affecting a patient's decision to accept risk of complication and symptom persistence when considering lumbar fusion. This relationship has not been previously shown for any surgical procedure. These data could potentially change the manner in which patients are counseled to make informed choices about spinal surgery. With growing interest in adverse events and complications, these data could be important in establishing guidelines for patient-directed surgical decision-making.
Spine 11/2012; · 2.08 Impact Factor
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ABSTRACT: Retrospective review of the data collected prospectively through the Spine Patient Outcomes Research Trial (SPORT).
To determine the effect that race or ethnicity had on outcomes after spine surgery in the 3 arms of SPORT.
There is a dearth of research regarding the effect of race or ethnicity on outcome after treatment of spinal disorders.
All participants from the 3 arms of the SPORT were evaluated in an as-treated analysis, with patients categorized as white, black, or other. Baseline and operative characteristics of the groups were compared using the χ test and analysis of variance. Differences in the changes between baseline and 1-, 2-, 3-, and 4-year time points in the operative and nonoperative treatments were evaluated with a mixed effects longitudinal regression model, and differences between racial groups were compared with a multiple degrees of freedom Wald test.
A total of 2427 patients (85% white, 8% black, and 7% other) were included. Surgery was performed on 67% of white patients, 54% of blacks, and 68% of others. Whites and others were significantly more likely to undergo surgery than blacks (67% and 68% vs. 54%, P = 0.003). Complications and the risk of additional surgeries were not significantly different between racial groups. Regardless of race, all patients improved more with surgical management than with nonoperative treatment for all outcome measures at all time points. The average 4-year area-under-the-curve results revealed surgical and nonoperative treatment resulted in statistically significant improvement in whites relative to blacks for SF-36 bodily pain (P < 0.001), physical function (P < 0.001), and Oswestry Disability Index (P < 0.001). No significant differences were noted in treatment effect for primary outcome measures or self-rated progress across racial groups.
These results illustrate important differences between racial groups in terms of response to spine care. Although there were quantitative differences between groups, these findings are not necessarily indications of health care disparities.
Spine 08/2012; 37(17):1505-15. · 2.08 Impact Factor
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ABSTRACT: Epidemiological study of a prospectively collected database.
This investigation sought to evaluate the incidence of symptomatic lumbar radiculopathy, and identify risk factors for its development, among individuals serving in the United States military over a 10-year period.
Risk factors for the development of lumbar radiculopathy are poorly understood and the incidence of this disorder has not been characterized earlier for a young, high-demand population.
The Defense Medical Epidemiology Database was queried for the years 2000 to 2009 using the International Classification of Diseases ninth revision code for lumbar radiculopathy (724.4). Overall incidence was determined and multivariate Poisson regression analysis was carried out to identify the influence of risk factors such as age, sex, race, military rank, and branch of service on the development of this condition.
In this population, the overall incidence of lumbar radiculopathy was 4.86 per 1000 person-years. Multivariate Poisson regression analysis showed that female sex, white race, senior positions within the rank structure, and service in the Army, Navy, or Air Force increased the risk of developing lumbar radiculopathy. Servicemembers of 30 years and older were found to have >3 times the risk of developing lumbar radiculopathy when compared with individuals <20.
The incidence of lumbar radiculopathy in this young, racially diverse, and physically active population is higher than many other degenerative conditions. In this study female sex and white race increased the risk of developing lumbar radiculopathy. However, increasing age seems to be one of the most significant independent factors for developing this disorder.
Level II, prognostic study.
Journal of spinal disorders & techniques 05/2012; 25(3):163-7. · 1.21 Impact Factor
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Michael G Fehlings,
Justin S Smith,
Branko Kopjar,
Paul M Arnold,
S Tim Yoon,
Alexander R Vaccaro,
Darrel S Brodke,
Michael E Janssen,
Jens R Chapman,
Rick C Sasso,
Eric J Woodard,
Robert J Banco,
Eric M Massicotte,
Mark B Dekutoski,
Ziya L Gokaslan, Christopher M Bono,
Christopher I Shaffrey
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ABSTRACT: Rates of complications associated with the surgical treatment of cervical spondylotic myelopathy (CSM) are not clear. Appreciating these risks is important for patient counseling and quality improvement. The authors sought to assess the rates of and risk factors associated with perioperative and delayed complications associated with the surgical treatment of CSM.
Data from the AOSpine North America Cervical Spondylotic Myelopathy Study, a prospective, multicenter study, were analyzed. Outcomes data, including adverse events, were collected in a standardized manner and externally monitored. Rates of perioperative complications (within 30 days of surgery) and delayed complications (31 days to 2 years following surgery) were tabulated and stratified based on clinical factors.
The study enrolled 302 patients (mean age 57 years, range 29-86) years. Of 332 reported adverse events, 73 were classified as perioperative complications (25 major and 48 minor) in 47 patients (overall perioperative complication rate of 15.6%). The most common perioperative complications included minor cardiopulmonary events (3.0%), dysphagia (3.0%), and superficial wound infection (2.3%). Perioperative worsening of myelopathy was reported in 4 patients (1.3%). Based on 275 patients who completed 2 years of follow-up, there were 14 delayed complications (8 minor, 6 major) in 12 patients, for an overall delayed complication rate of 4.4%. Of patients treated with anterior-only (n = 176), posterior-only (n = 107), and combined anterior-posterior (n = 19) procedures, 11%, 19%, and 37%, respectively, had 1 or more perioperative complications. Compared with anterior-only approaches, posterior-only approaches had a higher rate of wound infection (0.6% vs 4.7%, p = 0.030). Dysphagia was more common with combined anterior-posterior procedures (21.1%) compared with anterior-only procedures (2.3%) or posterior-only procedures (0.9%) (p < 0.001). The incidence of C-5 radiculopathy was not associated with the surgical approach (p = 0.8). The occurrence of perioperative complications was associated with increased age (p = 0.006), combined anterior-posterior procedures (p = 0.016), increased operative time (p = 0.009), and increased operative blood loss (p = 0.005), but it was not associated with comorbidity score, body mass index, modified Japanese Orthopaedic Association score, smoking status, anterior-only versus posterior-only approach, or specific procedures. Multivariate analysis of factors associated with minor or major complications identified age (OR 1.029, 95% CI 1.002-1.057, p = 0.035) and operative time (OR 1.005, 95% CI 1.002-1.008, p = 0.001). Multivariate analysis of factors associated with major complications identified age (OR 1.054, 95% CI 1.015-1.094, p = 0.006) and combined anterior-posterior procedures (OR 5.297, 95% CI 1.626-17.256, p = 0.006).
For the surgical treatment of CSM, the vast majority of complications were treatable and without long-term impact. Multivariate factors associated with an increased risk of complications include greater age, increased operative time, and use of combined anterior-posterior procedures.
Journal of neurosurgery. Spine 02/2012; 16(5):425-32. · 1.61 Impact Factor
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ABSTRACT: Increased fusion rates have been reported with the addition of an anterior cervical plate (ACP) to anterior cervical discectomy and fusion (ACDF). Bioabsorbable implants have become increasingly used in orthopedic and spine surgical procedures. There are limited data regarding the outcomes of bioabsorbable ACP (bACP) with ACDF.
To compare the clinical and radiographic outcomes of patients undergoing ACDF for single-level degenerative disorders with a bACP versus a conventional metal ACP (mACP).
Retrospective comparative cohort study.
Thirty-one patients undergoing ACDF for a single-level degenerative disorder (ie, disc herniation or spondylotic neural compression).
Incidence of early (within 2 weeks) complications, postoperative sagittal alignment, Odom's criteria, and pseudarthrosis rate.
The authors retrospectively reviewed the results of a consecutive series of patients undergoing ACDF for symptomatic single-level disc herniation or spondylotic neural compression with either a bACP or an mACP over a 3-year period. Operative notes, clinical charts, and radiographs were analyzed. Radiographic outcomes were assessed for intersegmental alignment, graft subsidence, fusion rate, prevertebral soft-tissue shadow, and graft containment. Clinical outcome was evaluated by Odom's criteria.
Fourteen patients underwent ACDF with a bACP and 15 with an mACP. Radiographic outcomes at the most recent follow-up demonstrated pseudarthrosis in 4 of 14 patients (29%) in the bACP group and 0 of 15 patients in the mACP group. Graft extrusion and anterior displacement was present in three of four pseudarthroses (75%). Comparing preoperative and final radiographs, cervical lordosis was maintained at the operative segment in only 3 of 14 bACP patients (21%) compared with 8 of 15 patients (53%) in the mACP group. The mean Cobb angle was 2.4°±1.9° lordosis in the mACP group and -2.7°±2.5° kyphosis in the bACP group (p=.12). In the mACP group, 14 of 15 patients had good or excellent results. In the bACP group, only 7 of 14 patients had good or excellent results.
Bioabsorbable ACP fixation was associated with a high rate of graft extrusion and early loss of intersegmental cervical alignment. Inferior clinical outcomes were observed in patients in the bACP group compared with the mACP group. Based on these findings, continued use of the bACP used in this study cannot be recommended.
The spine journal: official journal of the North American Spine Society 11/2011; 11(11):1002-8. · 2.90 Impact Factor
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ABSTRACT: Studies delineating the adjacent level effect of single level disc replacement systems have been reported in literature. The aim of this study was to compare the adjacent level biomechanics of bi-level disc replacement, bi-level fusion and a construct having adjoining level disc replacement and fusion system.
In total, biomechanics of four models- intact, bi level disc replacement, bi level fusion and fusion plus disc replacement at adjoining levels- was studied to gain insight into the effects of various instrumentation systems on cranial and caudal adjacent levels using finite element analysis (73.6N+varying moment).
The bi-level fusion models are more than twice as stiff as compared to the intact model during flexion-extension, lateral bending and axial rotation. Bi-level disc replacement model required moments lower than intact model (1.5Nm). Fusion plus disc replacement model required moment 10-25% more than intact model, except in extension. Adjacent level motions, facet loads and endplate stresses increased substantially in the bi-level fusion model. On the other hand, adjacent level motions, facet loads and endplate stresses were similar to intact for the bi-level disc replacement model. For the fusion plus disc replacement model, adjacent level motions, facet loads and endplate stresses were closer to intact model rather than the bi-level fusion model, except in extension.
Based on our finite element analysis, fusion plus disc replacement procedure has less severe biomechanical effects on adjacent levels when compared to bi-level fusion procedure. Bi-level disc replacement procedure did not have any adverse mechanical effects on adjacent levels.
Clinical biomechanics (Bristol, Avon) 10/2011; 27(3):226-33. · 1.76 Impact Factor
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Christopher M Bono
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ABSTRACT: COMMENTARY ON: Goz V, Koehler SM, Egorova NN, et al. Kyphoplasty and vertebroplasty: trends in use in ambulatory and inpatient settings. Spine J 2011;11:737-44 (in this issue).
The spine journal: official journal of the North American Spine Society 08/2011; 11(8):745-6. · 2.90 Impact Factor
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ABSTRACT: Systematic literature review from 1970 to 2007.
This study reports the results of a systematic review comparing surgical decompression ± radiation to radiation therapy alone among patients with metastatic spinal cord compression.
Currently, the optimal treatment of metastatic spine lesions is not well defined and is inconsistent. Radiation and surgical excision are both accepted and effective. There appears to be a favorable trend for improved neurological outcome with surgical excision and stabilization as part of the management.
A review of the English literature from 1970 to 2007 was performed in the Medline database using general MeSH terms. Relevant outcome studies for the treatment of metastatic spinal cord compression were selected through criteria defined a priori. The primary outcome was ambulatory capacity. A random effects model was built to compare results between treatment groups, based on calculated proportions from each study.
Of the 1595 articles screened, 33 studies (2495 patients) were selected based on our inclusion and exclusion criteria. Sixty-four percent of the patients who underwent surgical decompression, tumor excision, and stabilization had neurological improvement from nonambulatory to ambulatory status. Twenty-nine percent of the radiation therapy group regained the ability to ambulate after treatment (P < 0.001). Paraplegic patients had a 4-fold greater recovery rate to functional ambulation with surgical intervention than with radiation therapy alone (42% vs. 10%, P < 0.001). Pain relief was noted in 88% of the patients in the surgical studies and in 74% of the patients in studies of radiation therapy (P < 0.001). The overall surgical complication rate was 29%.
This systematic review suggests that surgical excision of tumor and instrumented stabilization may improve clinical outcomes compared with radiation therapy alone, with regard to neurological function and pain. However, most data in the current literature are from observational studies, where variations in patient population and treatments cannot be controlled. This compromised our ability to compare the results of both treatments directly.
Spine 06/2011; 37(1):78-84. · 2.08 Impact Factor
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Christopher M Bono,
Andrew Schoenfeld,
Giri Gupta,
James S Harrop,
Paul Anderson,
Alpesh A Patel,
John Dimar,
Bizhan Aarabi,
Andrew Dailey,
Alexander R Vaccaro,
Ralf Gahr,
Christopher Shaffrey,
David G Anderson,
Raj Rampersaud
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ABSTRACT: Radiographic measurement study.
To develop a standardized cervical injury nomenclature system to facilitate description, communication, and classification among health care providers. The reliability and reproducibility of this system was then examined.
Description of subaxial cervical injuries is critical for treatment decision making and comparing scientific reports of outcomes. Despite a number of available classification systems, surgeons, and researchers continue to use descriptive nomenclature, such as "burst" and "teardrop" fractures, to describe injuries. However, there is considerable inconsistency with use of such terms in the literature.
Eleven distinct injury types and associated definitions were established for the subaxial cervical spine and subsequently refined by members of the Spine Trauma Study Group. A series of 18 cases of patients with a broad spectrum of subaxial cervical spine injuries was prepared and distributed to surgeon raters. Each rater was provided with the full nomenclature document and asked to select primary and secondary injury types for each case. After receipt of the raters' first round of classifications, the cases were resorted and returned to the raters for a second round of review. Interrater and intrarater reliabilities were calculated as percent agreement and Cohen kappa (κ) values. Intrarater reliability was assessed by comparing a given rater's diagnosis from the first and second rounds.
Nineteen surgeons completed the first and second rounds of the study. Overall, the system demonstrated 56.4% interrater agreement and 72.8% intrarater agreement. Overall, interrater κ values demonstrated moderate agreement while intrarater κ values showed substantial agreement. Analyzed by injury types, only four (burst fractures, lateral mass fractures, flexion teardrop fractures, and anterior distraction injuries) demonstrated greater than 50% interrater agreement.
This study demonstrated that, even in ideal circumstances, there is only moderate agreement among raters regarding cervical injury nomenclature. It is hoped that more familiarity with the proposed system will increase reproducibility in the future. Additional research is required to establish the clinical utility of this novel nomenclature schema.
Spine 05/2011; 36(17):E1140-4. · 2.08 Impact Factor
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ABSTRACT: Radiographic measurement study.
To assess the interobserver reliability of radiographic measurements for subaxial cervical spine trauma; to compare the reliability of measurements made on computed tomography (CT) versus those made using plain radiographs.
Despite the importance of imaging and classification of subaxial cervical injuries, the persistent lack of a uniform measurement protocol remains an obstacle. Recently, the Spine Trauma Study Group published a proposal for a standardized set of measurement techniques for the radiographic evaluation of subaxial cervical spine trauma. While a worthwhile venture, the observer error of these methods was not tested.
Lateral cervical plain radiographs and CT images of 30 patients who sustained a broad spectrum of subaxial cervical spine injuries were distributed to surgeons. Participants were asked to measure kyphosis, translation, vertebral body height loss, and facet joint apposition. Each rater was provided with a pictorial diagram illustrating the prescribed measurement technique. All measurements were made using plain radiographs and CT images with the exception of facet joint apposition, which was assessed using only CT. Reliability was examined by calculating the ICC and Pearson correlation coefficients. RESULTS.: Vertebral body translation was the most reproducible method on both CT images and plain radiographs. Kyphosis measurements were less reproducible, though the endplate method demonstrated superior reliability to the posterior tangent method. Plain radiographic measurement of anterior vertebral body height loss demonstrated moderate reliability while all other height loss measurements were found to show poor reliability. Facet joint apposition measurement demonstrated poor reproducibility.
Despite a consensus regarding their importance in directing treatment, radiographic measurements for subaxial cervical spine trauma demonstrate inconsistent reliability. Even in the idealized setting used in this investigation, there was limited agreement between observers. Although translation and kyphosis showed satisfactory reproducibility, results for vertebral body height loss and facet joint apposition were unreliable. On the basis of these findings, it may be more appropriate to describe facet joint apposition binomially as "present" or "not present" instead of a numerical value; vertebral body height loss may be more appropriately characterized in quaternary terms, such as less than 25%, 25% to 50%, 50% to 75%, and more than 75%. Though simpler, such descriptions would need to be validated in future studies.
Spine 05/2011; 36(17):1374-9. · 2.08 Impact Factor
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ABSTRACT: Prior research has identified disparities in access to care, resource utilization, and outcomes in members of racial and ethnic minorities. However, the role that race/ethnicity may play in influencing outcomes after spine surgery has not been previously studied.
To characterize the effect of race and ethnicity on outcome after spine surgery.
Systematic literature review and meta-analysis.
Of 11 investigations selected in the initial analysis, four reported results in a fashion that enabled their inclusion in the meta-analysis. These four studies included a total of 128,635 patients.
"Favorable" or "unfavorable" postsurgical outcomes were determined based on parameters described in each included investigation.
A systematic literature review was performed to identify all studies documenting outcomes, complications, or mortality after spine surgical procedures. Eligible studies had to include raw data that enabled separate analysis of white and nonwhite patients. Outcome was categorized as "favorable" or "unfavorable" based on scales included in each investigation. The Q-statistic was used to determine heterogeneity, and a meta-analysis was performed to assess the relative risk for unfavorable outcome among nonwhite patients after spine surgery.
Eleven studies met initial selection criteria but only four were eligible for inclusion in the meta-analysis. The meta-analysis included 128,635 patients among whom 12,194 (9.5%) had unfavorable outcomes. Among white patients, 9.4% sustained an unfavorable outcome as compared with 10.4% of nonwhites.
In light of the small number of studies able to be included in the meta-analysis, no firm conclusions can be drawn regarding the effect of race/ethnicity on outcome after spinal surgery. There is a pressing need for more robust research regarding spine surgical outcomes among different racial and ethnic minority groups.
The spine journal: official journal of the North American Spine Society 05/2011; 11(5):381-8. · 2.90 Impact Factor
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ABSTRACT: Although outcome instruments have been used extensively in spine surgical research, few studies at present specifically address their use in investigations regarding spine trauma. In this review we provide a summary of the outcome instruments used most frequently in spine trauma research, identify the unique challenges of studying outcomes of spine trauma patients, and propose an integrated approach that may be beneficial for future studies.
We reviewed the use of outcome instruments applicable to spine trauma research, including generic health measures, inventories of back-specific function, pain scales, health related quality of life (HRQOL) instruments, and radiographic determinants of outcome.
Several inventories have been utilised to measure clinical outcomes following spinal trauma. Excluding measures of neurological function (e.g. ASIA motor score), none have been specifically validated for use with spine fractures. The SF-36, RMDQ, and ODI are amongst the most commonly used instruments. Importantly, the use of validated functional outcome measures in spine trauma research is hampered by the fact that the pre-morbid state of patients who sustain spine trauma may not be accurately represented by normative values established for the general population. The VAS is used most frequently to assess degree of neck and back pain. Most studies have relied on non-validated measures to determine radiographic results of treatment, although more elegant radiographic metrics exist.
Functional outcome measurement of traumatically injured spine patients is challenging because available generic and spine-specific instruments were not designed for or validated in this population. Furthermore, no single inventory is capable of capturing global data necessary to evaluate results following these injuries. Investigations seeking to quantify outcomes following spine trauma should consider the use of a combination of existing surveys in a complementary fashion that should include a generic health survey, a measure of back-specific function, and determinants of bodily pain and work-related disability.
Injury 03/2011; 42(3):265-70. · 1.98 Impact Factor
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ABSTRACT: Several reports indicate that patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) have increased mortality after cervical spine fractures. However, outcomes of the fractured hyperostotic cervical spine are incompletely described, and there are limited data regarding the covariable effects of patient age and medical comorbidities on mortality.
To determine mortality associated with cervical fractures in patients with hyperostotic disease.
Retrospective case-control study.
Forty-three patients identified through a registry as having fractures of the cervical spine in the setting of hyperostotic disease. These patients were matched to 43 controls who did not carry the diagnosis of hyperostotic disease.
Mortality at 3 months and 1, 2, and 3 years after fracture.
An institutional database was used to identify all cervical fractures sustained by patients aged 65 years and older from 1991 to 2006. Demographic information, date of injury, associated injuries, treatment type, presence of AS or DISH, and comorbidities were abstracted from medical records and radiographs. Mortality was ascertained using the National Death Index. Patients with AS or DISH were matched to controls who did not carry the diagnosis of hyperostotic disease. Risks of mortality were calculated at 3 months, 1 year, 2 years, and 3 years. Kaplan-Meier methods, logistic regression analysis, the two independent sample t test, and the Fisher exact test were used to compare mortalities between the two groups. Statistical significance was determined as p values <.05.
Forty-three patients were identified as having fractures in the setting of hyperostotic disease of the cervical spine. Twenty-seven individuals had DISH, and 16 had AS. The average age of both the study group and controls was 80 years, with an age range of 68 to 94. There was no significantly increased risk of mortality between the overall study group and control group at 3 months (p=.20), 1 (p=.22), 2 (p=.15), or 3 years (p=.50) after injury. Compared with controls, subgroup analysis of patients with AS showed a statistically increased risk of mortality at 3 months (p<.01) and at 1 and 2 years (p<.01 at both time points). When compared with individuals with DISH, those with AS had an increased risk of mortality at time points up to 2 years after fracture. Patients with DISH did not have an increased mortality risk at any time point when compared with controls.
The effect of fracture on mortality appears to be greatest in those with AS. Patients with DISH did not demonstrate an increased risk of mortality compared with age- and sex-matched controls. Future studies of patients with hyperostotic disease should analyze patients with DISH and AS separately instead of as a single homogenous group.
Level IV.
The spine journal: official journal of the North American Spine Society 03/2011; 11(4):257-64. · 2.90 Impact Factor
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Christopher M Bono,
Gary Ghiselli,
Thomas J Gilbert,
D Scott Kreiner,
Charles Reitman,
Jeffrey T Summers,
Jamie L Baisden,
John Easa,
Robert Fernand,
Tim Lamer,
Paul G Matz,
Daniel J Mazanec,
Daniel K Resnick,
William O Shaffer,
Anil K Sharma,
Reuben B Timmons,
John F Toton
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ABSTRACT: The North American Spine Society (NASS) Evidence-Based Clinical Guideline on the Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders provides evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of cervical radiculopathy from degenerative disorders. The guideline addresses these questions based on the highest quality clinical literature available on this subject as of May 2009. The guideline's recommendations assist the practitioner in delivering optimum efficacious treatment of and functional recovery from this common disorder.
Provide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with cervical radiculopathy from degenerative disorders.
Systematic review and evidence-based clinical guideline.
This report is from the Cervical Radiculopathy from Degenerative Disorders Work Group of the NASS' Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. Each member of the group formatted a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subjects of this report. A literature search addressing each question using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional evidence-based databases. The relevant literature was then independently rated by a minimum of three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.
Eighteen clinical questions were formulated, addressing issues of natural history, diagnosis, and treatment of cervical radiculopathy from degenerative disorders. The answers are summarized in this article. The respective recommendations were graded by the strength of the supporting literature, which was stratified by levels of evidence.
A clinical guideline for cervical radiculopathy from degenerative disorders has been created using the techniques of evidence-based medicine and best available evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.
The spine journal: official journal of the North American Spine Society 01/2011; 11(1):64-72. · 2.90 Impact Factor
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ABSTRACT: Retrospective cohort study.
To determine the influence of age, comorbidities, and treatment type on mortality in elderly patients with acute Type II odontoid fractures.
Prior studies have documented increased morbidity and mortality among geriatric patients sustaining odontoid fractures. However, there is limited data regarding the effect of patient age, medical comorbidities, and treatment selection on mortality after Type II odontoid (C2) fractures in the elderly.
An institutional registry was used to identify all Type II odontoid fractures sustained by patients aged 65 and older from 1991 to 2006. Demographic information, date of injury, associated injuries, treatment type, and comorbidities were abstracted from medical records. Mortality was ascertained using the National Death Index. Risks of mortality and their associated 95% confidence intervals (CIs) were calculated at 3 months, 1 year, 2 years, and 3 years. Multivariable Cox proportional hazard regression was used to evaluate independent factors affecting mortality stratified by age (65-74 years, 75-84 years, ≥ 85 years) and treatment type (operative or nonoperative treatment, and halo or collar immobilization).
Of 156 patients identified with Type II odontoid fracture, the average age was 82 years (SD = 7.8; Range: 65-101). One hundred and twelve patients (72%) were treated nonoperatively. At 3 years postinjury, there was a 39% (95% CI: 32-47) mortality rate for the entire cohort. Mortality for the operative group was 11% (95% CI: 2-21) at 3 months and 21% (95% CI: 9-32) at 1 year compared with 25% (95% CI: 17-33) at 3 months and 36% (95% CI: 27-45) at 1 year in the nonoperative group. The Cox regression model showed that the protective effect of surgery was seen in patients aged 65 to 74 years, in whom the hazard ratio associated with surgery for mortality after odontoid fracture was 0.4 (95% CI: 0.1-1.5). Those aged 75 to 84 years had a hazard ratio of 0.8 (95% CI: 0.3-2.3), and patients 85 years or older had a hazard ratio of 1.9 (95% CI: 0.6-6.1; P value for interaction between age and treatment = 0.09) with operative treatment having a protective effect in patients aged 65 to 74 years.
In a cohort of elderly patients, Type II odontoid fractures were associated with a high rate of mortality, regardless of intervention.
Spine 01/2011; 36(11):879-85. · 2.08 Impact Factor
