Ronald A Lehman

Walter Reed National Military Medical Center, Washington, Washington, D.C., United States

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Publications (128)322.72 Total impact

  • Military medicine 11/2014; · 0.77 Impact Factor
  • Scott C Wagner, Ronald A Lehman, John M Rhee
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    ABSTRACT: Goode AP, Richardson WJ, Schectman RM, Carey TS. Complications, revision fusions, readmissions, and utilization over a 1-year period after bone morphogenetic protein use during primary cervical spine fusions. Spine J 2014;14:2051-9 (in this issue).
    The spine journal: official journal of the North American Spine Society 09/2014; 14(9):2060-2062. · 2.90 Impact Factor
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    ABSTRACT: The use of a rod reduction device can have deleterious consequences on pedicle screw pull-out strength (POS) in the thoracic spine. However, posterior-only osteotomies in the thoracic spine are often performed to improve flexibility of the spine and offset forces of deformity correction maneuvers.
    The spine journal: official journal of the North American Spine Society 07/2014; · 2.90 Impact Factor
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    ABSTRACT: Transforaminal lumbar interbody fusion (TLIF) is increasingly popular for the surgical treatment of degenerative lumbar disease. The optimal construct for segmental stability remains unknown.
    The spine journal: official journal of the North American Spine Society 06/2014; · 2.90 Impact Factor
  • JBJS Case Connector. 06/2014; 2(2):e19-e19.
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    ABSTRACT: Study Design. Human cadaveric biomechanical analysis.Objective. Investigate the effect on cervical spine segmental stability that results from a posterior foraminotomy following cervical disc arthroplasty (CDA).Summary of Background Data. Posterior foraminotomy offers the ability to decompress cervical nerves roots while avoiding the need to extend a previous fusion or revise an arthroplasty to a fusion. However, the safety of a foraminotomy in the setting of CDA is unknown.Methods. Segmental non-destructive range of motion (ROM) was analyzed in nine human cadaveric cervical spine specimens. Following intact testing, each specimen was sequentially tested according to the following four experimental groups: Group 1 = C56 CDA, Group 2 = C56 CDA with unilateral C56 foraminotomy, Group 3 = C56 CDA with bilateral C56 foraminotomy, and Group 4 = C56 CDA with C56 and C45 bilateral foraminotomy.Results. No differences in ROM was found between the intact, CDA, and foraminotomy specimens at C4-5 or C6-7. There was a step-wise increase in C5-6 axial rotation from the intact state (8°) to Group 4 (12°), although the difference did not reach statistical significance. At C5-6, the degree of lateral bending remained relatively constant. Flexion and extension at C5-6 was significantly higher in the foraminotomy specimens, Groups 2 (18.1°), 3 (18.6°), and 4 (18.2°), compared to the intact state, 11.2°. However, no ROM difference was found within foraminotomy Groups (2-4) or between the foraminotomy groups and the CDA group (Group 1), 15.3°.Conclusions. Our results indicate that cervical stability is not significantly decreased by the presence, number, or level of posterior foraminotomies in the setting of CDA. The addition of foraminotomies to specimens with a pre-existing CDA resulted in small and insignificant increases in segmental ROM. Therefore, biomechanically, posterior foraminotomy(s) may be considered a safe and viable option in the setting of recurrent or adjacent level radiculopathy following cervical disc replacement.
    Spine 06/2014; · 2.16 Impact Factor
  • Scott C. Wagner, Ronald A. Lehman, John M. Rhee
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    ABSTRACT: Commentary on an article by Adam Goode, DPT, PhD, et al: “Complications, revision fusions, re-admissions and utilization over a one-year period following bone morphogenetic protein use during primary cervical spine fusions.”
    The Spine Journal 05/2014; · 3.36 Impact Factor
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    ABSTRACT: Cervical disc arthroplasty has emerged as a viable technique for the treatment of cervical radiculopathy and myelopathy, with the proposed benefit of maintenance of segmental range of motion. There are relatively few, non-industry sponsored studies examining the outcomes and complications of cervical disc arthroplasty. Therefore, we set out to perform a single center evaluation of the outcomes and complications of cervical disc arthroplasty. We performed a retrospective review of all patients from a single military tertiary medical center undergoing cervical disc arthroplasty from August 2008 to August 2012. The clinical outcomes and complications associated with the procedure were evaluated. A total of 219 consecutive patients were included in the review, with an average follow-up of 11.2 (±11.0) months. Relief of pre-operative symptoms was noted in 88.7% of patients, and 92.2% of patients were able to return to full pre-operative activity. There was a low rate of complications related to the anterior cervical approach (3.2% with recurrent laryngeal nerve injury, 8.9% with dysphagia), with no device/implant related complications. Symptomatic cervical radiculopathy is a common problem in both the civilian and active duty military populations and can cause significant disability leading to loss of work and decreased operational readiness. There exist several surgical treatment options for appropriately indicated patients. Based on our findings, cervical disc arthroplasty is a safe and effective treatment for symptomatic cervical radiculopathy and myelopathy, with a low incidence of complications and high rate of symptom relief.
    Journal of Clinical Neuroscience 05/2014; · 1.25 Impact Factor
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    ABSTRACT: Several studies have established the short-term safety and efficacy of cervical disc arthroplasty (CDA) as compared to anterior cervical discectomy and fusion (ACDF). However, few single-center comparative trials have been performed, and current studies do not contain large numbers of patients. We retrospectively reviewed all patients from a single military tertiary medical center between August 2008 to August 2012 who underwent single-level CDA or single-level ACDF and compared their clinical outcomes and complications. A total of 259 consecutive patients were included in the study, 171 patients in the CDA group with an average follow-up of 9.8 (±9.9) months and 88 patients in the ACDF group with an average follow-up of 11.8 (±9.6) months. Relief of pre-operative symptoms was 90.1% in the CDA group and 86.4% in the ACDF group with rates of return to full pre-operative activity of 93.0% and 88.6%, respectively. Patients who underwent CDA had a higher rate of persistent posterior neck pain (15.8% versus 12.5%), and patients who underwent ACDF were at risk for symptomatic pseudarthrosis at a rate of 3.4%. Reoperation rates were higher in the ACDF group (5.7% versus 3.5%). To our knowledge, this review is the largest, non-funded, comparison study between single-level CDA and single-level ACDF. This study demonstrates that CDA is a safe and reliable alternative to ACDF in the treatment of cervical radiculopathy and myelopathy resulting from spondylosis and acute disc herniation.
    Journal of Clinical Neuroscience 05/2014; · 1.25 Impact Factor
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    ABSTRACT: The need for posterolateral fusion (PLF) in addition to interbody fusion during minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) has yet to be established. Omitting a PLF significantly reduces overall surface area available for achieving a solid arthrodesis, however it decreases the soft tissue dissection and costs of additional bone graft. The authors sought to perform a meta-analysis to establish the fusion rate of MIS TLIF performed without attempting a PLF. We performed an extensive Medline and Ovid database search through December 2010 revealing 39 articles. Inclusion criteria necessitated that a one or two level TLIF procedure was performed through a paramedian MIS approach with bilateral posterior pedicle screw instrumentation and without posterolateral bone grafting. CT scan verified fusion rates were mandatory for inclusion. Seven studies (case series and case-controls) met inclusion criteria with a total of 408 patients who underwent MIS TLIF as described above. The mean age was 50.7years and 56.6% of patients were female. A total of 78.9% of patients underwent single level TLIF. Average radiographic follow-up was 15.6months. All patients had local autologous interbody bone grafting harvested from the pars interarticularis and facet joint of the approach side. Either polyetheretherketone (PEEK) or allograft interbody cages were used in all patients. Overall fusion rate, confirmed by bridging trabecular interbody bone on CT scan, was 94.7%. This meta-analysis suggests that MIS TLIF performed with interbody bone grafting alone has similar fusion rates to MIS or open TLIF performed with interbody supplemented with posterolateral bone grafting and fusion.
    Journal of Clinical Neuroscience 05/2014; · 1.25 Impact Factor
  • Daniel G Kang, Scott C Wagner, Ronald A Lehman
    The spine journal: official journal of the North American Spine Society 03/2014; · 2.90 Impact Factor
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    ABSTRACT: A previous biomechanical study using adult thoracic vertebrae (both normal and osteoporotic bone density) demonstrated the deleterious effect of the pedicle screw hubbing technique. Pedicle screw "hubbing" involves seating and engaging the ventral aspect of the screw head onto the dorsal lamina cortex. This technique is postulated to provide a load-sharing effect by improving pullout resistance, as well as decreasing cephalocaudad toggling and implant loosening. We hypothesized the elastic properties of immature bone may mitigate, and perhaps enhance the purported benefits of the hubbing technique. We set out to evaluate pullout strength of fixed-head pedicle screws after hubbing versus standard insertion in the immature thoracic calf spine. Twenty-two (n=22) single-level disarticulated fresh-frozen immature calf thoracic vertebra specimens (ranging from T2 to T13) were prepared. Twelve specimens were instrumented with pedicle screws in group I (nonhubbed) and group II (hubbed) in the opposite pedicle. Cyclic loading in a cephalocaudad direction was applied for 2000 cycles at a rate of 1 Hz. Pullout testing was performed in-line with the midline of the vertebra and peak pullout strength was measured in Newtons. Ten different specimens underwent micro-computed tomography evaluation to assess for trabecular architecture and incidence of iatrogenic microfractures. Hubbed screws resulted in significantly lower pullout strength (747±197 vs. 922±112 N, P=0.01). With the hubbing technique, the dorsal cortex demonstrated plastic deformation and conformed to the screw head in 83% of cases compared with no visible plastic deformation in the control group. Micro-computed tomography demonstrated microfractures of the dorsal cortex in 10/10 for the hubbed group compared with 1/10 for the control group. This is the largest study ever performed on immature thoracic vertebra to evaluate this topic. Hubbed pedicle screws have significantly decreased pullout strength and frequently cause iatrogenic microfractures of the dorsal cortex. The unique ability of immature bone to exhibit plastic deformation did not provide a protective effect on immediate fixation strength, and the increased insertional torque during the hubbing technique should not give a false sense of added fixation. This study, along with our adult study, provides critical information to the surgeon to avoid this common misunderstanding with screw insertion technique. In vitro fresh-frozen immature calf spine study.
    Journal of pediatric orthopedics 03/2014; · 1.23 Impact Factor
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    ABSTRACT: Some postoperative complications after anterior cervical fusions have been attributed to anterior cervical plate (ACP) profiles and the necessary wide operative exposure for their insertion. Consequently, low-profile stand-alone interbody spacers with integrated screws (SIS) have been developed. While SIS have demonstrated similar biomechanical stability to the ACP in single-level fusions, their role as a stand-alone device in multi-level reconstructions has not been thoroughly evaluated. To evaluate the acute segmental stability afforded by an SIS device compared to the traditional ACP in the setting of a multi-level cervical arthrodesis. In vitro human cadaveric biomechanical analysis. Thirteen human cadaveric cervical spines (C2-T1) were non-destructively tested with a custom six-degree-of-freedom spine simulator under axial rotation (AR), flexion-extension (FE) and lateral bending (LB) loading. After intact analysis, eight single-levels (C4-5/C6-7) from four specimens were instrumented and tested with: 1) ACP and 2) SIS. Nine specimens were tested with: 1) C5-7 SIS, 2) C5-7 ACP, 3) C4-7 ACP, 4) C4-7 ACP + posterior fixation, 5) C4-7 SIS, and 6) C4-7 SIS + posterior fixation. Testing order was randomized with each additional level instrumented. Full range of motion(ROM) data was obtained and analyzed by each loading modality utilizing mean comparisons with repeated measures analysis of variance. Paired t-tests were used for post-hoc analysis with Sidak's correction for multiple comparisons. No significant difference in ROM was noted between the ACP and SIS for single-level fixation (p>0.05). For multi-segment reconstructions (two and three levels) the ACP proved superior to SIS and intact condition, with significantly lower ROM in all planes (p<0.05). When either the three-level SIS or ACP constructs were supplemented with posterior lateral mass fixation, there was a greater than 80% reduction in ROM under all testing modalities (p<0.05) with no significant difference between the ACP and SIS constructs (p>0.05).There were no funding sources or relevant financial disclosures for this study. The SIS device may be a reasonable option as a stand-alone device for single-level fixation. However, SIS devices should be used with careful consideration as a stand-alone construct in the setting of multi-level cervical fusion. However, when supplemented with posterior fixation, SIS devices are a sound biomechanical alternative to ACP for multi-level fusion constructs.
    The spine journal: official journal of the North American Spine Society 01/2014; · 2.90 Impact Factor
  • Adam L Wollowick, Daniel G Kang, Ronald A Lehman
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    ABSTRACT: Hassanzadeh H, Gjolaj JP, El Dafrawy MH, et al. The timing of surgical staging has a significant impact on the complications and functional outcomes of adult spinal deformity surgery. Spine J 2013;13:1717-22 (in this issue).
    The spine journal: official journal of the North American Spine Society 12/2013; 13(12):1723-5. · 2.90 Impact Factor
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    ABSTRACT: With the increasing popularity of thoracic pedicle screws, the freehand technique has been espoused to be safe and effective. However, there is currently no objective, definable landmark to assist with freehand insertion of pedicle screws in the thoracic spine. With our own increasing surgical experience, we have noted a reproducible and unique anatomic structure known as the ventral lamina. We set out to define the morphologic relationship of the ventral lamina to the superior articular facet (SAF) and pedicle, and describe an optimal medial-lateral pedicle screw starting point in the thoracic spine. We conducted an in vitro fresh-frozen human cadaveric study. One hundred fifteen thoracic spine vertebral levels were evaluated. After the vertebral body was removed, Kirschner wires were inserted retrograde along the four boundaries of the pedicle. Using digital calipers, we measured width of the SAF and pedicle at the isthmus, and from the borders of the SAF to the boundaries of the pedicle. We calculated the morphologic relationship of the ventral lamina and the center of the pedicle (COP) to the SAF. Two hundred twenty-nine pedicles were measured, with one pedicle excluded because of fracture of the SAF during disarticulation. The ventral lamina was clearly identifiable at all levels, forming the roof of the spinal canal and confluent with the medial pedicle wall (MPW). The mean distance from the SAF midline to the MPW was 1.36±1.23 mm medial. The MPW was lateral to SAF midline in 34 pedicles (14.85%) and, on average, was a distance of 0.52±0.51 mm lateral. The mean distance from the SAF midline to the COP was 2.17±1.38 mm lateral. The COP was medial to SAF midline in only 11 pedicles (4.80%). The ventral lamina is an anatomically reproducible structure located consistently medial to the SAF midline (85%). We also found the COP consistently lateral to the SAF midline (95%). Based on these morphologic findings, the medial-lateral starting point for thoracic pedicle screws should be 2 to 3 mm lateral to the SAF midline (superior facet rule), allowing screw placement in the COP and avoiding penetration into the spinal canal.
    The spine journal: official journal of the North American Spine Society 11/2013; · 2.90 Impact Factor
  • Daniel G Kang, Ronald A Lehman, Lawrence G Lenke
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    ABSTRACT: Phan P, Mezghani N, Wai EK, et al. Artificial neural networks assessing adolescent idiopathic scoliosis: comparison with Lenke classification. Spine J 2013;13:1527-33 (in this issue).
    The spine journal: official journal of the North American Spine Society 11/2013; 13(11):1534-7. · 2.90 Impact Factor
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    ABSTRACT: There are no guidelines for when surgeons should allow patients to return to sports and athletic activities after spinal fusion for adolescent idiopathic scoliosis (AIS). Current recommendations are based on anecdotal reports and a survey performed more than a decade ago in the era of first/second-generation posterior implants. To identify current recommendations for return to sports and athletic activities after surgery for AIS. Questionnaire-based survey. Adolescent idiopathic scoliosis after corrective surgery. Type and time to return to sports. A survey was administered to members of the Spinal Deformity Study Group. The survey consisted of surgeon demographic information, six clinical case scenarios, three different construct types (hooks, pedicle screws, hybrid), and questions regarding the influence of lowest instrumented vertebra (LIV) and postoperative physical therapy. Twenty-three surgeons completed the survey, and respondents were all experienced expert deformity surgeons. Pedicle screw instrumentation allows earlier return to noncontact and contact sports, with most patients allowed to return to running by 3 months, both noncontact and contact sports by 6 months, and collision sports by 12 months postoperatively. For all construct types, approximately 20% never allow return to collision sports, whereas all surgeons allow eventual return to contact and noncontact sports regardless of construct type. In addition to construct type, we found progressively distal LIV resulted in more surgeons never allowing return to collision sports, with 12% for selective thoracic fusion to T12/L1 versus 33% for posterior spinal fusion to L4. Most respondents also did not recommend formal postoperative physical therapy (78%). Of all surgeons surveyed, there was only one reported instrumentation failure/pullout without neurologic deficit after a patient went snowboarding 2 weeks postoperatively. Modern posterior instrumentation allows surgeons to recommend earlier return to sports after fusion for AIS, with the majority allowing running by 3 months, noncontact and contact sports by 6 months, and collision sports by 12 months.
    The spine journal: official journal of the North American Spine Society 10/2013; · 2.90 Impact Factor
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    ABSTRACT: High-energy blasts are the most frequent cause of combat-related amputations in Operations Iraqi and Enduring Freedom (OIF/OEF). The nondiscriminating effects of this mechanism often result in both appendicular and axial skeletal injuries. Despite this recognized coincident injury pattern, the incidence and consequence of spine fractures in trauma-related combat amputees are unknown. This study sought to determine the incidence and morbidity of the associated spine fractures on patients with traumatic lower extremity amputation sustained during OIF/OEF. Retrospective case control. Two hundred twenty-six combat-related lower extremity amputees presenting to a single institution and injured between 2003 and 2008 were included for analysis. Physiologic and functional outcome measures were used to determine the influence of spine fractures on combat amputees. Physiologic measures included intensive care unit (ICU) admission rates, injury severity score (ISS), rate of narcotic/neuropathic pain use, and heterotopic ossification (HO) rates. Functional outcome measures included return-to-duty rates and ambulatory status at final follow-up. Data from 300 consecutive combat-related lower extremity amputations were retrospectively reviewed and grouped. Group 1 consisted of amputees with associated spine fractures, and Group 2 consisted of amputees without spine fractures. The results of the two groups were compared with regard to initial presentation and final functional outcomes. A total of 226 patients sustained 300 lower extremity amputations secondary to combat-related injuries, the most common mechanism being an improvised explosive device. Twenty-nine of these patients had a spine fracture (13%). Group 1 had a higher ISS than Group 2 (30 vs. 19, p<.001). Group 1 patients were also more likely to be admitted to the ICU (86% vs. 46%, p<.001). Furthermore, Group 1 patients had a significantly higher rate of HO in their residual limbs (82% vs. 55%, p<.005). The incidence of spine fractures in combat-related amputees is 13%. The results suggest that combat-related amputees with spine fractures are more likely to sustain severe injuries to other body systems, as indicated by the significantly higher ISS and rates of ICU admission. This group also had a significantly higher rate of HO formation, which may be attributable to the greater local and/or systemic injuries sustained by these patients.
    The spine journal: official journal of the North American Spine Society 09/2013; · 2.90 Impact Factor
  • Eugene J Carragee, Ronald A Lehman
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    ABSTRACT: Before the introduction of the poliomyelitis vaccination, paralysis due to poliovirus infection was a leading cause of spinal deformity in children and young adults. The severe, stiff spinal deformities associated with poliovirus infection were complicated by pulmonary dysfunction; spinal bracing, which was often ineffective in correcting the deformity or preventing the progression of scoliosis, also exacerbated restrictive pulmonary disease, pulmonary hypertension, and cor pulmonale. Today, coronal spinal deformity in children and young adults is nearly always adolescent idiopathic scoliosis: a flexible, three-dimensional, spinal curvature affecting primarily girls, beginning in adolescence, and very rarely leading to clinically significant cardiopulmonary disease. When . . .
    New England Journal of Medicine 09/2013; · 54.42 Impact Factor
  • Source
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    ABSTRACT: Study Design. Retrospective analysis of a prospectively collected database.Objective. To determine the overall incidence, location, and type of disc herniations in professional football players in order to target treatment issues and prevention.Summary of Background Data. Disc herniations represent a common and debilitating injury to the professional athlete. The National Football League's (NFL) Sports Injury Monitoring System is a surveillance database created to monitor the league for all injuries, including injuries to the cervical, thoracic, and lumbar spine.Methods. A retrospective analysis was performed on all disc herniations to the cervical, thoracic, and lumbar spine over a twelve-season period (2000-2012) using the NFL's surveillance database. The primary data points included the location of the injury, player position, activity at time of injury, and playing time lost due to injury.Results. Over the 12 seasons, 275 disc herniations occurred in the spine. In regard to location, 76% occurred in the lumbar spine and most frequently affected the L5-S1 disc. The offensive linemen were most frequently injured. As expected, blocking was the activity causing most injuries. Lumbar disk herniations rose in prevalence and had a mean loss of playing time of more than half the season (11.5 games). Thoracic disc herniations led to the largest mean number of days lost overall, whereas players with cervical disc herniations missed the most practices.Conclusions. Disc herniations represent a significant cause of morbidity in the NFL. While much attention is placed on spinal cord injuries, preventive measures targeting the cervical, thoracic, and lumbar spine may help to reduce the overall incidence of these debilitating injuries.
    Spine 09/2013; · 2.16 Impact Factor

Publication Stats

1k Citations
322.72 Total Impact Points

Institutions

  • 2002–2014
    • Walter Reed National Military Medical Center
      • • Division of Orthopaedic Surgery
      • • Department of Orthopaedics and Rehabilitation
      Washington, Washington, D.C., United States
  • 2013
    • Washington University in St. Louis
      • Department of Orthopaedic Surgery
      Saint Louis, MO, United States
    • Albert Einstein College of Medicine
      • Orthopaedic Surgery
      New York City, New York, United States
  • 2009–2012
    • Uniformed Services University of the Health Sciences
      • • Department of Surgery
      • • Department of Pharmacology
      Maryland, United States
  • 2011
    • William Beaumont Army Medical Center
      El Paso, Texas, United States
    • San Antonio Military Medical Center
      Texas City, Texas, United States
  • 2005–2006
    • Thomas Jefferson University
      • Department of Orthopaedic Surgery
      Philadelphia, PA, United States