David H Kim

New England Baptist Hospital, Boston, Massachusetts, United States

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Publications (61)118.69 Total impact

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    ABSTRACT: Despite interest in lumbar spinous process-based surgical innovation, there are no large published studies that have characterized morphometry of lumbar spinous processes. To provide accurate level-specific morphometric data with respect to human lumbar spinous processes using a human cadaveric lumbar spine model and to describe morphometric variation of lumbar spinous processes with respect to gender, race and age. Anatomic observational METHODS: This study utilized 2,955 cadaveric lumbar vertebrae from 591 adult spines at the Hamann-Todd Human Osteological Collection. Specimens were ages 20-79 years. Each vertebra was photographed in standardized positions and measured using ImageJ software. Direct measurements were made for spinous process (SP) length, width, height, slope and caudal morphology. Gender, race and age were recorded and analyzed. SP length was 24.8±4.6 mm (L5) to 33.9±3.9 mm (L3). Effective length varied from 19.5±2.6 mm (L1) to 24.6±3.3 mm (L4). Height was shortest at L5 (18.2±2.7 mm). Caudal width was greater than cranial width. Slope, caudal morphology and radius measures showed large inter-specimen variation. Slope at L5 was steeper than other levels (23.7±10.5 degrees, p<0.0001). Most specimens demonstrated convex caudal morphology. L4 had the highest proportion of convexity (80.7%). L1 was the only level with predominantly concave morphology. Measurements for female SPs were smaller, but slope was steeper. Anatomic and effective SP lengths were longer for specimens from white individuals. Specimens from black individuals had larger width and height, as well as steeper slope. Black specimens had more convex morphology at L4 and L5. With increasing age, SP length, effective length and width increased. Height increased with age only at L4 and L5. Slope and caudal radius of curvature decreased with age and increasingly convex morphology was noted at most levels. This large cadaveric study provides level-specific morphometric data regarding the osseous dimensions of lumbar spinous processes relevant to techniques and devices targeting lumbar spinous processes or the interspinous space. Of particular importance is the recognition that L5 has relatively different morphology when compared to more cranial levels. Potentially important differences were noted comparing female to male, black to white and aging populations. Copyright © 2015 Elsevier Inc. All rights reserved.
    The spine journal: official journal of the North American Spine Society 03/2015; 15(7). DOI:10.1016/j.spinee.2015.03.007 · 2.43 Impact Factor

  • David H Kim · Mark J Berkowitz ·

    03/2014; 35(6). DOI:10.1177/1071100714528497

  • The Spine Journal 09/2013; 13(9):S162. DOI:10.1016/j.spinee.2013.07.409 · 2.43 Impact Factor

  • The Spine Journal 09/2012; 12(9):S114. DOI:10.1016/j.spinee.2012.08.308 · 2.43 Impact Factor
  • David H Kim · Mark J Berkowitz ·

    Foot & Ankle International 06/2012; 33(6):524-5. DOI:10.3113/FAI.2012.0524 · 1.51 Impact Factor
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    ABSTRACT: Spinous process fracture is a recognized complication associated with interspinous process spacer (IPS) surgery. Although occasionally identified by plain radiographs, computed tomography (CT) appears to identify a higher rate of such fractures. Although osteoporotic insufficiency fracture is considered a contraindication for IPS surgery, a formal risk factor analysis for this complication has not previously been reported. To identify risk factor(s) associated with early spinous process fracture after IPS surgery. Prospective cohort study of 39 consecutive patients with lumbar stenosis and neurogenic claudication undergoing IPS surgery at a single institution. Patients underwent preoperative dual-energy X-ray absorptiometry (DXA) scans, lumbar spine CT, and plain radiographs. Postoperatively, patients underwent repeat CT imaging within 6 months of surgery and serial radiographs at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. Preoperative CT scans were analyzed by calculating average Hounsfield units for a 1 cm(2) area of the midsagittal reconstructed image for four separate locations: midvertebral body, subcortical bone subjacent to the superior margin of the midspinous process, subcortical bone above the inferior margin of the midspinous process, and the midspinous process. Thirty-eight patients underwent IPS surgery at a total of 50 levels (38 L4-L5, 12 L3-L4; 26 one-level, 12 two-level). One patient underwent laminectomy at index surgery and was excluded from the analysis. Implants included 34 titanium X-STOP (Medtronic, Memphis, TN, USA), 8 polyaryletheretherketone X-STOP (Medtronic, Memphis, TN, USA), and 8 Aspen (Lanx, Broomfield, CO, USA) devices. Eleven spinous process fractures were identified by CT in 11 patients (22.0% of levels). No fractures were apparent on plain radiographs. The rate of spondylolisthesis observed on preoperative radiographs was 100% (11 of 11) among patients with fractures compared with 33.3% (9 of 27) of patients without fracture (p=.0001). Overall, 21 of 39 patients in this series had spondylolisthesis, and the rate of fracture in this group was 52%. Among patients without spondylolisthesis, the fracture rate was 0%. A trend was observed toward decreased DXA lumbar spine and hip T-scores among fracture patients versus nonfracture patients (0.2 ± 1.7 vs. 0.8 ± 1.7; p=.389; -1.1 ± 1.4 vs. -0.3 ± 1.4; p=.201), but these differences were not significant. Similarly, bone density based on CT measurements at four different locations revealed a trend toward decreased density among fracture patients, but these differences were not significant. Degenerative spondylolisthesis appears strongly associated with the occurrence of spinous process fracture after IPS surgery. There is a trend toward increased fracture risk in patients with decreased bone mineral density as measured by both DXA scan and CT-based volume averaging of Hounsfield units, but osteoporosis appears to be a relatively weaker risk factor. The association between spondylolisthesis and fracture observed in this study may account for the relatively poorer outcome of IPS surgery in patients with spondylolisthesis that has been reported in previous series.
    The spine journal: official journal of the North American Spine Society 05/2012; 12(6):466-72. DOI:10.1016/j.spinee.2012.03.034 · 2.43 Impact Factor
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    ABSTRACT: Prospective observational study. To provide a more accurate estimate of the rate of acute spinous process fractures associated with IPS surgery. Biomechanical cadaveric studies have suggested adequate spinous process strength to support placement of interspinous process spacers (IPS). Postoperative spinous process fractures have been reported in one%-to 5.8% of patients in previous series based on routine biplanar radiographic evaluation. However, most fractures occur between the base and midportion of the spinous process in an area that is typically difficult to visualize on plain radiographs due to device design. All patients underwent preoperative biplanar plain radiographs and computed tomography (CT) of the lumbar spine to confirm anatomy favorable for IPS placement and rule out fracture or spondylolysis. Postoperatively, all patients underwent repeat CT imaging within six months of surgery, biplanar radiographs at two weeks, six weeks, three months, six months, and one year. All studies were reviewed independently by a neuroradiologist and two orthopedic spine surgeons. Fifty implants (38 L4-5, 12 L3-4) were placed in 38 patients who completed follow-up and were included in final analysis. Three IPS designs were included (34 Medtronic X-STOP titanium, 8 X-STOP PEEK, 8 Lanx Aspen). Postoperative CT revealed 11 nondisplaced spinous process fractures in 11 patients (28.9% of patients, 22% of levels). Five fractures were associated with mild to moderate lumbar back pain and six fractures were asymptomatic. No patient reported a traumatic incident. No fracture was identifiable on plain radiographs. One fracture displaced during follow-up evaluation. Three patients underwent IPS removal and laminectomy. Three fractures healed by CT in one year. Overall, patients with fractures tended toward poorer outcomes by Zurich Claudication Questionnaire (ZCQ) (28.5% vs. 34.8% improvement in symptom severity, P = 0.496; 21.4% vs. 30.7% improvement in physical function, P = 0.199) and tended toward lower satisfaction rates (50% vs. 73.7%, P = 0.24) at one year compared to patients without fracture. Interspinous process spacer surgery appears associated with a higher rate of early postoperative spinous process fracture than previously reported. In all cases, in this series, plain radiographs were inadequate to identify fractures because all fractures were initially minimal or nondisplaced, many patients were osteopenic, and the metallic wings of the devices often obscured fractures. Moreover, in most patients, fractures were associated with mild or no acute localized pain. This study suggests that unrecognized spinous process fracture may be responsible for a significant number of patients who experience unsatisfactory outcome after IPS surgery. CT imaging is required to identify the vast majority of such fractures.
    Spine 02/2011; 36(16):E1080-5. DOI:10.1097/BRS.0b013e318204066a · 2.30 Impact Factor
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    ABSTRACT: Surgical treatment for lumbar degenerative disc disease (DDD) has been associated with highly variable results in terms of postoperative pain relief and functional improvement. Many experts believe that DDD should be considered a chronic pain disorder as opposed to a degenerative disease. Genetic variation of the catechol-O-methyltransferase (COMT) gene has been associated with variation in human pain sensitivity and response to analgesics in previous studies. To determine whether genetic variation of COMT is associated with clinical outcome after surgical treatment for DDD. Prospective genetic association study. Sixty-nine patients undergoing surgical treatment for lumbar DDD. Diagnosis was based on documentation of chronic disabling low back pain (LBP) present for a minimum of 6 months and unresponsive to supervised nonoperative treatment, including activity modification, medication, physical therapy, and/or injection therapy. Plain radiographs and magnetic resonance imaging revealed intervertebral disc desiccation, tears, and/or collapse without focal herniation, nerve root compression, stenosis, spondylolisthesis, spondylolysis, or alternative diagnoses. Oswestry Disability Index (ODI) and visual analog score (VAS) for LBP. Surgical treatment included 65 instrumented fusions and four disc arthroplasty procedures. All patients completed preoperative and 1-year postoperative ODI questionnaires. DNA was extracted from a sample of venous blood, and genotype analysis was performed for five common COMT single nucleotide polymorphisms (SNPs). Potential genetic association between these COMT SNPs and the primary outcome variable, 1-year change in ODI, was investigated using both single-marker and haplotype association analyses. Association with VAS scores for LBP was analyzed as a secondary outcome variable. Single-marker analysis revealed that the COMT SNP rs4633 was significantly associated with greater improvement in ODI score 1 year after surgery (p=.03), with individuals homozygous for the less common "T" allele demonstrating the largest improvement in ODI. Haplotype analysis of four COMT SNPs, rs6269, rs4633, rs4818, and rs4680, also identified a common haplotype "ATCA" (haplotype frequency of 39.3% in the study population) associated with greater improvement in ODI (p=.046). The greatest mean improvement in ODI was observed in patients homozygous for the "ATCA"COMT haplotype. A nonsignificant trend was observed between SNP rs4633 and greater improvement in VAS score for LBP. This is the first study to report an association between surgical treatment success in DDD patients and genetic variation in the putative pain sensitivity gene COMT. These findings require replication in other DDD populations but suggest that genetic testing for pain-relevant genetic markers such as COMT may provide useful clinical information in terms of predicting outcome after surgery for patients diagnosed with DDD.
    The spine journal: official journal of the North American Spine Society 11/2010; 10(11):949-57. DOI:10.1016/j.spinee.2010.07.387 · 2.43 Impact Factor
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    ABSTRACT: Prospective observational study. To determine whether polymorphic variations of the guanosine triphosphate (GTP) cyclohydrolase 1 gene (GCH1) are associated with different outcomes in patients undergoing surgical treatment for lumbar degenerative disc disease (DDD). GCH1, the gene encoding the rate-limiting enzyme in tetrahydrobiopterin synthesis, has been strongly implicated as a determinant of pain experience in previous animal and human studies. METHODS.: A total of 69 patients undergoing surgical treatment for lumbar DDD were prospectively enrolled. Genomic DNA was extracted from a venous blood sample, and DNA sequence analysis was performed of GCH1. Surgery included 65 instrumented fusions and 4 disc arthroplasty procedures. Patients were observed prospectively for 1 year following surgery. Allelic and genotype frequencies were calculated for each of 14 single nucleotide polymorphisms (SNPs). One-year postoperative Oswestry Disability Index (ODI) scores were compared to preoperative scores and the absolute change in ODI score was used to perform genetic association analyses on the basis of both individual SNP markers as well as commonly observed haplotypes for the entire gene sequence. Single marker analysis revealed 1 SNP (rs998259; minor allele T) that was significantly associated with improvement in both absolute ODI score (P = 0.030) and Numerical Rating Scale back pain scores (P = 0.033) following surgery. Haplotype analysis identified a common GCH1 haplotype ("CACTTGTTTGAC") with a sample frequency of 12.3%, which was highly associated with improvement in absolute ODI score (P = 0.04). This haplotype frequency reflects the existence of both heterozygous and homozygous individuals in the study population. The presence of 1 unit of this haplotype was associated with an improvement in postoperative ODI score of 15.34 relative to the absence of this haplotype (P = 0.04). Preliminary results from this pilot genetic study of patients undergoing surgery for DDD suggests that the T allele at rs998259 of GCH1 may be associated with improved outcomes 1 year following surgery.
    Spine 10/2010; 35(21):1909-14. DOI:10.1097/BRS.0b013e3181eea007 · 2.30 Impact Factor
  • David H Kim · Carolyn E Schwartz ·
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    ABSTRACT: Variability in human pain experience appears to be at least partially determined by genetic inheritance. To the extent that awareness of individual pain sensitivity and the tendency to develop chronic pain after injury or surgery would be informative for clinical decision making, development and use of genetic testing for specific pain markers could contribute to improved outcomes in management of spinal disease. To review important and illustrative results from both classical and modern pain genetics studies and to introduce readers to critical definitions and concepts necessary to interpret the growing body of genetics literature relevant to spinal disease. Literature review and commentary. A review was performed of published English language studies in which genetic techniques were used to analyze the molecular basis of nociceptive signaling or processing with a particular emphasis on studies addressing genetic determinants of interindividual variability in pain sensitivity or predisposition to chronic pain. There is compelling evidence indicating that interindividual differences in pain sensitivity and the risk of developing chronic pain syndromes are genetically determined. Despite a growing list of putative "pain genes," genetic association studies remain plagued with difficulty replicating initial findings in different cohorts. Genome-wide association studies are potentially powerful means of identifying clinically relevant genetic markers predicting disease susceptibility, severity, and treatment response. However, accurate results require rigorous study design with use of large homogeneous populations and precise phenotypes.
    The spine journal: official journal of the North American Spine Society 09/2010; 10(9):827-40. DOI:10.1016/j.spinee.2010.05.013 · 2.43 Impact Factor
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    ABSTRACT: Surgical site infection has been identified as one of the most important preventable sources of morbidity and mortality associated with medical treatment. The purpose of the present study was to evaluate the feasibility and efficacy of an institutional prescreening program for the preoperative detection and eradication of both methicillin-resistant and methicillin-sensitive Staphylococcus aureus in patients undergoing elective orthopaedic surgery. Data were collected prospectively during a single-center study. A universal prescreening program, employing rapid polymerase chain reaction analysis of nasal swabs followed by an eradication protocol of intranasal mupirocin and chlorhexidine showers for identified carriers, was implemented. Surgical site infection rates were calculated and compared with a historical control period immediately preceding the start of the screening program. During the study period, 7019 of 7338 patients underwent preoperative screening before elective surgery, for a successful screening rate of 95.7%. One thousand five hundred and eighty-eight (22.6%) of the patients were identified as Staphylococcus aureus carriers, and 309 (4.4%) were identified as methicillin-resistant Staphylococcus aureus carriers. A significantly higher rate of surgical site infection was observed among methicillin-resistant Staphylococcus aureus carriers (0.97%; three of 309) compared with noncarriers (0.14%; seven of 5122) (p = 0.0162). Although a higher rate of surgical site infection was also observed among methicillin-sensitive Staphylococcus aureus carriers (0.19%; three of 1588) compared with noncarriers, this difference did not achieve significance (p = 0.709). Overall, thirteen cases of surgical site infection were identified during the study period, for an institutional infection rate of 0.19%. This rate was significantly lower than that observed during the control period (0.45%; twenty-four cases of surgical site infection among 5293 patients) (p = 0.0093). Implementation of an institution-wide prescreening program for the identification and eradication of methicillin-resistant and methicillin-sensitive Staphylococcus aureus carrier status among patients undergoing elective orthopaedic surgery is feasible and can lead to significant reductions in postoperative rates of surgical site infection. Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 08/2010; 92(9):1820-6. DOI:10.2106/JBJS.I.01050 · 5.28 Impact Factor
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    ABSTRACT: Although the role of radiographic abnormalities in the etiology of nonspecific low back pain (LBP) is unclear, the frequent identification of these features on radiologic studies continues to influence medical decision making. The primary purposes of the study were to evaluate the prevalence of lumbar spine degeneration features, evaluated on computed tomography (CT), in a community-based sample and to evaluate the association between lumbar spine degeneration features. The secondary purpose was to evaluate the association between spinal degeneration features and LBP. This is a cross-sectional community-based study that was an ancillary project to the Framingham Heart Study. A subset of 187 participants were chosen from the 3,529 participants enrolled in the Framingham Heart Study who underwent multidetector CT scan to assess aortic calcification. Self-report measures: LBP in the preceding 12 months was evaluated using a Nordic self-report questionnaire. Physiologic measures: Dichotomous variables indicating the presence of intervertebral disc narrowing, facet joint osteoarthritis (OA), spondylolysis, spondylolisthesis, and spinal stenosis and the density (in Hounsfield units) of multifidus and erector spinae muscles were evaluated on CT. We calculated the prevalence of spinal degeneration features and mean density of multifidus and erector spinae muscles in groups of individuals with and without LBP. Using the chi(2) test for dichotomous and t test for continuous variables, we estimated the differences in spinal degeneration parameters between the aforementioned groups. To evaluate the association of spinal degeneration features with age, the prevalence of degeneration features was calculated in four age groups (less than 40, 40-50, 50-60, and 60+ years). We used multiple logistic regression models to examine the association between spinal degeneration features (before and after adjustment for age, sex, and body mass index [BMI]) and LBP, and between all degeneration features and LBP. In total, 104 men and 83 women, with a mean age (+/-standard deviation) of 52.6+/-10.8 years, participated in the study. There was a high prevalence of intervertebral disc narrowing (63.9%), facet joint OA (64.5%), and spondylolysis (11.5%) in the studied sample. When all spinal degeneration features as well as age, sex, and BMI were factored in stepwise fashion into a multiple logistic regression model, only spinal stenosis showed statistically significant association with LBP, odds ratio (OR) (95% confidence interval [CI]): 3.45 [1.12-10.68]. Significant association was found between facet joint OA and low density of multifidus (OR [95% CI]: 3.68 [1.36-9.97]) and erector spinae (OR [95% CI]: 2.80 [1.10-7.16]) muscles. Degenerative features of the lumbar spine were extremely prevalent in this community-based sample. The only degenerative feature associated with self-reported LBP was spinal stenosis. Other degenerative features appear to be unassociated with LBP.
    The spine journal: official journal of the North American Spine Society 12/2009; 10(3):200-8. DOI:10.1016/j.spinee.2009.10.018 · 2.43 Impact Factor
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    ABSTRACT: Lumbar facet joint synovial cysts are benign degenerative abnormalities of the lumbar spine. Previous reports have supported operative and nonoperative management. Facet joint steroid injection with cyst rupture is occasionally performed, but there has been no systematic evaluation of this treatment option. To profile the role of facet joint steroid injections with cyst rupture in the treatment of lumbar facet joint synovial cysts. Retrospective chart review and long-term follow-up of patients treated for lumbar facet joint synovial cysts. One hundred one patients treated for lumbar facet joint synovial cysts with fluoroscopically guided corticosteroid facet joint injection and attempted cyst rupture. Oswestry Disability Index and numeric rating scale score for back and leg pain. A retrospective review and a subsequent interview were conducted to collect pretreatment and posttreatment pain and disability scores along with details of subsequent treatment interventions. Group differences in pain and disability scores were assessed using paired t test. Multiple clinical factors were analyzed in terms of risk for surgical intervention using logistic regression modeling and Cox proportional hazards modeling. Successful cyst rupture was confirmed fluoroscopically in 81% of cases. Fifty-five patients (54%) required subsequent surgery over a period averaging 8.4 months because of inadequate symptom relief. All patients reported significant improvement in back pain, leg pain, and disability at 3.2 years postinjection, regardless of their subsequent treatment course (p<.0001 in all groups). There was no significant difference in current pain between patients who received injections only and those who underwent subsequent surgery. This study presents the largest clinical series of nonsurgical treatment for lumbar facet joint synovial cysts. Lumbar facet joint steroid injection with attempted cyst rupture is correlated with avoiding subsequent surgery in half of treated patients. Successful cyst rupture does not appear to have added benefit, and it was associated with worse disability 3 years postinjection. Long-term outcomes are similar, regardless of subsequent surgery.
    The spine journal: official journal of the North American Spine Society 09/2009; 9(11):899-904. DOI:10.1016/j.spinee.2009.06.010 · 2.43 Impact Factor
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    ABSTRACT: Morbidity associated with autologous bone graft harvest is an important factor in determining the utility of expensive alternatives such as recombinant bone morphogenic protein. The most frequently reported complication associated with graft harvest is chronic pain. To prospectively determine the degree of pain and morbidity associated with autologous iliac crest bone graft harvest and its effect on activities of daily living. Prospective observational cohort study. One hundred ten adult patients undergoing elective posterior lumbar spinal fusion surgery involving autologous iliac crest bone graft harvest. Patient self-reported Visual Analog Scale (VAS) scores for pain and a study-specific questionnaire regarding activities of daily living. One hundred ten patients were prospectively enrolled. Postoperative VAS scores (0-100) for harvest site pain were obtained at 6-week, 6- and 12-month follow-up. Patients completed a 12-month questionnaire regarding the persistence of specific symptoms and resulting limitation of specific activities. One hundred four patients were available for 1-year follow-up. Mean VAS pain scores (scale 0-100) at 6 weeks, 6 and 12 months were 22.7 (standard deviation [SD], 25.9), 15.9 (SD, 21.5), and 16.1 (SD, 24.6), respectively. At 12 months, 16.5% reported more severe pain from the harvest site than the primary surgical site, 29.1% reported numbness, and 11.3% found the degree of numbness bothersome, whereas 3.9% were bothered by scar appearance. With respect to activity limitations resulting from harvest site pain at 1 year, 15.1% reported some difficulty walking, 5.2% with employment, 12.9% with recreation, 14.1% with household chores, 7.6% with sexual activity, and 5.9% irritation from clothing. There is a significant rate of persistent pain and morbidity from iliac crest bone graft harvest when associated with elective spine surgery. Mean pain scores progressively decline over the first postoperative year. Nevertheless, harvest site pain remains functionally limiting in a significant percentage of patients 1 year after surgery. Rates of functional limitation are higher than previously reported and may be because of increased sensitivity of the prospective study design and targeted investigation of these specific symptoms. Validity of these findings is necessarily limited by patient ability to discriminate harvest site pain from alternative sources of back and buttock pain.
    The spine journal: official journal of the North American Spine Society 07/2009; 9(11):886-92. DOI:10.1016/j.spinee.2009.05.006 · 2.43 Impact Factor
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    ABSTRACT: The prevalence of lumbar spinal stenosis (LSS) in the general population and association with low back pain (LBP) remain unclear. To evaluate the prevalence of congenital and acquired LSS observed on computed tomography in a community-based sample; and to evaluate the association between LSS and LBP. Cross-sectional observational study. This study was an ancillary project to the Framingham Heart Study. A total of 3,529 participants underwent multidetector computed tomography; 191 were enrolled in this study. Self-report measures: LBP in the preceding 12 months was evaluated using a self-report questionnaire. Physiologic measures: LSS (congenital and acquired) was characterized using two cut-points: 12mm for relative LSS and 10mm for absolute LSS. Using multiple logistic regression, we examined the association between LSS and LBP, adjusting for sex, age, and body mass index. In the congenital group, relative LSS was found in 4.7% and absolute LSS in 2.6% of patients. Acquired LSS was found in 22.5% and in 7.3%, respectively. Acquired LSS showed increasing prevalence with age less than 40 years, the prevalence of relative and absolute LSS was 20.0% and 4.0%, respectively, and in those 60 to 69 years the prevalence was 47.2% and 19.4%, respectively. The presence of absolute LSS was associated with LBP with an odds ratio of 3.16 (95% confidence interval [CI]: 1.05-9.53). The prevalence of congenital and acquired LSS in a community-based sample was characterized. The prevalence of acquired stenosis increased with age. LSS is associated with a threefold higher risk of experiencing LBP.
    The spine journal: official journal of the North American Spine Society 05/2009; 9(7):545-50. DOI:10.1016/j.spinee.2009.03.005 · 2.43 Impact Factor
  • David H Kim ·
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    ABSTRACT: Background One of the primary difficulties in evaluating the effectiveness of lumbar fusion is that, with the exception of spondylolisthesis, specific diagnostic indications for surgery are poorly defined. Diagnostic specificity beyond the symptom of low back pain or the presence of lumbar degeneration needs to be delineated such that outcomes data can be effectively translated into clinical decision making or evidence-based guidelines.
    The spine journal: official journal of the North American Spine Society 04/2009; 9(6):520; author reply 520; discussion 521. DOI:10.1016/j.spinee.2009.02.006 · 2.43 Impact Factor
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    ABSTRACT: Cross-sectional study. To determine prevalence rates of spondylolysis, isthmic, and degenerative spondylolisthesis in an unselected adult community-based population; and to evaluate the association of spondylolysis, isthmic, and degenerative spondylolisthesis with low back pain (LBP). Spondylolysis and spondylolisthesis are prevalent in the general population; however, the relationship between these conditions and LBP is controversial. This study was an ancillary project to the Framingham Heart Study. A sample of 3529 participants of the Framingham Heart Study aged 40 to 80 years underwent multidetector CT imaging to assess aortic calcification. One hundred eighty-eight individuals were consecutively enrolled in this study to assess radiographic features potentially associated with LBP. The occurrence of LBP in the preceding 12 months was evaluated using a self-report questionnaire. The presence of spondylolysis and spondylolisthesis was characterized by CT imaging. We used multiple logistic regression models to examine the association between spondylolysis, spondylolisthesis, and LBP, while adjusting for gender, age, and BMI. Twenty-one study subjects demonstrated spondylolysis on computed tomography (CT) imaging. The male-to-female ratio was approximately 3:1. Twenty-one percent of subjects with bilateral spondylolytic defects demonstrated no measurable spondylolisthesis. The male-to-female ratio of degenerative spondylolisthesis was 1:3, and the prevalence of degenerative spondylolisthesis increased from the fifth through 8 decades of life. Thirty-eight subjects (20.4%) reported significant LBP. No significant association was identified between spondylolysis, isthmic spondylolisthesis, or degenerative spondylolisthesis, and the occurrence of LBP. Based on CT imaging of an unselected community-based population, the prevalence of lumbar spondylolysis is 11.5%, nearly twice the prevalence of previous plain radiograph-based studies. This study did not reveal a significant association between the observation of spondylolysis on CT and the occurrence of LBP, suggesting that the condition does not seem to represent a major cause of LBP in the general population.
    Spine 02/2009; 34(2):199-205. DOI:10.1097/BRS.0b013e31818edcfd · 2.30 Impact Factor
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    ABSTRACT: Autogenous Iliac Crest Bone Graft (ICBG) has been the "gold standard" for spinal fusion. However, bone graft harvest may lead to complications, such as chronic pain, numbness, and poor cosmesis. The long-term impact of these complications on patient function and well-being has not been established but is critical in determining the value of expensive bone graft substitutes such as recombinant bone morphogenic protein. We thus aimed to investigate the long-term complications of ICBG. Our second aim was to evaluate the psychometric properties of a new measure of ICBG morbidity that would be useful for appropriately gauging spinal surgery outcomes. Prospective study of patients undergoing spinal fusion surgery with autologous ICBG. The SF-36v2, Oswestry Disability Index, and a new 14-item follow-up questionnaire addressing persistent pain, functional limitation, and cosmesis were administered with an 83% response rate. Multiple regression analyses examined the independent effect of ICBG complications on physical and mental health and disability. The study population included 170 patients with a mean age of 51.1 years (SD = 12.2) and balanced gender (48% male). Lumbar fusion patients predominated (lumbar = 148; cervical n = 22). At 3.5 years mean follow-up, 5% of patients reported being bothered by harvest site scar appearance, 24% reported harvest site numbness, and 13% reported the numbness as bothersome. Harvest site pain resulted in difficulty with household chores (19%), recreational activity (18%), walking (16%), sexual activity (16%), work activity (10%), and irritation from clothing (9%). Multivariate regression analyses revealed that persistent ICBG complications 3.5 years post-surgery were associated with significantly worse disability and showed a trend association with worse physical health, after adjusting for age, workers' compensation status, surgical site pain, and arm or leg pain. There was no association between ICBG complications and mental health in the multivariate model. Chronic ICBG harvest site pain and discomfort is reported by a significant percentage of patients undergoing this procedure more than three years following surgery, and these complications are associated with worse patient-reported disability. Future studies should consider employing a control group that does not include autologous bone graft harvest, e.g., a group utilizing rhBMP, to determine whether eliminating harvest-site morbidity does indeed lead to observable improvement in clinical outcome sufficient to justify the increased cost of bone graft substitutes.
    Health and Quality of Life Outcomes 02/2009; 7(1):49. DOI:10.1186/1477-7525-7-49 · 2.12 Impact Factor
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    Leonid Kalichman · David J Hunter · David H Kim · Ali Guermazi ·
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    ABSTRACT: The aim of this pilot study was to test the generally believed hypothesis that intervertebral disc degeneration is a prerequisite for degenerative spondylolisthesis (DS). This cross-sectional study was an ancillary project to the Framingham Study. A sample of 3529 participants aged 40-80 years had a CT scan performed to assess aortic calcification. 188 individuals were randomly enrolled in this study. The prevalence of intervertebral disc narrowing, facet joint osteoarthritis (FJOA) and DS were evaluated. We used the multiple logistic regressions to evaluate the association between DS as a dependent variable and FJOA, disc narrowing, age, sex and BMI as independent variables. There were 23 individuals (24 spinal segments) affected by DS (15 female, 8 male), mean age 62.0 +/- 6.8 years. In segments with DS, FJOA was observed and rated "severe" at 20 (83.3%) segments, "moderate" at 3 (12.5%) levels, and "mild" at 1 (4.2%) level. Intervertebral disc height was normal in 6 (25.0%), slightly decreased in 6 (25.0%), moderately decreased in 5 (20.8%) and severely decreased in 7 (29.2%) of the segments. Three (12.5%) segments with DS had severe FJOA but no apparent disc degeneration. In 9 (37.5%) segments with DS we found no or mild disc degeneration and severe FJOA. In a multiple regression analysis age, sex and FJOA, but not disc narrowing, showed significant associations with DS. The results of our study did not support the theory that disc degeneration necessarily precedes vertebral subluxation in DS.
    Journal of Back and Musculoskeletal Rehabilitation 01/2009; 22(1):21-5. DOI:10.3233/BMR-2009-0211 · 0.71 Impact Factor

Publication Stats

2k Citations
118.69 Total Impact Points


  • 2003-2015
    • New England Baptist Hospital
      Boston, Massachusetts, United States
  • 2014
    • Permanente Medical Group
      Pasadena, California, United States
  • 2013
    • Tufts Medical Center
      Boston, Massachusetts, United States
  • 2005-2012
    • Tufts University
      • • Department of Medicine
      • • Department of Orthopaedic Surgery
      Бостон, Georgia, United States
  • 2009
    • University of Massachusetts Boston
      • Clinical Epidemiology Research and Training Unit
      Boston, MA, United States
    • Boston College, USA
      Boston, Massachusetts, United States
    • Boston University
      Boston, Massachusetts, United States
  • 2008
    • Beverly Hospital, Boston MA
      BVY, Massachusetts, United States
  • 2006
    • Tripler Army Medical Center
      Honolulu, Hawaii, United States
  • 2003-2006
    • The Boston Spine Group
      Newton, Massachusetts, United States
    • Thomas Jefferson University
      • Department of Orthopaedic Surgery
      Filadelfia, Pennsylvania, United States
  • 2004-2005
    • Massachusetts General Hospital
      • Department of Orthopaedic Surgery
      Boston, Massachusetts, United States
    • Harvard Medical School
      Boston, Massachusetts, United States
    • Brigham and Women's Hospital
      • Department of Orthopaedic Surgery
      Boston, Massachusetts, United States
  • 2002
    • Boston Children's Hospital
      • Department of Orthopaedic Surgery
      Boston, Massachusetts, United States