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ABSTRACT: BACKGROUND CONTEXT: The Thoracolumbar Injury Classification System (TLICS) system has been developed to improve injury classification and guide surgical decision-making, yet validation of this new system remains sparse. PURPOSE: This study evaluates the use of the TLICS in a large, consecutive series of patients. STUDY DESIGN/SETTING: This is a retrospective case series. PATIENT SAMPLE: A total of 458 patients treated for thoracic or lumbar spine trauma between 2000 and 2010 at a single, tertiary medical center were included in this study. OUTCOME MEASURES: American Spinal Injury Association (ASIA) status and crossover from conservative to surgical treatment were measured. METHODS: Clinical and radiological data were evaluated, classifying the injuries by ASIA status, the Magerl/AO classification, and the TLICS system. RESULTS: A total of 310 patients (67.6%) was treated conservatively (group 1) and 148 patients (32.3%) were surgically (group 2) treated. All patients in group 1 were ASIA E, except one (ASIA C). In this group, 305 patients (98%) had an AO type A fracture. The TLICS score ranged from 1 to 7 (mean 1.53, median 1). A total of 307/310 (99%) patients matched TLICS treatment recommendation (TLICS≤4), except three with distractive injuries (TLICS 7) initially misdiagnosed. Nine patients (2.9%) were converted to surgical management. In group 2, 105 (70.9%) were ASIA E, whereas 43 (29%) had neurological deficits (ASIA A-D). One hundred and three patients (69.5%) were classified as AO type A, 36 (24.3%) as type B, and 9 (6%) as type C. The TLICS score ranged from 2 to 10 (mean 4.29, median of 2). Sixty-nine patients (46.6%) matched the TLICS recommendation; all discordant patients (53.4%) were treated for stable burst fractures (TLICS=2). No neurological complications occurred in either group. CONCLUSIONS: The TLICS recommendation matched treatment in 307/310 patients (99%) in the conservative group. However, in the surgical group, 53.4% of patients did not match TLICS recommendations, all were burst fractures without neurological injury (TLICS=2). The TLICS system can be used to effectively classify thoracolumbar injuries and guide conservative treatment. Inconsistencies, however, remain in the treatment thoracolumbar burst fractures.
The spine journal: official journal of the North American Spine Society 04/2013; · 2.90 Impact Factor
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ABSTRACT: Lumbar spinal stenosis affects many patients and is one of the most common reasons for spinal surgery in the elderly population. New research and surgical innovations have resulted in a better understanding of the disease and its diagnosis and treatment. To select the optimal treatment approach for each patient, it is helpful to review patient presentations, diagnostic workups, surgical and nonsurgical treatment options, evidence-based outcomes, and the pathophysiology of lumbar spinal stenosis.
Instructional course lectures 01/2013; 62:383-96.
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Journal of neurosurgery. Spine 12/2012; · 1.61 Impact Factor
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ABSTRACT: PURPOSE: The diagnostic assessment and prognostic value of the posterior ligamentous complex (PLC) remains a controversial topic in the management of patients with thoracolumbar spinal injury. The purpose of this review was to critically appraise the literature and present an overview of the: (1) precision, (2) accuracy, and (3) validity of detecting PLC injuries in patients with thoracic and lumbar spine trauma. METHODS: Studies evaluating the precision, accuracy and/or validity of detecting and managing PLC injuries in patients with thoracic and/or lumbar spine injuries were searched through the Medline database (1966 to September 2011). References were retrieved and evaluated individually and independently by two authors. RESULTS: Twenty-one eligible studies were identified. Few studies reported the use of countermeasures for sampling and measurement bias. In nine agreement studies, the PLC was assessed in various ways, ranging from use of booklets to a complete set of diagnostic imaging. Inter-rater and intra-rater kappa values ranged from 0.188 to 0.915 and 0.455 to 0.840, respectively. In nine accuracy studies, magnetic resonance (MR) imaging was most often (n = 6) compared with intra-operative findings. In general, MR imaging tended to demonstrate relatively high negative predictive values and relatively low positive predictive values for PLC injuries. CONCLUSIONS: A wide variety of methods have been applied in the evaluation of precision and accuracy of PLC injury detection, leaving spinal surgeons with a multitude of variable results. There is scant clinical evidence demonstrating the true prognostic value of detected PLC injuries in patients with thoracic and lumbar spine injuries. We recommend the conduct of longitudinal clinical follow-up studies on those cases assessed for precision and/or accuracy of PLC injuries.
European Spine Journal 12/2012; · 1.97 Impact Factor
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ABSTRACT: BACKGROUND CONTEXT: Surgical treatment of intracanal (both intramedullary and extramedullary) spine lesions requires posterior decompressive techniques in nearly all instances. Postoperative spinal deformities, most notably sagittal and coronal decompensation, are of significant concern for both the patient and the spinal surgeon. PURPOSE: To review and define principles and features of spinal deformities after posterior spinal decompression for intracanal spinal lesions, and to define patients who may benefit from the concomitant spinal fusion. METHODS: A systematic review of MEDLINE was conducted, including articles published between 1980 and 2011. Articles related to spinal deformities after posterior decompression for the treatment of intracanal spine lesions were identified. RESULTS: Ten articles met all inclusion and exclusion criteria. All were case series with limited evidence (Level IV). Many risk factors to deformity were implied but with limited evidence. Young age was the most commonly identified risk in these articles. CONCLUSIONS: Spinal deformity after posterior decompression is a common complication, most notably in children and young adults, after the removal of intramedullary tumors. Many risk factors have been implied to increase the postoperative development of spinal deformity, including young age, laminectomy extension, preoperative deformity, and extensive facet resection, among others. However, there is a lack of high-quality evidence to propose an algorithm for treatment or preventive measures. New studies with larger series of patients and standardized clinical outcomes are necessary to establish optimal treatment protocols.
The spine journal: official journal of the North American Spine Society 10/2012; · 2.90 Impact Factor
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ABSTRACT: STUDY DESIGN:: An in vitro biomechanical study of the cervical spine. OBJECTIVE:: To evaluate the biomechanical significance of the posterior longitudinal ligament (PLL) following anterior cervical corpectomy and reconstruction with a strut graft and anterior plate. SUMMARY OF BACKGROUND DATA:: Routine excision of the PLL during anterior cervical corpectomy is controversial. Many surgeons believe that maintaining the PLL following cervical corpectomy adds stability to the reconstruction, while others believe it can be excised without sequelae. There are no biomechanical studies to our knowledge evaluating the biomechanical significance of excising the PLL during corpectomy and whether this affects the stability of a reconstruction consisting of a strut graft and anterior plate. The purpose of this study was to evaluate the biomechanical effects of PLL excision during a complete anterior cervical corpectomy reconstructed with a strut graft and anterior plate. METHODS:: Seven human cadaveric fresh-frozen cervical spines C2-T1 were tested for range of motion before surgery and reconstruction. A complete C6 corpectomy was performed and an interbody strut spacer with load cell was placed along with an anterior plate. Range of motion was measured with ±2.5 Nm of torque in flexion-extension, lateral bending, and axial rotation. Load-sharing data were recorded with incremental axial loads. The PLL was excised and range of motion and load sharing testing was repeated. RESULTS:: There were no significant differences in range of motion or load sharing with an anterior corpectomy and reconstruction following PLL excision. CONCLUSIONS:: Excision of the PLL during anterior cervical corpectomy reconstructed with a strut graft and anterior plate does not significantly affect the construct stability or load-sharing of the graft.
Journal of spinal disorders & techniques 10/2012; · 1.21 Impact Factor
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ABSTRACT: Retrospective case series.
To analyze the causes of conversion to open for the surgical treatment of lumbar disc herniation with use of full endoscopic (FE) technique, and prophylaxis of conversion to open also proposed.
50 patients with lumbar disc herniation underwent discectomy using unilateral portal FE interlaminar approach collected from August 2008 to August 2010. All FE operations were performed under general anesthesia and endotracheal intubation. According to the level incision of the ligament flavum, the starting point of nerve root at the dura under endoscopic view was classified as: Type I (starting point of the nerve root was higher than the incision) and Type II (the starting point of nerve root was lower than the incision). The causes and effective prophylactic measurements for cases of conversion to open were analyzed.
There were 47 cases classified as Type I for a rate of 94 %, and Type II in 3 cases for a rate of 6 %. Five cases were converted to open surgery, and the conversion rate was 10 %. There were three males and two females with a mean age of 36.2 (29-44) years, the average duration of symptoms was 58.4 (35-105) days. The level was L5-S1 in four cases and L4-5 in one, lateral extrusion in three cases, paracentral extrusion in one, and sequestration in one. Leg pain resolved in three cases and improved in two after open surgery. Of five cases of conversion to open, misplacement of the working portal occurred in one case (Type I). Difficult dissection of nerve root and hemostasis resulting in open conversion occurred in one case (Type II); this patient sustained a dural injury. The nerve root could not be exposed in three cases (Type II), the FE changed to open finally. During the open procedure with Type II, we found that the location of origin of the nerve root was caudal to the inferior laminar edge. Therefore, partial removal of bony structures along lateral recess was necessary in order to visualize the nerve root.
Misplacement of working portal during the exposure of the ligament flavum and difficulty in indentifying anatomy are potential causes for conversion to open in the initial adoption of FE technique. However, uncommon conditions such as variation of the nerve root origin can also result in conversion to open in experienced hands. Endoscopic experience, proper patient selection and specific radiographic examination are needed to obtain optimal outcomes using a full endoscopic technique for microdiscectomies.
Archives of Orthopaedic and Trauma Surgery 07/2012; 132(11):1531-8. · 1.37 Impact Factor
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ABSTRACT: Vitamin D is an important component in musculoskeletal development, maintenance, and function. Adequate levels of vitamin D correlate with greater bone mineral density, lower rates of osteoporotic fractures, and improved neuromuscular function. Debate exists about both adequate levels required and intake requirements needed to prevent deficiency of vitamin D. Epidemiologic data have identified an increasing number of orthopaedic patients at risk for vitamin D deficiency, with potentially widespread consequences for bone healing, risk of fracture, and neuromuscular function.
The Journal of the American Academy of Orthopaedic Surgeons 03/2012; 20(3):123-9. · 2.66 Impact Factor
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ABSTRACT: We started this journey excited by the prospects of visiting Japan, a country with a proud and historic past. We ended the fellowship accomplishing those goals, and we left with a great deal of admiration for our orthopaedic colleagues halfway around the world for their excellence in education, clinical care, and research. Their hospitality and attention to the details of our visit were exemplary and a lesson to us as we host visiting fellows in the future. Japan reflects its past, but it also offers a preview into our own nation's future: an aging population, a shrinking workforce, a stagnant economy, nationalized health care, and a mushrooming national debt. Of all of these factors, it is the aging population that we, as orthopaedic surgeons, will be most acutely aware of and involved with. The degenerative disorders that affect elderly patients dominate the landscape of surgical care in Japan. Osteoporosis and osteopenia permeate many aspects of care across orthopaedic subspecialties. The surgeons in Japan are developing innovative and cost-effective means of treating the large volume of older patients within the fiscal constraints of a nationalized health-care system. We learned, and will continue to learn more, from Japan about the management of this growing patient population with its unique pathologies and challenges. With the recent natural disaster and ongoing safety concerns in Japan, the character and will of the people of Japan have been on display. Their courage and resolve combined with order and compassion are a testament to the nation's cultural identity. The seeds of the Traveling Fellowship were planted shortly after Japan's last wide-scale reconstruction, and the ties that have bound the JOA and the AOA together are strengthened through this trying time. We strongly urge our colleagues in the U.S. to help support the people, the physicians, and the health-care system of Japan through its most recent tribulations and offer them the same care and hospitality that we were shown during our fellowship. Japan is an open and friendly nation, and we encourage anyone interested to seek out opportunities to visit or work with our orthopaedic colleagues there. We are grateful to our hosts at each institution as well as to the JOA and AOA organizations for continuing this wonderful tradition. This exchange is now entering its twentieth year. It remains a “trip of a lifetime” for those fortunate enough to be selected. For us, as for many who have participated before us, it will shape our careers in the years to come.
The Journal of Bone and Joint Surgery 12/2011; 93(24):e150. · 3.27 Impact Factor
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ABSTRACT: The veteran population presents a unique confluence of biopsychosocial factors in the treatment of spinal conditions. In addition to poorer health status and higher numbers of chronic medical conditions compared with the general population, previous reports have highlighted the high prevalence of psychological disorders within the Department of Veterans Affairs (VA) health system. To our knowledge, no study has specifically evaluated psychological distress in patients with a spinal disorder within the VA health system.
To determine the prevalence of psychological distress among spine patients in a VA hospital and if higher levels of distress correlated with patient demographics and self-reported patient outcome scores.
Cross-sectional evaluation of adult patients at a regional VA outpatient orthopedic spine surgery clinic.
One hundred forty-nine adult patients presenting for treatment of spine-related disorders.
Patients were evaluated using the Distress and Risk Assessment Method (DRAM), a validated survey consisting of the Zung Depression Scale and the Modified Somatic Perception Questionnaire. In addition, self-reported pain, disability, and quality of life were assessed using the visual analog scale (VAS) for neck or back pain and the Neck Disability Index or Oswestry Disability Index (ODI) depending on the patient's location of pain.
The DRAM survey was used to determine the prevalence of psychological distress by classifying patients into normal, at-risk, and severe distress groups. Visual analog scale scores for neck and back pain, and self-reported disability scores, and demographic data including age, gender, combat experience, and use of antidepressant, anxiolytic, or narcotic medications were obtained at the time of enrollment.
The DRAM survey identified 79.9% of patients as having some degree of psychological distress, whereas the remaining 20.1% were classified as normal. Among those with psychological distress, 43.6% of patients were categorized as severe distress. Compared with the normal group, a history of combat was more frequent in all distressed patient groups including the at-risk (p=.04) and severe distress (p=.009) groups. Those in the severe distress category more commonly reported the use of narcotics (p=.043) and antidepressant/anxiolytics medications (p=.0001). Those in the severe distress group had significantly higher ODI scores (p<.0001) and back pain VAS scores (p=.0360) compared with the normal group.
We identified a large number of patients (80%) with some level of psychological distress and 43% with severe distress. The percent of patients with severe psychological distress in the VA was double that previously reported in a non-VA patient setting. Patients with severe distress had higher ODI scores, back pain VAS scores, use of narcotics and antidepressants, and a reported history of combat when compared with those without distress.
The spine journal: official journal of the North American Spine Society 11/2011; 12(9):798-803. · 2.90 Impact Factor
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Spine 11/2011; 37(1):E3-9. · 2.08 Impact Factor
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ABSTRACT: Study design: Systematic review.Study rationale: While magnetic resonance imaging (MRI) is used as the diagnostic gold standard for cauda equina syndrome (CES), many MRI scans obtained from patients presenting with signs and/or symptoms of CES do not reveal concordant pathology. As a result, the role of the history and physical examination remains unclear when determining which patients require emergent MRI.Objective or clinical question: Are there elements from the history or physical examination that are associated with CES as established by MRI?Methods: A systematic review of the literature was undertaken for articles published through April 13, 2011. PubMed, Cochrane, National Guideline Clearinghouse Databases, and bibliographies of key articles were searched. Two independent reviewers reviewed articles. Inclusion and exclusion criteria were set and each article was subject to a predefined quality-rating scheme.Results: We identified four articles meeting our inclusion criteria. All studies evaluated patients with symptoms suggestive of CES and compared symptoms and/or signs with findings at MRI. The mean prevalence of CES as diagnosed by MRI ranged from 14%-48% of patients. No symptoms or signs reported by more than one study showed high sensitivity and specificity, and all likelihood ratios were low. Symptoms included back/low back pain, bilateral sciatica, bladder retention, bladder incontinence, frequent urination, decreased urinary sensation, and bowel incontinence; signs included saddle numbness and reduced anal tone.Conclusions: There is low evidence that individual symptoms or signs from the patient history or clinical examination, respectively, can be used to diagnose CES. Additional prospective studies are needed to evaluate whether any single and/or combination of symptoms are associated with a positive diagnosis of CES.
Evidence-based spine-care journal. 11/2011; 2(4):27-33.
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ABSTRACT: The lateral transpsoas approach to the lumbar spine was developed to eliminate the need for an anterior-approach surgeon and retraction of the great vessels and has the potential for shorter operative times. However, the reported complications associated with this approach vary.
We identified the incidence of complications associated with the lateral transpsoas approach to the lumbar spine.
We retrospectively reviewed 45 patients who underwent a lateral transpsoas approach to the spine for various diagnoses between January 1, 2006, and October 31, 2010. The patients' average age was 63.3 years. Sixteen (35.6%) patients had prior lumbar spinal surgery. Twenty-one patients (46.7%) underwent supplemental posterior instrumentation. Minimum followup was 0 months (mean, 11 months; range, 0-34 months).
Eighteen of the 45 patients (40%) had complications: 10 (22.2%) developed postoperative iliopsoas weakness, three had quadriceps weakness, and one experienced foot drop. Eight patients (17.8%) developed anterior thigh hypoesthesia, which did not fully resolve in seven of the eight patients at an average of 9 months' followup. Three patients had postoperative radiculopathies, one a durotomy, and one died postoperatively from a pulmonary embolism.
We found a 40% incidence of complications and a nontrivial frequency and severity of postoperative weakness, numbness, and radicular pain in patients who underwent a lateral transpsoas approach to the spine. Given the expanding use of the approach, a thorough understanding of the risks associated with it is essential for patient education, medical decision making, and identifying methods of reducing such complications.
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 09/2011; 470(6):1621-32. · 2.53 Impact Factor
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Spine 06/2011; 36(14):E895-6. · 2.08 Impact Factor
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Spine 06/2011; 36(14):E897-903. · 2.08 Impact Factor
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ABSTRACT: Independent review and classification of therapeutic procedures performed on cadavers by surgeons blinded to purpose of study.
The objective of this study is to determine the rate of facet violation with the placement of percutaneous pedicle screws.
Improvements in percutaneous instrumentation and fluoroscopic imaging have led to a resurgence of percutaneous pedicle screw insertion in lumbar spine surgery in an attempt to minimize many of the complications associated with open techniques of pedicle screw placement. Rates of pedicle breech and neurologic injury resulting from percutaneous insertion are reportedly similar to those of open techniques. Postoperative pain because of impingement and instability is believed to result from violation of the facet capsule or facet joint. To the authors' knowledge, however, the rate of facet injury associated with the placement of percutaneous pedicle screws is unreported in the literature.
Percutaneous pedicle screw placement was performed on 4 cadaveric specimens by 4 certified orthopedic surgeons who had clinical experience in the procedure and who were blinded to the study's purpose. The surgeons were instructed to place pedicle screws from L1-S1 using their preferred clinical techniques and a 5.5-mm screw system with which they were all familiar. All surgeons utilized 1 OEC C-arm for fluoroscopic imaging. After insertion, 2 independent spine surgeons each reviewed and classified the placement of all facet screws.
A total of 48 screws were inserted and classified. The placement of 28 screws (58%) resulted in violation of facet articulation, with 8 of these screws being intra-articular. Interobserver reliability of the classification system was 100%.
Percutaneous pedicle screw placement may result in a high rate of facet violation. Facet injury can be reliability classified and therefore, perhaps, easily prevented.
Spine 05/2011; 36(26):E1749-52. · 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: Fractures and dislocations of the subaxial cervical spine may give rise to devastating consequences. Previous algorithms for describing cervical trauma largely depend on retrospective reconstructions of injury mechanism and utilize nonspecific terminology which thus diminish their clinical relevance add to the difficulty of educating doctors and performing prospective research.
We characterized the potential benefits of the Subaxial Injury Classification (SLIC) scale which considers three major variables that influence spinal stability: morphology, integrity of the discoligamentous complex, and neurologic status. Each category was assigned a certain number of points based on the severity of the injury which are added together to generate a total score; this value provides prognostic information and may also be useful for directing subsequent management (ie, nonoperative treatment versus operative intervention).
We examined the individual components that comprise the SLIC paradigm and reviewed the manner in which cervical injuries are scored and stratified. We also critically assessed the preliminary data comparing the SLIC scheme to preexisting classification systems.
The results of a preliminary analysis demonstrate that the intraclass coefficients (ICC) for the three primary components range between 0.49 and 0.90, suggesting that the overall reliability of the SLIC system appears to be at least as good as that of other conventional schemes for classifying subaxial cervical spine trauma (ICC between 0.41 and 0.53).
This scheme will hopefully facilitate the development of evidence-based guidelines that may influence other aspects of the therapeutic decision-making process (eg, which operative approach is most appropriate for a particular injury). We anticipate its accuracy and reproducibility will increase over time as surgeons become more familiar with the protocol.
Clinical Orthopaedics and Related Research 03/2011; 469(3):723-31. · 2.53 Impact Factor
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ABSTRACT: Compared with conventional microsurgical technique, the full endoscopic (FE) interlaminar approach is a more minimally invasive technique for the surgical treatment of lumbar disc herniations. Its efficacy and safety have been confirmed by numerous studies. However, a steep learning curve with the use of such a complex technique is a major concern for the initial adoption of this technique.
To evaluate the learning curve of using an FE interlaminar technique for the surgical treatment of lumbar disc herniation.
A prospective study of patients with lumbar disc herniation who underwent discectomy via interlaminar approach assisted by FE instruments.
Thirty patients with lumbar disc herniation underwent discectomy using an interlaminar endoscopic-only approach between 2008 and 2009.
The patients were divided into three groups of 10 sequential cases each. Group A consisted of the first 10 cases, Group B the subsequent 10 cases, and Group C the last 10 cases. The clinical evaluation data included operative time, length of hospital stay, visual analog scale (VAS) leg and back pain scores, complications, and rate of conversion to an open.
All patients were observed prospectively for 1.61 ± 0.22 years (range, 1.2-2.0 years). There was no measurable intraoperative bleeding and postoperative infections in the three groups. Compared with Group A, the operative time in Group B was significantly decreased (p < .001). The patients in Group C had much less operative time than in Group B (p = .002). There was no significant difference with length of hospital stay in the three groups (p = .897). The improvement of VAS leg and back pain scores in each group was similar: there was a significant improvement (p < .01) at 3 months after surgery when compared with preoperative scores, but there was no statistical difference (p > .05) in the VAS leg and back pain scores between 3 months after surgery and final follow-up. The complication rate was 12.5% for Group A, 10% for Group B, and 0% for Group C. The need for conversion to an open procedure for Group A was 20% compared with zero cases in both Groups B and C. There were no symptomatic recurrences in our study.
Excellent clinical and minimally invasive outcomes can be obtained in the surgical treatment of lumbar disc herniation via the interlaminar approach assisted by FE technique. However, attention must be paid to the steep learning curve by using this complex technique. Imprecise anatomic orientation and manipulation inside the spinal canal are key factors in the steep learning curve. Obtaining microsurgical experience, attending workshops, and suitable patient selection can help shorten the learning curve and decrease the complications.
The spine journal: official journal of the North American Spine Society 02/2011; 11(2):122-30. · 2.90 Impact Factor
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ABSTRACT: A genetic predisposition for the development of symptomatic lumbar disc disease has been suggested by several twin sibling studies and subsequent genetic marker studies. The purpose of the present study was to define population-based familial clustering among individuals with a diagnosis of, or treated for, lumbar disc herniation or disc degeneration.
The Utah Population Database allows analysis of combined health and genealogic data for over one million Utah residents. We used the International Classification of Diseases, Ninth Revision, diagnosis codes entered in patient records to identify patients with a diagnosis of either lumbar disc herniation or lumbar disc degeneration and genealogic data. The hypothesis of excess relatedness (familial clustering) was tested with use of the Genealogical Index of Familiality, which compares the average relatedness of affected individuals with expected population relatedness. Relative risks in relatives were estimated by comparing rates of disease in relatives with expected population rates (estimated from the relatives of matched controls). This methodology has been previously reported for other disease conditions but not for spinal diseases.
The Genealogical Index of Familiality test for 1264 patients with lumbar disc disease showed a significant excess relatedness (p < 0.001). Relative risk in relatives was significantly elevated in both first-degree (relative risk, 4.15; p < 0.001) and third-degree relatives (relative risk, 1.46; p = 0.027).
Excess relatedness of affected individuals and elevated risks to both near and distant relatives was observed, strongly supporting a heritable contribution to the development of symptomatic lumbar disc disease.
The Journal of Bone and Joint Surgery 02/2011; 93(3):225-9. · 3.27 Impact Factor
