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ABSTRACT: STUDY DESIGN:: Retrospective analysis of a prospective cohort. OBJECTIVE:: Change in cervical angular alignment may be associated with dysphagia. SUMMARY OF BACKGROUND DATA:: Bony deformities of the cervical spine may be associated with secondary contractures in soft tissues in the neck. Acute surgical deformity correction result in changes in soft tissue tension in the anterior neck, resulting in dysphagia. METHODS:: The study population included patients undergoing one and two level elective anterior cervical discectomy and fusion for cervical myelopathy or radiculopathy. Preoperative and postoperative radiographs at two weeks were measured by a blinded observer for c2-c7 endplate angle, c2-c7 posterior vertebral body length, and occipital condyle plumb line distance on upright lateral radiographs at 2, 6, and 12 weeks postoperatively. Patients were prospectively queried about dysphagia incidence and severity using a numeric rating scale. Multiple linear regression analysis was used to determine the effect of change in radiographic parameters controlling for demographic characteristics. RESULTS:: The study population included 25 patients with complete radiographs. The mean change in C2-C7 angle was -0.6 degrees (Standard Deviation (SD) 9), the mean change in C2-C7 length was 1.7 mm (SD 26), the mean change in occipital condyle plumb line distance was 2,3 mm (SD 20).Mulitple linear regression analysis was performed including operative time, age, gender, number of levels, and change in radiographic parameters as independent variables and using dysphagia score as the dependent variable. The change in C2-C7 angle and operative time were the only statistically significant predictors of change in dysphagia score at 2 and 6 weeks postoperatively. CONCLUSION:: These results indicate that lordotic change in spinal alignment and longer operative time are associated with increased postoperative dysphagia. Surgeons should counsel patients in whom a large angular correction is expected about the possibility for postoperative dysphagia. Furthermore, future studies on dysphagia incidence should include radiographic alignment as an independent predictor of dysphagia.
Journal of spinal disorders & techniques 03/2013; · 1.21 Impact Factor
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ABSTRACT: Study Design. Retrospective institutional database review.Objective. To determine whether preoperative in-room time is a risk factor for surgical site infection (SSI).Summary and Background Data. Prior to spine surgery, while the patient is in the operating room, several procedures that may be performed that may delay surgery. During this time, the sterile field may be exposed and may become contaminated. Preoperative in-room delay may increase risk of SSI however, the probable association has not yet been investigated.Methods. From 2005 to 2009, we identified 276 patients who developed SSI out of 7991 cases underwent spine surgery from 2005 to 2009.Patient demographic factors, ASA score, wound classification, number of levels, anatomic region, type of surgical approach and length of surgery were extrapolated. Preoperative time was calculated as the time after the patient was brought into the operating room prior to surgical incision. Multivariate analysis was performed to identify risk factors for SSI.Results. Mean preoperative time was significantly (p = 0.001) higher in patients with infection (68 minutes) compared to those without infection (60 minutes). The infection rate was higher in cases with preoperative in-room time > 1 hour compared to those < 1 hour (4.9% vs. 2.3%, p = 0.001). Preoperative delay > 1 hour was an independent risk factor for SSI, along with number of levels, ASA score and posterior approach. The highest percentage of cases with preoperative in-room time > 1 hour occurred in August and September.Conclusion. Preoperative in-room time prior to the start of surgical incision is an independent risk factor for SSI. All possible steps should be taken prior to entry into the operating theater to reduce in-room time and opening of surgical sterile instrumentation be delayed until the surgery is ready to proceed.
Spine 03/2013; · 2.08 Impact Factor
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ABSTRACT: Study Design. Prospective comparative studyObjective. To determine whether patients undergoing posterior cervical surgery will experience dysphagia post-operatively when compared to anterior cervical and lumbar control groups.Summary of Background Data. Dysphagia is a common complication after ACDF. However, current literature is scarce whether dysphagia occurs as a direct result of the anterior approach (dissection or instrumentation) or because of cervical spine surgery itself.Methods. Patients undergoing posterior cervical surgery were prospectively followed for dysphagia up to 6 months following surgery. Patients were evaluated for dysphagia preoperatively, at 2-weeks and 6-weeks postoperatively using the dysphagia numeric rating scale. The data was compared to a previously published cohort of anterior cervical and lumbar surgeries from the same institution. Statistical significance was evaluated using Fisher's exact testResults. Eighty five patients were included who underwent posterior cervical surgery. Baseline dysphagia was present in 11% (10/85) of patients. The incidence of new dysphagia was 10/85 (11%) at 2 weeks, 8/85 (8%) at 6 weeks, 13/85 (13%) at 12 weeks, and 5/85 (6%) at 24 weeks. The incidence of new dysphagia was significantly less than that of anterior cervical surgery at two weeks (posterior 11% vs anterior 61.5%, p = 0.0001), 6 weeks (P 8% vs A 44%, p = 0.0001), but not twelve weeks (P 13% vs A 11%, p = 1). The incidence of dysphagia after posterior cervical surgery was significantly increased compared to that of lumbar surgery at two weeks (P11% vs L 9%, p = 0.78), six weeks (P 8% vs L 0%, p = 0.02), and twelve weeks (P 13% vs L 0%, p = 0.007). At 12 weeks postoperatively, there was a statistically significant increase in postoperative neck pain (p = 0.008), tightness (p = 0.032), and peripheral pain/numbness (p = 0.032) in patients with dysphagia.Conclusion. Both anterior and posterior cervical surgery may result in long term dysphagia in a small number of patients, perhaps due to loss of motion or postoperative pain. Surgeons should counsel their patients about possibility for dysphagia prior to all cervical spine surgery.
Spine 01/2013; · 2.08 Impact Factor
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ABSTRACT: BACKGROUND CONTEXT: Minimally invasive techniques for spinal fusion have theoretical advantages for the reduction of iatrogenic injury. Although this topic has been investigated previously for posterior-only interbody surgery, such as transforaminal lumbar interbody fusion, similar studies have not evaluated these techniques after anteroposterior spinal fusion, a study design that can more accurately determine the effect of pedicle screw placement and decompression via a minimally invasive technique without the confounding effect of simultaneous interbody cage placement. PURPOSE: To compare process measures that provide insight into the morbidity of surgery, such as surgical time and the length of postoperative hospital stay between open and minimally invasive anteroposterior lumbar fusion; and to compare the complications during the intraoperative and early postoperative period between open and minimally invasive anteroposterior lumbar fusion. STUDY DESIGN: Retrospective case-control study. PATIENT SAMPLE: One hundred sixty-two patients. OUTCOME MEASURES: Estimated blood loss, length of surgery, intraoperative fluoroscopy time, length of postoperative hospital stay, malpositioned instrumentation on postoperative imaging, and postoperative complications, including pulmonary embolus and surgical site infection. METHODS: Patients who underwent open anterior lumbar interbody fusion followed by either traditional open posterior fusion (Open group) or minimally invasive posterior fusion (minimally invasive surgery [MIS] group) were matched by the number of surgical levels. A chart review was performed to document the intraoperative and postoperative process measures and associated complications in the two groups. Secondary analyses were performed to compare the subgroups of patients, who did and did not undergo a posterior decompression at the time of posterior instrumentation to determine the effect of decompression. RESULTS: Baseline characteristics were similar between the Open and MIS groups. Estimated blood loss and postoperative transfusion rate were significantly higher in the Open group, differences that the subanalyses suggested were largely because of those patients who underwent concomitant decompression. Length of stay was not significantly different between the groups but was significantly shorter for MIS patients treated without decompression than for Open patients treated without decompression. Intraoperative fluoroscopy time was significantly longer in the MIS group. There was no difference in the infection or complication rates between the groups. CONCLUSIONS: Our case-control study comparing patients who underwent anterior lumbar interbody fusion followed by open posterior instrumentation with those who underwent anterior lumbar interbody fusion followed by minimally invasive posterior instrumentation demonstrated that patients undergoing MIS fusion without decompression had less blood loss, less need for transfusion in the perioperative period, and a shorter hospital stay. In contrast, most outcome measures were similar between MIS and Open groups for patients who underwent decompression.
The spine journal: official journal of the North American Spine Society 12/2012; · 2.90 Impact Factor
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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: Despite the importance of the information provided by cost-utility analyses (CUAs), there has been a lack of these types of studies performed in the area of spinal care.
To systematically review cost-utility studies published on spinal care between 1976 and 2010.
Systematic review.
All CUAs pertaining to spinal care published between 1976 and 2010 were identified using the cost-effectiveness analysis (CEA) registry database (Tufts Medical Center, Institute for Clinical Research and Health Policy) and National Health Service Economic Evaluation Database (NHS EED). The keywords used to search both the registry databases were the following: spine, spinal, neck, back, cervical, lumbar, thoracic, and scoliosis. Search of the CEA registry provided a total of 28 articles, and the NHS EED yielded an additional 5, all of which were included in this review. Each article was reviewed for the study subject, methodology, and results. Data contained within the databases for each of the 33 articles were recorded, and the manuscripts were reviewed to provide insight into the funding source, analysis perspective, discount rate, and cost-utility ratios.
There was wide variation among the 33 studies in methodology. There were 17 operative, 13 nonoperative, and 3 imaging studies. Study subjects included lumbar spine (n=27), cervical spine (n=4), scoliosis (n=1), and lumbar and cervical spine (n=1). Twenty-three of the studies were based on the clinical data from prospective randomized studies, 7 on decision models, 2 on prospective observational data, and 1 on a retrospective case series. Sixty cost-utility ratios were reported in the 33 articles. Of the ratios, 19 of 60 (31.6%) were cost saving, 27 of 60 (45%) were less than $100,000/quality-adjusted life year (QALY) gain, and 14 of 60 (23.3%) were greater than $100,000/QALY gain. Only four of 33 (12%) studies contained the four key criteria of cost-effectiveness research recommended by the US Panel on Cost-Effectiveness in Health and Medicine.
Thirty-three CUA studies and 60 cost-utility ratios have been published on various aspects of spinal care over the last 30 years. Certain aspects of spinal care have been shown to be cost effective. Further efforts, however, are needed to better define the value of many aspects of spinal care. Future CUA studies should consider societal cost perspective and carefully consider the durability of clinical benefit in determining a study time horizon.
The spine journal: official journal of the North American Spine Society 07/2012; 12(8):676-90. · 2.90 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: Dysphagia is common in the early postoperative period after anterior cervical discectomy and fusion (ACDF). Several mechanisms, including soft-tissue swelling, have been implicated as a cause of postoperative dysphagia.
To determine whether anterior soft-tissue swelling is greater in patients with postoperative dysphagia.
Prospective cohort study.
Forty-three patients.
Validated dysphagia questionnaire, lateral cervical spine radiographs.
Patients undergoing one- or two-level ACDF using allograft bone and anterior instrumentation were enrolled. Baseline patient demographic characteristics and history were recorded. A dysphagia questionnaire, including a dysphagia numeric rating scale (DNRS; range, 0-10), was administered preoperatively and 2 and 6 weeks postoperatively. Lateral cervical radiographs were obtained preoperatively and 2 and 6 weeks postoperatively. The anterior cervical soft-tissue shadow width was measured at each level. Patients were divided into groups based on the 2-week dysphagia questionnaire: Group 1 (no symptoms/mild dysphagia) and Group 2 (moderate/severe dysphagia). Anterior soft-tissue shadow width at each level was compared between groups. Correlation was used to assess the relationship between DNRS and anterior soft-tissue swelling.
Forty-three patients (24 females; average age, 47.9) were enrolled. Fifteen patients had one-level and 28 patients had two-level ACDF. The anterior soft-tissue shadow width increased significantly from preoperative values at all levels except C1 at 2 and 6 weeks and C2 at 6 weeks. At 2 weeks, 18 patients had no symptoms/mild dysphagia (Group 1) and 25 patients had moderate/severe dysphagia (Group 2). The average DNRS was 1.1 for Group 1 and 5.3 for Group 2 (p<.001). This difference decreased by 6 weeks but remained significant. There were no significant differences in the soft-tissue measurements between groups at any level. There was no significant correlation between the DNRS and anterior soft-tissue swelling at any time point.
There is a significant increase in anterior cervical soft-tissue swelling after ACDF. The width of prevertebral soft-tissue does not correlate with postoperative dysphagia.
The spine journal: official journal of the North American Spine Society 05/2012; 12(8):639-44. · 2.90 Impact Factor
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ABSTRACT: The load-sharing score (LSS) of vertebral body comminution is predictive of results after short-segment posterior instrumentation of thoracolumbar burst fractures. Some authors have posited that an LSS > 6 is predictive of neurological injury, ligamentous injury, and the need for surgical intervention. However, the authors of the present study hypothesized that the LSS does not predict ligamentous or neurological injury.
The prospectively collected spinal cord injury database from a single institution was queried for thoracolumbar burst fractures. Study inclusion criteria were acute (< 24 hours) burst fractures between T-10 and L-2 with preoperative CT and MRI. Flexion-distraction injuries and pathological fractures were excluded. Four experienced spine surgeons determined the LSS and posterior ligamentous complex (PLC) integrity. Neurological status was assessed from a review of the medical records.
Forty-four patients were included in the study. There were 4 patients for whom all observers assigned an LSS > 6, recommending operative treatment. Eleven patients had LSSs ≤ 6 across all observers, suggesting that nonoperative treatment would be appropriate. There was moderate interobserver agreement (0.43) for the overall LSS and fair agreement (0.24) for an LSS > 6. Correlations between the LSS and the PLC score averaged 0.18 across all observers (range -0.02 to 0.34, p value range 0.02-0.89). Correlations between the LSS and the American Spinal Injury Association motor score averaged -0.12 across all observers (range -0.25 to -0.03, p value range 0.1-0.87). Correlations describing the relationship between an LSS > 6 and the treating physician's decision to operate averaged 0.17 across all observers (range 0.11-0.24, p value range 0.12-0.47).
The LSS does not uniformly correlate with the PLC injury, neurological status, or empirical clinical decision making. The LSSs of only one observer correlated significantly with PLC injury. There were no significant correlations between the LSS as determined by any observer and neurological status or clinical decision making.
Journal of neurosurgery. Spine 04/2012; 16(6):534-8. · 1.61 Impact Factor
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ABSTRACT: BACKGROUND:: Cervical laminectomy and fusion (CLF) is a treatment option for multilevel cervical spondylotic myelopathy. Postoperative C5 nerve palsy is a possible complication of CLF. It has been suggested that C5 nerve palsy may be due to posterior drift of the spinal cord related to a wide laminectomy trough. PURPOSE:: To test the hypothesis that excessive spinal cord drift into a wide laminectomy trough is associated with C5 palsy. STUDY DESIGN:: Retrospective case-control study. PATIENT SAMPLE:: Seventeen patients with C5 palsy, 8 patients as control group. OUTCOME MEASURES:: Spinal cord positional measurements on magnetic resonance imaging (MRI). METHODS:: All patients who underwent elective CLF for cervical spondylotic myelopathy or ossified posterior longitudinal ligament using posterior instrumentation between 2004 and 2008 were included. Patients who underwent CLF for trauma, infection, or tumors were excluded. Clinical and radiographic outcomes were assessed by chart review (minimum of 1 y follow-up). Patients who developed a new postoperative C5 nerve palsy underwent repeat MRI. The control group also underwent CLF, did not develop a neurological deficit, and received a postoperative MRI for evaluation of possible infection. MRI measurements included the width of the laminectomy trough, the distance from the posterior vertebral body or disk to the anterior spinal cord, the width of the spinal cord herniated into the laminectomy defect, and C2-7 sagittal alignment. Preoperative radiographic measurements included preoperative vertebral body diameter, spinal canal diameter, and sagittal vertical offset. RESULTS:: There were seventeen patients with C5 nerve root palsy and 8 patients without C5 nerve root palsy. There were no baseline differences in fusion levels, instrumentation used, patient age, or sex. MRI measurements revealed an increase in mean postoperative cord drift in patients with C5 palsy at C3 (4.2 vs. 2.2 mm, P=0.002), C4 (4.6 vs. 2.8 mm, P=0.056), C5 (5.1 vs. 2.4 mm, P=0.011), and C6 (5.2 vs. 2.4 mm, P=0.003). There was a significant increase in C5 laminectomy trough width among patients with postoperative C5 palsy (17.9 vs. 15.2 mm, P=0.032), but there was no difference in sagittal alignment. CONCLUSIONS:: A wider laminectomy at C5 was associated with an increased risk of postoperative C5 palsy. Increased preoperative spinal canal diameter is also associated with increased risk of C5 palsy. In addition, patients who experienced C5 nerve palsy had a significantly greater posterior spinal cord drift. Strategies to reduce postoperative laminectomy trough width and spinal cord drift may reduce the risk of postoperative C5 palsy.
Journal of spinal disorders & techniques 03/2012; · 1.21 Impact Factor
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ABSTRACT: A retrospective cohort study.
In this article, we examined the Spine Patient Outcomes Research Trial lumbar stenosis observational cohort to determine baseline patient characteristics that are predictive of the treatment patients chose. We also evaluated cutoff points on validated patient questionnaires that differentiate patients who chose surgery from those who chose nonsurgical management.
Although the evidence from current studies suggests that surgical intervention is effective for lumbar spinal stenosis, the same studies show that nonoperative patients also improve. Thus, the reasons for patients choosing surgery versus nonoperative care are of continuing interest.
Baseline patient and clinical characteristics between those who received operative intervention and those who received nonoperative care were compared to determine baseline predictors of lumbar spinal stenosis management. Also, an evaluation of responses to the 36-Item Short Form Health Survey Bodily Pain (BP), 36-Item Short Form Health Survey Physical Function (PF), and the modified Oswestry Disability Index (ODI) questionnaires was performed to determine the percentage of patients choosing surgical versus nonoperative care relative to their initial questionnaire values.
This analysis looked at the 356 patients in the observational spinal stenosis cohort of Spine Patient Outcomes Research Trial who completed at least 1 follow-up visit. Patients choosing surgery were younger (P = 0.022), had worse BP (P < 0.001), worse PF (P < 0.001), worse ODI (P < 0.001), worse Stenosis Bothersomeness Index (P < 0.001), were dissatisfied with their symptoms (P = 0.001), and had a worse self-assessed health trend (P < 0.001). Patients tended to choose surgery if they had lateral recess stenosis (P = 0.022). Kaplan-Meier curves demonstrate that patients with a BP score of 32 or less, PF score of 30 or less, and ODI greater than 29 chose surgery 75% of the time.
A greater understanding of baseline characteristics that influence patient choices in the treatment of lumbar spinal stenosis can aid the patient and the surgeon during the shared decision-making process.
Spine 03/2012; 37(19):1702-7. · 2.08 Impact Factor
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ABSTRACT: To study radiographic and clinical outcomes after transforaminal lumbar interbody fusion (TLIF) in order to determine the impact of TLIF on lumbar lordosis, intervertebral height and improvement in clinical outcome measures.
Forty-five patients who had undergone a single-level TLIF procedure for a single-level degenerative condition were retrospectively reviewed and their clinical histories, degree of pre- and post-operative lumbar lordosis, intervertebral height, and cage position recorded. Clinical assessment included use of modified Odom's criteria and a visual analog scale (VAS) for back and leg pain.
At 21 months, the patients had gained an average of 3.6° of lumbar lordosis and 4.5 mm disc height. Change in disc height was significantly associated with an anterior cage position while lumbar lordosis was unaffected by cage position. A spondylolisthesis subgroup demonstrated 31% reduction in the magnitude of anterior slip. Less lordosis was associated with worse back and leg pain as assessed by VAS and greater disk heights were associated with higher Odom's criteria scores. Patients with persistent leg pain at final follow-up had less lumbar lordosis and intervertebral height than patients without leg pain.
Intervertebral height and lumbar lordosis reconstruction are important for achieving good surgical results; guidance regarding the likely changes in lumbar lordosis and disk height after TLIF is provided by our findings.
Orthopaedic Surgery 02/2012; 4(1):15-20.
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ABSTRACT: Adjacent segment disease (ASD) was described after long-term follow-up of patients treated with cervical fusion. The term describes new-onset radiculopathy or myelopathy referable to a motion segment adjacent to previous arthrodesis and often attributed to alterations in the biomechanical environment after fusion. Evidence suggests that ASD affects between 2% and 3% of patients per year. Although prevention of ASD was one major impetus behind the development of motion-sparing surgery, the literature does not yet clearly distinguish a difference in the rate of ASD between fusion and disk replacement. Surgical techniques during index surgery may reduce the rate of ASD.
Orthopedic Clinics of North America 01/2012; 43(1):53-62, viii. · 1.25 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: Injuries to the thoracolumbar spine may lead to a complex array of clinical syndromes that result from dysfunction of the anterior motor units, lumbosacral nerve roots, and/or spinal cord. Neurologic dysfunction may manifest in the lower extremities as loss of fine and gross motor function, touch, pain, temperature, and proprioceptive and vibratory sense deficits. Two clinical syndromes sometimes associated with these injuries are conus medullaris syndrome (CMS) and cauda equina syndrome (CES).
To review the current management of thoracolumbar spinal cord injuries.
Literature review.
Index Medicus was used to search the primary literature for articles on thoracolumbar injuries. An emphasis was placed on the current management, controversies, and newer treatment options.
After blunt trauma, these syndromes may reflect a continuum of dysfunction rather than a distinct clinical entity. The transitional anatomy at the thoracolumbar junction, where the conus medullaris is present, makes it less likely that a "pure" CMS or CES syndrome will occur and more likely that a "mixed" injury will. Surgical decompression is the mainstay of treatment for incomplete spinal cord injury (SCI) and incomplete CMS and CES. The value of timing of surgical intervention in the setting of incomplete SCI is unclear at this time. This review summarizes the recent information on epidemiology, pathophysiology, diagnosis, and controversies in the management of thoracolumbar neurologic injury syndromes.
The spine journal: official journal of the North American Spine Society 09/2011; 11(9):884-92. · 2.90 Impact Factor
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ABSTRACT: Existing studies suggest a relatively high incidence of dysphagia after anterior cervical decompression and fusion (ACDF). The majority of these studies, however, are retrospective in nature and lack a control group.
We therefore (1) prospectively determined the incidence and severity of dysphagia after ACDF using lumbar decompression patients as a control group; and (2) determined which factors, if any, are associated with increased postoperative dysphagia.
Patients undergoing either one- or two-level ACDF (n=38) or posterior lumbar decompression (n=56) were prospectively followed. Baseline patient characteristics were recorded. A dysphagia questionnaire was administered preoperatively and during the 2-week, 6-week, and 12-week postoperative visits. We found no differences in patient age, body mass index, or the preoperative incidence and severity of dysphagia between the cervical and lumbar groups. We compared the incidence and severity of dysphagia between the patients who had cervical and lumbar surgery.
Postoperatively, 71% of patients having cervical spine surgery reported dysphagia at 2 weeks followup. This incidence decreased to 8% at 12 weeks followup. The incidence and severity of dysphagia were greater in the cervical group at 2 and 6 weeks followup with a trend toward greater dysphagia at 12 weeks followup. Body mass index, gender, location of surgery, and the number of surgical levels were not related to the risk of developing dysphagia. We observed a correlation between operative time and the severity of postoperative dysphagia.
Dysphagia is common after ACDF. The incidence and severity of postoperative dysphagia decreases over time, although symptoms may persist at least 12 weeks after surgery.
Level II, prospective, comparative study. See Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 03/2011; 469(3):658-65. · 2.53 Impact Factor
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ABSTRACT: Prospective controlled clinical study.
To determine the incidence and severity of GERD in patients undergoing anterior cervical decompression and fusion (ACDF), using patients undergoing posterior lumbar decompression as a control group.
The incidence gastroesophageal reflux disease (GERD) after anterior cervical decompression and fusion (ACDF) has not previously been studied.
Patients undergoing either 1- or 2-level ACDF (n = 38) or posterior lumbar decompression surgery (control group, n = 56) were prospectively enrolled. Baseline patient characteristics were recorded. Intraoperative and postoperative medical records were reviewed. A validated GERD measurement tool (GERD Impact Scale, GIS) and a dysphagia questionnaire (including a dysphagia numeric rating score, range, 0-10) were administered preoperatively, and during the 2-week, 6-week, and 12-week postoperative visits.
Cervical patients had a significantly higher incidence of GERD at 2 weeks than the lumbar patients (78.9% vs. 42.9%, P = 0.001). Cervical patients had a higher incidence of GERD at 6 and 12 weeks as well, but these differences were not statistically significant. The change in GIS score from baseline was significantly higher in the cervical group at all follow-up time periods. On average, cervical patients required 1.2 doses of antacid medication in the postoperative period, compared to an average of 0.5 doses required by lumbar patients (P = 0.006). There was a significant correlation between the severity of dysphagia and the GIS score at 2 weeks, but no correlation at 6 or 12 weeks. Operative time did not correlate with the GIS score at any of the follow-up time periods. The number of surgical levels (i.e., one vs. two) and level of surgery (i.e., above C5-C6 vs. at or below C5-C6) had no effect on the GIS score.
Compared to the lumbar control group, patients in the cervical group had increased incidence, and severity of GERD-like symptoms in the early postoperative period.
Spine 03/2011; 36(24):2039-44. · 2.08 Impact Factor
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ABSTRACT: A secondary analysis comparing diabetic patients with nondiabetic patients enrolled in the Spine Patient Outcomes Research Trial (SPORT).
To compare surgical outcomes and complications between diabetic and nondiabetic spine patients.
Patients with diabetes are predisposed to comorbidities that may confound the diagnosis and treatment of patients with spinal disorders.
Baseline characteristics and outcomes of 199 patients with diabetes were compared with those of the nondiabetic population in a total of 2405 patients enrolled in the Spine Patient Outcomes Research Trial for the diagnoses of intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS). Primary outcome measures include the 36-Item Short Form Health Survey (SF-36) Health Status questionnaire and the Oswestry Disability Index.
Patients with diabetes were significantly older and had a higher body mass index than nondiabetic patients. Comorbidities, including hypertension, stroke, cardiovascular disease, and joint disease, were significantly more frequent in diabetic patients than in nondiabetic patients. Patients with diabetes and IDH did not make significant gains in pain and function with surgical intervention relative to diabetic patients who underwent nonoperative treatment. Diabetic patients with SpS and DS experienced significantly greater improvements in pain and function with surgical intervention when compared with nonoperative treatment. Among those who had surgery, nondiabetic patients with SpS achieved marginally significantly greater gains in function than their diabetic counterparts (SF-36 physical function, P = 0.062). Among patients who had surgery for DS, diabetic patients did not have as much improvement in pain or function as did the nondiabetic population (SF-36 bodily pain, P = 0.003; physical function, P = 0.002). Postoperative complications were more prevalent in patients with diabetes than in nondiabetic patients with SpS (P = 0.002). There was an increase in postoperative (P = 0.028) and intraoperative (P = 0.029) blood replacement in DS patients with diabetes.
Diabetic patients with SpS and DS benefited from surgery, though older SpS patients with diabetes have more postoperative complications. IDH patients with diabetes did not benefit from surgical intervention.
Spine 02/2011; 36(4):290-307. · 2.08 Impact Factor
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Harvey E Smith,
Stewart M Kerr,
Michael G Fehlings,
Jens Chapman,
Mitchell Maltenfort,
James Zavlasky,
Eric Harris,
Todd J Albert,
James Harrop, Alan S Hilibrand,
D Greg Anderson,
Alexander R Vaccaro
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ABSTRACT: A retrospective cohort study of consecutive type II Odontoid fractures presenting to a Level 1 Regional Model Systems Spinal Cord Injury Center between June 1985 and July 2006.
To assess trends in management of type II Odontoid fractures presenting to a Level 1 Model Systems Regional Spinal Cord Injury Center over a 20-year period.
Type II Odontoid fracture management is controversial, and a majority of studies have had relatively small cohorts. There is no consensus regarding definitive treatment, particularly in older patients.
Medical records of 263 consecutive type II Odontoid fractures from June 1985 to July 2006 were retrospectively reviewed. Patients were excluded if they had neurologic deficits, nonacute fracture, or ambiguous fracture classification. A cohort of 192 neurologically intact, acute type II odontoid fractures were identified. Admission records were reviewed for age, date of injury, date of admission, date of discharge, mechanism of injury, associated injuries, medical comorbidities, and radiologic findings.
There was a statistically significant increase in the rate of presentation of type II odontoid fractures with time. The average age and medical comorbidities of the patient did not change over time. The probability of operative management markedly increased over time, corresponding to a statistically significant increase in length of hospital stay for patients undergoing surgery. The discharge disposition correlated significantly to both age of the patient and associated injuries.
The number and frequency of type II odontoid fractures compared with other spine injuries seems to be increasing over the last 2 decades, which may be correlated with the increasing number of elderly persons in the population, given that referral patterns have been unchanged at our institution. Prospective outcomes data are needed to better elucidate optimal treatment algorithms from both, an outcomes and cost-efficacy perspective.
Journal of spinal disorders & techniques 10/2010; 23(8):501-5. · 1.21 Impact Factor
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Alexander R Vaccaro,
Jeffrey A Rihn,
Davor Saravanja,
David G Anderson, Alan S Hilibrand,
Todd J Albert,
Michael G Fehlings,
William Morrison,
Adam E Flanders,
John C France,
Paul Arnold,
Paul A Anderson,
Brian Friel,
David Malfair,
John Street,
Brian Kwon,
Scott Paquette,
Michael Boyd,
Marcel F S Dvorak,
Charles Fisher
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ABSTRACT: Prospective diagnostic imaging study.
To determine the accuracy of magnetic resonance imaging (MRI) in diagnosing injury of the posterior ligamentous complex (PLC) in patients with thoracolumbar trauma.
Treatment decisions in thoracolumbar injury patients are currently based on the status of the PLC. It is, therefore, important to understand the accuracy of MRI in diagnosing varying degrees of PLC injury. Prior studies report that MRI is up to 100% sensitive for diagnosing PCL injury.
Patients with an acute injury from T1 to L3 who required posterior surgery were prospectively studied. A musculoskeletal radiologist, based on the preoperative MRI findings, characterized each of the 6 components of the PLC as intact, incompletely disrupted, or disrupted. During the surgical procedure, the surgeon identified each component of the PLC as intact, incompletely disrupted, or disrupted. The radiologist's interpretation and surgical findings were compared.
Forty-two patients with 62 levels of injury were studied. There were 33 males (78.6%) and 9 females (21.4%), and the average age was 35.7 years. According to the kappa score, there was a moderate level of agreement between the radiologist's interpretation and the intraoperative findings for all PLC components except the thoracolumbar fascia, for which there was slight agreement. The sensitivity for the various PLC components ranged from 79% (left facet capsule) to 90% (interspinous ligament). The specificity ranged from 53% (thoracolumbar fascia) to 65% (ligamentum flavum). There was less agreement between the radiologist and surgeon for the patients with less severe neurologic compromise, i.e., those patients with an AIS grade of either D or E.
The sensitivity and specificity of MRI for diagnosing injury of the PLC are lower than previously reported in the literature. The integrity of the PLC as determined by MRI should not be used in isolation to determine treatment.
Spine 11/2009; 34(23):E841-7. · 2.08 Impact Factor
