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ABSTRACT: BACKGROUND: Questions remain as to the effect that obesity has on patients managed for symptomatic lumbar disc herniation. The purpose of this study was to determine if obesity affects outcomes following the treatment of symptomatic lumbar disc herniation. METHODS: An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial for the treatment of lumbar disc herniation. A comparison was made between patients with a body mass index of <30 kg/m2 (nonobese) (n = 854) and those with a body mass index of ≥30 kg/m2 (obese) (n = 336). Baseline patient demographic and clinical characteristics were documented. Primary and secondary outcomes were measured at baseline and at regular follow-up time intervals up to four years. The difference in improvement from baseline between operative and nonoperative treatment was determined at each follow-up period for both groups. RESULTS: At the time of the four-year follow-up evaluation, improvements over baseline in primary outcome measures were significantly less for obese patients as compared with nonobese patients in both the operative treatment group (Short Form-36 physical function, 37.3 compared with 47.7 points [p < 0.001], Short Form-36 bodily pain, 44.2 compared with 50.0 points [p = 0.005], and Oswestry Disability Index, -33.7 compared with -40.1 points [p < 0.001]) and the nonoperative treatment group (Short Form-36 physical function, 23.1 compared with 32.0 points [p < 0.001] and Oswestry Disability Index, -21.4 compared with -26.1 points [p < 0.001]). The one exception was that the change from baseline in terms of the Short Form-36 bodily pain score was statistically similar for obese and nonobese patients in the nonoperative treatment group (30.9 compared with 33.4 points [p = 0.39]). At the time of the four-year follow-up evaluation, when compared with nonobese patients who had been managed operatively, obese patients who had been managed operatively had significantly less improvement in the Sciatica Bothersomeness Index and the Low Back Pain Bothersomeness Index, but had no significant difference in patient satisfaction or self-rated improvement. In the present study, 77.5% of obese patients and 86.9% of nonobese patients who had been managed operatively were working a full or part-time job. No significant differences were observed in the secondary outcome measures between obese and nonobese patients who had been managed nonoperatively. The benefit of surgery over nonoperative treatment was not affected by body mass index. CONCLUSIONS: Obese patients realized less clinical benefit from both operative and nonoperative treatment of lumbar disc herniation. Surgery provided similar benefit over nonoperative treatment in obese and nonobese patients. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
The Journal of Bone and Joint Surgery 11/2012; · 3.27 Impact Factor
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ABSTRACT: Study Design. Retrospective review of a prospectively collected databaseObjective. To examine whether short- and long-term outcomes after surgery for SPS and DS vary across centers.Summary of Background Data. Surgery has been shown to be of benefit for both lumbar stenosis (SPS) and degenerative spondylolisthesis (DS). For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated.Methods. Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of SPS or DS undergoing surgery were followed from baseline at 6 weeks, and 3, 6 and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Baseline characteristics and short- and long-term outcomes were analyzed.Results. 793 patients underwent surgery. Significant differences were found between centers with regard to patient race, body mass index, treatment preference, neurological deficit, stenosis location, severity and number of stenotic levels. Significant differences were also found in operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and wound infection. When baseline differences were adjusted for, significant differences were still seen between centers in changes in patient functional outcome (SF-36 bodily pain and physical function, and Oswestry disability index) at 1 year after surgery. In addition, the cumulative adjusted change in Oswestry disability index score at 4 years significantly differed among centers, with SF-36 scores trending towards significance.Conclusions. There is broad and statistically significant variation in short- and long-term outcomes after surgery for SPS and DS across various academic centers, when statistically significant baseline differences are adjusted for. The findings suggest choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important.
Spine 10/2012; · 2.08 Impact Factor
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ABSTRACT: STUDY DESIGN.: Combined prospective randomized controlled trial and observational cohort study of spinal stenosis (SpS) with an as-treated analysis. OBJECTIVE.: To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for SpS using subgroup analysis. SUMMARY OF BACKGROUND DATA.: The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for SpS at the group level. However, individual characteristics may affect TE. No previous studies have evaluated TE modifiers in SpS. METHODS.: SpS patients were treated with either surgery (n = 419) or nonoperative care (n = 235) and were analyzed according to treatment received. Fifty-three baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) over 4 years (TE = ΔODIsurgery - ΔODInonoperative). Variables with significant subgroup × treatment interactions (P < 0.05) were simultaneously entered into a multivariate model to select independent TE predictors. RESULTS.: Other than smokers, all analyzed subgroups including at least 50 patients improved significantly more with surgery than with nonoperative treatment (P < 0.05). Multivariate analysis demonstrated: baseline ODI ≤ 56 (TE -15.0 vs. -4.4, ODI > 56, P < 0.001), not smoking (TE -11.7 vs. -1.6 smokers, P < 0.001), neuroforaminal stenosis (TE -14.2 vs. -8.7 no neuroforaminal stenosis, P = 0.002), predominant leg pain (TE -11.5 vs. -7.3 predominant back pain, P = 0.035), not lifting at work (TE -12.5 vs. -0.5 lifting at work, P = 0.017), and the presence of a neurological deficit (TE -13.3 vs. -7.2 no neurological deficit, P < 0.001) were associated with greater TE. CONCLUSION.: With the exception of smokers, patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of other specific characteristics. However, TE varied significantly across certain subgroups, and these data can be used to individualize shared decision making discussions about likely outcomes. Smoking cessation should be considered before surgery for SpS.
Spine 10/2012; 37(21):1791-802. · 2.08 Impact Factor
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Spine Journal Meeting Abstracts. 08/2012;
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Spine Journal Meeting Abstracts. 08/2012;
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ABSTRACT: : Surgery has been shown to be of benefit for both lumbar stenosis and degenerative spondylolisthesis. For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated.
: Spine Patient Outcomes Research Trial cohort participants with spinal stenosis (SPS) or degenerative spondylolisthesis (DS) undergoing first-time open lumbar laminectomy with or without fusion were followed from baseline at 6 weeks, and 3, 6 and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Mean (SD) follow-up was 45.2 (13.8) months. Median (range) follow-up was 47.4 (1.2, 95.6) months. Baseline characteristics, perioperative events and short- and long-term outcomes were analyzed across the centers.
: 793 patients underwent surgery. Significant differences were found across centers in operative duration and blood loss, incidence of durotomy, length of hospital stay, and wound infection. There were no significant differences between centers in incidence of nerve root injury or post-operative mortality. Significant differences were seen in the adjusted change in all indices of functional outcome (SF-36 BP and PF, and Oswestry disability index) at 1 year after surgery and in cumulative adjusted change in ODI score at 4 years.
: There is broad and statistically significant variation in outcomes after surgery for SPS and DS across various academic centers, when baseline differences are adjusted for. The findings suggest choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important.
Neurosurgery 08/2012; 71(2):E545. · 2.79 Impact Factor
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ABSTRACT: : Lumbar discectomy is the most commonly performed spine procedure. Academic spine centers with potentially differing caseloads and experience may have different outcomes.
: To determine whether the choice of center in which surgery is performed affects lumbar discectomy outcomes.
: Spine Patient Outcomes Research Trial participants with a confirmed diagnosis of intervertebral disc herniation undergoing standard first-time open discectomy were followed from baseline at 6 weeks, and 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Patient data from this prospective study were reviewed. Enrollment began in March 2000 and ended in November 2004.
: Seven hundred ninety-two patients underwent first-time lumbar discectomy. Significant differences were found among centers in patient age and race, baseline levels of disability, and treatment preferences. There were no significant differences among the centers in other patient characteristics (eg, sex, body mass index, the prevalence of smoking, diabetes, or hypertension), or disease characteristics (herniation level or type). Some short-term outcomes varied significantly among centers, including operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and reoperation rate. However, there were no differences among the centers in incidence of nerve root injury, postoperative mortality, Short Form 36 scores of body pain or physical function, or Oswestry Disability Index at 4 years.
: Although mean blood loss, risk of durotomy, length of stay, and rate of reoperation vary among academic spine centers performing lumbar discectomy, there appears to be no difference in long-term functional outcomes.
: AUC, area under the curveIDH, intervertebral disc herniationSBI, Sciatica Bothersomeness IndexSF-36, Short Form 36SPORT, Spine Patient Outcomes Research Trial.
Neurosurgery 07/2012; 71(4):833-43. · 2.79 Impact Factor
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ABSTRACT: Study Design. Combined prospective randomized controlled trial and observational cohort study of spinal stenosis (SpS) with an as-treated analysis.Objective. To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for SpS using subgroup analysis.Summary of Background Data. SPORT demonstrated a positive surgical TE for SpS at the group level. However, individual characteristics may affect TE. No prior studies have evaluated TE modifiers in SpS.Methods. SpS patients were treated with either surgery (n = 419) or nonoperative care (n = 235) and were analyzed according to treatment received. Fifty-three baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) over 4 years (TE = ΔODIsurgery-ΔODInonoperative). Variables with significant subgroup by* treatment interactions (p<0.05) were simultaneously entered into a multivariate model to select independent TE predictors.Results. Other than smokers, all analyzed subgroups including at least 50 patients improved significantly more with surgery than with nonoperative treatment (p<0.05). Multivariate analysis demonstrated: baseline ODI ≤ 56 (TE -15.0 vs. -4.4 ODI > 56, p<0.001), not smoking (TE -11.7 vs. -1.6 smokers, p<0.001), neuroforaminal stenosis (TE -14.2 vs. -8.7 no neuroforaminal stenosis, p = 0.002), predominant leg pain (TE -11.5 vs. -7.3 predominant back pain, p = 0.035), not lifting at work (TE -12.5 vs. -8.5 lifting at work, p = 0.017), and the presence of a neurological deficit (TE -13.3 vs. -7.2 no neurological deficit, p<0.001) were associated with greater TE.Conclusions. With the exception of smokers, patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of other specific characteristics. However, TE varied significantly across certain subgroups, and these data can be used to individualize shared decision making discussions about likely outcomes. Smoking cessation should be considered prior to surgery for SpS.
Spine 06/2012; · 2.08 Impact Factor
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ABSTRACT: STUDY DESIGN.: Retrospective subgroup analysis of prospectively collected data according to treatment received. OBJECTIVE.: The purpose of this study was to determine whether obesity affects treatment outcomes for lumbar stenosis (SpS) and degenerative spondylolisthesis (DS). SUMMARY OF BACKGROUND DATA.: Obesity is thought to be associated with increased complications and potentially less favorable outcomes after the treatment of degenerative conditions of the lumbar spine. This, however, remains a matter of debate in the existing literature. METHODS.: An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial for the treatment of SpS or DS. A comparison was made between patients with a body mass index (BMI) of less than 30 ("nonobese," n = 373 SpS and 376 DS) and those with a BMI of 30 or more ("obese," n = 261 SpS and 225 DS). Baseline patient characteristics, intraoperative data, and complications were documented. Primary and secondary outcomes were measured at baseline and regular follow-up time intervals up to 4 years. The difference in improvement over baseline between surgical and nonsurgical treatment (i.e., treatment effect) was determined at each follow-up interval for the obese and nonobese groups. RESULTS.: At 4-year follow-up, operative and nonoperative treatment provided improvement in all primary outcome measures over baseline in patients with BMI of less than 30 and 30 or more. For patients with SpS, there were no differences in the surgical complication or reoperation rates between groups. Patients with DS with BMI of 30 or more had a higher postoperative infection rate (5% vs. 1%, P = 0.05) and twice the reoperation rate at 4-year follow-up (20% vs. 11%, P = 0.01) than those with BMI of less than 30. At 4 years, surgical treatment of SpS and DS was equally effective in both BMI groups in terms of the primary outcome measures, with the exception that obese patients with DS had less improvement from baseline in the 36-Item Short Form Health Survey (SF-36) physical function score than nonobese patients (22.6 vs. 27.9, P = 0.022). With nonoperative treatment, patients with SpS with BMI of 30 or more did worse in regard to all 3 primary outcome measures, and patients with DS with BMI of 30 or more had similar SF-36 bodily pain scores but less improvement over baseline in the SF-36 physical function and Oswestry Disability Index scores. Treatment effects for SpS and DS were significant within each BMI group for all primary outcome measures in favor of surgery. Obese patients had a significantly greater treatment effect than nonobese patients with SpS (Oswestry Disability Index, P = 0.037) and DS (SF-36 PF, P = 0.004) largely due to the relatively poor outcome of nonoperative treatment in obese patients. CONCLUSION.: Obesity does not affect the clinical outcome of operative treatment of SpS. There are higher rates of infection and reoperation and less improvement from baseline in the SF-36 physical function score in obese patients after surgery for DS. Nonoperative treatment may not be as effective in obese patients with SpS or DS.
Spine 05/2012; 37(23):1933-46. · 2.08 Impact Factor
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ABSTRACT: Retrospective review of a prospectively collected multi-institutional database.
In the present analysis, we investigate the impact of incidental durotomy on outcome in patients undergoing surgery for lumbar degenerative spondylolisthesis.
Surgery for lumbar degenerative spondylolisthesis has several potential complications, one of the most common of which is incidental durotomy. The effect of incidental durotomy on outcome, however, remains uncertain.
Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of lumbar degenerative spondylolisthesis undergoing standard first-time open decompressive laminectomy, with or without fusion, were followed from baseline at 6 weeks, at 3, 6, 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean (standard deviation [SD]) follow-up among all analyzed degenerative spondylolisthesis patients was 46.6 months (SD = 13.1) (no durotomy: 46.7 vs. had durotomy: 45.2, P = 0.49). The median (range) follow-up time among all analyzed degenerative spondylolisthesis patients was 47.6 months (SD = 2.5-84).
A 10.5% incidence of durotomy was detected among the 389 patients undergoing surgery. No significant differences were observed with or without durotomy in age, race, the prevalence of smoking, diabetes and hypertension, decompression level, number of levels, or whether a fusion was performed. There were no differences in incidence of nerve root injury, postoperative mortality, additional surgeries, 36-Item Short Form Health Survey (SF-36) scores of body pain or physical function, or Oswestry Disability Index at 1, 2, 3, and 4 years.
Incidental durotomy during first-time surgery for lumbar degenerative spondylolisthesis does not appear to impact outcome in affected patients.
Spine 03/2012; 37(5):406-13. · 2.08 Impact Factor
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ABSTRACT: The purpose of the present study was to determine if the duration of symptoms affects outcomes following the treatment of intervertebral lumbar disc herniation.
An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial (SPORT) for the treatment of intervertebral lumbar disc herniation. Randomized and observational cohorts were combined. A comparison was made between patients who had had symptoms for six months or less (n = 927) and those who had had symptoms for more than six months (n = 265). Primary and secondary outcomes were measured at baseline and at regular follow-up intervals up to four years. The treatment effect for each outcome measure was determined at each follow-up period for the duration of symptoms for both groups.
At all follow-up intervals, the primary outcome measures were significantly worse in patients who had had symptoms for more than six months prior to treatment, regardless of whether the treatment was operative or nonoperative. When the values at the time of the four-year follow-up were compared with the baseline values, patients in the operative treatment group who had had symptoms for six months or less had a greater increase in the bodily pain domain of the Short Form-36 (SF-36) (mean change, 48.3 compared with 41.9; p < 0.001), a greater increase in the physical function domain of the SF-36 (mean change, 47.7 compared with 41.2; p < 0.001), and a greater decrease in the Oswestry Disability Index score (mean change, -41.1 compared with -34.6; p < 0.001) as compared with those who had had symptoms for more than six months (with higher scores indicating less severe symptoms on the SF-36 and indicating more severe symptoms on the Oswestry Disability Index). When the values at the time of the four-year follow-up were compared with the baseline values, patients in the nonoperative treatment group who had had symptoms for six months or less had a greater increase in the bodily pain domain of the SF-36 (mean change, 31.8 compared with 21.4; p < 0.001), a greater increase in the physical function domain of the SF-36 (mean change, 29.5 compared with 22.6; p = 0.015), and a greater decrease in the Oswestry Disability Index score (mean change, -24.9 compared with -18.5; p = 0.006) as compared with those who had had symptoms for more than six months. Differences in treatment effect between the two groups related to the duration of symptoms were not significant.
Increased symptom duration due to lumbar disc herniation is related to worse outcomes following both operative and nonoperative treatment. The relative increased benefit of surgery compared with nonoperative treatment was not dependent on the duration of the symptoms.
The Journal of Bone and Joint Surgery 10/2011; 93(20):1906-14. · 3.27 Impact Factor
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ABSTRACT: Retrospective subgroup analysis of prospectively collected data according to treatment received.
The purpose of this study is to determine whether the duration of symptoms affects outcomes after the treatment of spinal stenosis (SS) or degenerative spondylolisthesis (DS).
The Spine Outcomes Research Trial (SPORT) study was designed to provide scientific evidence on the effectiveness of spinal surgery versus a variety of nonoperative treatments.
An as-treated analysis was performed on the patients enrolled in SPORT for the treatment of SS or DS. A comparison was made between patients with SS with 12 or fewer months' (n = 405) and those with more than 12 months' (n = 227) duration of symptoms. A comparison was also made between patients with DS with 12 or fewer months' (n = 397) and those with more than 12 months' (n = 204) duration of symptoms. Baseline patient characteristics were documented. Primary and secondary outcomes were measured at baseline and at regular follow-up time intervals up to 4 years. The difference in improvement among patients whose surgical or nonsurgical treatment began less than or greater than 12 months after the onset of symptoms was measured. In addition, the difference in improvement with surgical versus nonsurgical treatment (treatment effect) was determined at each follow-up period for each group.
At final follow-up, there was significantly less improvement in primary outcome measures in SS patients with more than 12 months' symptom duration. Primary and secondary outcome measures within the DS group did not differ according to symptom duration. There were no statistically significant differences in the treatment effect of surgery in SS or DS patients.
Patients with SS with fewer than 12 months of symptoms experienced significantly better outcomes with surgical and nonsurgical treatment relative to those with symptom duration greater than 12 months. There was no difference in the outcome of patients with degenerative spondylolisthesis according to symptom duration.
Spine 09/2011; 36(25):2197-210. · 2.08 Impact Factor
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ABSTRACT: Combined prospective randomized controlled trial and observational cohort study of intervertebral disc herniation (IDH), an as-treated analysis.
To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for intervertebral disc herniation (IDH) using subgroup analysis.
The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for IDH at the group level. However, individual characteristics may affect TE. No prior studies have evaluated TE modifiers in IDH.
IDH patients underwent either discectomy (n = 788) or nonoperative care (n = 404) and were analyzed according to treatment received. Thirty-seven baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) across 4 years (TE = ΔODI(surgery) -ΔODI(nonoperative)). Variables with significant subgroup-by-treatment interactions (P < 0.1) were simultaneously entered into a multivariate model to select independent TE predictors.
All analyzed subgroups improved significantly more with surgery than with nonoperative treatment (P < 0.05). In minimally adjusted univariate analyses, being married, absence of joint problems, worsening symptom trend at baseline, high school education or less, older age, no worker's compensation, longer duration of symptoms, and an SF-36 mental component score (MCS) less than 35 were associated with greater TEs. Multivariate analysis demonstrated that being married (TE, -15.8 vs. -7.7 single, P < 0.001), absence of joint problems (TE, -14.6 vs. -10.3 joint problems, P = 0.012), and worsening symptoms (TE, -15.9 vs. -11.8 stable symptoms, P = 0.032) were independent TE modifiers. TEs were greatest in married patients with worsening symptoms (-18.3) vs. single patients with stable symptoms (-7.8).
IDH patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of specific characteristics. However, being married, without joint problems, and worsening symptom trend at baseline were associated with a greater TE.
Spine 06/2011; 37(2):140-9. · 2.08 Impact Factor
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ABSTRACT: Incidental durotomy is a familiar encounter during surgery for lumbar spinal stenosis. The impact of durotomy on long-term outcomes remains a matter of debate.
To determine the impact of durotomy on the long-term outcomes of patients in the Spine Patient Outcomes Research Trial (SPORT).
The SPORT cohort participants with a confirmed diagnosis of spinal stenosis, without associated spondylolisthesis, undergoing standard, first-time, open decompressive laminectomy, with or without fusion, were followed up from baseline at 6 weeks, and 3, 6, and 12 months and yearly thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean follow-up among all analyzed patients was 43.8 months.
Four hundred nine patients underwent first-time open laminectomy with or without fusion. Thirty-seven of these patients (9%) had an incidental durotomy. No significant differences were observed with or without durotomy in age; sex; race; body mass index; the prevalence of smoking, diabetes mellitus, and hypertension; decompression level; number of levels decompressed; or whether an additional fusion was performed. The durotomy group had significantly increased operative duration, operative blood loss, and inpatient stay. There were, however, no differences in incidence of nerve root injury, mortality, additional surgeries, or primary outcomes (Short Form-36 Bodily Pain or Physical Function scores or Oswestry Disability Index) at yearly follow-ups to 4 years.
Incidental durotomy during first-time lumbar laminectomy for spinal stenosis did not impact long-term outcomes in affected patients.
Neurosurgery 02/2011; 69(1):38-44; discussion 44. · 2.79 Impact Factor
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ABSTRACT: As-treated analysis of the Spine Patient Outcomes Research Trial.
To compare baseline characteristics and surgical and nonoperative outcomes in degenerative spondylolisthesis (DS) and spinal stenosis (SpS) patients stratified by predominant pain location (i.e., leg vs. back).
Evidence suggests that DS and SpS patients with predominant leg pain may have better surgical outcomes than patients with predominant low back pain (LBP).
The DS cohort included 591 patients (62% underwent surgery), and the SpS cohort included 615 patients (62% underwent surgery). Patients were classified as leg pain predominant, LBP predominant, or having equal pain according to baseline pain scores. Baseline characteristics were compared between the 3 predominant pain location groups within each diagnostic category, and changes in surgical and nonoperative outcome scores were compared for 2 years. Longitudinal regression models including baseline covariates were used to control for confounders.
Among DS patients at baseline, 34% had predominant leg pain, 26% had predominant LBP, and 40% had equal pain. Similarly, 32% of SpS patients had predominant leg pain, 26% had predominant LBP, and 42% had equal pain. DS and SpS patients with predominant leg pain had baseline scores indicative of less severe symptoms. Leg pain predominant DS and SpS patients treated surgically improved significantly more than LBP predominant patients on all primary outcome measures at 1 and 2 years. Surgical outcomes for the equal pain groups were intermediate to those of the predominant leg pain and LBP groups. The differences in nonoperative outcomes were less consistent. Conclusion. Predominant leg pain patients improved significantly more with surgery than predominant LBP patients. However, predominant LBP patients still improved significantly more with surgery than with nonoperative treatment.
Spine 02/2011; 36(3):219-29. · 2.08 Impact Factor
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ABSTRACT: Comparison of intra- and interobserver reliability of digitized manual and computer-assisted intervertebral motion measurements and classification of "instability."
To determine if computer-assisted measurement of lumbar intervertebral motion on flexion-extension radiographs improves reliability compared with digitized manual measurements.
Many studies have questioned the reliability of manual intervertebral measurements, although few have compared the reliability of computer-assisted and manual measurements on lumbar flexion-extension radiographs.
Intervertebral rotation, anterior-posterior (AP) translation, and change in anterior and posterior disc height were measured with a digitized manual technique by three physicians and by three other observers using computer-assisted quantitative motion analysis (QMA) software. Each observer measured 30 sets of digital flexion-extension radiographs (L1-S1) twice. Shrout-Fleiss intraclass correlation coefficients for intra- and interobserver reliabilities were computed. The stability of each level was also classified (instability defined as >4 mm AP translation or 10° rotation), and the intra- and interobserver reliabilities of the two methods were compared using adjusted percent agreement (APA).
Intraobserver reliability intraclass correlation coefficients were substantially higher for the QMA technique THAN the digitized manual technique across all measurements: rotation 0.997 versus 0.870, AP translation 0.959 versus 0.557, change in anterior disc height 0.962 versus 0.770, and change in posterior disc height 0.951 versus 0.283. The same pattern was observed for interobserver reliability (rotation 0.962 vs. 0.693, AP translation 0.862 vs. 0.151, change in anterior disc height 0.862 vs. 0.373, and change in posterior disc height 0.730 vs. 0.300). The QMA technique was also more reliable for the classification of "instability." Intraobserver APAs ranged from 87 to 97% for QMA versus 60% to 73% for digitized manual measurements, while interobserver APAs ranged from 91% to 96% for QMA versus 57% to 63% for digitized manual measurements.
The use of QMA software substantially improved the reliability of lumbar intervertebral measurements and the classification of instability based on flexion-extension radiographs.
Spine 01/2011; 36(7):572-80. · 2.08 Impact Factor
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Spine Journal Meeting Abstracts. 09/2010;
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ABSTRACT: As-treated analysis of the Spine Patient Outcomes Research Trial.
To compare baseline characteristics and surgical and nonoperative outcomes between degenerative spondylolisthesis (DS) and spinal stenosis (SPS) patients.
DS and SPS patients are often combined in clinical studies despite differences in underlying pathology and treatment.
The DS cohort included 601 patients (369 [61%] underwent surgery), and the SPS cohort included 634 patients (394 [62%] underwent surgery). Baseline characteristics were compared between the 2 groups. Changes from baseline for surgical and nonoperative outcomes were compared at 1 and 2 years using longitudinal regression models. Primary outcome measures included the SF-36 bodily pain and physical function scores and the Oswestry Disability Index.
The DS patients included more females (69% vs. 39%, P < 0.001), were older (66.1 year vs. 64.6 years, P = 0.021), and were less likely to have multilevel stenosis (35% vs. 61%, P < 0.001) compared with the SPS patients. There were no significant baseline differences on any of the main outcome measures. DS patients undergoing surgery were much more likely to be fused than SPS patients (94% vs. 11%, P < 0.001) and improved more with surgery than SPS patients on all primary outcome measures (DS vs. SPS): physical function (+30.4 vs. +25.3, P = 0.004 at 1 year; + 28.3 vs. +21.4, P < 0.001 at 2 years), bodily pain (+32.3 vs. +27.5, P = 0.006 at 1 year; +31.1 vs. +26.1, P = 0.003 at 2 years), and Oswestry Disability Index (-25.9 vs. -21.0, P < 0.001 at 1 year; -24.7 vs. -20.2, P < 0.001 at 2 years). Patients treated nonoperatively improved less than those treated surgically, and there were no significant differences in nonoperative outcomes between the 2 cohorts.
Overall, DS and SPS patients had similar baseline characteristics. However, DS patients improved more with surgery than SPS patients. Future studies should probably not combine these heterogeneous patient populations.
Spine 02/2010; 35(3):298-305. · 2.08 Impact Factor
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William A Abdu, Jon D Lurie,
Kevin F Spratt,
Anna N A Tosteson,
Wenyan Zhao,
Tor D Tosteson,
Harry Herkowitz,
Michael Longely,
Scott D Boden,
Sanford Emery,
James N Weinstein
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ABSTRACT: Clinical trial subgroup analysis.
To compare outcomes of different fusion techniques treating degenerative spondylolisthesis (DS). Summary of Background Data. Surgery has been shown to be more effective than nonoperative treatment out to 4 years. Questions remain regarding the differential effect of fusion technique.
Surgical candidates from 13 centers in 11 states with at least 12 weeks of symptoms and confirmatory imaging showing stenosis and DS were studied. In addition to standard decompressive laminectomy, 1 of 3 fusion techniques was employed at the surgeon's discretion: posterolateral in situ fusion (PLF); posterolateral instrumented fusion with pedicle screws (PPS); or PPS plus interbody fusion (360 degrees). Main outcome measures were the SF-36 bodily pain (BP) and physical function (PF) scales and the modified Oswestry Disability Index (ODI) assessed at 6 weeks, 3 months, 6 months, and yearly to 4 years. The as-treated analysis combined the randomized and observational cohorts using mixed longitudinal models adjusting for potential confounders.
Of 380 surgical patients, 21% (N = 80) received a PLF; 56% (N = 213) received a PPS; 17% (N = 63) received a 360 degrees; and 6% (N = 23) had decompression only without fusion. Early outcomes varied, favoring PLF compared to PPS at 6 weeks (PF: 12.73 vs. 6.22, P < 0.020) and 3 months (PF: 25.24 vs.18.95, P < 0.025) and PPS compared to 360 degrees at 6 weeks (ODI: -14.46 vs. -9.30, P < 0.03) and 3 months (ODI: -22.30 vs. -16.78, P < 0.02). At 2 years, 360 degrees had better outcomes: BP: 39.08 versus 29.17 PLF, P < 0.011; and versus 29.13 PPS, P < 0.002; PF: 31.93 versus 23.27 PLF, P < 0.021; and versus 25.29 PPS, P < 0.036. However, these differences were not maintained at 3- and 4-year follow-up, when there were no statistically significant differences between the 3 fusion groups.
In patients with DS and associated spinal stenosis, no consistent differences in clinical outcomes were seen among fusion groups over 4 years.
Spine 09/2009; 34(21):2351-60. · 2.08 Impact Factor
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ABSTRACT: Distal radial fractures are common and confer a considerable financial burden on the health-care system; however, controversy surrounds the optimal treatment of these injuries. This study was performed to determine (1) the rate of distal radial fractures in the U.S. Medicare population stratified by hospital referral region and (2) whether the type of fracture treatment is affected by patient age, race, sex, comorbidity, or hospital referral region.
A 20% sample of Medicare Part-B claims from the years 1998 through 2004 was analyzed. Procedural codes for nonoperative treatment, percutaneous fixation, and open reduction and internal fixation of distal radial fractures were identified. These codes were then used to determine the overall rate of distal radial fracture. The rates of distal radial fracture were then evaluated according to hospital referral region and patient age, sex, comorbidity, and race. The types of treatment were determined and were also analyzed on the basis of hospital referral region and patient age, sex, comorbidity, and race. Regression analysis was performed with use of the above variables.
We identified 107,190 patients. The rate of distal radial fracture was 125 per 10,000 Medicare beneficiaries. The rate of the fracture in white individuals (136 per 10,000) was more than twice that in non-white individuals (fifty-nine per 10,000), and the rate in women (189 per 10,000) was 4.8 times higher than that in men (thirty-nine per 10,000). The overall fracture rate varied widely across the United States, from forty-seven per 10,000 beneficiaries in New Orleans, Louisiana, to 220 per 10,000 in Spartanburg, South Carolina. Treatment rates were similar across race, with the rate of nonoperative treatment being 84% for white beneficiaries compared with 83% for non-white beneficiaries, the rate of percutaneous fixation being 11% for white beneficiaries compared with 10% for non-white beneficiaries, and the rate of open treatment being 6% for white beneficiaries compared with 7% for non-white beneficiaries. There was variation across the country, with the rate of nonoperative treatment ranging from 60% in San Luis Obispo, California, to 96% in Covington, Kentucky; the rate of percutaneous fixation ranging from 2% in Boulder, Colorado, to 39% in San Luis Obispo, California; and the rate of open treatment ranging from 0.4% in Wilkes-Barre, Pennsylvania, to 25% in Great Falls, Montana. While the rates of percutaneous fixation and nonoperative treatment remained relatively stable, the overall rate of operative fixation nearly doubled from 5% in 1998 to 8% in 2004.
There is wide variation in the rate of distal radial fractures across sex, age, race, and geographic region in the United States. There is also significant variation in the treatment of these fractures, driven mainly by age and region. Between 1998 and 2004, a strong trend toward more frequent operative fixation was apparent. While white individuals had more than twice as many fractures as did non-white individuals, there did not appear to be significant racial variation in the treatment of this injury.
The Journal of Bone and Joint Surgery 07/2009; 91(6):1313-9. · 3.27 Impact Factor
